Every finding on record at Lifeline Hospice Care, Inc

Based on interview and record review the hospice agency failed to review and revise the emergency preparedness plan annually and provide emergency preparedness training to all staffs. This failure had the potential to result in staffs' lack knowledge of the current emergency protocol that could jeopardize the patients' health and safety during an emergency crises or disaster. --- Findings: A review of the hospice policy and procedure titled "Emergency Management Plan", indicated the policy had not been revised since 11/15/2019, with corresponding signatures by the governing body. Further review of the Disaster Drill training indicated no documented evidence it was provided to all staffs as required.During an interview with the DPCS (director of patient care services) on 7/13/23, at 11 a.m., stated she was aware that the policy should be reviewed annually but could not provide the signatures of the governing body's participation. Administrator stated she could not provide evidence of a disaster drill and emergency preparedness training for all the staffs.

Based on interviews and record review, the hospice agency (HA) failed to ensure the Condition of Participation on Patients Rights was met as follows: 1. The HA failed to provide two of 7 sampled patients (Patient 1 and Patient 6) information regarding their rights as a hospice patient in a language that would be understood and preferred by the patient. (Refer to L502). 2. The HA failed to inform four of 7 sampled patients (Patient 1, Patient 2, Patient 5, and Patient 6) about the services they provide, the limitations of those services, and what hospice care was. (Refer to L519). The cumulative effect of these systemic practices resulted in patients not knowing their hospice services with their limitations and their rights as hospice patients. --- .

Based on interview, and record review, the Hospice Agency failed to provide two of 7 sampled patients (Patient 1 and Patient 6) information on their rights as a hospice patient in a language that would be understood and preferred by the patient. This deficient practice resulted in the patients lack understanding and information for the care and services available, and not being able to exercise their right to decline the hospice services. --- Findings a. A review of Patient 1's clinical record indicated a start of care (SOC) date of 12/09/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (a disease caused by plaque buildup in the wall of the arteries that supply blood to the heart). A review of Patient 1s Informed Consent and Medicare/Medical Election of Hospice Benefits dated 12/09/2022, indicated a hospice agency name Lifeline Hospice Care Inc. The form which includes Patient/Family Bill of Rights indicated it was written and provided to the patient in English. On 7/11/2023 at 2:45 p.m., during a phone interview, Patient 1 stated he did not know what hospice care was and he thought having hospice was to get medical supplies, ensure and have a nurse visit him every week. Patient 1 stated he only speaks and read Spanish, and that the hospice nurse that came into their home does not speak Spanish. The hospice nurse let him sign the hospice consent forms and other paper works which was in English not understanding what was in it and was not explained to him in a language that he understood. On 7/13/2023, at 11:00 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS cannot provide any documented evidence that consent forms for hospice benefit was provided to the patient in the language that the patient understood. A review of the hospice agencys undated policy and procedure titled, "Rights/Responsibilities", indicated each patient will be an active, informed participant in his/her plan of care. Upon admission, each hospice patient and/or his/her representative will be given a written copy of the Patient Rights and Responsibilities. The Patient Rights and Responsibilities will be explained and distributed to the patient prior to the initiation of organization services. This explanation will be in a language that the patient and manager understand. A review of Patient 6's clinical record indicated a start of care (SOC) date of 6/20/23, with a terminal diagnosis of unspecified transient cerebral ischemic attack ( a brief stroke attack despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke). A review of Patient 6s Informed Consent and Medicare/Medical Election of Hospice Benefits dated 6/20/23, indicated a hospice agency name Lifeline Hospice Care Inc. The form which includes Patient/Family Bill of Rights indicated it was written and provided to the patient in English. On 7/13/2023 at 12 p.m., during a phone interview, Patient 6 stated she did not know what hospice care was and she thought having hospice was to get a nurse to visit one or two times a week to assist her with transfers and monitor her health condition. Patient 6 also stated she only speaks and read Spanish, and that the hospice nurse that came into their home does not speak Spanish. The hospice nurse let her sign the hospice consent forms and he told her to read the other paper works in the agency folder which was in English not understanding what was in it and was not explained to her in a language that she understood. On 7/13/23, at 1 p.m., during an interview with the DPCS (director of patient care services), she stated the agency should be sending a visiting nurse that could speak and understand spanish to provide patient care and teaching for a spanish speaking patient.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to inform four of 7 sampled patients (Patients 1, 2, 5, and 6) about the services they provide and the limitations on those services. This failure resulted in the patient not being aware about what hospice care was and what services are covered while being in hospice. --- Findings: a. A review of Patient 1's clinical record indicated a start of care (SOC) date of 12/09/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (a disease caused by plaque buildup in the wall of the arteries that supply blood to the heart). On 7/11/2023 at 2:45 p.m., during a phone interview, Patient 1 stated he did not know what hospice care was and he thought having hospice was to get medical supplies, ensure and have a nurse visit him every week. Patient 1 stated he was not dying, still drives, and that he was never told that he had six months or less to live. Patient 1 stated he had a heart surgery a few years back, visits his cardiologist (heart doctor) every four months, and was told that he was stable. b. A review of Patient 2's clinical record indicated a start of care (SOC) date of 4/12/2023, with a terminal diagnosis of heart failure, unspecified (a disorder where your heart is unable to pump the blood properly). On 7/12/2023 at 12:35 p.m., during a phone interview, Patient 2 stated he has multiple medical problem, but he was stable. He stated that he was never told that he had six months or less to live, still drives, and goes to work regularly. When asked if he knows what hospice care was, Patient 2 stated that a nurse will come visits him every week. When asked how he heard about the hospice agency, Patient 2 stated the owner of the agency came into their house and have them signed the hospice paper works. On 7/13/2023, at 11:00 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated hospice services were explained to all their patients on admission and on every follow up visit by the hospice nurse. A review of the facilitys undated policy and procedure titled, ";Rights/Responsibilities", indicated each patient will be an active, informed participant in his/her plan of care. The patient will be informed during the initial assessment visit, in advance of furnishing care, of the hospice philosophy and program of care, and the right to elect hospice care. A review of the facilitys undated policy and procedure titled, ";Admission Criteria and Process", indicated the patient must desire hospice services and be aware of the diagnosis and prognosis. b. A review of Patient 5's clinical record indicated a start of care (SOC) date of 5/10/23, with a terminal diagnosis of chronic kidney disease (longstanding disease of the kidneys leading to renal failure). On 7/12/2023 at 11 a.m., a home visit was conducted at Patient 5's residence with LVN 1. Patient 5 was seen lying in bed asleep. During an interview with Caregiver 1 (daughter), she stated the admitting nurse did not provide her any information about the scope of service the hospice will render to the patient. She also stated that she declined bereavement/chaplain services because the patient was not dying in six months and she does not need it. c. A review of Patient 6's clinical record indicated a start of care (SOC) date of 6/20/23, with a terminal diagnosis of unspecified transient cerebral ischemic attack ( a brief stroke attack despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke). On 7/13/2023 at 12 p.m., during a phone interview, Patient 6 stated she did not know what hospice care was and she thought having hospice was to get a nurse to visit one or two times a week to assist her with transfers and monitor her health condition. She also stated the admitting nurse had her sign the hospice consent forms and he told her to read the other paper works in the agency folder without explaining the information about the scope of service the hospice will provide to her. On 7/13/23, at 1 p.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should provide information about the scope of services that the hospice will provide for Patient 5 and 6 during their initial visits.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of Patients was met as follows: 1. The hospice agency failed to ensure the patients' comprehensive assessment (describes in detail a patient's medical, physical, and psychosocial condition and needs) were completed within five days after the election of hospice care for five of 7 sampled patients (Patient 1, Patient 3, Patient 4, Patient 5, and Patient 6). (Refer to L523) 2. The hospice agency failed to maintain an accurate, current medication profile for two of 7 sampled patients (Patient 3 and Patient 4). (Refer to L530) 3. The hospice agency failed to accurately assess the eligibility (the right to do something) for hospice (medical care given to people with life threatening diseases) services related to the palliation (relief of symptoms and suffering cause by life threatening diseases) and management of the terminal illness and related conditions for four out of 7 sampled patients (Patient 1, Patient 2, Patient 5, and Patient 6). (Refer to L532). The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily (right or legal way) mandated compliance with the Federal regulations for Initial & Comprehensive Assessment of Patients to ensure the highest quality of care is being provided to patients certified to receive the Medicare hospice benefits. --- .

Based on interview and record review, the hospice agency (HA) failed to ensure the patients comprehensive assessment (describes in detail a patient's medical, physical, and psychosocial condition and needs) were completed within five days after the election of hospice care for five of 7 sampled patients (Patients 1, 3, 4, 5 and 6). For Patient 1, the initial psychosocial assessment was not conducted within 5 days from the start of care date. For Patient 3, the recertification comprehensive assessment was not complete. For Patient 4, the initial comprehensive assessment was not complete, and the initial psychosocial assessment was not conducted within 5 days from the start of care. For Patients 5 and 6, the initial comprehensive assessments were not completed and not conducted within 5 days from the start of care. This deficient practice had the potential to cause patient harm or injury and the delay of necessary services required in the patients care. --- Findings: a. A review of Patient 1's clinical record indicated a start of care (SOC) date of 12/09/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (a disease caused by plaque buildup in the wall of the arteries that supply blood to the heart). A review of Patient 1s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 12/09/2022, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 3 prn (pro re nata, which means ";as needed") visits for pain and symptoms management, and for the Master of Social Work (MSW) and spiritual counselor (SC) to one-time visit then prn. Hospice aide (HA), and volunteer (VOL) were declined. A further review of Patient 1s clinical records indicated there was no psychosocial assessment conducted. b. A review of Patient 3's clinical record indicated he was admitted to the hospice agency on 3/02/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. A review of Patient 3s POC/IDG form dated 3/02/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 3 prn visits for pain and symptoms management, hospice aide to visit two times a week, volunteer to 2 visits per month, and MSW and SC to one-time visit then prn. A review of Patient 3's ";Re-cert Assessment" dated 5/29/2023, indicated the visiting nurse failed to complete the entire form, and the form was not signed. c. A review of Patient 4's clinical records indicated a SOC date of 5/25/2023, with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). A review of Patient 4s POC Summary, indicated the frequency of visits for the licensed vocational nurse (LVN) and the hospice aide to two visits per week, and for the MSW and SC to visit one-time then prn. A review of Patient 4's Comprehensive Nursing Assessment dated 5/25/2023, indicated the visiting nurse failed to complete the entire form, and the form was not signed. A further review of Patient 4s clinical records indicated Patient 4s psychosocial assessment was conducted on 6/05/2023, or 11 days after the SOC. On 7/13/2023 at 11:00 a.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated an initial psychosocial assessment was not conducted for Patient 1, and for Patient 4, it was performed on 6/05/2023 or 11 days after the SOC. The DPCS acknowledged Patient 3 recertification assessment and Patient 4 initial comprehensive assessment was not complete. The DPCS stated patients comprehensive assessment should have been conducted/completed and that an initial psychosocial assessment should have been done as part of the comprehensive assessment, within 5 days from SOC. A review of the hospice agencys undated policy and procedure titled, ";Comprehensive Assessment", indicated a comprehensive patient assessment will be performed by the hospice IDG no later than 5 calendar days after the election of hospice care in consultation with attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including the patients psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanisms and the patients and family/caregivers reaction to illness. A review of the hospice agencys undated policy and procedure titled, ";Psychosocial Services", indicated the purpose of the policy and procedure is to ensure that appropriate psychosocial services are provided to hospice patients and family/caregivers. The social worker will contribute to the comprehensive assessment and ongoing update to the comprehensive assessment based on the needs of the patient. Psychosocial assessments and interventions will be documented in the patients clinical record as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care. d. A review of Patient 5's clinical record indicated a start of care (SOC) date of 5/10/23, with a terminal diagnosis of chronic kidney disease (longstanding disease of the kidneys leading to renal failure). A review of Patient 5s POC Summary, indicated the frequency of visits for the licensed vocational nurse (LVN) and the hospice aide to two visits per week, and for the MSW and SC to visit one-time then prn. A review of Patient 5's Initial Comprehensive Nursing Assessment dated 5/10/2023, indicated the visiting nurse failed to complete the entire form, and the form was not signed. e. A review of Patient 6's clinical record indicated a start of care (SOC) date of 6/20/23, with a terminal diagnosis of unspecified transient cerebral ischemic attack ( a brief stroke attack despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke). A review of Patient 6s POC Summary, indicated the frequency of visits for the licensed vocational nurse (LVN) and the hospice aide to two visits per week, and for the MSW and SC to visit one-time then prn. A review of Patient 6's Initial Comprehensive Nursing Assessment dated 6/20/23, indicated the visiting nurse failed to complete the entire form, and the form was not signed. On 7/13/23, at 12 p.m., during an interview with the DPCS, she stated the initial comprehensive assessment should have been conducted/completed within 5 days from the start of care.

Based on observation, interview and record review, the hospice agency failed to maintain an accurate, current medication profile for two of seven sampled patients (Patient 3 and Patient 4). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions. --- Findings: a. A review of Patient 3's clinical record indicated he was admitted to the hospice agency on 3/2/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. A review of Patient 3s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 6/06/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 3 PRN visits for pain and symptoms management, and the Hospice aid to visit two times a week. The skilled nurse was to instruct the patient and/or caregiver regarding new medications or treatments, monitor for side effects, to monitor and assess effectiveness of the current and any new medications or treatments. On 7/11/2023, at 11:45 a.m., a joint home visit was conducted to Patient 3's residence, with the License Vocational Nurse (LVN 1). Patient 3 was observed awake, alert, oriented, and ambulatory using a cane without any assistance from family members. On 7/11/2023, at 12:10 p.m., during a review of Patient 3s current medications, Nasal Decongestant 12-hour relief maximum strength 0.05% nasal spray, and Guaifenesin-codeine 100-10 milligram (mg) cough syrup was not found. However, the patients current medication profile provided by the hospice staff indicated patient was taking the medication. During an interview with the patients caregiver (PCG 1), she stated Patient 3 was not taking these medications for several weeks. b. A review of Patient 4's clinical records indicated a SOC date of 5/25/2023, with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). A review of Patient 4s POC Summary, indicated the frequency of visits for the licensed vocational nurse (LVN) and the hospice aide to two visits per week, and for the MSW and SC to visit one-time then prn. On 7/11/2023, at 11 a.m., a joint home visit was conducted to Patient 4's residence, with the License Vocational Nurse (LVN 1). Patient 4 was observed lying on a hospital bed, alert, confused and a family member (PCG 2), the primary caregiver was next to her and available to answer any questions. On 7/11/2023, at 11:30 a.m., during a review of Patient 4s current medications, Aricept 5 mg 1 tablet daily for dementia (the loss of cognitive functioning -thinking, remembering, and reasoning) was not found. However, the patients current medication profile provided by the hospice staff indicated patient was taking the medication. During an interview with PCG 2, she stated Patient 4 was not taking the medicine for several months. On 7/13/2023, at 11 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated nursing staff need to review patients current medication every visit and update the medication profile in the patients clinical record. A review of the hospice agencys undated policy and procedure titled, ";Medication Profile", indicated patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Based on observation, interview, and record review, the hospice agency failed to accurately assess the eligibility (the right to do something) for hospice (medical care given to people with life threatening diseases) services related to the palliation (relief of symptoms and suffering cause by life threatening diseases) and management of the terminal illness and related conditions for four out of 7 sampled patients (Patient 1, Patient 2, Patient 5, and Patient 6). This deficient practice had the potential to result in misuse of the hospice services that could result in substandard (below) provision (supplying something for use) of patient care. --- Findings: a. A review of Patient 1's clinical record indicated a start of care (SOC) date of 12/09/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (a disease caused by plaque buildup in the wall of the arteries that supply blood to the heart). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 3. A review of Patient 1's Physicians Certification for Hospice Benefit, dated 12/09/2022 to 3/08/2023, benefit period #1, indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course and was eligible for hospice services under routine level of care, signed by MD 2 (previous Medical Director of the HA). The section ";Certifying Physician Summary" indicated Patient 1 was terminally ill, requires maximum assistance with ADLS, and met the criteria of NYHA Class IV level (New York Heart Association Stages of Heart Failure Class IV – patients who have severe limitations, experiences symptoms even while at rest, and mostly bedbound). A review of Patient 1s form titled, "LCD Hospice Eligibility Determination (Local Coverage Determination, guidelines used by hospice providers to determine eligibility of beneficiaries for hospice benefits)" for Heart Disease, indicated section 1 and 2 must be met. Section 1 was marked ";yes" that Patient 1 declined surgical procedures. Section 2 was marked ";yes" that Patient 1 met the criteria for NYHA Class IV level. A review of Patient 1's Comprehensive Nursing Assessment dated 12/09/2022, indicated Patient 1 was awake, alert, and oriented x 3 (time, place, person), and had normal speech. Patient 1 was ambulatory with the use of a walker and needed stand-by assist. Cardiac rate was regular, at 89 beats per minute, has no cardiac-related pain, and no edema observed. Patient 1 needs minimal assistance with transfers, bathing, and dressing. 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 Patient 1's clinical record indicated no documented evidence Patient 1 was ruled out as a candidate nor declined surgical procedure related to heart disease. There was also no documented evidence Patient 1 was on complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest. On 7/11/2023 at 2:45 p.m., during a telephone interview, Patient 1 stated he did not know what hospice care was and he thought having hospice was to get medical supplies, ensure and have a nurse visit him every week. Patient 1 stated he was not dying, still drives, and that he was never told that he had six months or less to live. Patient 1 stated he had a heart surgery a few years back, visits his cardiologist (heart doctor) every four months, and was told that he was stable. Patient 1 also stated he does not know or have any conversation with regards to his medical history with Physician 3. On 7/13/2023, at 11:00 a.m., during an interview with the Director of Patient Care Services (DPCS), DPCS stated she was not able to find documented evidence Patient 1 declined surgical procedure related to heart disease. DPCS also stated the referring physician, Physician 3, was one of the contracted physician of the hospice agency and not the attending physician of Patient 1. b. A review of Patient 2's clinical record indicated a start of care (SOC) date of 4/12/2023, with a terminal diagnosis of heart failure, unspecified (a disorder where your heart is unable to pump the blood properly). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 4/12/2023 to 7/10/2023, benefit period #1, indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course and was eligible for hospice services under routine level of care, signed by MD 1. The section ";Certifying Physician Summary" indicated Patient 1 was terminally ill, requires moderate assistance with ADLS, and met the criteria of NYHA Class IV level. A review of Patient 2s form titled, "LCD Hospice Eligibility Determination" for Heart Disease, dated 4/12/2023, indicated patient does not qualify per LCD Guidelines. A review of Patient 2's Comprehensive Nursing Assessment dated 4/12/2023, indicated Patient 2 was awake, alert, and oriented x 2 (place, person), and had normal speech. Patient 2 needed minimum to moderate assistance with ADLS and maximum assistance with ambulation with unsteady gait. Patient 2 had no cardiac-related pain, has pitting edema +2, and has mild shortness of breath with mild exertion. A review of Patient 2's clinical record indicated no documented evidence Patient 2 was ruled out as a candidate nor declined surgical procedure related to heart disease. There was also no documented evidence Patient 2 was on complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest. On 7/12/2023 at 12:35 p.m., during a phone interview, Patient 2 stated he has multiple medical problem, but he was stable. He stated that he was never told that he had six months or less to live, still drives, and goes to work regularly. When asked if he knows what hospice care was, Patient 2 stated that a nurse will come visits him every week. When asked how he heard about the hospice agency, Patient 2 stated the owner of the agency came into their house and have them signed the hospice paper works. On 7/13/2023, at 11:00 a.m., during an interview with the Director of Patient Care Services (DPCS), DPCS stated she was not able to find documented evidence Patient 2 declined surgical procedure related to heart disease nor patient was confined to bed or chair. DPCS stated Patient 2 was discharged from hospice because of non-compliance. c. A review of Patient 3's clinical record indicated he was admitted to the hospice agency on 3/02/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. A review of Patient 3's Physicians Certification for Hospice Benefit, dated 3/02/2023 to 5/30/2023, Benefit period #2, indicated Patient 3 had a life expectancy of six months or less, if the terminal illness runs its normal course and was eligible for hospice services under routine level of care, signed by MD 1. The section ";Certifying Physician Summary" indicated Patient 3 was terminally ill, requires maximum assistance with transfers, bathing, personal hygiene, dressing and medication management, and moderate assistance with ambulation. The Physician Summary also indicated Patient 3 and family opted for comfort measures and are no longer seeking aggressive treatment due to the patients present condition. A review of the form of "LCD Hospice Eligibility Determination" for Pulmonary Disease, indicated section 1 and section 2 should be met. It was mark "yes" in section 1 that Patient 3 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 3 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 3's clinical record indicated there was no documented evidence Patient 3 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators or had O2 saturation of 88% or less. On 7/11/2023, at 11:45 a.m., a joint home visit was conducted to Patient 3's residence, with the License Vocational Nurse (LVN 1). Patient 3 was observed awake, alert, oriented, and ambulatory using a cane without any assistance from family members. Patient 3 was observed not using supplemental oxygen, breathing normally, and had no shortness of breath. During an interview with the patients caregiver (PCG 1), PCG 1 stated Patient 3 only used oxygen to help him sleep well at night and have no shortness of breath when sitting in chair or in bed. On 7/13/2023, at 11:00 a.m., during an interview with the Director of Patient Care Services (DPCS), DPCS stated she was not able to find documented evidence Patient 3 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators or had O2 saturation of 88% or less. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated Lifeline Hospice Care, Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Lifeline Hospice Care Inc will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. c. A review of Patient 5's clinical record indicated a start of care (SOC) date of 5/10/23, with a terminal diagnosis of chronic kidney disease (longstanding disease of the kidneys leading to renal failure). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 3 (previous medical director). A review of Patient 5's Physicians Certification for Hospice Benefit, dated 5/10/23 to 8/7/23, benefit period #1, indicated the Medical Director signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 7/11/23, at 12 p.m., a home visit was conducted at Patient 5's residence with LVN 1 (license vocational nurse). The patient was observed lying in bed asleep. At 12:30 p.m., during an interview with Caregiver 1 (daughter) if Patient 5 was referred by her attending physician, she stated no. she also stated that a family friend recommended the hospice agency for Patient 5. d. A review of Patient 6's clinical record indicated a start of care (SOC) date of 6/20/23, with a terminal diagnosis of unspecified transient cerebral ischemic attack ( a stroke that last only few minutes). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 3 (previous medical director). A review of Patient 6's Physicians Certification for Hospice Benefit, dated 6/20/23 to 9/17/23, benefit period #1, indicated the Medical Director signed the attending physician referral section to indicate Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 7/13/23, at 2 p.m., during an interview with the Director of Patient Care Services (DPCS ), she stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. On 7/13/123 at 12:30 p.m., during a phone interview with Medical Director 1, he stated that he was not the attending physician, and he does not know who the attending physician for Patients 5 and 6. He stated since Patients 5 and 6 were admitted to their hospice service, he is now the patient's attending physician, that he signed the referral attending physician section because no one would sign it. Medical Director 1 further stated that he determined the patients were eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated Lifeline Hospice Care, Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Lifeline Hospice Care Inc will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician.

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 hospice agency failed to ensure the IDG group meetings were held by all the members of interdisciplinary group to discuss the patients comprehensive and ongoing assessments and care planning process for six of 7 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). (Refer to L541) 2. The hospice agency failed to ensure patient care plan was developed that included problem, interventions, and goals, for four of 7 sampled patients (Patient 4, Patient 5, Patient 6, and Patient 7). (Refer to L545) 3. The hospice agency failed to ensure wound care treatment was followed according to the plan of care, for one of 7 sampled patients (Patient 4). (Refer to L549) 4. The hospice agency failed to ensure home visits were conducted according to the plan of care for three of 7 sampled patients (Patient 1, Patient 3, and Patient 4). (Refer to L555) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the 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 (HA) failed to ensure the interdisciplinary group (IDG) meetings were held by all the members of interdisciplinary group to discuss the patients comprehensive and ongoing assessments and care planning process for six out of 7 sampled patients (Patients 1, 2, 3, 4, 5, and 6). This deficient practice has a potential for the patients 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 1's clinical record indicated a start of care (SOC) date of 12/09/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (a disease caused by plaque buildup in the wall of the arteries that supply blood to the heart). A review of Patient 1s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 12/09/2022, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 3 prn (pro re nata, which means ";as needed") visits for pain and symptoms management, and for the Master of Social Work (MSW) and spiritual counselor (SC) to one-time visit then prn. Hospice aide (HA), and volunteer (VOL) were declined. A review of Patient 1s POC/IDG meeting record indicated the registered nurse (RN) did not attend the meeting on 12/16/2022, MSW did not attend the meeting on 12/16/2022, 2/16/203, 2/28/2023 and 3/29/2023, and the chaplain (SC) did not attend the IDG meeting on 3/29/2023. b. A review of Patient 2's clinical record indicated a start of care (SOC) date of 4/12/2023, with a terminal diagnosis of heart failure, unspecified (a disorder where your heart is unable to pump the blood properly). A review of Patient 2s POC/IDG form dated 4/26/2023, indicated the frequency of visits for skilled nurse to one visit per 2 weeks plus 1 prn visit, hospice aide to one visit per week, and MSW and volunteer to one-time visit then prn. Chaplain service was declined. A review of Patient 2s POC/IDG meeting record indicated the registered nurse did not attend the meeting on 4/26/2023. c. A review of Patient 3's clinical record indicated he was admitted to the hospice agency on 3/02/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. A review of Patient 3s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 3/02/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 3 prn visits for pain and symptoms management, hospice aide to visit two times a week, volunteer to 2 visits per month, and MSW and SC to one-time visit then prn. A review of Patient 3s POC/IDG meeting record indicated the registered nurse and the MSW did not attend the meeting on 5/10/2023, 5/24/2023 and 6/06/2023. The chaplain did not attend the meeting on 6/06/2023. d. A review of Patient 4's clinical records indicated a SOC date of 5/25/2023, with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). A review of Patient 4s POC Summary, indicated the frequency of visits for the licensed vocational nurse (LVN) and the hospice aide to two visits per week, and for the MSW and SC to visit one-time then prn. A review of Patient 4s POC/IDG meeting record indicated the Medical Director, MSW and Chaplain did not attend the meeting on 6/07/2023. On 7/13/2023, at 11:00 a.m., during an interview with the Director of Patient Care Services (DPCS), DPCS 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). 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 Patient 1, 2, 3, 4, 5, 6 and 7 on the above days. A review of the agency's undated policy and procedure titled, "Interdisciplinary Group Meeting," 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 patients 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 patients condition requires. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor. e. A review of Patient 5's clinical record indicated a start of care (SOC) date of 5/10/23, with a terminal diagnosis of chronic kidney disease (longstanding disease of the kidneys leading to renal failure). A review of Patient 5s POC/IDG form dated 6/5/23, indicated the frequency of visits for skilled nurse to one visit per 2 weeks plus 1 prn visit, hospice aide to one visit per week, and MSW and Spritual Counseling to one-time visit then prn. A review of Patient 5s POC/IDG meeting record on dates 5/10, 5/24/23, 6/5/23 and 7/5/23,indicated the medical director, MSW and the chaplain did not attend the IDG meeting. f. A review of Patient 6's clinical record indicated a start of care (SOC) date of 6/20/23, with a terminal diagnosis of unspecified transient cerebral ischemic attack ( a stroke that last only few minutes). A review of Patient 6s POC/IDG form dated 6/20/23, indicated the frequency of visits for skilled nurse to one visit per 2 weeks plus 1 prn visit, hospice aide to one visit per week, and MSW and volunteer to one-time visit then prn. A review of Patient 2s POC/IDG meeting record indicated the registered nurse and the medical director did not attend the meeting on 4/26/2023.

Based on interview and record review, the hospice agency failed to ensure patient care plan was developed and completed that included problems, interventions, and goals, for four of 7 sampled patients (Patient 4, Patient 5, Patient 6, and Patient 7). This deficient practice had the potential to affect the necessary care and services needed to maintain the highest practicable physical, mental, and psychosocial well-being of the patients receiving hospice care services. --- Findings: a. A review of Patient 4's clinical records indicated a SOC date of 5/25/2023, with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). A further review of Patient 4s clinical record did not indicate a Plan of Care (POC) was developed and/or completed for Patient 4. On 7/10/2023, at 1:30 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), DPCS stated the registered nurse assigned to these patients was not able to complete the patient assessment and submit his documentation in a timely manner and that nurse just submitted his resignation from the agency. The DPCS stated the plan of care was supposed to be completed and then reviewed by the IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) within 2 days after the initial comprehensive assessment was done by the registered nurse. A review of the agency's undated policy and procedure titled, "Plan of Care", indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. b. A review of Patient 5's clinical record indicated a start of care (SOC) date of 5/10/23, with a terminal diagnosis of chronic kidney disease (longstanding disease of the kidneys leading to renal failure). A further review of Patient 5s clinical record did not indicate a Plan of Care (POC) was developed and/or completed for Patient 5. c. A review of Patient 6's clinical record indicated a start of care (SOC) date of 6/20/23, with a terminal diagnosis of unspecified transient cerebral ischemic attack ( a stroke that last only few minutes). A further review of Patient 6s clinical record did not indicate a Plan of Care (POC) was developed and/or completed for Patient 6. d. A review of Patient 7's clinical record indicated a start of care (SOC) date of 6/2/23, with a terminal diagnosis of unspecified heart disease ( a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet tissue metabolic requirements). A further review of Patient 7s clinical record did not indicate a Plan of Care (POC) was developed and/or completed for Patient 7.

Based on observation, interview and record review, the hospice agency (HA) failed to ensure the medication and treatment are administered according to the plan of care for one of 7 sampled patients (Patient 4). For Patient 4, the visiting nurse failed to provide wound care as ordered. This deficient practice placed the patient's wound at risk for delay of wound healing. --- Findings: a. A review of Patient 4's clinical records indicated a SOC date of 5/25/2023, with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). A review of Patient 4s POC Summary, indicated the frequency of visits for the licensed vocational nurse (LVN) and the hospice aide to two visits per week, and for the MSW and SC (spiritual) to visit one-time then PRN. There was a treatment ordered on 6/13/2023, to cleanse skin tear (a wound that happens when the layers of skin separate or peel back) on left shin with normal saline (NS, a cleansing solution for most wounds), pat dry, apply thin layer of triple antibiotic ointment (a medicine that aids in the healing of minor cuts, scrapes and burns), cover with non-adherent dressing, wrap with bandage and secure with tape twice a week. On 7/11/2023, at 11 a.m., a joint home visit was conducted to Patient 4's residence, with the License Vocational Nurse (LVN 1). Patient 4 was observed lying in a hospital bed, alert, and confused. Patient 4 was observed with an open wound on her left shin. A review of Patient 4's Visit Note LVN (license vocational nurse) form dated 6/21/2023, indicated no documented evidence the visiting nurse performed the wound care treatment as ordered. On 7/13/2023, at 11 a.m., during an interview with the Director of Patient Care Services (DPCS), DPCS stated the visiting nurse should be providing wound care during visits and to specifically document each wound treatment orders provided in their nursing notes. A review of the agency's undated policy and procedure titled, "Plan of Care", indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The individualized plan of care must specify the care and services necessary to meet the patient needs as identified in the assessment.

Based on interview and record review, the hospice agency failed to ensure home visits were conducted according to the plan of care (POC) for three of 7 sampled patients (Patient 1, Patient 3, and Patient 4). This failure had the potential to negatively affect the patients' physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. --- Findings: a. A review of Patient 1's clinical record indicated a start of care (SOC) date of 12/09/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (a disease caused by plaque buildup in the wall of the arteries that supply blood to the heart). A review of Patient 1s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 12/9/2022, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 3 PRN (pro re nata, which means ";as needed") visits for pain and symptoms management. A review of Patient 1s history of SN visits for the period starting January 2023 to March 2023, indicated the following: 1. For the week starting 1/22/2023 (Sunday) and ending 1/28/2023 (Saturday) – no visit conducted 2. For the 2-week period starting 2/19/2023 (Sunday) and ending 3/04/2023 (Saturday) – no SN visit conducted. There was no documented evidence the SN coordinated with the physician of the missed visits. b. A review of Patient 3's clinical record indicated he was admitted to the hospice agency on 3/02/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. A review of Patient 3s POC/IDG form dated 3/02/2023, indicated the frequency of visits for the skilled nurse to one visit per week plus 3 prn visits to assess pain and response to medications, assess alteration in mobility, and to educate and instruct patient and caregivers about safety measures to prevent fall and injury. A review of Patient 3s history of SN visits for the period starting March 2023 to June 2023, indicated the following: 1. For the 2-week period starting 3/05/2023 (Sunday) and ending on 3/18/2023 (Saturday) – no SN visit was conducted. 2. For the week starting 3/26/2023 (Sunday) and ending on 4/01/2023 (Saturday) – no SN visit was conducted. 3. For the week starting 4/09/2023 (Sunday) and ending on 4/15/2023 (Saturday) – no SN visit was conducted. 4. For the week starting 5/14/2023 (Sunday) and ending on 5/20/2023 (Saturday) – no SN visit was conducted. 5. For the week starting 5/28/2023 (Sunday) and ending on 6/03/2023 (Saturday) – no SN visit was conducted. 6. For the week starting 6/11/2023 (Sunday) and ending on 6/17/2023 (Saturday) – no SN visit was conducted. There was no documented evidence the SN coordinated with the physician of the missed visits. c. A review of Patient 4's clinical records indicated a SOC date of 5/25/2023, with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). A review of Patient 4s POC Summary, indicated the frequency of visits for the licensed vocational nurse (LVN) to two visits per week. A review of Patient 4s history of SN visits for the period starting May 2023 to July 2023, indicated the following: 1. For the week starting 5/28/2023 (Sunday) and ending on 6/03/2023 (Saturday) – no SN visits were conducted. 2. For the week starting 6/25/2023 (Sunday) and ending on 7/01/2023 (Sunday) – only one SN visit was conducted. There was no documented evidence the SN coordinated with the physician of the missed visits. On 7/13/2023, at 11 a.m., during an interview with the Director of Patient Care Services (DPCS), DPCS acknowledged the finding and stated patient care visit should be provided to patients according to the plan of care. A review of the agency's undated policy and procedure titled, "Plan of Care", indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on interview and record review, the hospice agency failed to provide documented evidence that Quality Assessment and Performance Improvement (QAPI, the coordinated application of two mutually-reinforcing aspects of a quality management system) program had been developed, and is ongoing, hospice wide. This failure had the potential that concerns, and issues identified by the agency will not be addressed, and will not help improve hospice performance in the care and services needed to provide quality care to the patients under the agencys care. --- During the record review of the Quality Assessment and Performance Improvement (QAPI, the coordinated application of two mutually reinforcing aspects of a quality management system) program on 7/13/23 at 2 p.m., there was no indication the QAPI program policy had been approved since 1/15/2022. The policy indicated the program will objectively and systematically monitor and evaluate the effectiveness and safety of services and quality of care provided for patient/families. During an interview with the Director of Patient Care Services (DPCS) on 7/13/2023 at 2:10 p.m., the DPCS could not provide the QAPI meeting minutes. The DPCS confirmed the policy should have been reviewed annually and there should be evidence of a functioning QAPI program. She confirmed she could not provide any current documentation. When asked, the DPCS stated the QAPI program is important to improve its hospice operations.

Based on interview and record review, the hospice agency failed to provide documented evidence of the hospice performance improvement projects. This failure had the potential to affect the care being provided to the patients. --- During record review on 7/13/23, at 2 p.m., there was no documented performance improvement projects provided when requested. During an interview with the Director of Patient Care Services (DPCS) on 7/13/23, at 2:30 p.m., stated she has not started on the projects and could not provide documentation. The agency's undated policy and procedure titled "Patient Focused Performance Improvement" indicated program related to performance improvement activities will focus on opportunities to improve overall organizational performance.

Based on interview and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Hospice Aide & Homemaker Services was met as follows: 1. The hospice agency failed to ensure ordered hospice aide services were provided in accordance with the plan of care for two of seven sampled patients (Patient 2 and Patient 3). (Refer to L626) 2. The hospice agency failed to ensure that a registered nurse supervisory visit for hospice aide was conducted every 14 days for two of seven sampled patients (Patient 3 and Patient 4). (Refer to L629) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver mandated compliance with Federal regulations for Hospice Aide & Homemaker Services to ensure highest quality healthcare is provided to patients assessed to receive hospice services. --- .

Based on interview and record review, the hospice agency (HA) failed to ensure ordered hospice aide services were provided in accordance with the plan of care (POC) for two of seven sampled patients (Patient 2 and Patient 3). This failure had the potential to negatively affect the patients' physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. --- Findings: a. A review of Patient 2's clinical record indicated a start of care (SOC) date of 4/12/2023, with a terminal diagnosis of unspecified heart failure (a disorder when the heart is unable to pump the blood properly). A review of Patient 2s Plan of Care (POC) Summary, indicated an order dated 4/12/2023 for the frequency of visits for the hospice aide to one visit per week to assist with personal care. A review of Patient 2s history of hospice aide visits for the month of April 2023, indicated that for the week starting 4/12/2023 (Wednesday/SOC) and ending on 4/15/2023 (Saturday), no hospice aide visit was conducted. b. A review of Patient 3's clinical record indicated Patient 3 was admitted to the hospice agency on 3/2/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. A review of Patient 3s POC/IDG (Interdisciplinary Group - a team responsible for the holistic care of the hospice beneficiary) form dated 3/2/2023, indicated the frequency of visits for the hospice aide to twice a week for personal hygiene and activities of daily living (ADL, activities related to personal care which includes bathing, grooming, dressing, toileting, and eating) assistance. A review of Patient 3s history of hospice aide visits for the period starting March 2023 to June 2023, indicated the following: 1. For the period starting 3/29/2023 to 4/14/2023, no hospice aide visit was conducted. 2. For the week starting 5/21/2023 (Sunday) and ending on 5/27/2023 (Saturday), only one hospice aide visit was conducted. On 7/13/2023 at 11:00 a.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated that if patient refused hospice aide visit, such refusal will be documented in the patients clinical record. DPCS was unable to provide documented evidence that Patient 2 and Patient 3 or their family refused hospice aide visits on the above days no visit was conducted. A review of the agency's undated policy and procedure titled, "The Plan of Care", indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on interview and record review, the hospice agency (HA) failed to ensure that a Registered Nurse (RN) supervisory visit for hospice aide was conducted every 14 days for two of seven sampled patients (Patient 3 and Patient 4). This deficient practice resulted in lack of oversight and had the potential to result in services not being provided. --- Findings: a. A review of Patient 3's clinical record indicated Patient 3 was admitted to the hospice agency on 3/2/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. A review of Patient 3s POC/IDG (Interdisciplinary Group - a team responsible for the holistic care of the hospice beneficiary) form dated 3/2/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week and three (3) as needed (prn) visits for pain and symptoms management, and the hospice aide to visit two times a week. A review of Patient 3's clinical record indicated that there was no hospice aide supervisory visit conducted by the RN on the dates between 5/18/2023 to 6/25/2023. b. A review of Patient 4's clinical records indicated an SOC date of 5/25/2023, with a terminal diagnosis of unspecified Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). A review of Patient 4s POC Summary dated 6/7/2023, indicated the frequency of visits for the licensed vocational nurse (LVN) and the hospice aide to two visits per week. A review of Patient 4's clinical record indicated that there was no hospice aide supervisory visit conducted by the RN for the month of June 2023. On 7/13/2023 at 11:00 a.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated the agency was having a work-related issue with the RN assigned to the patient. The DPCS stated hospice aide supervisory visit should be conducted every 14 days by the registered nurse. A review of the agency's undated policy and procedure titled "Responsibilities/Supervision of Clinical Services", indicated that a qualified individual is responsible for overseeing all clinical care and services. The Clinical Director will ensure that the following supervision is maintained within hospice: hospice aide supervisory visits will be conducted on-site at least every 14 days by a hospice registered nurse.

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Organizational environment was met as follows: The hospice agency failed to appoint a qualified administrator that addresses the functioning hospice operations and QAPI (Quality Assessment and Performance Improvement Minutes) program and responsible for day to day operation. (refer to L651). The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily (right or legal way) mandated compliance with the Federal regulations for Initial & Comprehensive Assessment of Patients to ensure the highest quality of care is being provided to patients certified to receive the Medicare hospice benefits. --- .

Based on interview and record review, the hospice agency failed to appoint a qualified administrator that addresses the functioning hospice operations and QAPI (Quality Assessment and Performance Improvement Minutes) program and responsible for day-to-day operation. This deficient practice has the potential to prevent the patients from receiving optimum quality hospice care and services. --- Findings: A review of the governing body minutes indicated that there was no documented evidence that a governing body existed that included a qualified administrator that assumes full legal authority and responsibility for the management of the hospice and its ongoing operations. During an interview with the Director of Patient Care Services (DPCS) on 7/13/23, 2:10 p.m., DPCS was unable to provide the Governing Body meeting minutes. The DPCS also stated that the hospice agency had no appointed administrator that is responsible for the management of the hospice and reviews and addresses the functioning of specific hospice operations, services and QAPI program at this time.

Based on interview and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Medical Director was met as follows: The HA failed to ensure, the medical director conducted an accurate assessment, review, and verify the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services, for four out of seven sampled patients (Patient 1, Patient 2, Patient 5, and Patient 6). (Refer to L 667). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services. --- .

Based on interview and record review, the hospice agency (HA) failed to ensure the Medical Director conducted an accurate assessment, review, and verify the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services, for four out of seven sampled patients (Patient 1, Patient 2, Patient 5, and Patient 6). The Medical Director certified the patients for hospice care without documentation to support diagnosis of terminal illness. This deficient practice resulted in the patients not receiving necessary care and services to meet the highest quality of care. --- a. A review of Patient 1's "Patient Information" indicated a start of care (SOC) date of 12/09/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (a disease caused by plaque buildup in the wall of the arteries that supply blood to the heart). The "Patient Information" further indicated the ";referring/attending/patient choice" physician was Physician 3. A review of Patient 1's Physicians Certification for Hospice Benefit, dated 12/09/2022 to 3/08/2023, benefit period #1, indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course and was eligible for hospice services under routine level of care, signed by MD 2 (previous Medical Director of the HA). The section ";Certifying Physician Summary" indicated Patient 1 was terminally ill, requires maximum assistance with ADLS, and met the criteria of NYHA Class IV level (New York Heart Association Stages of Heart Failure Class IV – patients who have severe limitations, experiences symptoms even while at rest, and mostly bedbound). A review of Patient 1s form titled, "LCD Hospice Eligibility Determination (Local Coverage Determination, guidelines used by hospice providers to determine eligibility of beneficiaries for hospice benefits)" for Heart Disease, indicated section 1 and 2 must be met. Section 1 was marked ";yes" that Patient 1 declined surgical procedures. Section 2 was marked ";yes" that Patient 1 met the criteria for NYHA Class IV level. A review of Patient 1's Comprehensive Nursing Assessment dated 12/09/2022, indicated Patient 1 was awake, alert, and oriented x 3 (time, place, person), and had normal speech. Patient 1 was ambulatory with the use of a walker and needed stand-by assist. Cardiac rate was regular, at 89 beats per minute, has no cardiac-related pain, and no edema observed. Patient 1 needs minimal assistance with transfers, bathing, and dressing. The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None". Patient 1's clinical records did not indicate documentation Patient 1 was ruled out as a candidate nor declined surgical procedure related to heart disease. There was also no documentation Patient 1 was on complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest. On 7/11/2023 at 2:45 p.m., during a telephone interview, Patient 1 stated he did not know what hospice care was and he thought having hospice was to get medical supplies, ensure and have a nurse visit him every week. Patient 1 stated he was not dying, still drives, and that he was never told that he had six months or less to live. Patient 1 stated he had a heart surgery a few years back, visits his cardiologist (heart doctor) every four months, and was told that he was stable. Patient 1 stated he does not know or have any conversation with regards to his medical history with Physician 3. On 7/13/2023, at 11:00 a.m., during an interview the Director of Patient Care Services (DPCS) stated, she was not able to find documentation of Patient 1 declined surgical procedure related to heart disease. DPCS stated the referring physician, Physician 3, was one of the contracted physician of the hospice agency and was not the attending physician of Patient 1. b. A review of Patient 2's "Patient Information" indicated a start of care (SOC) date of 4/12/2023, with a terminal diagnosis of heart failure, unspecified (a disorder where your heart is unable to pump the blood properly). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 4/12/2023 to 7/10/2023, benefit period #1, indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course and was eligible for hospice services under routine level of care, signed by MD 1. The section ";Certifying Physician Summary" indicated Patient 1 was terminally ill, requires moderate assistance with ADLS, and met the criteria of NYHA Class IV level. A review of Patient 2s form titled, "LCD Hospice Eligibility Determination" for Heart Disease, dated 4/12/2023, indicated patient does not qualify per LCD Guidelines. A review of Patient 2's Comprehensive Nursing Assessment dated 4/12/2023, indicated Patient 2 was awake, alert, and oriented x 2 (place, person), and had normal speech. Patient 2 needed minimum to moderate assistance with ADLS and maximum assistance with ambulation with unsteady gait. Patient 2 had no cardiac-related pain, has pitting edema +2, and has mild shortness of breath with mild exertion. A review of Patient 2's clinical record indicated no documented evidence Patient 2 was ruled out as a candidate nor declined surgical procedure related to heart disease. There was also no documented evidence Patient 2 was on complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest. On 7/12/2023 at 12:35 p.m., during a phone interview, Patient 2 stated he has multiple medical problem, but he was stable. He stated that he was never told that he had six months or less to live, still drives, and goes to work regularly. When asked if he knows what hospice care was, Patient 2 stated that a nurse will come visits him every week. When asked how he heard about the hospice agency, Patient 2 stated the owner of the agency came into their house and have them signed the hospice paper works. On 7/13/2023, at 11:00 a.m., during an interview, the Director of Patient Care Services (DPCS) stated, she was not able to find documentation of Patient 2 declined surgical procedure related to heart disease nor patient was confined to bed or chair. DPCS stated Patient 2 was discharged from hospice because of non-compliance. c. A review of Patient 5's "Patient Information" indicated a start of care (SOC) date of 5/10/23, with a terminal diagnosis of chronic kidney disease (longstanding disease of the kidneys leading to renal failure). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 3 (previous medical director). A review of Patient 5's Physicians Certification for Hospice Benefit, dated 5/10/23 to 8/7/23, benefit period #1, indicated the Medical Director signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 7/11/23, at 12 p.m., a home visit was conducted at Patient 5's residence with Licensed Vocational Nurse (LVN 1). The patient was observed lying in bed asleep. At 12:30 p.m., during an interview with Caregiver 1, if Patient 5 was referred by her attending physician, she stated no and that a family friend recommended the hospice agency for Patient 5. d. A review of Patient 6's "Patient Information" indicated a start of care (SOC) date of 6/20/23, with a terminal diagnosis of unspecified transient cerebral ischemic attack ( a stroke that last only few minutes). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 3 (previous medical director). A review of Patient 6's Physicians Certification for Hospice Benefit, dated 6/20/23 to 9/17/23, benefit period #1, indicated the Medical Director signed the attending physician referral section to indicate Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 7/13/23, at 11 a.m., during a phone interview, Patient 6 stated she was never told that he had six months or less to live. When asked if she knows what hospice care was, she stated that a nurse will come visits her every week. When asked how she heard about the hospice agency, she stated her friend referred her to the hospice agency. On 7/13/23 at 12:30 p.m., during a telephone interview, the Medical Director 1 stated, he was not the attending physician, and did not know who the attending physician for Patients 5 and 6. Medical Director 1 stated, he would be the attending physician for Patients 5 and 6, since admitted to their hospice service, that he signed the referral attending physician section because no one would sign it. Medical Director 1 further stated that he determined the patients were eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report by the registered nurse upon their initial visit to the patients. On 7/13/23, at 2 p.m., during an interview the Director of Patient Care Services (DPCS ) stated, in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician, and that Patient 5 and 6 did not had a referral from the primary physician. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated Lifeline Hospice Care, Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Lifeline Hospice Care Inc will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician.