Every finding on record at Hope Hospice Care, Inc

Based on review of documentation and interviews, it was determined that the hospice failed to: --- (L0502) provide the patient or representative with verbal (meaning spoken) and written notice of the patient's rights and responsibilities in a language and manner that the patient understands for 5 of 29 patients. (L0504) obtain the patient's or representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities for 5 of 29 patients. (L0515) provide the patient with a choice of an attending physician for 29 or 29 patients. The cumulative effect of these systemic deficient practices resulted in the hospice's failure to meet the requirement for Condition of Participation for Patient Rights.

Based on review of documentation and interviews, it was determined that the hospice service agency failed to provide patients with the Patient Bill of Rights for 5 of 29 patient records reviewed. This failure poses the potential risk that patients do not understand their rights and choices regarding hospice care services. --- Review of policy no. 2-002.1 titled "Patient Bill of Rights," revealed, "...2. Upon admission, the admitting clinician/technician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights. 3. The Patient Bill of Rights will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand. 4. The patient will be requested to sign the Patient Bill of Rights form. The original form will be kept in the patient's clinical record. A copy will be maintained by the patient. The patient's refusal to sign will be documented in the clinical record, including the refusal. 5. The admitting clinician will document that the patient has received a copy of the Patient Bill of Rights...." Review of policy no 4-021.5 title "Admission Criteria and Process," revealed, "...3. Assignment of appropriate hospice personnel to conduct the initial assessments...5...The purpose of the initial visit will be to:..B. Provide a written copy and explain (verbally) the patient's rights and responsibilities...G. Review appropriate forms and subsequently sign forms by patient and family/caregiver...8. The hospice registered nurse will document that the above information has been furnished to the patient and family/caregiver and any information not understood by the patient and family/caregiver...10. The patient or his/her representative will sign the required forms indicating election of hospice care and receipt of patient rights and privacy information...." Review of 29 patient records revealed 5 patients had no evidence of signature by the patient, family/caregiver, or any hospice agency personnel documenting that the patient received the Patient Bill of Rights. Review of 29 patient records revealed 24 patient rights forms were present but were not signed by the hospice registered nurse in order to document receipt, establish understanding, or refusal to sign. Review of forms and patient records revealed all patient rights were in English. No evidence of Notice of Patient Rights was found in any other language. During interviews on April 18, 2023, Employees #1 and #2 stated Employees #9 and #10 regularly admitted patients "most often from the reservation," and brought their packets to the office for other employees to "sign off on." Employee's #1 and #2 stated many patients living on the reservation did not read/write/understand English, adding some only spoke Spanish and/or other Native languages. Interviews were conducted with Employees #1 and #2 on April 21, 2023, during which both confirmed Employees #9 and #10 (who are not hospice registered nurses) had been obtaining signatures on the notice of patient rights form. Interviews with 5 patients (Patients #4, #7, #10, #11, and #16) between April 21-25, 2023, denied having a need for the hospice agency's services and did not know how or why they had been admitted to hospice services or recalled having received or been read (verbally) their patient rights.

Based on review of documentation and interviews, it was determined that the hospice service agency failed to ensure five (5) patients records contained documented signature by either the patient or patient representative confirming that he or she has received a copy of the notice of rights and responsibilities. This poses the risk that patients will be unaware of their rights in receiving service hospice care and services. --- Review of policy no. 2-002.1 titled "Patient Bill of Rights," revealed, "...2. Upon admission, the admitting clinician/technician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights...4. The patient will be requested to sign the Patient Bill of Rights form. The patient's refusal to sign will be documented in the clinical record, including the refusal. 5. The admitting clinician will document that the patient has received a copy of the Patient Bill of Rights...." Review of policy no. 4-021.5 title "Admission Criteria and Process," revealed, "....5...The purpose of the initial visit will be to:...G. Review appropriate forms and subsequently sign forms by patient and family/caregiver...8. The hospice registered nurse will document that the above information has been furnished to the patient and family/caregiver...10. The patient or his/her representative will sign the required forms indicating election of hospice care and receipt of patient rights and privacy information...." Review of 29 patient records revealed 5 patients had no evidence of notice of patient rights, consents and/or benefit elections or evidence of signature by the patient, family/caregiver, or any hospice agency personnel documenting refusal to sign. During interviews on April 18, 2023, Employees #1 and #2 confirmed 5 patients had no evidence of notice of patient rights, consents and/or benefit elections or evidence of signature by the patient, family/caregiver, or any hospice agency personnel documenting refusal to sign.

Based on review of documentation and interviews, it was determined that the hospice service agency failed to provide information to the patients, caregivers and family on the patient's rights and the option to choose their physician for 29 of 29 patient records reviewed. The failure to inform and provide the patients of their rights, denies and prevents the patients from exercising a choice in the selection of a physician with whom they have an established relationship and trust. --- Findings include: Review of policy no. 2-002.1 titled "Patient Bill of Rights" revealed, "Purpose. To encourage awareness of patient rights, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning...and choose a health care provider (including an attending physician)...." Review of medical records revealed 18 of 29 patient records did not have the "hospice election statement" providing the choice of an attending physician. Additionally, the records reviewed showed the medical director, referring physician, and attending physician were all the same physician, Employee #3. Interview with Employee #2 on April 19, 2023 confirmed all the patients that were admitted were always assigned to Employee #3 as the attending physician.

Based on review of documentation and interviews, it was determined the hospice service agency failed to: --- L0543 provide required services at the frequency documented on the plan of care and within the acceptable standards of care to patients who resided in a group home or personal residence for 29 of 29 patient clinical records. L0552 review, revise the patients plan of care no less than every 15 days for 29 or 29 patients. The cumulative effect of these systemic deficient practices resulted in the hospice's failure to meet the requirement for Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services which poses the potential risk that patients who are at the end of life will not receive consistent and responsive care that meets the needs of the patient.

Based on review of documentation and interviews, it was determined the hospice service agency failed to develop and implement an individualized plan of care for 29 of 29 patients reviewed which poses the potential risk that care and services provided will not meet the specific patient/family needs related to the terminal illness and related conditions. --- Findings Include: Review of Policy 4-001.1 titled "Interdisciplinary Group Membership and Responsibilities," revealed, "...The interdisciplinary group will collaborate with the patient's attending physician to develop an individualized written plan of care... The interdisciplinary group responsibilities include but are not limited to: A. Participation in the establishment of the plan of care for each patient admitted to the hospice service. B. Participation in the periodic review and updating of the plan of care for each patient receiving hospice services...." Review of Policy 4-027.1 titled "The Plan of Care," revealed, "...A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. This plan of care must be initiated at start of care...." Review of Policy 4-031.1 titled "Interdisciplinary Group Plan of Care," revealed, "...The hospice IDG will retain professional management responsibilities for the provision of services... and will insure (sic) that services are furnished in a safe and effective manner. ... 8. The IDG ... will conduct assessments, develop and update the plan of care and review the effectiveness of care a minimum of every 15 calendar days...." Review of 29 of 29 patient records failed to reveal evidence that written individualized patient and family/caregiver plan of care had been established or implemented. Interview with Employee #1 confirmed that the medical records did not contain the IDG comprehensive Plan of Care for 29 of 29 patient records reviewed.

Based on review of documentation and interviews, it was determined the hospice service agency failed to ensure the hospice interdisciplinary group (IDG) reviewed, revised and documented updates to the individualized plans of care no less frequently than every 15 days for 29 of 29 patients. The failure to communicate the needs identified during patient assessment and revise the plan of care through IDG meetings poses the risk that care and services provided will not appropriately address the needs of the patient as the terminal illness and/or related conditions develop. --- Review of Policy 4.027.1 revealed, ";...To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues...A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program...The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days...Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care. Review of Policy 4-031.1 titled "Interdisciplinary Group Plan of Care," revealed, "...The hospice IDG will retain professional management responsibilities for the provision of services... and will insure (sic) that services are furnished in a safe and effective manner...Documentation of all communications will be included in the clinical record on a communication note, IDG meeting form, and/or clinical note...8. The IDG ... will conduct assessments, develop and update the plan of care and review the effectiveness of care a minimum of every 15 calendar days..." Review of Policy 4-032.1 titled "Interdisciplinary Group Meeting," revealed, "The IDG will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths, and changes in patient and family/caregiver circumstances, referrals, and admission/certification and rectification of patients on the hospice program. Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires..." Review of 10 of 29 patient records revealed no evidence that an IDG meeting occurred in order to implement, review and/or update plan of care as required by facility policy. Review of 18 of 29 patient records revealed 4 IDG meetings were held between January 1, 2023, and April 18, 2023; however, the records failed to contain evidence that the IDG reviewed and revised the plan of care as required by facility policy. Interview with Employee #3 on April 21, 2023, confirmed that the hospice service agency does not conduct regular and organized IDG meetings to review and evaluate patient care plans as required by facility policy.

Based on review of documentation and interviews, it was determined that the hospice service agency failed to provide services to the patients as outlined in the plan of care. The failure to provide services places the patients at an increased risk for adverse outcomes. --- Review of policy no 4-101.1 titled "Missed Visits," revealed, "...Missed visits will be communicated to the Interdisciplinary Group at the IDG Meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. 1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor of the missed visit and reason for missed visit. B. Document in the patient's clinical record the following information: 1. Patient name. 2. Date and type of visit that was missed. 3. Reason for the missed visit. 4. Description of any unmet needs and how the patient's needs were met. 5. Any other follow-up needed. 6. Other person(s) that were notified of the missed visit. 7. Signature of staff member reporting the information...." Review of 29 patient records on April 19, 2023 revealed each patient had an established plan of care frequency of one skilled nursing visit per week and one PRN. The EMR report titled "Missed Visits" dated April 19, 2023 revealed that skilled nursing (SN) visits for 29 of 29 patients had not been conducted at the frequency outlined in the patient's plan of care for the time frame of January 1, 2023, through April 15, 2023. A total of 244 SN visits were missed for the time period specified with an average daily census of 88 patients. Further review of the 29 patient records failed to contain any documentation of communication or coordination notes that the Medical Director had been notified of the missed visits, nor was there documentation of attempts to reschedule the missed visits in accordance with the agency's policies. Interview with Employee #1 on April 20, 2023 confirmed that skilled nursing visits were not being conducted according to facility policy and the prescribed plan of care.

Based on review of documentation and interviews, it was determined that the hospice service agency failed to: --- (L591) Ensure that nursing services were conducted based on initial, comprehensive and updated assessments in order to reflect the current health status of the patients and to establish the need for continued hospice care services. The cumulative effect of these systemic practices resulted in the facility's failure to meet the Condition of Participation in Core Services. Failure to routinely provide substantially all core services directly by hospice employees in a manner consistent with acceptable standards of care poses the risk that hospice patients will not receive care and services as needed.

Based on review of documentation and interviews, it was determined that the hospice service agency failed to provide nursing services were provided based on the patient's initial assessment, comprehensive assessment, and updated assessments for 29 of 29 patients which poses the risk of patient nursing needs not being met. --- Findings Include: Review of policy 4.002.1 titled "Hospice Nursing Care," revealed, "Procedure 1. The hospice registered nurse performs the initial assessment and participates in the comprehensive assessment and ongoing updates of the comprehensive assessments to assess the impact of the terminal diagnosis on the patient's physical, functional, psychosocial, and environmental needs and activities of daily living..." Agency Policy no, 4.101.1, entitled "Missed Visits" contained "...1.If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor of the missed visit and reason for missed visit B. Document in the patient's clinical record,,, 7.Signature of staff member reporting the information... 4.The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits...." Review of facility report titled "Missed Visits" for the timeframe from January 1, 2023 to April 15, 2023, revealed that skilled nursing visits for 29 of 29 patients had not been conducted at the frequency outlined in the patients' plan of care as outlined below: 8 skilled nursing (SN) visits missed week 01/01/2023-01/07-2023 12 SN visits missed week 01/08/2023-01/14/2023 10 SN visits missed week 01/15/2023-01/21/2023 10 SN visits missed week 01/22/2023-01/28/2023 13 SN visits missed week 01/29/2023-02/04/2023 18 SN visits missed week 02/05/2023-02/11/2023 18 SN visits missed week 02/12/2023-02/18/2023 9 SN visits missed week 02/19/2023-02/25/2023 24 SN visits missed week 02/26/2023-03/04/2023 24 SN visits missed week 03/05/2023-03/11/2023 25 SN visits missed week 03/12/2023-03/18/2023 24 SN visits missed week 03/19/2023-03/25/2023 22 SN visits missed week 03/26/2023-04/01/2023 15 SN visits missed week 04/02/2023-04/08/2023 12 SN visits missed week 04/09/2023-04/15/2023 The medical record did not contain communication or coordination notes that the Medical Director had been notified of the missed visits, nor was there documentation of attempts to reschedule the missed visits which did not ensure that the nursing needs of the patient are met per their outlined plans of care. During interviews between April 18, 2023, and April 21, 2023, with Employee #1 the number and frequency of all missed visits was acknowledged and confirmed.

Based on review of documentation and interviews, it was determined that the hospice service agency failed to: --- (L0651) Designate or have a governing body that assumed responsibility for the provision of ensuring that the agency employed, trained and oriented an adequate number of qualified staff to deliver care to the patients. (L0652) Provide care and services in compliance with acceptable standards of care. (L0662) Provide an initial orientation to the Medical Director for the duties of the position and training on the EMR in which to document patient care. The cumulative effect of these systemic practices resulted in the facility failure to meet the Condition of Participation of Organization and Administration of Services. Failure of the facility to organize, manage, and administer its resources to provide the hospice care and services poses the risk that patients, caregivers, and families will not receive the necessary palliation and management of the terminal illness and related conditions.

Based on review of documentation and interviews, it was determined that the governing body failed to provide oversight and direction to the hospice service agency including appointing an qualified individual as the administrator responsible for the day to day operations of the facility. Failure of the governing body to ensure that the hospice is managed by the administrator poses the potential risk that the hospice's established policies and procedures will not be implemented to provide appropriate care and services to patients. --- Agency Policy #1-001. entitled "Governing Body" was reviewed. It contained, in part, "...The Governing Body will assume full legal authority, responsibility, decision-making and accountability for the overall management and operations, the provision of services...human resource management...The Governing Body will appoint a qualified Executive Director/Administrator and establish procedures of systematic communication between the two..." Agency Policy #1-002.2 titled "Governing Body" was reviewed. It contained, in part, "...8. The Governing Body will appoint a qualified Executive Director/Administrator and establish procedures of systematic communication between the two. Performance of the Executive Director/Administrator will be monitored annually through a procedure established by the Governing Body. The process and documentation will reflect that: A. Relevant findings of performance improvement activities are consistently provided to the Governing Body. B. Other information relevant to the quality of patient care...is also consistently provided through a defined process. 9. The Governing Body will appoint a Corporate Compliance Officer who is responsible for the day-to-day oversight of the Corporate Compliance Program and coordination of all compliance initiatives. The Corporate Compliance Officer will report to the CEO/Administrator and the Governing Body. 10. The Governing Body will appoint a Corporate Compliance Committee... who will be charged with the support and implementation of the Corporate Compliance Program in conjunction with the Corporate Compliance Officer. The The Committee will consist of members from the Governing Body and senior-level managers. The Committee members will be trained and well-informed of the policies and elements of the Compliance Program. The Committee will meet at least quarterly...13. The Governing Body will evaluate the organization's performance on a regular basis. Agency Policy #1-002.3 was reviewed. It contained, in part, ""...The Governing Body will...Review their responsibilities and accountabilities in improving organizational performance..." Agency Policy #1-007.1 titled "Appointment of Executive Director/Administrator" was reviewed. It contained, in part, "The Governing Body will appoint the Executive Director/Administrator through a procedure established by the Governing Body. The Executive Director/Administrator will: 1. Be responsible for the day-to-day operations of the organization. 2. Have the necessary authority to implement his/her responsibilities for the operations, as conferred by the Governing Body...4. Be knowledgeable of applicable law and regulation including Medicare Conditions of Participation as applicable, state regulations, licensure requirements, and any other applicable local/state/ or federal regulations. 5. Take reasonable steps to assure that: A. The organization complies with applicable law and regulation. B. Action is taken on reports and recommendations of any authorized planning or regulatory inspection process. Agency Policy #1-008.1, titled "Designation of Individual in Absence of Executive Director/Administrator" was reviewed. It contained, in part, "Hope Hospice Care will have an Executive Director/Administrator or designee available at all times. 1.In the event that the Executive Director/Administrator is absent, the Clinical Director will assume the operational duties and responsibilities at Hope Hospice Care. (See Clinical Director Job Description in the Human Resources manual.) 2. In the event both are absent, an appropriately qualified nurse will assume the responsibilities. 3. These individuals have been identified as qualified to act on behalf of the Executive Director/Administrator in his/her absence." Review of records showed no meetings, activity, or appointment of a Corporate Compliance Committee or a Corporate Compliance Officer to implement and support a Corporate Compliance Program. Review of records show no personnel file for Employee #8 despite him/her being listed as an active employee. Review of Employee #1's personnel file revealed there was no appointment as administrator, no training on administrator duties, and no job description identifying her/him as the administrator. In an interview conducted on April 18, 2023, at 1700, Employee #1 stated s/he had not been informed she was appointed as the administrator. S/he stated s/he learned of her/his appointment as administrator by calling the Arizona Department of Health Services, Bureau of Medical Licensing (the Department). Employee #1 stated s/he notified the Department via email of a change of administrator to employee #8 and alternate administrator to employee #1 on April 18, 2023. Multiple attempts to contact employee #8 were made on April 18, 2023, April 19, 2023, April 20, 2023, and April 21, 2023, via phone (x3 numbers), text message (x3 numbers), and email (x2 email addresses), without return communication. Requests were made to employees #1 and #2 to contact employee #8, and employee #8 did not respond to their attempts at communication. none

Based on documentation and interviews, it was determined that the hospice service agency failed to consistently and routinely deliver nursing services and other covered services consistent with accepted standards of practice. The failure to provide routine care and other covered services places patients at increased risk for adverse outcomes and potentially avoidable events. --- The review of policy number 4-101.1 entitled "Missed Visits" revealed, "...1.If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor of the missed visit and reason for missed visit B. Document in the patient's clinical record the following information: 1. Patient name 2. Date and type of visit that was missed 3. Reason for the missed visit 4. Description of any unmet needs and how the patient's needs were met 5. Any other follow-up needed 6. Other person(s) that were notified of the missed visit 7. Signature of staff member reporting the information. 4.The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits. If a patient is routinely refusing visits, the clinician and the IDG should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and Medical Director." The review of the electronic medical record (EMR) reports by the agency's electronic software company (Hospice MD) revealed: A total of 244 skilled nursing (SN) visits missed between January 1, 2023, and April 15, 2023, based on the frequency of 1 visit per week per patient for a 105-working-day calendar week). A total of four (4) SN employees to cover the geographic area of Pima, Pinal and Maricopa counties in Arizona. Fifteen (15) missed Spiritual Counselor visits, 175 hospice aide missed visits, and there was no frequency for or documentation of social worker visits between January 1, 2023, and April 15, 2023, The agency's average daily patient census during the same period was 88 patients. There were 58 patients on service at the time of the complaint investigation. No evidence of documentation or communication to the IDG or Medical Director of missed visits or attempts to reschedule missed visits was found. During interviews between April 18, 2023, and April 21, 2023, with Employee #1 the number and frequency of all missed visits was acknowledged and confirmed. He/she stated several missed visits were related to staffing coverage and few may have been EMR documentation failure.

Based on review of documentation and interviews, it was determined that the hospice service agency failed to provide orientation to employees that address the employee's specific job duties. This failure poses the risk that employees' unable to perform specific job duties would also be unable to provide care and service in alignment with facility policies and procedures. --- Review of policy no. 1-021.1 titled "Contracted Service Providers" revealed, "...Hope Hospice Care will verify and document the training and qualifications for professionals and paraprofessionals who provide services to the organization's patients via contractual agreement. 1. Documentation of training and professional qualifications may be maintained by Hope Hospice Care or by the contracted organization...2. Documentation will be maintained for at least the following items: A. Successful completion of an approved training course. B. Demonstration of skills competency. C. Completion of organization's orientation. D. Current personnel records containing the documentation required by Hope Hospice Care...."Review of policy no. 2-002.1 titled "Patient Bill of Rights," revealed, "...8. All organization personnel, both clinical and non-clinical, will be oriented to the patient's rights and responsibilities prior to the end of their orientation program, as well as annually. (See "Patient Privacy Rights" Policy No. 2-012.) Review of HR policy no. 1-002.1 titled "Human Resources," revealed, "...6. All new employees will complete an orientation program...7. Completion of the orientation process will be documented in the personnel record...."During the review of employee records, there were no records found or provided for Employees #9 and #10, and there was no evidence either employee had received orientation and training regarding hospice services. Review of employee records revealed no documentation that orientation was provided to Employee #3. During an interview on April 21, 2023, at 1533, Employee #9 identified his/her position with the facility as a community liaison who was currently employed with the agency but had not had any calls in the "last couple of weeks." Employee #9 stated his/her duties were driving and delivering supplies to patients. During an interview on April 21, 2023, at 15:41 pm, Employee #10 identified his/her position with the facility as "liaison - care navigator and marketing outreach." S/he stated s/he was currently employed with the agency, and delivers DME and supplies. Interviews were conducted with Employees #1 and #2 on April 21, 2023, during which both confirmed Employees #9 and #10 had no personnel records. Employee #3 was interviewed on April 21, 2023, at approximately 1:00 pm. Employee #3 stated that s/he had never received orientation or training on the EMR system that the hospice was using and was not informed of his/her obligation to enter documentation on the patients into the EMR, nor was it on the job description.

Based on review of documentation and interviews, it was determined that the hospice service agency failed to: --- (L0667) ensure the Medical Director or physician designee reviews the clinical information for each hospice patient and provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course for 11 of 29 patients. (L0668) ensure the Medical Director or physician designee review the patient's clinical information for recertification for 26 of 29 patients. The cumulative effect of these systemic deficient practices resulted in the hospice's failure to meet the requirement for Condition of Participation for Medical Director which poses the risk of unqualified patients receiving hospice agency services.

Based on review of documentation and interview, it was determined that the hospice service agency failed to ensure the Medical Director provided written certification of terminal illness and anticipated duration of patient's life expectancy is 6 months or less. This failure could result in patients being admitted to hospice who do not qualify for hospice services. --- Review of policy no. 4-022.1 titled, "Certification of Terminal Illness," revealed, "...1. At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness...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. Hospice services will be provided in two (2) 90-day periods and an unlimited number of 60-day periods if the patient is recertified at the beginning of each benefit period...4. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim...7. All physician certification and authorization for hospice services and the certification of terminal illness forms will be filed in the patient's permanent clinical record...." Review of records revealed 11 of 29 patient records did not contain a certification of terminal illness form signed by the hospice Medical Director and/or the patient's attending physician. Interview with Employee #1 confirmed 11 patient records did not contain a signed certification of terminal illness form. Interview with the current Medical Director, Employee #3, confirmed s/he did not sign the certification of terminal illness forms for 11 patients.

Based on review of documentation and interview, it was determined that the hospice service agency failed to ensure the Medical Director reviewed the patient's clinical information for the purposes of recertification. This failure could result in patients continuing hospice services who do not qualify for hospice services. --- Review of policy no. 4-022.1 titled, "Certification of Terminal Illness," revealed, "...5. A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient's medical record or, if applicable, examination of the patient. A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than fifteen (15) calendar days prior or two (2) calendar days after the first day of each period. The signed and dated certification must be present prior to billing for each recertification period. 6. The hospice physician or nurse practitioner must have a face-to-face encounter with the patient within the 30 days prior to the 3rd benefit period recertification and within 30 days prior to each subsequent benefit period recertification. 7. All physician certification and authorization for hospice services and the certification of terminal illness forms will be filed in the patient's permanent clinical record...." Review of policy no. 4-032.1 titled, "Interdisciplinary Group Meeting" revealed, "The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care...and recertification of patients on the hospice program...7. Patient approaching recertification will be reviewed for the appropriateness of continuation of care based on identifiable criteria and progression of the terminal illness..." Review of policy no. 4-078.2 titled, "Contents of Medical Record" revealed, "...X. Certification and recertification(s) of terminal illness including physician narrative and face-to-face encounters as needed..." Review of records revealed 26 patient records did not contain documentation of the Medical Director's review of the patient's clinical information as outlined per IDG meeting guidelines for recertification purposes for multiple benefit periods. Interviews with Employees #1 and #3 confirmed 26 records did not contain regular IDG meetings to review patients' clinical information with the Medical Director for recertification purposes for multiple benefit periods.

Based on documentation reviews and interviews, it was determined that the hospice failed to: --- (L0672) ensure the patients' initial plans of care and updates to plans of care were completed and/or present in the patients' records. (L0673) demonstrate evidence of signed copies of the notice of patient rights were completed and/or present in the patients' records. (L0676) ensure physician certification and recertification of terminal illness were completed and/or present in the patients' records. The cumulative effect of these systemic deficient practices resulted in the hospice's failure to meet the requirements for Condition of Participation for Clinical Records.

Based on documentation and interview, it was determined the agency failed to include updates to the plans of care and comprehensive assessments in the patients' records for 29 of 29 patients. This failure could lead to poor or missed patient care. --- Review of policy no. 4-030.1 titled "Prioritizing Patient Problems/Needs," revealed, "...1. The plan of care will be based on the initial, comprehensive and ongoing assessments...3. Using the data obtained during the initial, comprehensive and ongoing hospice assessments, the hospice interdisciplinary group members will develop a list of patient problems and needs, with corresponding goals and anticipated target dates for reaching those goals...6. The plan of care will be updated by the interdisciplinary group as often as the condition of the patient indicates or no less than every 15 days...." Review of patient records revealed no evidence of updates to the plans of care and updates to the comprehensive assessments in the patients' records for 29 of 29 records reviewed. Interview with Employee #1 confirmed there was no evidence of updates to the plans of care and updates to the comprehensive assessments in the patients' records for 29 of 29 records reviewed.

Based on documentation and interviews, it was determined the agency failed to ensure patient records contained signed copies of the notice of patient rights and election statement. This failure could result in --- Review of policy no. 2-002.1 titled "Patient Bill of Rights," revealed, "...2. Upon admission, the admitting clinician/technician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights. 3. The Patient Bill of Rights will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand. 4. The patient will be requested to sign the Patient Bill of Rights form. The original form will be kept in the patient's clinical record. A copy will be maintained by the patient. The patient's refusal to sign will be documented in the clinical record, including the refusal. 5. The admitting clinician will document that the patient has received a copy of the Patient Bill of Rights..." Review of policy no 4-021.5 title "Admission Criteria and Process," revealed, "...3. Assignment of appropriate hospice personnel to conduct the initial assessments...5...The purpose of the initial visit will be to:...B. Provide a written copy and explain (verbally) the patient's rights and responsibilities...G. Review appropriate forms and subsequently sign forms by patient and family/caregiver...8. The hospice registered nurse will document that the above information has been furnished to the patient and family/caregiver and any information not understood by the patient and family/caregiver...10. The patient or his/her representative will sign the required forms indicating election of hospice care and receipt of patient rights and privacy information...." Review of 29 patient records revealed 5 patients had no evidence of notice of patient rights, consents and/or benefit elections or evidence of signature by the patient, family/caregiver, or any hospice agency personnel. Review of 29 patient records revealed 24 consents, patient rights, and/or benefit elections were present but were not signed by the hospice registered nurse to document information had been furnished to the patient and family/caregiver, if the information was not understood by the patient and family/caregiver, or if the patient or family/caregiver refused to sign. Interviews were conducted with Employees #1 and #2 on April 21, 2023, during which both confirmed 5 patients had no evidence of notice of patient rights, consents and/or benefit elections or evidence of signature by the patient, family/caregiver, or any hospice agency personnel and 24 consents, patient rights, and/or benefit elections were present but were not signed by the hospice personnel. They added Employees #9 and #10 had been responsible for obtaining signatures on the notice of patient rights, consents, and benefit elections from patients in order that the patients be placed on hospice services. Interviews with 5 patients (Patients #4, #7,#10, #11, and #16) between April 21-25, 2023, denied having a need for the hospice agency's services and did not know how or why they had been admitted to hospice services or recalled having signed any documents.

Based on documentation and interview, it was determined the agency failed to ensure the medical director provided written certification that it is anticipated that the patient's life expectancy is 6 months or less. This failure could result in patients being admitted to hospice who do not qualify for hospice services. --- Review of policy no. 4-022.1 titled, "Certification of Terminal Illness," revealed, "...1. At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness...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. Hospice services will be provided in two (2) 90-day periods and an unlimited number of 60-day periods if the patient is recertified at the beginning of each benefit period...4. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim...7. All physician certification and authorization for hospice services and the certification of terminal illness forms will be filed in the patient's permanent clinical record...." Review of policy no. 4-032.1 titled, "Interdisciplinary Group Meeting" revealed, "The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care...and recertification of patients on the hospice program...7. Patient approaching recertification will be reviewed for the appropriateness of continuation of care based on identifiable criteria and progression of the terminal illness...." Review of policy no. 4-078.2 titled, "Contents of Medical Record" revealed, "...X. Certification and recertification(s) of terminal illness including physician narrative and face-to-face encounters as needed...." Review of records revealed 18 of 29 patient records did not contain certification or recertification of terminal illness form provided by the Medical Director. Interview with Employee #1 confirmed 29 patient records did not contain a certification or recertification of terminal illness form to include a signature by the hospice Medical Director and/or the patient's attending physician. Interviews with Employees #1 and #3 confirmed 29 records did not contain regular IDG meetings to review patients' clinical information with the medical director in order to recertify patients who required recertification. Interview with Employee #3 confirmed s/he did not sign 29 patients' certification or recertification of terminal illness form, stating s/he "never received orientation or training on the EMR system that the hospice was using and was not informed of his/her obligation to enter documentation on the patients into the EMR, nor was it on the job description."

Upon patient record review, 3 of 5 (Patient #1, 3, 5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1- The medication list included Nystop 100,000 units topical. The location of application was not included. Patient #3 and 5- The medical record contained evidence that the patient was on oxygen. Oxygen was not included on the medication list.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1- The plan of care includes orders for spiritual care provider for 1 x eval and then PRN.

Upon patient record review, 3 of 5 (Patient #1, 3, 5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1- The plan of care included and order for Nystop 100,000 units topical. The location of application was not included. Patient #3 and 5- The medical record contained evidence that the patient was on oxygen. Order for oxygen was not included on the plan of care.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #1, 2, 3, 4, 5- The election statement did not include required information about the patient's right to elect the "Notice of non-covered items, services and Drugs" or the QIO information.

Upon patient record review 2 of 11 (Patient #4, 7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #4 admitted on 12/13/21 spiritual assessment performed on 12/20/2021. Patient #7 admitted on 12/23/20 spiritual assessment performed on 12/29/20.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 11 (Patient #2 and #7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #2 RN ordered 1 per 2 week, no RN visit documented after 12/14/2021. No evidence of missed visits or refusals during this timeframe. No evidence of the RN providing continuous assessment of the patient. Patient #7 RN ordered 1qow during certification period beginning 2/16/22. No RN visit has been made from 12/14/21 to time of survey 3/22/22. No evidence of missed visits, refusals or updated orders. No evidence of the RN providing continuous assessment of the patient.

Upon patient record review, 7 of 11 (Patient #1,3,4,5,6,8,9) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient#1 MSW and Chaplain ordered as needed on 3/2/22 Patient #3 MSW frequency listed as needed on POC 10/19/21. No evidence of updated order with frequency. SC also listed as needed on POC 10/19/21. No evidence of updated order with frequency. Patient #4 SC ordered as 1xprn effective 12/13/21. No evidence of updated order with frequency. Patient #5 RN frequency left blank : i.e. RN ____xwk and 3 prn. No evidence of updated order with frequency. Patient #6 MSW frequency listed as 1x as needed on POC dated 2/28/22. No evidence of updated order with frequency. Patient #8 MSW ordered as needed on poc dated 2/25/22. No evidence of updated order with frequency. Patient #9 MSW frequency listed as 1x as needed on POC dated 2/16/21. No evidence of updated order with frequency.

Upon client record review, 7 of 11 (Patient #1,2,4,5,6,7,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#1 SN frequency 1xw plus 3 prn for March 2022. Visits performed 3/20/22, and 3/21/22. No visits marked PRN. Patient #2 RN ordered 1 per 2 week, no RN visit documented after 12/14/2021. No evidence of missed visits or refusals during this timeframe. SC was not ordered on POC. Visits were performed 1/19/22 and 2/24/22. No evidence of an order for visits. Patient #4 RN ordered 1xwk plus 3 prns effective 12/13/21. No evidence of nursing visit the week of 1/2/22, 1/16/22, and 1/30/22. Patient #5 MSW and SC ordered 1xwk and 1 prn on POC dated 3/11/22. No evidence of MSW and SC visits or refusal of visits the week of 3/11/22 or 3/13/22. Patient #6 RN ordered 1xwk and 3 prn effective 2/28/22. No evidence of a RN visit the week of 3/6/22 or refusal of visit. Patient #7 RN ordered 1qow during certification period 2/16/22, No RN visit has been made from 12/14/21 to time of survey 3/22/22. No evidence of missed visits, refusals or updated orders. Patient #9 SC performed a visit on 3/3/22 however there is no evidence of an order for SC services. RN ordered 1xwk plus 3 prn. RN visits documented 3/3/22, 3/4/22, 3/5/22, 3/6/22. None marked prn. No evidence of updated order frequency

Upon patient record review 3 of 7 applicable (Patient #4, #9, 10) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #4 Aide frequency on POC dated 12/13/21 listed as 2xwk, no evidence of visits made the week of 12/13/21 and the week of 12/19/21. Aide frequency on POC dated 12/13/21 listed as 2xwk. Aide care plan created on 1/4/2022 however visits were made on 12/28/21 and 12/30/21 prior to aide care plan being developed. Patient #9 HHA ordered 3xwk effective 2/16/22. No evidence of visits or missed visits documented during week one. Patient #10 HHA visits ordered 2xwk effective week of 1/30/22. HHA visits documented on 2/8/22 and 2/22/22. No evidence of a second visit these weeks or of refusal of visits.