Every finding on record at Lifelink Hospice & Palliative Care, Inc.

Observed in Record Review. In 1 of 10 patient records reviewed, During RR6 it was noted the last comprehensive assessment documented by the RN was the end of August without an update for 28 days. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 7 of 10 patient records reviewed, During RR1 it was noted the following goals were not individualized: Patient will have stable/controlled blood pressure and decreased leg edema, maintain optimal peripheral circulation, Patient will be safe in home setting following nurse intervention and teachings, Mental and neurological issues will be met on a day to day basis as communicated. During RR3 it was noted the following goals were not individualized: Family will be able to cope with changes, patient will have optimal participation in ADLs, PCG will verbalize having bowel elimination needs met, patient will remain free of preventable discomfort and/or complications, and patient will maintain optimal wakefulness during daytime hours. During RR4 it was noted the following goals were not individualized: Patient will remain free of preventable discomfort and/or complications, patient will have optimum neurologic status as evidenced by decreased episodes of anxiety, mental and neurological issues will be met on a day to day basis as communicated, minimize episodes of depression. During RR5 it was noted lack of individualized goals on the POC as follows: Pt will experience optimum level of independence through assistance with personal care, patient will have decreased discomfort due to edema, maintain optimal peripheral circulation by next IDG meeting and Pt will have optimum level of oxygen. During RR6 it was noted lack of individualized goals as follows: Be able to cope with changes, patient will be safe in home setting following nurse intervention and teachings, patient will have a regular bowel elimination and comfort. Promote optimal rest status for Pt in the next 14 days. During RRHV1 it was noted the following goals were not individualized: Pt/Family/PCG will verbalize having bowel elimination needs met all through out recertification period with no signs and symptoms of constipation or diarrhea, mental and neurological issues will be met on a day to day basis as communicated, patient’s son and family to cope adequately with the patient's condition and will have psychosocial support, Pt will have decreased anxiety related to respiratory changes, Pt will have optimum level of oxygen in the next 14 days. During RRHV3 it was noted the following goal were not individualized: Patient will have optimum neurologic status as evidenced by decreased episodes of anxiety within the next 2 weeks and will be re-evaluated during the next IDT Meeting, mental and neurological issues will be met on a day to day basis, complete final arrangements, pt/family/PCG will verbalize comfort in taking care of their loved ones needs, Pt will have optimum level of oxygen in the next 14 days. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 4 of 10 patient records reviewed, During RR1 and RRHV3 it was noted the patients were prescribed Plavix daily however there was lack of interventions on the POC related to S/S bleeding and bleeding precautions on the POC. During RR4 it was noted lack of interventions for the respiratory deficit on the POC. During RR2 the patient was prescribed Xarelto daily however the POC lacked interventions related to S/S bleeding and bleeding precautions. This was discussed with the DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, During RR1 it was noted interventions and goals on the POC for oxygen therapy as needed for SOB however there was lack of an order for oxygen therapy and the RN initial assessment for an oxygen safety assessment is documented as N/A. This was discussed with the DPCS.

Observed in Record Review. In 2 of 14 patient records reviewed, During RR2 it was noted the POC orders were not followed. The aide visits were ordered for 3x/week however the first aide visit was documented 10 days after the assignment was completed by the RN. Endocrine interventions on the POC were not documented as completed on SN notes after the initial RN assessment. The interventions included: Administer oral hypoglycemics as ordered: Glipizide 2.5mg Extended-Release Tablet 1 tab daily in AM, adjusting dosage as needed to keep blood glucose levels stable, monitor blood glucose levels regularly to ensure they are within the comfort range and adjust as needed, educate family and caregivers about recognizing signs of hyperglycemia and hypoglycemia, and how to respond appropriately, monitor for reports feelings of fatigue, increased thirst, and frequent urination for hyperglycemia, monitor for reports for sweating, confusion, tremors for hypoglycemia and assess for possible weight loss or dehydration. During RR4 it was noted the aide visits were ordered for 2x/week. The first aide visit was completed 10 days after the RN completed the aide assignment form. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 2 of 10 patient records reviewed, During RR2 and RR3 it was noted the aide visits were ordered for 3x/week however the first aide visit in each record was documented 10 days after the assignment was completed by the RN. There was lack of documentation that the IDG was notified of the delay. This was discussed with the Administrator and DPCS.

Observed in Data Session. During review of the QAPI plan it was noted lack of the activities or frequency for evaluating contract services that include pharmacy, DME, therapy and SNFs. This was discussed with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, During RRHV1 the SN, after disinfecting the equipment used to assess vital signs, placed the equipment immediately back in her bag and did not follow the manufacture's guidelines for undisturbed wait time of 2 minutes before moving the equipment. This was discussed with the leadership team.

Observed in Record Review. In 1 of 10 patient records reviewed, During RR6 it was noted lack of documentation that the RN performed an aide supervisory visit at least once every 14 days with a gap of 28 days from the end of August 2025 to date. This was discussed with the Administrator and DPCS.

Observed in Regulatory Review. During review of the volunteer program it was noted lack of documentation of recruitment efforts to attract volunteers. This was discussed with the Administrator and DPCS.

Observed in Regulatory Review. During review of the volunteer program it was noted lack of documentation of the cost savings achieved through the use of volunteers. This was corrected during the survey. This was discussed with the Administrator.

Observed in Record Review. In 2 of 10 patient records reviewed, During RR4 it was noted orders for wound care to left and right lower extremities on the POC. One SN visit in August and one the beginning of September documented wound care given per orders and the other documented wound care done on left and right lower extremity as ordered, without specific wound care orders documented. During RRHV3 it was noted the SN did not follow the physician order for wound care. The order was to apply a border dressing after cleansing and apply triple antibiotic ointment and the SN wrapped the legs with kerlix and tape. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 1 of 2 patient records reviewed, who were discharged alive. During live d/c 1 it was noted the inpatient facility was not provided a summary of care on transfer. This was discussed with the Administrator and DPCS.

Observed in Document Review. In 1 of 5 contracts reviewed, During review of the SNF contract it was noted lack of a provision stating that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice. This was discussed with the Administrator

Observed in Document Review. In 1 of 5 contracts reviewed, During review of the SNF contract is was noted lack of the delineation of the responsibilities of the hospice and the SNF, NF, or ICF/IID to provide bereavement services to SNF, NF, or ICF/IID staff. This was discussed with the Administrator.

Observed in Document Review. In 1 of 5 contracts reviewed, During review of the therapy contract it was noted lack of a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed with the Administrator.

Based on observation, interview, record review, the hospice agency failed to ensure the Condition of Participation for Initial and Comprehensive Assessment of the Patient was met as evidenced by: 1. The hospice agency failed to maintain a current medication profiles for three of 11 patients (Patients 1, 6, and 8). (Refer to L530). 2. The hospice staff failed to develop and implement plans of care for skin integrity for two of 11 patients (Patients 1 and 8) with wounds. (Refer to L 543). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Initial and Comprehensive Assessment of the Patients to ensure the highest quality of care are provided to the patients eligible to receive benefits for hospice care and services. --- .

Based on observation, interview, and record review, the hospice agency failed to ensure the comprehensive assessment of patients contained the accurate and current medication profiles for three of eleven patients (Patients 1, 6, and 8). This failure had the potential to put the patient at risk for medication errors and adverse drug reactions which could affect the patients' health status and wellbeing. --- A review of Patient 1's face sheet on indicated the patient was admitted to the hospice agency on 8/6/22, with primary diagnosis of hypertensive heart disease with heart failure ( a heart condition caused by high blood pressure). A review of Patient 1's "POC Summary" dated 8/6/22, indicated the Skilled Nurse (SN) visit was three times a week, the spiritual counselor visit was once a month, and the hospice aid (HA) service was twice a week. On 11/2/22, at 2 p.m., during a joint home visit with Registered Nurse 1 (RN 1), Patient 1 was observed awake and was ambulatory using an assistive device. During Patient 1's medication review compared with the medication profile, it was noticed that the patient had containers of Simvastatin 10 milligram (mg) to take one tablet via gastric tube (GT) everyday, Ondansetron 4 mg one tab three times via GT daily and Furosemide 20 mg one tab via GT daily. During an interview with Patient 1's caregiver, she stated that the patient no longer takes the Simvastatin 10 mg, Ondansetron 4 mg and Furosemide 20 mg medications since the patient was admitted to hospice service in August 2022. During an interview with RN 1 on 11/2/22, at 2:45 p.m., she stated she should have asked the patient's caregiver if patient was still taking his prescribed medications on every visits. A review of the agency's policy titled " Medication Profile " , indicated the medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. b. A review of Patient 6s Patient Profile indicated a start of care (SOC) date of 5/17/2022 with a primary diagnosis of hypertensive heart disease hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen). A review of Patient 6s Plan of Care dated 9/6/2022 indicated a Skilled (SN) was to visit twice a week and with an additional two visits as needed (PRN) per week for symptom management. A review of Patient 6s Interdisciplinary Team Plan of Care and Review of Comprehensive Assessment dated 10/24/2022 indicated in the Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) report section of the assessment that the caregiver gave Patient 6 Furosemide, 20 milligram (mg), one tablet oral once daily as needed and Bumetanide, 0.5 mg, one tablet oral, once daily for edema. During an interview on 11/4/2022 at 10:20 am, the Director of Patient Care Services designee (DPCSD) stated that every time the nurse visits the patient, the patients medications should be checked, and the doctor notified of any update in the medications. The DPCSD stated that the nurse checks and documents the medications during the initial assessment and then reports it to the doctor. During a telephone interview on 11/4/2022 at 1:09 pm, Caregiver (CGR 2) stated Patient 6 takes the following medications for hypertension: Enapril, 5 mg, twice a day Isosorbide, 5 mg, twice a day Carvedilol, 3.125mg, twice a day. A review of Patient 6s Medication Profile did not indicate an order for furosemide, bumetanide, enapril, isorbide or carvedilol. During an interview on 11/4/2022 at 1:15 pm, the Director of Patient Care Services designee (DPCSD) stated that the nurse fills out an admission packet during the initial assessment of a new patient. The DPCSD stated that the nurse performs a complete head to toe assessment, interviews the patient and family, asks them questions about patient and the patients existing medications, and checks each of the patients medications. The DPCSD stated once the initial assessment is done, the nurse takes the admission packet to the DPCS for further discussion. The DPCSD stated the nurse notifies the hospice doctor of the patients medications and the doctor determines whether the patient needs the medications and then orders it. The DPCSD stated the hospice agency then calls the pharmacy to notify they of the new admission and the new medication orders. The DPCSD stated it was the responsibility of the nurse to make sure all the medications were ordered. c. A review of Patient 8's Patient Profile indicated a start of care (SOC) date 10/10/2022 with a primary diagnosis of 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 8s Initial Orders and Plan of Care (POC) dated 10/10/2022, indicated a Skilled Nurse (SN) was to visit two times per week with an additional one visit as needed (PRN) for symptom management. The POC indicated that the hospice plan of care included initial orders and plan of care, plan of care problems identified in assessments and the medication profile. A review of Patient 8s Medication Profile for election period 10/10/2022-01/07/2023 indicated for the following: Spiriva Inhalation Spray, 2.5 microgram inhaler, one puff, respiration inhalation, once daily at bedtime for chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing) Meloxicam 7.5 mg oral (by mouth), one tablet, oral, once daily for arthritis Carvedilol 12.5 mg oral, one tablet, oral twice daily with meals for hypertension Advair Diskus 100 mg, one puff, respiratory inhalation, twice daily (AM and PM) for COPD Tylenol, one tablet, oral, every 12 hours as needed for knee pain Ondansetron, 4 milligram (mg) disintegrating tablet, one tablet, oral three times a day as needed for nausea and vomiting Morphine sulfate, 20 mg/ milliliter(mL), 0.25 mL, oral, every two hours as needed for moderate to severe pain and shortness of breath Lorazepam, 2 mg/mL, 0.25 mL, oral, every four hours as needed for anxiety and seizure Hyoscyamine 0.125 mg ODT (oral disintegrating tablet), one tablet, sublingual (under the tongue) every three hours as needed for excessive oral secretions Bisacodyl, 10 mg rectal suppository, one rectal suppository, rectal (by rectum), daily as needed for constipation Albuterol sulfate, 2.5 mg/3 mL vial, one vial, inhale via hand held nebulizer every four hours as needed for shortness of breath and congestion Acetaminophen 650 mg, rectal suppository, one rectal suppository, rectal every four hours as needed On 11/3/2022 at 9 am, a home visit was conducted at Patient 8s home residence with Registered Nurse (RN 2). Patient 8 was sitting at the kitchen table drinking coffee. RN 2 took Patient 8s vital signs, asked about his pain and checked his medications. The following medications were checked: Spiriva Inhalation Spray, 2.5 microgram inhaler, one puff, respiration inhalation, once daily at bedtime for chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing) Meloxicam 7.5 mg oral (by mouth), one tablet, oral, once daily for arthritis Carvedilol 12.5 mg oral, one tablet, oral twice daily with meals for hypertension Advair Diskus 100 mg, one puff, respiratory inhalation, twice daily (AM and PM) for COPD Tylenol #2 (Acetaminophen/Codeine), one tablet every 12 hours as needed. FM 1 stated Patient 8 only took five medications. RN 2 stated that the Family Member (FM 1) refused the comfort pack medications when the pharmacy delivered it because FM 1 did not want Patient 8 taking morphine which was included in the comfort pack. RN 2 stated that the comfort pack medications were returned to the pharmacy and that there were no comfort pack medications such as ondansetron, morphine sulfate, lorazepam, hyoscyamine, bisacodyl, albuterol sulfate or acetaminophen suppository in Patient 8s home. During an interview on 11/4/2022 at 10:12 am, the DPCSD stated that the nurse should have documented that the FM 1 refused the comfort pack medications and notified the doctor and discontinued the medication from medication profile. The DPCSD stated that the medication profile also should have specified the type of Tylenol the patient was taking because it contained codeine. A review of the Hospice Agencys policy, Patient Admission Criteria, revised June 2019, indicated during the initial assessment, the Registered Nurse (RN) will develop a medication profile. A review of the Hospice Agencys (undated) policy, Initial Assessment/Comprehensive Assessment, indicated that each patients comprehensive assessment includes a review of all medications the patient is currently taking (prescription, non-prescription, herbs, home remedies, other alternative treatments, etc.) to identify: Drug effectiveness Side effects Actual or potential drug interactions Noncompliance with medications Duplicate therapy Ineffective therapy Potential adverse effects Medication reactions Drug therapy associated with lab monitoring. A review of the Hospice Agencys (undated) policy, Medication Monitoring, indicated that a Registered nurse reviews all of the patients prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy on an ongoing basis. The policy indicated that the review is done in collaboration with other Interdisciplinary Group (IDG) members which may include a physician, and/or pharmacist during the IDG meeting and whenever needed.

Based on observation, interview, and record review, the hospice staff failed to develop and implement plans of care for skin integrity for two of 11 patients (Patient 1 and 8). Patient 1 had a physician's order for the skilled nurse to provide wound care to right and left buttocks (Stage 1). There was no documented evidence of wound assessment was conducted every visit. Patient 8 was incontinent of bowel and bladder and had rashes on the inguinal (groin) area. There was no care plan developed for the skin rashes. This deficient practice placed the patients at a potential risk for a delay of wound healing that could lead to patient's discomfort and further integumentary complications. --- A review of Patient 1's face sheet on indicated the patient was admitted to the hospice agency on 8/6/22, with primary diagnosis of hypertensive heart disease with heart failure ( a heart condition caused by high blood pressure). A review of Patient 1's "POC Summary" dated 8/6/22, indicated the Skilled Nurse (SN) visit was three times a week, to assess changes in wound status-check size, integrity, location, type/stage. signs and symptoms of infection and drainage on every visit. There was a physician's order dated 10/27/22, to provide wound care to right and left buttocks redness as follows: to cleanse with normal saline, pat dry, apply triple antibiotic and cover with foam dressing. On 11/2/22, at 2 p.m., during a joint home visit with Registered Nurse 1 (RN 1), Patient 1 was observed awake and was sitting on her couch at living room and her right and left buttocks redness healed. At 2:30 p.m., during an interview with RN 1, when asked if she does wound skin assessment for Patient 1 on her visits, she stated she does her skin assessments on every visits. A review of Patient 1's Hospice Nursing Clinical Notes dated 10/25, and 10/27/22, indicated no documented evidence that the visiting nurse measured the Stage 1 pressure ulcer on right and left buttocks as part of their skin assessment. On 11/4/22, at 12 p.m., during an interview with RN 1, she stated the visiting nurses should measure the wound as part of their skin assessment to determine if the wound is healing by wound size getting bigger or smaller. According to the agency's policy and procedure "Wound Assessment", indicated during initial and follow-up nursing visits, any non-intact skin areas shall be assessed and document, to complete measurement of the wound (length, width, depth) shall be documented during visits. b. A review of Patient 8's Patient Profile indicated a start of care (SOC) date 10/10/2022 with a primary diagnosis of 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 8s Initial Orders and Plan of Care (POC) dated 10/10/2022, indicated a Skilled Nurse (SN) was to visit two times per week with an additional one visit as needed (PRN) for symptom management. The POC indicated that the hospice plan of care included initial orders and plan of care, plan of care problems identified in assessments and the medication profile. The POC indicated that Patient 8s skin was assessed with no problem found. A review of Patient 8s Initial Assessment, dated 10/10/2022 indicated that Patient 8 was incontinent of bowel and bladder and had rashes on the inguinal (groin) area. During a concurrent interview and record review with the Director of Patient Care Services designee (DPCSD) on 11/4/2022 at 11:10 am, the Patient 8s Initial Orders and POC was reviewed. DPCSD stated there was no care plan for impaired skin integrity and there should have been a care plan to address Patient 8s rashes on the inguinal area. A review of the Hospice Agencys (undated) policy titled Wound Care Policy indicated that the clinician, in conjunction with the patient a caregiver, will develop an appropriate plan of care based on the patients needs and assessment findings. The policy indicated that each patient will be evaluated and treated using an individualized care plan based on the patients unique medical condition. The policy indicated that the nurse will provide wound care per physician orders and continue to implement and evaluate the plan of care based on the effectiveness of treatment regimen, response to treatment, effectiveness of interdisciplinary services, need for assessment by Wound Care Specialist, patient/caregiver participation and identification of obstacles/risk factors interfering with wound healing. The policy indicated the nurse/therapist will notify the physician for any change in the patient condition or lack of progress. The policy further indicated that at each visit the patients skin will be assessed.

Based on interview and record review, the hospice agency failed to provide documented evidence of performance improvement projects (QAPI, the coordinated application of two mutually-reinforcing aspects of a quality management system) conducted by the hospice that included the number and topics of projects based on the results of their quality monitoring and other quality information such as the results of the State surveys. The last recertification survey was conducted on 10/25/2017. This failure had the potential for the hospice' inability to identify and monitor decline or improvements of patient care services to ensure the best quality of patient care are provided to the patients receiving the hospice benefits. --- On 11/4/22 at 12:45 p.m., the hospice's Quality Assurance and Performance Improvement (QAPI) both previous and ongoing improvement projects were requested from the administrator to be reviewed. During an interview with the administrator on 11/4/22, at 12:50 p.m., stated they should have at least four projects for patient care issues however, the administrator was not able to provide any documented evidence of performance improvement projects were conducted. According to the Department's certification information, the hospice last recertification survey was on 10/27/2017.

Based on interview and record review, the hospice agency failed to hire a qualified volunteer coordinator. This deficient practice has the potential for volunteers to lack knowledge to provide hospice services in a manner consistent with acceptable standards of practice. --- Findings: On 11/1/22, at 10 a.m., an unannounced re-certification visit was conducted at the hospice agency. On 11/4/22, at 11:30 a.m., during an interview with the administrator, she stated the Bereavement Coordinator 1 was their volunteer coordinator. At 12 p.m., during a review of Bereavement Coordinator 1 's resume indicated no certificate to show training completion or volunteer coordinator experience. At 1:30 p.m., during an interview with administrator, she stated she had no copies of their volunteer coordinator's documentations to prove he has experience being a volunteer coordinator nor a training online certificate at this time.

Based on observation, interview, and record review, the hospice failed to ensure the Condition of Participation for Volunteers was met as evidenced by: Failed to provide volunteers for two of 11 patients (Patients 1 and 8). (L642) Failed to maintain, document, and provide volunteer orientation and training consistent with the hospice standard of practice. (L643) Failed to provide volunteers to assist in direct patient care roles. (L644) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Volunteer services. --- .

Based on observation, interview, and record review, the hospice agency failed to ensure volunteer service program was maintained and was offered /provided to the patients for two of 11 sample patients (1 and 8). This deficient practice prevented the patients from receiving the hospice benefit to be provided volunteer services. --- A review of Patient 1's face sheet on indicated the patient was admitted to the hospice agency on 8/6/22, with primary diagnosis of hypertensive heart disease with heart failure (a heart condition caused by high blood pressure). A review of Patient 1's "POC Summary" dated 8/6/22, indicated the Skilled Nurse (SN) visit was three times a week, the spiritual counselor visit was once a month, and the hospice aid (HA) service was twice a week. However, the volunteer service was not indicated in the POC. On 11/2/22, at 2 p.m., during a joint home visit with Registered Nurse 1 (RN 1), Patient 1 was observed awake and was ambulatory using an assistive device. On 11/2/22, at 2:10 p.m., during an interview with Patient 1's caregiver (daughter), she stated she would like to have somebody to help her for grocery shopping, laundry, and for visiting the doctor. She also stated that nobody from the hospice agency had informed her that the hospice agency was to provide this volunteer service , and if she was offered, she will gladly take the service right away. On 11/2/22, at 2:30 p.m., during an interview with RN 1, she stated she did the initial visit but did not mention or offer the volunteer service to Patient 1. A review of the patient's clinical record indicated there was no documented evidence the patient was informed regarding the agency's volunteer services and the agency provides the volunteer services to the patient without any cost. A review of the agency's policy of "Volunteer Services" ,indicated the hospice will provide volunteer services under the direction of a volunteer coordinator or staff member responsible for planning, organizing and directing a comprehensive volunteer services program and with the assistance of trained hospice volunteers.

Based on interview and record review, the hospice agency failed to provide volunteer orientation and training for one of one personnel file reviewed. This deficient practice has the potential for the volunteers to lack knowledge to provide hospice services in a manner consistent with acceptable standards of practice. --- On 11/1/22, at 10 a.m., an unannounced recertification survey visit was conducted at the hospice agency. On 11/4/22, at 11 a.m., during an interview with the administrator, she stated the hospice agency had no monthly orientation and training offered for volunteers. During further interview and observation, the office has one volunteer personnel working at the office. There were no other volunteers providing direct patient care services to Patients 1 and 8 requesting for the services.

Based on observation, interview and record review, the hospice agency failed to ensure volunteer services were offered and provided for two of 11 patients. (Patients 1 and 8). This deficient practice resulted in patients not receiving volunteer services to provide companionship and comfort during their end-of-life experience. --- A review of Patient 8's Patient Profile indicated a start of care (SOC) date 10/10/2022 with a primary diagnosis of 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 8s Initial Orders and Plan of Care (POC) dated 10/10/2022, indicated a Skilled Nurse (SN) was to visit two times per week with an additional one visit as needed (PRN) for symptom management. The POC indicated that the hospice plan of care included initial orders and plan of care, plan of care problems identified in assessments and the medication profile. On 11/3/2022 at 9 am, a home visit was conducted at Patient 8s home residence with Registered Nurse (RN 2). Patient 8 was sitting at the kitchen table drinking coffee. RN 2 took Patient 8s vital signs, asked about his pain and checked his medications. During an interview at 9:15 am, the Caregiver (CGR 2) stated she was not aware of the volunteer services offered by the hospice agency. A review of Patient 8s Initial Assessment indicated that the assessment for Volunteer Services was left blank. Further review of Patient 8s clinical chart indicated no documented evidence that Volunteer Services were offered to Patient 8 or CGR 2. A review of Patient 1's face sheet on indicated the patient was admitted to the hospice agency on 8/6/22, with primary diagnosis of hypertensive heart disease with heart failure ( a heart condition caused by high blood pressure). A review of Patient 1's "POC Summary" dated 8/6/22, indicated the Skilled Nurse (SN) visit was three times a week, the spiritual counselor visit was once a month, and the hospice aid (HA) service was twice a week. However, the volunteer service was not indicated in the POC. On 11/2/22, at 2 p.m., during a joint home visit with Registered Nurse 1 (RN 1), Patient 1 was observed awake and was ambulatory using an assistive device. On 11/2/22, at 2:10 p.m., during an interview with Patient 1's caregiver (daughter), she stated she would like to have somebody to help her for grocery shopping, laundry, and for visiting the doctor. She also stated that nobody from the hospice agency had informed her that the hospice agency was to provide this volunteer service , and if she was offered, she will gladly take the service right away. On 11/2/22, at 2:30 p.m., during an interview with RN 1, she stated she did the initial visit but did not mention or offer the volunteer service to Patient 1. A review of the patient's clinical record indicated there was no documented evidence the patient was informed regarding the agency's volunteer services and the agency provides the volunteer services to the patient without any cost. A review of the agency's policy of "Volunteer Services" ,indicated the hospice will provide volunteer services under the direction of a volunteer coordinator or staff member responsible for planning, organizing and directing a comprehensive volunteer services program and with the assistance of trained hospice volunteers.

Based on interview and record review, the hospice agency's Medical Director failed to ensure the patients clinical information was reviewed prior to admission to hospice services for two of 11 sample patients. (Patient 1 and 8). These deficient practices resulted in the hospice Medical Director certifying patients without clinical documentation. --- A review of Patient 8's Patient Profile indicated a start of care (SOC) date 10/10/2022 with a primary diagnosis of 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 8s Initial Orders and Plan of Care (POC) dated 10/10/2022, indicated a Skilled Nurse (SN) was to visit two times per week with an additional one visit as needed (PRN) for symptom management. On 11/3/2022 at 9 am, a home visit was conducted at Patient 8s home residence with Registered Nurse (RN 2). Patient 8 was sitting at the kitchen table drinking coffee. RN 2 took Patient 8s vital signs, asked about his pain and checked his medications. Patient 8 was able to slowly ambulate with assistance using a walker from the kitchen table to a reclining chair in the living room about 15 to 20 feet. During an interview on 11/4/2022 at 9:20 am, the Family Member (FM 1) stated that RN 2 was providing care to another family member at their home when RN 2 referred Patient 8 to hospice. FM 1 stated she was concerned about Patient 8s health and decided to go with the hospice agencys program. During a telephone interview on 11/3/2022 at 1:47 pm, the medical assistant (MA 1) of Patient 8s Primary Physician (PP) stated that there was no referral to hospice in the patients clinical chart. MA 1 stated that PP was Patient 8s primary attending and had last seen Patient 8 during a telehealth visit on 10/12/2022. MA 1 stated that Patient 8s weight was 169 pounds (lbs) on 10/12/2022 and 180 lbs on 7/28/2021 and 8/4/2022. A review of Patient 8s Certification of Terminal Illness indicated that the Hospice Medical Director (MD 1) signed for the attending physician and the hospice physician. During an interview on 11/1/2022 at 12:55 pm, the Hospice Medical Director (MD) stated that Patient 8 was not her personal patient prior to admitting to the hospice agency. The MD stated that a face to face was not performed with Patient 8. The MD stated that a nurse practitioner (NP) performed an assessment of the Patient 8 and the MD reviewed the assessment and discussed with the NP. When asked if Patient 8 had a 10% weight loss within the last six month prior to Patient 8s SOC, the MD stated she did not speak with Patient 8's PP or review Patient 8's medical records. The MD stated she could look at the patient to make an estimate or ask a family member about weight loss. The MD stated she did not compare Patients 8 weight from SOC to six months ago. The MD stated that if the hospice agency cannot get a hold of the patients primary attending, the MD or NP would do an assessment. During an interview on 11/4/2022 at 1:32 pm, the Administrator (ADM) stated that the hospice agencys first step is to find out if the patient has an attending physician because know if the patient is declining and appropriate for hospice. The ADM stated that they look to the attending physician for patients referral to hospice. The ADM stated that if there is no attending and if the patient chooses our medical director, we send an NP to assess the patient, discuss with the MD and a collaboration is made to determine the patients eligibility for hospice. A review of the hospice agencys policy, Patient Admission Criteria, revised June 2019, indicated that patients are accepted for treatment on the basis of a reasonable expectation that the patients needs can be met adequately by Hospice in the patients place of residence. The policy indicated patients will be accepted for care only if Hospice can meet a patients identified needs. The policy indicated that the criteria of admission included Medicare patients must be certified as being terminally ill with a prognosis of six months or less, if the terminal illness runs its normal course. The policy indicated that the Hospice admits a patient only on the recommendation of the Medical Director in consultation with, or input from the patients attending physician (if any). The policy indicated in reaching a decision to certify that the patient is terminally ill, the Medical Director must consider the following information: diagnosis of the terminal condition of the patient, other health conditions, whether related or unrelated to the terminal condition, and current clinically relevant information supporting all diagnoses. a. A review of Patient 1's face sheet on indicated the patient was admitted to the hospice agency on 8/6/22, with primary diagnosis of hypertensive heart disease with heart failure ( a heart condition caused by high blood pressure). A review of Patient 1's "POC Summary" dated 8/6/22, indicated the Skilled Nurse (SN) visit was three times a week, the spiritual counselor visit was once a month, and the hospice aid (HA) service was twice a week. On 11/2/22, at 2 p.m., during a joint home visit with Registered Nurse 1 (RN 1), Patient 1 was observed awake and was sitting on her couch at living room. Patient 1 was observed alert and oriented, was able to communicate well, and was ambulatory without using assistive device. During an interview with Patient 1's caregiver (daughter), she stated the patient's health condition got better now and she is ready to be discharged from hospice services. She also stated that the patient's former home health certified nursing assistant referred them to this hospice agency. She further stated that Patient 1's attending was not aware that the patient was under hospice services at this time. A review of Patient 1's Certification of Terminal Illness dated 8/6/22 to 11/3/22, indicated that the Hospice Medical Director (MD 1) signed for the attending physician and the hospice physician stating that Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. It was indicated the certification was based on "Medical history, record, patient's status, and team assessment. On 11/1/2022 at 12:55 p.m., during an interview with the Medical Director 1(MD 1), she stated that Patient 1 was not her personal patient prior to admitting to the hospice agency. MD 1 also stated that a face to face was not performed with Patient 1. The MD further stated that a nurse practitioner (NP) performed an assessment of the Patient 1 and MD 1 reviewed the assessment and discussed with the NP. The MD 1 further stated that if the hospice agency cannot get a hold of the patients primary attending, the MD or NP would do an assessment. On 11/4/2022 at 1:32 pm, during an interview with the Administrator 1 (ADM 1), she stated that the hospice agencys first step is to find out if the patient has an attending physician to know if the patient is declining and appropriate for hospice service. ADM 1 also stated that they look to the attending physician for patients referral to hospice. The ADM stated that if there is no attending and if the patient chooses our medical director, we send an NP to assess the patient, discuss with the MD and a collaboration is made to determine the patients eligibility for hospice.