Every finding on record at Htn Hospice, Inc

Based on interview and record review, the hospice agency (HA) failed to ensure one of six sampled patients (Patients 4) was informed in writing of his/her rights in a language the patient understands before admission for hospice care. This deficient practice has the potential to result in the patients lack knowledge and understanding of their care and responsibilities as a patient certified to receive the hospice benefits. --- Findings: A review of Patient 4s Patient Information Sheet indicated a Start of Care (SOC) of 6/9/2022 with a primary diagnosis of heart disease. A review of Patient 4s Certification of Terminal Illness (CTI) indicated the patient's illness included a prognosis (course of the illness) of having 6 months to live or less. A review Patient 4's Re-Certification Statement for Next 60-day period from 12/6/2022 to 2/3/2023 indicated a primary diagnosis was heart disease. The CTI included a prognosis (course of the illness) of having 6 months to live or less. During a phone interview on 7/12/2023, at 11:20 am., Patient 4 stated, an unknown person came to her door offering six months of health care. Patient 4 did not know what company enrolled her for hospice services. Patient 4 further stated she believed sometime last year someone came and offered a box of free Ensure (nutritional supplement) if she signed for hospice. Patient 4 signed the paper not knowing what she was signing for. There was no documented evidence Patient 4's rights and responsibilities was explained by the hospice. Patient 4 was receiving hospice services since SOC of 6/9/2022.

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Initial and Comprehensive Assessment of Patient was met as evidenced by: The Hospice failed to conduct an accurate 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) that reflected the patients current health status that identified the patients needs for hospice care and services for four of six sampled patients (Patients 3, 4, 5, and 6) Refer to L524. The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated Federal compliance for Initial and Comprehensive Assessment of Patient to ensure highest quality of care was provided for patients certified to receive hospice care benefits.

Based on interview, observation, and record review, the hospice agency failed to conduct the accurate comprehensive assessments (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness, in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) to meet the patients' needs during the terminal stage of the illness for four of six sampled patients (Patients 3, 4, 5, and 6). This deficient practice resulted in the provision of hospice services to patients who were not accurately assessed to receive hospice care and services. --- Findings: a. During a review of Patient 3's electronic clinical record indicated a start of care date of 7/12/2022, with a terminal diagnosis of Atherosclerotic heart disease of native coronary artery (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow), with unspecified Angina Pectoris (chest pain or discomfort due to coronary artery disease), with documented spasm. Patient 3's clinical record identified the patient with progressive decline in physical/functional/cognitive decline, alert, oriented x 3, lower back pain, increased shortness of breath (SOB) with exertion, ambulates occasionally. A review of Patient 3's initial Nursing Assessment Narrative /Summary visit by the Registered Nurse (RN), dated 7/12/2022, indicated Patient 3 was admitted to hospice under routine level of care for primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris and co-morbidities such diabetes Mellitus (DM- a group of diseases that result in too much sugar in the blood), Hypertension (HTN- high blood pressure), KPS ( Karnofsky Performance Status Scale ( measures the level of patient activity and medical care requirements) of 40%. Patient 3was a Full code, has dizziness, shortness of breath with minimal exertion. Patient 3 was incontinent of bladder. Patient 3 has increasing physical activities intolerance being unable to perform physical activity without dyspnea. Patient3 needs maximum level of assistance. Patient 3 has poor appetite and fluid intake and is a high risk for skin breakdown. A review of Patient 3's "Physician's Certification Of Terminal Illness," for the first 90- day period from 7/12/2022 to 9/9/2023, indicated Patient 3's terminal diagnosis was atherosclerotic heart disease of native coronary artery with unspecified angina pectoris with documented spasms ", and coexisting comorbidities of gastroesophageal reflux disease (GERD- a digestive disease in which stomach acid or bile irritates the food pipe lining), hypothyroidism ( a condition in which the thyroid gland does not produce enough thyroid hormone which can slow your heart rate, weight gain, tiredness and weakness), and hypertension ( high blood pressure). There was no documented evidence the RN assessment for Patient 3's needs were further assessed comprehensively for the provision of the patient's needs identified such as pain assessment for low back pain and angina pectoris, blood sugar monitoring for diabetes, BP monitoring for hypertension, skin integrity for urinary incontinence, Physical therapy services for progressive physical decline, and dietary assessment for poor appetite. There was no documented evidence the comprehensive assessment was conducted by other services to meet the psychosocial and spiritual needs of the patient. 2. A review of Patient 4's electronic clinical record indicated a start of hospice care date of 11/1/2022, with a terminal diagnosis of Atherosclerotic heart disease of native coronary artery (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow), with unspecified Angina Pectoris (chest pain or discomfort due to coronary artery disease). A review of the initial Nursing Assessment Narrative /Summary visit by the Registered Nurse (RN), dated 11/1/2022, indicated Patient 4 was admitted to hospice under routine level of care for primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris and co-morbidities such diabetes Mellitus (DM- a group of diseases that result in too much sugar in the blood), Hypertension (HTN- high blood pressure). Patient 4 is a full code, has dizziness, shortness of breath with minimal exertion. Patient was incontinent of bladder. Patient 4has increasing physical activities intolerance being unable to perform physical activity without dyspnea. Patient 4 needs maximum level of assistance. Patient 4 has poor appetite and fluid intake and is a high risk for skin breakdown. A review of Patient 4s "IDG Conference Notes/Update To Plan Of Care ," dated 11/1/2022, indicated the skilled nurse (SN) visit frequency for Patient 5s was once a week for 60 days . To measure pulse and blood pressure, RR, and oxygen saturation every visit for symptom management, and for the SN to check O2 saturation (sat) PRN for Shortness Of Breath (SOB)-call MD for oxygen at less than 90%, nursing assessment of patient/caregiver (cg) needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). There was no documented evidence the IDG assessment for Patient 4's needs were further assessed for the provision of the patient's needs that included BP and O2 monitoring, and assessments conducted by other services to meet the psychosocial and spiritual needs of the patient. 3. During a review of Patient 5's electronic clinical record indicated a start of care date of 3/1/2022, with a primary terminal diagnosis of heart failure, unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet the tissue metabolic requirements." A review of the initial Nursing Assessment Narrative /Summary visit by the Registered Nurse (RN), dated 3/1//2023, indicated Patient 5 was admitted to hospice under routine level of care for primary diagnosis of heart failure, unspecified and co-morbidities such Hyperlipidemia( high concentrations of fat particles/lipids in the in the blood), Diabetes Mellitus (DM- a group of diseases that result in too much sugar in the blood), chronic kidney disease ( kidney damage and loses their ability to filter waste and fluid out of your blood which can lead to kidney failure), and Hypertension (HTN- high blood pressure). Patient 5 was incontinent of bladder. Patient 5 requires maximum assistance with activities of daily living and spends almost 75% of the time in bed. Patient 5 has poor appetite and fluid intake and was a high risk for skin breakdown. There was no documented evidence the RN assessment for Patient 5's needs were further assessed comprehensively for the provision of the patient's needs identified such as blood sugar monitoring for diabetes, BP monitoring for hypertension, skin integrity for incontinence, Physical therapy services for progressive physical decline, and dietary assessment for poor appetite. There was no documented evidence the comprehensive assessment was conducted by other services to meet the psychosocial and spiritual needs of the patient. A review of Patient 5s "IDG Conference note/Update to Plan of Care," dated 3/1/2023, indicated the skilled nurse (SN) visit frequency for Patient 1 was once a week for 60 days, to measure pulse and blood pressure, RR, and oxygen saturation every visit for symptom management, and for the SN to check O2 saturation (sat) PRN for Shortness Of Breath (SOB)-call MD for oxygen at less than 90%, nursing assessment of patient/caregiver (cg) needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). On 7/12/2023, at 10:30 a.m., a joint home visit was conducted with the Medical Social Worker (MSW), Patient 5's caregiver (PCG), and family member (FM)1. Patient 5 was observed sitting on the side of his bed, alert and oriented. During an interview with the PCG and FM, they both stated Patient 5 receives hemodialysis every day by them at home. The PCG stated, she was not aware Patient 5 had six months or less to live and that the nurse comes once a week to take Patient 5s blood pressure. When asked about the hospice agency was providing spiritual counseling, FM stated Patient 5 walks with the wife sometimes to their church close by. Patient 5, PCG, and FM, stated that he eats well and does not have a poor appetite. Patient 5s PCG and family member stated that patient was doing great, and they have no concerns regarding his health. 4. During a review of Patient 6's electronic clinical record indicated a start of care date of 5/15/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow ), with unspecified Angina Pectoris (chest pain or discomfort due to coronary artery disease). A review of the initial Nursing Assessment Narrative /Summary visit by the Registered Nurse (RN), dated 5/15/2023, indicated Patient 6 was admitted to hospice under routine level of care for primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris and co-morbidities such as H/O Angioplasty ( a surgical procedure using a balloon to stretch open/a narrowed or blocked artery.), Diabetes Mellitus (DM- a group of diseases that result in too much sugar in the blood), Hypertension (HTN- high blood pressure). Patient 6 was incontinent of bladder, requires maximum assistance with activities of daily living and spends almost 75 % of the time in bed. Patient has poor appetite and fluid intake and is a high risk for skin breakdown. Given the terminal condition, the family has decided against any form of aggressive treatment and only wants comfort measures, symptom management and pain management. There was no documented evidence the RN assessment for Patient 6's needs were further assessed comprehensively for the provision of the patient's needs identified such as blood sugar monitoring for diabetes, BP monitoring for hypertension, skin integrity for incontinence, physical therapy services for progressive physical decline, and dietary assessment for poor appetite. There was no documented evidence the comprehensive assessment was conducted by other services to meet the psychosocial and spiritual needs of the patient. During a joint interview with the Director of Patient Care Services on 7/13/2023, at 2 pm., he stated he comes to the hospice agency about one time a week. DPCS designee stated she was in the office a few times a week. When asked what the hospices admission criteria both stated, they receive a referral from physician, review the history and physical with the medical director, prior to admission to hospice, send the RN out to conduct initial evaluation, and admit patients.

Based on interview, observation, and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows: The Hospice Medical Director or physician designee failed to review and verify the clinical information for each hospice patient with their primary physician for four of six sampled patients (Patients 3, 4, 5, and 6). Refer to L667 The Hospice Medical Director or physician designee failed to ensure the recertification of terminal illness for three of six sampled patients (Patients 3, 4, and 6) were reviewed and verified the clinical information necessary for certification of these patients for hospice care services. Refer to L668 The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Medical Director to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on observation, interview, and record review, the hospice Medical Director or physician designee to failed to review and verify the clinical information for each hospice patient and failed to provide written certification that it was anticipated the patient's life expectancy is 6 months or less if the illness runs its normal course for four of six sampled patients (Patient 3, 4, 5, and 6). This deficient practice had resulted for these patients being certified to receive hospice care services and benefits. --- Findings: a. During a review of Patient 3's electronic clinical record indicated a start of care date of 7/12/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow), with unspecified angina pectoris (chest pain or discomfort due to coronary artery disease), with documented spasm. A review of the initial Nursing Assessment Narrative /Summary visit by the Registered Nurse (RN), dated 7/12/2022, indicated Patient 3 was admitted to hospice under routine level of care for primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris and co-morbidities such diabetes Mellitus (DM- a group of diseases that result in too much sugar in the blood), Hypertension (HTN- high blood pressure), KPS ( Karnofsky Performance Status Scale ( measures the level of patient activity and medical care requirements) of 40%. Patient was a full code, has dizziness, shortness of breath with minimal exertion. Patient 3 was incontinent of bladder. Patient 3 has increasing physical activities intolerance being unable to perform physical activity without dyspnea. Patient 3 needs maximum level of assistance. Patient 3 has poor appetite and fluid intake and is a high risk for skin breakdown. Given the terminal condition, the family has decided against any form of aggressive treatment and only wants comfort measures, symptom management and pain management. Patient 3 was appropriate for hospice care, meeting the criteria for LCD eligibility. A review of Patient 3s "IDG Conference Notes/Update to Plan of Care," dated 11/1/2022, indicated the skilled nurse (SN) visit frequency for Patient 5s was once a week for 60 days. SN was to take vital signs, and check O2 saturation (O2 sat) as needed (PRN) for shortness of breath (SOB). SN to call MD for O2 sat less than 90%, nursing assessment of patient/caregiver (cg) needs, evaluation of patient/caregiver response to effectiveness of intervention, Social Worker to visit once a month to assess, evaluation of communication, coping of patient/caregiver, community resources intervention of patient and anticipatory grief needs. The Registered Nurse (RN) supervisory visits every 14 days. Volunteer, spiritual care services, and MSW were "Declined". Chaplain initial evaluation within 5 days of admission and every recertification starting on 11/1/2022. A review of the "Physician's Certification Of Terminal Illness," for the first 90 day period from 7/12/2022 to 9/9/2023, indicated Patient 3's terminal diagnosis was atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, with documented spasms" and coexisting comorbidities of gastroesophageal reflux disease (GERD- a digestive disease in which stomach acid or bile irritates the food pipe lining), hypothyroidism ( a condition in which the thyroid gland does not produce enough thyroid hormone which can slow your heart rate, weight gain, tiredness and weakness.)and Hypertension ( high blood pressure). Patient 3 with progressive decline in physical/functional/cognitive decline, alert, oriented x 3, Lower back pain, increased SOB with exertion, ambulates occasionally. The hospice physician certified Patient 3 indicating the patient has a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice Medical director or the physician designee coordinated with the primary physician regarding Patient 3's clinical information to qualify or be certified to receive hospice care. b. During a review of Patient 4's electronic clinical record indicated a start of hospice care date of 11/1/2022, with a terminal diagnosis of Atherosclerotic heart disease of native coronary artery (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow ), with unspecified Angina Pectoris (chest pain or discomfort due to coronary artery disease). A review of the "Physician's Certificate Of Terminal Illness," for the first 90- day period from 11/1/2022 to 1/29/2023, indicated Patient 4's terminal diagnosis was Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris , without Angina Pectoris ", and coexisting comorbidities. Patient 4 with progressive decline in physical/functional/cognitive decline, alert, oriented x 3, Lower back pain, increased SOB with exertion, ambulates occasionally .There was no documented evidence the hospice medical director or the hospice attending physician communicated with the primary physician to certify that Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of the initial Nursing Assessment Narrative /Summary visit by the Registered Nurse (RN), dated 11/1/2022, indicated Patient 4 was admitted to hospice under routine level of care for primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris and co-morbidities such diabetes Mellitus (DM- a group of diseases that result in too much sugar in the blood), Hypertension (HTN- high blood pressure), KPS ( Karnofsky Performance Status Scale ( measures the level of patient activity and medical care requirements) of 40%. Patient is a full code, has dizziness, shortness of breath with minimal exertion. Patient 4 is incontinent of bladder. Patient 4 has increasing physical activities intolerance being unable to perform physical activity without dyspnea. Patient 4 needs maximum level of assistance. Patient 4 has poor appetite and fluid intake and is a high risk for skin breakdown. Given the terminal condition, the family has decided against any form of aggressive treatment and only wants comfort measures, symptom management and pain management. Patient 4 is appropriate for hospice care, meeting the criteria for LCD eligibility. A review of Patient 4s "IDG Conference Notes/Update To Plan Of Care ," dated 11/1/2022, indicated the skilled nurse (SN) visit frequency for Patient 5s was once a week for 60 days . To measure pulse and blood pressure, RR, and oxygen saturation every visit for symptom management, and for the SN to check O2 saturation (sat) PRN for Shortness Of Breath (SOB)-call MD for oxygen at less than 90%, nursing assessment of patient/caregiver (cg) needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). Continued review of the Initial orders and Plan of care instructed the social worker to visit once a month to assess, evaluation of communication, coping of patient/caregiver, community resources intervention of patient and anticipatory grief needs. It also stipulated that volunteer, and spiritual care was "Declined". The Registered Nurse (RN) visits for every 14 days-supervisory visits. Chaplain initial evaluation within 5 days of admission and every recertification starting on 11/1/2022. Medical Social Worker indicated Decline starting on 11/1/2022. c. A review of Patient 5's electronic clinical record indicated a start of care date of 3/1/2022, with a primary terminal diagnosis of heart failure, unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet the tissue metabolic requirements." A review of the "Physician's Certificate Of Terminal Illness," for the first 90- day period from 3/1/2023 to 5/29/2023, indicated Patient 5's terminal diagnosis was heart failure, unspecified, and other coexisting comorbidities Hypertension ( High blood pressure), SOB( Shortness of Breath, chest pain, Diabetes Mellitus type 2 ( a chronic condition that affects the way the blood processes sugar (glucose) , the body either does not produce enough insulin, or either it resist insulin). Patient 5 with progressive decline in physical/functional/cognitive decline, alert, oriented x3, intermittently forgetful, increased shortness of breath with exertion = 1 edema of Bilateral lower extremities, ambulates occasionally with use of walker, cane and personal assistance. There was no documented evidence the hospice medical director or the hospice attending physician communicated with the primary physician to certify that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of the initial Nursing Assessment Narrative /Summary visit by the Registered Nurse (RN), dated 3/1//2023, indicated Patient 5 was admitted to hospice under routine level of care for primary diagnosis of heart failure, unspecified and co-morbidities such Hyperlipidemia( high concentrations of fat particles/lipids in the in the blood), Diabetes Mellitus (DM- a group of diseases that result in too much sugar in the blood), chronic kidney disease ( kidney damage and loses their ability to filter waste and fluid out of your blood which can lead to kidney failure), and Hypertension (HTN- high blood pressure), and patient is status post hospitalization. Patient 5 is incontinent of bladder, with a KPS( Karnofsky Performance Status Scale ( measures the level of patient activity and medical care requirements) of 40%.Patient 5 requires maximum assistance with activities of daily living and spends almost 75% of the time in bed. Patient 5 has poor appetite and fluid intake and is a high risk for skin breakdown. Given the terminal condition, the family has decided against any form of aggressive treatment and only wants comfort measures, symptom management and pain management. Patient 5 is appropriate for hospice care, meeting the criteria for LCD eligibility. A review of Patient 5s "IDG CONFERENCE NOTE/UPDATE TO PLAN OF CARE," dated 3/1/2023, indicated the skilled nurse (SN) visit frequency for Patient 5 was once a week for 60 days, to measure pulse and blood pressure, RR, and oxygen saturation every visit for symptom management, and for the SN to check O2 saturation (sat) PRN for Shortness Of Breath (SOB)-call MD for oxygen at less than 90%, nursing assessment of patient/caregiver (cg) needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). Continued review of the Initial orders and Plan of care instructed the social worker to visit once a month to assess, evaluation of communication, coping of patient/caregiver, community resources intervention of patient and anticipatory grief needs. It also stipulated that volunteer, and spiritual care was "Declined". The Registered Nurse (RN) visits for every 14 days-supervisory visits. Chaplain initial evaluation within 5 days of admission and every recertification starting on 3/1/2023. Medical Social Worker, (MSW) services, indicated Decline starting on 3/1/2023. Further review of Patient 5s "IDG Conference Notes/Update To Plan Of Care ," for the certification period of 5/30/2023 to 8/27/2023 dated 7/7/2022, indicated the skilled nurse (SN) visit frequency for Patient 5s was once a week for 60 days, with Registered Nurse (RN) visits for every 14 days-supervisory visits. Chaplain initial evaluation within 5 days of admission and every recertification starting on 5/30/2023. Medical Social Worker indicated Decline starting on 5/30/2023. On 7/12/2023, at 10:30 a.m., a joint home visit was conducted with the Medical Social Worker (MSW), Patient 5's caregiver (PCG), and family member (FM)1. Patient 5 was observed sitting on the side of his bed, alert and oriented. During an interview with the PCG and FM, they stated Patient receives hemodialysis every day by them at home. The PCG stated, she was not aware patient 5 had six months or less to live and that the nurse comes once a week to take Patient 5s blood pressure. When asked about if the hospice provided spiritual counseling FM stated, Patient 5 walks with the wife sometimes to their church close by. Patient 5s PCG and FM stated that he eats well and does not have a poor appetite. Patient 5s PCG and family member stated that patient was doing great, and they have no concerns regarding his health. d. During a review of Patient 6's electronic clinical record indicated a start of hospice care date of 5/15/2022, with a terminal diagnosis of Atherosclerotic heart disease of native coronary artery (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow), with unspecified Angina Pectoris (chest pain or discomfort due to coronary artery disease). A review of the "Physician's Certificate of Terminal Illness," for the first 90- day period from 5/15/2022 to 7/113/2023, indicated Patient 6's terminal diagnosis was Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, without Angina Pectoris ", and coexisting comorbidities. Patient 6 with progressive decline in physical/functional/cognitive decline, alert, oriented x 3, Lower back pain, increased SOB with exertion, ambulates occasionally. There was no documented evidence the hospice medical director or the hospice attending physician communicated with the primary physician to certify that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of the initial Nursing Assessment Narrative /Summary visit by the Registered Nurse (RN), dated 5/15/2023, indicated Patient 6 was admitted to hospice under routine level of care for primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris and co-morbidities such as H/O Angioplasty ( a surgical procedure using a balloon to stretch open/a narrowed or blocked artery.), Diabetes Mellitus (DM- a group of diseases that result in too much sugar in the blood), Hypertension (HTN- high blood pressure), and patient is status post hospitalization. Patient 6 is incontinent of bladder, with a KPS ( Karnofsky Performance Status Scale ( measures the level of patient activity and medical care requirements) of 50%. Patient 6 requires maximum assistance with activities of daily living and spends almost 75% of the time in bed. Patient 6 has poor appetite and fluid intake and is a high risk for skin breakdown. Given the terminal condition, the family has decided against any form of aggressive treatment and only wants comfort measures, symptom management and pain management. Patient 6 is appropriate for hospice care, meeting the criteria for LCD eligibility. A review of the "Initial orders and Plan of Care," dated 5/15/2022, indicated the skilled nurse (SN) visit frequency for Patient 6 was once a week for 60 days with Registered Nurse (RN) visits for every 14 days-supervisory visits. To measure pulse and blood pressure, RR, and oxygen saturation every visit for symptom management, and for the SN to check O2 saturation (sat) PRN for Shortness of Breath (SOB)-call MD for oxygen at less than 90%, nursing assessment of patient/caregiver (cg) needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). Continued review of the Initial orders and Plan of care instructed the social worker to visit once a month to assess, evaluation of communication, coping of patient/caregiver, community resources intervention of patient and anticipatory grief needs. It also stipulated that volunteer, and spiritual care was "Declined". On 7/13/22 at 11:02 a.m., during a telephone interview with the hospice agency's Medical Doctor (MD) regarding determining hospice criteria, he stated that sometimes patients are referred by their apartment managers, a friend-of- a -friend and that the RN reviews the supporting evidence to determine hospice from records from the hospital, records from primary doctors, labs, diagnostic records, reviews the chart, discuss it with the RN, he might do a Zoom to see patient on face time and document in the chart. The agency hospice MD stated it is the office staff who was responsible for informing the primary physician and getting the past history and physicals. During a joint interview with the Director of Patient Care Services on 7/13/2023, at 2 pm, he stated he comes to the hospice agency about one time a week. The DPCS designee stated she is in the office a few times a week. When asked about the hospices admission criteria stated, they receive a referral from physician, review the history and physical with the Medical director, prior to admission to hospice, send the RN out to conduct initial evaluation, and admit patients. The DPCS and DPCS designee were sked to provide the history, physical, x-rays, laboratory values that supported the sample patients criteria for hospice, they stated they did not have them and were unable to provide the requested documentation. A review of the hospice agencys policy and procedure titled, "; Admission Criteria and Process, policy No. 4-021.1", revised April 2018, under Procedure #1., documents, "; The organization will utilize referral information provided by family/caregiver, health care clinicians from acute facilities, skilled or intermediate nursing facilities, other agencies, and physician offices in the determination of eligibility for admission to the program."

Based on interview and record review, the medical director or physician designee failed to ensure the recertification of terminal illness for three of six sampled patients, (Patients 3, 4, and 6) were reviewed and verified signed by the medical director and/or physician designee. This deficient practice had resulted for these patients to be recertified for hospice care lacking verification of clinical information to continue provision of hospice care which can affect their quality of life and well being. --- Findings: a. During a review of Patient 3s Patient Intake Sheet indicated a Start of Care (SOC) date of 7/12/2022, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow), with unspecified angina pectoris (chest pain or discomfort due to coronary artery disease), with documented spasm. A review of Patient 3s first Certification of Terminal illness (CTI, illness with a prognosis of having 6 months of life or less) for 7/12/2022 to 9/9/2022, indicated that per the IDTs (Interdisciplinary group, team who is responsible for the holistic care of the hospice beneficiary), discussion, and recommendations, Patient 3 was determined as appropriate for hospice services". The physicians face-to face and narrative summary dated 7/12/2022, indicates patient has a primary diagnosis of atherosclerotic heart disease of native coronary artery, with unspecified Angina Pectoris with documented spasm. Patient 3s condition has progressively worsened and has a life expectancy of six months or less, if the terminal illness runs its normal course. A review of Patient 3s recertification statement for the certification period of 11/1/2022 to 1/29/2023, for the 4th benefit period indicated the registered nurses prognosis summary and the physician's face-to face and narrative summary indicated Patient 3s primary diagnosis of atherosclerotic heart disease of native coronary artery, with unspecified Angina Pectoris with documented spasm, a rapid decline in physical, functional and cognitive abilities. Patient 3 was recertified with no documented evidence of a comprehensive re-assessment of the patient's hospice status that included physical, and clinical status that was conducted thoroughly by the hospice medical director or designee. b. A review of Patient 4s Patient Intake Sheet indicated a Start of Care (SOC) date of 7/12/2022, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow), with unspecified Angina Pectoris (chest pain or discomfort due to coronary artery disease), with documented spasm. A review of Patient 4s first Certification of Terminal illness (CTI, illness with a prognosis of having 6 months of life or less) for 11/1/2022 to 1/29/2023, indicated that per the IDTs (Interdisciplinary group, team who is responsible for the holistic care of the hospice beneficiary), discussion, and recommendations, Patient 4 was determined as appropriate for hospice services. The physicians face-to face and narrative summary dated 7/12/2022, indicated patient has a primary diagnosis of Atherosclerotic heart disease of native coronary artery, with unspecified Angina Pectoris with documented spasm. Patient 4s condition has progressively worsened and has a life expectancy of six months or less, if the terminal illness runs its normal course. A review of Patient 4s recertification statement for the certification period of 6/29/2023 to 8/27/2023, for the 4th benefit period indicated the registered nurses prognosis summary and the physician's face-to face and narrative summary indicated Patient 4s primary diagnosis of Atherosclerotic heart disease of native coronary artery, with unspecified Angina Pectoris. With a rapid decline in physical, functional and cognitive abilities. Patient 4 was recertified with no documented evidence of a comprehensive re-assessment of the patient's hospice status that included physical, and clinical status that was conducted thoroughly by the hospice medical director or designee. During a phone interview on 7/12/2023, at 11:20 am., Patient 4 stated, an unknown person came to her door offering six months of health care. Patient 4 did not know what company enrolled her for hospice services. Patient 4 further stated she believed sometime last year someone came and offered a box of free Ensure (nutritional supplement) if she signed for hospice. Patient 4 signed the paper not knowing what she was signing for. c. A review of patient 6s Patient Intake Sheet indicated a Start of Care (SOC) date of 5/15/2022, with a primary diagnosis of Atherosclerotic heart disease of native coronary artery (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow), with unspecified Angina Pectoris (chest pain or discomfort due to coronary artery disease), A review of patient 6s first Certification of Terminal illness (CTI, illness with a prognosis of having 6 months of life or less) for the first benefit period for the certification period of 5/19/2022 to 7/13/2022, indicated that per the IDTs (Interdisciplinary group, team who is responsible for the holistic care of the hospice beneficiary), discussion, and recommendations, Patient 6 was determined as appropriate for hospice services". The physicians face-to face and narrative summary dated 5/15/2022, indicates patient has a primary diagnosis of Atherosclerotic heart disease of native coronary artery, with unspecified Angina Pectoris with documented spasm. Patient 6s condition has progressively worsened and has a life expectancy of six months or less, if the terminal illness runs its normal course. A review of Patient 6s recertification statement for the certification period of 9/12/2023 to 11/10/2023, indicated the registered nurses prognosis summary and the physician's face-to face and narrative summary indicated Patient 3s primary diagnosis of Atherosclerotic heart disease of native coronary artery, with unspecified Angina Pectoris with documented spasm, rapid decline in physical, functional and cognitive abilities. Patient 6 was recertified with no documented evidence of a comprehensive re-assessment of the patient's hospice status that included physical, and clinical status that was conducted thoroughly by the hospice medical director or designee. On 7/13/22, at 11:02 a.m., during a telephone interview with the hospice agency's Medical Doctor (MD) regarding determining hospice criteria, he stated that sometimes patients are referred by their apartment managers, a friend-of- a -friend and that the RN reviews the supporting evidence to determine hospice from records from the hospital, records from primary doctors, labs, diagnostic records, reviews the chart, discuss it with the RN, he might do a Zoom to see patient on face time and document in the chart. The agency hospice MD stated it is the office staff who was responsible for informing the primary physician and getting the past history and physicals. During a joint interview with the Director of Patient Care Services on 7/13/2023, at 2 pm., he stated he comes to the hospice agency about one time a week. The DPCS designee stated she is in the office a few times a week. When asked about the hospices admission or re-admission criteria stated, they receive a referral from physician, review the history and physical with the Medical director, prior to admission to hospice, send the RN out to conduct initial evaluation, and admit patients. The DPCS and DPCS designee were sked to provide the history, physical, x-rays, laboratory values that supported the sample patients' criteria for hospice, they stated they did not have them and were unable to provide the requested documentation.