Every finding on record at Medz Hospice Care, LLC

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Conditions of Participation (the terms healthcare organizations must meet to participate in federally funded healthcare programs) regarding Patients Rights was met as follows: --- 1. The HA failed to provide seven of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 7, Patient 10, and Patient 11) information of their rights and responsibilities in a language the patients preferred and understood. This deficient practice resulted for the patients not to exercise their patient rights. (Refer to L502). 2. The HA failed to ensure four of 14 sampled patients had access to their plan of care and or be involved in developing his or her hospice plan of care (Patient 1, Patient 5, Patient 7, and Patient 10). This deficient practice had the potential for the patients not to participate in their care. (Refer to L513). The cumulative effect of these systemic practice resulted in the failure of the hospice to deliver statutorily mandated (written law) compliance for Patients Rights to ensure their rights are not violated and receive the highest quality of hospice care.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have seven months or less to live) failed to provide six of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 7, Patient 10, and Patient 11) information of their rights and responsibilities in a language the patients preferred and understood. This deficient practice resulted for the patients not to exercise their patient rights. --- E. A review of Patient 10s untitled admission sheet, indicated a start of care date on 3/24/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). It further indicated that P10s primary language is listed as ";Spanish". During a joint home visit observation and at Patient 10s (P10) residence on 6/11/2024, at 11:00 a.m., with the Licensed Vocational Nurse 2 (LVN2), Patient 10 was observed alert and oriented and was walking using a walker (a type of mobility aid that provides stability and support while walking). Patient 10 stated, in his native language (Spanish), that he is still under his own Primary Care Physician (PCP) and stated he was not sure if his PCP knows that he is under hospice care. P10 stated that he was not sure if the hospice program was explained to him during his admission to hospice. It was noted during the home visit that Patient 10 was not able to locate his hospice home folder. Patient 10 stated he was unsure if a home folder was provided to him by the hospice nurse, he stated that the documents he signed is in English Language. On 6/13/2024, at 2:20 p.m., during a concurrent interview and record review of Patient 10s clinical records titled ";Hospice Admission Services Agreement" (informed consent), dated 3/24/24, with the Director of Patient Care Services (DPCS), DPCS confirmed that it was written in English Language and not in P10s native and primary language (Spanish) as listed in his untitled admission sheet and the DPCS verified that the consents signed by Patient 10 is in English text. The DPCS stated the consent was explained to Patient 10 in Spanish. When the DPCS was asked if RN 1 spoke Spanish, the DPCS stated no. According to the DPCS, there was another skilled nurse who explained the consent to Patient 10 in his native language, however the DPCS was not able to provide documentation that a Spanish-speaking skilled nurse assistance was utilized. During a telephone interview on 6/13/2024 at 3:26 p.m. with RN 1, RN 1 stated she did not speak Spanish. When asked if a Spanish-speaking nurse assisted her in interpretation, RN 1 stated she did not know and she was unable to remember. F. A review of Patient 11s (P11) untitled admission sheet, indicated a start of care date on 2/14/2023 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). ). It further indicated that P10s primary language is listed as ";Spanish". On 6/12/24, at 10:50 a.m., during a telephone interview with P11 and his wife (FM1), FM1 stated that her husband speaks in his native language (Spanish) only. FM1 stated that P11 still sees his own primary care doctor, and the hospice program was not explained to them completely by the hospice nurse. FM1 stated that they received a call one day from a lady, stated she forgot her name and offered them a program for the elder people to get a free medical supply, lower co-pays for their medications and free nurse visits. FM1 stated that they are not aware of her spouse P11 has a terminal illness, she stated he does not have a terminal illness and he is not dying in 6 months or less, she stated it was not explained to them by the hospice nurses. FM1 stated that the documents that were signed was in English language, and they preferred that it should be in their native language (Spanish). FM1 stated she does not remember any more if an Spanish interpretation by a nurse was done during her husbands (P11) admission. On 6/13/2024, at 2:20 p.m., during a concurrent interview and record review of Patient 11s clinical records titled ";Hospice Admission Services Agreement" (informed consent), dated 2/14/23, with the Director of Patient Care Services (DPCS), DPCS confirmed that it was written in English Language and not in P11s native and primary language (Spanish) as listed in his untitled admission sheet and the DPCS verified that the consents signed by Patient 11 is in English text. The DPCS stated the consent was explained to Patient 11 in Spanish. When the DPCS was asked if RN 1 spoke Spanish, the DPCS stated no. According to the DPCS, there was another skilled nurse who explained the consent to Patient 11 in his native language, however the DPCS was not able to provide documentation that a Spanish-speaking skilled nurse assistance was utilized. During a telephone interview on 6/13/2024 at 3:26 p.m. with RN 1, RN 1 stated she did not speak Spanish. When asked if a Spanish-speaking nurse assisted her in interpretation, RN 1 stated she did not know and she was unable to remember. A review of Patient 1s record untitled admission sheet, indicated a start of date on 2/14/2023 with a primary diagnosis of heart disease (a chronic disease of the heart), unspecified. During an interview on 6/11/2024 at 10:20 AM with Patient 1s daughter, daughter stated she didnt know her mother was on hospice. During an interview on 6/11/2024 at 10:23 AM with Patient 1s daughter, daughter stated that her mother does not fit under hospice. During an interview on 6/11/2024 at 10:24 AM with Patient 1, Patient 1 stated she does not have a terminal illness. During an interview on 6/11/2024 at 10:25 AM with Patient 1s daughter, daughter stated that she had denied hospice services last year from this agency but was still provided with services. During an interview on 6/11/2024 at 10:25 AM with Patient 1s daughter, daughter stated that the person who came to her house to sign her mother up for these services told them that Patient 1s Primary Care Provider (PCP) had ordered these services. During an interview on 6/11/2024 at 10:31 AM stated the nurses kept saying that her PCP sent them. During an interview on 6/11/2024 at 10:31 AM with Patient 1, Patient 1 stated she does not want hospice care. During an interview on 6/12/2024 at 8:08 AM with Patient 1s PCP, PCP stated Patient 1 does not qualify for hospice. During an interview on 6/12/2024 at 12:13 PM with Patient 1s PCP, PCP stated she did not refer Patient 1 to a hospice agency. During an interview on 6/12/2024 at 12:13 PM with Patient 1s PCP, PCP stated Patient 1 is not a hospice candidate. A review of Patient 2s record untitled admission sheet, indicated a start of date on 3/1/2024 with a primary diagnosis of heart disease (a chronic disease of the heart), unspecified. During an interview on 6/13/2024 at 10:18 AM with Patient 2, Patient 2 stated she was referred to this agency while visiting the Gutierrez offices off of Atlantic and Pomona in Los Angeles. During an interview on 6/13/2024 at 10:18 AM with Patient 2, Patient 2 stated she has been diagnosed with high blood pressure, epilepsy (a disorder of the brain characterized by repeated seizures), osteoporosis (decreased amount and thickness of bone tissue), but not heart disease that she is aware of. During an interview on 6/13/2024 at 10:18 AM with Patient 2, Patient 2 stated hospice is for people who are going to die, and they help keep them comfortable before death; that is how she remembers they do for people in Mexico. During an interview on 6/13/2024 at 10:18 AM with Patient 2, Patient 2 stated, ";No I do not want hospice. I want help around my house and for someone to run errands for me. I want CPR. I want to live." A review of Patient 3s record untitled admission sheet, indicated a start of date on 5/20/2024 with a primary diagnosis of heart disease (a chronic disease of the heart), unspecified. During an interview on 6/12/2024 at 3:53 PM with Patient 3, Patient 3 stated she doesnt know what hospice is nor can she remember how services began. During an interview on 6/12/2024 at 3:53 PM with Patient 3, Patient 3 stated she does not have a terminal illness that she is aware of. A review of Patient 4s record untitled admission sheet, indicated a start of date on 11/4/2023 with a primary diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important functions), unspecified. During an interview on 6/14/2024 at 9:46AM with Patient 4s son, the son stated that hospice are was never discussed with the administrator at Blessed Senior Living (LVN X). During an interview on 6/14/2024 at 9:46AM with Patient 4s son, the son stated that Patient 4 had been on hospice previously in a different facility. During an interview on 6/14/2024 at 9:46AM with Patient 4s son, the son stated that LVN X had told him that she needed approval from medicare to move Patient 4s hospice paperwork from the old facility into Blessed Senior Living. During an interview on 6/14/2024 at 9:46AM with Patient 4s son, the son stated that he used to think hospice was only when the person was near the end of life and it was to make the person comfortable. During an interview on 6/14/2024 at 9:46AM with Patient 4s son, the son stated that now he knows that ";hospice has various levels such as 24 hour care when the person is helped to get up, use the bathroom, assisted if thirsty, assisted if they have signs of low blood sugar, they are given insulin as necessary, and are cared for 24 hours of day; just like a hospital, sorta." During an interview on 6/14/2024 at 9:46AM with Patient 4s son, the son stated, "; I never would have signed a Physician Orders for Life-Sustaining Treatment (POLST)" During an interview on 6/13/2024 at 1:30 PM with DPCS, DPCS stated that their services for hospice are verbally explained to the patient as well as with each consent signed. During an interview on 6/13/2024 at 1:30 PM with DPCS, DPCS stated that the term hospice is explained to the patient to be comfort care, end of life care for terminally ill patients. d. A review of Patient 7s ";Personal Information" indicated a start of care (SOC) date of 3/1/2024, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). During a telephone interview on 6/11/2024 at 4 p.m. with Patient 7 in his native language (Spanish), Patient 7 stated he did not speak English. Patient 7 stated he was never diagnosed with heart disease, nor was he ever diagnosed with a terminal illness. Patient 7 stated he had high blood pressure (a condition in which the force of the blood against the artery [blood vessel] walls is too high) and diabetes (a chronic disease characterized by elevated levels of blood glucose in the blood). Patient 7 stated his primary care physician (PCP) never told him that he had six months or less to live. When Patient 7 was asked who referred him to the HA, Patient 7 stated, ";One day there was this woman, Licensed Vocational Nurse 1 (LVN 1), came knocking on my door. I did not know who she was. She asked me if I was on medications. I made the mistake of showing her all my medications. She jotted down my medications on her phone. She said she was going to help me get my medications and send me oxygen. I told her I did not need oxygen, but the oxygen arrived anyway." During a joint home visit observation at Patient 7s residence on 6/12/2024, at 1 p.m., with the Administrator Designee (AD)/Licensed Vocational Nurse (LVN, Patient 7 was observed alert and oriented and was walking using a walker (a type of mobility aid that provides stability and support while walking). Patient 7 stated he did not know how to read and write other than his own name. It was noted during the home visit that Patient 7 was not provided with a home folder by the HA. Patient 7 stated he was never given a home folder by the HA. The survey team observed a home folder from Patient 7s Primary Care Physician (PCP) office only. The AD brought a home folder for Patient 7 with her to the home visit. Copy of signed ";Hospice Admission Services Agreement" (informed consent) and the ";Patient and Family Rights and Responsibilities" were observed inside the folder. Both documents were written entirely in English, a language Patient 7 did not understand. Both documents were signed by Patient 7 and co-signed by Registered Nurse 1 (RN 1) as the HAs representative. During a concurrent interview and review of ";Hospice Admission Services Agreement" (informed consent) and the ";Patient and Family Rights and Responsibilities" with Patient 7, Patient 7 confirmed that it was his handwriting in the signature line. When Patient 7 was asked to briefly explain what the documents he signed were about, Patient 7 stated he did not understand. Patient 7 also reinstated he did not know how to read. There was no signature of Patient 7s representative observed on the ";Hospice Admission Services Agreement" and ";patient and Family Rights and Responsibilities." During a concurrent record review and interview with the AD on 6/12/2024 at 2:15 p.m., the AD verified that the consents signed by Patient 7 were in English. The AD stated the consent was explained to Patient 7 in Spanish. When the AD was asked if RN 1 spoke Spanish, the AD said no. According to the AD, there was a family member who explained the consent to Patient 7, however the AD was not able to provide documentation that a Spanish-speaking family members assistance was utilized. During a telephone interview on 6/13/2024 at 3:26 p.m. with RN 1, RN 1 stated she did not speak Spanish. RN 1 stated she did not see Patient 1 on 3/1/2024. RN 1 stated she did not see Patient 7 until 5/24/2024. When asked if another RN visited Patient 7 and had him sign the consent forms on 3/1/2024, RN 1 stated she did not know. A review of the HAs policy, titled ";Patient Bill of Rights/Responsibilities," (Policy No. 2-002.1), revised November 2021, indicated the Patient Bill of Rights/Responsibilities will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure four of 14 sampled patients had access to their plan of care and or be involved in developing his or her hospice plan of care (Patient 1, Patient 5, Patient 7, and Patient 10). This deficient practice had the potential for the patients not to participate in their care. --- D. A review of Patient 10s untitled admission sheet, indicated a start of care date on 3/24/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). During a joint home visit observation and at Patient 10s (P10) residence on 6/11/2024, at 11:00 a.m., with the Licensed Vocational Nurse 2 (LVN2), Patient 10 was observed alert and oriented and was walking using a walker (a type of mobility aid that provides stability and support while walking). When the surveyor requested to review the patients home folder as part of the home visit, the home folder was not available. LVN 2 was not able to find the home folder in Patient 10s residence. Patient 1 was not sure where it was kept. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 6/11/24 at 11:48 a.m., LVN 2 stated she did not know if Patient 10 had a home folder or if his wife kept it somewhere. LVN 2 stated that all patients should have been provided with a home folder that contains information pertinent to their care. During an interview with the Director of Patient Care Services (DPCS) on 6/13/24, at 2:40 p.m., DPCS stated that home folder should be provided and readily accessible by patients. DPCS stated that the home folder should include the patients current medication list and plan of care which can be easily understand by the patients and their family members/caregivers. DPCS stated that patients are part in their formulation of care plans. A policy regarding the content of hospice folder was not provided by the HA as requested by the survey team. A review of the HAs policy titled ";Patient Bill of Rights/Responsibilities," revised November 2021, indicated the patient has the right to be advised in advance of the right to participate in the planning of care or service and in planning changes in care and services. b. A review of Patient 5s ";Personal Information" indicated a start of care (SOC) date of 4/2/2024, with a primary diagnosis of chronic (persisting for a long time or constantly recurring) diastolic congestive heart failure (a condition where the lower left chamber of the heart [left ventricle] is not able to fill properly with blood during the diastolic phase [when the heart relaxes and fills with blood], reducing the amount of blood pumped out to the body). Over time, this causes blood to build up inside the left atrium, and then in the lungs, leading to fluid congestion and symptoms of heart failure. During a joint home visit observation at Patient 5s residence on 6/11/2024, at 11 a.m., with the Administrator Designee (AD)/Licensed Vocational Nurse (LVN, Patient 5 was observed alert and oriented and was walking using a walker (a type of mobility aid that provides stability and support while walking). During a review of Patient 5s home folder with the AD at 11:10 a.m., as part of the home visit, it was noted the HA did not provide Patient 5 with a copy of the Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver). During an interview with the AD on 6/11/2024 at 12:15 p.m., the AD stated the HA did not provide a copy of the POC to its patients. The AD stated that she thought it would be better if patients were provided a copy of the POC, so patients and their families could review the POC and be familiar with it. The AD stated if the patient and/or family understood about their plan of care, they would be able to participate more. c. A review of Patient 7s ";Personal Information" indicated a start of care (SOC) date of 3/1/2024, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). During a joint home visit observation at Patient 7s residence on 6/12/2024, at 1 p.m., with the Administrator Designee (AD)/Licensed Vocational Nurse (LVN, Patient 7 was observed alert and oriented and was walking using a walker. It was noted during the home visit that Patient 7 was not provided with a home folder by the HA. Patient 7 stated he was never given a home folder by the HA. The survey team observed a home folder from Patient 7s Primary Care Physician (PCP) office only. During a concurrent record review and interview with the AD on 6/12/2024 at 2:15 p.m., the AD reviewed Patient 7s ";Plan of Care," dated 6/12/2024, ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 5/30/2024, 5/16/2024, 5/2/2024, 4/18/2024, 4/4/2024, 3/7/2024, and 3/1/2024. The AD confirmed there was no plan of care generated for Patient 7 since his admission date of 3/1/2024. During the interview, the AD stated the HA would provide Patient 7 with a copy of the POC as soon as his POC was completed. A review of the HAs policy, titled ";Patient Bill of Rights/Responsibilities," (Policy No. 2-002.1), revised November 2021, indicated that patient has the right to: - Be advised in advance of the right to participate in planning the care or service and in planning changes in the care and service. - Be informed of disciplines furnishing care and the frequency of visits. Be informed of anticipated outcomes of care and any barriers in outcome achievement. a. A review of Patient 1s record untitled admission sheet, indicated a start of date on 2/14/2023 with a primary diagnosis of heart disease (a chronic disease of the heart), unspecified. During an interview on 6/11/2024 at 10:21 AM as part of the home visit, the Patient 1 stated that there are no signatures or paperwork from the hospice agency. During an interview on 6/11/2024 at 10:29 AM as part of the home visit, Patient 1 stated that she cant remember if a binder was provided with agency information.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Initial and Comprehensive Assessment (an evaluation of the patient's physical, psychosocial [mental, social, and spiritual aspects], and emotional status related to the terminal illness [illness with a prognosis of having six months of life or less to live]) of the patient was met as follows: --- 1.The HA failed to conduct an initial comprehensive assessment within 48 hours of admission date of 3/1/2024, to develop and implement an individualized plan of care to address the physical, emotional, and spiritual needs for one of 14 sampled patients (Patient 7). (Refer to L522) 2.The HA failed to ensure the HAs Administrator/Director of Patient Care Services (ADM/DPCS) oversaw the completion of the initial comprehensive assessment for one of 14 sampled patients (Patient 7) within 48 hours of admission. (Refer to L522) As a result, the HA did not identify the critical needs of Patient 7 who had a diagnosis of diabetes (a medical condition characterized by the body's inability to regulate blood sugar levels), and did not monitor Patient 7 for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) that could lead to serious harm, hospitalization, and/or death. 3. The HA failed to conduct a complete skin wound assessment for one of 14 sampled patients (Patient 12). Patient 12 who had a diabetic ulcer (open wound or sore) on her right leg, did not have a complete skin assessment to address Patient 7s right diabetic ulcer. As a result, Patient 12 went to the hospital due to uncontrolled right leg pain and had the potential for serious complications. (Refer to L524). 4.The HA failed to conduct an initial bereavement (the experience of losing someone) assessment for one of 14 sampled patients (Patient 13). This deficient practice had the potential to result in placing Patient 13 and Patient 13s family/caregiver at risk of spiritual and emotional distress. (Refer to L531). 5. The HA, agency failed to: a, Ensure to conduct a complete skin assessment and update the comprehensive assessment that reflected the skin abnormality in the patients right lower leg area for one of 14 sampled patients (Patient 12). b. Ensure the interdisciplinary group (IDG, meeting where the Registered Nurse [RN], Medical Social Worker [MSW, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) conducted biweekly (twice a week) meetings to update the comprehensive assessment of patients and reflected current health status, for five of 14 sampled patients (Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 ). These deficient practices resulted in patients not being evaluated and had the potential to affect the patients' care and prevented from reaching their goals. (Refer to L533). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (State Law) compliance with Federal Regulations for Initial and Comprehensive Assessment of Patient to ensure the highest quality health care is provided to patients assessed to receive hospice services.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients) failed to develop an Initial Assessment (assessment to gather the critical information necessary to treat the patient/familys immediate care needs) for one of 14 sampled patients (Patient 7) by failing to: 1. Ensure the HA conducted an initial assessment within 48 hours of Patient 7s admission on 3/1/2024 to address the critical information necessary to treat Patient 7s immediate care needs. 2. Ensure the Administrator/Director of Patient Care Services (ADM/DPCS) oversaw the completion of the initial comprehensive assessment for Patient 7 within 48 hours of admission. As a result, the HA did not identify the critical needs of Patient 7 who had a diagnosis of diabetes (a medical condition characterized by the body's inability to regulate blood sugar levels), and did not monitor Patient 7 for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) that could lead to serious harm, hospitalization, and/or death. On 6/13/2024, at 4:20 p.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was called in the presence of the agencys ADM/DPCS and Administrator Designee/Licensed Vocational Nurse (AD/LVN) related to the agencys failure of completing an initial comprehensive assessment within 48 hours for Patient 7 that caused a delay in Patient 7s care and placed Patient 7 at risk for serious harm. On 6/14/2024, at 4:30 p.m., the survey team completed the survey tasks, and conducted an exit conference with the HAs ADM/DPCS and ADMD, with the IJ situation not removed. The HA was informed to submit an acceptable IJ Removal Plan. --- Findings: During a review of Patient 7s Personal Information, the Personal Information indicated a start of care (SOC) date of 3/1/2024, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). During a review of Patient 7s Physician Orders with a start date of 3/1/2024, the Physician Orders indicated for Patient 7 to take Tradjenta (medication to control high blood sugar 5milligrams (mg, a unit of measurement) one tablet daily for diabetes, and Jardiance (medication to control high blood sugar) 25 mg one tablet daily for diabetes. During a review of Patient 7s Visit Note LVN (Licensed Vocational Nurse), dated 5/3/2024 and 5/17/2024, the Visit Note LVN indicated the ";diabetes-blood sugar" section was marked ";none." The Visit Note LVN, indicated there was no assessment for Patient 7s blood sugar in the narrative section. During a telephone interview on 6/11/2024, at 4 p.m., with Patient 7 in his native language (Spanish), Patient 7 stated he was never diagnosed with heart disease, nor was he ever diagnosed with a terminal illness. Patient 7 stated he had high blood pressure (a condition in which the force of the blood against the artery [blood vessel] walls is too high) and diabetes. Patient 7 stated his primary care physician (PCP) never told him he had six months or less to live. Patient 7 stated he had been out of his high blood pressure and diabetes medications (unidentified medications). During a joint home visit observation at Patient 7s residence on 6/12/2024, at 1 p.m., with the AD/LVN, Patient 7 was observed alert and oriented and was walking using walker (is a type of mobility aid that offers stability and support while walking). During a concurrent observation and interview at Patient 7s residence on 6/12/2024, at 1:35 p.m., with the AD/LVN, a medication review was conducted. The survey team observed the containers for Tradjenta 5 mg tablet and Jardiance 25 mg were empty. The AD/LVN stated the containers of Patient 7s Tradjenta 5 mg tablet and Jardiance 25 mg were empty. During an observation on 6/12/2024, at 2 p.m., the AD/LVN checked Patient 7s blood sugar. Patient 7s blood sugar was 180 milligrams per deciliter (mg/dL, a unit of measure, normal ranges from 70 mg/dL to 100 mg/dL). During a concurrent interview and record review on 6/12/2024, at 2 p.m., with the AD/LVN, Patient 7s Comprehensive Nursing Assessment, dated 3/1/2024, and Patient 7s Plan of Care, dated 6/12/2024, was reviewed. The AD/LVN stated the Comprehensive Nursing Assessment, and the initial comprehensive assessment were not done. The AD/LVN stated Patient 7 did not have a Plan of Care in place. The AD/LVN stated, ";The nurses are lazy, to be honest with you. They knew they were supposed to complete the assessment in 48 hours." The AD/LVN stated Registered Nurse 1 (RN1) assessed Patient 7 on 3/1/2024. During an interview on 6/13/2024, at 1:45 p.m., with Patient 7 in his native language (Spanish), Patient 7 stated he did not know how to check his blood sugar, and his wife was the one checking his blood sugar. Patient 7 stated his blood sugar had not been checked because his wife was hospitalized. Patient 7 stated he could not read and write and that his wife did not record his blood sugars. During a concurrent record review and interview, on 6/13/2024, at 1:50 p.m., with the ADM/DPCS, the ADM/DPCS stated Patient 7s initial comprehensive assessment on 3/1/2024 was not done. The ADM/DPCS stated an initial comprehensive assessment needed to be done within 48 hours of admission. The ADM/DPCS stated a timely completion of Patient 7s initial assessment was very important, as the information in the initial assessment would be utilized in formulating a plan of care for Patient 7. The ADM/DPCS stated she was not aware Patient 7 did not have an initial comprehensive assessment. The ADM/DPCS was not able to provide a blood sugar log for Patient 7 upon request. The ADM/DPCS stated the negative outcome of not completing the initial comprehensive assessment within 48 hours were that Patient 7s needs could not be identified, which could result Patient 7 not receiving the care and services needed, such as blood sugar monitoring. The ADM/DPCS did not provide a policy on initial assessment as requested by the survey team. During a telephone interview on 6/13/2024, at 3:26 p.m., with RN 1, RN 1 stated she did not visit or assess Patient 7 on 3/1/2024. RN 1 stated she did not see Patient 7 until 5/24/2024. RN1 stated she did not know if another RN assess Patient 7 on 3/1/2024. A review of the HAs policy, titled, ";Comprehensive Assessment," (Policy No- 4-042.1), revised November 2021, indicated that a comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. The assessment should determine: A. Probable prognosis of six months or less. B. Patient problem and needs related to the terminal illness. C. Patient goals related to the terminal illness. D. Type of services, frequency, and duration needed to meet patient.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to conduct a complete skin wound assessment for one of 14 sampled patients (Patient 12). Patient 12 who had a diabetic ulcer (open wound or sore) on her right leg, did not have a complete skin assessment to address Patient 7s right diabetic ulcer. As a result, Patient 12 went to the hospital due to uncontrolled right leg pain and had the potential for serious complications. --- Findings: During a review of Patient 12s untitled admission record, the admission record indicated a start of care date on 3/4/2024 with a primary diagnosis of chronic systolic heart failure (he left ventricle of the heart, which pumps most of the blood, has become weak) and congestive heart failure (CHF, the heart cannot pump enough blood). During a joint home visit interview on 6/12/2024, at 1 p.m., with the Administrator Designee/Licensed Vocational Nurse (AD/LV) to Patient 12 and Patient 7 (Patient 12s spouse) home. Patient 7 stated Patient 12 was asleep and resting because she was discharged from the hospital for her right leg and foot pain and Patient 12 was not available for an interview. During a concurrent record review and interview, on 6/13/2024, at 1:30 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 12s clinical record titled ";Re-Cert Assessment," dated 5/22/2024, was reviewed. The ADM/DPCS stated Patient 12s ";Integumentary-Skin" indicated there was no ";Wound/Skin Impairment – No," and under ";Other Observations (if applicable)" – ";Skin was clean and intact." The ADM/DPCS stated the ";Narrative and Disease Trajectory," section, ";Skin assessment done with Wound Care Orders for Right Medial (middle)Lower Leg: Cleanse the wound with cleanser and pat dry with gauze, apply Tetracyte (antibiotic for the skin) to the wound bed, followed by alginate (an antibacterial). Cover with non-bordered foam dressing and wrap with rolled gauze, followed by self-adhesive bandage twice weekly and PRN (as needed) for soiled or loose dressing. The ADM/DPCS stated there were inconsistencies with Registered Nurses (RN1) documentations and incomplete wound assessment. The ADM/DPCS stated a wound assessment should include the location, classification, staging if applicable, measurements, color, drainage if any and odor. The ADM/DPCS stated RN 1 did not complete Patient 12s wound assessment. The ADM/DPCS stated she was not familiar with Patient 12 and did not know the type and location of Patient 12s wound. The ADM/DPCS stated RN1 needed to complete a ";Skin Impairment Assessment." Upon concurrent review with the ADM/DPCS of Patient 12s EMR (Electronic Medical Record), the ADM/DPCS stated there was no ";Skin Impairment Assessment." completed on 5/22/2024. During a concurrent record review and interview, on 6/13/2024, at 1:40 p.m., with the ADM/DPCS Patient 12s clinical record titled ";Progress Report," from the ";Wound Pros/Wound Care Experts,(outside company)" dated 5/24/2024 was reviewed. The ADM/DPCS stated the ";Wound Details," section, ";Location: Right Medial (middle) Lower Leg," ";Classification: Diabetic Ulceration," ";Status: New," ";Stage: None," ";Width: 5.7 centimeters (cm, a unit of measurement)," ";Length: 2.61 cm," ";Depth: 0.5cm." The DPCS stated Patient 12s ";Progress Report" from the" Wound Pros/Wound Care Experts," dated 5/30/2024, indicated in the ";Wound Details" section, ";Location: Right Medial Lower Leg", ";Classification: Diabetic Ulceration," ";Status: Improving," ";Stage: None," ";Width: 4.66 cm," ";Length: 2.28 cm," ";Depth: 0.2 cm." The ADM/DPCS stated HAs skilled nurses needed to conduct and document their own skin/wound assessments when they visited the patients (in general). During a concurrent record review and interview, on 6/13/2024, at 1:47 p.m., with the ADM/DPCS, of Patient 12s clinical record titled ";Current Treatment/Medication/DME (Durable Medical Equipment) List," was reviewed. The ADM/DPCS stated the Current Treatment/Medication/DME indicated an order date of 5/23/2024- ";Referral to Wound Pros for Wound Assessment and Treatment," ";Note: Right Lateral (to the side) Anterior (front) Foot," and an order date of 5/24/2024-";Wound Care Orders for Right Medial Lower Leg: Cleanse the wound with cleanser and pat dry with gauze. Apply Tetracyte to the wound bed, followed by alginate. Cover with non-bordered foam dressing and wrap with rolled gauze, followed by self-adhesive bandage twice weekly and PRN (as needed) for soiled or loose dressing. Secure dressing with tape as needed. Note: The wound dressing will be changed by the Wound Pros clinician once a week and twice weekly by the treatment nurse or PRN." The ADM/DPCS stated that right lateral foot was documented wrong, and it should be in the right medial lower leg. During a concurrent record review and interview, on 6/13/2024, at 2:08 p.m., with the ADM/DPCS Patient 12s clinical record titled ";Visit Note LVN," dated 5/24/2024 and 5/30/2024, was reviewed. The ADM/DPCS stated the Visit Note LVN indicated in the ";Pain" section, documented ";Is Pain Controlled? Yes/"Pain Level reported at this visit – 0", ";Integumentary-Skin" section, ";Wounds" documented as ";None" and in ";Narrative" Section documented ";SN (Skilled Nurse) head to toe assessment," no further documentation of Patient 12s wound to any part of her body. The ADM/DPCS stated Patient 12s clinical records, titled ";Communication log," dated 5/24/2024, indicated in the ";comm comments"- ";SN (LVN1) called hospice to report that the patient was seen today by the Wound Pros and per visiting Clinician Patient foot was red and swollen and asked for a medication to help with pain. MD (Medical Doctor) was notified and per MD orders send Tylenol (medication for pain)500 mg (milligrams) One tablet by mouth every 4-6 hours as needed for pain. The ADM/DPCS stated there were inconsistencies with the documentations of RN1 and LVN1 including the pain assessments. The ADM/DPCS stated LVN 1 should have documented her own assessment to Patient 12s wound from right medial lower leg since LVN 1 called the office and was aware of Patient 12s pain with her right foot. The ADM/DPCS stated that assessment should be documented to the SN visits, comprehensive/updated assessments and not in the communication logs. During an interview on 6/13/2024, at 2:20 p.m., with the AD, the AD stated the HA received a call on 6/11/2024 from the Wound Pros treatment nurse that attempted to visit Patient 12 on 6/6/2024 in her home but was unavailable. The AD stated Patient 12 was hospitalized due to pain and infection to her right leg/foot. The AD stated Patient 12 was hospitalized from 6/5/2024 to 6/8/2024. The AD stated Patient 12 was supposed to have an SN visit on the week of 6/2/2024 to 6/8/2024. During a concurrent review with AD of Patient 12s ";Monthly Schedule" for May-June 2024, the AD stated the Monthly Schedule indicated no scheduled visit for the week of 6/2/2024 to 6/8/2024. The AD stated she did not know what happened and why there was a missed visit. The AD stated Patient 12 was supposed to have a visit from the SN for that week. The AD stated that if an SN visit had made, Patient 12s pain to her right leg and foot could have been addressed and hospitalization could have been prevented. A request to have a telephone interview with LVN1 was made from the AD but stated LVN 1 was busy doing her visit with the patients and unavailable at this time. On 6/13/2024, at 2:53 p.m., a telephone call to Patient 12 was made but was unsuccessful. During a telephone interview on 6/13/2024, at 3:26 pm, with Registered Nurse 1 (RN 1), RN1 stated she should have documented a thorough and complete skin/wound assessment for Patient 12 which included the type, description, measurement, and appearance of Patient 12s skin condition. RN 1 stated she documented wrong in the skin section and should have documented yes to confirmed Patient 12s wound and she should have completed a skin impairment assessment form, stated it was her mistake. RN 1 stated that a care plan should also formulated to address Patient 12's wound and pain management and to have an effective coordination of care. During a telephone interview on 6/14/2024, at 10 a.m., with Patient 12 in her native language (Spanish), Patient 12 stated that on 6/5/2024 she called her primary doctor for her unbearable, uncontrolled throbbing, burning pain and redness/swelling of her right lower leg and right foot. Patient 12 stated she had Tylenol 500mg medication for pain, but it was not effective. Patient 12 stated her primary doctor advised her to go to urgent care for further treatment. Patient 12 stated she went to the local urgent care on the same day and during her visit, she was advised to go to the emergency department for further treatment of her foot infection and uncontrolled pain. Patient 12 stated she then proceeded to the local emergency department, and she was treated there for antibiotics and pain relief medications. Patient 12 state she was admitted to the hospital from 6/5/2024 and was discharged on 6/8/2024. Patient 12 stated she did not call the hospice agency as she did not have their telephone number. During a telephone interview on 6/14/2024, at 1:10 p.m., with LVN 1, LVN 1 stated she should have documented a complete skin/wound assessment for Patient 12 which included the type, description, measurement, and appearance of Patient 12s skin. LVN 1 stated she documented wrong in the integumentary (skin) section and should have documented yes to confirmed Patient 12s wound and she stated it was her mistake. LVN 1 stated she visited Patient 12 on 6/3/2024 and was aware of Patient 12s pain to her right lower leg and right foot, stated she called the agency to report it. During a record review and interview on 6/14/2023, at 1:17 p.m., with the ADM/DPCS and LVN1 Patient 12s EMR was reviewed. The ADM/DPCS stated there was no documented evidence of LVN1 SN visit dated on 6/3/2024. LVN 1 stated she did not know why there was no documentation of her visit with Patient 12 on 6/3/2024. LVN1 stated she might have forgotten to upload it, stated she should have documented her visit to reflect Patient 12s current health status. The ADM/DPCS stated that each SN visit should have been documented as evidence that a visit has been made by nurse, an assessment which includes Patient 12s wound, pain, response to current pain medication and to address patients existing or potential problems in a timely manner. During a review of the hospice agencys policy and procedure titled ";Patient Bill of Rights/Responsibilities", revised date of November 2021, indicated that the Patient Bill of Rights/Responsibilities statement defines the right of the patient which includes to received effective pain and symptom management for conditions related to terminal illness. During review of the hospice agencys policy and procedure titled ";Interdisciplinary Group Membership and Responsibilities", revised date of November 2021, indicated that the interdisciplinary group will collaborate with the patients attending physician to develop an individualized written plan of care. The hospice agency did not provide a policy and procedure related to wound and pain assessment, entries to clinical records, skilled nurse missed visit, content and accuracy of clinical records as requested by the surveyors. A review of the hospice agencys policy and procedure titled ";Comprehensive Assessment", revised November 2021, indicated that during the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least the following information, as relevant: section A. An assessment of pain, including the origin, location, duration, severity, and relief measures. section G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient's terminal illness. It further indicated that 5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but a minimum every 15 days, and section 5.(c.) If there has been a change in the patients condition/status, then the comprehensive assessment must be updated. A review of the hospice agencys policy and procedure titled ";Patient Bill of Rights/Responsibilities", revised date of November 2021, indicated that the Patient Bill of Rights/Responsibilities statement defines the right of the patient which includes to received effective pain and symptom management for conditions related to terminal illness.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to provide initial bereavement (is the physical and mental impact of losing a loved one) assessment for one of fourteen sampled patients (Patient 13). This failure had the potential to result in placing the patient and family/caregiver at risk of spiritual and emotional distress. --- Findings: During a review of Patient 13s untitled admission record, indicated a start of care date on 5/1/2024 with a primary diagnosis of heart disease unspecified (a type of disease that affects the heart). During a review of Patient 3s ";POC (Plan of Care, documentation of patients needs with plan of nursing interventions to meet the needs)/IDG (Interdisciplinary Group members from different disciplines: Medical Director, Registered Nurse, Medical Social Worker and Spiritual Chaplain that collaborates to address patients goals and needs) Review," dated 5/1/2024, indicated in the ";Frequency of Visit" section: ";MSW (Medical Social Worker) – Initial assessment within 5 days of admission to provide psycho-social support to patient and family; SC (Spiritual Chaplain) – Initial assessment within 5 days of admission to complete initial Spiritual assessment and planning." The POC indicated in the ";IDG Discussion/Updated Comprehensive Assessment Review" section: ";Spiritual: blank; Psychosocial: blank; were left blank and no entered documentations. During a concurrent interview and a record review, on 6/14/2024 at 2 p.m., with the Director of Patient Care Services (DPCS), Patient 13s POC/IDG were reviewed. The DPCS stated there was no initial bereavement risk assessment conducted and Patient 13s clinical record page, titled ";History of Bereavement Assessment," was blank. The DPCS stated there were no other documented evidence that an Initial Bereavement Assessment was conducted for Patient 13. The DPCS stated a bereavement assessment needed to be conducted within five days of admission. The DPCS stated Patient 13 did not have an initial bereavement assessment conducted based on the clinical records and the Spiritual Chaplain (SC) or the Medical Social Worker (MSW) should have been completed it. On 6/14/2024, at 2:17 p.m., a telephone call was made to Spiritual Chaplain (SC) but was no answer. During a review of the agency's policy and procedure titled "Bereavement Services," with a revised date of November 2021, indicated the hospice agency will provide bereavement services to the families/caregivers of hospice patients both before and after the patients death in accordance with the plan of care, a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice and information gathered will be incorporated into the plan of care and considered in the bereavement plan of care.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to: 1. Ensure to conduct a complete skin assessment and update the comprehensive assessment that reflected the skin abnormality in the patients right lower leg area for one of 14 sampled patients (Patient 12). 2. Ensure the interdisciplinary group (IDG, meeting where the Registered Nurse [RN], Medical Social Worker [MSW, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) conducted biweekly (twice a week) meetings to update the comprehensive assessment of patients and reflected current health status, for five of 14 sampled patients (Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 ). These deficient practices resulted in patients not being evaluated and had the potential to affect the patients' care and prevented from reaching their goals. --- Findings: a. During a review of Patient 10s untitled admission sheet, indicated a start of care date on 3/24/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). During a review of Patient 10s Plan of Care/Interdisciplinary Group review dated 3/24/2024, 4/4/2024, 4/18/2024, 5/2/2024, 5/16/2024 and 5/30/2024, indicated incomplete IDG signatures from IDG team attendees (Medical Director, Medical Social Worker, Registered Nurse and Chaplain) and no evaluation of Patient 10s response to care, treatment, services provided and there was no progress toward desired outcome documented every 14 days. b. During a review of Patient 11s untitled admission record, the admission record indicated a start of care date on 2/14/2023 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) congestive heart failure (heart not pumping blood properly). During a review of Patient 11s Plan of Care/Interdisciplinary Group review dated 4/4/2024, 4/18/2024, 5/2/2024, 5/16/2024 and 5/30/2024, indicated there were missing IDG signatures from the IDG team attendees (Medical Director, Medical Social Worker, Registered Nurse and Chaplain) and no evaluation of Patient 11s response to care, treatment, services provided and there was no progress toward desired outcome documented every 14 days. c. During a review of Patient 12s untitled admission record, the admission record indicated a start of care date on 3/4/2024 with a primary diagnosis of chronic systolic heart failure (he left ventricle of the heart, which pumps most of the blood, has become weak) and congestive heart failure (CHF, the heart cannot pump enough blood). During a joint home visit interview on 6/12/2024, at 1 p.m., with the Administrator Designee/Licensed Vocational Nurse (AD/LV) to Patient 12 and Patient 7 (Patient 12s spouse) home. Patient 7 stated Patient 12 was asleep and resting because she was discharged from the hospital for her right leg and foot pain and Patient 12 was not available for an interview. During a concurrent record review and interview, on 6/13/2024, at 1:30 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 12s clinical record titled ";Re-Cert Assessment," dated 5/22/2024, was reviewed. The ADM/DPCS stated Patient 12s ";Integumentary-Skin" indicated there was no ";Wound/Skin Impairment – No," and under ";Other Observations (if applicable)" – ";Skin was clean and intact." The ADM/DPCS stated the ";Narrative and Disease Trajectory," section, ";Skin assessment done with Wound Care Orders for Right Medial (middle)Lower Leg: Cleanse the wound with cleanser and pat dry with gauze, apply Tetracyte (antibiotic for the skin) to the wound bed, followed by alginate (an antibacterial). Cover with non-bordered foam dressing and wrap with rolled gauze, followed by self-adhesive bandage twice weekly and PRN (as needed) for soiled or loose dressing. The ADM/DPCS stated there were inconsistencies with Registered Nurses (RN1) documentations and incomplete wound assessment. The ADM/DPCS stated a wound assessment should include the location, classification, staging if applicable, measurements, color, drainage if any and odor. The ADM/DPCS stated RN 1 did not complete Patient 12s wound assessment. The ADM/DPCS stated she was not familiar with Patient 12 and did not know the type and location of Patient 12s wound. The ADM/DPCS stated RN1 needed to complete a ";Skin Impairment Assessment." Upon concurrent review with the ADM/DPCS of Patient 12s EMR (Electronic Medical Record), the ADM/DPCS stated there was no ";Skin Impairment Assessment." completed on 5/22/2024. During a concurrent record review and interview, on 6/13/2024, at 1:40 p.m., with the ADM/DPCS Patient 12s clinical record titled ";Progress Report," from the ";Wound Pros/Wound Care Experts,(outside company)" dated 5/24/2024 was reviewed. The ADM/DPCS stated the ";Wound Details," section, ";Location: Right Medial (middle) Lower Leg," ";Classification: Diabetic Ulceration," ";Status: New," ";Stage: None," ";Width: 5.7 centimeters (cm, a unit of measurement)," ";Length: 2.61 cm," ";Depth: 0.5cm." The DPCS stated Patient 12s ";Progress Report" from the" Wound Pros/Wound Care Experts," dated 5/30/2024, indicated in the ";Wound Details" section, ";Location: Right Medial Lower Leg", ";Classification: Diabetic Ulceration," ";Status: Improving," ";Stage: None," ";Width: 4.66 cm," ";Length: 2.28 cm," ";Depth: 0.2 cm." The ADM/DPCS stated HAs skilled nurses needed to conduct and document their own skin/wound assessments when they visited the patients (in general). During a concurrent record review and interview, on 6/13/2024, at 1:47 p.m., with the ADM/DPCS, of Patient 12s clinical record titled ";Current Treatment/Medication/DME (Durable Medical Equipment) List," was reviewed. The ADM/DPCS stated the Current Treatment/Medication/DME indicated an order date of 5/23/2024- ";Referral to Wound Pros for Wound Assessment and Treatment," ";Note: Right Lateral (to the side) Anterior (front) Foot," and an order date of 5/24/2024-";Wound Care Orders for Right Medial Lower Leg: Cleanse the wound with cleanser and pat dry with gauze. Apply Tetracyte to the wound bed, followed by alginate. Cover with non-bordered foam dressing and wrap with rolled gauze, followed by self-adhesive bandage twice weekly and PRN (as needed) for soiled or loose dressing. Secure dressing with tape as needed. Note: The wound dressing will be changed by the Wound Pros clinician once a week and twice weekly by the treatment nurse or PRN." The ADM/DPCS stated that right lateral foot was documented wrong, and it should be in the right medial lower leg. During a concurrent record review and interview, on 6/13/2024, at 2:08 p.m., with the ADM/DPCS Patient 12s clinical record titled ";Visit Note LVN," dated 5/24/2024 and 5/30/2024, was reviewed. The ADM/DPCS stated the Visit Note LVN indicated in the ";Pain" section, documented ";Is Pain Controlled? Yes/"Pain Level reported at this visit – 0", ";Integumentary-Skin" section, ";Wounds" documented as ";None" and in ";Narrative" Section documented ";SN (Skilled Nurse) head to toe assessment," no further documentation of Patient 12s wound to any part of her body. The ADM/DPCS stated Patient 12s clinical records, titled ";Communication log," dated 5/24/2024, indicated in the ";comm comments"- ";SN (LVN1) called hospice to report that the patient was seen today by the Wound Pros and per visiting Clinician Patient foot was red and swollen and asked for a medication to help with pain. MD (Medical Doctor) was notified and per MD orders send Tylenol (medication for pain)500 mg (milligrams) One tablet by mouth every 4-6 hours as needed for pain. The ADM/DPCS stated there were inconsistencies with the documentations of RN1 and LVN1 including the pain assessments. The ADM/DPCS stated LVN 1 should have documented her own assessment to Patient 12s wound from right medial lower leg since LVN 1 called the office and was aware of Patient 12s pain with her right foot. The ADM/DPCS stated that assessment should be documented to the SN visits, comprehensive/updated assessments and not in the communication logs. During an interview on 6/13/2024, at 2:20 p.m., with the AD, the AD stated the HA received a call on 6/11/2024 from the Wound Pros treatment nurse that attempted to visit Patient 12 on 6/6/2024 in her home but was unavailable. The AD stated Patient 12 was hospitalized due to pain and infection to her right leg/foot. The AD stated Patient 12 was hospitalized from 6/5/2024 to 6/8/2024. The AD stated Patient 12 was supposed to have an SN visit on the week of 6/2/2024 to 6/8/2024. During a concurrent review with AD of Patient 12s ";Monthly Schedule" for May-June 2024, the AD stated the Monthly Schedule indicated no scheduled visit for the week of 6/2/2024 to 6/8/2024. The AD stated she did not know what happened and why there was a missed visit. The AD stated Patient 12 was supposed to have a visit from the SN for that week. The AD stated that if an SN visit had made, Patient 12s pain to her right leg and foot could have been addressed and hospitalization could have been prevented. A request to have a telephone interview with LVN1 was made from the AD but stated LVN 1 was busy doing her visit with the patients and unavailable at this time. On 6/13/2024, at 2:53 p.m., a telephone call to Patient 12 was made but was unsuccessful. During a telephone interview on 6/13/2024, at 3:26 pm, with Registered Nurse 1 (RN 1), RN1 stated she should have documented a thorough and complete skin/wound assessment for Patient 12 which included the type, description, measurement, and appearance of Patient 12s skin condition. RN 1 stated she documented wrong in the skin section and should have documented yes to confirmed Patient 12s wound and she should have completed a skin impairment assessment form, stated it was her mistake. RN 1 stated that a care plan should also formulated to address Patient 12's wound and pain management and to have an effective coordination of care. During a telephone interview on 6/14/2024, at 10 a.m., with Patient 12 in her native language (Spanish), Patient 12 stated that on 6/5/2024 she called her primary doctor for her unbearable, uncontrolled throbbing, burning pain and redness/swelling of her right lower leg and right foot. Patient 12 stated she had Tylenol 500mg medication for pain, but it was not effective. Patient 12 stated her primary doctor advised her to go to urgent care for further treatment. Patient 12 stated she went to the local urgent care on the same day and during her visit, she was advised to go to the emergency department for further treatment of her foot infection and uncontrolled pain. Patient 12 stated she then proceeded to the local emergency department, and she was treated there for antibiotics and pain relief medications. Patient 12 state she was admitted to the hospital from 6/5/2024 and was discharged on 6/8/2024. Patient 12 stated she did not call the hospice agency as she did not have their telephone number. During a telephone interview on 6/14/2024, at 1:10 p.m., with LVN 1, LVN 1 stated she should have documented a complete skin/wound assessment for Patient 12 which included the type, description, measurement, and appearance of Patient 12s skin. LVN 1 stated she documented wrong in the integumentary (skin) section and should have documented yes to confirmed Patient 12s wound and she stated it was her mistake. LVN 1 stated she visited Patient 12 on 6/3/2024 and was aware of Patient 12s pain to her right lower leg and right foot, stated she called the agency to report it. During a record review and interview on 6/14/2023, at 1:17 p.m., with the ADM/DPCS and LVN1 Patient 12s EMR was reviewed. The ADM/DPCS stated there was no documented evidence of LVN1 SN visit dated on 6/3/2024. LVN 1 stated she did not know why there was no documentation of her visit with Patient 12 on 6/3/2024. LVN1 stated she might have forgotten to upload it, stated she should have documented her visit to reflect Patient 12s current health status. The ADM/DPCS stated that each SN visit should have been documented as evidence that a visit has been made by nurse, an assessment which includes Patient 12s wound, pain, response to current pain medication and to address patients existing or potential problems in a timely manner. d. During a review of Patient 13s untitled admission record, indicated a start of care date on 5/1/2024 and end of care date of 5/15/2024, with a primary diagnosis of Heart disease unspecified (a type of disease that affects the heart). During a review of Patient 13s Plan of Care/Interdisciplinary Group review dated 5/1/2024, indicated incomplete IDG signatures from IDG team attendees (Medical Director, Medical Social Worker, Registered Nurse and Chaplain) and no evaluation of Patient 13s response to care, treatment, services provided and there was no progress toward desired outcome documented every 14 days. e. A review of Patient 14s untitled admission sheet, indicated a start of care date on 5/7/2023 and end of care date of 2/10/24, with a primary diagnosis of Cerebral Infarct (occurs as a result of interrupted blood flow to the brain due to problems with the blood vessels that supply it, a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). During a review of Patient 14s Plan of Care/Interdisciplinary Group review dated 11/30/2024, 12/14/2023, 1/11/2024, 1/25/2024 and 2/8/2024, indicated incomplete IDG signatures from IDG team attendees (Medical Director, Medical Social Worker, Registered Nurse and Chaplain) and no evaluation of Patient 14s response to care, treatment, services provided and there was no progress toward desired outcome documented every 14 days. During a telephone interview on 6/13/2024, at 11:50 a.m., with the Medical Director (MD), the MD stated that whenever the hospice agency staff would bring him the certification, he would sign the documents. The MD stated he was not good with computers. The MD stated the hospice nurses (in general) had his permission to log into the Hospice MD (electronic medical record system) and would sign his name in the CTI (Certificate of Terminal Illness). The MD stated he had not logged in to the computer and he did not sign any IDGs in the Hospice MD. The MD stated he had not given a specimen of his signature to the hospice agency. The MD stated the IDG members met every other week to discuss patients needs, goals and developments. The MD stated the HA had an attendance sign in sheet for all the members present during the meeting. During an interview on 6/13/2024, at 1:35 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the IDG members including, the Registered Nurse, doctor, social worker, and chaplain were required to attend the meetings. The DPCS stated it was important to document the findings in the IDG meetings in the patients (in general), record to know what the needs of the patient were and what information the group needed to know to follow up on. The DPCS stated the HA had an attendance sign in sheet for every meeting. The DPCS stated the HAs ";IDG Meeting" sign in sheet log folder, indicated the signatures of the disciplines (Medical Director, Registered Nurse, Spiritual Chaplain and Medical Social Worker) attended the meetings on the following dates: 3/7/2024,3/21/2024, 4/4/2024, 4/18/2024, 5/2/2024, 5/16/2024 and 5/30/2024. The DPCS stated she was unable to provide the list of the patients were discussed in the meetings. The DPCS stated the patients were discussed alternately on every IDG meetings and we supposed to have the list of the patients that were discussed during the meetings to ensure we did not missed or forgot the patients that was not included in the previous meetings. A review of the hospice agencys policy and procedure titled ";Interdisciplinary Group Membership and Responsibilities", revised date of November 2021, indicated that the interdisciplinary group will collaborate with the patients attending physician to develop an individualized written plan of care. A review of the hospice agencys policy and procedure titled ";Comprehensive Assessment", revised November 2021, indicated that during the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least the following information, as relevant: section A. An assessment of pain, including the origin, location, duration, severity, and relief measures. section G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient's terminal illness. It further indicated that 5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but a minimum every 15 days, and section 5.(c.) If there has been a change in the patients condition/status, then the comprehensive assessment must be updated.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met as follows: --- 1. The HA failed to develop an individualized Plan of Care (POC, a document that maps out needs and services supplied for a patient's family/caregiver) for two of 14 sampled patients (Patient 7 and Patient 12) to address the management of Patient 7 and Patient 12s health status. (Refer to L545). a. For Patient 7 who had a diagnosis of diabetes (a medical condition characterized by the body's inability to regulate blood sugar levels), the HA did not monitor Patient 7 for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) that could lead to serious harm, hospitalization, and/or death. Patient 7 did not have Tradjenta (medication to control high blood sugar 5milligrams (mg, a unit of measurement) one tablet daily for diabetes, and Jardiance (medication to control high blood sugar) 25 mg one tablet daily for diabetes available as ordered by the physician. b. Patient 12 had a diabetic ulcer (open wound or sore) on her right leg and did not have an individualized care plan to address Patient 7s right leg ulcer. On 6/5/2024, Patient 12 was hospitalized due to uncontrolled pain from her right leg diabetic ulcer. As a result, Patient 7 did not receive diabetes management and Patient 12 went to the hospital due to uncontrolled right leg pain and had the potential for serious complications. 2.The HA failed to provide medications necessary to meet the needs of two of 14 sampled patients (Patient 5 and Patient 7). This deficient practice had the potential to result in uncontrolled symptoms, which could affect the patients quality of life. (Refer to L549). 3. The HA failed to provide the necessary medical supplies for three of 14 sampled patients (Patient 5, Patient 7, and Patient 10). This deficient practice had the potential not to meet the medical needs of Patient 5, Patient 7, and Patient 10). (Refer to L550). 4. The failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) participated in the plan of care of 13 of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This deficient practice had the potential to affect the patients care. (Refer to L554). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients.

Based on observation, interview, and record review, the hospice agency failed to develop an individualized Plan of Care (POC, a document that maps out needs and services supplied for a patient's family/caregiver) for two of 14 sampled patients (Patient 7 and Patient 12) to address the management of Patient 7 and Patient 12s health status. a. For Patient 7 who had a diagnosis of diabetes (a medical condition characterized by the body's inability to regulate blood sugar levels), the HA did not monitor Patient 7 for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) that could lead to serious harm, hospitalization, and/or death. Patient 7 did not have Tradjenta (medication to control high blood sugar 5milligrams (mg, a unit of measurement) one tablet daily for diabetes, and Jardiance (medication to control high blood sugar) 25 mg one tablet daily for diabetes available as ordered by the physician. b. Patient 12 had a diabetic ulcer (open wound or sore) on her right leg and did not have an individualized care plan to address Patient 7s right leg ulcer. On 6/5/2024, Patient 12 was hospitalized due to uncontrolled pain from her right leg diabetic ulcer. As a result, Patient 7 did not receive diabetes management and Patient 12 went to the hospital due to uncontrolled right leg pain and had the potential for serious complications. On 6/13/2024, at 4:45 p.m., a second Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was called in the presence of the agencys Administrator/Director of Patient Care Services (ADM/DPCS) and the Administrator Designee related to the agencys failure to ensure that an individualized Plan of Care was developed for Patient 7 and Patient 12 based on identified initial and updated assessments to address the management of health status of the patients that placed the patients at risk for serious harm On 6/14/2024, at 4:30 p.m., the survey team completed the survey tasks, and conducted an exit conference with the HAs ADM/DPCS and ADMD, with the IJ situation not removed. The HA was informed to submit an acceptable IJ Removal Plan. --- b. A review of Patient 12s untitled admission sheet, indicated a start of care date on 3/4/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). During a joint home visit on 6/12/2024 at 1:00 p.m. with the Administrator Designee (AD), who is a Licensed Vocational Nurse, to Patient 7 (Patient 12s spouse) and Patient 12s home, Patient 7 stated that Patient 12 is sleeping and resting because she was just discharged from the hospital few days ago for right leg and foot pain. Patient 12 was not available for interview. On 6/13/2024 at 2:53 p.m., a telephone call to P12 was made but was unsuccessful. On 6/13/2024, at 1:30 p.m., during a concurrent review and interview with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 12s clinical record titled ";Re-Cert Assessment", dated 5/22/2024, indicated in the ";Integumentary-Skin" section, ";Wound/Skin Impairment – No", and under ";Other Observations (if applicable)" – ";Skin was clean and intact". It further indicated in the ";Narrative and Disease Trajectory" section, ";Skin assessment done with Wound Care Orders for Right Medial Lower Leg: Cleanse the wound with cleanser and pat dry with gauze. Apply Tetracyte to the wound bed, followed by alginate AG. Cover with non-bordered foam dressing and wrap with rolled gauze, followed by self-adhesive bandage 2x weekly and PRN (as needed) for soiled or loose dressing. Secure dressing with tape as needed. Note: The wound dressing will be changed by the Wound Pros clinician once a week and 2x weekly by the treatment nurse or PRN". ADM/DPCS stated that there were inconsistencies with Registered Nurses (RN1) documentations and incomplete wound assessment. ADM/DPCS stated that a wound assessment should include the location, classification, staging if applicable, measurements, color, drainage if any and odor. ADM/DPCS stated that RN 1 did not complete wound assessment for P12. ADM/DPCS stated that she is not familiar with P12 and does not know the type and location of P12s wound. ADM/DPCS stated that RN1 should also completed a ";Skin Impairment Assessment". Upon concurrent review with the ADM/DPCS of P12s EMR (Electronic Medical Record), there was no ";Skin Impairment Assessment" completed on 5/22/2024. On 6/13/2024, at 1:40 p.m., during a concurrent review and interview with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 12s clinical record titled ";Progress Report" from the ";Wound Pros/Wound Care Experts", dated 5/24/2024, indicated in the ";Wound Details" section, ";Location: Right Medial Lower Leg", ";Classification: Diabetic Ulceration", ";Status: New", ";Stage: None", ";Width: 5.7 cm (centimeters)", ";Length: 2.61 cm", ";Depth: 0.5cm". A further review of P12s clinical record with the ADM/DPCS, titled ";Progress Report" from the" Wound Pros/Wound Care Experts", dated 5/30/2024, indicated in the ";Wound Details" section, ";Location: Right Medial Lower Leg", ";Classification: Diabetic Ulceration", ";Status: Improving", ";Stage: None", ";Width: 4.66 cm", ";Length: 2.28 cm", ";Depth: 0.2 cm". ADM/DPCS stated that Wound Pros services the hospice agency for their patients that was referred for wound consult. ADM/DPCS stated that Wound Pro treatment nurses provide wound treatments for their patients, but hospice agencys skilled nurses also should conduct and document their own skin/wound assessments when they visit the patients. On 6/13/2024, at 1:47 p.m., during a concurrent review and interview with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 12s clinical record titled ";Current Treatment/Medication/DME (Durable Medical Equipment) List", indicated an order date of 5/23/2024- ";Referral to Wound Pros for Wound Assessment and Treatment", ";Note: Right Lateral Anterior Foot", and an order date of 5/24/2024-";Wound Care Orders for Right Medial Lower Leg: Cleanse the wound with cleanser and pat dry with gauze. Apply Tetracyte to the wound bed, followed by alginate AG. Cover with non-bordered foam dressing and wrap with rolled gauze, followed by self-adhesive bandage 2x weekly and PRN (as needed) for soiled or loose dressing. Secure dressing with tape as needed. Note: The wound dressing will be changed by the Wound Pros clinician once a week and 2x weekly by the treatment nurse or PRN". ADM/DPCS stated that right lateral foot was documented wrong, and it should be in the right medial lower leg. On 6/13/2024, at 1:58 p.m., during a concurrent review and interview with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 12s clinical record titled ";POC (Plan of Care)/IDG (Interdisciplinary) Review (is a team consists of the doctor, social worker, registered nurse and spiritual chaplain which is responsible for development and review of the patient's plan of care), dated 5/30/2024, indicated no plan of care that address for P12s diagnosis for diabetes mellitus (uncontrolled blood sugar levels), diabetic ulceration (a serious complication caused by a combination of poor circulation, sensitive to infection and nerve damage from high blood sugar levels) and pain management. ADM/DPCS confirmed that there were no care plans formulated to address P12s problems and stated a care plan should have been made and discussed in the IDG meetings to better manage P12s potential and existing problems. On 6/13/2024, at 2:08 p.m., during a concurrent review and interview with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 12s clinical record titled ";Visit Note LVN", dated 5/24/2024 and 5/30/2024, indicated in the ";Pain" section, documented ";Is Pain Controlled? Yes/"Pain Level reported at this visit – 0", ";Integumentary-Skin" section, ";Wounds" documented as ";None" and in ";Narrative" Section documented ";SN (Skilled Nurse) head to toe assessment", no further documentation of P12s wound to any part of her body. Upon further review of Patient 12s clinical records, titled ";Communication log", dated 5/24/2024, indicated in the ";comm comments"- ";SN (LVN1) called hospice to report that the patient was seen today by the Wound Pros and per visiting Clinician Patient foot was red and swollen and asked for a medication to help with pain. MD was notified and per MD orders send Tylenol 500 mg (milligrams) One tab oral every 4-6 hours as needed for pain. (Do not exceed more than 6 tablets in 24 hours). IDG team has been notified." ADM/DPCS stated that there were inconsistencies with the documentations of RN1 and Licensed Vocational Nurse (LVN1) including the pain assessments. ADM/DPCS stated that LVN 1 should have documented her own assessment to P12s wound from right medial lower leg since LVN 1 called the office and is aware of P12s pain with her right leg/foot. ADM/DPCS stated that assessment should be documented to the SN visits, comprehensive/updated assessments and not in the communication logs. On 6/13/2024, at 2:20 p.m., during an interview with the AD, she stated that they received a call on 6/11/2024 from Wound Pros treatment nurse that attempted to visit P12 on 6/6/2024 in her home but was unavailable, stated that P12 was hospitalized due to pain and infection to her right leg/foot. AD stated that P12 was hospitalized from 6/5/2024 to 6/8/2024. AD stated that P12 supposed to have an SN visit on the week of 6/2/2024 to 6/8/2024. During a concurrent review with AD of P12s ";Monthly Schedule" for May-June 2024, indicated no scheduled visit for week of 6/2/2024 to 6/8/2024. AD stated she does not know what happened and why there was a missed visit, P12 supposed to have a visit from the SN for that week. AD stated that if an SN visit had made, P12s pain to her right leg and foot could have been address and hospitalization could have been prevented. A request to have a telephone interview with LVN1 was made from the AD but stated LVN 1 is busy doing her visit with the patients and unavailable at this time. On 6/13/2024, at 3:26 pm, during a telephone interview with RN 1, she stated that she should have documented a thorough and complete skin/wound assessment for P12 which include the type, description, measurement, and appearance. RN 1 stated that she documented wrong in the integumentary section and should have documented yes to confirmed P12s wound and she should have completed a skin impairment assessment form, stated it was her mistake. RN 1 stated that a care plan should also formulated to address P12's wound and pain management and to have an effective coordination of care. On 6/14/2024 at 10:00 a.m., during a telephone interview with P12 in her native language (Spanish), P12 stated that on 6/5/2024 she called her primary doctor for her unbearable, uncontrolled throbbing, burning pain and redness/swelling of her right lower leg and right foot. P12 stated she has Tylenol 500mg medication for pain, but it was not effective. P12 stated that her primary doctor advised her to go to urgent care for further treatment. P12 stated she went to local urgent care on the same day and during her visit, she was advised to go to the emergency department for further treatment of her foot infection and uncontrolled pain. P12 stated that she then proceeded to the local emergency department, and she was treated there for antibiotics and pain medications. P12 stated that she was admitted to the hospital from 6/5/2024 and was discharged on 6/8/2024. P12 stated she did not call the hospice agency as she does not have their telephone number. On 6/14/2024, at 1:10 p.m., during a telephone interview with LVN 1, she stated that she should have documented a complete skin/wound assessment for P12 which include the type, description, measurement, and appearance. LVN 1 stated that she documented wrong in the integumentary section and should have documented yes to confirmed P12s wound and she stated it was her mistake. LVN 1 stated that she visited P12 on 6/3/2024 and was aware of her pain from right lower leg and right foot, stated she called the agency to report it. At 1:17 p.m., during a concurrent review with ADM/DPCS of P12s EMR, there was no documented evidence of her SN visit dated on 6/3/2024. LVN 1 stated she does not know why there was no documentation of her visit with P12 on 6/3/2024, stated she might have forgotten to upload it, stated she should have documented her visit to reflect P12s current health status. ADM/DPCS stated that each SN visit should have been documented as evidence that a visit has been made by nurse, an assessment which includes P12s wound, pain, response to current pain medication and to address patients existing or potential problems in a timely manner. A review of the hospice agencys policy and procedure titled ";Patient Bill of Rights/Responsibilities", revised date of November 2021, indicated that the Patient Bill of Rights/Responsibilities statement defines the right of the patient which includes to received effective pain and symptom management for conditions related to terminal illness. A review of the hospice agencys policy and procedure titled ";Interdisciplinary Group Membership and Responsibilities", revised date of November 2021, indicated that the interdisciplinary group will collaborate with the patients attending physician to develop an individualized written plan of care. Upon request, the hospice agency was unable to provide a policy and procedure which is related to wound and pain assessment, entries to clinical records, skilled nurse missed visit, content and accuracy of clinical records. a. A review of Patient 7s ";Personal Information" indicated a start of care (SOC) date of 3/1/2024, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). A review of Patient 7s ";Plan of Care," dated 6/12/2024, indicated the ";Intervention and Goals, ";Level of Care" and ";Frequency of Visit" sections were all blank. A review of Patient 7s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 5/30/2024, 5/16/2024, 5/2/2024, 4/18/2024, 4/4/2024, 3/7/2024, and 3/1/2024, indicated the ";Plan of Care (Problem/Intervention/Goals/Status)" section was blank. The sections marked with ";Level of Care" and ";Frequency of Visit" were blank. The signature section for physician (MD), social worker (MSW), Registered Nurse (RN), and Chaplain were blank. During a telephone interview on 6/11/2024 at 4 p.m. with Patient 7 in his native language (Spanish), Patient 7 stated he was never diagnosed with heart disease, nor was he ever diagnosed with a terminal illness. Patient 7 stated he had high blood pressure (a condition in which the force of the blood against the artery [blood vessel] walls is too high) and diabetes (a chronic disease characterized by elevated levels of blood glucose in the blood). Patient 7 stated his primary care physician (PCP) never told him that he had six months or less to live. Patient 7 stated he had been out of his high blood pressure, cholesterol, and diabetes medications. During a joint home visit to Patient 7s residence on 6/12/2024 at 1 p.m. with the Administrator Designee (AD), who is a Licensed Vocational Nurse, Patient 7 was observed alert and oriented. Observed Patient 7 ambulating with a walker. A medication review with the AD was conducted during the home visit, at 1:35 p.m. During medication review, the survey team observed the containers for Tradjenta (a medication to treat diabetes) 5 mg tablet, one tablet daily, and Jardiance (a medication to treat diabetes) 25 mg tablet, one tablet daily, were empty. The label on Tradjenta 5 mg tablet was showing a fill date of 5/8/2024 and a quantity of 30 tablets, indicating Patient 7 would have the Tradjenta 5 mg supply until 6/7/2024. The label on Jardiance 25 mg tablet was showing a fill date of 4/23/2024 and a quantity of 30 tablets., indicating Patient 7 would have the Jardiance 25 mg supply until 5/23/2024. A review of Patient 7s ";Current Treatment/Medication/DME List," undated, indicated that Tradjenta 5 mg tablet was ordered on 6/6/2024 and Jardiance 25 mg tablet was ordered on 6/11/2024. During an interview with Patient 7 on 6/13/2024 at 1:45 p.m. in his native language (Spanish), Patient 7 stated he did not know how to read and how to write because he never attended school. Per Patient 7, he only knows how to write his name. Patient 7 stated he did not know how to check his blood sugar, and his wife was the one checking his blood sugar. Patient 7 stated his blood sugar had not been checked for the last week because his wife was hospitalized. When asked if his wife logged his blood sugar readings, Patient 7 stated that she never recorded them. Per Patient 7, his wife was currently sleeping and was not able for interview. According to Patient 7, he received his blood pressure and cholesterol medications the previous night, after he spoke to the surveyor. Patient 7 stated he had not received his diabetes medications. During the home visit on 6/12/2024, the AD checked Patient 7s blood sugar at 2 p.m., and it was 180 mg/dL. During an interview with the AD on 6/12/2024 at 2:10 p.m., the AD stated the visiting was responsible to check for patients medications every visit, so the nurse could reconcile the medication list if patient had a new medication or a different medication dose. The AD stated that by checking patients medication with each visit, the nurse would find out if patient needed medication refill so that patient would not run out of medications. The AD stated that running out of diabetes medications could have a negative effect for Patient 7, such as causing elevated blood glucose level. The AD also stated that visiting nurses for Patient 7 checked his blood sugar and documented it. A review of ";Visit Note LVN" for Patient 7, dated 5/3/2024 and 5/17/2024, indicated the ";diabetes-blood sugar" section was marked ";none." On both visit notes, there was no documentation on Patient 7s blood sugar in the narrative section. The HA was not able to provide a blood sugar log for Patient 7 upon request on 6/13/2024. During a concurrent record review and interview with the AD on 6/12/2024 at 2:15 p.m., the AD reviewed Patient 7s ";Plan of Care," dated 6/12/2024, ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 5/30/2024, 5/16/2024, 5/2/2024, 4/18/2024, 4/4/2024, 3/7/2024, and 3/1/2024. The AD confirmed there was no plan of care generated for Patient 7 since his admission date of 3/1/2024. The AD stated the purpose of plan of care was to provide guidance for the staff so they could provide the appropriate care for the patient. When asked how staff could provide the appropriate care for Patient 7 since no plan of care had been formulated for him, the AD stated that staff could do endorsement over the telephone regarding Patient 7s care. ";Visit Note LVN" for Patient 7, dated 5/3/2024 and 5/17/2024, were reviewed. There was no documented evidence of telephone endorsement regarding Patient 7s care. During a concurrent record review and interview with the Director of Patient Care Services on 6/14/2024 at 2:10 p.m., the DPCS reviewed Patient 7s ";Plan of Care," dated 6/12/2024, ";Plan of Care/Interdisciplinary Group Review," dated 5/30/2024, 5/16/2024, 5/2/2024, 4/18/2024, 4/4/2024, 3/7/2024, and 3/1/2024. The DPCS confirmed there was no plan of care in place for Patient 7 since his admission date of 3/1/2024. When the DPCS was asked how the HA staff would be able to provide the necessary interventions for Patient 7 since no plan of care had been formulated for him, the DPCS stated, ";As a nurse, you can assess the patient during your patient to determine his needs and concerns and provide the interventions he needed. It doesnt mean the patient doesnt need a care plan, but since he has no care plan then thats what the nurses would have to do." According to the DPCS, an individualized plan of care is necessary because each patient has different needs that require different interventions. The HAs ";IDG Meeting Sign-In Sheet" was reviewed for the following dates: 5/30/2024, 5/16/2024, 5/2/2024, 4/18/2024, 4/4/2024, 3/21/2024, and 3/7/2024. There was no documented evidence that Patient 7 was discussed on those IDG meetings. During an interview on 6/15/2024 at 1:15 p.m., the DPCS stated the IDG members had a meeting every two weeks to discuss the patients concerns. The DPCS was asked which patients were discussed during each meeting. The DPCS stated the HA needed to come up with a system to document the patients names who were discussed during each IDG meeting. The DPCS stated she was not aware Patient 7 did not have a plan of care in place because it was never brought to her attention. A review of the HAs policy, titled ";Interdisciplinary Group Membership and Responsibilities," (Policy No. 4-001.1), revised November 2021, indicated the interdisciplinary group responsibilities include but are not limited to: A. Participation in the establishment of the plan of care for each patient admitted to the hospice service. B. Participation in the periodic review and updating of the plan of care for each patient receiving hospice services. A review of the HAs policy, titled ";Interdisciplinary Group Plan of Care," (Policy No. 4-031.1), revised November 2021, indicated the type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The policy also indicated the following: - Written evidence of care coordination will be found in the plan of care and/or interdisciplinary team meeting forms in the patients clinical record and will involve the hospice patients attending physician. The interdisciplinary group (in collaboration with the attending physician, if any) will conduct assessments, develop, and update the plan of care, and review the effectiveness of care a minimum of every 15 calendar days.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to provide medications necessary to meet the needs of two of 14 sampled patients (Patient 5 and Patient 7). This deficient practice had the potential to result in uncontrolled symptoms, which could affect the patients quality of life. --- Findings: During a review of Patient 5s Personal Information indicated a start of care (SOC) date of 4/2/2024, with a primary diagnosis of chronic (persisting for a long time or constantly recurring) diastolic congestive heart failure (a condition where the lower left chamber of the heart [left ventricle] is not able to fill properly with blood during the diastolic phase [when the heart relaxes and fills with blood], reducing the amount of blood pumped out to the body). During a review of Patient 5s Current Treatment/Medication/DME List indicated the HA last ordered Furosemide (medication to help treat fluid retention and swelling) 20 milligrams (mg, a unit of measurement) one tablet, Omeprazole (medication to treat certain conditions where there is too much acid in the stomach) 20 mg delayed-release tablet, and Potassium Chloride (a medication used in the management and treatment of hypokalemia [low potassium level]) 10 Milliequivalent (MEQ, a unit of measurement) for Patient 5 on 4/29/2024. During a review of Patient 5s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 5/30/2024, indicated the Skilled Nursing (SN; licensed nurse in general) visit frequency for Patient 5 was not written. The POC/IDG indicated, the SN was responsible for assessments, clinical care, and support as needed for ongoing evaluation pf patients condition). The POC/IDG indicated Patient 5 had an order for Registered Nurse (RN) visit for initial evaluation then every fourteen days thereafter for ongoing comprehensive assessment and supervisory visit. During a joint home visit observation on 6/11/2024, at 11 a.m., at Patient 5s residence on with the Administrator Designee/Licensed Vocational Nurse (AD/LVN), Patient 5 was observed alert and oriented and was walking using a walker (a type of mobility aid that provides stability and support while walking). During medication review on 6/11/2024, at 11:40 a.m., with the AD/LVN, the following medication containers were observed empty: Furosemide 20 mg one tablet daily. The label on the container indicated it was filled on 4/29/2024 with a quantity of 30 tablets. Omeprazole 20 mg one tablet daily. The label on the container indicated it was filled on 4/29/2024 with a quantity of 30 tablets. Potassium Chloride 10 MEQ, one tablet daily. The label on the container indicated it was filled on 4/29/2024 with a quantity of 30 tablets. During interview on 6/11/2024, at 11:50 a.m., with Patient 5., Patient 5 stated she did not remember how long the medication containers were empty. During an interview on 6/11/2024, at 12 p.m., with the AD/LVN, the AD/LVN stated the visiting nurses (in general) was responsible to check for the patients medication with every visit. The AD/LVN stated that by checking the patients medication with each visit, the nurse would find out if patient needed medication refill so that patient would not run out of medications. b. During a review of Patient 7s Personal Information, indicated a start of care (SOC) date of 3/1/2024, with a primary diagnosis of heart disease, unspecified (a type of disease that affects the heart). During a review of Patient 7s undated Current Treatment/Medication/DME List, indicated that Tradjenta (a medication to treat high blood sugar) 5 mg tablet was ordered on 6/6/2024 and Jardiance (a medication to treat high blood sugar) 25 mg tablet was ordered on 6/11/2024. During a joint home visit observation on 6/12/2024, at 1 p.m., at Patient 7s residence with the AD/LVN, Patient 7 was observed alert and oriented and was walking using a walker. During a medication review on 6/12/2024, at 1:35 p.m., with the AD/LVN was conducted. During the medication review, the survey team observed the containers for Tradjenta 5 mg tablet, one tablet daily, and Jardiance 25 mg tablet, one tablet daily, were empty. The label on Tradjenta 5 mg tablet was showing a fill date of 5/8/2024 and a quantity of 30 tablets, indicating Patient 7 would have the Tradjenta 5 mg supply until 6/7/2024. The label on Jardiance 25 mg tablet was showing a fill date of 4/23/2024 and a quantity of 30 tablets, indicating Patient 7 would have the Jardiance 25 mg supply until 5/23/2024. During an interview on 6/12/2024, at 2:10 p.m., with the AD/LVN, the AD/LVN stated the visiting nurses (in general) were responsible to check for Patient 7s medications every visit, so the nurse could reconcile (medication comparison) the medication list if patient had a new medication or a different medication dose. The AD/LVN stated that by checking patients medication with each visit, the nurse would find out if patient needed medication refill so that patient would not run out of medications. The AD/LVN stated that running out of diabetes (a medical condition characterized by the body's inability to regulate blood sugar levels) medications could have a negative effect for Patient 7, such as causing elevated blood glucose level. During a review of the HAs policy, titled ";Interdisciplinary Group Membership and Responsibilities," (Policy No. 4-001.1), revised November 2021, indicated the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) responsibilities include but are not limited to: Provision and/or supervision and coordination of hospice care and services.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide three of 14 sampled patients (Patient 5, Patient 7, and Patient 10) with necessary medical supplies. This deficient practice had the potential not to meet the medical needs of Patient 5, Patient 7, and Patient 10). --- a. A review of Patient 5s ";Personal Information" indicated a start of care (SOC) date of 4/2/2024, with a primary diagnosis of chronic (persisting for a long time or constantly recurring) diastolic congestive heart failure (a condition where the lower left chamber of the heart [left ventricle] is not able to fill properly with blood during the diastolic phase [when the heart relaxes and fills with blood], reducing the amount of blood pumped out to the body). Over time, this causes blood to build up inside the left atrium, and then in the lungs, leading to fluid congestion and symptoms of heart failure. A review of Patient 5s ";Current Treatment/Medication/DME List" indicated oxygen at 2 liters per minute via nasal cannula (a medical device used to deliver supplemental oxygen to patients who need additional oxygen support) as needed for shortness of breath. During a joint home visit observation at Patient 5s residence on 6/11/2024, at 11 a.m., with the Administrator Designee (AD)/Licensed Vocational Nurse (LVN, Patient 5 was observed alert and oriented and was walking using a walker (a type of mobility aid that provides stability and support while walking). During an interview with Patient 5 on 6/11/2024 at 11:30 a.m., Patient 5 stated she would use the oxygen concentrator (a medical device that separates nitrogen from the air so a person can breathe up to 95% pure oxygen) as needed, usually at nighttime. When Patient 5 was asked to show the nasal cannula, she was not able to find one. During an interview with the AD on 6/11/2024 at 12 p.m., the AD stated it was important to ensure that Patient 5 had nasal cannula available, so that she could use the oxygen concentrator when she needed it. A review of ";Visit Note LVN" for Patient 5, dated 5/7/2024, 5/14/2024, 5/21/2024, and 5/28/2024, indicated there was no documentation on whether the nurse who visited Patient 5 on those dates ensure if nasal cannula was available at Patient 5s residence. b. A review of Patient 7s ";Personal Information" indicated a start of care (SOC) date of 3/1/2024, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). During a telephone interview on 6/11/2024 at 4 p.m. with Patient 7 in his native language (Spanish), Patient 7 stated he had high blood pressure (a condition in which the force of the blood against the artery [blood vessel] walls is too high) and diabetes (a chronic disease characterized by elevated levels of blood glucose in the blood). During a joint home visit observation at Patient 7s residence on 6/12/2024, at 1 p.m., with the Administrator Designee (AD)/Licensed Vocational Nurse (LVN, Patient 7 was observed alert and oriented and was walking using a walker. During an interview with Patient 7 on 6/13/2024 at 1:45 p.m. in his native language (Spanish), Patient 7 stated he did not know how to check his blood sugar, and his wife was the one checking his blood sugar. A glucometer (a medical device for determining the approximate concentration of glucose in the blood), lancet device (a small, sharp, spring-loaded device that takes small blood samples), and glucometer strips (disposable strips that react with blood glucose and are used with a glucometer to measure blood glucose levels) were observed at Patient 7s residence. There was no sharps container (containers made from rigid puncture-resistant plastic or metal with leak-resistant sides and bottom, and a tight-fitting, puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter) observed. Patient 7 stated the HA did not provide him with a sharps container. When Patient 7 was asked how his wife disposed of the used lancet after checking his blood sugar, Patient 7 stated that his wife would recap the used lancet before disposing in in the trash can. During an interview with the AD on 6/12/2024 at 2:05 p.m., the AD stated that disposing used lancet in the trash presented a risk for injury and infection. The AD stated that Patient 7 should have been provided with a sharps container to prevent injury and infection. A review of the HAs policy, titled ";Interdisciplinary Group Plan of Care," (Policy No. 4-031.1), revised November 2021, indicated that core hospice services (nursing, social work, physician, and counselors) will be available 24 hours a day, 7 days a week, as will be drugs, biologicals, and medical supplies. .C. A review of Patient 10s untitled admission sheet, indicated a start of care date on 3/24/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). During a joint home visit observation and at Patient 10s (P10) residence on 6/11/2024, at 11:00 a.m., with the Licensed Vocational Nurse 2 (LVN2), Patient 10 was observed alert and oriented and was walking using a walker (a type of mobility aid that provides stability and support while walking). At 11:21 a.m., during interview with Patient 10, P10 stated, in his native language (Spanish), that he is still under his own Primary Care Physician (PCP) and he check his blood sugar daily, and a glucometer (a medical device for determining the approximate concentration of glucose in the blood), lancet device (a small, sharp, spring-loaded device that takes small blood samples), and glucometer strips (disposable strips that react with blood glucose and are used with a glucometer to measure blood glucose levels) were observed at Patient 10s residence. When asked how does P10 dispose his used trips and lancets (is a small, sharp needle used to prick the skin and draw blood), P10 stated that he put it in a glass jar and he stated that there was no sharps container (containers made from rigid puncture-resistant plastic or metal with leak-resistant sides and bottom, and a tight-fitting, puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter). Patient 10 stated the HA did not provide him with a sharps container. During an interview with the AD on 6/12/2024 at 2:05 p.m., the AD stated that disposing used lancet in the trash presented a risk for injury and infection. The AD stated that Patient 10 should have been provided with a sharps container to prevent injury and infection.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) participated in the plan of care of 13 of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This deficient practice had the potential to affect the patients care. --- A review of Patient 1s record untitled admission sheet, indicated a start of date on 2/14/2023 with a primary diagnosis of heart disease (a chronic disease of the heart), unspecified. During a concurrent interview and record review on 6/13/2024 at 1:50 PM with the Director of Patient Care Services (DPCS) of Patient 1s Clinical record, titled Visit Notes and dated 5/30/2024, 5/22/2024, 5/16/2024, 5/7/2024 and 4/30/2024, there were no signatures on Hospice MD indicating who completed the document. The DPCS stated she wasnt sure why on Hospice MD there were not signatures but on the printed Visiting Notes that were given on 6/11/2024 there were signatures. Further review of Patient 1s Electronic Medical Record (EMR) indicated there were no signatures for the IDGs on 5/30/2024, 5/16/2024, 4/18/2024, and 4/4/2024. The DPCS stated she was not sure why not everyone had signed the IDG notes. A review of Patient 2s record untitled admission sheet, indicated a start of date on 3/1/2024 with a primary diagnosis of heart disease (a chronic disease of the heart), unspecified. During a concurrent interview and record review on 6/13/2024 at 1:50 PM with DPCS of Patient 2s Clinical record, titled Visit Notes and dated 5/28/2024, 5/21/2024, 5/14/2024, 5/7/2024, and 4/30/2024, there were no signatures on Hospice MD indicating who completed the document. The DPCS stated she wasnt sure why on Hospice MD there were not signatures but on the printed Visiting Notes that were given on 6/11/2024 there were signatures. Further review of Patient 2s Electronic Medical Record (EMR) indicated there were no signatures for the IDGs on 4/14/2024. The DPCS stated she was not sure why not everyone had signed the IDG notes. A review of Patient 3s record untitled admission sheet, indicated a start of date on 5/20/2024 with a primary diagnosis of heart disease (a chronic disease of the heart), unspecified. During a concurrent interview and record review on 6/13/2024 at 1:50 PM with DPCS of Patient 3s Clinical record, titled Visit Notes and dated 5/30/2024 and 5/23/2024 there were no signatures on Hospice MD indicating who completed the document. The DPCS stated she wasnt sure why on Hospice MD there were not signatures but on the printed Visiting Notes that were given on 6/11/2024 there were signatures. Further review of Patient 3s Electronic Medical Record (EMR) indicated there were no signatures for the IDGs on 5/30/2024 and 5/20/2024. The DPCS stated she was not sure why not everyone had signed the IDG notes. A review of Patient 4s record untitled admission sheet, indicated a start of date on 11/4/2023 with a primary diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important functions), unspecified. During a concurrent interview and record review on 6/13/2024 at 1:50 PM with DPCS of Patient 4s Clinical record, titled Visit Notes and dated 12/18/2023, 12/17/2023, 12/16/2023, 12/8/2023, 12/6/2023, 11/28/2023, 11/21/2023, and 11/14/2023 there were no signatures on Hospice MD indicating who completed the document. The DPCS stated she wasnt sure why on Hospice MD there were no signatures. Further review of Patient 4s Electronic Medical Record (EMR) indicated there were no signatures for the IDGs on 12/28/2023, 12/14/2023, 11/30/2023, 11/6/2023, and 11/4/2023. The DPCS stated she was not sure why not everyone had signed the IDG notes. During a review of the facilitys policy and procedure titled, ";Clinical Record Review" dated November 2021 the Clinical Record Review indicated, ";the final documented report must be signed by the clinician who conducted the patient care to ensure accountability and accuracy." 2e. A review of Patient 5s ";Personal Information" indicated a start of care (SOC) date of 4/2/2024, with a primary diagnosis of chronic (persisting for a long time or constantly recurring) diastolic congestive heart failure (a condition where the lower left chamber of the heart [left ventricle] is not able to fill properly with blood during the diastolic phase [when the heart relaxes and fills with blood], reducing the amount of blood pumped out to the body). Over time, this causes blood to build up inside the left atrium, and then in the lungs, leading to fluid congestion and symptoms of heart failure. During a concurrent record review and interview with the DPCS on 6/14/2024 at 11:20 a.m., the DPCS reviewed Patient 5s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 4/4/2024, 4/18/2024, 5/2/2024, 5/16/2024, and 5/30/2024. The DPCS verified the POC/IDG Reviews for the above dates were missing the Medical Directors (MD) and Chaplains signatures. 2f. A review of Patient 6s ";Personal Information" indicated a start of care (SOC) date of 3/11/2024, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). During a concurrent record review and interview with the Administrator Designee (AD) on 6/14/2024 at 11:30 a.m., the AD reviewed Patient 6s ";Plan of Care/Interdisciplinary Group Review," dated 5/30/2024, 5/16/2024, 5/2/2024, and 4/18/2024. The DPCS verified the POC/IDG Reviews for the above dates were not signed by any of the IDG members. 2g. A review of Patient 7s ";Personal Information" indicated a start of care (SOC) date of 3/1/2024, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). During a concurrent record review and interview with the AD on 6/12/2024 at 2:15 p.m., the AD reviewed Patient 7s ";Plan of Care/Interdisciplinary Group Review," dated 5/30/2024, 5/16/2024, 5/2/2024, 4/18/2024, 4/4/2024, 3/7/2024, and 3/1/2024. The AD confirmed there was no plan of care generated for Patient 7 since his admission date of 3/1/2024, and therefore the POC/IDG Review for the dates above were not signed by any of the IDG members. h. A review of Patient 8s ";Personal Information" indicated a start of care (SOC) date of 8/18/2023, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). During a concurrent record review and interview with the AD on 6/14/2024 at 11:40 a.m., the AD reviewed Patient 8s ";Plan of Care/Interdisciplinary Group Review," dated 5/30/2024. The DPCS verified the POC/IDG Reviews for the above date was not signed by any of the IDG members. The HAs ";IDG Meeting Sign-In Sheet" was reviewed for the following dates: 5/30/2024, 5/16/2024, 5/2/2024, 4/18/2024, 4/4/2024, 3/21/2024, and 3/7/2024. There was no documentation which patients were being discussed on each IDG meeting. During an interview on 6/15/2024 at 1:15 p.m., the DPCS stated the IDG members had a meeting every two weeks to discuss the patients concerns. The DPCS was asked which patients were discussed during each meeting. The DPCS stated the HA needed to come up with a system to document the patients names who were discussed during each IDG meeting. A review of the HAs policy, titled ";Interdisciplinary Group Membership and Responsibilities," (Policy No. 4-001.1), revised November 2021, indicated the interdisciplinary group responsibilities include but are not limited to: A. Participation in the establishment of the plan of care for each patient admitted to the hospice service. B. Participation in the periodic review and updating of the plan of care for each patient receiving hospice services. A review of the HAs policy, titled ";Interdisciplinary Group Plan of Care," (Policy No. 4-031.1), revised November 2021, indicated the type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The policy also indicated the following: - Written evidence of care coordination will be found in the plan of care and/or interdisciplinary team meeting forms in the patients clinical record and will involve the hospice patients attending physician. The interdisciplinary group (in collaboration with the attending physician, if any) will conduct assessments, develop, and update the plan of care, and review the effectiveness of care a minimum of every 15 calendar day I. A review of Patient 10s untitled admission sheet, indicated a start of care date on 3/24/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). A review of Patient 10s Plan of Care/Interdisciplinary Group review dated 3/24/24, 4/4/24, 4/18/24, 5/2/24, 5/16/24 and 5/30/24, indicated incomplete IDG signatures from IDG team attendees (Medical Director, Medical Social Worker, Registered Nurse and Chaplain) and no documented evidence of an evaluation of Patient 10s response to care, treatment, services provided and there was no progress toward desired outcome documented every 14 days. J. A review of Patient 11s untitled admission sheet, indicated a start of care date on 2/14/2023 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). A review of Patient 11s Plan of Care/Interdisciplinary Group review dated 4/4/24, 4/18/24, 5/2/24, 5/16/24 and 5/30/24, indicated incomplete IDG signatures from IDG team attendees (Medical Director, Medical Social Worker, Registered Nurse and Chaplain) and no documented evidence of an evaluation of Patient 11s response to care, treatment, services provided and there was no progress toward desired outcome documented every 14 days. K. A review of Patient 12s untitled admission sheet, indicated a start of care date on 3/4/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). On 6/13/2024, at 1:58 p.m., during a concurrent review and interview with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 12s clinical record titled ";POC (Plan of Care)/IDG (Interdisciplinary) Review (is a team consists of the doctor, social worker, registered nurse and spiritual chaplain which is responsible for development and review of the patient's plan of care), dated 5/30/2024, indicated no plan of care that address for P12s diagnosis for diabetes mellitus (uncontrolled blood sugar levels), diabetic ulceration (a serious complication caused by a combination of poor circulation, sensitive to infection and nerve damage from high blood sugar levels) and pain management. Upon further review of P12s POC/IDG Review dated, and, indicated incomplete IDG signatures from IDG team attendees (Medical Director, Medical Social Worker, Registered Nurse and Chaplain), no documented evidence of an evaluation of Patient 12s response to care, treatment, services provided and there was no progress toward desired outcome documented every 15 days. ADM/DPCS confirmed that there were no care plans formulated to address P12s problems and stated a care plan should have been made and discussed in the IDG meetings to better manage P12s potential and existing problems, also confirmed and stated that there were no signatures of the IDG members of P12s POC/IDG records dated 4/4/24, 4/18/24, 5/2/24, 5/16/24,5/30/24 and 5/30/24, she further stated that IDG members should sign to their respective discipline to validate their discussions and documentations regarding P12s potential/existing problems. L. A review of Patient 13s untitled admission sheet, indicated a start of care date on 5/1/2024 and end of care date of 5/15/24, with a primary diagnosis of Heart disease, unspecified (is a general term that describes a disease of the heart or blood vessels). A review of Patient 13s Plan of Care/Interdisciplinary Group review dated 5/1/24, indicated incomplete IDG signatures from IDG team attendees (Medical Director, Medical Social Worker, Registered Nurse and Chaplain) and no documented evidence of an evaluation of Patient 13s response to care, treatment, services provided and there was no progress toward desired outcome documented every 14 days. M. A review of Patient 14s untitled admission sheet, indicated a start of care date on 5/7/2023 and end of care date of 2/10/24, with a primary diagnosis of Cerebral Infarct (occurs as a result of interrupted blood flow to the brain due to problems with the blood vessels that supply it, a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). A review of Patient 14s Plan of Care/Interdisciplinary Group review dated 11/30/24, 12/14/23, 1/11/24, 1/25/24 and 2/8/24, indicated incomplete IDG signatures from IDG team attendees (Medical Director, Medical Social Worker, Registered Nurse and Chaplain) and no documented evidence of an evaluation of Patient 114s response to care, treatment, services provided and there was no progress toward desired outcome documented every 14 days. On 6/13/24, at 11:50 a.m., during a telephone interview with the Medical Director (MD), he stated that whenever the hospice agency staff bring him the certification, he signs the paper. He stated that he is not good with computers. He stated that the hospice nurses have his permission to log into the Hospice MD electronic medical record system and sign his name in the CTI (Certificate of Terminal Illness). He stated that he has not logged in to the computer and he did not sign any IDGs in the Hospice MD. MD stated that he has not given a specimen of his signature to the hospice agency. MD stated that the IDG members met every other week to discuss patients needs, goals and developments. MD stated that they have an attendance sign in sheet for all the members present during the meeting. On 6/13/24, at 1:35 p.m., During an interview with the Director of Patient Care Services (DPCS) stated the IDG members including, the registered nurse, doctor, social worker, and chaplain were required to attend the meetings, stated it was important to document the findings in the IDG meetings in the patients, record to know what the needs of the patient were and what information the group needs to know to follow up on. DPCS stated that they have an attendance sign in sheet for every meeting. During concurrent review with the DPCS of the hospice agencys ";IDG Meeting" sign in sheet log folder, it indicated the signatures of the disciplines (Medical Director, Registered Nurse, Spiritual Chaplain and Medical Social Worker) attended the meetings on the following dates: 3/7/24,3/21/24, 4/4/24, 4/18/24, 5/2/24, 5/16/24 and 5/30/24 but the DPCS was unable to provide the list of the patients that were discussed in the meetings. DPCS stated that the patients were discussed alternately on every IDG meetings and we supposed to have the list of the patients that were discussed during the meetings to ensure we did not missed or forgot the patients that was not included in the previous meetings. A review of the hospice agencys policy and procedure titled ";Interdisciplinary Group Membership and Responsibilities", revised date of November 2021, indicated that the interdisciplinary group will collaborate with the patients attending physician to develop an individualized written plan of care.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to follow infection control practices related to the disposal of contaminated waste for two of 14 sampled patients (Patient 7 and Patient 10). This deficient practice had the potential to expose Patient 7 and Patient 10 and their caregivers to infections caused by blood-borne pathogens (germs in human blood). --- a. A review of Patient 7s ";Personal Information" indicated a start of care (SOC) date of 3/1/2024, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). During a telephone interview on 6/11/2024 at 4 p.m. with Patient 7 in his native language (Spanish), Patient 7 stated he had high blood pressure (a condition in which the force of the blood against the artery [blood vessel] walls is too high) and diabetes (a chronic disease characterized by elevated levels of blood glucose in the blood). During a joint home visit observation at Patient 7s residence on 6/12/2024, at 1 p.m., with the Administrator Designee (AD)/Licensed Vocational Nurse (LVN, Patient 7 was observed alert and oriented and was walking using a walker. During an interview with Patient 7 on 6/13/2024 at 1:45 p.m. in his native language (Spanish), Patient 7 stated he did not know how to check his blood sugar, and his wife was the one checking his blood sugar. A glucometer (a medical device for determining the approximate concentration of glucose in the blood), lancet device (a small, sharp, spring-loaded device that takes small blood samples), and glucometer strips (disposable strips that react with blood glucose and are used with a glucometer to measure blood glucose levels) were observed at Patient 7s residence. There was no sharps container (containers made from rigid puncture-resistant plastic or metal with leak-resistant sides and bottom, and a tight-fitting, puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter) observed. Patient 7 stated the HA did not provide him with a sharps container. When Patient 7 was asked how his wife disposed of the used lancet after checking his blood sugar, Patient 7 stated that his wife would recap the used lancet before disposing in in the trash can. During an interview with the AD on 6/12/2024 at 2:05 p.m., the AD stated that disposing used lancet in the trash presented a risk for injury and infection. The AD stated that Patient 7 should have been provided with a sharps container to prevent injury and infection. A review of the HAs policy, titled ";Contaminated Waste Disposal," (Policy No. 6-010.1), revised November 2021, indicated the following: - Personnel will teach patients and family/caregivers proper contaminated waste disposal. - Needles, syringes, and razor blades should be placed in a puncture-prrof container and labeled as contaminated waste when ¾ full. Puncture-proof containers should be bagged, secured, and returned to the office for disposal. Never recap needles. B. A review of Patient 10s untitled admission sheet, indicated a start of care date on 3/24/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). During a joint home visit observation and at Patient 10s (P10) residence on 6/11/2024, at 11:00 a.m., with the Licensed Vocational Nurse 2 (LVN2), Patient 10 was observed alert and oriented and was walking using a walker (a type of mobility aid that provides stability and support while walking). At 11:21 a.m., during interview with Patient 10, P10 stated, in his native language (Spanish), that he is still under his own Primary Care Physician (PCP) and he check his blood sugar daily, and a glucometer (a medical device for determining the approximate concentration of glucose in the blood), lancet device (a small, sharp, spring-loaded device that takes small blood samples), and glucometer strips (disposable strips that react with blood glucose and are used with a glucometer to measure blood glucose levels) were observed at Patient 10s residence. When asked how does P10 dispose his used trips and lancets (is a small, sharp needle used to prick the skin and draw blood), P10 stated that he put it in a glass jar and he stated that there was no sharps container (containers made from rigid puncture-resistant plastic or metal with leak-resistant sides and bottom, and a tight-fitting, puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter). Patient 10 stated the HA did not provide him with a sharps container. During an interview with the AD on 6/12/2024 at 2:05 p.m., the AD stated that disposing used lancet in the trash presented a risk for injury and infection. The AD stated that Patient 10 should have been provided with a sharps container to prevent injury and infection.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation for Medical Director was met as follow: --- The HA failed to ensure, the medical director conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial certifications for five of fourteen sampled patients ( Patient 7, Patient 8, Patient 10, Patient 11 and Patient 12) to support diagnosis of the patients' terminal illnesses (a health condition that cannot be cured) and 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. The HA failed to ensure there were documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice care and services. (Refer to L667). 2. The HA failed to ensure, the medical director to assume responsibility for the medical component of the hospices patient care program for seven of fourteen sampled patients (Patient 5, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11 and Patient 12). (Refer to L 669). 3. The Hospice Agencys (HA) Medical Director (MD) or physician designee failed to conduct a face-to-face encounter prior to the start of the third episode and prior to each subsequent recertification of hospice services for two of fourteen sampled patients (Patient 7 and Patient 8). (Refer to L668).

Based on observation, interview and record review the Hospice Agency (agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Medical Director conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial Certification of illness (CTI) to support diagnosis of the patients' terminal illnesses and to qualify for hospice care for five of fourteen sample patients (Patient 7, Patient 8, Patient 10, Patient 11 and Patient 12). The HA did not have documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice care and services. This deficient practice resulted in patient being enrolled in hospice and receiving care without a proper verification of patient eligibility and had the potential for Patient 7, Patient 8, Patient 10, Patient 11, and Patient 12 not to receive the necessary care and healthcare resources to meet their care goals. --- a. A review of Patient 7s ";Personal Information" indicated a start of care (SOC) date of 3/1/2024, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). During a telephone interview on 6/11/2024 at 4 p.m. with Patient 7 in his native language (Spanish), Patient 7 stated he was never diagnosed with heart disease, nor was he ever diagnosed with a terminal illness. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 6/13/2024 at 1:50 p.m., the DPCS confirmed that initial comprehensive assessment on 3/1/2024 for Patient 7 was not completed. The DPCS also reviewed ";LCD (Local Coverage Determination) Hospice Eligibility Determination," dated 3/1/2024, for Patient 7. LCD is used by hospice providers to determine eligibility for beneficiaries for hospice benefits. The DPCS verified that based on the LCD reviewed, Patient 7 did not qualify to receive hospice services. The DPCS stated the Registered Nurse who was responsible to conduct initial comprehensive assessment was supposed to complete the LCD based on his or her assessment. The DPCS stated that since the initial comprehensive assessment for Patient 7 was not completed, thus disqualifying Patient 7 to receive hospice benefits. During this time, the survey team requested the DPCS to provide clinical documentation that would support Patient 7s terminal diagnosis. A review of Patient 7s ";Physicians Certification for Hospice Benefit," dated 5/30/2024 to 7/28/2024, indicated Patient 7 was certified based on face to face encounter, however the ";Face to Face Narrative" was blank. The ";Medical Director/Hospice Physician Designee/Attending Physician Attestation/Certification stated, ";I attest/confirm that I composed this narrative based on my review of patients medical records, team assessment, and or examination of the patient." There were no physician signature and date on the signature and date line. b. A review of Patient 8s ";Personal Information" indicated a start of care (SOC) date of 8/18/2023, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). During a telephone interview with Patient 8 on 6/11/2024 at 3:40 p.m., Patient 8 stated that he did have heart disease or terminal illness. Patient 8 stated that he had never been told by a physician that he had 6 months or less to live. Per Patient 8, he had high blood pressure. Patent 8 stated he did not have a Primary Care Physician (PCP; a medical doctor trained to prevent, diagnose, and treat a wide range of illnesses and injuries in the general population). Patient 8 stated that he was last seen by a physician when he went to the Emergency Room (ER), about six months ago. During the same interview, Patient 8s primary caregiver (PCG 1) stated the nurse who signed Patient 8 up for the hospice services told them that hospice was for people with long-term (chronic) illness. PCG 1 stated that Patient 8 had high blood pressure, which was a long term illness. PCG 1 stated he was with Patient 8 when he signed the hospice paperwork. During a concurrent record review and interview with the DPCS on 6/13/2024 at 2 p.m., the DPCS reviewed Patient 8s LCD, dated 5/10/2024. The survey team requested the DPCS to provide clinical documentation that would support Patient 8s terminal diagnosis. A review of Patient 8s ";Physicians Certification for Hospice Benefit," dated 4/14/2024 to 6/12/2024, indicated Patient 8 was certified through face to face encounter, however the ";Face to Face Narrative" was blank. The ";Medical Director/Hospice Physician Designee/Attending Physician Attestation/Certification stated, ";I attest/confirm that I composed this narrative based on my review of patients medical records, team assessment, and or examination of the patient." There were no physician signature and date on the signature and date line. During an interview with the Medical Director (MD) on 6/13/2024 at 11:50 a.m., the MD stated that verifying the patients eligibility, including ensuring that patient had clinical documentation that supported the terminal diagnosis prior to enrolling the patient to hospice was the HAs responsibility, not his. The MD stated that he did not review patients clinical information because it should have been done by the HA. The MD stated he would write his narrative for the ";Physicians Certification for Hospice Benefit" and sign it himself. The MD also stated that if he had had a face to face encounter with a patient, he would have documented his assessment and signed it. On 6/16/2024 at 12:35 p.m., the DPCS stated the HA was not able to provide the clinical documentation to support Patient 7s and Patient 8s terminal diagnosis as requested by the survey team on 6/13/2024. A review of a document provided by the HA regarding the job description of ";Hospice Medical Director," revised November 2021, indicated the Hospice Medical Director will have overall responsibility for the medical component of the hospice program. The Hospice Medical Director responsibilities will include but not limited to the following: - Adhering to requirements, terms, and conditions required by Medicare Conditions of Participation, accrediting body, and federal and state statutes governing the provision of services. - Reviewing patients medical eligibility for hospice services, in accordance with hospice program and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness. - Documenting care provided in the patients clinical record, providing evidence of progression of the end-stage disease process. C. A review of Patient 10s untitled admission sheet, indicated a start of care date on 3/24/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). A review of Patient 10s clinical record titled ";Comprehensive Assessment", dated 3/24/2024, indicated in the Activities of Daily Living (ADL, activities related to personal care which include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) Assessment the total number of activities with complete dependence (0-6) was 2 out six, and that Patient 10 was dependent to ambulation and transfer. Patient 10's Comprehensive Assessment indicated that Patient 10 required a walker for movement with maximum assist, has mild dyspnea (difficulty in breathing) with mild exertion, clear lung sounds, normal respirations, and pitting edema (characterized by an excess of watery fluid collecting in the cavities or tissues of the body) in bilateral lower extremities. A review of Patient 10s clinical record titled ";Physicians Certification for Hospice Benefit", with date of certification of 3/24/2024 to 6/21/2024, indicated Patient 10s ability to carry out daily activities prognosis, scores (range from 0 to 100, a higher score means the patient is better able to carry out daily activities). Patient 10s score was determined as 50 percent. A review of Patient 10s ";Physicians Certification for Hospice Benefit," dated 3/24/2024 to 6/21/2024, indicated Patient 10 was certified and The ";Medical Director/Hospice Physician Designee/Attending Physician Attestation/Certification stated, ";I attest/confirm that I composed this narrative based on my review of patients medical records, team assessment, and or examination of the patient." It further indicated that there were no physician signature and date on the signature and date line. D. A review of Patient 11s untitled admission sheet, indicated a start of care date on 2/14/2023 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). A review of Patient 11s clinical record titled ";Updated Assessment", dated 5/20/2024, indicated in the Activities of Daily Living (ADL, activities related to personal care which include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) Assessment the total number of activities with complete dependence (0-6) was 5 out six, and that Patient 11 was dependent to ambulation, toileting, transfer, dressing and bathing. Patient 11's Updated Assessment indicated that Patient 11s ";Mobility" section was checked marked as ";Stand-By Assist" and ";Maximum Assist, has moderate dyspnea (difficulty in breathing) with mild exertion, clear lung sounds, normal respirations, and no edema (characterized by an excess of watery fluid collecting in the cavities or tissues of the body). On 6/12/24, at 10:50 a.m., during a telephone interview with P11 and his wife (FM1), FM1 stated that her husband speaks in his native language (Spanish) only. FM1 stated that P11 still sees his own primary care doctor, and the hospice program was not explained to them completely by the hospice nurse. FM1 stated that they received a call one day from a lady, stated she forgot her name and offered them a program for the elder people to get a free medical supply, lower co-pays for their medications and free nurse visits. FM1 stated that they are not aware of her spouse P11 has a terminal illness, she stated he does not have a terminal illness and he is not dying in 6 months or less, she stated it was not explained to them by the hospice nurses. FM1 stated that the documents that were signed was in English language, and they preferred that it should be in their native language (Spanish). FM1 stated she does not remember any more if an Spanish interpretation by a nurse was done during her husbands (P11) admission. During a concurrent record review and interview with the DPCS on 6/13/2024 at 2:00 p.m., the DPCS reviewed Patient 11s LCD, dated 6/8/2024, DPCS stated that in P11s LCD, P11 is eligible per LCD Guidelines, when asked regarding her understanding of NYHA Classification, DPCS stated that to be able for a patient to meet the condition, the patient should be unable to carry on physical activity without discomfort and symptoms of shortness of breath or diminished lung sounds must be present even at rest. DPCS stated she completed P11s ";Updated Assessment" dated 5/20/24, when asked if a clear lung sounds, normal respirations and no edema are expected to a patient with NYHA classification, DPCS stated no and it depends if the patients condition is improving, if a patients condition is improving then the patient must be re-evaluated if the prognosis improved. The survey team requested the DPCS to provide clinical documentation that would support Patient 11s terminal diagnosis. E. A review of Patient 12s untitled admission sheet, indicated a start of care date on 3/4/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). During a joint home visit on 6/12/2024 at 1:00 p.m. with the Administrator Designee (AD), who is a Licensed Vocational Nurse, to Patient 7 (Patient 12s spouse) and Patient 12s home, Patient 7 stated that Patient 12 is sleeping and resting because she was just discharged from the hospital few days ago for right leg and foot pain. Patient 12 was not available for interview. On 6/13/2024 at 2:53 p.m., a telephone call to P12 was made but was unsuccessful. A review of Patient 12s ";Physicians Certification for Hospice Benefit," dated 3/4/2024 to 6/1/2024, indicated Patient 12 was certified and the Medical Director (MD) as the Referring Physician. It further indicated that there were no physician signature and date on the signature and date line. During an interview with the Medical Director (MD) on 6/13/2024 at 11:50 a.m., the MD stated that verifying the patients eligibility, including ensuring that patient had clinical documentation that supported the terminal diagnosis prior to enrolling the patient to hospice was the HAs responsibility, not his. The MD stated that he did not review patients clinical information because it should have been done by the HA. The MD stated he would write his narrative for the ";Physicians Certification for Hospice Benefit" and sign it himself. The MD also stated that if he had had a face-to-face encounter with a patient, he would have documented his assessment and signed it. On 6/16/2024 at 12:35 p.m., the DPCS stated the HA was not able to provide the clinical documentation to support Patient 10, 11 and 12's terminal diagnoses as requested by the survey team on 6/13/2024.

Based on interview and record review, the Hospice Agencys (HA agency providing care to terminally ill patients who have six months or less to live) Medical Director (MD) or physician designee failed to conduct a face-to-face encounter prior to the start of the third episode and prior to each subsequent recertification of hospice services for two of fourteen sampled patients (Patient 7 and Patient 8). This deficient practice resulted in Patient 7 and Patient 8 not evaluated by a qualified physician to determine the patients continued eligibility to receive hospice services. --- a. A review of Patient 7s ";Personal Information" indicated a start of care (SOC) date of 3/1/2024, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). A review of Patient 7s ";Physicians Certification for Hospice Benefit (CTI)," for the date of certification from 5/30/2024 to 7/28/2024, indicated that Patient 7 was currently in the third hospice certification episode. The document indicated that Patient 7 was certified based on face to face encounter, however the ";Physician Narrative: Face to Face Narrative" was blank. The CTI was not signed by the certifying physician. A review of Patient 7s "Face to Face Visit Notes List" indicated there was no face-to-face physician encounter documented since admission; the entire ";Face to Face Visit Notes List" was blank. b. A review of Patient 8s ";Personal Information" indicated a start of care (SOC) date of 8/18/2023, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). A review of Patient 8s ";Physicians Certification for Hospice Benefit (CTI)," for the date of certification from 2/14/2024 to 4/13/2024, indicated that Patient 8 was in the third hospice certification episode during that timeframe. The document indicated that Patient 8 was certified based on face to face encounter, however the ";Physician Narrative: Face to Face Narrative" was blank. The CTI was not signed by the certifying physician. A review of Patient 8s ";Physicians Certification for Hospice Benefit (CTI)," for the date of certification from 4/14/2024 to 6/12/2024, indicated that Patient 8 was currently in the fourth hospice certification episode. The document indicated that Patient 8 was certified based on face to face encounter, however the ";Physician Narrative: Face to Face Narrative" was blank. The CTI was not signed by the certifying physician. A review of Patient 8s ";Face to Face Visit Notes List" indicated there was no face-to-face physician encounter documented since admission; the entire ";Face to Face Visit Notes List" was blank. During a telephone interview with the MD on 6/13/2024 at 11:50 a.m., the MD stated he was familiar with the electronic health record (EHR) system used by the HA and knew how to document in a patients chart. The MD stated he always personally documented and signed his assessment under the CTI, if he saw and assessed the patient. The MD stated he could not particularly remember if he had a face-to-face encounter with Patient 7 and Patient 8. According to the MD, the HA would arrange a home visit for him when it was time to see a patient. During an interview with the Director of Patient Care Services (DPCS) on 6/13/2024 at 2:05 p.m., the DPCS stated that face-to-face encounter with the hospice physician was required prior to the start of a patients third recertification episode by the Centers for Medicare and Medicaid Services (CMS, a federal agency that provides health coverage through Medicare, Medicaid, the Children's Health Insurance Program, and the Health Insurance Marketplace). The DPCS stated she was not aware there was no documentation of no face-to-face encounter for Patient 7 and Patient 8. A review of a document provided by the HA regarding the job description of ";Hospice Medical Director," revised November 2021, indicated the Hospice Medical Director will have overall responsibility for the medical component of the hospice program. The Hospice Medical Director responsibilities will include but not limited to the following: - Adhering to requirements, terms, and conditions required by Medicare Conditions of Participation, accrediting body, and federal and state statutes governing the provision of services. - Perform face-to-face encounters within thirty (30) days of the third and subsequent hospice benefit certification periods and attest to the encounter. - Documenting care provided in the patients clinical record, providing evidence of the progression of the end-stage disease process.

Based on interview and record review, the Hospice Agencys (HA, agency providing care to terminally ill patients who have six months or less to live) failed to assume responsibility for the medical component of the hospices patient care program for six of fourteen sampled patients (Patient 5, Patient 7, Patient 8, Patient 10, Patient 11, and Patient 12). This deficient practice resulted in patients being enrolled to the HA without oversight of the implementation of the hospice services to ensure the patients and patients familys needs were being met. --- a. A review of Patient 5s ";Personal Information" indicated a start of care (SOC) date of 4/2/2024, with a primary diagnosis of chronic (persisting for a long time or constantly recurring) diastolic congestive heart failure (a condition where the lower left chamber of the heart [left ventricle] is not able to fill properly with blood during the diastolic phase [when the heart relaxes and fills with blood], reducing the amount of blood pumped out to the body). Over time, this causes blood to build up inside the left atrium, and then in the lungs, leading to fluid congestion and symptoms of heart failure. During a joint home visit observation at Patient 5s residence on 6/11/2024, at 11 a.m., with the Administrator Designee (AD)/Licensed Vocational Nurse (LVN, Patient 5 was observed alert and oriented and was walking using a walker (a type of mobility aid that provides stability and support while walking). Patient was observed breathing with no shortness of breath, without supplemental oxygen. During an interview with Patient 5 on 6/11/2024 at 11:25 a.m., Patient 5 stated she was never diagnosed with terminal illness by her physician, nor was she ever informed by her physician that she had six months or less to live. Patient 5 stated she was offered to be enrolled to the HA by the AD, which she knew when her late husband, who was on hospice, lived in a board and care facility (a residential care option catering to individuals requiring assistance with daily living activities). Patient 5 stated, ";I just tagged along," when she was asked who referred her to the HA. During a concurrent record review and interview with the DPCS on 6/13/2024 at 1:35 p.m., the DPCS reviewed Patient 5s LCD (Local Coverage Determination), dated 5/28/2024. LCD is used by hospice providers to determine eligibility for beneficiaries for hospice benefits. The DPCS confirmed that Patient 5s terminal diagnosis was heart disease. The survey team requested the DPCS to provide clinical documentation that would support Patient 5s terminal diagnosis. b. A review of Patient 7s ";Personal Information" indicated a start of care (SOC) date of 3/1/2024, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). During a telephone interview on 6/11/2024 at 4 p.m. with Patient 7 in his native language (Spanish), Patient 7 stated he was never diagnosed with heart disease, nor was he ever diagnosed with a terminal illness. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 6/13/2024 at 1:50 p.m., the DPCS confirmed that initial comprehensive assessment on 3/1/2024 for Patient 7 was not completed. The DPCS also reviewed ";LCD Hospice Eligibility Determination," dated 3/1/2024, for Patient 7. The DPCS verified that based on the LCD reviewed, Patient 7 did not qualify to receive hospice services. The DPCS stated the Registered Nurse who was responsible to conduct initial comprehensive assessment was supposed to complete the LCD based on his or her assessment. The DPCS stated that since the initial comprehensive assessment for Patient 7 was not completed, thus disqualifying Patient 7 to receive hospice benefits. During this time, the survey team requested the DPCS to provide clinical documentation that would support Patient 7s terminal diagnosis. c. A review of Patient 8s ";Personal Information" indicated a start of care (SOC) date of 8/18/2023, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). During a telephone interview with Patient 8 on 6/11/2024 at 3:40 p.m., Patient 8 stated that he did have heart disease or terminal illness. Patient 8 stated that he had never been told by a physician that he had 6 months or less to live. Per Patient 8, he had high blood pressure. Patent 8 stated he did not have a Primary Care Physician (PCP; a medical doctor trained to prevent, diagnose, and treat a wide range of illnesses and injuries in the general population). Patient 8 stated that he was last seen by a physician when he went to the Emergency Room (ER), about six months ago. During the same interview, Patient 8s primary caregiver (PCG 1) stated the nurse who signed Patient 8 up for the hospice services told them that hospice was for people with long-term (chronic) illness. PCG 1 stated that Patient 8 had high blood pressure, which was a long term illness. PCG 1 stated he was with Patient 8 when he signed the hospice paperwork. During a concurrent record review and interview with the DPCS on 6/13/2024 at 2 p.m., the DPCS reviewed Patient 8s LCD, dated 5/10/2024. The survey team requested the DPCS to provide clinical documentation that would support Patient 8s terminal diagnosis. During an interview with the Medical Director (MD) on 6/13/2024 at 11:50 a.m., the MD stated that verifying the patients eligibility, including ensuring that patient had clinical documentation that supported the terminal diagnosis prior to enrolling the patient to hospice was the HAs responsibility, not his. The MD stated that he did not review patients clinical information because it should have been done by the HA. A review of a document provided by the HA regarding the job description of ";Hospice Medical Director," revised November 2021, indicated the Hospice Medical Director will have overall responsibility for the medical component of the hospice program. The Hospice Medical Director responsibilities will include but not limited to the following: - Adhering to requirements, terms, and conditions required by Medicare Conditions of Participation, accrediting body, and federal and state statutes governing the provision of services. - Reviewing patients medical eligibility for hospice services, in accordance with hospice program and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness. - Documenting care provided in the patients clinical record, providing evidence of progression of the end-stage disease process. D. A review of Patient 10s untitled admission sheet, indicated a start of care date on 3/24/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). It further indicated that Patient 10s primary language is listed as ";Spanish". During a joint home visit observation and at Patient 10s residence on 6/11/2024, at 11:00 a.m., with the Licensed Vocational Nurse 2 (LVN2), Patient 10 was observed alert and oriented and was walking using a walker (a type of mobility aid that provides stability and support while walking), Patient 10 was observed breathing normally with no shortness of breath, without supplemental oxygen. Patient 10 stated, in his native language (Spanish), that he is still under his own Primary Care Physician (PCP) and stated he was not sure if his PCP knows that he is under hospice care. P10 stated that he was not sure if the hospice program was explained to him during his admission to hospice. It was noted during the home visit that Patient 10 was not able to locate his hospice home folder. Patient 10 stated he was unsure if a home folder was provided to him by the hospice nurse, he stated that the documents he signed is in English Language. Patient 10 stated he was never diagnosed with terminal illness by his physician and was never informed by his physician or the HA that he had six months or less to live. E. A review of Patient 11s untitled admission sheet, indicated a start of care date on 2/14/2023 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). ). It further indicated that Patient 10s primary language is listed as ";Spanish". On 6/12/24, at 10:50 a.m., during a telephone interview with P11 and his wife (FM1), FM1 stated that her husband speaks in his native language (Spanish) only. FM1 stated that Patient 11 still sees his own primary care doctor, and the hospice program was not explained to them completely by the hospice nurse. FM1 stated that they received a call one day from a lady, stated she forgot her name and offered them a program for the elder people to get a free medical supply, lower co-pays for their medications and free nurse visits. FM1 stated that they are not aware of her spouse Patient 11 has a terminal illness, she stated he does not have a terminal illness and he is not dying in 6 months or less, she stated it was not explained to them by the hospice nurses. FM1 stated that the documents that were signed was in English language, and they preferred that it should be in their native language (Spanish). FM1 stated she does not remember any more if an Spanish interpretation by a nurse was done during her husbands (Patient11) admission. F. A review of Patient 12s untitled admission sheet, indicated a start of care date on 3/4/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). During a joint home visit on 6/12/2024 at 1:00 p.m. with the Administrator Designee (AD), who is a Licensed Vocational Nurse, to Patient 7 (Patient 12s spouse) and Patient 12s home, Patient 7 stated that Patient 12 is sleeping and resting because she was just discharged from the hospital few days ago for right leg and foot pain. Patient 12 was not available for interview. On 6/13/2024 at 2:53 p.m., a telephone call to Patient12 was made but was unsuccessful. During a telephone interview on 6/14/2024, at 10 a.m., with Patient 12 in her native language (Spanish), Patient 12 stated that on 6/5/2024 she called her primary doctor for her unbearable, uncontrolled throbbing, burning pain and redness/swelling of her right lower leg and right foot. Patient 12 stated she had Tylenol 500mg medication for pain, but it was not effective. Patient 12 stated her primary doctor advised her to go to urgent care for further treatment. Patient 12 stated she went to the local urgent care on the same day and during her visit, she was advised to go to the emergency department for further treatment of her foot infection and uncontrolled pain. Patient 12 stated she then proceeded to the local emergency department, and she was treated there for antibiotics and pain relief medications. Patient 12 state she was admitted to the hospital from 6/5/2024 and was discharged on 6/8/2024. Patient 12 stated she did not call the hospice agency as she did not have their telephone number. Patient 12 stated she was never diagnosed with terminal illness by his physician and was never informed by his physician or the HA that she had six months or less to live. During a concurrent record review and interview with the DPCS on 6/13/2024 at 1:35 p.m., the DPCS stated that LCD (Local Determination Coverage) is used by hospice providers to determine eligibility for beneficiaries for hospice benefits. The DPCS confirmed that Patient 10, Patient 11 and Patient 12s terminal diagnoses were heart failure. The survey team requested the DPCS to provide clinical documentations that would support Patient 10, Patient 11 and Patient 12s terminal diagnoses. On 6/13/2024, at 4:30 p.m., the DPCS was unable to provide clinical documentations that would support Patient 10,Patient 11, and Patient 12s terminal diagnoses.

Based on interview, observation, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation on Clinical Records was met as follows: --- 1. The HA failed to ensure the clinical records for two of fourteen sampled patients (Patient 7 and Patient 12) included the plan of care, initial assessment, comprehensive assessments, and clinical notes that reflected the patients current health status, correct and updated assessments. (Refer to L672). The cumulative effect of these systemic practices resulted in Patient 7 and Patient 12 not having complete and accurate clinical records which potentially could not identify a change in patients conditions and may affect the patients care and services. This could lead to hospitalization and death when clinical records did not include current, correct, and updated comprehensive assessments of the patients. 2. The HA failed to ensure any amendments, correction or late entries within an electronic health record clearly identified the original content, the modified content, date, and authorship of each record modification for five of fourteen sampled patients (Patient 5, Patient 7, Patient 8, Patient 11, and Patient 12). (Refer to L679). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records are safeguarded from unauthorized access by any individuals or hospice staff.

Based on interview, observation, and record review, the Hospice Agency (HA) failed to ensure the clinical records for two of fourteen sampled patients (Patient 7 and Patient 12) included the plan of care, initial assessment, comprehensive assessments, and clinical notes that reflected the patients current health status. This deficient practice resulted in Patient 7 and Patient 12 not having complete and accurate clinical records that potentially could not identify a change in patients conditions and may affect the patients care and services. --- a. A review of Patient 7s ";Personal Information" indicated a start of care (SOC) date of 3/1/2024, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). During a joint home visit observation at Patient 7s residence on 6/12/2024, at 1 p.m., with the Administrator Designee (AD)/Licensed Vocational Nurse (LVN, Patient 7 was observed alert and oriented and was walking using a walker (a mobility aid that provides support and stability while walking). A concurrent interview and record review with the AD was conducted during the home visit, at 2 p.m. Patient 7s ";Comprehensive Nursing Assessment," dated 3/1/2024, was reviewed. The AD stated that ";Comprehensive Nursing Assessment," or the initial comprehensive assessment was not completed. The AD also confirmed that Patient 7 did not have a Plan of Care in place. During a concurrent record review and interview with the AD on 6/12/2024 at 2:15 p.m., the AD reviewed Patient 7s ";Plan of Care," dated 6/12/2024, ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 5/30/2024, 5/16/2024, 5/2/2024, 4/18/2024, 4/4/2024, 3/7/2024, and 3/1/2024. The AD confirmed there was no plan of care generated for Patient 7 since his admission date of 3/1/2024. During an interview with the Director of Patient Care Services (DPCS) on 6/14/2024 at 1:10 p.m., the DPCS stated all patients must have the plan of care, initial assessment, comprehensive assessments, and other clinical notes as part of their clinical record. According to the DPCS, complete and accurate clinical record can help ensure that patients received the care they needed. The HA did not provide a policy for content of patients clinical record as requested by the survey team. B. A review of Patient 12s untitled admission sheet, indicated a start of care date on 3/4/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). During a joint home visit on 6/12/2024 at 1:00 p.m. with the Administrator Designee (AD), who is a Licensed Vocational Nurse, to Patient 7 (Patient 12s spouse) and Patient 12s home, Patient 7 stated that Patient 12 is sleeping and resting because she was just discharged from the hospital few days ago for right leg and foot pain. Patient 12 was not available for interview. On 6/13/2024 at 2:53 p.m., a telephone call to P12 was made but was unsuccessful. On 6/13/2024, at 1:30 p.m., during a concurrent review and interview with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 12s clinical record titled ";Re-Cert Assessment", dated 5/22/2024, indicated in the ";Integumentary-Skin" section, ";Wound/Skin Impairment – No", and under ";Other Observations (if applicable)" – ";Skin was clean and intact". It further indicated in the ";Narrative and Disease Trajectory" section, ";Skin assessment done with Wound Care Orders for Right Medial Lower Leg: Cleanse the wound with cleanser and pat dry with gauze. Apply Tetracyte to the wound bed, followed by alginate AG. Cover with non-bordered foam dressing and wrap with rolled gauze, followed by self-adhesive bandage 2x weekly and PRN (as needed) for soiled or loose dressing. Secure dressing with tape as needed. Note: The wound dressing will be changed by the Wound Pros clinician once a week and 2x weekly by the treatment nurse or PRN". ADM/DPCS stated that there were inconsistencies with Registered Nurses (RN1) documentations and incomplete wound assessment. ADM/DPCS stated that a wound assessment should include the location, classification, staging if applicable, measurements, color, drainage if any and odor. ADM/DPCS stated that RN 1 did not complete wound assessment for P12. ADM/DPCS stated that she is not familiar with P12 and does not know the type and location of P12s wound. ADM/DPCS stated that RN1 should also completed a ";Skin Impairment Assessment". Upon concurrent review with the ADM/DPCS of P12s EMR (Electronic Medical Record), there was no ";Skin Impairment Assessment" completed on 5/22/2024. On 6/13/2024, at 1:40 p.m., during a concurrent review and interview with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 12s clinical record titled ";Progress Report" from the ";Wound Pros/Wound Care Experts", dated 5/24/2024, indicated in the ";Wound Details" section, ";Location: Right Medial Lower Leg", ";Classification: Diabetic Ulceration", ";Status: New", ";Stage: None", ";Width: 5.7 cm (centimeters)", ";Length: 2.61 cm", ";Depth: 0.5cm". A further review of P12s clinical record with the ADM/DPCS, titled ";Progress Report" from the" Wound Pros/Wound Care Experts", dated 5/30/2024, indicated in the ";Wound Details" section, ";Location: Right Medial Lower Leg", ";Classification: Diabetic Ulceration", ";Status: Improving", ";Stage: None", ";Width: 4.66 cm", ";Length: 2.28 cm", ";Depth: 0.2 cm". ADM/DPCS stated that Wound Pros services the hospice agency for their patients that was referred for wound consult. ADM/DPCS stated that Wound Pro treatment nurses provide wound treatments for their patients, but hospice agencys skilled nurses also should conduct and document their own skin/wound assessments when they visit the patients. On 6/13/2024, at 1:47 p.m., during a concurrent review and interview with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 12s clinical record titled ";Current Treatment/Medication/DME (Durable Medical Equipment) List", indicated an order date of 5/23/2024- ";Referral to Wound Pros for Wound Assessment and Treatment", ";Note: Right Lateral Anterior Foot", and an order date of 5/24/2024-";Wound Care Orders for Right Medial Lower Leg: Cleanse the wound with cleanser and pat dry with gauze. Apply Tetracyte to the wound bed, followed by alginate AG. Cover with non-bordered foam dressing and wrap with rolled gauze, followed by self-adhesive bandage 2x weekly and PRN (as needed) for soiled or loose dressing. Secure dressing with tape as needed. Note: The wound dressing will be changed by the Wound Pros clinician once a week and 2x weekly by the treatment nurse or PRN". ADM/DPCS stated that right lateral foot was documented wrong, and it should be in the right medial lower leg. On 6/13/2024, at 1:58 p.m., during a concurrent review and interview with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 12s clinical record titled ";POC (Plan of Care)/IDG (Interdisciplinary) Review (is a team consists of the doctor, social worker, registered nurse and spiritual chaplain which is responsible for development and review of the patient's plan of care), dated 5/30/2024, indicated no plan of care that address for P12s diagnosis for diabetes mellitus (uncontrolled blood sugar levels), diabetic ulceration (a serious complication caused by a combination of poor circulation, sensitive to infection and nerve damage from high blood sugar levels) and pain management. ADM/DPCS confirmed that there were no care plans formulated to address P12s problems and stated a care plan should have been made and discussed in the IDG meetings to better manage P12s potential and existing problems. On 6/13/2024, at 2:08 p.m., during a concurrent review and interview with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 12s clinical record titled ";Visit Note LVN", dated 5/24/2024 and 5/30/2024, indicated in the ";Pain" section, documented ";Is Pain Controlled? Yes/"Pain Level reported at this visit – 0", ";Integumentary-Skin" section, ";Wounds" documented as ";None" and in ";Narrative" Section documented ";SN (Skilled Nurse) head to toe assessment", no further documentation of P12s wound to any part of her body. Upon further review of Patient 12s clinical records, titled ";Communication log", dated 5/24/2024, indicated in the ";comm comments"- ";SN (LVN1) called hospice to report that the patient was seen today by the Wound Pros and per visiting Clinician Patient foot was red and swollen and asked for a medication to help with pain. MD was notified and per MD orders send Tylenol 500 mg (milligrams) One tab oral every 4-6 hours as needed for pain. (Do not exceed more than 6 tablets in 24 hours). IDG team has been notified." ADM/DPCS stated that there were inconsistencies with the documentations of RN1 and Licensed Vocational Nurse (LVN1) including the pain assessments. ADM/DPCS stated that LVN 1 should have documented her own assessment to P12s wound from right medial lower leg since LVN 1 called the office and is aware of P12s pain with her right leg/foot. ADM/DPCS stated that assessment should be documented to the SN visits, comprehensive/updated assessments and not in the communication logs. On 6/13/2024, at 2:20 p.m., during an interview with the AD, she stated that they received a call on 6/11/2024 from Wound Pros treatment nurse that attempted to visit P12 on 6/6/2024 in her home but was unavailable, stated that P12 was hospitalized due to pain and infection to her right leg/foot. AD stated that P12 was hospitalized from 6/5/2024 to 6/8/2024. AD stated that P12 supposed to have an SN visit on the week of 6/2/2024 to 6/8/2024. During a concurrent review with AD of P12s ";Monthly Schedule" for May-June 2024, indicated no scheduled visit for week of 6/2/2024 to 6/8/2024. AD stated she does not know what happened and why there was a missed visit, P12 supposed to have a visit from the SN for that week. AD stated that if an SN visit had made, P12s pain to her right leg and foot could have been address and hospitalization could have been prevented. A request to have a telephone interview with LVN1 was made from the AD but stated LVN 1 is busy doing her visit with the patients and unavailable at this time. On 6/13/2024, at 3:26 pm, during a telephone interview with RN 1, she stated that she should have documented a thorough and complete skin/wound assessment for P12 which include the type, description, measurement, and appearance. RN 1 stated that she documented wrong in the integumentary section and should have documented yes to confirmed P12s wound and she should have completed a skin impairment assessment form, stated it was her mistake. RN 1 stated that a care plan should also formulated to address P12's wound and pain management and to have an effective coordination of care. On 6/14/2024 at 10:00 a.m., during a telephone interview with P12 in her native language (Spanish), P12 stated that on 6/5/2024 she called her primary doctor for her unbearable, uncontrolled throbbing, burning pain and redness/swelling of her right lower leg and right foot. P12 stated she has Tylenol 500mg medication for pain, but it was not effective. P12 stated that her primary doctor advised her to go to urgent care for further treatment. P12 stated she went to local urgent care on the same day and during her visit, she was advised to go to the emergency department for further treatment of her foot infection and uncontrolled pain. P12 stated that she then proceeded to the local emergency department, and she was treated there for antibiotics and pain medications. P12 stated that she was admitted to the hospital from 6/5/2024 and was discharged on 6/8/2024. P12 stated she did not call the hospice agency as she does not have their telephone number. On 6/14/2024, at 1:10 p.m., during a telephone interview with LVN 1, she stated that she should have documented a complete skin/wound assessment for P12 which include the type, description, measurement, and appearance. LVN 1 stated that she documented wrong in the integumentary section and should have documented yes to confirmed P12s wound and she stated it was her mistake. LVN 1 stated that she visited P12 on 6/3/2024 and was aware of her pain from right lower leg and right foot, stated she called the agency to report it. At 1:17 p.m., during a concurrent review with ADM/DPCS of P12s EMR, there was no documented evidence of her SN visit dated on 6/3/2024. LVN 1 stated she does not know why there was no documentation of her visit with P12 on 6/3/2024, stated she might have forgotten to upload it, stated she should have documented her visit to reflect P12s current health status. ADM/DPCS stated that each SN visit should have been documented as evidence that a visit has been made by nurse, an assessment which includes P12s wound, pain, response to current pain medication and to address patients existing or potential problems in a timely manner. a. A review of Patient 7s ";Personal Information" indicated a start of care (SOC) date of 3/1/2024, with a primary diagnosis of unspecified heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). During a joint home visit observation at Patient 7s residence on 6/12/2024, at 1:00 p.m., with the Administrator Designee (AD)/Licensed Vocational Nurse (LVN), Patient 7 was observed alert and oriented and was walking using a walker (a mobility aid that provides support and stability while walking). During an interview and concurrent record review with the AD on 6/12/2024 at 2:00 p.m. during the home visit, Patient 7s ";Comprehensive Nursing Assessment," dated 3/1/2024, was reviewed. The AD stated that ";Comprehensive Nursing Assessment," or the initial comprehensive assessment was not completed. The AD confirmed that Patient 7 did not have a Plan of Care in place. During an interview and concurrent record review with the AD on 6/12/2024 at 2:15 p.m., the AD reviewed Patient 7s ";Plan of Care," dated 6/12/2024, ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) dated 5/30/2024, 5/16/2024, 5/2/2024, 4/18/2024, 4/4/2024, 3/7/2024, and 3/1/2024. The AD confirmed that there was no plan of care generated for Patient 7 since his admission date of 3/1/2024. During an interview with the Director of Patient Care Services (DPCS) on 6/14/2024 at 1:10 p.m., the DPCS stated all patients must have the plan of care, initial assessment, comprehensive assessments, and other clinical notes as part of their clinical record. According to the DPCS, complete and accurate clinical record can help to ensure that patients received the care they needed. b. A review of Patient 12s untitled admission sheet, indicated an SOC date of 3/4/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle [is the largest and strongest chamber of the heart that is responsible for pumping oxygenated blood from the lungs to the rest of the body] of the heart is weak) congestive heart failure (heart not pumping blood properly). During a joint home visit on 6/12/2024 at 1:00 p.m. with the Administrator Designee (AD)/LVN at Patient 7's (Patient 12s spouse) and Patient 12s home, Patient 7 stated that Patient 12 is sleeping and resting because she was just discharged from the hospital few days ago for the right leg and foot pain. Patient 12 was not available for interview. During an interview and concurrent record review on 6/13/2024, at 1:30 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 12s clinical record, titled ";Re-Cert Assessment", dated 5/22/2024, the record indicated in the ";Integumentary-Skin" section, ";Wound/Skin Impairment – No", and under ";Other Observations (if applicable)" – ";Skin was clean and intact". The record further indicated in the ";Narrative and Disease Trajectory" section, ";Skin assessment done with Wound Care Orders for Right Medial Lower Leg: Cleanse the wound with cleanser and pat dry with gauze. Apply Tetracyte (a medication to prevent growth and spread of bacteria) to the wound bed, followed by alginate AG (a type of dressing). Cover with non-bordered foam dressing and wrap with rolled gauze, followed by self-adhesive bandage 2x (twice) weekly and PRN (as needed) for soiled or loose dressing. Secure dressing with tape as needed. Note: The wound dressing will be changed by the clinician once a week and 2x weekly by the treatment nurse or PRN". ADM/DPCS stated that there were inconsistencies with Registered Nurses (RN1) documentations and wound assessment was incomplete. ADM/DPCS further stated that a wound assessment should include the location, classification, staging if applicable, measurements, color, drainage if any and odor. ADM/DPCS stated that RN 1 did not complete wound assessment for Patient 12. ADM/DPCS stated that she is not familiar with Patient 12 and does not know the type and location of Patient 12s wound. ADM/DPCS further added that RN1 also should have completed a ";Skin Impairment Assessment". Upon concurrent review with the ADM/DPCS of Patient 12s EMR (Electronic Medical Record), there was no ";Skin Impairment Assessment" completed on 5/22/2024. During an interview and concurrent record review on 6/13/2024 at 1:40 p.m. with the ADM/DPCS of Patient 12s clinical record titled ";Progress Report" from the ";Wound Pros/Wound Care Experts", dated 5/24/2024, the record indicated in the ";Wound Details" section, ";Location: Right Medial Lower Leg", ";Classification: Diabetic Ulceration (a diabetic wound caused by the poor circulation and high blood sugar levels)", ";Status: New", ";Stage: None", ";Width: 5.7 centimeters (cm, a unit of length)", ";Length: 2.61 cm", ";Depth: 0.5cm". A further review of Patient 12s clinical record with the ADM/DPCS, titled ";Progress Report" from the" Wound Pros/Wound Care Experts", dated 5/30/2024, indicated in the ";Wound Details" section, ";Location: Right Medial Lower Leg", ";Classification: Diabetic Ulceration", ";Status: Improving", ";Stage: None", ";Width: 4.66 cm", ";Length: 2.28 cm", ";Depth: 0.2 cm". ADM/DPCS further stated that although wound was referred for wound consult and their nurses provide wound treatments to their patients, but hospice agencys skilled nurses also should conduct and document their own skin/wound assessments when they visit the patients. During an interview and concurrent record review on 6/13/2024 at 1:47 p.m. with the ADM/DPCS of Patient 12s clinical record, titled ";Current Treatment/Medication/DME (Durable Medical Equipment) List", indicated an order date of 5/23/2024 for ";Referral to Wound Consult for Wound Assessment and Treatment", ";Note: Right Lateral Anterior Foot". The record further indicated an order date of 5/24/2024 for ";Wound Care Orders for Right Medial Lower Leg: Cleanse the wound with cleanser and pat dry with gauze. Apply Tetracyte... Secure dressing with tape as needed. Note: The wound dressing will be changed by the Wound clinician once a week and 2x weekly by the treatment nurse or PRN". ADM/DPCS stated that right lateral foot was documented wrong, and it should be in the right medial lower leg. During an interview and concurrent record review on 6/13/2024 at 1:58 p.m. with the ADM/DPCS of Patient 12s clinical record, titled ";POC (Plan of Care)/IDG (Interdisciplinary Group) Review (is a team consists of the doctor, social worker, registered nurse and spiritual chaplain which is responsible for development and review of the patient's plan of care), dated 5/30/2024, indicated no plan of care was developed for Patient 12s diagnosis for diabetes mellitus (uncontrolled blood sugar levels), diabetic ulceration (a serious complication caused by a combination of poor circulation, sensitive to infection, and it is a nerve damage from high blood sugar levels), and pain management. ADM/DPCS confirmed that there were no care plans formulated to address Patient 12s problems and stated a care plan should have been developed and discussed in the IDG meetings to better manage Patient 12s potential and existing problems. During an interview and concurrent record review on 6/13/2024 at 2:08 p.m. with the ADM/DPCS of Patient 12s clinical record, titled ";Visit Note LVN", dated 5/24/2024 and 5/30/2024, indicated in the ";Pain" section, documented ";Is Pain Controlled? Yes/"Pain Level reported at this visit – 0", ";Integumentary-Skin" section, ";Wounds" documented as ";None" and in ";Narrative" Section documented ";SN (Skilled Nurse) head to toe assessment". No further documentation noted for Patient 12s wound in any body part. Upon further review of Patient 12s clinical records, titled ";Communication log", dated 5/24/2024, indicated in the ";Com comments"- ";SN (LVN1) called hospice to report that the patient was seen today by the Wound Consult and per visiting Clinician patient's foot was red and swollen and asked for a medication to help with pain. Medical Director (MD) was notified and per MD orders send Tylenol (medication to treat pain) 500 milligrams (mg, a unit of mass), one tablet, oral every four to six hours as needed for pain... IDG team has been notified." ADM/DPCS stated that there were inconsistencies with RN 1's and LVN1's documentation including the pain assessments. ADM/DPCS further stated that LVN 1 should have been documented her own assessment of Patient 12s wound from right medial lower leg since LVN 1 called the office and was aware of Patient 12s pain with her right leg/foot. ADM/DPCS stated that assessment should be documented in the skilled nurse (SN) visits, comprehensive/updated assessments and not in the communication logs. During an interview and concurrent record review on 6/13/2024 at 2:20 p.m. with AD, AD stated that they received a call on 6/11/2024 from Wound Consultant treatment nurse that attempted to visit Patient 12 on 6/6/2024 in her home, but was unavailable. AD further stated that Patient 12 was hospitalized due to pain and infection to her right leg/foot. AD stated that Patient 12 was hospitalized from 6/5/2024 to 6/8/2024. AD further stated that Patient 12 supposed to have an skilled nursing (SN) visit on the week of 6/2/2024 to 6/8/2024. During a concurrent review of Patient 12s ";Monthly Schedule" for May-June 2024 with AD, the record indicated no scheduled visit for week of 6/2/2024 to 6/8/2024. AD stated that she does not know what happened and why there was a missed visit, Patient 12 supposed to have a visit from the SN for that week. AD further added that if an SN visit had made, Patient 12s pain to her right leg and foot could have been addressed and hospitalization could have been prevented. A request to have a telephone interview with LVN1 was made from the AD but stated LVN 1 is busy doing her visit with the patients and unavailable at this time. On 6/13/2024 at 2:53 p.m., a telephone call to Patient 12 was made, but was unsuccessful. During a telephone interview with RN 1 on 6/13/2024 at 3:26 p.m., RN 1 stated that she should have documented a thorough and complete skin/wound assessment for Patient 12's wound by including the type, description, measurement, and appearance. RN 1 further stated that she documented wrong in the integumentary section and should have documented "yes" to confirm Patient 12s wound. RN 1 stated she should have completed a skin impairment assessment form and that it was her mistake. RN 1 further added that a care plan should also been formulated to address Patient 12's wound and pain management and to have an effective coordination of care. During a telephone interview with Patient 12 in her primary language (Spanish) on 6/14/2024 at 10:00 a.m., Patient 12 stated that on 6/5/2024 she called her primary doctor for her unbearable, uncontrolled throbbing, burning pain, and redness/swelling of her right lower leg and right foot. Patient 12 stated she had Tylenol 500 mg medication for pain, but it was not effective. Patient 12 further stated that her primary doctor advised her to go to the urgent care for further treatment. Patient 12 stated she went to local urgent care on the same day and during her visit, she was advised to go to the emergency department for further treatment of her foot infection and uncontrolled pain. Patient 12 further stated that she then went to the local emergency department and was treated with antibiotics and pain medications. Patient 12 added that she was admitted to the hospital from 6/5/2024 and was discharged on 6/8/2024. Patient 12 stated she did not call the hospice agency as she does not have their telephone number. During a telephone interview with LVN 1 on 6/14/2024 at 1:10 p.m., LVN 1 stated that she should have documented a complete skin/wound assessment for Patient 12's wound which included the type, description, measurement, and appearance of the wound. LVN 1 stated that she documented wrong in the integumentary section and should have documented "yes" to confirm Patient 12s wound and that it was her mistake. LVN 1 further stated that she visited Patient 12 on 6/3/2024, was aware of her pain from right lower leg and right foot, and called the agency to report it. A concurrent review of Patient 12's EMR with ADM/DPCS at 1:17 p.m. EMR indicated there was no documented evidence of LVN 1's SN visit dated on 6/3/2024. LVN 1 stated she does not know why there was no documentation of her visit with Patient 12 on 6/3/2024. LVN 1 further stated that she might have forgotten to upload it and that she should have been documented her visit to reflect Patient 12s current health status. ADM/DPCS stated that each SN visit should have been documented as evidence that a visit has been made by nurse, an assessment which included Patient 12s wound, pain, response to current pain medication and to address patients existing or potential problems in a timely manner. During survey requested the HA to provide policy for content of patients clinical record, the agency did not provide a policy as requested by the survey team.

The HA failed to ensure to clearly identify the original content, the modified content, date, and authorship of each record modification for any amendments, correction or late entries within an electronic health record for five of fourteen sampled patients (Patient 5, Patient 7, Patient 8, Patient 11, and Patient 12) Based on interview and record review, the Hospice Agency (HA) failed to ensure the contents of the Clinical Records were protected from any modifications (making partial or minor changes) by other facility personnel who was not directly assigned to five of fourteen sampled patients (Patient 5, Patient 7, Patient 8, Patient 11, and Patient 12). This deficient practice had the potential for unauthorized access by any individuals or hospice staff and for inaccurate clinical records which can affect quality of care and services provided patients receiving hospice care benefits. --- a. A review of Patient 7s ";Personal Information" indicated a start of care (SOC) date of 3/1/2024, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). During a concurrent interview and record review with the manager of the electronic health record (EHR) system used by the HA on 6/14/2024 at 12 p.m., the manager reviewed the audit log for Patient 7, from 3/1/2024 to 6/13/2024, ";all staff," ";all module." The manager stated the ";Modified Date" column indicated the date and time a patients record was accessed and/or modified. The manager stated the ";Patient" column indicated the patient whose chart was accessed and/or modified, the ";Staff" column indicated the person who logged in to the EHR system and accessed the patients chart, the ";Module" section indicated which module was modified, the Visit Date" column indicated for which visit date the patients chart was being modified, the ";Field/Section" column indicated which section of the ";Module" was modified, ";Current Value" section indicated the information entered or added by the staff who modified the patients chart/record, ";Previous Value" section indicated the information that was previously on the section before it was modified. When the EHR manager was asked to explain the entry in Patient 7s ";Audit Log" from 3/1/2024 to 6/13/2024, for the modified date of 6/13/2024, 1:07 p.m., the manager stated the entry indicated that on 6/13/2024, at 1:07 p.m., Patient 7s record was accessed and modified by Licensed Vocational Nurse 1 (LVN 1), the modified module was ";Nursing Assessment," the modification was done for the visit date of 6/7/2024, the assigned staff for the 6/7/2024 visit was Registered Nurse 1 (RN 1). According to the manager, the document was not signed, and that was why it showed RN 1 in the ";Current Value" section. Per EHR manager, had LVN 1, as the staff who performed the modification, signed the Nursing Assessment, the ";Current Value" section would show ";Signed on: (date of the documents was signed), by LVN 1. A review of the same audit log for Patient 7 indicated that on 6/12/2024, at 5:40 p.m., LVN 1 modified a Nursing Assessment which took place on 3/1/2024. The audit log indicated that LVN 1 modified the narrative for the initial RN comprehensive assessment for Patient 1 on 3/1/2024. The audit log indicated that on 6/12/2024, LVN 1 also modified RN assessment for the visit dates of 3/15/2024, 3/29/2024, and 4/12/2024. On 6/13/2024, LVN 1 modified RN assessment for the following visit dates: 4/26/2024, 5/10/2024, 5/24/2024, and 6/7/2024. On all the RN assessment with the dates above, there was no RN signature and there was no documented evidence that LVN 1 received endorsement from the RN who conducted the assessment of Patient 7. During a telephone interview on 6/13/2024 at 3:26 p.m. with RN 1, RN 1 stated that she did not see or assess Patient 7 on 3/1/2024. RN 1 stated she did not see Patient 7 until 5/24/2024, which was the only time she visited Patient 7. When asked if another RN visited and assessed Patient 7 on 3/1/2024, RN 1 stated she did not know. A review of the ";Audit Log" for Patient 7, dated from 3/1/2024 to 6/13/2024, ";all staff," ";all module," indicated that on 6/13/2024, at 5:52 a.m., LVN 1 modified the ";Certification MD" module, ";Physician Narrative: Certifying Physician Summary" section, which was for the Certification done on 5/30/2024, as follows: ";Certify that 78 year old male patient to Hospice with diagnosis of heart disease, unspecified... Patient is terminally ill and has a life expectancy of six (6) months or less if the terminal illness runs its normal course." LVN 1 also documented under the ";Physician Narrative: Face to Face Summary" section of the Certification MD as follows: ";I certify that Patient 7 considered terminally ill with a life expectancy of six (6) months or less if the terminal illness runs its normal course." The Certification MD was not signed by the MD. There was no documented evidence the Medical Director (MD) of the HA dictated the information to LVN 1 to enter in the EHR system. b. A review of Patient 5s ";Personal Information" indicated Patient 5 was an eighty four year old female, with a start of care (SOC) date of 4/2/2024, with a primary diagnosis of chronic (persisting for a long time or constantly recurring) diastolic congestive heart failure (a condition where the lower left chamber of the heart [left ventricle] is not able to fill properly with blood during the diastolic phase [when the heart relaxes and fills with blood], reducing the amount of blood pumped out to the body). Over time, this causes blood to build up inside the left atrium, and then in the lungs, leading to fluid congestion and symptoms of heart failure. A review of the ";Audit Log" for Patient 5, dated from 4/2/2024 to 6/14/2024, ";all staff," ";all module," indicated that on 6/11/2024, at LVN 1 modified ";Nursing Assessment" that was conducted on 5/28/2024, 4/30/2024, 4/16/2024, and 4/2/2024. There was no RN signature for the Nursing Assessments. There was no documented evidence that LVN 1 received endorsement from the RN who conducted the assessment of Patient 5 on those dates. The same audit log indicated that on 6/11/2024 at 10:03 a.m., LVN 1 also modified ";Certification MD" module, ";Physician Narrative: Certifying Physician Summary" section, which was for the Certification done on 4/2/2024, as follows: Certify that 86 years old Caucasian female patient to Hospice with diagnosis of chronic diastolic congestive heart failure... Patient is terminally ill and has a life expectancy of six (6) months or less if the terminal illness runs its normal course." On 6/11/2024, at 10 a.m., LVN 1 documented under the ";Physician Narrative: Face to Face Summary" section of the Certification MD as follows: ";Face to Face encounter with 93 years old female with primary diagnosis of hypertensive heart disease with heart failure. Patient with generalized body weakness, non-ambulatory bed bound, transfer bed/chair, and maximum assistance." The Certification MD was not signed by the MD. There was no documented evidence the Medical Director (MD) of the HA dictated the information to LVN 1 to enter in the EHR system. During a joint home visit observation at Patient 5s residence on 6/11/2024, at 11 a.m., with the Administrator Designee (AD)/Licensed Vocational Nurse (LVN, Patient 5 was observed alert and oriented, and was walking using a walker (a type of mobility aid that provides stability and support while walking). c. A review of Patient 8s ";Personal Information" indicated a start of care (SOC) date of 8/18/2023, with a primary diagnosis of heart disease, unspecified (heart conditions that include diseased vessels, structural problems, and blood clots). A review of the ";Audit Log" for Patient 8, dated from 8/18/2023 to 6/13/2024, ";all staff," ";all module," indicated that on 6/13/2024, LVN 1 modified ";Nursing Assessment" that was conducted on 6/13/2024, and on 6/12/2024, LVN 1 modified ";Nursing Assessment" that was conducted on 5/24/2024 and 6/7/2024. There was no RN signature on the Nursing Assessments. There was no documented evidence that LVN 1 received endorsement from the RN who conducted the assessment of Patient 8 on those dates. The same audit log indicated that on 6/13/2024 at 5:57 a.m., LVN 1 modified ";Certification MD" module, ";Physician Narrative: Certifying Physician Summary" section, which was for the Certification done on 6/13/2024, as follows: Certify that 69 years old patient under routine level of care for the 5th benefit period...Patient is terminally ill and has a life expectancy of six (6) months or less if the terminal illness runs its normal course." LVN 1 documented under ";Physician Narrative: Face to Face Summary" section of the Certification MD as follows: ";I certify that 4/14/2024 to 6/12/2024 considered terminally ill with a life expectancy of six (6) months or less if the terminal illness runs its normal course." In the same ";Physician Narrative: Face to Face Summary" section, LVN 1 documented as follows: ";Patient to be admitted to the HA for 5th benefit period from 6/13/2024 to 8/11/2024 with primary diagnosis of chronic systolic congestive heart failure." The primary diagnosis on Patient 8s ";Personal Information" was heart disease, unspecified, and not chronic systolic congestive heart failure." There was no MD signature on the Certification MD. There was no documented evidence the Medical Director (MD) of the HA dictated the information to LVN 1 to enter in the EHR system. During a telephone interview with LVN 1 on 6/14/2024 at 12:46 p.m., LVN 1 stated that she had weekly meetings with the MD, where in the meeting she and the MD would sit side-by-side in a room, and the MD would dictate to her what to put the MD Certification for each patient. LVN 1 stated she was the one who charted the RN assessments for Patient 5, Patient 7, and Patient 8 based on the endorsement. When LVN 1 was asked to provide the RN endorsement she received to the survey team, LVN 1 was not able to provide it as requested. During a telephone interview with the MD on 6/13/2024 at 11:50 a.m., the MD stated he was familiar with the EHR system used by the HA and knew how to document in a patients chart. The MD stated he always personally documented and signed his assessment under the Certification MD, if he saw and assessed the patient. The MD stated he did not authorize LVN 1 to document on his behalf. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 6/14/2024 at 11:10 a.m., the DPCS reviewed the audit log for Patient 5, Patient 7, and Patient 8. The DPCS stated, ";The nurses can chart on behalf of another nurse, they might endorse the care or assessment to one another." When the DPCS was asked in which part of the documentation the endorsement was indicated, the DPCS stated there was no indication in any of the modification done by LVN 1 that she received endorsement regarding the RN assessments of the patients. When the DPCS was asked if LVN 1 was supposed to modify or document the Certification MD, the DPCS stated she was not aware that LVN 1 had been modifying or documenting the Certification MD. A review of the HAs undated policy, titled ";Documentation of Patient Care Observations by Designated Individuals," indicated that clinicians are permitted to dictate assessments and other observations of patient care to designated individuals for documentation purposes; designated individuals must accurately transcribe and document the dictated information in a timely manner and in accordance with established documentation standards and protocols. The policy indicated the documented report must clearly indicate that it was transcribed based on the clinicians dictation and include the name of the clinician who provided the patient care. D. A review of Patient 11s untitled admission sheet, indicated a start of care date on 2/14/2023 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). During a concurrent interview and record review with the manager of the electronic health record (EHR) system used by the HA on 6/14/2024 at 1:00 p.m., the manager reviewed the audit log for Patient 11, from 2/14/2024 to 6/13/2024, ";all staff," ";all module." The manager stated the ";Modified Date" column indicated the date and time a patients record was accessed and/or modified. The manager stated the ";Patient" column indicated the patient whose chart was accessed and/or modified, the ";Staff" column indicated the person who logged in to the EHR system and accessed the patients chart, the ";Module" section indicated which module was modified, the Visit Date" column indicated for which visit date the patients chart was being modified, the ";Field/Section" column indicated which section of the ";Module" was modified, ";Current Value" section indicated the information entered or added by the staff who modified the patients chart/record, ";Previous Value" section indicated the information that was previously on the section before it was modified. When the EHR manager was asked to explain the entry in Patient 11s ";Audit Log" from 6/11/2024 to 6/12/2024, for the modified date of 6/12/2024, 2:12 p.m., the manager stated the entry indicated that on 6/12/2024, at 2:12 p.m., Patient 11s record was accessed and modified by Licensed Vocational Nurse 1 (LVN 1), the modified module was ";Certification MD," the modification was done for the dates of 4/9/2024 and 6/8/2024, the assigned staff for the dates of 4/9/2024 and 6/8/2024 was Medical Director (MD). According to the manager, the document was not signed, and that was why it showed MD in the ";Current Value" section. Per EHR manager, had LVN 1, as the staff who performed the modification, signed the Certification MD, the ";Current Value" section would show ";Signed on: (date of the documents was signed), by LVN 1. A review of the same audit log for Patient 11 indicated that on 6/12/2024, at 2:12 p.m., LVN 1 modified a ";Certification MD" which took place on 4/9/2024 and 6/8/2024. The audit log indicated that LVN 1 modified the ";Physician Narrative: Certifying Physician Summary" narrative for the Certification MD for Patient 1 on 4/9/2024 and 6/8/2024. There was no MD signature on the Certification MD. There was no documented evidence the Medical Director (MD) of the HA dictated the information to LVN 1 to enter in the EHR system. E. A review of Patient 12s untitled admission sheet, indicated a start of care date on 3/4/2024 with a primary diagnosis of chronic systolic (lifelong condition in which the left ventricle (is the largest and strongest chamber of the heart that is responsible for pumping oxygen rich blood from the lungs to the rest of the body) of the heart is weak) congestive heart failure (heart not pumping blood properly). During a concurrent interview and record review with the manager of the electronic health record (EHR) system used by the HA on 6/14/2024 at 1:00 p.m., the manager reviewed the audit log for Patient 12, from 3/4/2024 to 6/13/2024, ";all staff," ";all module." The manager stated the ";Modified Date" column indicated the date and time a patients record was accessed and/or modified. The manager stated the ";Patient" column indicated the patient whose chart was accessed and/or modified, the ";Staff" column indicated the person who logged in to the EHR system and accessed the patients chart, the ";Module" section indicated which module was modified, the Visit Date" column indicated for which visit date the patients chart was being modified, the ";Field/Section" column indicated which section of the ";Module" was modified, ";Current Value" section indicated the information entered or added by the staff who modified the patients chart/record, ";Previous Value" section indicated the information that was previously on the section before it was modified. When the EHR manager was asked to explain the entry in Patient 12s ";Audit Log" from 6/13/2024, for the modified date of 6/13/2024, 5:45 a.m., the manager stated the entry indicated that on 6/13/2024, at 5:45 a.m., Patient 12s record was accessed and modified by Licensed Vocational Nurse 1 (LVN 1), the modified module was ";Certification MD," the modification was done for the dates of 3/4/2024 and 6/2/2024, the assigned staff for the 3/4/24 and 6/2/2024 was Medical Director (MD). According to the manager, the document was not signed, and that was why it showed MD in the ";Current Value" section. Per EHR manager, had LVN 1, as the staff who performed the modification, signed the Certification MD, the ";Current Value" section would show ";Signed on: (date of the documents was signed), by LVN 1. A review of the same audit log for Patient 12 indicated that on 6/13/2024, at 5:45 a.m., LVN 1 modified a ";Certification MD" which took place on 3/4/2024 and 6/2/2024. The audit log indicated that LVN 1 modified the ";Physician Narrative: Certifying Physician Summary" narrative for the Certification MD for Patient 12 on 3/4/2024 and 6/2/2024. There was no MD signature on the Certification MD. There was no documented evidence the Medical Director (MD) of the HA dictated the information to LVN 1 to enter in the EHR system. During a telephone interview with LVN 1 on 6/14/2024 at 12:46 p.m., LVN 1 stated that she had weekly meetings with the MD, where in the meeting she and the MD would sit side-by-side in a room, and the MD would dictate to her what to put the MD Certification for each patient. During a telephone interview with the MD on 6/13/2024 at 11:50 a.m., the MD stated he was familiar with the EHR system used by the HA and knew how to document in a patients chart. The MD stated he always personally documented and signed his assessment under the Certification MD, if he saw and assessed the patient. The MD stated he did not authorize LVN 1 to document on his behalf. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 6/14/2024 at 12:30 p.m., the DPCS reviewed the audit logs for Patient 11 and Patient 12. The DPCS stated, ";The nurses can chart on behalf of another nurse, they might endorse the care or assessment to one another." When the DPCS was asked in which part of the documentation the endorsement was indicated, the DPCS stated there was no indication in any of the modification done by LVN 1 that she received endorsement regarding the RN assessments of the patients. When the DPCS was asked if LVN 1 was supposed to modify or document the Certification MD, the DPCS stated she was not aware that LVN 1 had been modifying or documenting the Certification MD.