Every finding on record at Honest Hospice Care Inc

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live), failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Patient Rights was met as followed: --- The HA failed to ensure to inform four out of 14 sampled patients (Patients 1, Patient 2, Patient 3, and Patient 5) about the services the HA provided and the limitations of those services. This deficient practice resulted in Patients 1, Patient 2, Patient 3, and Patient 5, not aware about the care and services the HA provided and had the potential for misinformation, misunderstanding and miscommunication of hospice care and services provided for the patients. ( Refer to L519). The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated Federal compliance for Patients Rights to ensure Patients 1's, Patient 2's, Patient 3's, and Patient 6's rights were not violated and patients received quality hospice care.

Based on observation, interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure to inform four out of 14 sampled patients (Patients 1, Patient 2, Patient 3, and Patient 5), about the services the HA provided and the limitations of those services. This deficient practice resulted in Patients 1, Patient 2, Patient 3, and Patient 5, not aware about the care and services the HA provided and had the potential for misinformation, misunderstanding and miscommunication of hospice care and services provided to the patients. ( Refer to L519). --- a. During a review of Patient 1s Patient Information Sheet, the Patient Information indicated a start of care (SOC) date of 7/3/2024, with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 1's Physicians Certification for Hospice Benefit, dated 7/3/2024 to 9/30/2024, the Physicians Certification for Hospice Benefit period Number (#) one (1) indicated Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During an home visit observation 8/10/2024, at 1 p.m., at Patient 1's residence with Registered Nurse (RN) 1, Patient 1 was lying in bed awake, alert, and oriented. Patient 1 used a walker (is a type of mobility aid that offers stability and support while walking) to walk. During an interview on 8/10/2024, at 1:30 p.m., with Family Member 1 (FM 1), FM 1 stated she did not have an idea what hospice services were about. FM 1 stated the HA would send a nurse (unidentified) to come visit Patient 1 every week to take her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). FM 1 stated the visiting nurse (unidentified) came and visited only once during the initial (first) visit (FM 1 did not mention date of the initial visit). FM 1 stated the HA offered to provide free medical supplies such as lotions, incontinent pads (absorbent pads), and shampoo upon Patient 1s admission to the HAs hospice service. b. During a review of Patient 2s Patient Information Sheet, the Patient Information Sheet indicated a start of care (SOC) date of 8/5/2024, with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 2's Physicians Certification for Hospice Benefit, dated 8/5/2024 to 11/2/2024, the Physicians Certification for Hospice Benefit period #1 indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a telephone interview on 8/12/2024, at 12:55 p.m., with Patient 2, Patient 2 stated she was unaware that she was enrolled in a hospice program. Patient 2 stated she heard about the agency through a promotion outside of a store where an HA staff (unidentified) informed her about the hospice program and signed her up. Patient 2 stated she was offered for a nurse to come visit her weekly, provide her with medications, shower chair, bed pads, boxes of milk, machine to check her blood sugar, creams for her skin, and monetary assistance. Patient 2 stated she received a shower chair, a box of bed pads, a box of milk and was still waiting for the money that was offered to her every month once enrolled to the HAs services. Patient 2 stated the HA did not tell her she had a terminal illness with six months or less to live. Patient 2 stated she was not sick and only had pain in her knees and back, and used a cane to walk. c. During a review of Patient 3s Patient Information Sheet, the Patient Information Sheet indicated a start of care (SOC) date of 8/5/2024, with a terminal diagnosis of hypertensive heart disease. During a review of Patient 3's Physicians Certification for Hospice Benefit, dated 8/5/2024 to 11/2/2024, the Physicians Certification for Hospice Benefit period #1 indicated Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a telephone interview on 8/12/2024, at 2 p.m., with FM 2, the FM 2 stated the hospice agency did not inform Patient 3 regarding hospice services during his admission, and Patient 3 was not sick and was not dying in six months. d. During a review of Patient 5s Patient Information Sheet, the Patient Information Sheet indicated a start of care (SOC) date of 6/13/2024, with a terminal diagnosis of hypertensive heart disease. During a review of Patient 5's Physicians Certification for Hospice Benefit, dated 6/13/2024 to 9/10/2024, the Physicians Certification for Hospice Benefit period #1 indicated Physician 1 signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a telephone interview on 8/12/2024, at 12:15 p.m., Patient 5 stated she was in a program where a nurse would go to see her and provide her with things, but did not know the name or the type of the program. Patient 5 stated she heard about the agency through a man (unidentified), whom she met at a local swap meet (a gathering for the sale or barter of usually secondhand objects), where she worked selling used clothing on the weekends. Patient 5 stated the man was a staff from the HA who informed her of the services for people 65 years and older where a nurse would visit the patients at their home and would provide medication. Patient 5 stated the man offered her a nurse who would go to her house to visit, provide medication, check vital signs, a machine to check her blood pressure, wipes, adult briefs, and monetary assistance. Patient 5 stated she had been with agency for about one month and a nurse (unidentified) visited her once. Patient 5 stated during the first visit, the nurse from the HA, provided her with $500.00 dollars and told her she would receive $400.00 dollars every month after. Patient 5 stated she had high blood pressure, diabetes (a medical condition characterized by the body's inability to regulate blood sugar levels), and high cholesterol (a fat-like substance that is found in all the cells in the body), and she would take medication to control the illnesses. Patient 5 stated she was not sick and not dying in six months. Patient 5 stated the HA never told her what hospice service was all about. During an interview with the Director of Patient Care Services Designee (DPCSD) on 8/12/2024, at 12 p.m., the DPCSD stated that she comes once a month or as needed when the agency owner calls her. DPCSD stated that the admission process starts when they get referrals from patients' friends, or community referrals. DPCSD stated then they explain the hospice benefits, look at their prognosis and decline and look into medical records if they have it. DPCSD stated they ask the medical director (MD) when the patients referred to the agency especially if these patients had not seen or visited their primary doctors and the MD will be the referring and the attending doctor for that patient. DPCSD stated that she knows that the agency owners hire marketers to find patients for admission for hospice. DPCSD stated she does not know who the marketers were. A review of the agency's document tilted " Admission Information" revised 2/2022, the document indicated: "To provide patients with accurate information to make informed decisions regarding care or services. The scope of services: nursing, hospice aide and homemaker services, physical therapy, occupational therapy, speech language pathology, social worker, physician services, volunteers, counselors, dietary counseling, home medical equipment related to terminal illness, drugs and biologicals related to terminal illness, short term inpatient care, respite care, continuous care, bereavement counseling and medical supplies. At time of initial assessment, Hospice will provide each patient with a statement of the scope of services provided directly and/or through contractual/written agreement. Patients will also be provided the following information: Care/service limitations, eligibility criteria, charges or patient liability for care/services, information regarding the Medicare Hospice benefit."

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) regarding Initial and Comprehensive Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process of the Patient) was met as follows: --- 1. The Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for six of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11). (Refer to L524). 2. The HA failed to ensure the accurate labeling, disposal, and administration of all drugs and biologicals in accordance to professional standards and manufacturers recommendations to meet the needs of two out of 14 sampled patients (Patients 9 and Patient 10). (Refer to L530). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care were being provided to patients certified to receive the Medicare hospice benefits.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for six of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11). This deficient practice had the potential to result for the patients not to receive appropriate healthcare services that could affect their quality of life. --- a. During a review of Patient 1s Patient Information Sheet, the Patient Information indicated a start of care (SOC) date of 7/3/2024, with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 1's Physicians Certification for Hospice Benefit, dated 7/3/2024 to 9/30/2024, the Physicians Certification for Hospice Benefit period number (#) one (1) indicated Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During an home visit observation on 8/10/2024, at 1 p.m., at Patient 1's residence with Registered Nurse (RN) 1, Patient 1 was lying in bed awake, alert, and oriented. Patient 1 used a walker (is a type of mobility aid that offers stability and support while walking) to walk. During an interview on 8/10/2024, at 1:30 p.m., with Family Member 1 (FM 1), FM 1 stated she did not have an idea what hospice services was about. FM 1 stated the HA would send a nurse (unidentified) to come visit Patient 1 every week to take her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). FM 1 stated the visiting nurse (unidentified) came and visited only once during the initial (first) visit (FM 1 did not mention date of the initial visit). FM 1 stated the HA offered to provide free medical supplies such as lotions, incontinent pads (absorbent pads), and shampoo upon Patient 1s admission to the HAs hospice service. b. During a review of Patient 2s Patient Information Sheet, the Patient Information Sheet indicated a start of care (SOC) date of 8/5/2024, with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 2's Physicians Certification for Hospice Benefit, dated 8/5/2024 to 11/2/2024, the Physicians Certification for Hospice Benefit period #1 indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a telephone interview on 8/12/2024, at 12:55 p.m., with Patient 2, Patient 2 stated she was unaware that she was enrolled in a hospice program. Patient 2 stated she heard about the agency through a promotion outside of a store where an HA staff (unidentified) informed her about the hospice program and signed her up. Patient 2 stated she was offered for a nurse to come visit her weekly, provide her with medications, shower chair, bed pads, boxes of milk, machine to check her blood sugar, creams for her skin, and monetary assistance. Patient 2 stated she received a shower chair, a box of bed pads, a box of milk and was still waiting for the money that was offered to her every month once enrolled to the HAs services. Patient 2 stated the HA did not tell her she had a terminal illness with six months or less to live. Patient 2 stated she was not sick and only had pain on her knees and back, and used a cane to walk. c. During a review of Patient 3s Patient Information Sheet, the Patient Information Sheet indicated a start of care (SOC) date of 8/5/2024, with a terminal diagnosis of hypertensive heart disease. During a review of Patient 3's Physicians Certification for Hospice Benefit, dated 8/5/2024 to 11/2/2024, the Physicians Certification for Hospice Benefit period #1 indicated Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a telephone interview on 8/12/2024, at 2 p.m., with FM 2, the FM 2 stated the hospice agency did not inform Patient 3 regarding hospice services during his admission, and Patient 3 was not sick and was not dying in six months. d. During a review of Patient 4s Patient Information Sheet, the Patient Information Sheet indicated a start of care (SOC) date of 7/22/2024, with a terminal diagnosis of atherosclerosis heart disease of native coronary artery (lesions in walls of the arteries). During a review of Patient 4's Physicians Certification for Hospice Benefit, dated 7/22/2024 to 10/19/2024, the Physicians Certification for Hospice Benefit period #1 indicated Physician 1 signed the attending physician referral section to indicate Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. e. During a review of Patient 5s Patient Information Sheet, the Patient Information Sheet indicated a start of care (SOC) date of 6/13/2024, with a terminal diagnosis of hypertensive heart disease. During a review of Patient 5's Physicians Certification for Hospice Benefit, dated 6/13/2024 to 9/10/2024, the Physicians Certification for Hospice Benefit period #1 indicated Physician 1 signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a telephone interview on 8/12/2024, at 12:15 p.m., Patient 5 stated she was in a program where a nurse would go to see her and provide her with things, but did not know the name or the type of the program. Patient 5 stated she heard about the agency through a man (unidentified), whom she met at a local swap meet (a gathering for the sale or barter of usually secondhand objects), where she worked selling used clothing on the weekends. Patient 5 stated the man was a staff from the HA who informed her of the services for people 65 years and older where a nurse would visit the patients at their home and would provide medication. Patient 5 stated the man offered her a nurse who would go to her house to visit, provide medication, check vital signs, a machine to check her blood pressure, wipes, adult briefs, and monetary assistance. Patient 5 stated she had been with agency for about one month and a nurse (unidentified) visited her once. Patient 5 stated during the first visit, the nurse from the HA, provided her with $500.00 dollars and told her she would receive $400.00 dollars every month after. Patient 5 stated she had high blood pressure, diabetes (a medical condition characterized by the body's inability to regulate blood sugar levels), and high cholesterol (a fat-like substance that is found in all the cells in the body), and she would take medication to control the illnesses. Patient 5 stated she was not sick and not dying in six months. Patient 5 stated the HA never told her what hospice service was all about. f. During a review of Patient 11s Patient Information Sheet, the Patient Information Sheet indicated an SOC date of 7/13/2024, with a diagnosis of atherosclerotic heart disease (a disease that causes plaque to build up in the arteries, narrowing them and reducing blood flow) During a review of Patient 11's Physicians Certification for Hospice Benefit, dated 7/13/2024 to 10/10/2024, the Physicians Certification for Hospice Benefit period #2 indicated Physician 1 signed the attending physician referral section to indicate Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During an interview with the Director of Patient Care Services Designee (DPCSD) on 8/12/2024, at 12 p.m., the DPCSD stated that she comes once a month or as needed when the agency owner calls her. DPCSD stated that the admission process starts when they get referrals from patients' friends, or community referrals. DPCSD stated then they explain the hospice benefits, look at their prognosis and decline and look into medical records if they have it. DPCSD stated they ask the medical director (MD) when the patients referred to the agency especially if these patients had not seen or visited their primary doctors and the MD will be the referring and the attending doctor for that patient. DPCSD stated that she knows that the agency owners hire marketers to find patients for admission for hospice. DPCSD stated she does not know who the marketers were. Requested from DPCSD to provide evidence to support terminal diagnoses of Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11, the DPCSD was unable to provide evidence to support terminal diagnoses for the selected patients at this time. During an interview on 8/12/024, at 12:20 p.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated she did not ask Physician 1 for any laboratory works for baseline admission for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11. During a telephone interview on 8/12/2024, at 1:40 p.m., with the HAs Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11, and he did not discuss the patients medical history with them. Physician 1 stated he was acting as their attending physician now because Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11 were admitted to the hospice agency. Physician 1 stated he determined the patients were eligible for hospice care because he spoke with the patients on the telephone to conduct an assessment, based on the Registered Nurses assessment/visit notes, reviewing patients past medical records, and following the Local Coverage Determination (LCD, provide guidance in determining medical necessity of services) guidelines. Physician 1 stated the HA did not obtain any past medical records of Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11 and as a hospice physician, he could determine eligibility to hospice by interviewing the patients regarding present health condition, checking patient's medications, and doing head to toe assessment. A review of the agency's undated document titled " Medical Director Job Description", the document indicated a Medical Director, or Clinical Medical Director, is responsible for overseeing daily operations of a healthcare facility. The document indicated their duties include reviewing healthcare laws and regulations to implement on daily practices, monitoring facility or department budgets, developing strategies to improve communication between medical professionals and patients, and ensuring that the medical staff and facility comply with the federal rules, regulations and codes. A review of the agency's document tilted " Admission Information" revised 2/2022, indicated: "To provide patients with accurate information to make informed decisions regarding care or services. The scope of services: nursing, hospice aide and homemaker services, physical therapy, occupational therapy, speech language pathology, social worker, physician services, volunteers, counselors, dietary counseling, home medical equipment related to terminal illness, drugs and biologicals related to terminal illness, short tern inpatient care, respite care, continuous care, bereavement counseling and medical supplies. At time of initial assessment, Hospice will provide each patient with a statement of the scope of services provided directly and/or through contractual/written agreement. Patients will also be provided the following information: Care/service limitations, eligibility criteria, charges or patient liability for care/services, information regarding the Medicare Hospice benefit. Patient referrals may be made by anyone including the family, physician, discharge planners, healthcare workers, friends, relatives or the patient. When a telephone or verbal referral is received by Hospice, a referral form is completed by a RN. Referrals may also be received by fax in person or in the mail. The referral form includes at least the following information from the attending physician; • Patient identification information, e.g., name, address, telephone number, date of birth, sex, Medicare or social security number, insurance information, emergency contact and telephone number.• Physician's name, address and telephone number and alternative physician to contact if attending is not available.• Referral source. • Primary admitting terminal diagnosis and other diagnosis.• Medications and treatments required, including orders for treatments and symptom management.• Date of hospital discharge, if applicable.• Care or treatments to be provided, including frequency and duration.• Dietary restrictions.• Any other information reported, e.g., medical management of conditions unrelated to the terminal illness and current medical findings.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the accurate labeling, disposal, and administration of all drugs and biologicals in accordance to professional standards and manufacturers recommendations to meet the needs of two out of 14 sampled patients (Patients 9 and Patient 10). These deficient practices had the potential to result in inconsistent medication administration, risks of physical and chemical incompatibilities between the medications, and patient altered drug responses. --- a. A review of Patient 9s "Physician Certification For Hospice Benefit" for the recertification period of 3/28/2024 to 6/28/2024, the "Physician Certification For Hospice Benefit" indicated a start of care (SOC) date of 3/28/2024 with the medical diagnosis of heart disease (a general term for a variety of conditions that affect the heart and blood vessels. These conditions can impact the heart's structure or function) and Diabetes Mellitus Type 2 (a chronic metabolic condition that occurs when the body's cells don't respond normally to insulin, or the pancreas [a gland helps to regulate blood sugar] doesn't produce enough insulin). A review of Patient 9s ";Current Treatment/Medication List" dated 3/28/2024, the ";Current Treatment/Medication List" indicated that Patient 9 has a current order for Humulin 70/30 insulin (a mixture of 70% [%, percent, unit if proportion] Human Insulin Isophane Suspension and 30% Human Insulin Injection, a medication used to treat diabetes which works by lowering levels of glucose in the blood), 30 units, give subcutaneously (SQ, beneath or under the skin, or relating to something that is located below the epidermis) with a sliding scale (a sliding scale varies the dose of insulin based on blood glucose level. The higher the blood glucose level, the more insulin will be needed) of 0-150 mg/dL (milligrams of sugar per deciliter) to give 0 (zero) units, 151-200 mg/dL to give 2 (two) units, 201-250 mg/dL to give 4 (four) units, 251-300 mg/dL to give 6 (six) units, 301-350 mg/dL to give 8 (eight) units, 351-400 mg/dL to give 10 units, 450 mg/dL and above to give 12 units and call physician. During a joint home visit with the Director of Patient Care Services Designee (DPCSD) on 8/10/2024 at 11:45 a.m., Patient 9s blood sugar was 230 mg/dL (milligrams per deciliter, a unit of measurement). The insulin was not dated. During an interview on 8/10/2024 at 12:45 p.m., with Patient 9s caregiver at the board and care, the caregiver stated that she gave 2 (two) units per the sliding scale. On concurrent review of Patient 9's sliding scale order for insulin that Patient 9's caregiver had in the list, the order was different from the hospice agencys insulin sliding scale order in the medication profile. The caregiver stated that she opened the insulin vial (container) three to four days ago. During an interview on 8/10/2024 at 12:45 p.m., with the DPCSD, the DPCSD stated that the insulin order in Patient 9's medication profile was reviewed and confirmed with hospice doctor. During a telephone interview on 8/11/2024 at 12:20 p.m., with the hospice medical director (MD), MD stated that he did not order Humulin 70/30 to use as insulin coverage on Patient 9s sliding scale. MD stated that the order should be to use Regular insulin (short acting insulin) for the sliding scale coverage. MD stated he called the agency for a verbal order of the regular insulin. During a concurrent telephone interview and record review on 8/11/2024 at 12:20 p.m., with the MD, the MD confirmed that there was no order for the regular insulin in the current medication profile. b. A review of Patient 10s "Physician Certification For Hospice Benefit" for the recertification period of 7/22/2024 to 10/19/2024, the "Physician Certification For Hospice Benefit" indicated an SOC date of 4/23/2024 with the medical diagnosis of atrial fibrillation (a heart condition that causes the upper chambers of the heart to beat irregularly and rapidly) and Diabetes Mellitus Type 2. A review of Patient 10s ";Current Treatment/Medication List" dated 4/23/2024, the ";Current Treatment/Medication List" indicated that Patient 10 has a current order for Humulin Kwik pen (a pre-filled, disposable pen that contains human insulin and it is used to treat diabetes. It is injected just under the skin to control blood sugar levels). During a joint home visit with the DPCSD on 8/10/2024 at 12:00 p.m., Patient 10s blood sugar was 289 mg/dl. The insulin pen was not dated and Pantoprazole (a medication to treat heart burn) 40 milligrams (mg, a unit of measurement), one tablet, twice a day was at the board and care, but it was not listed on Patient 10's medication profile. Patient 10's Medication list indicated Propanolol (medication to treat blood pressure) 40 mg, one tablet, twice daily for GERD (Gastroesophageal reflux disease, a chronic digestive disorder that occurs when stomach contents move back up into the esophagus). During an interview with the DPCSD on 8/10/2024 at 12:45 p.m., the DPCSD stated that the insulin pen should be dated to know until when it is viable for use and to monitor its effectivity. The DPCSD stated that the pharmacy called and clarified the order that it should be Pantoprazole and not Propanolol and she was not able to update the medication profile. A review of the hospice agencys policy titled ";Job Description: Hospice Medical Director" revised 4/2024, the policy indicated that the duties and responsibilities of the Medical Director will include, but not limited to: managing oversight of the patients medications and treatments. A review of the hospice agencys policy titled ";Administration and Documentation of Medications", revised 4/2019, the policy indicated licensed nursing personnel will administer and document only those medications which have been ordered by the physician as part of the plan of care and have been approved for safe administration and monitoring during a hospice visit. As part of the assessment process, a drug history will be taken and a comparison made between the physicians orders and the current medication the patient is taking. Any discrepancies or contradictions should be reported to the physician for resolution. A review of the hospice agencys policy titled ";Medication Profile" revised 4/2019, the policy indicated patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Upon admission hospice, the admitting nurse will initiate a medication profile to document the current medication regimen, including the name, dose, strength, route, frequency, date, and time of administration.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met as follows: --- The Hospice Agency failed to: 1. Ensure Patient 9 received the correct dose of insulin (helps the body turn food into energy and controls the blood sugar levels). 2. Ensure Patient 9 and Patient 9s Caregiver (CG1) followed the ordered sliding scale (varies the dose of insulin based on blood glucose level). 3. Ensure to follow and transcribe (write down) Patient 9s Medical Director/Attending Physician (MD/AP), verbal order for regular insulin. 4. Ensure Licensed Vocational Nurse 1 (LVN 1) performed medication reconciliation (comparing medications) for Patient 9 during each home visit and checked all prescribed medications. 5. Ensure LVN 1 checked and documented Patient 9s blood sugar readings. As a result, Patient 9 received the wrong dose of insulin from 3/28/2024 to 8/11/2024. Patient 9 was at risk for serious side effect of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) that included confusion, rapid heart rate, loss of consciousness (awareness), diabetic ketoacidosis (a serious diabetes complication when blood glucose levels remain dangerously high), diabetic coma (caused by severe dehydration and very high blood sugar levels), hospitalization, and death. (Refer to L543). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met as follows: The Hospice Agency failed to: 1. Ensure Patient 9 received the correct dose of insulin (helps the body turn food into energy and controls the blood sugar levels). 2. Ensure Patient 9 and Patient 9s Caregiver (CG1) followed the ordered sliding scale (varies the dose of insulin based on blood glucose level). 3. Ensure to follow and transcribe (write down) Patient 9s Medical Director/Attending Physician (MD/AP), verbal order for regular insulin. 4. Ensure Licensed Vocational Nurse 1 (LVN 1) performed medication reconciliation (comparing medications) for Patient 9 during each home visit and checked all prescribed medications. 5. Ensure LVN 1 checked and documented Patient 9s blood sugar readings. As a result, Patient 9 received the wrong dose of insulin from 3/28/2024 to 8/11/2024. Patient 9 was at risk for serious side effect of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) that included confusion, rapid heart rate, loss of consciousness (awareness); diabetic ketoacidosis (a serious diabetes complication when blood glucose levels remain dangerously high); diabetic coma (caused by severe dehydration; and very high blood sugar levels), hospitalization, and death. (Refer to L543). On 8/11/2024 at 1:12 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agencys Director of Patient Care Services Designee (DPCSD) related to the HAs failure to ensure that the plan of care was followed and implemented per physicians orders for Patient 9. As a result, Patient 9 received the wrong dose of insulin from 3/28/2024 to 8/11/2024. Patient 9 was at risk for serious side effect of hyperglycemia and hypoglycemia that included confusion, rapid heart rate, loss of consciousness, diabetic ketoacidosis; diabetic coma; hospitalization; and death. On 8/13/2024, at 1:30 p.m., the HA's IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) for the first IJ was not accepted, and the HA was unable to submit a revised removal plan. On 8/13/2024, at 3 p.m., the HA was unable to submit an IJ removal plan. On 8/14/2024, at 3:30 p.m., the survey team completed the survey tasks and conducted an exit conference, with the DPCSD, with the IJ situation not removed. --- Findings: During a review of Patient 9s Physicians Certification for Hospice Benefit for the certification period of 6/26/2024 to 8/24/2024, the Physicians Certification for Hospice Benefit indicated Patient 9 had a start of care (SOC) date of 3/28/2024 with diagnoses of heart disease (describes a range of conditions that affect the heart). During a review of Patient 9s Plan of Care dated 3/28/2024, the Plan of Care indicated Patient 9 had a history of diabetes mellitus (DM, a medical condition characterized by the body's inability to regulate blood sugar levels) with unstable sugar levels. The Plan of Care indicated the intervention was to follow the sliding scale (varies the dose of insulin based on blood glucose level) of 0-150 units=0, 151-200=2units, 201-250=4units, 251-300=6units, 301-350=8units, 351-400=10units, if greater than 450 =12 units and call the doctor. The Plan of Care indicated the goal was for Patient 9s blood sugar not to be less than 80 milligrams per deciliter (mg/dL, a unit of measurement) or more than 200 mg/dL within two weeks. The Plan of Care indicated for the Licensed Vocational Nurse to visit once a week and the Registered Nurse twice a month. During a review of Patient 9s Current Treatment/Medication, the Current Treatment/Medication with a start date of 3/28/2024 indicated for Patient 9 to take Humulin 70/30 (an insulin that works for many hours throughout the day to help lower your blood sugar levels) with a sliding scale of 0-150 units=0, 151-200=2units, 201-250=4units, 251-300=6units, 301-350=8units, 351-400=10units, greater than 450 =12 units and call the doctor. During a joint home visit observation and an interview, on 8/10/2024, at 12:30 p.m., with the DPCSD, there was one Humulin 70/30 insulin vial and there was no regular insulin vial. Patient 9s Caregiver (CG1) stated she would only give Humulin 70/30 two units as coverage if Patient 9s blood sugar reading was greater than 200 mg/dL. The CG 1 showed a notepad and stated she would use the sliding scale: if Patient 9s blood sugar was below 80 to give Patient 9 juice and recheck, 81-200-do not give insulin, 201-250=two units, 251-300=four units, 301-350=six units, 351-400= eight units, 400= give ten units and notify the doctor. During an interview on 8/11/2024, at 11:50 a.m., with DPCSD, the DPCSD stated she did not record Patient 9s blood sugar readings on the electronic medical record. DPCSD did not answer how she or other nurses in general would monitor Patient 9s blood sugar readings weekly. During a concurrent interview and record review on 8/11/2024, at 11:54 am, with the DPCSD, Patient 9s clinical record and nursing notes were reviewed. The DPCSD stated Licensed Vocational Nurse 1 (LVN 1) did not document Patient 9s blood sugar readings during the home visits (7/2/2024, 7/9/2024, 7/16/2024, 7/23/2024, 7/30/2024, and 8/6/2024). During a telephone interview 8/11/2024, at 12:20 pm, with the Medical Director/Attending Physician (MD/AP), the MD/AP stated he called the agency (unidentified date) and gave a ";verbal order," of regular insulin (short acting insulin) with moderate sliding scale for Patient 9. The MD/AP stated, ";I never told them to give Humulin 70/30 to be used as coverage." The MD/AP stated the agency did not write down his orders for Patient 9 to receive regular insulin. During a review of the agencys policy and procedure (P&P) titled, ";Medication Monitoring," revised on April 2019, the P&P indicated that ongoing patient medication monitoring will use a collaborative approach between the clinicians, physicians, pharmacists, patients, and families/caregivers. The case manager will assess the effect of medications on the patient. The assessment will identify drug interactions, duplicative drug therapy, and non-compliance with drug therapy. The clinical effects of medications will be obtained through direct observation during assessment performed during home visits, review of assessment information as well as clinical results of diagnostic studies. The information obtained through patient medication monitoring will be documented in the patients clinical record and if applicable in the pharmacy record. During a review of the agencys policy and procedure (P&P) titled, ";Interdisciplinary Group Membership and Responsibilities" revised on 4/2019, the P&P indicated the interdisciplinary group will collaborate with the patients attending physician to develop an individualized written plan of care. During a review of the agencys policy and procedure (P&P) titled, ";Ongoing Assessments," revised 4/2019, indicated during each home visit, the case manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. The nurse will assess each patient on each visit for: secondary symptoms related to the terminal illness such as nausea, vomiting, and respiratory distress and patients response to medications and other interventions.

Based on interview and record review, the hospice agency failed to ensure hospice aide training program (a service provided by the hospice agency responsible for providing long-term assistance with activities of daily living such as bathing, dressing, grooming, and other personal care services.) was maintained, documented, and provided orientation and training that is consistent with hospice industry standards. This deficient practice had the likelihood to prevent the patients from receiving benefit and standard level of care provided by the hospice aide. --- On 8/13/2024 at 1:30 p.m., a request was made to the Director of Patient Care Services (DPCSD) for their hospice aid program. During an interview on 8/13/2024 at 1:30 p.m., with the DPCSD, the DPCSD stated that they do have a one hospice aide. During a concurrent review and interview with the DPCSD, the DPCSD provided an empty hospice aide training program book. DPCSD provided only print outs of in-service materials they use for the training program. There was no documented evidence that the agency provided hospice aide training for the past year or this year and in-service sign sheets were not signed. The DPCSD stated it was the DPCS and the Administrator who supposed to do the training. DPCSD stated she only does admissions and visits. The DPCSD stated the Administrator was out of the country and the DPCS was in an emergency leave. On 8/13/2024 at 1:30 p.m., requested the DPCSD to provide policy and procedure for hospice aid program, the DPCSD was not able to provide.

Based on observation, interview, and record review, the hospice agency failed to ensure volunteer service program (a service provided by the hospice agency to provide support to patients and their families through companionship, emotional support, and practical help) was maintained, documented, and provided orientation and training that is consistent with hospice industry standards. This deficient practice had the likelihood to prevent the patients from receiving benefit and standard level of care provided by the volunteers from the volunteer program. --- On 8/13/2024 at 1:30 p.m., a request was made to the Director of Patient Care Services (DPCSD) for their Volunteer program. During an interview on 8/13/2024 at 1:30 p.m., with the DPCSD, the DPCSD stated that they do have a volunteer and the volunteer spends two to three hours, one to two days doing mostly paper work, filing charts, answering the phone, calling patients to know how they are. During an interview and concurrent record review with the DPCSD, the DPCSD could not find the employee file for the volunteer and the volunteer program book did not contain any trainings, number of hours spent, and any kind of documentation how the volunteer was utilized. The DPCSD stated it was the DPCS and the Administrator who supposed to do the training. DPCSD stated she only does admissions and visits. The DPCSD stated the Administrator was out of the country and the DPCS was in an emergency leave. A review of the hospice agencys undated policy titled "; Volunteer Services" indicated the agency will provide volunteer services under the direction of the volunteer coordinator and with the assistance of trained hospice volunteers. The duties and responsibilities of the volunteer coordinator and volunteers will be identified in appropriate job descriptions. Volunteers may work in a variety of capacities, including: 1. Patient Care volunteers - provide emotional support and practical assistance that enhances the comfort and quality of life for patients/family/caregivers. 2. Bereavement Volunteers- provide anticipatory counseling and bereavement support to family/caregivers. 3. Errands and transportation volunteers - offers practical support including picking up prescriptions, supplies, or grocery shopping. 4. Office volunteers - lend their services working in hospices administrative offices. The policy indicated the volunteers will document their activities on volunteer activity/clinical notes and submit this documentation for the patient's clinical records. The volunteer coordinator will track the use of volunteers, cost savings achieved, and that hours of volunteer services exceed 5 percent of the total patient care hours of paid and contracted hospice personnel. The volunteer coordinator will document ongoing efforts to recruit, train, and retain volunteers of all ages and ethnic backgrounds. A review of the agency's undated document titled "Volunteer Agreement", indicated that the volunteers agree to serve as a hospice volunteer and understand the they may be assigned patient/family services, community services, and or administrative services. The goal is to always to provide needed services in a professional and caring manner. The volunteer recognizes their duties will include: completion of a volunteer program, attendance in hospice continuing education meeting, support group and social activity. accurate and timely documentation submitted as required in the hospice program.

Based on interview and record review, the Hospice Agency (HA) failed to: 1) Ensure the governing body and Administrator assumed full responsibility for the day-to-day operation and the provision of hospice care and services. 2) Ensure continuous patients health assessment and quality patient care and services were provided to patients admitted to the hospice agencys (HA, agency providing care to terminally ill patients who have six months or less to live). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with Federal regulations for organization and administration of services. --- During an entrance in the agency on 8/9/2024 at 3 p.m., there was only one office personnel (OP) and a consultant present. During an interview on 8/9/2024 at 3 p.m., with the office personnel (OP), OP stated that the Director of Patient Care Services (DPCS) and the Administrator were not available at this time. OP called the DPCS Designee (DPCSD) to come to the office after her home visits. During an entrance conference on 8/9/2024 at 4 p.m., with the DPCSD, reminded DPCSD to notify the Administrator and the Director of Patient Care Services (DPCS) to be present during the survey. A request was made on 8/13/2024 to the DPCSD to provide the books for their in-services, trainings, employee files, hospice aide program, volunteer program, and governing body information and meetings. The DPCSD was unable to provide the requested information. During an interview on 8/13/2024 at with 1:30 p.m., DPCSD stated that the DPCS and the Administrator were supposed to maintain the records. The DPCSD stated that the Administrator is out of the country and the DPCS had a family emergency and will be out for a week or two. The DPCSD stated that she mostly conducts the admissions and home visits and she is not in the office most of the time. During the course of the complaint validation survey from 8/9/2024 to 8/13/2024, the Administrator and DPCS were both not present during the survey. A review of the hospice agency's employee files on 8/13/2024, the employee files indicated the following: a. Reviewed the employee files of two hospice aides (HA). One of the HA's had no current HA license on file and had an expired cardiopulmonary resuscitation certificate (CPR, an emergency lifesaving procedure performed when the heart stops beating). Second HA had an expired CPR since 11/18/2023. b. Medical Director (MD) had no license on file and CPR was expired. c. Medical Director Designee (MDD) had an expired license and no CPR on file. d. Director of Patient Care services (DPCS) had no current license and CPR on file. e. Director of Patient care Services Designee (DPCSD) had no CPR on file. f. Three licensed visiting nurses had no current license and one has an expired CPR on file. A review of the hospice agencys policy titled ";Director of Patient Care Services" revised 4/2019, indicated: "The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. Hires, evaluates, and terminates organization personnel. Conducts annual evaluations on clinicians, or more frequently if indicated. Oversees the maintenance of patient clinical records, statistics, reports and records for purposes of evaluation and reporting of organization activities. Assures proper maintenance of clinical records in compliance with local, state, and federal laws. A review of the hospice agencys policy titled ";Executive Director/Administrator" revised 4/2019, indicated" "The Executive Director/Administrator is responsible for the overall direction of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly. and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. Ensuring organizational compliance with legal, regulatory and accreditation requirements. Assures that all business conduct is above the minimum standards required by law and will not condone any activities that achieve results through violation of the law. unethical business or patient care practices. Staff development including orientation, in-service, continuing education, competency testing and quality assessment performance improvement."

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [is a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Medical Director was met as evidenced by: --- The hospice agency failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for six out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11). (Refer to L667). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory (written rules or law) mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was provided to the patients certified to receive hospice services.

Based on observation, interview and record review, the hospice agency failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for six out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11). This deficient practice resulted in patients being admitted for hospice care with no documented evidence of patients written clinical information was being reviewed and evaluated by the Medical Director and/or physician designee to support their diagnoses of terminal illness. --- a. During a review of Patient 1s Patient Information Sheet, the Patient Information indicated a start of care (SOC) date of 7/3/2024, with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 1's Physicians Certification for Hospice Benefit, dated 7/3/2024 to 9/30/2024, the Physicians Certification for Hospice Benefit period number (#) 1 (one) indicated Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During an home visit observation 8/10/2024, at 1 p.m., at Patient 1's residence with Registered Nurse (RN) 1, Patient 1 was lying in bed awake, alert, and oriented. Patient 1 used a walker (is a type of mobility aid that offers stability and support while walking) to walk. During an interview on 8/10/2024, at 1:30 p.m., with Family Member 1 (FM 1), FM 1 stated she did not have an idea what hospice services was about. FM 1 stated the HA would send a nurse (unidentified) to come visit Patient 1 every week to take her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). FM 1 stated the visiting nurse (unidentified) came and visited only once during the initial (first) visit (FM 1 did not mention date of the initial visit). FM 1 stated the HA offered to provide free medical supplies such as lotions, incontinent pads (absorbent pads), and shampoo upon Patient 1s admission to the HAs hospice service. b. During a review of Patient 2s Patient Information Sheet, the Patient Information Sheet indicated a start of care (SOC) date of 8/5/2024, with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 2's Physicians Certification for Hospice Benefit, dated 8/5/2024 to 11/2/2024, the Physicians Certification for Hospice Benefit period #1 indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a telephone interview on 8/12/2024, at 12:55 p.m., with Patient 2, Patient 2 stated she was unaware that she was enrolled in a hospice program. Patient 2 stated she heard about the agency through a promotion outside of a store where an HA staff (unidentified) informed her about the hospice program and signed her up. Patient 2 stated she was offered for a nurse to come visit her weekly, provide her with medications, shower chair, bed pads, boxes of milk, machine to check her blood sugar, creams for her skin, and monetary assistance. Patient 2 stated she received a shower chair, a box of bed pads, a box of milk and was still waiting for the money that was offered to her every month once enrolled to the HAs services. Patient 2 stated the HA did not tell her she had a terminal illness with six months or less to live. Patient 2 stated she was not sick and only had pain on her knees and back, and used a cane to walk. c. During a review of Patient 3s Patient Information Sheet, the Patient Information Sheet indicated a start of care (SOC) date of 8/5/2024, with a terminal diagnosis of hypertensive heart disease. During a review of Patient 3's Physicians Certification for Hospice Benefit, dated 8/5/2024 to 11/2/2024, the Physicians Certification for Hospice Benefit period #1 indicated Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a telephone interview on 8/12/2024, at 2 p.m., with FM 2, the FM 2 stated the hospice agency did not inform Patient 3 regarding hospice services during his admission, and Patient 3 was not sick and was not dying in six months. d. During a review of Patient 4s Patient Information Sheet, the Patient Information Sheet indicated a start of care (SOC) date of 7/22/2024, with a terminal diagnosis of atherosclerosis heart disease of native coronary artery (lesions in walls of the arteries). During a review of Patient 4's Physicians Certification for Hospice Benefit, dated 7/22/2024 to 10/19/2024, the Physicians Certification for Hospice Benefit period #1 indicated Physician 1 signed the attending physician referral section to indicate Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. e. During a review of Patient 5s Patient Information Sheet, the Patient Information Sheet indicated a start of care (SOC) date of 6/13/2024, with a terminal diagnosis of hypertensive heart disease. During a review of Patient 5's Physicians Certification for Hospice Benefit, dated 6/13/2024 to 9/10/2024, the Physicians Certification for Hospice Benefit period #1 indicated Physician 1 signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a telephone interview on 8/12/2024, at 12:15 p.m., Patient 5 stated she was in a program where a nurse would go to see her and provide her with things, but did not know the name or the type of the program. Patient 5 stated she heard about the agency through a man (unidentified), whom she met at a local swap meet (a gathering for the sale or barter of usually secondhand objects), where she worked selling used clothing on the weekends. Patient 5 stated the man was a staff from the HA who informed her of the services for people 65 years and older where a nurse would visit the patients at their home and would provide medication. Patient 5 stated the man offered her a nurse who would go to her house to visit, provide medication, check vital signs, a machine to check her blood pressure, wipes, adult briefs, and monetary assistance. Patient 5 stated she had been with agency for about one month and a nurse (unidentified) visited her once. Patient 5 stated during the first visit, the nurse from the HA, provided her with $500.00 dollars and told her she would receive $400.00 dollars every month after. Patient 5 stated she had high blood pressure, diabetes (a medical condition characterized by the body's inability to regulate blood sugar levels), and high cholesterol (a fat-like substance that is found in all the cells in the body), and she would take medication to control the illnesses. Patient 5 stated she was not sick and not dying in six months. Patient 5 stated the HA never told her what hospice service was all about. f. During a review of Patient 11s Patient Information Sheet, the Patient Information Sheet indicated an SOC date of 7/13/2024, with a diagnosis of atherosclerotic heart disease (a disease that causes plaque to build up in the arteries, narrowing them and reducing blood flow) During a review of Patient 11's Physicians Certification for Hospice Benefit, dated 7/13/2024 to 10/10/2024, the Physicians Certification for Hospice Benefit period #2 indicated Physician 1 signed the attending physician referral section to indicate Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During an interview with the Director of Patient Care Services Designee (DPCSD) on 8/12/2024, at 12 p.m., the DPCSD stated that she comes once a month or as needed when the agency owner calls her. DPCSD stated that the admission process starts when they get referrals from patients' friends, or community referrals. DPCSD stated then they explain the hospice benefits, look at their prognosis and decline and look into medical records if they have it. DPCSD stated they ask the medical director (MD) when the patients referred to the agency especially if these patients had not seen or visited their primary doctors and the MD will be the referring and the attending doctor for that patient. DPCSD stated that she knows that the agency owners hire marketers to find patients for admission for hospice. DPCSD stated she does not know who the marketers were. Requested from DPCSD to provide evidence to support terminal diagnoses of Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11, the DPCSD was unable to provide evidence to support terminal diagnoses for the selected patients at this time. During an interview on 8/12/024, at 12:20 p.m., with the DPCSD, the DPCSD stated she did not ask Physician 1 for any laboratory works for baseline admission for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11. During a telephone interview on 8/12/2024, at 1:40 p.m., with the HAs Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11, and he did not discuss the patients medical history with them. Physician 1 stated he was acting as their attending physician now because Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11 were admitted to the hospice agency. Physician 1 stated he determined the patients were eligible for hospice care because he spoke with the patients on the telephone to conduct an assessment, and based on the Registered Nurse assessment/visit notes, reviewing patients past medical records, and following the Local Coverage Determination (LCD, provide guidance in determining medical necessity of services) guidelines. Physician 1 stated the HA did not obtain any past medical records of Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11 and as a hospice physician, he could determine eligibility to hospice by interviewing the patients regarding present health condition, checking patient's medications, and doing head to toe assessment. During a review of the agencys policy and procedure titled, ";Physician Services-Medical Director," revised November 2021, the policy and procedure indicated the hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care. During a review of the agencys undated policy and procedure titled, ";Certification of Terminal Illness," the policy and procedure indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. During a review of the agency's undated policy and procedure titled, " Admission Criteria And Process," the policy and procedure indicated the patient must have a life limiting illness with a life expectancy of six months or less, as determined by the attending physician utilizing standard clinical prognosis criteria developed by LCD guidelines.

Based observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation for Clinical Records was met as follows: --- 1. The hospice agency (HA) failed to ensure the Medical Director (Physician 1) conducted an assessment, reviewed and verified the patients clinical information necessary for the Initial Certification of Terminal Illness (CTI) for six out of 14 sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11), to support the diagnosis of the patients' terminal illnesses and qualify for hospice care (specialized care that provides physical comfort and emotional, social and spiritual support for people nearing the end of life). As a result, Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11, were enrolled in hospice without a verification of the patients terminal illness eligibility and received care, services, supplies, and monetary assistance. This deficient practice had the potential to result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11 not receiving the necessary care and services that could lead to potential hospitalization and death. (Refer to L676). The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated Federal compliance for Clinical Records to ensure the patients clinical records contained truthful information regarding the patients clinical condition.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Medical Director (Physician 1) conducted an assessment, reviewed and verified the patients clinical information necessary for the Initial Certification of Terminal Illness (CTI) for six out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11), during the initial admission to support the diagnosis of the patients' terminal illnesses and qualify for hospice care (specialized care that provides physical comfort and emotional, social and spiritual support for people nearing the end of life). As a result, Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11, were enrolled in hospice without a verification of the patients terminal illness eligibility and received care, services, supplies, and monetary assistance. This deficient practice had the potential to result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11 not receiving the necessary care and services that could lead to potential hospitalization and death. On 8/12/2024 at 3:25 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agencys Director of Patient Care Services Designee (DPCSD) related to the HAs failure to ensure the Medical Director (Physician 1) conducted an assessment, reviewed and verified the patients clinical information necessary for the Initial Certification of Terminal Illness (CTI) for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11 during the initial admission to support the diagnosis of the patients' terminal illnesses and qualify for hospice care. Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11 were enrolled in hospice without a verification of the patients terminal illness eligibility and received care, services, supplies, and monetary assistance. On 8/13/2024, at 3:40 p.m., the HA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 8/4/2024, at 4 p.m., the survey team completed the survey tasks and conducted an exit conference, with the DPCSD, with the IJ situation not removed. --- a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 7/3/2024, with a terminal diagnosis of hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 7/3/2024 to 9/30/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. On 8/10/2024, at 1 p.m., a home visit was conducted at Patient 1's residence with RN 1 (registered nurse) Patient 1 was lying in bed awake, alert and oriented. Patient 1 uses a walker for ambulation. During an interview on 8/10/2024, at 1:30 p.m., with FM 1 (family member), FM 1 stated she did not have an idea what hospice services was about. FM 1 stated the HA would send a nurse (unidentified) to come visit her every week to take her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). FM 1 stated the visiting nurse (unidentified) came and visited only once during the initial (first) visit. FM 1 stated the HA offered to provide free medical supplies such as lotions, incontinent pads (absorbent pads), and shampoo upon patient admission to their hospice service. b. During a review of Patient 2s admission record indicated a start of care (SOC) date of 8/5/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 8/5/2024 to 11/2/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. On 8/13/2024, at 12:55 p.m., during a phone interview with Patient 2, Patient 2 stated she was unaware that she was enrolled into a hospice program. Patient 2 stated she heard about the agency through a promotion outside of a store where a HA staff informed her about it and signed her up. Patient 2 stated she was offered for a nurse to come visit her weekly, provide her with medications, shower chair bed pads, boxes of milk, machine to check her blood sugar, creams for her skin and monetary assistance. Patient 2 stated as of this time, she has received shower chair, box of bed pads, box of milk but still waiting for the money that was offered to give her every month once enrolled to their services. Patient 2 further stated she has not been told by the HA that she has a terminal illness with 6 months or less to live. Patient stated she was not sick but she only have health problems like pain to her knees and back and uses a cane to walk. c. During a review of Patient 3s Admission Record, the Admission Record indicated a start of care (SOC) date of 8/5/2024, with a terminal diagnosis of hypertensive heart disease. A review of Patient 3's Physicians Certification for Hospice Benefit, dated 8/5/2024 to 11/2/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a phone interview on 8/13/2024, at 11 a.m., with FM 2, she stated the hospice agency did not inform Patient 3 regarding hospice services during his admission and Patient 3 was not sick and dying in six months. d. During a review of Patient 4s Admission Record, the Admission Record indicated a start of care (SOC) date of 7/22/2024, with a terminal diagnosis of atherosclerosis heart disease of native coronary artery (lesions in walls of the arteries). A review of Patient 4's Physicians Certification for Hospice Benefit, dated 7/22/2024 to 10/19/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a review of Patient 5s Admission Record, the Admission Record indicated a start of care (SOC) date of 6/13/2024, with a terminal diagnosis of hypertensive heart disease. A review of Patient 5's Physicians Certification for Hospice Benefit, dated 6/13/2024 to 9/10/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a phone interview on 8/13/2024, at 12:15 p.m., Patient 5 stated she is in a program where a nurse comes to see her and provide her with things but did not know the name or type of program. Patient 5 stated she heard about the agency through a man who she met at the local swap meet, where she works selling used clothing on the weekends. Patient 5 stated the man was a staff from the HA that informed her of services for people 65 years and older where a nurse visits them at their home and provides medication. Patient 5 stated she was offered a nurse to come visit her, medication to be provided, check vital signs, machine to check her blood pressure, wipes and diapers and monetary assistance. Patient stated she has been with agency for about 1 month and has been visited once by a nurse. Patient 5 stated during the first visit by the nurse from the HA, she was provided with $500 for the first and she would be receiving $400 every moth after. Patient stated she has health issues like high blood pressure, diabetes, high cholesterol and she takes medication for them but she was not sick and dying in six months. Patient 5 further stated she was never told of what hospice service was all about. During a telephone interview on 8/12/2024 at 1:40 p.m. with the hospice Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 11, and have not spoken and/or discussed patients medical history with them. Physician 1 also stated he is acting as their attending physician now because these patients were admitted to the hospice agency. When asked how he determine patients were eligible for hospice care, Physician 1 stated these patients were eligible because of his face to face encounter/assessment of the patient, the registered nurse assessment/visit notes, reviewing patients past medical records, and following the LCD guidelines. Physician 1 further stated that the HA have not obtained any past medical records of these patients but as a hospice physician, he could determine eligibility to hospice by interviewing the patients regarding present health condition ,checking patient's medications and doing head to toe assessment. During a review of the agencys policy and procedure titled, ";Physician Services-Medical Director", revised November 2021, indicated the hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care. During a review of the agencys undated policy and procedure titled ";Certification of Terminal Illness", indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. During a review of the agency's undated policy " Admission Criteria And Process", indicated the patient must have a life limiting illness with a life expectancy of six moths or less, as determined by the attending physician utilizing standard clinical prognosis criteria developed by LCD guidelines. e. During a review of Patient 11s admission record indicated an SOC date of 7/13/2024, with a diagnosis of atherosclerotic heart disease (a disease that causes plaque to build up in the arteries, narrowing them and reducing blood flow) A review of Patient 11's Physicians Certification for Hospice Benefit, dated 7/13/2024 to 10/10/2024, benefit period #2, indicated the Physician 1 signed the attending physician referral section to indicate Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis.