Every finding on record at Hestia Hospice and Palliative Care Corporation

Based on observation, interview and record review, the hospice agency (HA) failed to ensure the Conditions of Participations regarding initial and Comprehensive Assessments of Patients was met as follow: 1. The hospice agency (HA) staff failed to conduct and document an accurate initial 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 one of 19 sample patients (Patient 1). This deficient practice had a potential for the patients not receiving healthcare services to meet the patient health needs. (Refer to L 522). 2. The HA failed to ensure to conduct and complete the comprehensive assessment by the interdisciplinary group (IDG, a team of skilled professionals responsible for the holistic care of the hospice beneficiary to discuss a patient's plan of care), with the consultation with the physician, no later than 5 calendar days after election of hospice care for two of 19 sampled patients (Patient 11 and Patient 12). This deficient practice had the potential to result to not identifying the patients health care and service needs to meet the patient care goals. (Refer to L 523). 3. The HA staff failed to review all medications the patients were taking and update the medication profiles with the current medications for three of 19 sample patients (Patient 1, Patient 11, and Patient 12). This deficient practice placed the patients at risk for medication errors and adverse drug reactions from medication (Refer to L 530). 4. The hospice agency failed to ensure the interdisciplinary group (IDG) updated and implemented the patients' the comprehensive assessment at least every 15 days for five out of 19 sample patients (Patient 1, Patient 2, Patient 3, Patient 11 and Patient 12). (Refer to L 533). The cumulative effect of these systemic practices resulted in the hospice agency failure to deliver statutory mandated compliance with Federal regulations for Initial and Comprehensive Assessment of Patient to ensure the highest quality of care for the patient receiving Medicare hospice benefit. --- .

Based on observation, interview, and record review the Hospice Agency (HA) staff 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 hospice eligibility and management of terminal illness for one of 19 sample patients (Patient 1). This deficient practice had the potential for the patients not receiving healthcare services to meet the patient care goals.. --- A review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 12/28/2022 with a primary diagnoses including chronic kidney disease (a gradual loss of kidney function). During a home visit on 6/7/23, at 10:05 a.m., Registered Nurse 1 (RN 1) was observed providing care to P1. P1 was sitting in a chair, drinking from a cup. P1 was awake, alert, and oriented. During the home visit and an interview on 6/7/23, at 10:06 a.m., P1s caregiver (CG2) stated, her understanding of hospice care was to provide help, as P1 is getting older. CG2 stated, P1 did not have a terminal disease and the physician had not discussed life expectancy with Patient 1. CG2 stated, the physician referred P1 to hospice care only for assistance at home because it was hard for the patient to leave the home to go to appointment with the physician. CG2 stated Patient 1 fell at home and hurt herself, and the physician wanted the patient to go to the hospital but did not want to go, and one of the reasons the patient was referred to hospice care. During a concurrent interview and record review on 6/8/23, at 1:18 p.m., P1s record titled ";Comprehensive Nursing Assessment", dated 12/28/22, was reviewed with RN 1. The record indicated, ";Vitals & Measurements...O2 sats. 97% RA (Room air). RN 1 stated the reading meant the patient was oxygenating blood, perfusing sufficiently. RN 1 stated, P1 was not on oxygen therapy was not exhibiting any signs of respiratory distress. During a concurrent interview and record review on 6/9/23, at 12:25 p.m., P1s record titled, ";Physicians Certification for Hospice Benefit (CTI)", for certification period 12/28/22 to 3/27/23, was reviewed with Medical Director 1 (MD 1). The record indicated, ";Certifying Physician Summary...Patient has mild shortness of breathing with at rest. Oxygen at 2L/min (L-liters, unit of measurement. Min-minutes) via nasal cannula (a respiratory tool placed over the opening of the nose to deliver oxygen) continuously and breathing treatment as needed for SOB (shortness of breath)/respiratory distress. Oxygen saturation level room air at 54%...". MD 1 stated, the record was a nurse examination because he was not there during the assessment. MD 1 stated, the documentation was wrong on the CTI. MD 1 stated, P1 was not in respiratory distress. MD 1 stated he had signed the CTI on 12/28/22. The signature meant he had reviewed the documentation and agreed with the record. A review of facilitys policy and procedure titled ";Comprehensive Assessment" revised November 2021, indicated ";The Clinical Supervisor/Nursing Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. 5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days. B. If no changes are needed, then that must be documented. C. If there has been a change in the patients condition/status then the comprehensive assessment must be updated."

Based on interview and record review, the Hospice Agency (HA) failed to ensure to conduct and complete the comprehensive assessment by the interdisciplinary group (IDG, a team of skilled professionals responsible for the holistic care of the hospice beneficiary to discuss a patient's plan of care), with the consultation with the physician, no later than 5 calendar days after election of hospice care for two of 19 sampled patients (Patient 11 and Patient 12). This deficient practice had the potential to result in not identifying the patients health care and service needs to meet the patient care goals. --- A review of Patient 11s (P11) ";Personal Information", indicated P11 had a Start of Care (SOC) date of 1/22/2020 with a primary diagnoses including Alzheimers disease (progressive mental deterioration). A review of P11s Electronic Medical Record (EMR), the EMR indicated ";IDG Discussion/Updated Comprehensive Assessment Review – other/physician" dated 1/22/2020 was left blank. A review of Patient 12s (P12) ";Personal Information", indicated P12 had a Start of Care (SOC) date of 3/24/2022 with a primary diagnoses including malignant neoplasm of colon, unspecified (colon cancer). A review of P12s Electronic Medical Record (EMR), the EMR indicated the ";IDG Discussion/Updated Comprehensive Assessment Review – RN Signature" dated 5/23/2023, was left blank. During an interview on 6/8/2023 at 3:30 p.m. the Administrator 1 (ADM1) stated, ";The IDG/POC (Interdisciplinary Group/Plan of Care) is comprised within the IDG group the doctors the registered nurses (RN), license vocation nurses (LVN), social worker (SW), spiritual counselor (SC), thats the time we discuss the patient condition, needs, concerns problems, discharge. During that time all the discipline that are visiting this patient, they have the opportunity to discuss. We do it every two weeks." ADM1 also stated, ";Under the discussion part, they will put the patients condition. That lets me know that they were involved. If there is no documentation, they forgot or its late." During an interview on 6/9/2023 at 3:25 p.m. the ADM stated that the IDG input information/discussion needs to be filled out. ADM stated, ";It is supposed to be filled, by the nurse if it is the nurse, psychosocial is a portion of the social worker. Its their input of the patient status is and that is what we discussed in out meeting." A review of facilitys policy and procedure titled ";Interdisciplinary Group Coordination of Care" undated, indicated ";The interdisciplinary group will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of two (2) weeks..." A review of facilitys policy and procedure titled ";Ongoing Comprehensive Assessments" revised November 2021, indicated ";Based on the assessments, the plan of care... will be reviewed and updated by the interdisciplinary group members..." A review of facilitys policy and procedure titled ";The Plan of Care" undated, indicated ";The care provided to the patient must be in accordance with the plan of care. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by the members of the interdisciplinary group..."

Based on observation, interview and record review, the Hospice Agency (HA) staff failed to review all medications the patients were taking and update the patient's medication profiles with the currently used medications for three of 19 sampled patients (Patient 1, Patient 11, and Patient 12). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. --- a). A review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 12/28/2022 with a primary diagnoses including chronic kidney disease (a gradual loss of kidney function). During a concurrent observation and interview of the home visit on 6/7/23, at 10:50 a.m., Registered Nurse 1 (RN1) was observed reviewing P1s medications. RN 1 picked up P1s medications bottles, looked at them, then placed them back. There were no documents present during the review of the medications. RN1 stated she reviews medications every visit to make sure the patient has enough supply and to identify if a medication need to be refilled. RN1 stated the expectation was to review all the medications and compare them to the medication list and check to make sure the dosages are correct. RN1 stated it was important to review the medications with the medication list to make sure the patient was on the correct treatment. RN 1 stated she did not have a medication list or any other document during the review of the medications. b). A review of Patient 11s (P11) ";Personal Information", indicated P11 had a Start of Care (SOC) date of 1/22/2020 with a primary diagnoses including Alzheimers Disease (progressive mental deterioration). During a joint home visit on 6/13/2023 at 10 a.m. with Registered Nurse 3 (RN3) to P11s home. P11 was noted laying supine on hospital bed, clean and covered with eyes closed. A review of P11s ";Medication List" and medications was done with Registered Nurse 3 (RN3). The findings were: 1. Tylenol (pain medication) suppositories were in a small plastic bag, without a pharmacy label. 2. Bisacodyl (stool softer medication) suppository label was not legible. 3. Albuterol (inhaled respiratory medication) were in a small plastic bag, without a pharmacy label. RN3 stated labels were important to have on medications. RN3 stated, ";Its important to know how to give it and how often to give, to avoid medication errors." 4. Flagyl (anti-fungal medication) 500mg (milligrams) was documented on the medication list, but the medication was not at P11s home. 5. Medi honey (topical wound treatment medication) was documented on the medication list, but the medication was not at P11s home. RN3 stated, ";They should have gotten discontinued once the wound healed. This was before I started seeing her." 6. Atropine (medication to reduce saliva and fluid in the lungs), part of the comfort kit (supply of medications kept at patients home to be readily available to treat symptoms that may occur in a patient with a terminal illness) was documented on the medication list, but the medication was not at P11s home. RN3 stated, ";I check their medication, medication reconciliation, at every visit. We do it to make sure patient is getting proper meds, making sure they are getting the right medication." c). A review of Patient 12s (P12) ";Personal Information", indicated P12 had a Start of Care (SOC) date of 3/24/2022 with a primary diagnoses including malignant neoplasm of colon, unspecified (colon cancer). During a joint home visit on 6/13/2023 at 11:45 a.m. with Registered Nurse 3 (RN3) to P12s home. P12 was noted laying supine on hospital bed. A review of P12s ";Medication List" and medications was done with Registered Nurse 3 (RN3). The findings were: 1. Anti-diarrheal 2 mg take 2 capsules... RN3 stated, ";It should be written as needed". Administrator 2 (ADM2) stated, ";It should be PRN (as needed), we dont give it every day." 2. Hydrocortisone (anti-itch topical medication) 1% apply... once daily... ADM2 stated, ";He does not need it every day, last time he used it was two months ago." 3. Medication list: Quetiapine Fumarate (to treat agitation/restlessness) 75mg tablet take 1 tab by mouth once daily at night. Medication label: Quetiapine Fumarate 50mg take 1 ½ tabs... RN3 stated, ";The dosage of the tablet is different. It should match, for safety." During an interview on 6/8/2023 at 10:35 a.m. with the Administrator 1 (ADM1), ADM1 stated, ";It is important because safety is our main goal, if there is no label even if its not visible, we need to make sure is readable. I dont understand why there is no label. For safety for accuracy there should be a consistent and accurate label." ADM1 also stated, ";Medication is reconciled for safety and its a doctors order. We need to make sure there is not going to be any errors which is one of the important things when giving medication." A review of facilitys policy and procedure titled ";Medication Profile" undated, indicated ";Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. For accuracy and to completely reconcile medications... the admitting organization will obtain and document a complete list of the patients current medication upon the patients entry to the organization. A comparison of the medication ordered for the patient while under the organizations care will be made to those on the list. During subsequent hospice visit, the medication profile will be used as a care planning and teaching guide..." A review of facilitys policy and procedure titled ";Medication Monitoring" undated, indicated "; The information obtained through patient medication monitoring will be documented in the patients clinical record..." A review of facilitys policy and procedure titled ";Identification of Medication for Administration" undated, indicated ";Medication will be properly labeled with the patients name, an additional patient identifier, name of drug, dosage, diluent, date of preparation, expiration date... The nurse will review the medication label for name, additional patient identifier, drug, dosage, and prescription. A review of facilitys policy and procedure titled ";The Plan of Care" undated, indicated ";The care provided to the patient must be in accordance with the plan of care. Any change in the patients condition must result in a change in the plan of care, prior to implementation of the new service."

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG) updated and implemented the patients' comprehensive assessment, for at least every 15 days for five out of 19 sample patients (Patient 1, Patient 2, Patient 3, Patient 11, and Patient 12). This deficient practice had potential for patients lack of care and services and not meeting the patient care goals. --- a). A review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 12/28/2022 with a primary diagnoses including chronic kidney disease (a gradual loss of kidney function). During a concurrent observation and interview of the home visit on 6/7/23, at 10:21 a.m., RN 1 was observed assessing P1. RN1 stated P1s vital signs (clinical measurements that indicate the state of a patients essential body functions) indicated P1s O2 (oxygen) saturation (the percentage of oxygen in the blood) was 98% (percentage, unit of measurement) and P1 did not have shortness of breath. During a concurrent observation and interview of the home visit on 6/7/23, at 10:35 a.m., P1s DME (durable medical equipment) was observed with the RN and CG2. CG2 stated her mom last used oxygen a month ago, during the night when she felt short of breath. CG2 stated her moms respiratory symptoms were weather dependent. During a concurrent observation and interview of the home visit on 6/7/23, at 10:38 a.m., P1s DME was reviewed with the RN and CG 2. The suction machine (a medical device used to remove obstructions like saliva, mucus, etc.) and nebulizer device (a device used for inhaling a medicinal drug) were not in the P1s living area. RN 1 and CG2 walked to another part of the house, P1 identified as storage room. The suction and nebulizer device were observed in an enclosed bag, unopened. CG2 stated her mom had not used the suction or nebulizer machine and stated, ";hopefully, we dont need it.". During a concurrent observation and interview of the home visit on 6/7/23, at 10:45 a.m., P1s DME was reviewed with the RN and CG2. A portable oxygen tank was observed in P1s identified storage room. CG2 stated the portable oxygen tank was not in use because her mom did not need it. CG2 stated P1 enjoys going outside to the garden, and she does not have a need to use oxygen. During a concurrent interview and record review on 6/8/23, at 1:18 p.m., P1s record titled ";Re-Cert Assessment", dated 3/21/23, was reviewed with RN 1. The record indicated, ";Vitals & Measurements...O2 sats. 97% RA (Room air). RN 1 stated P1 had sufficient perfusion of oxygen in the blood. During a concurrent interview and record review on 6/8/23, at 1:22 p.m., P1s record titled ";Re-Cert Assessment", dated 3/21/23, was reviewed with RN 1. The record indicated, ";Respiratory...Is patient on O2 therapy, none..." RN 1 stated P1 was not oxygen dependent. During an interview on 6/8/23, at 1:24 pm. RN 1 stated P1 at no point had respiratory distress since being cared by the hospice agency. During a concurrent interview and record review on 6/9/23, at 12:40 p.m., P1s record titled, ";Physicians Certification for Hospice Benefit (CTI)", for certification period 3/28/23 to 6/25/23, was reviewed with Medical Director 1 (MD 1). The record indicated, ";Certifying Physician Summary...Patient has mild shortness of breathing with at rest. Oxygen at 2L/min (L-liters, unit of measurement. Min-minutes) via nasal cannula (a respiratory tool placed over the opening of the nose to deliver oxygen) continuously and breathing treatment as needed for SOB (shortness of breath)/respiratory distress. Oxygen saturation level room air at 54%...". MD 1 stated he did not think he documented these findings. This was the exact same thing as documented on the initial CTI for certification period 12/28/22 to 3/27/23. MD 1 stated he had signed the CTI on 3/28/23. The signature meant he had reviewed the documentation and agreed with the record. MD 1 stated the record was wrong. b). A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 4/22/2021 with a primary diagnoses including Parkinsons disease (a progressive disease of the nervous system). During a home visit on 6/7/23 at 1:30 p.m., P2 was observed being fed by P2s daughter. P2s daughter was feeding a pureed white food in a small cup using a metal spoon. During an interview on 6/8/23 at 2:05 p.m. Registered Nurse 2 (RN 2) stated she was P2s primary nurse for more than 1 year. RN 2 stated P2 has been able to eat since last year sometime. RN 2 stated she did not remember the last time P2 choked but it might have been last year sometime. RN 2 stated P2s last pneumonia episode was back in 2021, when P2 was admitted to hospice care. During a concurrent interview and record review on 6/8/23, at 2:21 p.m. P2s record titled, ";Re-Cert Assessment", dated 4/11/23, was reviewed with RN 2. The record indicated, ";LCD Hospice Eligibility Determination (LCD)...2a. Weight Loss a. Weight loss > (greater than) 10% in the last 6 months or > 7.5 % in the last 3 months? Yes....". RN 2 stated she was monitoring P2s weight by taking a MAC (mid upper arm circumference) measurement because P2 could not stand on a scale. RN 2 stated an increase of MAC means weight gain. A decrease of MAC means weight loss. On 4/11/23 P2s MAC was 26 cm (centimeters, unit of measurement) indicating he had gained weight. RN 2 stated the LCD was wrong. P2 did not lose weight. Further review of the record indicated, ";2c. Current HX (history) of pulmonary aspiration not responsive to speech language pathology intervention...Yes." RN 2 stated she was thinking of when she did a speech evaluation when P2 could not swallow, about last year. RN 2 stated the question ";current history" meant the findings of last year also. RN 2 stated she performed the swallow evaluation on 7/2021, not a speech language pathologist, because the office had instructed her to do the swallow evaluation. During a concurrent interview and record review on 6/8/23, at 2:38 p.m. P2s record titled, ";Re-Cert Assessment", dated 4/11/23, was reviewed with RN 2. The record indicated, ";LCD Hospice Eligibility Determination (LCD)...";2d. Dysphagia (difficulty swallowing) severe enough to prevent patient from continuing fluids/foods necessary to sustain life and patient does not receive artificial nutrition and hydration? Yes.". RN 2 stated she thought she was referring to the history again, and the answer to the assessment should have been P2s current situation. RN 2 stated the purpose of the recertification assessment was to document the changes and decline from the last certification period to assess if P2 is declining. RN 2 stated the answers to question 2a should have been ";no", 2c: should have been ";no", and 2d: should have been ";no". When asked if the recertification assessment was accurate, RN 2 stated, ";I regret and admit to my mistake. Its not accurate." RN 2 stated an accurate assessment was appropriate, so we can make sure patients are appropriate for hospice service and to provide whatever they need. RN 2 stated P2 should have not been recertified based on the recertification assessment. c). A record review of Patient 3s (P3) ";Personal Information", indicated P3 had a Start of Care (SOC) date of 5/29/2020 with a primary diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of plaque inside the artery walls affecting the arteries that supply the heart with blood). During a concurrent interview and record review on 6/9/23, at 5:12 p.m., P3s record titled, ";Physicians Certification for Hospice Benefit", for certification period #17 3/15/23 to 5/13/23, was reviewed with ADM 1. The record indicated, ";Certifying Physician Summary...Plan...if this patient exhibits no significant decline in the next 1-2 months, then consider discharge planning and transition her to home health.". The ADM 1 stated P3s medical justification for continuing hospice care was as documented in ";interval history". Continued review of the record indicated, ";Interval history...takes PRN (as needed) Tylenol (a pain-relieving medication) for...pain...remains quite confused..." During a concurrent interview and record review on 6/9/23, at 5:12 p.m., P3s record titled, ";Physicians Certification for Hospice Benefit", for certification period #18 5/14/23 to 7/12/23, was reviewed with ADM 1. The record indicated, ";Certifying Physician Summary...Plan: Consider discharge planning and transition her to home health." ADM 1 stated P3 had not been discharged because we are looking for home health to transition. ADM 1 stated discharge planning began on 5/23/23. During a concurrent interview and record review on 6/9/23, at 5:24 p.m., P3s record titled, ";POC/IDG Review", dated 5/23/23 was reviewed with the ADM 1. The ADM stated the discharge planning was note addressed/documented in the meeting. I dont see any communication note or IDG. We should put it in the communication notes, or IDG. There is no documentation to show when discharge planning was initiated, what interventions were taken, and what response occurred. ADM 1 stated it was important to document on the POC/IDG review so at least everyone is aware of the discharge planning. d). A record review of Patient 11s (P11) ";Personal Information", indicated P11 had a Start of Care (SOC) date of 1/22/2020 with a primary diagnoses including Alzheimers Disease (progressive mental deterioration). During a review of P11s ";POC (Plan of Care)/IDG (Interdisciplinary) Review" dated 5/23/2023, indicated the documentation in the ";IDG Discussion / Updated Comprehensive Assessment Review" was the same documentation on ";POC/IDG Review" dated 6/6/2023. It also indicated the forms had the same documentation, with exception to the signatures and signature dates. During a review of P11s ";Re-Cert Assessment" dated 5/3/2023, indicated ";Nature & Condition of Terminal Illness/LCD (Local Coverage Determination - a decision made by a Medicare on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare) was left blank. It also indicated ";Care plan has been updated upon recertification." e). A record review of Patient 12s (P12) ";Personal Information", indicated P12 had a Start of Care (SOC) date of 3/24/2022 with a primary diagnoses including malignant neoplasm of colon, unspecified (colon cancer). During a review of P12s ";POC (Plan of Care)/IDG (Interdisciplinary) Review" dated 5/23/2023, indicated the documentation in the ";IDG Discussion / Updated Comprehensive Assessment Review – Spiritual, Psychosocial, and Other/Physician" were the same documentation on ";POC/IDG Review" dated 6/6/2023. During a review of P12s ";Re-Cert Assessment" dated 5/17/2023 indicated ";Care plan has been updated upon recertification." During a telephone interview on 6/9/2023 at 1 p.m. with the Medical Director 1 (MD1), MD1 stated the POC/IDG meetings are done every other Tuesday. MD1 stated, ";Last IDG meeting, it was supposed to be this week on Tuesday, but we didnt because you were there. Before that, it was two weeks ago. They havent sent out an email with date of next IDG. They will probably do it on Monday or Tuesday. The last IDG was on the 23rd of May." A review of facilitys policy and procedure titled ";Entries into the Clinical Record" undated, indicated ";A clinical record will be initiated and maintained for each patient receiving care or services... and will include at a minimum: G. Current patient status and progress toward goals." A review of facilitys policy and procedure titled ";Interdisciplinary Group Coordination of Care" undated, indicated ";The interdisciplinary group will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of two (2) weeks..." A review of facilitys policy and procedure titled ";Comprehensive Assessment" revised November 2021, indicated ";During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant: C. Nature and condition causing admission... H. A physical assessment... J. Patients functional status... 2. A. The assessment should determine: A. Probable prognosis of six (6) months or less. 4. The Clinical Supervisor/Nursing Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. 5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days. B. If no changes are needed, then that must be documented. C. If there has been a change in the patients condition/status then the comprehensive assessment must be updated." A review of facilitys policy and procedure titled ";Ongoing Comprehensive Assessments" revised November 2021, indicated ";During each home visit, the Case Manager or other discipline will evaluate the patient... and thereafter the comprehensive assessment. The nurse will assess the patient on each visit, for: D. Current treatment related to the identified symptoms... K. Functional status... P. Progress toward hospice goals and patient needs and problems... Ongoing comprehensive assessment should focus on: B. Changes in patient condition... Based on the assessments, the plan of care... will be reviewed and updated by the interdisciplinary group members..." A review of facilitys policy and procedure titled ";The Plan of Care" undated, indicated ";The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by the members of the interdisciplinary group and will be reviewed on a regular basis but no less that every fifteen (15) days. Any change in the patients condition must result in a change in the plan of care, prior to implementation of the new service."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation regarding care planning and coordination of services for patients was met as follows: 1. The HA failed to review and update the patient's the plan of care (POC) to reflect the most current plans of treatment for two out of 19 sampled patients (Patient 11 and Patient 12). For Patient 11, the HA did not review and update the patient's POC, when the medication was completed and discontinued. For Patient 12, the HA did not update and document the patient's Foley catheter irrigation as ordered. This deficient practice had a potential to result in medication error that could place the patient at risk for side effect form the completed and discontinued medication. (Refer to L552). 2. The HA failed to follow the patient's individualized plans of care (POC, an individualized plan that maps out the needs and services supplied to patient and their care givers) for three of 19 sampled patients (Patient 10, Patient 12, and Patient 15). For Patient 10, Patient 12, and Patient 15, the HA did not conduct home visits as indicated in the POC. For Patient 12, the HA did not irrigate the patient's Foley catheter (F/Cath - a soft hollow tube inserted into the urinary bladder through the abdominal wall) as ordered by the physician. This deficient practice had a potential for the patient not to receive care and services to meet their care goals. (Refer to L555). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal regulations for Care Planning and Coordination of Services to ensure the highest quality of care. --- -

Based on interview and record review the HA failed review and update the patients' plan of care (POC) to reflect the most current plans of treatment for two out of 19 sampled patients (Patient11 and Patient 12). For Patient 11, the HA did not review and update the patient's POC, when the medication was completed and discontinued. For Patient 12, the HA did not update and document the patient's Foley catheter irrigation as ordered. This failure had the potential to result in medication error that could place the patient at risk for side effect from medications that was completed and discontinued. --- A review of Patient 11s (P11) ";Personal Information", indicated P11 had a Start of Care (SOC) date of 1/22/2020 with a primary diagnoses including Alzheimers Disease (progressive mental deterioration). A review of P11s medical record titled, ";POC (Plan of Care – an individualized plan for care) Summary" indicated ";Medication – Order Date 9/20/2022 – Flagyl (anti-fungal medication) 500mg (milligrams) tablets..." It indicated ";Medication – Order Date 8/25/2022 - Medi honey (topical wound treatment medication) ..." During a joint home visit on 6/13/2023 at 10 a.m. with Registered Nurse 3 (RN3) to P11s home. P11 was noted laying supine on hospital bed, clean and covered with eyes closed. A review of P11s ";Medication List" and medications was conducted with Registered Nurse 3 (RN3), as follows, 1. Flagyl (anti-fungal medication) 500mg (milligrams) was documented on the medication list, but not at P11s home. 2. Medi honey (topical wound treatment medication) was documented on the medication list, but not at P11s home. RN3 stated, ";They should have gotten discontinued once the wound healed. This was before I started seeing her." During a review of P11s ";POC (Plan of Care)/IDG (Interdisciplinary) Review" dated 5/23/2023, indicated the documentation in the ";IDG Discussion / Updated Comprehensive Assessment Review" was the same documentation on ";POC/IDG Review" dated 6/6/2023. It indicated the forms had the same documentation, with exception to the signatures and signature dates. During a review of P11s ";Re-Cert Assessment" dated 5/3/2023, indicated ";Nature & Condition of Terminal Illness/LCD (Local Coverage Determination - a decision made by a Medicare on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare) was left blank. It indicated ";Care plan has been updated upon recertification." A review of Patient 12s (P12) ";Personal Information", indicated P12 had a Start of Care (SOC) date of 3/24/2022 with a primary diagnoses including malignant neoplasm of colon, unspecified (colon cancer). A review of P12s Plan of Care (POC) Summary" indicated ";Treatment – ordered date 1/20/2023 – SN (Skilled Nurse) to perform Foley catheter irrigation/flushing 10 ml (milliliters) Normal Saline (NS, a mixture of sodium chloride and water that can use to remove the plugs to drain urine) weekly and as needed for increased sediments." It indicated ";Treatment – ordered date 3/24/2022 – SN (Skilled Nurse) to perform Foley catheter irrigation/flushing 30-60 ml (milliliters) NS as needed for increased sediments." During a joint home visit on 6/13/2023 at 11:45 a.m. with Registered Nurse 3 (RN3) to P12s home. P12 was noted laying supine on hospital bed, an F/Cath was noted hanging on the hospital bed side rail, off the floor. Registered Nurse 3 (RN3) was asked if he was going to do anything with the F/Cath. RN3 stated, ";It has been changed, by another employee. Irrigation is only done if there are sediments noted." RN 3 did not irrigate the patient's Foley Catheter as indicated in the patient's POC to irrigate the Foley catheter once a week and as needed, for increase sediments. During a review of P12s ";POC (Plan of Care)/IDG (Interdisciplinary) Review" dated 5/23/2023, indicated the documentation in the ";IDG Discussion / Updated Comprehensive Assessment Review – Spiritual, Psychosocial, and Other/Physician" were the same documentation on ";POC/IDG Review" dated 6/6/2023. During a telephone interview on 6/9/2023 at 1 p.m. with the Medical Director 1 (MD1), MD1 stated the POC/IDG meetings are done every other Tuesday. MD1 stated, ";Last IDG meeting, it was supposed to be this week on Tuesday, but we didnt because you were there. Before that, it was two weeks ago. They havent sent out an email with date of next IDG. They will probably do it on Monday or Tuesday. The last IDG was on the 23rd of May." A review of facilitys policy and procedure titled ";Interdisciplinary Group Coordination of Care" undated, indicated ";The interdisciplinary group will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of two (2) weeks..." A review of facilitys policy and procedure titled ";The Plan of Care" undated, indicated ";The care provided to the patient must be in accordance with the plan of care. Any change in the patients condition must result in a change in the plan of care, prior to implementation of the new service."

Based on interview and record review the Hospice Agency (HA) failed to follow the patient's individualized plans of care (POC) for three out of 19 sampled patients (Patient 10, Patient 12, and Patient 15). For Patient 10, Patient 12, and Patient 15, the HA did not conduct home visits as indicated in the POC. For Patient 12, the HA did not follow the POC to irrigate the patient's Foley Catheter (a soft hollow tube inserted into the urinary bladder through the abdominal wall) and as ordered by the physician. This deficient practice resulted in the patients not receiving care/services from the home visits and placed the patients at risk by not being provided care/services when they needed. --- A review of Patient 12s (P12) ";Personal Information", indicated P12 had a Start of Care (SOC) date of 3/24/2022 with a primary diagnoses including malignant neoplasm of colon, unspecified (colon cancer). A review of P12s medical record titled, ";POC (Plan of Care – an individualized plan for care) Summary" indicated ";SN (Skilled Nurse) 1 per week..." A review of P12s Electronic Medical Record (EMR), the EMR indicated there was no nurse visit documentation for the week of 5/7/2023. A review on 6/8/2023 at 9:40 a.m. of P12s EMR, the EMR indicated ";List of Orders - SN to perform Foley catheter irrigation/flushing 10 ml (milliliters) Normal Saline (NS) weekly and as needed for increased sediments." During a review of P12s medical record titled, ";POC Summary" indicated ";Treatment – ordered date 1/20/2023 – SN to perform Foley catheter irrigation/flushing 10 ml (milliliters) Normal Saline (NS) weekly and as needed for increased sediments." It also indicated ";Treatment – ordered date 3/24/2022 – SN to perform Foley catheter irrigation/flushing 30-60 ml NS as needed for increased sediments." During a joint home visit on 6/8/2023 at 11:45 a.m. with RN3 to P12s home. P12 was noted laying supine on hospital bed, an F/Cath was noted hanging on the hospital bed side rail, off the floor. RN3 was asked if he was going to do anything with the F/Cath. RN3 stated, ";It has been changed, by another employee. Irrigation is only done if there are sediments noted." A review of Patient 15s (P15) ";Personal Information", indicated P15 had a Start of Care (SOC) date of 2/23/2021 with a primary diagnoses including Parkinsons disease (a progressive disease of the nervous system). A review of P15s EMR, the EMR indicated there was no nurse visit documentation for the week of 3/26/2023. During an interview on 6/8/2023 at 10:35 a.m. with the Administrator 1 (ADM1), ADM1 stated, ";its a doctors order and every order its catered towards the patient care and needs, everything in there should be delivered. In case the POC is not followed it might lead to some complications." A review of facilitys policy and procedure titled ";Missed Visit" undated, indicated ";If a visit will be missed for any reason, the clinician should attempt to reschedule it for the same week... If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor... B. Document in the patient clinical record the following information: patient name, date and type of visit that was missed; reason...; description...; any other follow up needed; other persons that were notified...; signature of staff member reporting the information. If an aide visit is missed the aide will contact the case manager..." A review of facilitys policy and procedure titled ";The Plan of Care" undated, indicated ";The care provided to the patient must be in accordance with the plan of care. Any change in the patients condition must result in a change in the plan of care, prior to implementation of the new service." a)A review of Patient 10's Patient Information, indicated the patient Start of Care (SOC) dated 8/26/21, with admitting diagnosis of Alzheimer's disease (brain disorder which gradually impairs and destroys the ability of thinking). A review of patient 10s plan of care (POC) summary indicated, skilled nurse (SN) visits of 1x/week, HA visits of 2x/week, and MSW visits of 1/month. A review of the agencys EMR indicated missed visits between the following dates: 11/28/22 to 12/12/22 (missed 1 visit). On 6/9/23 at 4:50 p.m., during an interview with the DPCS in the agency's conference room, DPCS stated that some home visits for PT10 was missed and the agency failed to properly document the missed visit.

Based on interview, and record review, the agency failed to ensure that supervisory visits were conducted for one of 19 sampled patients (PT15). This deficient practice placed PT 15 at risk for not receiving monitored/supervised care which could potentially lead to substandard care. --- A review of facilitys policy and procedure titled ";Responsibilities/Supervision of Clinical Services" undated, indicated ";Hospice aide supervisory visits will be conducted on-site at least every 14 days by a hospice registered nurse. A review of Patient 15's face sheet indicated she was admitted to the Hospice agency on 2/23/21, with admitting diagnosis of Parkinsons Disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement). A review of patient 15s plan of care summary indicated skilled nurse visits of 1x/wk and HA visits of 2x/wk. A review of the agencys EMR indicated missed supervisory visits between the following dates: 3/20/23 to 5/8/23 (missed 1 visit) 5/8/23 to present (missed 1 visit) On 6/9/23 at 4:50 p.m., during an interview with the DPCS in the agency's conference room, DPCS stated that some supervisory visits for PT15 was missing and the agency failed to properly document the missed supervisory visits.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Medical Director was met as evidenced by: --- 1. The hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications for six of 19 sample patients (Patient 1, Patient 2, Patient 5, Patient 7, Patient 11 and Patient 15) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The agency failed to: Ensure there was a physicians signature and documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice are and services. (Refer to L 667). 2. The hospice agency failed to ensure medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services three of 19 sample patients (Patient 1 Patient 2, and Patient 11). (Refer to L 668). 3. The hospice agency failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospices patient care program, that included, conducting an assessment, review, and verify patient clinical information to consistently meet the needs for one of 19 sampled patients (Patient 11). (Refer to L 669). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on interview and record review, the hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications for six of 19 sample patients (Patient 1, Patient 2, Patient 5, Patient 7, Patient 11 and Patient 15) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The agency failed to: Ensure there was a physicians signature and documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice are and services. These deficient practices resulted in the hospice medical director and/or the hospice attending physicians certified the patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses and could result to lack and inappropriate care provided to the patients.. --- a). A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 12/28/2022 with a primary diagnoses including chronic kidney disease (a gradual loss of kidney function). During an interview on 6/9/23, at 12:21 p.m., Medical Director 1 (MD 1) stated his process for certifying patients for hospice care was as follows: the office staff send information on patients diagnoses, where they are, the DNR (do not resuscitate) status, history and physical and the progress note written in the last doctor visit. Next, MD 1 makes sure the patient has a qualifying diagnosis for hospice and that they will be passing away in the next 6 months. MD 1 stated he gets medical information from the nurse either through a phone call or email. MD 1 stated he documented on the physician narrative of the CTI in the EMR (electronic medical record). During a concurrent interview and record review on 6/9/23, at 12:25 p.m., P1s record titled, ";Physicians Certification for Hospice Benefit (CTI)", for certification period 12/28/22 to 3/27/23, was reviewed with Medical Director 1 (MD 1). The record indicated, ";Certifying Physician Summary...Patient has mild shortness of breathing with at rest. Oxygen at 2L/min (L-liters, unit of measurement. Min-minutes) via nasal cannula (a respiratory tool placed over the opening of the nose to deliver oxygen) continuously and breathing treatment as needed for SOB (shortness of breath)/respiratory distress. Oxygen saturation level room air at 54%...". MD 1 stated the record was a nurse examination because he was not there during the assessment. MD 1 stated the documentation was wrong on the CTI. MD 1 stated P1 was not in respiratory distress. MD 1 stated the case manager had entered the note in the physician narrative. MD 1 stated the case manager should have not had access to document in the physicians notes. MD 1 stated he had signed the CTI on 12/28/22. The signature meant he had reviewed the documentation and agreed with the record. b). A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 4/22/2021 with a primary diagnoses including Parkinsons disease (a progressive disease of the nervous system). During a concurrent interview and record review on 6/9/23, at 5:00 p.m., P2s record titled, ";Physicians Certification for Hospice Benefit", for certification dates of 4/22/21 to 6/20/21, was reviewed with Administrator 1 (ADM 1). The record indicated, ";Referring Physician Attestation: It is my clinical judgement that this patient has a life expectancy of six months or less...Signature: signature on file/verified by..." ADM 1 name was documented. ADM 1 stated MD 1 had signed the document but a signature from the referring doctor was missing. ADM 1 stated she did not see the signature for both doctors, the referring doctor and the medical director. The regulation requires two physician signatures. ADM 1 stated two physician signatures were important to endorse patient condition. The doctor who knows the patient very well, (primary/referring) is attesting that this patient can be under hospice service. c). A record review of Patient 5s (P5) ";Personal Information", indicated P5 had a Start of Care (SOC) date of 3/30/2023 with a primary diagnoses including unspecified systolic congestive heart disease (heart not pumping blood effectively). During a concurrent interview and record review on 6/9/23, at 5:11 p.m., P5s record titled, ";Physicians Certification of Terminal Illness", for certification dates of 3/30/23 to 6/28/23, was reviewed with Administrator 1 (ADM 1). ADM 1 stated there was not signature from the referring doctor. d). A record review of Patient 7s (P7) ";Personal Information", indicated P7 had a Start of Care (SOC) date of 1/28/2022 with a primary diagnoses including atherosclerosis of aorta (plaque build in inside the wall of a large blood vessel called the aorta). During a concurrent interview and record review on 6/9/23, at 5:07 p.m., P7s record titled, ";Physicians Certification of Terminal Illness", for certification dates of 1/28/22 to 4/28/22, was reviewed with Administrator 1 (ADM 1). ADM 1 stated there was not signature from the referring doctor. e). A record review of Patient 11s (P11) ";Personal Information", indicated P11 had a Start of Care (SOC) date of 1/22/2020 with a primary diagnoses including Alzheimers Disease (progressive mental deterioration). During a review of P11s Electronic Medical Record (EMR) on 6/8/2023 at 12:16 p.m., the EMR indicated form ";Physician Certification for Hospice Benefits" dated 1/22/2020 to 3/21/2020, was signed by the Administrator 1 (ADM1) verifying Physician 4s (MD4) signature on file. During a concurrent interview and record review on 6/8/2023 at 3:30 p.m. with the Administrator 1 (ADM1) of P11s EMR, ADM1 stated that she signs the CTI when a patients primary physician does not want to follow the patient into hospice. ADM1 stated that she attempted to contact the physician for their signature but was unable to. ADM1 stated that she faxed over the CTI for the physician to sign. ADM1 was unable to locate the fax confirmation. ADM1 stated, ";I wouldnt have a trace of the fax confirmation... we need to put the fax cover sheet with the documentation." f). A record review of Patient 15s (P15) ";Personal Information", indicated P15 had a Start of Care (SOC) date of 2/23/2021 with a primary diagnoses including Parkinsons disease (a progressive disease of the nervous system). During a review on 6/6/2023 at 8:56 p.m. of P15s Electronic Medical Record (EMR), the EMR indicated form ";Physician Certification for Hospice Benefits" dated 2/23/2023 to 5/23/2023, was signed by the Administrator verifying Physician 3s (MD3) signature on file. A review of facilitys policy and procedure titled ";Certification of Terminal Illness" undated, indicated ";At the time of admission to hospice, the hospice Medical Director, physician member... and/or the patients attending physician will complete a certification narrative that reflects the patients individual circumstances based on his/her review of the patients medical records or, if applicable, examination of the patient. The hospice Medical Director... and/or the patients attending physician will sign the certification of terminal illness and authorized for hospice services..." A review of facilitys policy and procedure titled ";Entries into the Clinical Record" undated, indicated ";A clinical record will be initiated and maintained for each patient receiving care or services... and will include at a minimum: G. Current patient status and progress toward goals." A review of facilitys policy and procedure titled ";Comprehensive Assessment" revised November 2021, indicated ";During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant: C. Nature and condition causing admission... H. A physical assessment... J. Patients functional status... 2. A. The assessment should determine: A. Probable prognosis of six (6) months or less. 4. The Clinical Supervisor/Nursing Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. 5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days. B. If no changes are needed, then that must be documented. C. If there has been a change in the patients condition/status then the comprehensive assessment must be updated." A review of facilitys policy and procedure titled ";The Plan of Care" undated, indicated ";The hospice Medical Director will need to review the patients history and physical... to be able to sign the certification of terminal illness section of the plan of care." A review of facilitys ";Professional Services Agreement Hospice Physician" undated, indicated ";6. (c) Hospice Physician will review and sign initial hospice certification or terminal illness and recertification and indicated. (d) Hospice Physician will perform face to face ancounters as necessary.

Based on observation, interview and record review the Hospice Agency (HA) failed to ensure the medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for three of 19 sample patients (Patient 1, Patient 2, and Patient 11). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- a). A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 12/28/2022 with a primary diagnoses including chronic kidney disease (a gradual loss of kidney function). During a concurrent interview and record review on 6/9/23, at 12:40 p.m., P1s record titled, ";Physicians Certification for Hospice Benefit (CTI)", for certification period 3/28/23 to 6/25/23, was reviewed with Medical Director 1 (MD 1). The record indicated, ";Certifying Physician Summary...Patient has mild shortness of breathing with at rest. Oxygen at 2L/min (L-liters, unit of measurement. Min-minutes) via nasal cannula (a respiratory tool placed over the opening of the nose to deliver oxygen) continuously and breathing treatment as needed for SOB (shortness of breath)/respiratory distress. Oxygen saturation level room air at 54%...". MD 1 stated he did not think he documented these findings. This was the exact same thing as documented on the initial CTI for certification period 12/28/22 to 3/27/23. MD 1 stated he had signed the CTI on 3/28/23. The signature meant he had reviewed the documentation and agreed with the record. MD 1 stated the record was wrong. b.). A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 4/22/2021 with a primary diagnoses including Parkinsons disease (a progressive disease of the nervous system). During a concurrent interview and record review on 6/9/23, at 12:40 p.m., P2s record titled, ";Physicians Certification for Hospice Benefit (CTI #19)", for certification period 4/12/23 to 6/10/23, was reviewed with Medical Director 1 (MD 1). MD 1 stated he had certified P2 for continuation of hospice care. MD 1 stated he did not enter the note but did sign the document. The signature indicated he reviewed and agreed with the findings. During a concurrent interview and record review on 6/9/23, at 12:42 p.m., P2s record titled, ";Physicians Certification for Hospice Benefit (CTI #17)", for certification period 12/13/22 to 2/10/23, was reviewed with MD 1. The record indicated, ";Medical Director Attestation/Certification: I attest/confirm that I composed this narrative...". MD 1 stated the case manager reviewed his written note and documented it in the record for him to sign. During a concurrent interview and record review on 6/9/23, at 12:49 p.m., P2s record titled, ";Physicians Certification for Hospice Benefit (CTI #18)", for certification period 2/11/23 to 4/11/23, was reviewed with MD 1. The record indicated, ";Medical Director Attestation/Certification: I attest/confirm that I composed this narrative...". MD 1 stated the case manager reviewed his written note and documented it in the record for him to sign. During a concurrent interview and record review on 6/9/23, at 12:51 p.m., P2s record titled, ";Physicians Certification for Hospice Benefit (CTI #19)", for certification period 4/12/23 to 6/10/23, was reviewed with Medical Director 1 (MD 1). The record indicated, ";Certifying Physician Summary...left arm MAC(measuring mid-arm circumference) is 19 cm...". When told Registered Nurse 2 (RN 2) had indicated P2s MAC to be 26 cm on 4/11/23, MD 1 stated he did not know how the nurse got the measurement. MD 1 stated you could look at somebody and look that he is losing weight. P2 weighed a lot more when he was admitted. MD 1 stated P2 had less muscle mass. MD 1 stated he was not sure how RN 2 was saying P2 is increasing weight. MD 1 stated he could not remember when P2s current history of pulmonary aspiration (material enter the airway and lungs) was and could not remember off hand. MD 1 stated P2 did not have severe dysphagia (difficulty swallowing), P2 had mild dysphagia. During an interview on 6/9/23 at 12:58 p.m., Medical Director 1 (MD1) stated he documented face to face evaluations on a paper document and staff take the note and document it on the CTI (Physicians Certification for Hospice Benefit). During an interview on 6/9/12, at 1:05 p.m., MD 1 stated it was not best practice for others to enter notes on behalf of the doctor. A record review of P2s document titled, ";LCD Hospice Eligibility Determination", dated 4/22/21, indicated, ";...2...a. Weight Loss a. Weight loss > (greater than) 10% in the last 6 months or > 7.5 % in the last 3 months? Yes...c. Current hx (history) of pulmonary aspiration not responsive to speech language pathology intervention...Yes. 2d. Dysphagia (difficulty swallowing) severe enough to prevent patient from continuing fluids/foods necessary to sustain life and patient does not receive artificial nutrition and hydration? Yes." A record review of P2s document titled, ";Comprehensive Nursing Assessment", dated 4/22/21, indicated, ";Vitals & Measurements...MAC (cm) 22 left. A record review of P2s document titled, ";Physicians Certification for Hospice Benefit", for certification period #7 4/22/21 to 6/20/21, indicated, ";Physician Narrative...MAC-LA (mid-arm circumference left arm) 22 cm..." c.). A record review of Patient 11s (P11) ";Personal Information", indicated P11 had a Start of Care (SOC) date of 1/22/2020 with a primary diagnoses including Alzheimers Disease (progressive mental deterioration). During a review of P11s ";LCD (Local Coverage Determination - a decision made by a Medicare on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare) Hospice Eligibility Determination" dated 5/3/2023, indicated ";Dementia due to Alzheimers (1 must be met and at least one of the conditions in 2)." It also indicated ";2. Documented History/Progression of at least any one of the following" in which there were two chosen by the facility: a. aspiration pneumonia in past 12 months and inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl. During an interview on 6/8/2023 at 3:14 p.m. with the Administrator 1 (ADM1), ADM1 stated, ";The LCD; Its the local determining diagnosis, the eligibility. You are going to be able to know if the patient is eligible for hospice." During a review of P11s ";Re-Cert Assessment" dated 5/3/2023, indicated ";MAC (Mid Arm Circumference – a measurement that determines if a patient is malnourished) (cm – centimeters) was 27 Left." It also indicated ";Nature & Condition of Terminal Illness/LCD" was left blank. It also indicated P11 had no wounds. During a review of P11s Electronic Medical Record (EMR) indicated P11s MAC was documented as follows: 10/20/2022-MAC20.5; 11/3/2022- MAC23; 12/29/2022- MAC23; 2/3/2023- MAC23; 3/2/2023- MAC23; 4/27/2023- MAC23; 5/3/2023- MAC27; 5/31/2023- MAC26. During a concurrent interview and record review on 6/8/2023 at 3:14 p.m. with the ADM1 of P11s EMR, ADM1 stated that P11 has been gaining weight since 10/20/2022. ADM1 also stated that they use MAC if the patient is unable to be weight with a scale. During an interview on 6/8/2023 at 3:30 p.m. with ADM1, ADM1 stated, ";Looking at it now, based on the MAC that we saw and the patient, the last change of condition was in March." During a joint home visit on 6/7/2023 at 10 a.m. with Registered Nurse 3 (RN3), P11 was observed laying on the bed. RN3 completed a skin assessment and concluded that there were no wounds. P11 had Medi Honey (wound treatment medication) and Flagyl (anti-fungal medication) ordered. RN3 stated, ";They should have gotten discontinued once the wound healed. This was before I started seeing her." P11s Care Giver1 (CG1) stated that P11 had no wounds. During a review of P11s ";POC (Plan of Care" Summary" dated 5/9/2023, indicated ";Order date 12/8/2022 Resume in person regular visit." During a review of P11s ";MD Visit Note" dated 4/22/2023, indicated the recertification face to face visit was conducted via ";audio/video enable tele-visit". It also indicated the Nurse Practitioner (NP) documented under section ";Clinical Finding Summary co-morbidities (the simultaneous presence of two or more medical conditions in a patient) are stage IV ulcer of RLL (right lower leg)." It also indicated ";I confirm that I had a face-to-face encounter with this patient on the date noted above and that the clinical findings of that encounter have been provided to the certifying physician for use in determining continued eligibility for hospice care." Lastly, it indicated it was sign by NP on 4/22/2023. During a review of P11s ";MD Visit Note" dated 2/21/2023, indicated the recertification face to face visit was conducted via ";audio/video enable tele-visit". It also indicated the NP documented under section ";Clinical Finding Summary are stage IV ulcer of RLL." It also indicated ";I confirm that I had a face-to-face encounter with this patient on the date noted above and that the clinical findings of that encounter have been provided to the certifying physician for use in determining continued eligibility for hospice care." Lastly, it indicated it was sign by NP on 2/21/2023. During a telephone interview on 6/9/2023 at 2:36 p.m. with the NP, NP stated, ";I typically, once I get a face-to-face list, I do chart review and coordinate with patient directly or a family member or responsible party to schedule an in person visit, at times there is a handful of patients Ive done virtual visit. I write my face to face note on (facilitys Electronic Medical Record – EMR)." NP stated that he has done several virtual patient visits. NP stated, ";pretty much the same thing, their caregivers, I would ask the same. I tell the person holding the camera to show the upper body, lower legs, I want to make sure there is no edema." NP was asked if he discusses P11s findings with Medical Doctor 2 (MD2). NP stated, ";I, myself, have been a hospice veteran for quite some time. I dont believe I had the need to contact the doctor recently unless it was something complex or something I needed help with. I dont recall the last time I spoke with the doctor, for at least a year ago, I dont recall needing to call (MD2) or (MD1)." During a review of P11s ";Physician Certification for Hospice Benefit" dated 5/6/2023 to 7/4/2023, indicated NPs documentation was under section ";Physician Narrative – Co-morbidity are stage IV ulcer of RLL." It also indicated it was signed by MD2. During a telephone interview on 6/9/2023 at 2:20 p.m. with MD2, MD2 stated that he signs the CTI after reviewing it and talking with the NP. MD2 stated, ";I signed the CTI with the assumption that they are providing the right information. I am just relying on them. In terms of me trying to get everything myself done, its impossible." A review of facilitys policy and procedure titled ";Face to Face Encounter" revised November 2021, indicated ";The Physician/NP who performs the face-to-face encounter will attest in writing that he/she had the face-to-face encounter... To qualify for face-to-face exemption ";prior to" third and subsequent benefit periods, the following would apply: A. Requirements 1. New hospice admission, and 2. Patient is determined to be entering the third or later benefit period A review of facilitys policy and procedure titled ";Certification of Terminal Illness" undated, indicated ";A subsequent recertification... the hospice Medical Director must compose and sign the narrative based on a review of the patients medical record or, if applicable, examination of the patient. A review of facilitys policy and procedure titled ";Entries into the Clinical Record" undated, indicated ";A clinical record will be initiated and maintained for each patient receiving care or services... and will include at a minimum: G. Current patient status and progress toward goals" A review of facilitys policy and procedure titled ";Comprehensive Assessment" revised November 2021, indicated ";During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant: C. Nature and condition causing admission... H. A physical assessment... J. Patients functional status... 2. A. The assessment should determine: A. Probable prognosis of six (6) months or less. 4. The Clinical Supervisor/Nursing Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. 5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days. B. If no changes are needed, then that must be documented. C. If there has been a change in the patients condition/status then the comprehensive assessment must be updated." A review of facilitys policy and procedure titled ";The Plan of Care" undated, indicated ";The hospice Medical Director will need to review the patients history and physical... to be able to sign the certification of terminal illness section of the plan of care."

Based on observation, interview and record review the Hospice Agency (HA) failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospices patient care program, that included, conducting an assessment, review, and verify patient clinical information to consistently meet the needs for one of 19 sampled patients (Patient 11). This failure resulted in the hospice medical director and/or the hospice attending physicians certified the patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses and could result to lack and inappropriate care provided to the patients.. --- A record review of Patient 11s (P11) ";Personal Information", indicated P11 had a Start of Care (SOC) date of 1/22/2020 with a primary diagnoses including Alzheimers Disease (progressive mental deterioration). During a review of P11s ";Re-Cert Assessment" dated 5/3/2023, indicated ";Nature & Condition of Terminal Illness/LCD" was left blank. It also indicated P11 had no wounds. During a joint home visit on 6/7/2023 at 10 a.m. with Registered Nurse 3 (RN3), P11 was observed laying on the bed. RN3 completed a skin assessment and concluded that there were no wounds. P11 had Medi Honey (wound treatment medication) and Flagyl (anti-fungal medication) ordered. RN3 stated, ";They should have gotten discontinued once the wound healed. This was before I started seeing her." P11s Care Giver1 (CG1) stated that P11 had no wounds. During a review of P11s ";MD Visit Note" dated 4/22/2023, indicated the recertification face to face visit was conducted via ";audio/video enable tele-visit". It also indicated the Nurse Practitioner (NP) documented under section ";Clinical Finding Summary co-morbidities (the simultaneous presence of two or more medical conditions in a patient) are stage IV ulcer of RLL (right lower leg)." It also indicated ";I confirm that I had a face-to-face encounter with this patient on the date noted above and that the clinical findings of that encounter have been provided to the certifying physician for use in determining continued eligibility for hospice care." Lastly, it indicated it was sign by NP on 4/22/2023. During a review of P11s ";MD Visit Note" dated 2/21/2023, indicated the recertification face to face visit was conducted via ";audio/video enable tele-visit". It also indicated the NP documented under section ";Clinical Finding Summary are stage IV ulcer of RLL." It also indicated ";I confirm that I had a face-to-face encounter with this patient on the date noted above and that the clinical findings of that encounter have been provided to the certifying physician for use in determining continued eligibility for hospice care." Lastly, it indicated it was sign by NP on 2/21/2023. During a telephone interview on 6/9/2023 at 2:36 p.m. with the NP, NP stated, ";I typically, once I get a face-to-face list, I do chart review and coordinate with patient directly or a family member or responsible party to schedule an in person visit, at times there is a handful of patients Ive done virtual visit. I write my face to face note on (facilitys Electronic Medical Record – EMR)." NP stated that he has done several virtual patient visits. NP stated, ";pretty much the same thing, their caregivers, I would ask the same. I tell the person holding the camera to show the upper body, lower legs, I want to make sure there is no edema." NP was asked if he discusses P11s findings with Medical Doctor 2 (MD2). NP stated, ";I, myself, have been a hospice veteran for quite some time. I dont believe I had the need to contact the doctor recently unless it was something complex or something I needed help with. I dont recall the last time I spoke with the doctor, for at least a year ago, I dont recall needing to call (MD2) or (MD1)." During a review of P11s ";Physician Certification for Hospice Benefit" dated 5/6/2023 to 7/4/2023, indicated NPs documentation was under section ";Physician Narrative – Co-morbidity are stage IV ulcer of RLL (right lower limb)." It also indicated it was signed by MD2. During a telephone interview on 6/9/2023 at 2:20 p.m. with MD2, MD2 stated that he signs the CTI after reviewing it and talking with the NP. MD2 stated, ";I signed the CTI with the assumption that they are providing the right information. I am just relying on them. In terms of me trying to get everything myself done, its impossible." A review of facilitys policy and procedure titled ";Entries into the Clinical Record" undated, indicated ";A clinical record will be initiated and maintained for each patient receiving care or services... and will include at a minimum: G. Current patient status and progress toward goals." A review of facilitys policy and procedure titled ";The Plan of Care" undated, indicated ";The hospice Medical Director will need to review the patients history and physical... to be able to sign the certification of terminal illness section of the plan of care."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation on Clinical Records was met as follows: --- 1. The HA failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for four of 19 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 12). (Refer to L679). 2. The HA failed to ensure contents and information in the patients medical records are safeguarded from unauthorized access by HA staff and contracted staff to make any alterations or modifications one of 19 sampled patients (Patient 1). (Refer to L680). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records are safeguarded from unauthorized access by any individuals or hospice staff.

Based on interview and record review, the hospice agency (HA) failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for four of 19 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 12). This failure has the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients' medical records that could affect the patients quality of care and well-being. --- a). A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 12/28/2022 with a primary diagnoses including chronic kidney disease (a gradual loss of kidney function). During a concurrent interview and record review on 6/9/23 at 1:31 p.m., P1s record titled, ";Audit Log (a document indicating who documented, changed, or accessed a record)", dated 12/28/22 to 6/9/22, was reviewed with the administrator (ADM 1). The record indicated that on 1/10/23 at 4:46 a.m., ADM 1 documented on P1s record titled, ";Certification MD" for visit 12/28/22, ";Physician Narrative: Certifying Physician Summary, this is...under routine level of care for 1st 90-Day certification period from 12/29/233 to 3/27/2023...Patient with less than 6 months life expectancy with natural course of disease..." ADM 1 stated MD 1 wanted her to transcribe the notes into the CTI for all his patients. ADM 1 stated the agency did not have a transcription policy. ADM 1 stated the CTI needed to be accurate because it is a document all disciplines should follow. Otherwise, the information will be wrong for the next person. The record indicated MD 1 was not the author of the note written. During an interview on 6/9/23, at 3:20 p.m., ADM 1 stated the process of making a note for the physician narrative of the CTI involved making sure the assessment of the nurse and doctor matches. "If it doesnt we verify and confirm first with the nurse, inform the doctor, if doctor approves it, we change the document. Unfortunately, we do not document that we notified the doctor of the change to the CTI. Yes, we compose the note based on the nurses and doctors note." b). A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 4/22/2021 with diagnoses including Parkinsons disease (a progressive disease of the nervous system). During a concurrent interview and record review on 6/9/23, at 12:40 p.m., P2s record titled, ";Physicians Certification for Hospice Benefit (CTI #19)", for certification period 4/12/23 to 6/10/23, was reviewed with Medical Director 1 (MD 1). MD 1 stated he had certified P2 for continuation of hospice care. MD 1 stated he did not enter the note but did sign the document. The signature indicated he reviewed and agreed with the findings. During a concurrent interview and record review on 6/9/23, at 12:42 p.m., P2s record titled, ";Physicians Certification for Hospice Benefit (CTI #17)", for certification period 12/13/22 to 2/10/23, was reviewed with MD 1. The record indicated, ";Medical Director Attestation/Certification: I attest/confirm that I composed this narrative...". MD 1 stated the case manager reviewed his written note and documented it in the record for him to sign. During a concurrent interview and record review on 6/9/23, at 12:49 p.m., P2s record titled, ";Physicians Certification for Hospice Benefit (CTI #18)", for certification period 2/11/23 to 4/11/23, was reviewed with MD 1. The record indicated, ";Medical Director Attestation/Certification: I attest/confirm that I composed this narrative...". MD 1 stated the case manager reviewed his written note and documented it in the record for him to sign. During a concurrent interview and record review on 6/9/23 at 1:53 p.m. P2s record titled, ";Audit Log, dated 4/22/21 to 522/21, was reviewed with ADM 1. The record indicated that on 5/11/21 at 3:52 p.m., the Administrator Designee (AD) documented ";Physician Narrative: Certifying Physician Summary", for the CTI for visit date 4/22/21. ADM 1 stated the AD enters notes into the CTI also. During a concurrent interview and record review on 6/9/23 at 1:53 p.m. P2s record titled, ";Physicians Progress Note", dated 4/1/23, and ";Physicians Certification for Hospice Benefit" for certification period 4/12/23 to 6/10/23, was reviewed with ADM 1. ADM 1 stated she and the AD were not transcribing word by word from MD 1s written note into the electronic medical record. During a concurrent interview and record review on 6/9/23 at 2:03 p.m. P2s record titled, ";Physicians Progress Note", dated 1/27/23, and ";Physicians Certification for Hospice Benefit" for certification period 2/11/23 to 4/11/23, was reviewed with ADM 1. ADM 1 stated the physician narrative was taken from the nursing assessment. We actually take the nursing assessment and doctors progress notes, we integrate the information and create a note. c). A record review of Patient 3s (P3) ";Personal Information", indicated P3 had a Start of Care (SOC) date of 5/29/2020 with a primary diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of plaque inside the artery walls affecting the arteries that supply the heart with blood). During a concurrent interview and record review on 6/9/23, at 2:50 p.m., P3s record titled, ";Physicians Certification for Hospice Benefit," for certification period #17 3/15/23 to 5/13/23, was reviewed with ADM 1. ADM 1 stated the information written under ";Certifying Physician Summary" was obtained from the Nurse Practitioner (NP) visit note on 3/15/23. ADM 1 stated she copied it and pasted onto the CTI under physician narrative. The doctor reviews the note and signs it. d). A record review of Patient 12s (P12) ";Personal Information", indicated P12 had a Start of Care (SOC) date of 3/24/2022 with a primary diagnoses including malignant neoplasm of colon, unspecified (colon cancer). During a review of P12s medical record titled, ";POC (Plan of Care – an individualized plan for care) Summary" indicated ";SN (Skilled Nurse) 1 per week..." It also indicated ";Order date 3/14/2023 Recertify... for the 12th recertification period from 3/19/2023 to 5/17/2023." During a review on 6/6/2023 at 4:30 p.m. of P12s Electronic Medical Record (EMR), the EMR indicated there was no nurse visit documentation for the week of 5/7/2023. During a review on 6/8/2023 at 12:51 p.m. of P12s EMR, the EMR indicated there was a nurse visit documentation for the week of 5/7/2023 dated 5/9/2023. During a review of form ";Audit Log" dated 6/6/2023 to 6/9/2023, indicated the log was printed for P12, which included ";all staff" and ";all modules". It indicated the following: ---Modification Date: 6/6/2023 1:50:08 PM; Staff: Administrator Designee; Module: Physician Order; Visit Date: 3/14/2023; Field/Section: Created; Current Value: blank; Previous Value: blank; Module ID: 6964767. ---Modification Date: 6/6/2023 1:52:21 PM; Staff: Administrator Designee; Module: Physician Order; Visit Date: 3/14/2023; Field/Section: Signed; Current Value: RN electronically signed 3/14/2023; Previous Value: blank; Module ID: 6964767.- --Modification Date: 6/6/2023 1:55:26 PM; Staff: Administrator; Module: Physician Order; Visit Date: 3/14/2023; Field/Section: Update Item; Current Value: Medication ID ... Medication Recertify... for the 12th recertification period from 3/19/2023 to 5/17/2023; Previous Value: Medication ID ... Medication Recertify... for the 12th recertification period from 3/19/2023 to 5/17/2023; Module ID: 6964767. A review of facilitys policy and procedure titled, ";Entries into the Clinical Record" undated, indicated ";Entries into the clinical record will be made on the day care is provided to the patient. The clinical note will include: E. Signature of clinician... 10. All entries into the clinical record will reflect the date care was provided, including the time, month, day, and year. 12. Late entries and amendments will be documented, stating ";late entry or amendment for visit of (date and time of visit)" ..."

Based on interview and record review, the Hospice Agency (HA) failed to ensure contents and information in the patients medical records are safeguarded from unauthorized access by HA staff and contracted staff to make any alterations or modifications on one of 19 sampled patients (Patient 1). This failure has the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients clinical record that could affect the patients quality of care and well-being. --- A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 12/28/2022 with a primary diagnoses including chronic kidney disease (a gradual loss of kidney function). During a concurrent interview and record review on 6/9/23, at 12:25 p.m., P1s record titled, ";Physicians Certification for Hospice Benefit (CTI)", for certification period 12/28/22 to 3/27/23, was reviewed with Medical Director 1 (MD 1). The record indicated, ";Certifying Physician Summary...Patient has mild shortness of breathing with at rest. Oxygen at 2L/min (L-liters, unit of measurement. Min-minutes) via nasal cannula (a respiratory tool placed over the opening of the nose to deliver oxygen) continuously and breathing treatment as needed for SOB (shortness of breath)/respiratory distress. Oxygen saturation level room air at 54%...". MD 1 stated the record was a nurse examination because he was not there during the assessment. MD 1 stated the documentation was wrong on the CTI. MD 1 stated P1 was not in respiratory distress. MD 1 stated the case manager had entered the note in the physician narrative. MD 1 stated the case manager should have not had access to document in the physicians notes. MD 1 stated he had signed the CTI on 12/28/22. The signature meant he had reviewed the documentation and agreed with the record.

Observed in Patient Home. In 1 of 2 skilled nursing visits, the organization did not assess potential medication-related problems, including adverse effects, drug reactions, significant side effects/interactions, ineffective drug therapy, duplicate drug therapy, and/or noncompliance with drug therapy. In HV#3, it was noted a complete medication reconciliation was not completed by the RN with the facility staff/caregiver per organizational policy/practice. The order for the patient's PRN Norco, in addition to two other prn analgesics, was documented in the hospice plan of care and SNF record. The hospice medication profile, utilized for medication reconciliation every visit, did not include the prn Norco. This was reveiwed and confirmed with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization did not assess/reassess its patient. In RR#9, the hospice interdisciplinary group did not update the comprehensive assessment every 15 days. Although the organization scheduled Interdisciplinary Team (IDT) Meetings every 14 days, it was noted in review of an IDT note, the update and/or signature from the MSW and Spiritual Care/Chaplin was not documented. This was reveiwed and confirmed with the Administrator/Director of Patient Care Services.

Observed in Document Review. In 5 of 13 patient records reviewed, the organization did not plan the patient's care by including all services needed for the palliation and management of the terminal illness and related conditions. The patient's plan of care did not include medications/treatments necessary to meet the patient's needs. In HV#2, the Board & Care Facility caregiver indicated, the patient had not had a bowel movement in four (4) days. The Hospice LVN did administer the Bisacodyl Suppository, ordered once daily as needed for constipation, and provided education to the caregiver . The facility caregiver was not aware of when this prn medication was to be given, or when to contact hospice. There was no specific indications/instructions for use included in the Bisacodyl order beyond for constipation. It was also noted the patient's plan of care included three prn medications for pain, with no clear indications for use documented for Tramadol 50mg 1 tablet by mouth every 6 hours as needed (when to take the Tramadol versus the Morphine or Acetaminophen). In RR#3, RR#5, and RR#6, the patient's plan of care included orders for two prn medications for constipation, with no clear indications for use. In review of the record for HV#3, the patient's order for prn oxygen was unclear/conflicting. The hospice plan of care included two orders for prn Oxygen (one order was for 2 liters per nasal cannula prn, and the other order was for 4 liters prn). It was verified the patient was currently on 2 liters of oxygen. This was reveiwed and confirmed with the Administrator/Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement its planned infection prevention and control activities to minimize, reduce, or eliminate the risk of infection. In HV#1. the hospice aide entered the patient's home with an open/unzipped field bag. The aide's equipment (BP monitor, stethoscope, temporal thermometer) was stored in an unzipped/open plastic bag placed in the open compartment of the field bag. This practice was not consistent with the organization's Bag Technique Policy and Procedure. This was reveiwed and confirmed with the Administrator/Director of Patient Care Services.