Every finding on record at Graceful Palms Hospice and Palliative Care Corp.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: Vitamin D3 was not included on medication list. Corrected On Site.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #4: The Initial Bereavement Assessment not not completed timely. This assessment was completed late on 10/7/24 (start of care was 9/23/24).

Upon patient record review, 2 of 14 (Patients #1, 4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient #1: The LVN and RN visit frequency indicated, "LVN 1X week and as needed" and "RN every 14 days and as needed". These frequencies did not include number of PRN visits for the LVN or RN (8/19/24). Patient #4: Chaplain visit frequency of, "monthly and as needed." This frequency did not include number of PRN visits for the Chaplain.

Upon client record review, 1 of 14 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care (POC). Patient #7: The POC listed Skilled Nursing visit frequency of, 2 X's per week (11/8/24). For first Benefit Week there was only 1 visit on 11/8/24.

Upon patient record review, 2 of 14 (Patient #5, 8) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #5, 8: The wound care is documented that it is not related, the agency has a contract for wound care but there is no documentation of coordination of care.

Upon personnel record review, 1 of 12 (Personnel # 8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #8: ·Normal range of motion and positioning competency indicated a verbal evaluation, not an observed task completed with patient or pseudo patient.

Upon patient record review 5 of 14 (Patients #3,5,6,7,9) 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 (POC) Patient #3: The POC listed Aide visit frequency of, 2 X's per week (9/27/24). There were no visits made by the Aide for first Benefit Week. Patient #5: The POC (3/2/24) listed Aide visit frequency of, 2 X's per week (start 4/2/24). The IDG indicated 3X's per week (3/2/24). There were no visits by the Aide for first Benefit Week. Patient #6: The POC listed Aide visit frequency of, 2 X's per week (8/2/24). There were no visits made by the Aide for first Benefit Week. Patient #7: The POC listed Aide visit frequency of, 2 X's per week (11/8/24). There were no visits made by the Aide for first Benefit Week. Patient #9: The POC listed Aide visit frequency of, 3 X's per week (1/29/24). There was only 1 visit on 2/2/24 for First Benefit Week,

Upon patient client record review, 4 of 14 (Patients #8,9,12,14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #8,9,12,14: The Election Statement did not have BFCC-QIO or Notice Non Covered Items information on the form. Agency did have updated form as evidenced by March 2024 patients forward.

Based on interview and record review, the Hospice Agency (HA) failed to specify the hospice care and services necessary to meet the patient and family specific need identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions for 2 of 3 sampled patients Patient 1 and Patient 2. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Patient 1 and Patient 2. Findings: a. A review of Patient 1's Plan of Care (POC) dated 5/20/22, indicated Patient 1 was admitted to the HA on 5/13/22, with the diagnoses of malignant neoplasm of the bronchus or lung(also known as bronchogenic carcinoma or lung cancer, is a malignant cancer that originates in the bronchi, bronchioles, or other parts of the lung), and hypertension (A condition in which the force of the blood against the artery walls is too high causing high blood pressure). A review of Patient 1's POC indicated hospice aide to visit 3 times a week, licensed vocational nurse (LVN) visits 3 times per week, social worker (SW) visits once a month and as needed, Registered nurse (RN) once every other 2 weeks and as needed, Chaplain visits once a month and one as needed. A review of Patient 1's psychosocial assessment dated 5/20/2022, indicated Patient 1's living condition was found to be unsafe and unhealthy, piles of things everywhere around the patient and throughout the home. Patient 1 presented high risk of falling and smokes cigarettes inside the home. Patient 1's couch smelled of urine. Patient 1 presented as oriented to place and time, frail, slim, pale color, weak , irritable, poorly groomed, non-ambulatory, poor memory, uncooperative and confused. Patient 1 reported to feeling pain and was unable to reach medications. Patient 1 was reported to stay alone from 6:00 a.m. to 4:00 p.m., is not eating well and is unable to go to the restroom. During the LCSW (licensed clinical social worker) visit, Patient 1 stated she had not eaten for 2 days. The patient and daughter had a strained relationship, negative, argumentative relationship. Patient 1's daughter declined suggestions by the LCSW and refused volunteers to help. A review of Patient 1's hospice staff's visit note dated 5/16/22 between 5:00 p.m. to 5:45 p.m., indicated Patient 1's chief complaint was fire hazard/fall precautions. Patient 1's visit note indicated no narrative notes, no vital signs were recorded, head to toe assessment was incomplete, no COVID 19 infection screening done, questions for fall/incidence occurrence,safety issues and care provided was left blank and was not electronically signed by visiting nurse. A review of Patient 1's skilled nurse (SN) visit note dated 5/17/22 between 4:00 p.m., and 4:25 p.m., SN indicated no answer on door, SN waited 20 minutes and no one was at Patient 1's home. SN informed supervisor and staffing department. A review of Patient 1's visit note dated 5/19/22 between 1;15 p.m. to 1:25 p.m., indicated SN contacted Patient 1's daughter prior to arrival for supervisory visit. Patient 1's daughter verbalized that all staff visits needed to be after 4 p.m.. SN asked if there was a way to visit without the daughter and daughter stated " No there is not, all visits after 4 p.m.". A review of Patient 1's clinical record indicated no documented evidence a care plan was developed identifying the family's request for specific time the hospice staff are able to visit the patient to provide the care services. b. A review of Patient 2's Plan of care dated 5/20/22 for the certification period of 5/20/22 to 8/17/22, indicated Patient 2's diagnosis included non-Hodgkin's lymphoma (Cancer that starts in the lymphatic system. The condition occurs when the body produces too many abnormal lymphocytes, a type of white blood cell. Symptoms include swollen lymph nodes, fever, belly pain, or chest pain. Treatments may include chemotherapy, radiation therapy, stem-cell transplant, or medications.) A review of Patient 2's POC/IDG discussion indicated Patient 2 was in denial regarding end of life signs and symptoms. Patient 2 has a long history of drug use with meth as his drug of choice. Patient was homeless, currently living with friend and smokes cigarettes inside the home. Patient 2 was weak, KPS ( karnofsky performance status-an assessment tool for predicting of length of survival in terminally ill patients. A KPS of 40 percent means disabled and requires special care and assistance and PPS(Palliative performance scale-a reliable and valid tool and correlates well with actual survival and median survival time for cancer patients in outpatient and ambulatory settings is 40 means mainly in bed unable to do any activity due to extensive disease. A review of the Patient 2's POC indicated no care plan for home safety and smoking. On 5/24/22 at 11:20 a.m., during an interview with Registered Nurse Case manager( RNCM) stated that she asks patient for any special needs/ instructions, spiritual need, any concerns regarding their care/ status, dietary, wound care, falls, emergency protocols. RNCM stated that she calls the care team and develops and assigns staff for the plan of care. A review of the HA's document titled " Changes in Care, Treatment and Services-Patient notification" indicated to define the requirements for patient notification of changes in care, treatment and services. plan of care notification documentation includes the date and time, specific changes in the plan of care and the patient, family or caregiver response. A review of the HA's document titled " Notice of Hospice Patient Rights and Responsibilities" indicated patients to receive considerate and respectful care, provided a safe environment. Have your cultural, psychosocial, spiritual and personal values , beliefs and preferences respected. To assure these preferences are identified and communicated to staff, a discussion of these issues, including the availability of spiritual and counseling services will be included during the initial nursing admission assessment. Be informed by knowledgeable staff about your medical condition, to the extent known and be given an opportunity to participate in designing a care plan that addresses your needs and preferences and updating it as your condition changes.

d. A review of Patient 5's clinical record indicated, Patient 5 was 46 years female who started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The Skilled Nurse (SN) visit was once a week and as needed. The Medical Social Worker (MSW) visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. During a joint home visit with RN 1 on 9/7/2022, at 10:20 a.m., Patient 5 was observed walking using a cane from her car (which was parked in front of the house) to her house (back unit of the house). During an interview with RN 1 at the same time, she stated Patient 5 could drive. During an interview with Patient 5 on 9/7/2022, at 10:30 a.m., it was observed Patient 5 was alert, oriented, and was able to communicate well. Patient 5 stated she lives alone at her unit and she could drive her car to the doctor's office, grocery store, and she could go out for eating. She stated she could cook and shower. She stated she had declined the HA service because she could shower herself. When asked whether she had a pulmonary disease, she stated she had "Asthma" not pulmonary disease, and she did not think she would die within 6 months. A review of Patient 5's "Comprehensive Nursing Assessment" dated 12/28/2021 indicated Patient 5 was alert and oriented, had functional limitation of endurance, was ambulatory using a cane, and had steady gait. Patient 5 had mild dyspnea with mild exertion, and requires oxygen at 2 liters per minute as needed. Patient 5 was observed using chest accessory muscle after activity or walking, and the oxygen saturation at room air was 85 percent. The patient took two puffs of her Albuterol HFA 90 mcg oral inhalation, and after few minutes of rest, the patient's oxygen saturation had improved to 90 percent. Patient 5 had dull ache pain on both lower legs at a level of 4/10 on a pain scale. Diclofenac Sodium 1 % topical 2-4 times per day for pain management, and the pain was managed well ( reassessed pain prior to end the visit and the pain level was 2/10). A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine patient's eligibility for hospice services) of "Pulmonary Disease," dated 12/28/2021, indicated the section 1 and 2 should be met. It indicated Patient 5 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, is less than 30 percent of predicted * Increased visits to Emergency Room A review of Patient 5's record indicated there was no documented evidence Patient 5 was poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity, had Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. A review of Patient 5's record indicated there was no documentation supporting the LCD assessment. A review of Patient 5's form titled, "Physician's Certification for Hospice Benefit" (the document that showed a physician certified a patient's eligibility for hospice benefit), from 12/28/2021 to 3/27/2022, indicated, Patient 5's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 5's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". e. A review of Patient 6's clinical record indicated, Patient 6 was 64 years old male who started hospice care on 7/14/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit once per 2 week plus one visit and LVN visit once per week and one visit as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 6's "Comprehensive Nursing Assessment" dated 7/14/2021 indicated Patient 6 was alert and oriented, used a cane for ambulation, and bowel and urinary status was continent. Patient 6 had mild dyspnea with mild exertion, and oxygen saturation was 96 percent. The need of Hospice aide, volunteer and community support was check marked as "None". A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 7/14/2021, indicated the section 1 and 2 should be met. It indicated Patient 6 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Increased visits to Emergency Room *Oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor A review of Patient 6's record indicated there was no documented evidence Patient 6 was poorly responsive or unresponsive to bronchodilators, or had Increased visits to Emergency Room, and the oxygen saturation rate was less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 6's record indicated there was no documentation supporting the LCD assessment. A review of Patient 6's form titled, "Physician's Certification for Hospice Benefit" from 7/14/2021 to 10/11/2021, indicated, Patient 6's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 6's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 6 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". f. A review of Patient 7's clinical record indicated, the patient was 60 years old male who started hospice care on 2/8/22, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit two times per 2 weeks 2 week plus one visit as needed and LVN visit once per week and as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 7's "Comprehensive Nursing Assessment" dated 2/28/2022 indicated Patient 7 was alert and oriented, used a cane for ambulation. Patient 7 had mild dyspnea with mild exertion, and oxygen saturation was 97 percent. It indicated "No" for the question of whether the patient was uncomfortable because of pain. The need of Hospice aide, was check marked as "None". The need for the Volunteer or community support was blank. The nurse's narrative indicated Patient 7 was observed with on and off shortness of breath and was on Albuterol 90 mcg/Actuation inhalation Aerosol 90 mcg 1-2 puffs inhaler three times a day as needed for shortness of breath/wheezing. Patient 7 had generalized body pain and was on Norco 10 mg-325 mg one tablet by mouth every 6 hours as needed for pain. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 2/28/2022, indicated the section 1 and 2 should be met. It indicated Patient 7 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure *Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 millimeter Mercury (mmHg). A review of Patient 7's record indicated there was no documented evidence Patient 7 was poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, Hypoxemia (an abnormally low concentration of oxygen in the blood) at rest on room air, as evidenced by pO2 (partial pressure of oxygen - a measure of the tension or pressure of oxygen dissolved in the blood - If a pO2 level is lower than 80 mmHg, it means that a person is not getting enough oxygen) less than or equal to 55 millimeter mercury (mmHg). A review of Patient 7's record indicated there was no documentation supporting the LCD assessment. A review of Patient 7's form titled, "Physician's Certification for Hospice Benefit" from 7/14/2021 to 10/11/2021, indicated, Patient 7's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 7 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 7's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". g. A review of Patient 8's clinical record indicated, the patient was 44 years old male who started hospice care on 1/21/22, with a terminal diagnosis of COPD. It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated the RN visits for initial assessment, supervisory visit, and ongoing comprehensive assessment, reassessment, recertification and as needed. The Skilled Nurse (SN) visit once a week and onece per week as needed. The MSW was to visit within 5 days from the SOC, Certification and as needed. The HA service and the volunteer services were offered and declined. A review of Patient 8's "Comprehensive Nursing Assessment" dated 1/21/2022 indicated Patient 8 was alert and oriented, needed stand by assist for ambulation. Patient 8 had mild dyspnea with mild exertion, and oxygen saturation was 92 percent. Patient 8 was continent in bowel and bladder. The need of Hospice aide, and the need of community support were check marked as "None". The need for the Volunteer was check marked for errands. The nurse's narrative indicated Patient 8 was 43 years old male with last hospitalization on 9/18/2021 to 9/21/2021 for evaluation and treatment of left lower extremity torn ligament. According to the patient, his condition had progressively deteriorated in the past few months, evidence of dyspnea with activity and even at rest. Upon assessment, the patient was sitting in a chair and had a pain level to be 8/10. The patient was placed with medication of Norco 10/325 mg one tablet orally every 6 hours as needed for moderate to severe pain and Tylenol 500 mg every 6 hours for breakthrough pain. At the end of the visit and assessment, the patient was noted relaxed without any discomfort, no shortness of breath, and the pain level was 0/10. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 1/21/2022, indicated the section 1 and 2 should be met. It indicated Patient 8 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure * Oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documented evidence Patient 8 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documentation supporting the LCD assessment. A review of Patient 8's form titled, "Physician's Certification for Hospice Benefit" from 1/21/2022 to 4/20/2022, indicated, Patient 8's terminal diagnoses was COPD. It was indicated in the physician's narrative that Patient 8 no longer wants to continue aggressive treatment and stated he wanted comfort measures only. It was indicated in the section of "Certifying Physician Summary" that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 8's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". During an interview with the Director of Patient Care Services (DPCS) on 9/8/2022, at 4:15 p.m., she stated she was not able to find the documented evidence Patient 5, 6, 7, 8 were poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity, Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patients' primary physicians that Patient 5, 6, 7, 8, had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of the agency's comprehensive assessment revised in April 2017 indicated the agency must assure the data elements allow for measurement of outcomes, and the Clinical Supervisor/Nursing Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. A review of the agency's undated policy titled "Admission Criteria and Process" indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). A review of the agency's undated Policy and Procedure titled "Certification of Terminal Illness" indicated the clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. b. On 12/20/21, at 10:30 a.m., a review of Patient 8's "Patient Face Sheet", indicated Patient 8 was admitted to the facility services on 2/28/20, with a primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). On 12/22/21, at 3:10 p.m., during an interview and record review with the DON (Director of Nursing), Patient 8's undated "LCD Hospice eligibility determination", was reviewed. The LCD Hospice eligibility determination form indicated, "Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl? Yes". The DON stated there was no weight documented in Patient 8's medical record. The DON stated patients were supposed to be weighed every month. The DON stated if weights are not taken it is difficult to know if patients are losing or gaining weight. A review of the facility's policy and procedure titled, "Weight Assessment", dated December 2021, indicated, "On each visit, visiting nurses will assess and measure patient's weight, height, MAC (mid arm circumference) and BMI monitor patterns of weight loss". c. On 12/20/21 at 10:30 a.m., a review of Patient 9's "Patient Face Sheet", indicated Patient 9 was admitted to the facility services on 12/6/2020, with a primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). On 12/22/21, at 3:35 p.m., during an interview and record review with the DON (Director of Nursing), Patient 9's undated "LCD Hospice eligibility determination", was reviewed. The LCD Hospice eligibility determination form indicated, "Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl? Yes". The DON stated Patient's 9 weights were recorded as follows: 12/6/20: Weight 165 lbs. 5/20/21: Weight 165 lbs, MAC (mid arm circumference-used to estimate weight in adults and adolescents)) 26.5 cm. 6/3/21: Weight 165 lbs, MAC 26.5 cm. 7/27/21: Weight 165 lbs, MAC 26.5 cm. 9/23/21: Weight 165 lbs, MAC 26.5 cm. 12/1/21: Weight 165 lbs, MAC 26.67 cm. The DON stated, the overall patient's measurements indicated weight gain, not weight loss. The DON stated the LCD Hospice eligibility determination was not accurate. A review of the facility's policy and procedure titled, "Admission Criteria and Process", dated 2019, indicated, "The patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs).

Based on interview and record review, the hospice failed to ensure the interdisciplinary (IDG) group meetings were held by all the members of interdisciplinary group to discuss the patients comprehensive and ongoing assessments and care planning process for 10 of 13 sampled patients (Patient 1, 2, 3, 4, 5, 6, 8, 9, 10, and 11). This deficient practice has a potential for the patients progress or decline will not be identified by the IDG, interventions will not be implemented, and patient care goals will not be achieved. Findings: a. A review of Patient 1's admission record indicated the patient was admitted to the hospice agency on 6/11/2021, with diagnosis of Alzheimer's disease. A review of the Plan of Care (POC) summary dated 12/3/2021 indicated Licensed Vocational Nurse (LVN) was to make one visit per week and as needed three times, the chaplain was to visit once a month and a Medical Social Worker was to visit once a month. The hospice aide (HA) visit was declined and volunteer visit was not indicated. A review of Patient 1's IDG meeting record indicated blank spaces or not signed to indicate MSW participated the meeting on 12/3/2021 and 12/17/2021. The spiritual counselor also showed no evidence of being in the meeting on 12/17/2021. b. A review of Patient 2's admission record indicated the patient was admitted to the hospice on 9/9/2020, with diagnosis of acute respiratory failure with hypoxia ( a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level). The POC Summary dated 11/5/2021, indicated RN visit once every two weeks, LVN visit two times per week, the chaplain and the MSW visit once a month. The hospice aide (HA) visit was not indicated, and volunteer visit was declined. A review of Patient 2's IDG meeting record indicated blank spaces or not signed to indicate the RN participated on 12/3/2021. The MSW also showed no evidence of being in the meeting on 12/17/2021. c. A review of Patient 3's admission record indicated the patient was admitted to the hospice on 7/2/2020, with diagnosis of cerebral infarction. The POC/IDG Review dated 12/3/2021 indicated LVN visit once a week, the MSW and chaplain was to visit once a month. The HA and the volunteer services were declined. A review of Patient 3's IDG meeting record indicated indicated blank spaces or not signed to indicate the MSW participated on 12/17/2021. d. A review of Patient 4's admission record indicated the patient was admitted to the hospice agency on 1/20/2020, with diagnosis of non Hodgkin's lymphoma. The Added/updated Plan of Care dated 11/22/2021 indicated RN was to visit the patient every 14 days for supervision and evaluation, SN visit two times per week, the chaplain and the MSW was to visit the patient for evaluation and recertification, and the HA was to visit three times a week. A review of Patient 4's IDG meeting record indicated blank spaces or no signature to indicate the MSW participated on 12/3/2021 and 12/17/2021. The spiritual counselor also showed no evidence of being in the meeting on 12/17/2021. e. A review of Patient 5's admission record indicated the patient was admitted to the hospice on 1/28/2021, with diagnosis of malignant neoplasm of the colon. The Added/updated Plan of Care dated 11/22/2021 indicated LVN visit once a week, the HA visit was three times per week, the chaplain and the MSW were to visit once a month. A review of Patient 5's IDG meeting record indicated blank spaces or not signed to indicate the MSW participated on 12/3/2021 and 12/17/2021. The RN also indicated no evidence of being in the meeting on 12/3/2021. f. A review of Patient 6's admission record indicated the patient was admitted to the hospice agency on 4/25/2021, with diagnosis of liver cirrhosis. The POC/IDG Review dated 12/3/2021 indicated LVN visit twice a week, the HA visit 5 times per week, the MSW and the chaplain was to visit once a month, and the volunteer visit was declined. A review of Patient 6's IDG meeting record indicated blank spaces or no signatures the MSW participated on 12/3/2021 and 12/17/2021. The spiritual counselor also indicated no evidence of being in meeting on 12/17/2021. During an interview with the Director of Patient Care Services (DPCS) on 12/21/2021, at 11:15 a.m., stated all the members of interdisciplinary group should have participated the IDG meeting. DPCS was not able to provide the documented evidence the RN, MSW, and spiritual counselor had participated in the IDG meetings on the dates scheduled for Patient 1, 2, 3, 4, 5, and 6. A review of the agency's policy of "Interdisciplinary Group Meeting" revised/adapted 2019 indicated the hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice clinical supervisor/nursing supervisor. g. On 12/22/21, at 3:10 p.m., during an interview and record review with the DON (Director of Nursing) Patient 8's electronic medical record was reviewed. The DON stated there was no evidence the Social Worker (SW) and the Chaplain attended the interdisciplinary group meeting (IDG) on 12/17/21. h. On 12/22/21, at 3:35 p.m., during an interview and record review with the DON, Patient 9's electronic medical record was reviewed. The DON stated there was no evidence the SW and an RN (registered nurse) attended the IDG on 11/19/21. The DON stated there was no evidence the RN attended the IDG meeting on 12/7/21. i. On 12/20/21 at 10:30 a.m., a review of Patient 10's "Patient Face Sheet", indicated Patient 10 was admitted to the facility services on 4/30/19, with a primary diagnosis of heart failure. On 12/22/21, at 3:52 p.m., during an interview and record review with the DON, Patient 10's electronic medical record was reviewed. The DON stated there was no evidence the RN and SW attended the IDG meeting on 11/19/21. The DON stated there was no evidence the SW attended the IDG on 12/3/21. j. On 12/20/21 at 10:30 a.m., a review of Patient 11's "Patient Face Sheet", indicated Patient 11 was admitted to the facility services on 9/16/21, with a primary diagnosis of breast cancer. On 12/23/21, at 1:25 p.m., during an interview and record review with the DON, Patient 11's electronic medical record was reviewed. The DON stated there was no evidence the SW attended the IDG meeting on 11/3/21 and 11/5/21. The DON stated there was no evidence the RN attended the IDG meeting on 11/19/21. A review of the facility's policy and procedure titled, "IDT attendance" dated 2021, indicated "All core disciplines involved in patient care are required to attend regularly the interdisciplinary group meeting to give their updates to the plan of care and to discuss patient family/caregiver changes and progress, deaths and changes inpatient and family/caregiver circumstances."

Based on interview and record review, the facility failed to provide nursing services in accordance to the plan of care for four of thirteen sampled patients (Patient 8, Patient 11, Patient 12, Patient 13). This deficient practice had the potential to negatively impact the quality of care received. Findings: A. On 12/22/21, at 3:10 p.m., during an interview and record review with the DON, Patient 8's medical record was reviewed. Medical record titled: "Current treatment/medication/ DME list dated 6/30/20, indicated, "RN Telephone Assessment 3 x week d/t COVID 19 exposure". The DON stated the RN was not seeing the patient three times a week. B. On 12/23/21, at 1:25 p.m., during an interview and record review with the DON, Patient 11's medical record was reviewed. Medical record titled: "Current treatment/medication/DME list, dated 9/16/21, indicated, "LVN visit 2 x week" (licensed vocational nurse). The DON stated the LVN visits were initiated on 10/19/21. The DON stated he did not know the reason why the services were not started within 48 hours from when the order was written. The DON stated there were no documented LVN visits for the week of 12/5/21 and 12/12/21, with no documented reasons for the missed visits. C. On 12/20/21, at 10:30 a.m., a review of Patient 12's "Patient Face Sheet", indicated Patient 12 was admitted to the facility services on 5/21/21, with a primary diagnosis of malignant neoplasm of breast (breast cancer). On 12/23/21, at 1:05 p.m., during an interview and record review with the DON, Patient 12's medical record was reviewed. Medical record titled: "Current treatment/medication/DME list, dated 12/13/21, indicated, "LVN visit every other week alternating with RN visit". The DON stated for the week of 8/22/21 and 8/29/21, there were no LVN visits. The DON stated there was no documentation regarding the missed visits or notification to the doctor regarding the reason for the missed visits. D. On 12/20/21, at 10:30 a.m., a review of Patient 13's "Patient Face Sheet", indicated Patient 13 was admitted to the facility services on 11/19/20, with a primary diagnosis of chronic kidney disease (kidney failure). On 12/23/21, at 12:56 p.m., during an interview and record review with the DON, Patient 13's medical record was reviewed. Medical record titled: "Current treatment/medication/DME list, dated 11/19/20, indicated, "RN visit every other week". The DON stated the RN visited the patient on 11/19/20, with no subsequent visits made. The DON stated the medical record did not have any documentation explaining the reason for the missed visits. A review of the facility's policy and procedure titled, "Missed Visits", dated 2019, indicated, "If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled the clinician will ...B. Document in the patient' clinical record the following information ...reason for the missed visit ...". A review of the facility's policy and procedure titled, "Admission criteria and process", dated 2019, indicated, "...the purpose of the initial visit will be to ...H. Provide services, as needed and ordered by physician ...".

Based on observation, interview and record review, the hospice failed to develop an integrated care plan with the skilled nursing facility (SNF) for one of 13 patients (2). This deficient practice has the potential for the patient's care and services will not be coordinated effectively and continuity of care will not be maintained at the SNF. Findings: A review of Patient 2's admission record indicated the patient was admitted to the hospice on 9/9/2020, with diagnosis of acute respiratory failure with hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level). The POC/IDG Review dated 12/3/2021 indicated RN visit once every two weeks, LVN visit two times per week, the chaplain and the MSW was to visit once a month. The hospice aide (HA) visit was declined and volunteer visit was not indicated. On 12/20/2021, at 4:15 p.m., a joint home visit was made for Patient 2 with the Director of Patient Care Services (DPCS) at the skilled nursing facility 1 (SNF 1). Patient 2 was sitting in bed, alert and oriented, and was able to communicate well. During an interview with Patient 2, she stated she had never met a HA, and had not refused any services from the hospice. On 12/20/2021, at 4:35 p.m., during an interview with the DPCS he stated he Patient 2 had declined the HA service. On 12/20/2021, at 4:50 p.m., during an interview with the Director of Nursing (DON) of SNF 1, she stated CNAs of SNF 1 had been taking care of Patient 2 because Patient 2 was SNF 1's patient. She stated however, there was no evidence the HA's job from the agency was endorsed to SNF 1, and there was no integrated care plan developed between SNF 1 and the agency. During an interview with the DPCS on 12/22/2021, at 12:15 p.m., he was not able to provide the documented evidence that an integrated care plan was developed with the coordination of SNF 1. A review of the "Contract Agreement" between the agency and SNF 1 dated 3/20/2020 indicated the Hospice shall, in coordination with the Nursing Facility, develop a hospice POC for each new nursing home hospice resident.

Based on interview and record review, the facility failed to ensure a registered nurse made an on-site supervisory visit at the patients' home for two of thirteen sampled patients (Patient 8, Patient 13). This deficient practice had the potential to negatively impact the quality of care received due to missed evaluation of services being received. Findings: A. On 12/22/21, at 3:10 p.m., during an interview and record review with the DON, Patient 8's medical record was reviewed. Medical record titled: "Current treatment/medication/ DME list dated 4/23/21, indicated, "Recertification 60 day POC update, continue with routine level of care ...CHHA 3 x weekly ...". The DON stated the RN was supposed to complete supervisory visits once every 2 weeks. The DON stated the RN missed supervisory visits on the week of 11/7/21 and 12/12/21. B. On 12/23/21, at 12:56 p.m., during an interview and record review with the DON, Patient 13's medical record was reviewed. Medical record titled: "Current treatment/medication/DME list, dated 11/30/20, indicated, "CHHA visit 1x week on Sunday". The DON stated no RN supervisory visits were made. The DON stated the medical record did not have any documentation explaining the reason for the missed supervisory visits. A review of the facility's policy and procedure titled, "RN Supervisory Visits", dated March 1, 2017, indicated, "RN supervisory visits of hospice aides are conducted every 14 days for patients who get hospice aide services as part of their Plan of Care.

Based on observation, interview and record review, the hospice failed to ensure volunteer services were provided for five of 13 patients. (1, 2, 8, 12, 13). This deficient practice can result in patients not receiving the services to assist the patient and family and provide companionship and comfort during their end of life experience. Findings: a. A review of Patient 1's admission record indicated the patient was admitted to the hospice agency on 6/11/2021, with diagnosis of Alzheimer's disease. The Plan of care (POC)/Interdisciplinary group (IDG) Review dated 12/3/2021 indicated Licensed Vocational Nurse (LVN) was to make one visit per week and as needed three times, chaplain was to visit once a month and Medical Social Worker (MSW) was to visit once a month. The hospice aide (HA) visit was declined and volunteer visit was not indicated. On 12/20/2021, at 1:30 p.m., a joint home visit was made for Patient 1 with the Director of Patient Care Services (DPCS) at Patient 1's residence. Patient 1 was lying in a bed with closed eyes. Caregiver 1 and a Family member were next to the patient. During an interview with Family member 1 at 1:45 p.m., he stated the agency did not inform him about volunteer services and was not offered the voluteer services. He stated he hired Caregiver 1 and pays Caregiver 1 out of his pocket. A review of Patient 1's record indicated there was no documented evidence Patient 2 or Family member was informed about volunteer service, and was offered volunteer service. b. A review of Patient 2's admission record indicated the patient was admitted to the hospice agency on 9/9/2020, with diagnosis of acute respiratory failure with hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level). The POC/IDG Review dated 12/3/2021 indicated RN visit once every two weeks, LVN visit two times per week, chaplain and MSW were to visit once a month. The hospice aide (HA) visit was declined and volunteer visit was not indicated. On 12/20/2021, at 4:15 p.m., a joint home visit was made for Patient 2 with the DPCS at the skilled nursing facility. Patient 2 was sitting in a bed, alert and oriented, and was able to communicate well. During an interview with Patient 2, she stated the hospice staff did not offer the volunteer services and had never refused the services. A review of Patient 2's record indicated there was no documented evidence Patient 2 or Family member was informed and offered volunteer services. During an interview with the volunteer coordinator on 12/21/2021, at 10:50 a.m., she stated the RN or chaplain informs the volunteer coordinator whether the new patient needed volunteer service or not. The volunteer coordinator stated if the RN or chaplain does not inform her of the need of volunteer services for the patient, she would not even contact the patient/family. The volunteer coordinator was not able to provide the documented evidence Patient 1/family member and Patient 2/family member were informed and offered the volunteer services. A review of the agency's policy titled "Volunteer Services" dated 3/1/2017 indicated the agency shall use volunteers to provide assistance in the hospice's ancillary and office activities, as well as in direct patient care services, and/or help patients and families with household chores, shopping, transportation and companionship.

Based on interview and record review, the hospice failed to ensure the clinical records contained current skilled nurse (SN) visit notes that were submitted timely as indicated in their policy and procedure for three of 13 sampled patients (Patients 4, 5, 6). This deficient practice has the potential to result in the lack of coordination and continuity of care for the patients. Findings: a. A review of Patient 4's admission record indicated the patient was admitted to the hospice on 1/20/2020, with diagnosis of non Hodgkin's lymphoma. The Added/updated Plan of Care dated 11/22/2021 indicated RN was to visit the patient every 14 days for supervision and evaluation, SN visit two times per week, the chaplain and the MSW was to visit the patient for evaluation and recertification, and the HA was to visit three times a week. A review of Patient 4's SN visit notes with the Director of Patient Services (DPCS) on 12/22/2021, at 1:25 p.m., indicated the SN visit notes were not in Patient 4's clinical record since 11/10/2021. b. A review of Patient 5's admission record indicated the patient was admitted to the hospice agency on 1/28/2021, with diagnosis of malignant neoplasm of colon. The Added/updated Plan of Care dated 11/22/2021 indicated LVN visit once a week, the HA visit was three times per week, the chaplain and the MSW were to visit once a month. A review of Patient 5's SN visit notes with the DPCS on 12/22/2021, at 1:25 p.m., indicated the SN visit notes were not in Patient 4's clinical record from 11/21/2021 to 12/4/2021 and from 12/12/2021 to 12/18/2021. On 12/23/2021 at 12:10 p.m., during a telephone interview with Licensed Vocational Nurse 1 (LVN 1) who visited Patient 4 and Patient 5, she stated the SN visit notes should have been submitted within 72 hours. c. A review of Patient 6's admission record indicated the patient was admitted to the hospice agency on 4/25/2021, with diagnosis of liver cirrhosis. The POC/IDG Review dated 12/3/2021 indicated LVN visit twice a week, the HA visit 5 times per week, the MSW and the chaplain was to visit once a month, and the volunteer visit was declined. A review of Patient 6's record with the DPCS on 12/22/2021, at 1:25 p.m., indicated the SN visit notes for 12/8/2021, 12/10/2021, 12/15/2021/ 12/17/2021 were not in Patient 6's clinical record. On 12/23/2021 at 12:30 p.m., during a telephone interview with LVN 2 who visited Patient 6, she stated the SN visit notes should have been submitted within 72 hours. A review of the agency's policy titled "Documentation Submission and the use of abbreviations, acronyms and symbols" dated 3/1/2017 indicated visit notes must be turned in within 72 hours of visit.

Based on observation, interview and record review, the hospice failed to ensure patients were provided with comfort kits (medications used during the death process, to keep the patient comfortable), and failed to ensure the medications in the comfort kit were not expired for two of 13 sample patients (1 and 10). This deficient practice has the potential for the patient not receiving medication related to the palliation and management of the terminal illness that could result in the patient's discomfort during the end of life experience. Findings: a. On 12/22/21, at 3:52 p.m., during an interview and record review with the DON, Patient 10's electronic medical record was reviewed. The DON stated there was no evidence comfort kit (medications used during the death process, to keep the patient comfortable) were ordered for the patient. The DON stated every patient should get comfort medications. The DON stated, "I don't want to think about what kind of death she would have without the comfort kit. She should have the kit". A review of the facility's policy and procedure titled, "Comfort Kit", dated 3/1/14, indicated, " The hospice nurse performing the hospice admission will contact the patient's physician or Hospice Medical Director at the time of admission for orders about specific emergency medication to be supplied in a comfort kit for every patient admitted by Graceful Palms Hospice and Palliative Care". Based on observation, interview and record review, the hospice agency failed to ensure patients were provided with comfort kits for two of 13 sampled patients (Patient 3 and 5). This deficient practice can prevent the patient from receiving benefit of comforting medication during the end of life experience. Findings: b. A review of Patient 5's clinical record indicated, the patient started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The Skilled Nurse (SN) visit was once a week and as needed. The Medical Social Worker (MSW) visit was on initial assessment, certification and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. During a joint home visit with RN 1 on 9/7/2022, at 10:20 a.m., Patient 5 was observed walking with a cane from her car. Patient was alert, oriented, and was able to communicate well. At 10:55 a.m., when asked about the comfort kit, both RN 1 and Patient 5 did not know where the comfort kit was. A review of Patient 5's record indicated there was no documented evidence the comfort kit was provided to Patient 5. The agency was not able to provide the documented evidence the comfort kit was provided to Patient 5 except the receipt dated 9/9/2022, two days after the surveyor mentioned about the missing comfort kit. The policy regarding the Comfort kit was not provided by the agency.