Every finding on record at Golden Key Hospice, Inc

Based on interview and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients) failed to ensure the Condition of Participation (condition that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Patient Rights was met as follows: --- The HA failed to address a complaint allegation that the family member's request was not granted to send a skilled nurse (in general) immediately to assess Patient 1, who was coughing out blood, and was not in the HA's grievance (complaint) log and its resolution ( decision) for one out of 7 sampled patients (Patient 1). This deficient practice placed Patient 1 at risk that grievances presented to the HA will not be addressed and resolved. (Refer to L505). The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated Federal compliance for Patients Rights to ensure Patients 1's rights were not violated and received quality hospice care.

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 address a complaint allegation reported, to the HA regarding a family member's to send a nurse immediately to assess Patient 1, who was coughing out blood, and was not in the HA grievance (complaint) log and its resolution ( decision) for one out of 7 sampled patients (Patient 1). This deficient practice placed Patient 1 at risk that grievances presented to the HHA will not be addressed and resolved. --- During a a complaint validation survey on 10/24/2024, at 11 a.m., conducted at the HA of an allegation that the HAs Office Manager (OM) was notified by Patient 1s Family Member 1 (FM 1) on 9/29/2024, at around 10 p.m. of Patient 1 was experiencing a change of condition (COC) of coughing out blood. The HA did not send a nurse to immediately assess Patient 1 on 9/29/2024. The HA sent Licensed Vocational Nurse 1 (LVN1) on 9/30/2024, at 8:10 a.m., and at 8:44 a.m. During a review of Patient 1s Patient Information Sheet, the Patient Information sheet indicated Patient 1s start of care (SOC) date was 9/29/2024, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of multiple myeloma (is a cancer that forms in a type of white blood cell). During a review of Patient 1's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 9/29/2024, the POC indicated an order for Skilled Nurse (SN, a licensed healthcare professional who has received advanced training and certification to provide a high level of care) to provide skilled nursing visits (a brief, targeted nursing service that a registered nurse (RN) or licensed practical nurse (LPN) provides in a patient's home to help with short-term medical needs) once a week with three as needed visits SC (spiritual counseling) once a month and as needed. During an interview with FM 1 on 10/22/2024 at 12:36 p.m., FM 1 stated that when Patient 1 started coughing out blood on 9/29/2024, at 7 p.m., FM 1 stated that she (FM 1) panicked and did not know what to do. FM stated that she (FM1) attempted to call the HA between the hours of 7 p.m. to 10:30 p.m. FM 1 stated that she (FM 1) received a text message from OM on 9/30/2024 at 12:52 a.m., indicating that the OM will send a nurse at 7:00 am. FM 1 stated the visiting nurse arrived on 9/30/2024 at around 8:10 a.m. FM 1 stated Patient 1 passed away (died) at 8:44 p.m. due to multiple myeloma and cardiopulmonary arrest. FM 1 stated that she (FM1) was upset and angry that there was no nurse to attend to Patient 1 to provide comfort care (a type of medical treatment that focuses on providing comfort and quality of life for patients who are near the end of their life) immediately as it took the HA 10 hours before LVN 1 was able to visit Patient 1. During an interview with OM on 10/23/2024, at 2 p.m., the OM stated that she (OM) received a phone call from FM 1 on 9/29/2024 at 10 p.m. requesting a nurse visit to check Patient 1 who was coughing blood. OM stated she attempted to call the DPCS to relay the message, but the OM could not reach the DPCS. OM further stated she sent a message to FM1 at 12:52 a.m. On 9/30/2024, LVN 1 arrived at 8:10 a.m. to evaluate Patient 1s condition. During a telephone interview with the Director Of Patient Care Services (DPCS) on 10/23/2024 at 12 p.m., the DPCS stated that he (DPCS) did not receive a report regarding Patient 1s condition on 9/29/2024. TheDPCS stated that he (DPCS) was given a report about Patient 1s condition by LVN 1 who did a visit on 9/30/24, at 8:10 a.m. DPCS further stated that if the(DPCS) had known about the incident of Patient 1 coughing up blood on 9/29/2024, DPCS would have sent a nurse; or he (DPCS) would have gone to Patient 1s residence right away to provide continuous care (a type of hospice care that provides 24-hour nursing care to patients who are terminally ill and experiencing severe symptoms). A request for a review of Patient 1's Communication Log dated 9/29/2024, from the DPCS, the DPCS could not provide any documented evidence of FM 1 call to the agency requesting for a nurse visit for Patient 1. During an interview with the DPCS on 10/25/2024, at 1 p.m., The DPCS stated that he was aware of FM 1's grievance, but the agency failed to document the complaint in their grievance book with the corrective action or resolution as per their agencys policy. During a review of the agencys undated policy and procedure titled, ";Complaint/Grievance Process", the policy indicated at the time of admission, and as needed, patient/client and/or family/caregiver shall be informed of their rights to voice grievances regarding treatment or care, lack of respect of property, or recommend changes in policy, staff, or service/care without restraint, interference, coercion, discrimination, or reprisal. Grievances received from a patient/client and/or family/caregiver will be promptly reported to Office Leadership/Designee for assessment determination. Complaints and any actions taken will be documented in the complaint form. Corrective action should be specific and related to the complaint. All complaints will be logged, tracked, trended, and filed in the performance improvement office.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (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 Initial and Comprehensive Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process of the Patient) was met as follows. --- a. The HA failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to the management of terminal illness and hospice eligibility for four of four sampled patients (Patient 2, Patient 3, Patient 4, and Patient 5).   As a result, the non-compliance resulted in Patient 2, Patient 3, Patient 4, and Patient 5, to have the potential to lose their hospice eligibility and hospice benefits and not receive hospice care when needed, and not be eligible for hospice care in the future; due to actively being enrolled in hospice services that could lead to potential hospitalization and death. (Refer to L524) b. The HA failed to maintain a current medication profile for one of 7 sampled patients (Patient 2). This deficient practice had the potential to place Patient 2 at risk for medication errors and adverse drug reactions (harmful, unintended result caused by taking medication). (Refer to L530). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care were being provided to patients certified to receive the Medicare hospice benefits.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill (patients who have six months or less to live) failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to the manage of terminal illness (a disease or condition due to which a patient's death is anticipated in six months) and hospice eligibility for four of four sampled patients (Patient 2, Patient 3, Patient 4, and Patient 5).    As a result, the non-compliance resulted in Patient 2, Patient 3, Patient 4, and Patient 5, to have the potential to lose their hospice eligibility and or hospice benefits; not receive hospice care when needed, and not be eligible for hospice care in the future due to actively being enrolled in hospice services that could lead to potential hospitalization and death. On 10/25/2024 at 2:20 p.m., the Department called Immediate Jeopardy (IJ- a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a patient) in the presence of the HAs Director of Patient Care Services (DPCS) and Administrator related to the failure to conduct and document an accurate comprehensive 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 four of four sampled patients (Patient 2, Patient 3, Patient 4 and Patient 5). As a result, the non-compliance resulted in Patient 2, Patient 3, Patient 4, and Patient 5, to have the potential to lose their hospice eligibility and or hospice benefits; not receive hospice care when needed, and not be eligible for hospice care in the future due to actively being enrolled in hospice services that could lead to potential hospitalization and death. On 10/25/2024, at 4:15 p.m., the survey team completed the survey tasks and conducted an exit conference, in the presence of the DPCS with the IJ situations not removed. --- a. During a review of Patient 2s Patient Information Sheet, the Patient Information sheet indicated Patient 2s start of care (SOC) date was 9/14/2024, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of cerebral vascular disease (hypertensive heart disease (conditions that affect blood flow to the brain). During a review of the agencys Local Coverage Determination (LCD, the agencys patients eligibility for medical necessity and hospice eligibility assessment form) guidelines, indicated that there was no LCD form completed by the visiting nurse. During a review of Patient 2's Physicians Certification for Hospice Benefit also known as Certification of Terminal Illness (CTI, is the narrative summary, 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), dated 9/14/2024 to 12/12/2024, the Physicians Certification for Hospice Benefit period number one indicated the HAs Medical Director (MD) signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. On 10/24/2024, at 11:30 a.m., a home visit was conducted at Patient 2's residence. Patient 2 was observed lying in bed, well groomed and sleeping. During a phone interview with Family Member (FM2) on 10/24/2024, at 11:50 p.m., she stated she called the HA asking to have a nurse to visit the patient every week, so she signed for hospice services. She further stated the HA staff did not explain to the patient regarding the hospice service, that they were not told the patient had six months to live. b. During a review of Patient 3s Patient Information Sheet, the Patient Information indicated a start of care (SOC) date of 7/19/2024. During a review of the LCD (agencys assessment form), the LCD indicated that Patient 3 has a terminal diagnosis of Parkinsons Disease (a disorder of the central nervous system that affects movement). During a review of the agencys Local Coverage Determination (LCD, the agencys patients eligibility for medical necessity and hospice eligibility assessment form) guidelines, indicated that there was no LCD form completed by the visiting nurse. During a review of Patient 3's Physicians Certification for Hospice Benefit also known as Certification of Terminal Illness (CTI, is the narrative summary, 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), dated 7/19/2024 to 10/16/2024, the Physicians Certification for Hospice Benefit period number one indicated the HAs Medical Director (MD) signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. On 10/24/2024, at 12:30 p.m., a home visit was conducted at Patient 3's residence. Patient 3 was observed lying in bed, well groomed, alert, oriented and able to move both upper and lower extremities. . During a phone interview with family member (FM3) on 10/25/2024, at 1:45 p.m., he stated the social worker from his work referred the patient to the HA staff to have a nurse to visit the patient. He further stated the HA staff did not explain to the patient regarding the hospice service, that they were not told the patient had six months to live. On 10/25/2024, at 11 a.m., during an interview with the DPCS, the DPCS stated as part of the admission process, the DPCS expects that the visiting nurse to utilize the LCD guideline form to determine eligibility for hospice when doing their initial visits. The DPCS further stated that the visiting nurse who did the initial visits for both Patient 2 and 3 did not complete a LCD guidelines form at all. During a telephone interview on 9/20/2024, at 1:40 p.m., with Physician 1, Physician 1 stated he was not the attending physician of Patient 2, Patient 3, Patient 4, and Patient 5, and he did not discuss the patients medical history with them. Physician 1 stated he was acting as their attending physician now because Patient 2, 3, 4, and 5 were admitted to the hospice agency. MD stated he determined the patients (Patient 2, Patient 3, Patient 4, and Patient 5) were eligible for hospice care based on the Registered Nurses assessment/visit notes and LCD guidelines. When Physician 1 was asked if he reviewed the LCD guidelines completed by the visiting nurse for Patient 2 and 3, Physician 1 stated he could not remember anymore.  During a review of the undated Hospice Agency's document titled, "Admission Criteria and Process" , the document indicated the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determinations. c. During a review of Patient 4s Patient Information Sheet, the Patient Information indicated a start of care date of 3/18/2024. During a review of the LCD (agencys assessment form), the LCD indicated that Patient 4 has a terminal diagnosis of Alzheimers disease (a brain disorder that causes a gradual decline in memory, thinking, and reasoning skills) During a review of Patient 4's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the fifth hospice benefit period from 10/14/2024 to 12/12/2024, indicated Patient 4's terminal diagnoses was Alzheimers disease. The Medical Director (Physician 1) indicated Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 4s terminal illness diagnosis. During a review of Patient 4s LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) Hospice Eligibility Determination form for Dementia due to Alzheimers dated 10/14/2024, indicated Patient 4 was not eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. d. During a review of Patient 5s Patient Information Sheet, the Patient Information indicated a start of care date of 7/11/2023. During a review of the LCD (agencys assessment form), the LCD indicated that Patient has a terminal diagnosis of atherosclerotic heart disease (a disease caused by plaque buildup in the arteries, which can lead to conditions like coronary heart disease and stroke). During a review of Patient 5's "Physician Certification for Hospice Benefit" for the seventh hospice benefit period from 9/3/2024 to 11/1/2024, indicated Patient 6's terminal diagnoses was Atherosclerotic heart disease. The Medical Director (Physician 1) indicated Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 5s terminal illness diagnosis. Findings: a. During a review of Patient 2s Patient Information Sheet, the Patient Information sheet indicated Patient 2s start of care (SOC) date was 9/14/2024, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis (outcome) and no known cure) of cerebral vascular disease (a group of conditions that affect blood flow and the blood vessels in the brain and spinal cord). During a review of the Patient 2s HAs Local Coverage Determination (LCD, the agencys patients eligibility for medical necessity and hospice eligibility assessment form) guidelines,  from 9/14/24 to 10/24/24 there was no documented evidence that the LCD form completed by the Registered Nurse 1 (RN 1) for Patient 2.  During a review of Patient 2's Physicians Certification for Hospice Benefit also known as Certification of Terminal Illness (CTI, is the narrative summary, 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), dated 9/14/2024 to 10/12/2024, the Physicians Certification for Hospice Benefit period number one indicated Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with Patient 2s primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis.  During a home visit conducted on 10/24/2024, at 11:30 a.m., Patient 2 was observed lying in bed, well groomed and sleeping. During a phone interview with Family Member (FM2) on 10/24/2024, at 11:50 p.m., FM 2 stated that she called the HA asking to have a nurse visit Patient 2 weekly. FM 2 stated that FM 2 was then asked by the HA to sign for Patient 2 to receive hospice services on the stat of care. FM 2 stated that the HA staff did not explain to Patient 2 regarding hospice services. FM 2 stated that FM 2 were not told Patient 2 had six months to live. During an interview with DPCS on 10/25/2024, at 11 a.m., DPCS stated that as part of the admission  process, DPCS expects that the visiting nurse of the HA will utilize the LCD guideline form to determine a patients eligibility for hospice during the initial visits. DPCS further stated that the HA visiting nurse who did the initial visit for Patient 2 did not complete a LCD guideline form. During a telephone interview on 9/20/2024, at 1:40 p.m., with Physician 1, Physician 1 stated he (Physician 1) was not initially the primary physician of Patient 2. Physician 1 stated that he did not discuss Patients 2s medical record with Patient 2. Physician 1 stated that he (Physician 1) was now the attending physician for Patient 2 as Patient 2 was now admitted to the HA. Physician 1 stated that he (Physician 1) determined Patient 2s eligibility for hospice care based on Patient 2s LCD, as well as Patient 2s CTI from 9/14/24 to 10/12/24. When Physician 1 was asked if he (Physician 1) reviewed an LCD guideline for Patient 2, Physician 1 stated that he (Physician 1) could not remember anymore. During a review of the undated Hospice Agency's document titled, "Admission Criteria and Process" , the document indicated the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determinations. During a review of the undated Hospice Agency's document titled, "Admission Criteria and Process" , the document indicated the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determinations. b. During a review of Patient 3s Patient Information Sheet, the Patient Information indicated a SOC date of 7/19/2024. During a review of the HAs LCD dated 7/19/2024 to 10/24/2024, the LCD indicated tha Patient 3 has a terminal diagnosis of Parkinsons Disease (a disorder of the central nervous system that affects movement). During a review of Patient 3s LCD guidelines from 7/19/2024 to 10/24/24, there was no documented evidence that the LCD form was completed by RN 1.  During a review of Patient 3's Physicians Certification for Hospice Benefit also known as CTI, dated 7/19/2024 to 10/16/2024, the Physicians Certification for Hospice Benefit period number one indicated Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with Patient 3s primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis.  During a home visit conducted on 10/24/2024, at 12:30 p.m., Patient 3 was observed lying in bed, well groomed, alert, oriented (a medical term that describes a patients level of awareness of themselves, their surroundings, and the time), and able to move both upper and lower extremities (referring to arms and legs). During a phone interview with Patient 3s FM3 on 10/25/2024, at 1:45 p.m., FM 3 stated that the social worker (Social Worker 1 [SS 1]) from FM 3 work referred Patient 3 to the HA. FM3 stated Physician 1 did not explain to Patient 3 regarding the hospice services. FM 3 stated, that they (FM 3) were not told that Patient 3 had six months to live. During an interview with DPCS on 10/25/2024, at 11 a.m., during an interview with the DPCS, the DPCS stated that as part of the admission  process, DPCS expects that the visiting nurse of the HA will utilize the LCD guideline form to determine a patients eligibility for hospice when doing theirduring the initial visits. DPCS stated that the HA visiting nurse who did the initial visits for both Patient 2 and Patient 3 did not complete a LCD guidelines form. During a telephone interview on 9/20/2024, at 1:40 p.m., with Physician 1, Physician 1 stated he (Physician 1) was not the initially the attending primary physician of Patient 32. Physician 1 stated that he did not discuss Patients 3s medical record with Patient 3. Physician 1 stated that he (Physician 1) was now the attending physician for Patient 3 as Patient 3 was now admitted to the HA. Physician 1 stated that he (Physician 1) determined Patient 3s edibility for hospice care based on Patient 3s LCD. When Physician 1 was asked if he (Physician 1) reviewed an LCD guideline for Patient 3, Physician 1 stated that he (Physician 1) could not remember anymore. During a review of the undated Hospice Agency's document titled, "Admission Criteria and Process" , the document indicated the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determinations. During a review of the undated Hospice Agency's document titled, "Admission Criteria and Process" , the document indicated the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determinations. During a review of Patient 4s Patient Information Sheet, the Patient Information indicated a SOC date of 3/18/2024. c. During a review of the LCD dated 10/14/2024, the LCD indicated  that Patient 4 has a terminal diagnosis of Alzheimers disease (a brain disorder that causes a gradual decline in memory, thinking, and reasoning skills) During a review of Patient 4's the Physician Certification for Hospice Benefit for the fifth hospice benefit period from 10/14/2024 to 12/12/2024, the Physician Certification for Hospice Benefit indicated Patient 4's terminal diagnoses was Alzheimers disease. The Physician Certification for Hospice Benefit indicated Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course as documented by Physician 1. The "Certifying Physician Section" did not indicate any documented evidence and supporting narrative from the Physician 1 that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 4s terminal illness diagnosis. During a review of Patient 4s HAs LCD Hospice Eligibility Determination form for Dementia (loss of memory, language, problem-solving and other thinking abilities) due to Alzheimers, dated 10/14/2024, the LCD indicated Patient 4 was not eligible per LCD guidelines. The LCD form indicated Section one (describes the activities of daily living) and Section two (describes the progression of the disease) must be met. During a telephone interview on 9/20/2024, at 1:40 p.m., with Physician 1, Physician 1 stated he (Physician 1) was not initially the primary physician of Patient 4. Physician 1 stated that he did not discuss Patients 4s medical record with Patient 4. Physician 1 stated that he (Physician 1) was now the attending physician for Patient 4 as Patient 4 was now admitted to the HA. Physician 1 stated that he (Physician 1) determined Patient 4s edibility for hospice care based on the Registered Nurses assessment/visit notes and LCD guidelines. When Physician 1 was asked if he (Physician 1) reviewed the LCD guidelines completed by the visiting nurse for Patient 4, Physician 1 stated that he (Physician 1) could not remember anymore. During a review of the undated Hospice Agency's document titled, "Admission Criteria and Process" , the document indicated the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determinations. During a review of the undated Hospice Agency's document titled, "Admission Criteria and Process" , the document indicated the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determinations. d. During a review of Patient 5s Patient Information Sheet, the Patient Information indicated a SOC date of 7/11/2023. During a review of Patient 5s HAs LCD dated 10/15/2024, the LCD indicated  that Patient has a terminal diagnosis of atherosclerotic heart disease (a disease caused by plaque buildup in the arteries, which can lead to conditions like coronary heart disease and stroke). During a review of Patient 5's Physician Certification for Hospice Benefit for the seventh hospice benefit period reviewed (a benefit period starts the day you begin to get hospice care, and it ends when your 90 day or 60 day benefit period ends. This is the seventh benefit period meaning the patient was recertified 6 times) from 9/3/2024 to 11/1/2024, the Physician Certification for Hospice Benefit indicated Patient 6's terminal diagnoses was Atherosclerotic heart disease. The Physician Certification for Hospice Benefit indicated that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course as documented by Physician 1. The "Certifying Physician section did not indicate any documented evidence and supporting narrative from Physician 1 that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 5s terminal illness diagnosis. During a review of the undated Hospice Agency's document titled, "Admission Criteria and Process" , the document indicated the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determinations. During a review of the undated Hospice Agency's document titled, "Admission Criteria and Process" , the document indicated the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determinations.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to maintain an accurate current medication profile for one of 7 sampled patients (Patient 2). This deficient practice had the potential to place Patient 2 at risk for medication errors and adverse drug reactions (harmful, unintended result caused by taking medication). --- During a review of Patient 2s Patient Information Sheet, the Patient Information sheet indicated Patient 2s start of care (SOC) date was 9/14/2024, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis (outcome) and no known cure) of cerebral vascular disease (a group of conditions that affect blood flow and the blood vessels in the brain and spinal cord). During a review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 9/14/2024, the POC/IDG indicated the frequency of visits of Licensed Vocational Nurse (LVN, in general) to one visit per week plus one prn (as needed) visits to administer and monitor the effectiveness of medication, and to instruct the patient caregiver (PCG) regarding prescribed medication and side effects (are unwanted undesirable effects). During a joint home visit conducted with the LVN1 on 10/24/2024, at 11:30 a.m., at Patient 2's home, Patient 2 was observed lying in bed, well groomed and sleeping. During a review of Patient 2s current medication at home on 10/24/2024, at 12:20 p.m., with LVN 1, there was a bottle of Risperidone (medication to treat mental/mood disorder) one milligrams (mg, a unit of measure ) ½ tab (0.5 mg) daily and Latanoprost one drop on left eye at bedtime. Patient 2s current medication profile provided by the HA did not indicate the Risperidone and Latanoprost medications and were not included in the list. During an interview on 10/24/2024, at 1:35 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the visiting nurse needed to review patients current medication on every visit and update the medication profile in the patients clinical record. During a review of the hospice agencys undated policy and procedure titled, ";Medication Profile," indicated patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

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] patients) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities] for IDG (Interdisciplinary group- which is a team of professionals that work together to provide holistic care for hospice patients that consists of a doctor, registered nurse, social worker , counselor and patients family and primary caregiver) Care Planning, and Coordination of Services was met as follows: --- The HAs Office Manager (OM) failed to coordinate care by ensuring to send a nurse immediately for one of seven (7) sampled patients (Patient 1)experiencing a change of condition (COC- a sudden or significant change in a patient's) when on 9/29/2024, Patient 1 first began coughing out blood. As a result, the non-compliance resulted in Patient 1 delay of care, placing Patient 1 at increased risk for discomfort, pain, and or other signs of physical, emotional, spiritual needs when transitioning to the final stages of the dying process which could jeopardized Patient 1s health condition that could lead to potential hospitalization and death. (Refer to L556). The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Federal regulation IDG, Care Planning, and Coordination of Services to ensure Patient 1 received the quality of hospice care.

Based on interview and record review, the Hospice Agency's (HA, agency providing care to terminally ill [patients who have six months or less to live] patients) Office Manager (OM) failed to coordinate care by ensuring to send a nurse immediately for one of 7 sampled patients (Patient 1) experiencing a change of condition (COC- a sudden or significant change in a patient's ) when on 9/29/2024, Patient 1 first began coughing out blood . As a result, the non-compliance resulted in Patient 1 experiencing a delay of care, placing Patient 1 at increased risk for discomfort, pain, and or other signs of physical, emotional, spiritual needs when transitioning to the final stages of the dying process; which could jeopardized Patient 1s health condition that could lead to potential hospitalization and death. On 10/25/2024 at 1:09 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the hospice agency's (HA) Director of Patient Care Services (DPCS) and Administrator, related to failure to coordinate care by ensuring to send a nurse immediately for a patient having a change of condition, who was coughing out blood, for one of seven (7) sampled patients (Patient 1). As a result, the non-compliance resulted in Patient 1 experiencing a delay of care, placing Patient 1 at increased risk for discomfort, pain, and or other signs of physical, emotional, spiritual needs when transitioning to the final stages of the dying process; which could jeopardized Patient 1s health condition that could lead to potential hospitalization and death. On 10/25/2024, at 4:15 p.m., the survey team completed the survey tasks and conducted an exit conference in the presence of the DPCS with the IJ situations not removed. --- Findings: On 10/24/2024, at 11 a.m., a complaint validation survey was conducted at the HA that included a complaint allegation that the HAs OM was notified by Patient 1s Family Member 1 (FM 1) on 9/29/2024, at around 10 p.m. that Patient 1 was experiencing a COC by coughing out blood. The HA did not send a nurse to immediately assess Patient 1 on 9/29/2024. The HA sent LVN 1 (licensed vocational nurse 1) on 9/30/2024, at 8:10 a.m., and at 8:44 a.m., Patient 1 passed away due to multiple myeloma (a cancer that forms in a type of white blood cell called a plasma cell ) and cardiopulmonary arrest (when the heart and lungs suddenly stop working, resulting in a lack of circulation and respiration). During a review of Patient 1s Patient Information Sheet, the Patient Information sheet indicated Patient 1s start of care (SOC) date was 9/29/2024, with a terminal diagnosis of multiple myeloma During a review of Patient 1's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 9/29/2024, the POC indicated the following: 1. An order for Skilled Nurse (SN- a licensed healthcare professional who has received advanced training and certification to provide a high level of care) to provide skilled nursing visits (a brief, targeted nursing service that a registered nurse (RN) or licensed practical nurse (LPN) provides in a patient's home to help with short-term medical needs) once a week with three as needed visits SC (spiritual counseling) once a month and as needed. A review of Patient 1s Visit Noted dated 9/30/2024, at 8:10 a.m., and documented by Licensed Vocational Nurse 1 (LVN 1) indicated that License Vocational Nurse 1 (LVN 1) called and reported to Physician 1 that the Patient 1 had no vital signs and no respirations. The Visit Noted dated 9/30/2024 and documented by LVN 1 indicated that Physician 1 pronounced Patient 1s death at 8:44 a.m. During an interview with FM 1 on 10/22/2024 at 12:36 p.m., FM 1 stated that when Patient 1 started coughing out blood on 9/29/2024, at 7 p.m., FM 1 stated that she (FM 1) panicked and did not know what to do. FM 1stated that she (FM 1)tried to call the HA between the hours of 7 p.m. to 10:30 p.m. FM 1 stated that she (FM 1) received a text message from OM on 9/30/2024 at 12:52 a.m., indicating that the OM will send a nurse at 7:00 am. FM 1 stated the visiting nurse arrived on 9/30/2024 at around 8:10 a.m. FM 1 stated Patient 1 passed away (died) at 8:44 p.m. due to multiple myeloma and cardiopulmonary arrest. FM 1 further stated that she (FM1) was upset and angry that there was no nurse to attend to Patient 1 to provide comfort care (a type of medical treatment that focuses on providing comfort and quality of life for patients who are near the end of their life) immediately as it took the HA 10 hours before LVN 1 was able to visit Patient 1. During an interview with OM on 10/23/2024, at 2 p.m., the OM stated that she (OM) received a phone call from FM 1 on 9/29/2024 at 10 p.m. requesting a nurse visit to check Patient 1 who was coughing blood. OM stated she attempted to call the DPCS to relay the message, but the OM could not reach the DPCS. OM further stated she sent a message to FM1 at 12:52 a.m. On 9/30/2024, LVN 1 arrived at 8:10 a.m. to evaluate Patient 1s condition. During a telephone interview with the Director Of Patient Care Services (DPCS) on 10/23/2024 at 12 p.m., the DPCS stated that he (DPCS) did not receive a report regarding Patient 1s condition on 9/29/2024. TheDPCS stated that he (DPCS) was given a report about Patient 1s condition by LVN 1 who did a visit on 9/30/24, at 8:10 a.m. DPCS further stated that if the(DPCS) had known about the incident of Patient 1 coughing up blood on 9/29/2024, DPCS would have sent a nurse; or he (DPCS) would have gone to Patient 1s residence right away to provide continuous care (a type of hospice care that provides 24-hour nursing care to patients who are terminally ill and experiencing severe symptoms). A review of the HAs undated policy and procedure " Coordination of Care with Contract Agreement", indicated the hospice program will retain responsibility forL evaluating services, maintaining professional management responsibility, and ensuring continuity of care in all settings through its performance improvement program or corporate compliance program.

Based on observation, interview, and record review, the Hospice Agency (HA) the Condition of Participation for Organization and administration of services was not met as follows: --- The HA failed to ensure to meet the agency's staff professional standards and principles that necessary care was provided consistently for patients who was receiving hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) for one of seven sampled residents (Patient 1) by: 1. the HA failed to provide skilled nursing services (hospice licensed nurse) were made available on a 24-hour basis , 7 days a week as ordered by the hospice physician and Patient 1's family member 1 (FM1) call was addressed on a timely manner by the on-call hospice licensed nurse. (Refer to L655) 2. the to ensure that a designated staff were made available when care and services are needed by the patients and their families on a 24-hour 7 days a week and coordinate hospice services to alleviate pain and promote comfort for Patient 1 who was coughing out blood. (Refer to L652) The cumulative effects of these deficient practices had the led to the delay care and services at the time the patient and family needed help and resulted in a delay or lack of coordination in delivery of hospice care and services for Patient 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 coordinate hospice services to alleviate pain and promote comfort for one of seven sampled patients (Patient 1) who was coughing out blood. This deficient practice resulted the delay or lack of coordination of care and services at the time the Patient 1 and family needed help. --- During a review of Patient 1s admission record indicated a start of care (SOC) date was 9/29/2024, with a terminal diagnosis of multiple myeloma (a cancer of the plasma cells). On 10/24/2024, at 11 a.m., a complaint validation survey was conducted at the hospice agency (HA) that included a complaint allegation that the HA was notified by Family Member (FM 1) on 9/29/2024, at 10 p.m., that Patient 1 was coughing out blood but there was no nurse sent right away to assess Patient 1, who was having a change of condition (COC). The HA told FM 1 thru a text message that the HA will send licensed vocational nurse 1 (LVN 1) on 9/30/2024, at 7 a.m. to administer prescribed Morphine (a medication used to treat pain) medication. On 9/30/2024, LVN 1 arrived at 8:10 a.m., and Patient 1 passed away at 8:44 am. During an interview with Family member 1 (FM1) on 10/22/2024 at 12:36 p.m., FM1 stated that when Patient 1 started coughing out blood on 9/29/2024. FM 1 stated she panicked and does not know what to do. FM 1 stated that she and another family member tried to call the HA between the hours of 6:00 p.m. to 7:00 p.m. and no one picked up the phone. FM 1 stated that since the HA did not call her back, FM 1 called 911 (emergency hotline) for help because she did not know what to do and she does not have any medications to help make Patient 1 comfortable. FM 1 stated that she received a text message on 9/30/2024 at 12:52 a.m., indicating the office manager (OM) will send a nurse at 7:00 am and the medications will arrive at 6:00 a.m. FM 1 stated the visiting nurse arrived at 8:10 a.m. FM 1 stated Patient 1 passed away at 8:44 p.m. During an interview with the Administrator (Admin) on 10/22/2024 at 3:00 p.m., the Admin stated that he was the assigned ";on-call" staff when the incident happened. Admin stated he did not receive any calls that day. Admin stated that he later knew that his phone network was down and was the reason why he did not receive the phone call. Admin also stated that the agency uses a call center after office hours. During an interview with Office Manager (OM) on 10/23/2024, at 2 p.m., she stated she received a phone call from FM 1 on 9/29/2024,at 10 p.m., requesting a nurse visit to check Patient 1 who was coughing blood. OM also stated she attempted to call the DPCS to relay the message, but she could not reach the DPCS. OM further stated she told FM 1 thru text message that a nurse will arrive the following day on 9/30/2024, at 7 a.m. to evaluate the patients condition. During an interview with the Director Of Patient Care Services Designee (DPCSD) on 10/23/2024, at 12 p.m., the DPCS stated that she did not received a report regarding Patient 1s condition on 9/29/2024. The DPCSD was given a report about Patient 1s condition by the visiting nurse who visited the patient on 9/30/24, after the death of Patient 1. The DPCSD further stated if she knew about the patient condition, the DPCSD would have sent a nurse or she would go to Patient 1s residence right away to provide continuous care. A review of the agencys document titled "; Job Title/Position: Executive Director/Administrator" revised 11/2021, indicated that the position qualifications stipulated demonstrates an ability to supervise and direct professional and administrative personnel. Ensuring appropriate staff supervision during all service hours. A review of the agencys document titled "; Job Title/Position: Clinical Director/Director of Patient care Services" revised 11/2021, indicated that The Clinical Director/Dire􀀤or of Patient Care Services is responsible for the overall direction of hospice clinical services. he Clinical Director/Director of Patient Care Services establishes, implements and evaluate !goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel.

Based on interview and record review, the Hospice Agency (HA, providing care to terminally ill patients who have six months or less to live) failed to ensure one of 7 sampled patients (Patient 1) was treated with dignity, comfort, and respect. This deficient practice resulted the delay or lack of coordination of care and services at the time the patient and family needed help. --- On 10/24/2024, at 11 a.m., a complaint validation survey was conducted at the hospice agency (HA) that included a complaint allegation that the HA was notified by Family Member (FM 1) on 9/29/2024, at 10 p.m., that Patient 1 was coughing out blood but there was no nurse sent right away to assess Patient 1, who was having a change of condition (COC). The HA told FM 1 thru a text message that the HA will send licensed vocational nurse 1 (LVN 1) on 9/30/2024, at 7 a.m. to administer prescribed Morphine (a medication used to treat pain) medication. On 9/30/2024, LVN 1 arrived at 8:10 a.m., and Patient 1 passed away at 8:44 am. During an interview with Family member 1 (FM1) on 10/22/2024 at 12:36 p.m., FM1 stated that when Patient 1 started coughing out blood on 9/29/2024. FM 1 stated she panicked and does not know what to do. FM 1 stated that she and another family member tried to call the HA between the hours of 6:00 p.m. to 7:00 p.m. and no one picked up the phone. FM 1 stated that since the HA did not call her back, FM 1 called 911 (emergency hotline) for help because she did not know what to do and she does not have any medications to help make Patient 1 comfortable. FM 1 stated that she received a text message on 9/30/2024 at 12:52 a.m., indicating the office manager (OM) will send a nurse at 7:00 am and the medications will arrive at 6:00 a.m. FM 1 stated the visiting nurse arrived at 8:10 a.m. FM 1 stated Patient 1 passed away at 8:44 p.m. On 10/25/2024 at 1:05 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agencys Administrator and the Director of Patient Care Services (DPCS) due to the facilitys failure to treat Patient 1 with comfort, dignity, and respect and also placed the remaining 3 active patients (Patient 2, 3 4 and 5) at risk for not being treated with comfort, dignity, and respect. On 10/25/2024, at 4:15 p.m., the survey team completed the survey tasks, and exited with the Immediate Jeopardy not removed. On 10/30/2024 at 9:51 a.m., the Administrator called the district office and stated that the agency decided to surrender and voluntarily terminate their provider number.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [is a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Medical Director was met as evidenced by: --- 1. he hospice agency failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for four of four sampled patients (Patient 2, Patient 3, Patient 4 and Patient 5) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory (written rules or law) mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was provided to the patients certified to receive hospice services.

Based on observation, interview and record review, the hospice agency failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for four of four sampled patients (Patient 2, Patient 3, Patient 4 and Patient 5). This deficient practice resulted in patients being admitted for hospice care with no documented evidence of patients written clinical information was being reviewed and evaluated by the Medical Director and/or physician designee to support their diagnoses of terminal illness. --- c. During a review of Patient 4's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the fifth hospice benefit period (indicating the patient was recertified(the process of reassessing a patient's eligibility for hospice care at specific intervals four times) reviewed for 10/14/2024 to 12/12/2024, indicated Patient 4's terminal diagnoses was Alzheimers disease. The Medical Director (Physician 1) indicated Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 4s terminal illness diagnosis. During a review of Patient 4s LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) Hospice Eligibility Determination form for Dementia due to Alzheimers dated 10/14/2024, indicated Patient 4 was not eligible per LCD guidelines. The LCD form indicated Section 1( assessment for activities of daily living) and Section 2 (assessment for the progression of the disease) must be met. During a concurrent interview and record review with the DPCS on 10/25/2024 at 11:33 a.m., the DPCS stated that he oversees the patients admitted in the agency and reviews the patients charts, go over nurses notes, coordinate care with the hospice medical director , conducts in-services once a month for infection control, disposal of biohazard wastes and sharps, and make sure that durable medical equipment was delivered. DPCS also stated that to his knowledge, the MD should perform an assessment first and if the MDs assessment satisfies the patient to be recertified for hospice, the MD should write the order on the clinical record. DPCS stated that if there was no documentation of such order , then it was not done. DPCS stated that Patient 4 should not have been recertified for hospice services. d. During a review of Patient 5s Patient Information Sheet, the Patient Information indicated a start of care date of 7/11/2023. During a review of the LCD (agencys assessment form), the LCD indicated that Patient has a terminal diagnosis of atherosclerotic heart disease (a disease caused by plaque buildup in the arteries, which can lead to conditions like coronary heart disease and stroke). During a concurrent record review and interview with the DPCS on 10/25/2024 at 12:14 p.m., of Patient 5's "Physician Certification for Hospice Benefit" for the seventh hospice benefit period (indicating the patient was recertified(the process of reassessing a patient's eligibility for hospice care at specific intervals six times) reviewed from 9/3/2024 to 11/1/2024, indicated Patient 5's terminal diagnoses was Atherosclerotic heart disease. The Medical Director (Physician 1) indicated Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician section" of the note did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 5s terminal illness diagnosis. DPCS also confirmed that there was no MD face-to-face visit note for Patient 5. DPCS stated that the MD should have conducted a thorough review by doing a face-to-face visit to determine the patients eligibility for hospice admission. During a telephone interview with the HAs Medical Director (Physician 1) on 10/25/2024 at 1:27 p.m., Physician 1 stated that he is also the attending physician for all 4 patients. Physician 1 stated that he usually fills out the CTI and the LCD guidelines, reviews the records from the hospital prior to admission to hospice. Physician 1 also stated that he assigns a nurse practitioner to conduct his home visits when he is not able to. a. During a review of Patient 2s Patient Information Sheet, the Patient Information sheet indicated Patient 2s start of care (SOC) date was 9/14/2024, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis (outcome) and no known cure) of cerebral vascular disease (a group of conditions that affect blood flow and the blood vessels in the brain and spinal cord). During a review of the Patient 2s HAs Local Coverage Determination (LCD, the agencys patients eligibility for medical necessity and hospice eligibility assessment form) guidelines,  from 9/14/24 to 10/24/24 there was no documented evidence that the LCD form completed by the Registered Nurse 1 (RN 1) for Patient 2.  During a review of Patient 2's Physicians Certification for Hospice Benefit also known as Certification of Terminal Illness (CTI, is the narrative summary, 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), dated 9/14/2024 to 10/12/2024, the Physicians Certification for Hospice Benefit period number one indicated Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with Patient 2s primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis.  During a home visit conducted on 10/24/2024, at 11:30 a.m., Patient 2 was observed lying in bed, well groomed and sleeping. During a phone interview with Family Member (FM2) on 10/24/2024, at 11:50 p.m., FM 2 stated that she called the HA asking to have a nurse visit Patient 2 weekly. FM 2 stated that FM 2 was then asked by the HA to sign for Patient 2 to receive hospice services on the stat of care. FM 2 stated that the HA staff did not explain to Patient 2 regarding hospice services. FM 2 stated that FM 2 were not told Patient 2 had six months to live. During an interview with DPCS on 10/25/2024, at 11 a.m., DPCS stated that as part of the admission  process, DPCS expects that the visiting nurse of the HA will utilize the LCD guideline form to determine a patients eligibility for hospice during the initial visits. DPCS further stated that the HA visiting nurse who did the initial visit for Patient 2 did not complete a LCD guideline form. During a telephone interview on 9/20/2024, at 1:40 p.m., with Physician 1, Physician 1 stated he (Physician 1) was not initially the primary physician of Patient 2. Physician 1 stated that he did not discuss Patients 2s medical record with Patient 2. Physician 1 stated that he (Physician 1) was now the attending physician for Patient 2 as Patient 2 was now admitted to the HA. Physician 1 stated that he (Physician 1) determined Patient 2s eligibility for hospice care based on Patient 2s LCD, as well as Patient 2s CTI from 9/14/24 to 10/12/24. When Physician 1 was asked if he (Physician 1) reviewed an LCD guideline for Patient 2, Physician 1 stated that he (Physician 1) could not remember anymore. During a review of the undated Hospice Agency's document titled, "Admission Criteria and Process" , the document indicated the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determinations. During a review of the undated Hospice Agency's document titled, "Admission Criteria and Process" , the document indicated the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determinations. b. During a review of Patient 3s Patient Information Sheet, the Patient Information indicated a SOC date of 7/19/2024. During a review of the HAs LCD dated 7/19/2024 to 10/24/2024, the LCD indicated tha Patient 3 has a terminal diagnosis of Parkinsons Disease (a disorder of the central nervous system that affects movement). During a review of Patient 3s LCD guidelines from 7/19/2024 to 10/24/24, there was no documented evidence that the LCD form was completed by RN 1.  During a review of Patient 3's Physicians Certification for Hospice Benefit also known as CTI, dated 7/19/2024 to 10/16/2024, the Physicians Certification for Hospice Benefit period number one indicated Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with Patient 3s primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis.  During a home visit conducted on 10/24/2024, at 12:30 p.m., Patient 3 was observed lying in bed, well groomed, alert, oriented (a medical term that describes a patients level of awareness of themselves, their surroundings, and the time), and able to move both upper and lower extremities (referring to arms and legs). During a phone interview with Patient 3s FM3 on 10/25/2024, at 1:45 p.m., FM 3 stated that the social worker (Social Worker 1 [SS 1]) from FM 3 work referred Patient 3 to the HA. FM3 stated Physician 1 did not explain to Patient 3 regarding the hospice services. FM 3 stated, that they (FM 3) were not told that Patient 3 had six months to live. During an interview with DPCS on 10/25/2024, at 11 a.m., during an interview with the DPCS, the DPCS stated that as part of the admission  process, DPCS expects that the visiting nurse of the HA will utilize the LCD guideline form to determine a patients eligibility for hospice when doing theirduring the initial visits. DPCS stated that the HA visiting nurse who did the initial visits for both Patient 2 and Patient 3 did not complete a LCD guidelines form. During a telephone interview on 9/20/2024, at 1:40 p.m., with Physician 1, Physician 1 stated he (Physician 1) was not the initially the attending primary physician of Patient 32. Physician 1 stated that he did not discuss Patients 3s medical record with Patient 3. Physician 1 stated that he (Physician 1) was now the attending physician for Patient 3 as Patient 3 was now admitted to the HA. Physician 1 stated that he (Physician 1) determined Patient 3s edibility for hospice care based on Patient 3s LCD. When Physician 1 was asked if he (Physician 1) reviewed an LCD guideline for Patient 3, Physician 1 stated that he (Physician 1) could not remember anymore. During a review of the undated Hospice Agency's document titled, "Admission Criteria and Process" , the document indicated the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determinations. During a review of the undated Hospice Agency's document titled, "Admission Criteria and Process" , the document indicated the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determinations. A review of the agencys policy and procedure titled ";Physician Services-Medical Director", revised November 2020, indicated hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care. A review of the agencys policy and procedure titled ";Certification of Terminal Illness", revised November 2020, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, and the hospice Medical Director. 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.

Based on observation, interview and record review, the Hospice Agency (HA- agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation regarding Personnel Qualification was met as follows: --- The HA failed to ensure that their licensed professional staff, the Nurse Practitioner (NP) were hired or employed under an individual contract or under an arrangement with the HA, to perform assessment and provide patient care for three out of three sampled patients (Patient 3, Patient 4, and Patient 5). As a result, the non-compliance resulted in Patient 3, Patient 4, and Patient 5, delayed hospice care and services from unemployed NP and had the potential to result in improper treatment, worsening conditions, hospitalization, or death. (Refer to L784). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily (written law) mandated compliance with Federal regulation for Personnel Qualifications to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure that their licensed professional staff, the Nurse Practitioner (NP) was hired or employed under an individual contract or under an arrangement with the HA, to perform assessment and provide patient care for three out of three sampled patients (Patient 3, Patient 4, and Patient 5). This deficient practice resulted in Patient 3, Patient 4, and Patient 5, delayed hospice care and services from unemployed NP and had the potential to result in improper treatment, worsening conditions, hospitalization, or death. On 10/25/2024 at 3:50 p.m., the Department called an Immediate Jeopardy Situation (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the HAs Director of Patient Care Services (DPCS) and Administrator related to the HAs failure ensure to ensure that their licensed professional staff, the Nurse Practitioner (NP) was hired or employed under an individual contract or under an arrangement with the HA, to perform assessment and provide patient care for Patient 3, Patient 4, and Patient 5. This failure resulted in Patient 3, Patient 4, and Patient 5, delayed hospice care and services from unemployed NP and had the potential to result in improper treatment, worsening conditions, hospitalization, or death. --- b. During a review of Patient 4s Patient Information Sheet, the Patient Information indicated a start of care date of 3/18/2024 indicated that Patient 4 has a terminal diagnosis of Alzheimers disease (a brain disorder that causes a gradual decline in memory, thinking, and reasoning skills). During a review of Patient 4's face to face visit note on 10/25/2024, dated 6/14/2024 and 8/14/2024 indicated NP provided a head-to-toe assessment for Patient 4. c. During a review of Patient 5s Patient Information Sheet, the Patient Information indicated a start of care date of 7/11/2023. During a review of the LCD (agencys assessment form), the LCD indicated that Patient has a terminal diagnosis of atherosclerotic heart disease (a disease caused by plaque buildup in the arteries, which can lead to conditions like coronary heart disease and stroke). During a review of Patient 5's face to face visit note on 10/25/2024, dated 8/31/2024 indicated NP provided a head-to-toe assessment for Patient 5. a. During a review of Patient 3s Patient Information Sheet, the Patient Information indicated a start of care (SOC) date of 7/19/2024. During a review of the LCD (agencys assessment form), the LCD indicated that Patient 3 has a terminal diagnosis of Parkinsons Disease (a disorder of the central nervous system that affects movement). On 10/24/2024, at 12:30 p.m., a home visit was conducted at Patient 3's residence. Patient 3 was observed lying in bed, well groomed, alert, oriented and able to move both upper and lower extremities. During a phone interview with family member (FM3) on 10/25/2024, at 1:45 p.m., FM 3 stated the social worker from his work referred the patient to the HA staff to have a nurse to visit the patient. FM 3 also stated the HA staff did not explain to the patient regarding the hospice service, that they were not told the patient had six months to live. FM 3 further stated that he have spoken to Nurse practitioner (NP 1) to provide face to face encounter with the patient on 7/19/2024. During a review of the NP 1's employee personnel files indicated that there was no application nor signed contract found on file. During an interview with the DPCS on 10/25/2024, at 12 p.m., the DPCS stated that NP 1 was an employee at the agency but NP 1 have not signed a contract or filled up an application with the agency. During a telephone interview on 9/20/2024, at 1:40 p.m., with Physician 1, Physician 1 stated he sent NP 1 to do a face-to-face encounter with Patient 3, Patient 4, and Patient 5, to formulate a H&P for these patients to evaluate hospice eligibility. An attempt to call for an interview with the NP on 10/25/2024, at 1 p.m., and 2 p.m., but NP 1 did not return there here the NP did not return back call. A review of the HAs undated policy and procedure ";Selection/Hiring Process", indicated an individual seeking an employment will complete an application, including information and verification about education, work experience, job history and references, and have personnel interview.

Upon patient record review 1 of 14 (Patient #6) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice car Patient #6, Patient admitted on 10/17/22, SC assessment was completed on 12/27/22.

Upon patient record review 8 of 14 (Patient #4,6,8,9,10,11,13,14) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #4,6,8,10, SC assessment was incomplete, documentation of Christian as religion without any additional assessment information. Patient #9,11,13,14, No SC assessment was completed, documenting patient declined SC. RN assessment was incomplete for spiritual assessment.

Upon patient record review, 3 of 14 (Patient #4,11,13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #4, LVN note on 12/21/22 states patient on contact isolation due to scabies. Plan of care was not updated with this information. Patient #11, Care Plan states pt/family have a need for spiritual comfort. SC documented service declined on 12/16/22. Patient #13, Care Plan states spiritual distress r/t fear of the unknown, SC documented service declined.

Upon client record review, 2 of 14 (Patient #4,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4, RN ordered every 14 days, on 12/30/22 RN visits for supervisory only, no assessment was made by RN. Patient #9, SN visit 1x/week, patient seen 4/24/20, 4/30/20.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1, #2, #3, LVN placed barrier between bag and chair then removed items from nursing bag and place on table without having barrier before placing on table.

Upon patient record review, 5 of 14 (Patient #8,10,11,12,13) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #8,11,13, post bereavement follow-up completed, missing bereavement plan of care. Patient #10, bereavement letter due to be sent on 2/2/23, currently overdue. Patient #12, bereavement letter due to be sent on 10/29/22, 12/29/22, 3/29/23, currently all overdue.

Upon patient record review 3 of 14 (Patient #4,5,6) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #4, Aide ordered 2x/week on 12/16/22, Aide visits started on 1/2/23 without missed visits documented. Patient #5, Aide ordered 2x/week on 2/7/23, Aide visit started on 2/20/23 without missed visits documented. Patient #6, Aide ordered 3x/week on 10/17/22, Aide visit started on 11/5/22 with only 1 Aide visit instead of 3. No documented missed visit.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #13, No CTI for first episode. CTI for 2nd episode started for dates of 11/2/22 to 1/30/23. Patient died on 9/29/22.

Upon patient client record review, 1 of 14 (Patient #12) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #12, Effective date of the election was not filled on Election of Hospice Medicare benefit form.

Upon patient client record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14, All IDG notes missing signature from MD, RN SC, MSW on all IDG notes with the exception of #4,5,6, IDG note on 3/31/23 has MSW signature. Patient #9,10,11,12,13,14, No MD signature on POC. Patient #6, Missing MD signature on certification period #6, #7, and #8 was verified by Administrator though missing MD signature.

Upon client record review, 1 of 14 (Patient #9) did not have evidence that the discharge summary includes all required information. Patient #9, Missing dx, symptoms and pain management.