Every finding on record at Immanuel Hospice, Inc

Based on interview and record review, the hospice agency (HA) failed to ensure the emergency preparedness plan/drill for all staffs were completed in an annual basis. This failure had the potential for the staff to lack the knowledge to respond effectively during a emergency/disaster situation. Findings: During a review of the emergency preparedness plan of the HHA on 6/7/22 at 3:00 p.m., the HA did not have evidence of Emergency Preparedness training/disaster drill for all field staff. During a joint interview with the Human Resources Manager (HR) and the Office manager on 6/7/22 at 3:00 p.m., they stated they could not provide evidence of the field staff receiving Emergency Preparedness training/disaster drill training. The Hospice Agency policy and procedure titled "Emergency Operations Plan" indicated that the plan will be tested and evaluated annually at each site either in response to an actual emergency or in a planned exercise. The exercise will focus on hospice ability to continue to serve patients in the event of an emergency. All staffs will be oriented and trained to the emergency operations plan. Ongoing staff education and training will occur annually as part of an exercise or in response to an actual emergency.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Initial and Comprehensive Assessment was met as follws: 1. The HA failed to accurately assessed the patient's eligibility for hospice services related to the palliation and management of the terminal illness and related conditions for eleven of 13 sampled patients (Patient 2, 3, 4, 5, 6, 7, 8,10, 11, 12 and 13). (Refer to L521) 2. The HA failed to ensure comprehensive assessment including vital signs, height, weight, and oxygen saturation (the fraction of oxygen-saturated hemoglobin relative to total hemoglobin in the blood- normal pulse oximeter readings usually range from 95 to 100 percent) was conducted to the patients for 8 of 13 sampled patients (Patient 4, 5, 6, 7, 8, 10, 11 and 12). (Refer to L524) 3. The HA staff failed to ensure one of 13 sampled patients (Patient 3) had home medications listed in the medication profile. (Refer to L530) 4. The HA failed to provide initial bereavement assessments for eight of 13 sampled patients (Patients 1, 4, 6, 7, 10, 11, 12 and 13). (Refer to L531) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with the Initial and Comprehensive Assessment of Patient to ensure highest quality of care are provided to the patients assessed for eligibility to receive hospice care and services.

Based on observation, interview, and record review, the hospice agency (HA) failed to accurately assessed the patient's eligibility for hospice services related to the palliation and management of the terminal illness and related conditions for eleven of 13 sampled patients (Patient 2, 3, 4, 5, 6, 7, 8, 10, 11, 12 and 13). This deficient practice has the potential risk to result in the misuse of the hospice provision of services that could result to a substandard provision of patient care. Findings: h. A review of Patient 10's admission record indicated the patient was admitted to the HA on 1/07/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated skilled nurse (SN) visits once per week and once per week as needed and change of condition for assessment and comfort monitoring, the spiritual counselor (SC) and medical social worker (MSW) to do assessment within 5 days from SOC (start of care), certification & as needed. The hospice aide (HA) and volunteer visit were declined. On 9/07/2022, at 11:25 a.m., a joint home visit was made for Patient 10 with the Registered Nurse (RN 1) at the patient's residence. Patient 10 was not at home. Several phone calls were made to Patient 10's three phone number listed on her clinical records, but calls have either no dial tone and/or went straight to voicemail. At 11:35 a.m., during an interview, RN 1 stated she does not know where Patient 10 was located. A review of the form of "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" of Pulmonary Disease dated 1/12/2022, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 10 had a disabling dyspnea (shortness of breath) at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways), resulting in decreased functional capacity. Section 2 was mark "yes" that Patient 10 had O2 sat (Oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 95-100%) less than or equal to 88% determined by O2 sat monitors. A review of Patient 10's clinical record indicated there was no documented evidence Patient 10 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators or had O2 saturation of 88% or less. During an interview with the DPCS on 9/12/2022, at 2:35 p.m., she stated she was not able to find the documented evidence Patient 10 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators or had O2 saturation less than or equal to 88%. i. A review of Patient 11's admission record indicated the patient was admitted to the HA on 10/17/2021, with diagnosis of heart disease, unspecified (a type of disease that affects the heart or blood vessels). A review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated the registered nurse visit once every 2 weeks and as needed, and the licensed vocational nurse visit of once a week and one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of the form of "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" of Heart Disease dated 10/31/2021 and 2/02/2022, indicated section 1 - "Untreatable Condition", and section 2 - New York Heart Association (NYHA) Classification" must be met. It was mark "yes" in section 1 that Patient 11 has been ruled out as a candidate for surgical procedure. Section 2 was mark "yes" that Patient 11 met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). A review of Patient 11s clinical record indicated no documented evidence Patient 11 was ruled out as a candidate for surgical procedure related to heart disease. There was no documented evidence Patient 11 was on complete rest, confined to bed and chair, any physical activity brings on discomfort and symptoms occurs at rest. During a phone interview with Patient 11, on 9/12/2022 at 10:30 a.m., Patient 11 stated he was not aware of any surgical procedure about his heart, and he was doing okay. He stated he has mild symptoms when he went out for a walk but has no symptoms if he was in bed or chair. Patient 11 stated nobody told him that he has life expectancy of 6 months or less. During an interview with the DPCS on 9/12/2022, at 2:35 p.m., she stated she was not able to find the documented evidence Patient 11 was ruled out as a candidate for a surgical procedure related to heart disease or had symptoms of heart disease even when patient was at rest. j. A review of patient 12's admission record indicated the patient was admitted to the HA on 6/27/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 12's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated skilled nurse (SN) visits once per week and one as needed. The hospice aide (HA), MSW, SC, and volunteer service were declined. On 9/08/2022, at 2:55 p.m., a home visit was conducted for Patient 12. Patient 12 was observed awake, alert, ambulatory, not on oxygen and not showing any signs and symptoms of pulmonary disease. Patient 12 stated he walks to the market everyday several blocks away from where he lives and does not have shortness of breath. Patient 12 stated he was diagnosed with COPD since 2010, takes his medication/inhalers daily and is not going to die within 6 months. A review of the form of "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" of Pulmonary Disease dated 6/27/2022, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 12 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. Section 2 was mark "yes" that Patient 10 had O2 sat less than or equal to 88% determined by O2 sat monitors. A review of Patient 12's clinical record indicated there was no documented evidence Patient 12 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators and had O2 saturation of 88% or less. During an interview with the DPCS on 9/12/2022, at 2:35 p.m., she stated she was not able to find the documented evidence Patient 12 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators or had O2 saturation less than or equal to 88%. k. A review of Patient 13's admission record indicated the patient was admitted to the HA on 6/28/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 13's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated RN visits once every two weeks plus one visit as needed, and LVN visit once a week plus one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of the form of "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" of Pulmonary Disease, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 13 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. Section 2 was mark "yes" that Patient 10 had O2 sat less than or equal to 88% determined by O2 sat monitors. A review of Patient 13's clinical record indicated there was no documented evidence Patient 13 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators and had O2 saturation of 88% or less. During an interview with the DPCS on 9/12/2022, at 2:35 p.m., she stated she was not able to find the documented evidence Patient 13 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators or had O2 saturation less than or equal to 88%. A review of the agency's policy and procedure titled, "Admission Criteria and Process", revised April 2017, indicated, "Devina Hospice Care, Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs)". d. A review of Patient 5's clinical record indicated, Patient 5 was 46 years female who started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The Skilled Nurse (SN) visit was once a week and as needed. The Medical Social Worker (MSW) visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. During a joint home visit with RN 1 on 9/7/2022, at 10:20 a.m., Patient 5 was observed walking using a cane from her car (which was parked in front of the house) to her house (back unit of the house). During an interview with RN 1 at the same time, she stated Patient 5 could drive. During an interview with Patient 5 on 9/7/2022, at 10:30 a.m., it was observed Patient 5 was alert, oriented, and was able to communicate well. Patient 5 stated she lives alone at her unit and she could drive her car to the doctor's office, grocery store, and she could go out for eating. She stated she could cook and shower. She stated she had declined the HA service because she could shower herself. When asked whether she had a pulmonary disease, she stated she had "Asthma" not pulmonary disease, and she did not think she would die within 6 months. A review of Patient 5's "Comprehensive Nursing Assessment" dated 12/28/2021 indicated Patient 5 was alert and oriented, had functional limitation of endurance, was ambulatory using a cane, and had steady gait. Patient 5 had mild dyspnea with mild exertion, and requires oxygen at 2 liters per minute as needed. Patient 5 was observed using chest accessory muscle after activity or walking, and the oxygen saturation at room air was 85 percent. The patient took two puffs of her Albuterol HFA 90 mcg oral inhalation, and after few minutes of rest, the patient's oxygen saturation had improved to 90 percent. Patient 5 had dull ache pain on both lower legs at a level of 4/10 on a pain scale. Diclofenac Sodium 1 % topical 2-4 times per day for pain management, and the pain was managed well ( reassessed pain prior to end the visit and the pain level was 2/10). A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine patient's eligibility for hospice services) of "Pulmonary Disease," dated 12/28/2021, indicated the section 1 and 2 should be met. It indicated Patient 5 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, is less than 30 percent of predicted * Increased visits to Emergency Room A review of Patient 5's record indicated there was no documented evidence Patient 5 was poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity, had Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. A review of Patient 5's record indicated there was no documentation supporting the LCD assessment. A review of Patient 5's form titled, "Physician's Certification for Hospice Benefit" (the document that showed a physician certified a patient's eligibility for hospice benefit), from 12/28/2021 to 3/27/2022, indicated, Patient 5's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 5's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". e. A review of Patient 6's clinical record indicated, Patient 6 was 64 years old male who started hospice care on 7/14/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit once per 2 week plus one visit and LVN visit once per week and one visit as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 6's "Comprehensive Nursing Assessment" dated 7/14/2021 indicated Patient 6 was alert and oriented, used a cane for ambulation, and bowel and urinary status was continent. Patient 6 had mild dyspnea with mild exertion, and oxygen saturation was 96 percent. The need of Hospice aide, volunteer and community support was check marked as "None". A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 7/14/2021, indicated the section 1 and 2 should be met. It indicated Patient 6 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Increased visits to Emergency Room *Oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor A review of Patient 6's record indicated there was no documented evidence Patient 6 was poorly responsive or unresponsive to bronchodilators, or had Increased visits to Emergency Room, and the oxygen saturation rate was less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 6's record indicated there was no documentation supporting the LCD assessment. A review of Patient 6's form titled, "Physician's Certification for Hospice Benefit" from 7/14/2021 to 10/11/2021, indicated, Patient 6's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 6's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 6 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". f. A review of Patient 7's clinical record indicated, the patient was 60 years old male who started hospice care on 2/8/22, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit two times per 2 weeks 2 week plus one visit as needed and LVN visit once per week and as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 7's "Comprehensive Nursing Assessment" dated 2/28/2022 indicated Patient 7 was alert and oriented, used a cane for ambulation. Patient 7 had mild dyspnea with mild exertion, and oxygen saturation was 97 percent. It indicated "No" for the question of whether the patient was uncomfortable because of pain. The need of Hospice aide, was check marked as "None". The need for the Volunteer or community support was blank. The nurse's narrative indicated Patient 7 was observed with on and off shortness of breath and was on Albuterol 90 mcg/Actuation inhalation Aerosol 90 mcg 1-2 puffs inhaler three times a day as needed for shortness of breath/wheezing. Patient 7 had generalized body pain and was on Norco 10 mg-325 mg one tablet by mouth every 6 hours as needed for pain. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 2/28/2022, indicated the section 1 and 2 should be met. It indicated Patient 7 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure *Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 millimeter Mercury (mmHg). A review of Patient 7's record indicated there was no documented evidence Patient 7 was poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, Hypoxemia (an abnormally low concentration of oxygen in the blood) at rest on room air, as evidenced by pO2 (partial pressure of oxygen - a measure of the tension or pressure of oxygen dissolved in the blood - If a pO2 level is lower than 80 mmHg, it means that a person is not getting enough oxygen) less than or equal to 55 millimeter mercury (mmHg). A review of Patient 7's record indicated there was no documentation supporting the LCD assessment. A review of Patient 7's form titled, "Physician's Certification for Hospice Benefit" from 7/14/2021 to 10/11/2021, indicated, Patient 7's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 7 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 7's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". g. A review of Patient 8's clinical record indicated, the patient was 44 years old male who started hospice care on 1/21/22, with a terminal diagnosis of COPD. It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated the RN visits for initial assessment, supervisory visit, and ongoing comprehensive assessment, reassessment, recertification and as needed. The Skilled Nurse (SN) visit once a week and onece per week as needed. The MSW was to visit within 5 days from the SOC, Certification and as needed. The HA service and the volunteer services were offered and declined. A review of Patient 8's "Comprehensive Nursing Assessment" dated 1/21/2022 indicated Patient 8 was alert and oriented, needed stand by assist for ambulation. Patient 8 had mild dyspnea with mild exertion, and oxygen saturation was 92 percent. Patient 8 was continent in bowel and bladder. The need of Hospice aide, and the need of community support were check marked as "None". The need for the Volunteer was check marked for errands. The nurse's narrative indicated Patient 8 was 43 years old male with last hospitalization on 9/18/2021 to 9/21/2021 for evaluation and treatment of left lower extremity torn ligament. According to the patient, his condition had progressively deteriorated in the past few months, evidence of dyspnea with activity and even at rest. Upon assessment, the patient was sitting in a chair and had a pain level to be 8/10. The patient was placed with medication of Norco 10/325 mg one tablet orally every 6 hours as needed for moderate to severe pain and Tylenol 500 mg every 6 hours for breakthrough pain. At the end of the visit and assessment, the patient was noted relaxed without any discomfort, no shortness of breath, and the pain level was 0/10. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 1/21/2022, indicated the section 1 and 2 should be met. It indicated Patient 8 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure * Oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documented evidence Patient 8 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documentation supporting the LCD assessment. A review of Patient 8's form titled, "Physician's Certification for Hospice Benefit" from 1/21/2022 to 4/20/2022, indicated, Patient 8's terminal diagnoses was COPD. It was indicated in the physician's narrative that Patient 8 no longer wants to continue aggressive treatment and stated he wanted comfort measures only. It was indicated in the section of "Certifying Physician Summary" that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 8's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". During an interview with the Director of Patient Care Services (DPCS) on 9/8/2022, at 4:15 p.m., she stated she was not able to find the documented evidence Patient 5, 6, 7, 8 were poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity, Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patients' primary physicians that Patient 5, 6, 7, 8, had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of the agency's comprehensive assessment revised in April 2017 indicated the agency must assure the data elements allow for measurement of outcomes, and the Clinical Supervisor/Nursing Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. A review of the agency's undated policy titled "Admission Criteria and Process" indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). A review of the agency's undated Policy and Procedure titled "Certification of Terminal Illness" indicated the clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification.

Based on interview and record review, the hospice agency failed to complete the initial assessment conducted by the Registered Nurse (RN) necessary to provide the patient/family's immediate care needs related to the terminal illness and condition for threee of 13 sampled patients (Patients 6, 7, and 10). This deficient practice has the potential for the patient's immediate physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions not to be assessed timely that could result in the delay to initiate the plan of care and the delay to identify certification or eligibility for hospice services. Findings: a. A review of Patient 6's clinical record indicated the start of care date was 8/17/2021, with a diagnosis including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 6's initial assessment conducted by the RN for certification period from 8/27/2021 to 6/03/2022, indicated the initial assessment was not completed that identified core services frequency of visits for skilled nursing (SN), medical social worker (MSW) and spiritual counselor (SC). The RN assessment identified Patient 6 was awake, alert, oriented, ambulatory with the use of a walker with maximum assist, continent (good control) of bowel/bladder, exhibits dyspnea (shortness of breath) with mild exertion, but not using an oxygen (O2), has generalized body pain with a pain scale of 4/10 (moderate), which was relieved by Norco 10 milligrams(mg)-325 mg 1 tablet orally every 6 hours as needed. There was no documented evidence the RN assessment identified Patient 6's immediate physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions to provide the immediate necessary care and services. b. A review of Patient 7's clinical record indicated the start of care date was 8/16/2021, with a diagnosis including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 7's initial assessment conducted by the RN for certification period from 8/27/2021 to 6/03/2022, indicated the initial assessment was not completed that identified core services frequency of visits for skilled nursing (SN), medical social worker (MSW) and spiritual counselor (SC). A review of the RN assessment dated 8/16/2021, indicated Patient 7 was awake, alert, oriented with episodes of anxiety and confusion, ambulatory with the use of a walker with maximum assist, incontinent of bladder but continent of bowel, exhibited dyspnea with mild exertion, has generalized body pain with a pain scale of 3/10, which was relieved by Norco 10 milligrams(mg)-325 mg 1 tablet orally every 6 hours as needed. There was no documented evidence the RN assessment identified Patient 7's immediate physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions to provide the immediate necessary care and services. A review of Patient 7's "Visit Note LVN "(Licensed Vocational Nurse) dated 5/01/2022 and 5/08/2022, indicated the patient had "light dyspnea." There was no indication when the patient had light dyspnea. The section for "Musculoskeletal" indicated the patient can stand with little support. A review of the narrative section, indicated Patient 7 required mild assistance in activities of daily living (ADLs). However, in the section of "ADL Assessment", Patient 7 was maximum/complete assistance for ambulation, transfer, and bathing; and moderate assistance on toileting, dressing and feeding. On 6/10/2022 at 12:40 p.m., during an interview with the Director of Patient Care Services (DPCS) Designee, she stated that the RN had to perform comprehensive assessment for the initial benefit period and on every recertification of benefit. A review of the agency's policy and procedure titled, "Comprehensive Assessment", revised October 2009, indicated the comprehensive assessment is updated by the interdisciplinary group as frequently as the patient's condition requires but at a minimum of every 15 days. c. A review of Patient 10's admission record indicated Patient 10 was admitted to the hospice agency on 8/4/2021, with diagnosis of heart disease. A review of Patient 10's POC/IDG Review dated 8/5/2021, indicated the Registered Nurse (RN) visit was for initial assessment/evaluation and within 14 days for comprehensive/supervisory visits, the Medical Social Worker (MSW) and the spiritual counselor visit was one for assessment and evaluation. Health Aide visit and the volunteer visit were offered, but declined. A review of Patient 10's Comprehensive Assessment dated 8/5/2021, done by the Registered Nurse (RN) indicated the patient was awake, alert and oriented x 3, with intermittent episodes of anxiety and confusion. Patient 10 had shortness of breath on moderate exertion. It indicated Patient 10 was assessed as 50 percent for KPS (50 percent of KPS indicated the patient required considerable assistance and frequent medical care) and 50 percent of PPS (50 percent of PPS indicated mainly sit/lie, considerable assistance required). Patient 10 was assessed as NYHA IV (Patient with cardiac disease resulting in inability to carry on any physical activity without discomfort of heart failure or of the anginal syndrome may be present even at rest). A review of Patient 10's record indicated there was no other comprehensive assessment documented by the RN beside the assessment dated 8/5/2021. A review of Patient 10's "Visit Note LVN "(Licensed Vocational Nurse) dated 5/5/2022, 5/12/2022, 5/26/2022, indicated the patient had "light dyspnea (difficulty breathing). There was no indication when the patient had light dyspnea. The section for "Ambulatory" and "Non- Ambulatory" were blank. In the narrative section, Patient 10 required extensive or moderate assistance for the activities of daily livings (ADLS). However, in the section of "ADL Assessment" indicated Patient 10 was independent for all ADLs including ambulation, transfer, feeding, toileting, dressing and bathing. A review of Patient 10's record indicated there was no documented evidence the RN had visited/assessed the patient after 8/5/2021. On 6/10/2022 at 9:50 a.m., during a telephone interview with Patient 10, she stated she had high blood pressure but did not have heart problem. Patient 10 stated she had pain on the leg and could not walk very well due to pain in her leg. Patient 10 stated she had joined the hospice service because she needed walker and cane. She stated she did not think that she would die soon. During an interview with the Designee of Director of Patient Care Services (DPCS) on 6/10/2022 at 11:20 a.m., she stated the RN had to perform comprehensive assessment for initial assessment and at least every recertification of benefit. A review of the agency's job description titled, "Registered Nurse " revised on October 2009 indicated the RN was to regularly re-evaluate the patient's nursing needs. Identify discharge planning needs as part of the care plan development and implement prior to discharge of the patient.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met as follows: 1. The plan of care (POC) failed to specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment related to the terminal illness and related conditions for two out of 13 sampled patients (Patients 6 and 7) (L538). 2. The POC failed to be developed with all the members of hospice interdisciplinary group in collaboration with the patient or caregiver for eight of 13 sampled patients (Patients 2, 3, 6, 7, 8, 9, 10 and 11). (Refer to L541) 2. The POC failed to include detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs for two of 13 sampled patients (Patients 6 and 7). (Refer to L547) 3. The hospice failed to develop and maintain a system of communication and integration and ensure that the care and services are provided in accordance with the plan of care for one of 13 sampled patients (Patient 9). (Refer to L555). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated federal compliance for IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients accurately assessed to receive hospice care and services.

Based on interview and record review, the hospice agency failed to ensure the plan of care (POC) included the frequency of home visit of hospice staff to render hospice care and services for two out of 13 sampled patients, (Patients 6 and 7). This deficient practice placed the patients at risk of not being cared for by the agency and has the potential to negatively affect the patient's quality of life. Findings: a. A review of Patient 6's record indicated the start of care date was 8/17/2021, with a diagnosis that included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 6's initial POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 8/17/2021, did not indicate the frequency of visits and/or assessment by SN, MSW and SC. Subsequent POC/IGD form from 8/27/2022 to 6/03/2022 of Patient 6 were reviewed and did not indicate the frequency of visit and/or assessment by SN, MSW and SC. A review of the History of Skilled Nursing (SN) visits note indicated Licensed Vocational Nurse (LVN) 1 visited Patient 6 at least once a week from 8/21/2021 to 5/28/2022. A review of the History of Spiritual Assessment indicated the Spiritual Counselor (SC) did the comprehensive assessment and reassessment of Patient 6 on 8/18/2021, 11/03/2021, 2/07/2022 and 4/03/2022. A review of the History of Psychosocial Assessment indicated the Medical Social Worker (MSW) did the initial assessment of Patient 6 on 8/19/2021 and reassessment on 6/08/2022. b. A review of Patient 7's record indicated the start of care date was 8/16/2021, with a diagnosis that included COPD. A review of Patient 7's initial POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 8/16/2021, did not indicate the frequency of visits and/or assessment by SN, MSW and SC. Subsequent POC/IGD form from 8/27/2022 to 6/03/2022 of Patient 7 was reviewed and did not indicate the frequency of visit and/or assessment by SN, MSW and SC A review of the History of Skilled Nursing (SN) visits note indicated LVN 1 visited Patient 7 at least once a week from 8/18/2021 to 5/29/2022. A review of the History of Spiritual Assessment indicated the SC did the comprehensive assessment and reassessment of Patient 7 on 8/17/2021, 10/16/2021, 11/09/2021, 2/06/2022 and 4/02/2022. A review of the History of Psychosocial Assessment indicated the MSW did the initial assessment of Patient 7 on 8/19/2021 and reassessment on 4/13/2022. During an interview with the Director of Patient Care Services (DPCS) designee on 6/10/2022, at 12:40 p.m., she was not able to provide the documented evidence that the frequency of visits of each hospice discipline/services was included in the POC for Patient 6 and 7. The DPCS designee stated the frequency of visit of SN, MSW and SC should have been included in the POC. A review of the agency's policy and procedure titled "The Plan of Care", revised in October 2009, indicated the plan of care will identify the patient's needs and services to meet those needs. It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs.

Based on interview and record review, the hospice agency (HA) failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings were held by all the members of interdisciplinary group to discuss the patient's 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, ongoing assessments and care planning process for four of 13 sampled patients, (Patients 3, 5, 12 and 13). This deficient practice has a potential for the patient's progress or decline will not be identified by the IDG, interventions will not be implemented, and patient care goals will not be achieved. Findings: a. A review of Patient 3's clinical record indicated a start of care (SOC) date of 12/22/2020, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 8/1/2022, indicated skilled nurse (SN) frequency of visits of once per week and one as needed, Hospice Aide once per week, Social Worker (MSW) and Spiritual Counsellor (SC) on initial 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), recertification, and as needed. Volunteer service was declined. A review of Patient 3's "POC/IDG Review" dated 7/5/2022, 7/18/2022, and 8/1/2022, indicated the spaces for MSW signature were left blank. A review of the "IDG Log" dated 7/5/2022, 7/18/22, and 8/1/2022 indicated there was no MSW signature. During an interview with the Director of Patient Care Services (DPCS), on 9/12/2022, at 2:35 p.m., she stated that the IDG team meeting should be held every two weeks with participation of all the IDG members (Medical doctor, DPCS, SN, MSW and spiritual counselor) even though the patient had refused any of above service. She stated when the IDG members participated in the IDG meeting, they should have signed right away. The DPCS was not able to provide the documented evidence all the IDG members had participated in the IDG meeting for 7/5/2022, 7/18/2022, and 8/1/2022. c. A review of Patient 5's clinical record indicated Patient 5 started hospice care on 12/28/21, with a terminal diagnosis of COPD. It indicated the Medical Director was the referring/attending/patient choice doctor. A review of the POC/IDG Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The SN visit was once a week and as needed. The MSW visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. A review of the "POC/IDG Review" dated 7/5/2022, 7/18/22, 8/1/2022, 8/15/2022, 8/29/2022 indicated the spaces of signature for the social worker, were blank. A review of the "IDG Log" dated 7/5/2022, 7/18/22, 8/1/2022, 8/15/2022, 8/29/2022 did not indicate signatures of the social worker. During an interview with the DPCS on 9/12/2022, at 3 p.m., she was not able to provide the documented evidence that the social worker had participated in the POC/IDG meetings. d. A review of Patient 12's clinical record indicated the patient was admitted to the HA on 6/27/2022, with diagnosis of unspecified COPD. A review of Patient 12's POC/IDG, dated 7/05/2022, SN frequency of visits of once per week and one as needed. The HA, MSW, SC, and volunteer service were declined. A review of Patient 12's POC/IDG meeting record indicated blank spaces, no signatures to indicate the Medical MSW had participated the meetings on 7/05/2022, 7/18/2022/, 8/01/2022 and 8/15/2022. e. A review of Patient 13's clinical record indicated the patient was admitted to the HA on 6/28/2022, with diagnosis of unspecified COPD. A review of Patient 13's POC/IDG, dated 7/05/2022, indicated RN frequency of visits to once every two weeks plus one visit as needed, and LVN visit to once a week plus one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of Patient 13's POC/IDG meeting record indicated blank spaces, no signatures to indicate the MSW had participated the meetings on 7/05/2022, 7/18/2022/, 8/01/2022, 8/15/2022 and 8/29/2022. During an interview with the DPCS, on 9/12/2022, at 2:35 p.m., she stated that the IDG team meeting should be held every two weeks with participation of all the IDG members (Medical doctor, DPCS, SN, MSW and spiritual counselor) even though the patient had refused any of above service. She stated when the IDG members participated in the IDG meeting, they should have signed right away. The DPCS was not able to provide the documented evidence that all the IDG members had participated in the IDG meeting for Patient 12 and 13 on the above days. A review of the agency's policy and procedure titled "Interdisciplinary Group Meeting," revised April 2017, indicated 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. 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. Members of the interdisciplinary group meeting will sign an attendance from that will be kept by the hospice Clinical Supervisor/Nursing Supervisor. A review of the agency's policy titled, "Interdisciplinary Group Coordination of Care" revised in April 2017, indicated the care will be provided by an interdisciplinary group made up of physicians, nurses, social workers, certified hospice aides, homemakers, clergy, counselors, volunteers, and therapists. The interdisciplinary group (in collaboration with the attending physician, if, any) will conduct assessment, develop and update the plan of care, and review the effectiveness of care at minimum of every two (2) weeks. d. A review of Patient 9's admission record indicated Patient 9 was admitted to the hospice agency on 6/17/2021, with diagnosis that included hypertensive heart disease with heart failure (heart conditions caused by high blood pressure, includes heart failure). A review of the Plan of Care (POC) Summary indicated a physician order dated 6/18/2021 for RN initial assessment/evaluation and within 14 days, Skilled Nurse (SN) visit one time per week and three times as needed, psychosocial visit and spiritual care visit once for assessment. The hospice aide and the volunteer services were offered but declined. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 4/8/2022, 4/22/2022, 5/6/2022, 6/3/2021, indicated the Registered Nurse (RN) visit once per week and one visit as needed, the Medical Social Worker (MSW) and the spiritual counselor visit on admission and recertification plus as needed visits. A review of Patient 9's clinical record from 4/14/2022 to 6/12/2022 indicated the POC/IDG meeting were held on 4/8/2022, 4/22/2022, 5/6/2022, 6/3/2021. The spaces for the Medical Director (MD) and the MSW were blank to indicate both MD and MSW attended the IDG meetings. e. A review of Patient 10's admission record indicated Patient 10 was admitted to the hospice agency on 8/4/2021, with diagnosis of heart disease (any disorder that affects the heart). A review of the POC/IDG Review dated 8/5/2021, indicated the Registered Nurse (RN) visit was for initial assessment/evaluation and within 14 days for comprehensive/supervisory visits, the SN visits was once a week and as needed three times, the Medical Social Worker (MSW) and the spiritual counselor visit was one for assessment and evaluation. HA visit and the volunteer visit was offered but declined. A review of Patient 10's clinical record from 4/8/2022 to 6/12/2022, indicated the POC/IDG meetings were held on 4/8/2022, 4/22/2022, 5/6/2022, 6/3/2021. The spaces for signatures of the Medical Director (MD), RN, and the MSW were blank to indicate the MD, RN, and MSW attended the IDG meetings. f. A review of Patient 11's admission record indicated Patient 11 was admitted to the hospice agency on 8/8/2021, with diagnosis of heart disease. A review of the POC/IDG Review dated 4/8/2022, 4/22/2022, 5/6/2022, 6/3/2021, indicated the Registered Nurse (RN) visit was for initial assessment/evaluation and within 14 days for comprehensive/supervisory visits, the SN visits were once a week and as needed three times, the Medical Social Worker (MSW) and the spiritual counselor visit was one for assessment and evaluation. HA visit and the volunteer visit was offered but declined. A review of Patient 11's clinical record from 4/8/2022 to 6/12/2022 indicated the POC/IDG meetings were held on 4/8/2022, 4/22/2022, 5/6/2022, 6/3/2021. The spaces for the MSW's signature were blank on 4/22/2022, 5/6/2022, 6/3/2021. During an interview with the Director of Patient Care Services (DPCS) designee on 6/10/2022, at 11:20 a.m., the IDG team meeting should have been held every two weeks with the participation of all the IDG members (Medical doctor, DPCS, SN, MSW and spiritual counselor) even if the patient had refused any of above services. The DPCS designee stated when the IDG members participated in the IDG meeting, they should have signed right away. The DPCS designee was not able to provide the documented evidence of all the IDG members who had participated in the IDG meetings for Patients 9, 10 and 11. A review of the agency's policy and procedure titled "IDG Care Planning Process" revised in the year of 2014 indicated the members of IDG consists of a physician, Registered Nurse, social worker, and pastoral or other counselor. It indicated the IDG works together to meet the physical, medical, psychosocial, emotional and spiritual needs of Hospice patients and families. A review of the agency's policy and procedure titled "Interdisciplinary Group Membership and Responsibilities" revised in October 2009 indicated the interdisciplinary group will participate in periodic review and update of the plan of care for each patient and family receiving hospice services.

Based on interview and record review, the agency staff failed to ensure the plan of care (POC) included the frequency of home visits to be provided by the hospice staff for two out of 13 sampled patients, (Patients 6 and 7). This deficient practice placed the patients at risk of not being cared for by the agency and has the potential to negatively affect the patient's quality of life. Findings: a. A review of Patient 6's record indicated the start of care date was 8/17/2021, with a diagnosis that included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of the History of Skilled Nursing (SN) visits note indicated Licensed Vocational Nurse (LVN) 1 visited Patient 6 at least once a week from 8/21/2021 to 5/28/2022. A review of the History of Spiritual Assessment indicated the Spiritual Counselor (SC) did the comprehensive assessment and reassessment of Patient 6 on 8/18/2021, 11/03/2021, 2/07/2022 and 4/03/2022. A review of the History of Psychosocial Assessment indicated the Medical Social Worker (MSW) did the initial assessment of Patient 6 on 8/19/2021 and reassessment on 6/08/2022. A review of Patient 6's initial POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 8/17/2021, did not indicate the frequency of visits and/or assessment by SN, MSW and SC. Review of the POC/IDG form from 8/27/2022 to 6/03/2022, indicated the frequency of visits and/or assessment by SN, MSW and SC were not identified for each services to be rendered. b. A review of Patient 7's record indicated the start of care date was 8/16/2021, with a diagnosis that included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of the History of Skilled Nursing (SN) visits note indicated LVN 1 visited Patient 7 at least once a week from 8/18/2021 to 5/29/2022. A review of the History of Spiritual Assessment indicated the SC did the comprehensive assessment and reassessment of Patient 7 on 8/17/2021, 10/16/2021, 11/09/2021, 2/06/2022 and 4/02/2022. A review of the History of Psychosocial Assessment indicated the MSW did the initial assessment of Patient 7 on 8/19/2021 and reassessment on 4/13/2022. A review of Patient 7's initial POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 8/16/2021, did not indicate the frequency of visits and/or assessment by SN, MSW and SC. Review of the POC/IDG form from 8/27/2022 to 6/03/2022 did not indicate the frequency of visit and/or assessment by SN, MSW and SC. During an interview with the Director of Patient Care Services (DPCS) designee on 6/10/2022, at 12:40 p.m., she was not able to provide the documented evidence that the frequency of visits of each hospice discipline/services were included in the POC for Patient 6 and 7. The DPCS designee stated the frequency of visit of SN, MSW and SC should have been included in the POC. A review of the agency's policy and procedure titled "The Plan of Care", revised in October 2009, indicated the plan of care will identify the patient's needs and services to meet those needs. It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs.

c. A review of Patient 5's clinical record indicated the patient started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of Patient 5's Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The Skilled Nurse (SN) visit was once a week and as needed. The Medical Social Worker (MSW) visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. A review of Patient 5's record indicated there was documented evidence the skilled nurse (SN) had visited Patient 5 for the weeks from 7/3/2022 to 7/9/2022 and 8/28/2022 to 9/3/2022. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/12/2022, at 1:20 p.m., she stated she was not able to find the documented evidence the SN had visited Patient 5 on above time period. LVN 1 stated the above missed visits should have been rescheduled, but she was not able to provide the documented evidence rescheduled visit was made. d. A review of Patient 6's clinical record indicated the patient started hospice care on 7/14/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). A review of Patient 6's Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit once per 2 week plus one visit and LVN visit once per week and one visit as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 6's record indicated there was documented evidence the skilled nurse (SN) had visited Patient 6 the weeks from 8/7/2022 to 8/13/2022 and 8/21/2022 to 8/27/2022. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/12/2022, at 1:30 p.m., she stated she was not able to find the documented evidence the SN had visited Patient 6 on the above time period. LVN 1 stated the above missed visits should have been rescheduled, but she was not able to provide the documented evidence rescheduled visit was made. e. A review of Patient 7's clinical record indicated the patient started hospice care on 2/8/22, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit two times per 2 weeks plus one visit as needed and LVN visit once per week and as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 7's record indicated there was no documented evidence the skilled nurse (SN) had visited Patient 7 from 3/13/2022 to 3/26/2022 (for two weeks) and 8/12/2022 to 9/11/2022 (for four weeks). During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/12/2022, at 1:35 p.m., she stated she was not able to find the documented evidence the SN had visited Patient 7 on the above days. LVN 1 stated she could not find the reason why the SN visit was not made on above days, and could not find the documentation the above missed visit was reported to the IDG. A review of the agency's policy titled, "Miss Visit" revised in April 2017 indicated if visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit was missed and not rescheduled, the clinician would notify the IDG and clinical supervisor of the missed visit and reason for missed visit. 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.

Based on interview, and record review, the hospice agency failed to ensure the staffs are fit tested for the use of N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) masks to prevent COVID-19 (an acute respiratory illness) transmission. This failure had the potential for an increased risk of cross contamination and spread of infection. During a joint interview and record review with the Human Resources(HR) manager and Office manager on 6/7/22, at 3:30 p.m. , both could not provide evidence that all of the HA staff were fit tested for N95 masks. HR Manager stated that field staff did not have N95 fit testing since they started on the hospice agency in 2019. The HA's policy and procedure titled, "Infection Control Plan," revised 2016 indicated that the HA comply with applicable local, state, federal regulations and accepted standards of practice including but not limited to: State and Federal Occupational safety and health administration(OSHA) mandates, CDC recommendations and guidelines, State Practice Acts, Agency for healthcare research and quality(AHRQ), Association for Professionals in Infection control and Epidemiology(APIC)

Based on interview and record review the hospice agency failed to maintain documented evidence of infection control education and training to all staffs. This failure had the potential for the staffs to lack knowledge to control and prevent the spread of infection. Findings: A review of the HA's infection control log on 6/7/22 at 3:30 p.m., indicated the hospice did not conduct or perform infection control inservices since 2020. On 6/7/22 at 3:30 p.m., during a joint interview with the Human Resources(HR) Manager and the Office Manager, stated that they did not allow staff to come in the office since the pandemic. They also stated that they do not know how to conduct inservice meetings online during the pandemic. A review of the HA's document titled "Infection Control Plan" revised October 2016, indicated that the purpose is to establish the mechanism by which the organization will address surveillance, prevention, identification, control and reporting of infections, utilizing current scientific methods and epidemiologic methods. Educate organization personnel, patients/caregivers and others in the prevention and control of infections.

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows: 1. The hospice agency's Medical Director and/or physician designee failed to review and verify the patient's clinical information to determine eligibility or needs for recertification of terminal illness, to continue hospice care and services for 4 of 13 sampled patients (Patients 9, 10, 6, and 7) Refer to L 668. 2. The hospice agency failed to ensure the medical director or physician designee assumed the overall responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, review, and verify patient clinical information to consistently meet the patient's needs of 4 of 13 sampled patients (Patients 9, 10, 6, and 7) Refer to L 669. The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for Medical Director services 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 agency failed to ensure the hospice services were provided by a physician who reviewed the patient's clinical information prior to approving another 60 days of hospice service to obtain justification for continuing hospice services for nine out of 13 sampled patients (Patient 2, 3, 4, 5, 6, 7, 8, 10 and 11). This deficient practice result in providing hospice care to a patient who did not meet readmission criteria and did not qualify for the Medicare hospice benefit. Findings: d. A review of Patient 5's clinical record indicated, Patient 5 was 46 years female, started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. During a joint home visit with RN 1 on 9/7/2022, at 10:20 a.m., Patient 5 was observed walking with using a cane from her car (which was parked in front of the house) to her house (back unit of the house). During an interview with RN 1 at the same time, she stated Patient 5 can drive. During an interview with Patient 5 on 9/7/2022, at10:30 a.m., she stated she lives alone at her unit and she could drive her car to the doctor's office, grocery store, and she could go out for eating. She stated she could cook and shower. She stated she had declined the HA service because she could shower herself. When asked whether she had a pulmonary disease, she stated she had "Asthma" not pulmonary disease, and she did not think she would die within 6 months. A review of Patient 5's "Comprehenive Nursing Assessment" dated 6/24/2022 indicated Patient 5 was alert and oriented, had functional limitation of endurance, was ambulatory using a cane. A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine patient's eligibility for hospice services) of "Pulmonary Disease," dated 3/27/2022, 6/24/2022, indicated Patient 5 was assessed as "yes" with followings: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, is less than 30 percent of predicted * Increased visits to Emergency Room *Oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitors A review of Patient 5's record indicated there was no documented evidence Patient 5 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity, Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room, and Oxygen saturation rate was less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitors. A review of Patient 6's record indicated there was no documentation supporting the LCD assessment. A review of Patient 5's form titled, "Physician's Certification for Hospice Benefit" (the document that showed a physician certified a patient's eligibility for hospice benefit), from 3/28/2022 to 6/25/2022, and from 6/26/2022 to 8/24/2022 indicated Patient 5's terminal diagnoses was COPD, and Patient 5 meets LCD Medical guide lines to receive hospice service. It was indicated Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 5's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". e. A review of Patient 6's clinical record indicated, the patient started hospice care on 7/14/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit once per 2 weeks plus one visit and LVN visit once per week and one visit as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 6's "Comprehenive Nursing Assessment" dated 8/4/2022 indicated Patient 6 was alert and oriented, needed stand by assist, used a cane for ambulation. Patient 6 had mild dyspnea with mild exertion, and oxygen saturation was 96 percent. The section whether the patient was uncomfortable because of pain indicated "No". The need of Hospice aide, volunteer and community support was check marked as "None". A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 9/1/2022, indicated the section 1 and 2 should be met. It indicated Patient 6 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Hospitalization for pulmonary infections *Oxygen saturation less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 6's record indicated there was no documented evidence Patient 6 was poorly responsive or unresponsive to bronchodilators, hospitalization for pulmonary infections, and the oxygen saturation rate was less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 6's record indicated there was no documentation supporting the LCD assessment. A review of Patient 6's form titled, "Physician's Certification for Hospice Benefit" from 9/7/2022 to 11/5/2021, indicated, Patient 6's terminal diagnoses was COPD. The "Certifying Physician Summary" indicated Patient 6 met the LCD Medical Guidelines to receive the hospice service, and Patient 6 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course", while there was no documentation supporting the LCD assessment. A review of Patient 6's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". f. A review of Patient 7's clinical record indicated, the patient started hospice care on 2/8/22, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit two times per 2 weeks plus one visit as needed and LVN visit once per week and as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 7's "Comprehenive Nursing Assessment" dated 5/3/2022 indicated Patient 7 was alert and oriented, used a cane for ambulation. The section whether the patient was uncomfortable because of pain indicated "No". The spaces for the vital signs (blood pressure, pulse, temperature) and oxygen saturation was blank. It indicated the patient did not have dyspnea. It indicated "No" for the question of whether the patient was uncomfortable because of pain. The need of Hospice aide, Volunteer, and community support was check marked as "None". The nurse's narrative indicated Patient 7 was 60 year old male, recertified via telehealth. Per primary caregiver (PCG), Patient 7 did not have shortness of breath, but complained of generalized pain with the pain pain level 2/10 on a pain scale. PCG was instructed to give Norco 10 mg-325 mg one tablet every 6 hours as needed. When rechecked, the pain level was 1/10 on a pain scale. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 5/3/2022, indicated the section 1 and 2 should be met. It indicated Patient 7 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure *Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mililimeter Mercury (mmHg). However, a review of Patient 7's record indicated there was no documented evidence Patient 7 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, Hypoxemia (an abnormally low concentration of oxygen in the blood) at rest on room air, as evidenced by pO2 (partial pressure of oxygen - a measure of the tension or pressure of oxygen dissolved in the blood - If a pO2 level is lower than 80 mmHg, it means that a person is not getting enough oxygen) less than or equal to 55 mililimeter mercury (mmHg). A review of Patient 7's record indicated there was no documentation supporting the LCD assessment. A review of Patient 7's form titled, "Physician's Certification for Hospice Benefit" from 5/9/2022 to 8/6/2022, indicated, Patient 7's terminal diagnoses was COPD. The "Certifying Physician Summary" indicated Patient 6 met LCD Medical Guidelines to receive the hospice service, and Patient 6 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 7's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". A review of Patient 7's record indicated there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's other physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". g. A review of Patient 8's clinical record indicated, the patient started hospice care on 1/21/22, with a terminal diagnosis of COPD. It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated the RN visits for initial assessment, supervisory visit, and ongoing comprehensive assessment, reassessment, recertification and as needed. The Skilled Nurse (SN) visit once a week and onece per week as needed. The MSW was to visit within 5 days from the SOC, Certification and as needed. The HA service and the volunteer services were offered and declined. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 7/8/2022, indicated the section 1 and 2 should be met. It indicated Patient 8 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure * Oxygen saturation less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documented evidence Patient 8 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, Oxygen saturation less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documentation supporting the LCD assessment. A review of Patient 8's form titled, "Physician's Certification for Hospice Benefit" from 7/20/2022 to 9/17/2022, indicated, Patient 8's terminal diagnoses was COPD. It was indicated in the RN Prognosis Summary that Patient 8 was 43 years old, ambulatory usines cane, had pain on left ankle with pain level 8/10, and takes Norco 10/325 mg one tablet every 6 hours as needed for moderate to severe pain. When reassessed the pain level at the end of the visit, the pain was 0/10. Patient 8 was continent with both urinary and bowel functions, and the patient did not have respiratory distress. It was indicated in the section of "Certifying Physician Summary" that Patient 8 meets LCD Medical Guidelines to receive ospice service, the patient was appropriate to remain and receive hospice care with a terminal prognosis of 6 months or less if disease process follows its normal course. A review of Patient 8's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". During an interview with the Director of Patient Care Services (DPCS) on 9/8/2022, at 4:15 p.m., she stated she was not able to find the documented evidence Patient 5, 6, 7, 8, , were poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity, Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. The DPCS was not able to provide the documentation supporting the LCD assessment of Patient 5, 6, 7, 8, on above days. Also, the DPCS was not able to provide the documented evidence that the hospice medical director or the hospice attending physician communicated, with the patients' primary physicians to verify Patient 5, 6, 7, 8, had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". On 9/9/2022 at 12:15 p.m., a telephone interview was conducted with the Medical Director of the agency. When asked whether he had his primary patient at the agency, he stated he had a lot of patients and he was not sure/recall. And then, he stated he was not a primary physician for all of the agency's patients. He stated he decides eligibility of hospice care based on signs/symptoms, diagnoses (including history and Physical, labs), ADLs, stability, bed bound status and frequency of hospitalization, and LCD assessment. He stated the Nurse Practitioner (NP) who had been working for him was supposed to review all the assessment and documentation including the History and Physical. He stated he had not actually reviewed the patients' clinical documentation and LCD Assessment. instead, he relied on NP's judgement. When informed the Medical director that there was no documentation supporting the LCD assessment and the patient's diagnoses, he stated he did not know that. He stated NP 1, who had been working for him for 4-5 months, had been signed his signature electronically in the "Physician's Certification for Hospice Benefit" behalf of him. He stated he had another NP worked for him before NP 1, and he always had a NP work for him. He stated he did not have any supportive documentation for the hospice eligibility assessment, and had not communicated with the patients' attending physician. He stated he should have overseen things like eligibility of patients for the hospice service. A review of the agency's undated policy titled "Admission Criteria and Process" indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). A review of the agency's undated Policy and Procedure titled "Certification of Terminal Illness" indicated the clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. According to the LCD, the physician must briefly synthesize the clinical information supporting the terminal diagnosis, and attest that they composed the narrative after reviewing the clinical information and where applicable, examining the patient. A review of the agency's job description summary titled "Hospice Medical Director" revised April 2017 indicated the duties and responsibilities of the Medical Director will include, but not limited to, the following: * Reviewing patients'medical eligibility for hospice services, in accordance with the dhospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness * Reviewing necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician. * Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services. *Providing written certification of the terminal illness for all subsequent benefit periods. h. A review of Patient 10's admission record indicated the patient was admitted to the HA on 1/07/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Patient 10's admission information sheet (face sheet) indicated the hospice Medical Director was also the patient's referring and attending physician. A review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated skilled nurse (SN) visits once per week and once per week as needed and change of condition for assessment and comfort monitoring, the spiritual counselor (SC) and medical social worker (MSW) to do assessment within 5 days from SOC (start of care), certification & as needed. The hospice aide (HA) and volunteer visit were declined. A review of Patient 10's Comprehensive Nursing Recertification Assessment, dated 7/05/2022, indicated Patient 10 was awake, alert, oriented (to time, place, person) and verbally responsive. Patient 10 was ambulatory using a cane with stand-by assist and able to perform ADLs (or activities of daily living, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) with minimal assistance. Patient 10 has normal respiration, no cough, no shortness of breath, and her vitals (blood pressure, temperature, pulse, respiratory rate) and oxygen saturation was not assessed. The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." A review of the "Physician's Certification for Hospice Benefit (the patient must be certified as being terminally ill to receive hospice care)" from 7/06/2022 to 9/03/2022, signed by the Medical Director who was also the referring doctor, indicated "I attest that I composed this narrative based on my review of patient's medical records, team assessment and/or examination of patient". It indicated Patient 10 was recertified for hospice and was appropriate for hospice admission with a terminal prognosis of 6 months or less if disease process follows its normal course. There has no documented evidence the hospice medical director communicated with the primary physician, to certify that Patient 10 had a life expectancy of 6 months or less, if the terminal illness runs it normal course. A review of the form "LCD Hospice Eligibility Determination" of Pulmonary Disease dated 7/05/2022, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 10 had a disabling dyspnea (shortness of breath) at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways), resulting in decreased functional capacity. Section 2 was mark "yes" that Patient 10 had O2 sat (Oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 95-100%) less than or equal to 88% determined by O2 sat monitors. A review of Patient 10's clinical record indicated there was no documented evidence Patient 10 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators and/or had O2 saturation of 88% or less. i. A review of Patient 11's admission record indicated the patient was admitted to the HA on 10/17/2021, with diagnosis of heart disease, unspecified (a type of disease that affects the heart or blood vessels). Patient 11's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. A review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated the registered nurse visit once every 2 weeks and as needed, and the licensed vocational nurse visit of once a week and one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of Patient 11's Comprehensive Nursing Recertification Assessment, dated 6/10/2022, indicated Patient 11 was awake, alert, and oriented (to person, place, and time). Patient 11 was ambulatory using a walker, and able to perform ADLs with minimal or moderate assistance. Patient 11 has no cardiac-related pain, no edema observed, no shortness of breath and has normal respirations. Patient 11's oxygen saturation was 97% on room air, and the rest of his vitals was not assessed. Patient 11's NYHA documented classification was IV (New York Heart Association Class IV - patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest). The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." A review of the "Physician's Certification for Hospice Benefit" signed by the Medical Director who was also the referring doctor, indicated Patient 11 has a life expectancy of six months or less, if the terminal illness runs its normal course. There has no documented evidence the hospice medical director communicated with the primary physician, to certify that Patient 11 had a life expectancy of 6 months or less, if the terminal illness runs it normal course. A review of the form "LCD Hospice Eligibility Determination" of Heart Disease, dated 2/02/2022, indicated section 1 - "Untreatable Condition", and section 2 - New York Heart Association (NYHA) Classification" must be met. It was mark "yes" in section 1 that Patient 11 has been ruled out as a candidate for surgical procedure. Section 2 was mark "yes" that Patient 11 met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). A review of Patient 11s clinical record indicated no documented evidence Patient 11 was ruled out as a candidate for surgical procedure related to heart disease. There was no documented evidence Patient 11 was on complete rest, confined to bed and chair, any physical activity brings on discomfort and symptoms occurs at rest. During a phone interview with Patient 11, on 9/12/2022 at 10:30 a.m., Patient 11 stated he was not aware of any surgical procedure about his heart, and he was doing okay. He stated he has mild symptoms when he went out for a walk but has no symptoms if he was in bed or chair. Patient 11 stated nobody told him that he has life expectancy of 6 months or less. On 9/9/2022 at 12:15 p.m., a telephone interview was conducted with the Medical Director of the agency. When asked whether he had his primary patient at the agency, he stated he had a lot of patients and he was not sure/recall. And then, he stated he was not a primary physician for all of the agency's patients. He stated he decides eligibility of hospice care based on signs/symptoms, diagnoses (including history and Physical, labs), ADLs, stability, bed bound status and frequency of hospitalization, and LCD assessment. He stated the Nurse Practitioner (NP) who had been working for him was supposed to review all the assessment and documentation including the History and Physical. He stated he had not actually reviewed the patients' clinical documentation and LCD Assessment. instead, he relied on NP's judgement. When informed the Medical director that there was no documentation supporting the LCD assessment and the patient's diagnoses, he stated he did not know that. He stated NP 1, who had been working for him for 4-5 months, had been signed his signature electronically in the "Physician's Certification for Hospice Benefit" behalf of him. He stated he had another NP worked for him before NP 1, and he always had a NP work for him. He stated he did not have any supportive documentation for the hospice eligibility assessment, and had not communicated with the patients' attending physician. He stated he should have overseen things like eligibility of patients for the hospice service. A review of the agency's undated policy titled "Admission Criteria and Process" indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). A review of the agency's undated Policy and Procedure titled "Certification of Terminal Illness" indicated the clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. According to the LCD, the physician must briefly synthesize the clinical information supporting the terminal diagnosis, and attest that they composed the narrative after reviewing the clinical information and where applicable, examining the patient. A review of the agency's job description summary titled "Hospice Medical Director" revised April 2017 indicated the duties and responsibilities of the Medical Director will include, but not limited to, the following: * Reviewing patients'medical eligibility for hospice services, in accordance with the dhospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness * Reviewing necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician. * Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services. *Providing written certification of the terminal illness for all subsequent benefit periods.

Based on interview and record review, the hospice agency failed to ensure, the agency's medical director or physician designee assumed the overall responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, review, and verify patient clinical information necessary for recertification of terminal illness for 4 of 13 sampled patients (Patients 9, 10, 6 and 7). This deficient practice resulted in the hospice medical director and/or the hospice attending physician certifying patients with inaccurate terminal diagnoses, without documentation of clinical evidence to support the diagnoses as required for patients provided or receiving hospice care benefits. Findings: a. A review of Patient 9's admission record indicated Patient 9 was admitted to the hospice agency on 6/17/2021, with diagnoses of hypertensive heart disease with heart failure (heart conditions caused by high blood pressure, includes heart failure), The referring physician was Physician 1. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 4/8/2022, 4/22/2022, 5/6/2022, 6/3/2021, indicated the Registered Nurse (RN) visit once per week, the Medical Social Worker (MSW) and the spiritual counselor visit on admission and recertification. A review of the Comprehensive Assessment, dated 6/18/2021, indicated the patient was awake, alert and oriented x 3, with periods of confusion. Patient 9 was noted with mild shortness of breath upon exertion. It indicated Patient 9 was assessed as 60 percent for Karnofsky Performance Scale (KPS: index allows patients to be classified as to their impairment - 60 percent of KPS indicated the patient required occasional assistance, but is able to care for most of personal needs), and 60 percent of Palliative Performance Scale (PPS : for evaluating patients requiring palliative care - 60 percent of PPS indicated reduced ambulation, requires occasional assistance). It indicated Patient 9 was assessed as New York Heart Association IV (NYHA IV - Patient with cardiac disease resulting in inability to carry on any physical activity without discomfort of heart failure or of the anginal syndrome may be present even at rest). A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine patient's eligibility for hospice services) of "Heart Disease," dated 6/18/2021, indicated that the sections for "untreatable condition" and "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated that Patient 1 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of Patient 9's record indicated there was no other "LCD Hospice Eligibility Determination" beside the one dated 6/18/2021. A review of the "Nursing Re-certification Assessment" dated 9/2/2021, indicated Patient 9 was assessed with KPS and PPS 40 percent. Patient had no chest discomfort and shortness of breath "at this time", but reported to have with exertion, movements/activities. NYHA classification was not included in the "Nursing Re-certification Assessment" A review of the "Nursing Re-certification Assessment" dated 12/3/2021, 2/1/2022, 4/1/2022, 6/7/2022 indicated Patient 9 was assessed with KPS and PPS 40 percent. However, there was no assessment of NYHA functional classification. Instead, it was indicated Patient 9 had no chest discomfort and shortness of breath reported to have with exertion, movement/activities. A review of Patient 9's record indicated there was no documented supportive evidence Patient 9 was to be assessed as NYHA Class IV level to meet the eligibility for hospice service as indicated in the LCD assessment dated 6/18/2022. A review of the "Physician's Certification for Hospice Benefit" (the document that showed a physician certified a patient's eligibility for hospice benefit), dated 6/18/2021, indicated Patient 9 was assessed as 60 percent for KPS and PPS, and NYHA Class IV. It indicated Patient 9 had episodes of mild dyspnea upon exertion, and required mild to moderate assistance with all the activities of daily livings. It indicated the Medical Director had certified that Patient 1 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. A review of "Physician's Certification for Hospice Benefit" for the benefit period from 9/16/2021 to 12/14/2021, from 12/15/2021 to 2/12/2022, from 2/13/2022 to 4/13/2022, from 4/14/2022 to 6/12/2022, indicated Patient 9 was assessed as 40 percent for KPS and PPS, and NYHA Class IV on above benefit period. There was no check mark for "Medical history, record and patient status", "Team Assessment", and "Face to Face Encounter". The spaces for "Face to Face Summary" was blank. It indicated the Medical director attested/confirmed that he/she composed this narrative based on his/her review of patient's medical records, team assessment and/or examination of the patient. However, the spaces for the Medical Director and the date were blank. A review of Patient 9's record indicated there was no documented evidence the Medical Director/designated physician had performed face to face assessment since admission on 6/18/2021 until 6/10/2022. On 6/10/2022, at 11:05 a.m., during a telephone interview with the office manager at the Medical Director's office stated the Medical Director was not available because he was so busy, stated the Medical Director had been working for the hospice agency since last year. The office manager stated when the hospice agency send paper work to the doctor's office, they send the completed paper work back to the agency through E mail or via fax after the doctor completed the paper work. The office manager stated the Medical Director would visit the patient upon the hospice agency's request. The office manager stated the Medical Director did not have other doctor working for him, and would not sign electronically. On 6/10/2022, at 11:45 a.m., during an interview with the DPCS designee she stated the Medical Director was to review "Medical history, record and patient status", "Team Assessment", and to perform the Face to Face encounter for recertification hospice benefit. She stated the agency should have obtained completed "Physician's Certification for Hospice Benefit" including the physician's signature for recertification benefit. b. A review of Patient 10's admission record indicated Patient 10 was admitted to the hospice agency on 8/4/2021, with diagnoses of heart disease. A review of the POC/IDG Review dated 8/5/2021, indicated the Registered Nurse (RN) visit was for initial assessment/evaluation and within 14 days for comprehensive/supervisory visits, the Medical Social Worker (MSW) and the spiritual counselor visit was one for assessment and evaluation. Health aide visit and the volunteer visit were offered, but declined. A review of the form titled, "LCD Hospice Eligibility Determination" of "Heart Disease," dated 8/5/2021, indicated that the sections for "untreatable condition" and "NYHA classification" must be met to determine patient's eligibility for hospice services. The form indicated that Patient 1 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of Patient 10's record indicated there was no other "LCD Hospice Eligibility Determination" completed after 8/5/2021. A review of the Comprehensive Assessment dated 8/5/2021, done by the Registered Nurse (RN) indicated the patient was awake, alert and oriented x 3, with intermittent episodes of anxiety and confusion. Patient 10 had shortness of breath on moderate exertion. It indicated Patient 10 was assessed as 50 percent for KPS (50 percent of KPS indicated the patient required considerable assistance and frequent medical care) and 50 percent of PPS (50 percent of PPS indicated mainly sit/lie, considerable assistance required). It indicated Patient 10 was assessed as NYHA IV (Patient with cardiac disease resulting in inability to carry on any physical activity without discomfort of heart failure or of the anginal syndrome may be present even at rest). A review of Patient 10's record indicated there was no other comprehensive assessment documented after 8/5/2021. A review of the "Visit Note LVN "(Licensed Vocational Nurse) dated 5/5/2022, 5/12/2022, 5/26/2022, indicated the patient had "light dyspnea (difficulty breathing). There was no indication when the patient had light dyspnea. The section for "Ambulatory" and "Non- Ambulatory" were blank. It was indicated in the narrative section, that Patient 10 required extensive or moderate assistance for the activities of daily livings (ADLs). However, in the section of "ADL Assessment" indicated Patient 10 was independent for all ADLs including ambulation, transfer, feeding, toileting, dressing and bathing. A review of Patient 10's record indicated there was no documented evidence Patient 10 was to be assessed as NYHA Class IV level to meet the eligibility for hospice service as indicated in the LCD assessment dated 8/5/2021. A review of the "Physician's Certification for Hospice Benefit" dated 8/5/2021, indicated Patient 10 was assessed as 50 percent for KPS and PPS, and NYHA Class IV level. It indicated Patient 10 had hypertension, and had shortness of breath on moderate exertion. It indicated the Medical Director had certified that Patient 10 was terminally ill and had a life expectancy of six months or less if the disease continues to run. A review of the "Physician's Certification for Hospice Benefit" for the benefit period from 11/3/2021 to 1/31/2022, from 2/1/2022 to 4/1/2022, from 4/2/2022 to 5/31/2022, from 6/1/2022 to 7/30/2022 indicated there were section for "RN Assessment Narrative" and "Physician Narrative" including 'Face to Face Summary' and 'Certifying Physician Summary. However, both "RN Assessment Narrative" and "Physician Narrative" including 'Face to Face Summary' and 'Certifying Physician Summary were blank for above benefit periods. Also, the spaces for the physician's signature and date were blank. A review of Patient 10's record indicated there was no documented evidence the Medical Director/designated physician had performed Face to face assessment since admission on 8/5/2021 until 6/10/2022. On 6/10/2022, at 9:50 a.m., during a telephone interview with Patient 10, she stated she had high blood pressure but did not have heart problem. Patient 10 stated she had pain on the leg and could not walk very well due to pain on her leg. Patient 10 stated she had signed the hospice service because she needed walker and cane. Patient 10 further stated she did not have any visit by the hospice doctor, and she did not think that she would die soon. On 6/10/2022, at 11:05 a.m., during a telephone interview with the office manager at the Medical Director's office who stated the Medical Director was not available for an interview because he was "so busy", stated the Medical Director had been working for the hospice agency since last year. The office manager stated when the hospice agency sent paper work to the doctor's office, they sent the completed paper work back to the agency through E mail or via fax after the doctor completed the paper work. She stated the Medical Director would visit the patient upon the hospice agency's request. She stated the Medical Director did not have other doctor working for him, and he would not sign electronically. On 6/10/2022, at 11:20 a.m., during an interview with the Designee of Director of Patient Care Services (DPCS) she stated the Medical Director was to review the History and physical, discharge summary if the patient came from the hospital, progress note, reason for hospice service and was to perform Face to Face assessment. She stated then, the agency should have obtained completed "Physician's Certification for Hospice Benefit" including the physician's signature for recertification benefit. However, the designee of DPCS was not able to provide the documented evidence the the agency had provided the patients clinical record to the Medical Director including History and Physical, attending physician's progress note for the need of hospice service, and whether the Medical Director had conducted face to face assessment for Patient 9 and Patient 10. A review of the agency's policy titled Hospice Medical Director revised on October 2016 indicated the duties and responsibilities of the Medical Director include reviewing the clinical record and/or performing medical examination to confirm the appropriateness of services, providing written certification of the terminal illness for all subsequent benefit period, and performing face to face encounters within thirty (30) days of the third and subsequent hospice benefit certification periods and attest to the encounter. It indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The duties and responsibilities of the Medical Director will include reviewing the clinical record and/or performing medical examination to confirm the appropriateness of services. c. A review of Patient 6's clinical record indicated the start of care date was 8/17/2021, with a diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 6's POC/IDG meeting record indicated blank spaces or not signed to indicate the Medical Director (MD) participated in the meeting from 8/27/2021 to 5/20/2022 for a total of 20 IDG meetings held. The Medical Social Worker (MSW) also showed no evidence of being in the meeting on 9/10/2021, 9/24/2021, 10/08/2021, 10/22/2021, 11/05/2021, 11/19/2021, 12/03/2021 and 12/17/2021. A review of Patient 6's "Physician's Certification for Hospice Benefit" for the benefit period from 8/17/2021 to 11/14/2021, from 11/15/2021 to 2/12/2022, from 2/13/2022 to 4/13/2022, and from 4/14/2022 to 6/12/2022, indicated Patient 6 has a life expectancy of six months or less if the terminal illness runs it normal course. The space for "Physician Narrative: Face to Face Summary and Certifying Physician Summary" were blank. The space for "Medical Director attestation/certification", indicated, "I attest/confirm that I composed this narrative based on my review of patient's medical records, team assessment and/or examination of the patient". However, there was no signature of the Medical Director. The space of the RN (Registered Nurse) assessment narrative indicated, "Patient is eligible for hospice service and meets LCD guidelines". A review of Patient 6's LCD (Local Coverage Determination, it provides guidance in determining medical necessity of services) Hospice Eligibility Determination form, undated, indicated Patient 6 does not qualify per LCD guidelines. d. A review of Patient 7's clinical record indicated the start of care date was 8/16/2021, with a diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 7's POC/IDG meeting record indicated black spaces or not signed to indicate the Medical Director (MD) participated in the meeting from 8/27/2021 to 5/20/2022 for a total of 20 IDG meetings held. The Medical Social Worker (MSW) also showed no evidence of being in the meeting on 4/22/2022, 5/06/2022, and 5/20/2022. A review of Patient 7's "Physician's Certification for Hospice Benefit" for the benefit period from 8/16/2021 to 11/13/2021, from 11/14/2021 to 2/11/2022, from 2/12/2022 to 4/12/2022, and from 4/13/2022 to 6/11/2022, indicated that Patient 7 has a life expectancy of six months or less if the terminal illness runs it normal course. The space for "Physician Narrative: Face to Face Summary and Certifying Physician Summary" were blank. The space for "Medical Director attestation/certification", indicated, "I attest/confirm that I composed this narrative based on my review of patient's medical records, team assessment and/or examination of the patient". However, there was no signature of the Medical Director. The space for "RN assessment narrative", for benefit period from 8/16/2021 to 11/13/2021, indicated, "Patient is eligible for hospice service and meets LCD guidelines". The space for "RN assessment narrative" for the benefit period from 2/12/2022 to 4/12/2022, and from 4/13/2022 to 6/11/2022 were blank. A review of Patient 7's LCD Hospice Eligibility Determination form, undated, indicated Patient 7 does not qualify per LCD guidelines. On 6/10/2022, at 11:05 a.m., during a telephone interview with the office manager at the Medical Director's office who stated the Medical Director was not available for an interview because he was "so busy", stated the Medical Director had been working for the hospice agency since last year. The office manager stated when the hospice agency sends paperwork to the doctor's office, the office sends the completed paperwork back to the agency through e-mail or via fax after the doctor completed the paperwork. She stated the Medical Director would visit the patient upon the hospice agency's request. She stated the Medical Director did not have another doctor working for him, and he would not sign electronically On 6/10/2022, at 12:40 p.m., during an interview with the Director of Patient Care Services (DPCS) Designee, she stated the Medical Director was to review the history and physical, discharge summary if the patient came from the hospital, progress note, reason for hospice service and was to perform Face to Face assessment. She stated the agency should have obtained completed "Physician's Certification for Hospice Benefit" including the physician's signature for recertification benefit. However, the DPCS Designee was not able to provide the documented evidence the agency had provided the patients clinical record to the Medical Director including History and Physical, attending physician's progress note for the need of hospice service, and whether the Medical Director had conducted face to face assessment for Patient 6 and 7.

Based on interview and record review the facility failed to provide a "Comfort Kit" (a prescribed set of medications that are kept in a patient's home in the event of an emergency) for one out of 13 sampled patients (Patient 5). This failure had the potential to result in patients not receiving their comfort medications on a timely basis. Findings: A review of Patient 5's clinical record indicated she was admitted to the hospice agency on 7/09/2021, with a diagnosis including hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 5's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 7/09/2021 to 10/06/2021, the space "Physician Summary" indicated Patient 5 has increasing shortness of breath (SOB, difficulty in breathing) on mild exertion, even at short distances of walks, inability to carry on physical activity without discomfort, and mainly sit or lie which requires minimal to moderate assistance in ADL's (activities of daily living, like bathing, toileting, dressing, eating, mobility). It also indicated Patient 5 has a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 5's POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form, dated 3/11/2022, indicated Skilled Nursing (SN) was to visit once a week plus 3 prn (as needed) visits for pain and symptoms management, MSW (Social worker) to follow-up monthly plus 1 prn visit for initial assessment of psychosocial and emotional needs of patient and family. SC (Spiritual Counselor) and volunteer was declined. During a joint home visit to Patient 5's home, on 6/08/2022 at 2:15 p.m., with License Vocational Nurse (LVN 1), Patient 5 was observed fully clothed, lying in bed awake and patient's caregiver sitting next to her. During an interview on 6/08/2022 at 2:40 p.m., LVN 1 was asked to provide the Comfort kit for Patient 5 but LVN 1 stated, "she does not have comfort kit". During an interview with the Director of Patient Care Services (DPCS) designee on 6/10/2022 at 12:40 p.m., DPCS designee stated Patient 5 does not have a comfort kit. DPCS designee stated patients should have a comfort kit ready for symptoms management. The hospice agency was unable to provide a policy and procedure addressing the need of a hospice patient to have a comfort kit readily available to them.