Every finding on record at N S Hospice, Inc

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] patients) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding the Initial and Comprehensive Assessment of Patients (an assessment to identify the physical, psychosocial [relating social conditions to mental health], emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) was met as follows: 1. The HA failed to include in the comprehensive assessment the objective data to support the Local Coverage Determination (LCD, an assessment to determine if an individual is eligible to receive hospice services) for one of five sampled patients (Patient 22). This deficient practice had the potential to cause inaccurate assessment and thus the patients needs not addressed appropriately. (Refer to L525). 2. The HA failed to review and identify possible duplicate drug therapy for one of five sampled patients (Patient 2). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. (Refer to L530). 3. The HA failed to update the comprehensive assessment and included the changes in skin integrity for one of five sampled patients (Patient 2). This deficient practice may result in failure to identify changes in patients needs and inability to provide the care and services necessitated by the change. (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 record review and interview the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to include in the comprehensive assessment the objective data to support the Local Coverage Determination (LCD, an assessment to determine if an individual is eligible to receive hospice services) for one of five sampled patients (Patient 22). This deficient practice had the potential to result in an inaccurate assessment to appropriately address patients hospice needs. --- During a review of Patient 22s ";Personal Information", indicated a start of care (SOC) date of 9/13/2023, with a primary diagnosis of heart disease unspecified (condition affecting the heart or the blood vessels and associated with a build-up of fatty deposits inside the arteries [atherosclerosis] and an increased risk of blood clots). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 1/8/2025 at 12:20 p.m., of Patient 22s clinical record titled ";LCD (Local Coverage Determination, is a decision made by a Medicare Administrative Contractor (MAC) on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the specific jurisdiction that the MAC oversees) Hospice Eligibility Determination" dated 12/30/2024, the LCD indicated on section 1. (c.) Is patient optimally treated for heart disease with diuretics and vasodilators? Documented as ";Yes". The DPCS reviewed Patient 22s ";Current Treatment/Medication/DME (Durable Medical Equipment) List" indicated medications which include Losartan Potassium 50 milligram (mg, unit of weight) tablet to treat hypertension (also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure, blood is carried from the heart to all parts of the body in the vessels) and Amlodipine Besylate 10 mg tablet to treat hypertension. DPCS stated that the two blood pressure medications were not classified as diuretics (medicines that help reduce fluid buildup in the body) nor vasodilators (medicines that open, also called dilate, blood vessels). The DPCS confirmed and stated that Patient 22s ";Current Treatment/Medication/DME List" indicated no medications classified as diuretics or vasodilators. The DPCS stated that Patient 22 might be on vasodilators or diuretics medications prior to admission to hospice but was unable to provide Patient 22s previous medical records. DPCS stated that the Medical Director completed LCD for patients with the assistance of the nurses. DPCS stated that she does not know why Patient 22 was documented taking diuretics and vasodilators. DPCS stated that when documenting LCD, it must be supported by objective data which include patients previous clinical records. During a telephone interview with the hospice Medical Director (MD) on 1/8/2025 at 12:35 p.m., the MD stated that Losartan and Amlodipine are medications to treat for hypertension and are not classified as vasodilators nor diuretics. MD stated that she completed Patient 22s LCD with assistance from the nurses. MD stated that it could have been documented wrongly as Patient 22 was no longer on any diuretics nor vasodilators. MD stated that LCD must be documented accurately to provide appropriate care and necessary treatments for the patients. During a review of the HAs policy and procedure, titled ";Admission Criteria and Process," revised November 2020, the policy indicated that the patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determinations (LCDs).

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] patients) failed to review the patient's medications and identify duplicate drug therapy for one of five sampled patients (Patient 2). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. --- During a review of Patient 2s Personal Information, the Personal Information indicated that Patient 2 was admitted to the HA on 10/18/2023 with a primary diagnosis of senile degeneration of brain (a general term for a range of neurological disorders that cause a gradual decline in cognitive abilities). During a joint home visit with Registered Nurse 1 (RN 1) on 1/7/2025 at 1 p.m., Patient 2 was observed awake and alert. Observed Patient 2 sitting on a wheelchair. According to Family Member 1 (FM 1), who acted as Patient 2s primary caregiver, Patient 2 was non-ambulatory (unable to walk). During a medication review that was conducted during the joint home visit, it was observed that Lorazepam (a medication prescribed to treat anxiety, trouble sleeping, agitation, and seizure disorders) 2 mg/ml (a unit measurement) concentrate solution, with the administration instruction indicating to give 0.5 ml (1 mg) by mouth/under the tongue every 2 hours as needed for anxiety/agitation and Ativan (a brand name for Lorazepam) 0.5 mg (a unit measurement) tablet, with the administration instruction to give 0.5 mg (1/2 tablet) every 6 hours as needed. It was also observed the Ativan tablets in a bubble pack packaging, already halved. Observed packaging intact with no tablets used. Observed the Lorazepam concentrate solution in a dropper bottle, with the seal intact. During a review of Patient 2s Current Treatment/Medication/DME (Durable Medical Equipment, medically necessary items for people with medical conditions, disabilities, or injuries) List, the Current Treatment/Medication/DME List indicated that Lorazepam 2 mg/ml concentrate solution was ordered on 7/24/2024 and Ativan 0.5 mg tablet was ordered on 10/11/2024. During an interview with FM 1 on 1/7/2025 at 1:55 p.m., FM 1 stated that she had never given Lorazepam concentrate solution or Ativan tablet to Patient 2. FM 1 stated that Patient 2 had received Lorazepam in the past, and it made her hallucinate (sensory perception of something that is not actually present). During an interview with RN 1 on 1/7/2025 at 2:05 p.m., RN 1 stated she did a supervisory visit for Patient 2 on 12/27/2025. RN 1 stated she conducted medication reconciliation during her visit on 12/27/2025, but she only checked the Ativan tablets and not the Lorazepam concentrate solution. RN 1 stated that she was not aware Patient 2 had Lorazepam concentrate solution at home. RN 1 was asked what the safe dose for Lorazepam was within 24 hours was. RN 1 stated she was not sure, but she believed it was around 10 mg within 24 hours. A call to Licensed Vocational Nurse 1 (LVN 1) was made on 1/7/2025 at 3:08 p.m. but was not answered or returned. LVN 1 has been visiting Patient 2 weekly. On 1/8/2025, the HAs administrator stated that LVN 1 was sick. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 1/8/2025 at 11:20 a.m., the DPCS reviewed Patient 2s Current Treatment/Medication/DME List. The DPCS stated that Lorazepam 2 mg/ml concentrate solution was ordered by the HAs physician on 7/24/2024 as part of the comfort kit (a set of medications kept at home, used for fast relief when pain, agitation, or sickness become worse in hospice patients). The DPCS stated that Patient 2 was put under continuous care on 7/24/2024 because her symptoms worsened. The DPCS stated that Lorazepam 2 mg/ml should only be administered by a nursing staff from the HA. The DPCS acknowledged there was no instruction printed on the medication label or on the medication list for the family or caregiver that indicated Lorazepam 2 mg/ml concentrate solution should only be given by a nurse. Per DPCS, the Lorazepam 2 mg/ml concentrate solution should have been discontinued when Patient 2 was no longer on continuous care. During a phone interview with the HAs Medical Director (MD) on 1/8/2025 at approximately 12:35 p.m., the MD stated the safe dose for Lorazepam concentrate solution is 0.25 mg every 6 hours, which may be increased to 0.25 mg every 4 hours. The MD stated that Lorazepam concentrate solution in the comfort kit should have been discontinued when a patient was no longer on continuous care. During a review of the HAs policy and procedure, titled ";Medication Profile," revised November 2020, the policy and procedure indicated that a drug regimen review will be performed at the time of initial and comprehensive assessment. The review will assist in evaluating effectiveness and appropriateness, identify potential and actual drug/food interactions, adverse reactions, duplicate therapy and noncompliance issues, omissions, and unclear information.

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] patients) failed to update the comprehensive assessment and included the changes in skin integrity for one of five sampled patients (Patient 2). This deficient practice has the potential to result in failure to identify changes in patients needs and inability to provide the care and services necessitated by the change. --- During a review of Patient 2s Personal Information, the Personal Information indicated that Patient 2 was admitted to the HA on 10/18/2023 with a primary diagnosis of senile degeneration of brain (a general term for a range of neurological disorders that cause a gradual decline in cognitive abilities). During a review of Patient 2s 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 12/19/2024, the POC/IDG Review indicated that Patient 2 complained of right foot pain specifically in the fourth toe that appeared red and swollen. The POC/IDG Review also indicated that Patient 2 was at risk for skin breakdown due to having fragile skin. During a joint home visit with Registered Nurse 1 (RN 1) on 1/7/2025 at 1 p.m., Patient 2 was observed awake and alert. Observed Patient 2 sitting on a wheelchair. According to Family Member 1 (FM 1), who acted as Patient 2s primary caregiver, Patient 2 was non-ambulatory (unable to walk). During the joint home visit, the surveyor observed that Patient 2 had an open wound on her right big toe and right fourth toe. RN 1 stated that she discovered the wound on the right fourth toe during her supervisory visit on 12/27/2024. RN 1 stated the wound on the right big toe was not present on 12/27/2024. RN 1 stated she took a picture of the wound on the right fourth toe on 12/27/2024 . RN 1 subsequently showed the wound picture on her cellular phone to the surveyor, dated 12/27/2024, which showed the wound on the patients right fourth toe. According to RN 1, she immediately notified the HAs case manager about the wound, and the case manager would be responsible to notify the HAs physician. During an interview with FM 1 on 1/7/2024 at 1:40 p.m., FM 1 stated that a wound specialist came to see Patient 2 on 12/31/2024 and examined her wound. FM 1 stated that when the wound specialist came, Patient 2 only had the wound on the right fourth toe. FM 1 stated she was not sure when exactly Patient 2 developed a wound on the right big toe. During a review of Patient 2s Visit Note RN, dated 12/27/2024, completed by RN 1, the Visit Note RN indicated that Patient 2 did not have any wounds and/or ulcer/bed sores. The narrative section did not mention any findings related to open wound on right fourth toe. During a review of Patient 2s Visit Note LVN, dated 12/30/2024, completed by Licensed Vocational Nurse 1 (LVN 1), the Visit Note LVN indicated that Patient 2 did have any wounds and/or ulcer/bed sores. The narrative section was left blank. A call to Licensed Vocational Nurse 1 (LVN 1) was made on 1/7/2025 at 3:08 p.m. but was not answered or returned. LVN 1 was a staff of the HA who has been visiting Patient 2 weekly. On 1/8/2025, the HAs administrator stated that LVN 1 was sick. During a phone interview with RN 1 on 1/7/2025 at 3:11 p.m., RN 1 was asked if she documented her assessment of Patient 2s wound when she discovered it on 12/27/2024. RN 1 stated that she remembered taking a picture of the wound and reported it to the HAs case manager, but she was not sure if she documented it on the visit note. RN 1 stated she did not take the measurement of the wound as she just wanted to make sure it was reported immediately. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 1/8/2025 at 11:55 a.m., the DPCS reviewed Patient 2s RN Visit Note, dated 12/27/2024, and LVN Visit Note, dated 12/30/2024. The DPCS was asked what the nurse needed to assess regarding to a newly discovered wound. The DPCS stated, ";The nurse needs to assess and document the location of the wound, the type of the wound, if its a skin tear, a pressure ulcer, if it has any exudate, the measurement, and if theres any pain. The nurse also needs to take a picture." The DPCS confirmed there was no wound assessment documented on the RN Visit Note and LVN Visit Note. The DPCS stated the wound was documented in the communication log when RN 1 called the case manager on 12/27/2024. The DPCS stated that communication log is not an assessment. The DPCS stated that it was very important to document wound assessment so that the HA would have a baseline. During a review of the HAs policy and procedure, titled ";Ongoing Comprehensive Assessments," revised November 2020, the policy and procedure indicated that the nurse would assess the patient on each visit for: G. Skin integrity. The policy and procedure also indicated that ongoing comprehensive assessments should focus on: B. Changes in patient condition, level of deterioration. During a review of the HAs undated policy and procedure, titled ";Wound Care Protocol," the policy and procedure indicated that wounds needed to be measured on the first visit of each week by the same Registered Nurse (RN) for consistency. The policy and procedure also indicated that wound assessment would be done every visit as well as done very 7 days since last visit as needed.

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 education and training as appropriate to their responsibilities for the care and services for two of eight sampled patients (Patient 15 and Patient 18). This failure resulted in the HA staffs inability to ensure patients/patient caregivers understanding of possible risks and side effects while on anti-coagulant (A substance that is used to prevent and treat blood clots in blood vessels and the heart) medication. --- b. A review of Patient 18s untitled admission record indicated a Start of Care (SOC) date of 5/14/2024 with a primary diagnosis of hemiplegia (one sided muscle paralysis or weakness) following cerebral infarct ( occurs as a result of inerrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side. During a review of Patient 18s clinical record ";Current Treatment/Medication/DME (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living)" indicated listed medication which includes: - Eliquis 5 milligrams (mg, unit of weight) tablet, one tablet, oral (by mouth), twice a day for CVA (Cerebrovascular Accidents, are caused by blood clots and broken blood vessels in the brain). During a concurrent observation and interview on 9/25/2024, at 10 a.m., with Registered Nurse (RN1), in Patient 18s residence for a joint home visit, Patient 18 was comfortably sitting on his chair with his walker by his side. Patient 18s Primary Caregiver (PCG1) confirmed that Patient 18 is still taking Eliquis medication to prevent further incidents of strokes or blood clots. Patient 18 and PCG1 stated that they were unsure of what to look for while on Eliquis. PCG1 stated that he was unsure if RN1 provided teachings to them of what to look for while Patient 18 is on anti-coagulant medication. During review of Patient 18s hospice agencys home folder, there was no indication of any written instructions for Patient 18 or his PCG1 related to anti-coagulant therapy use. RN1 stated that she provided some teachings to Patient 18 and his PCG1 of what to look for while on anti-coagulant medication like bleeding, unusual bruising and black stools. RN 1 stated that it was her mistake not to provide written instructions to Patient 18 and his PCG1 for their reference when they needed to review it. During an interview with the Director of Patient Care Services (DPCS) on 9/26/2024, at 11:30 a.m., DPCS stated that it is important for the clinical staffs to provide verbal teachings and written instructions to patients if they are taking some medications that could potentially have side effects, like anti-coagulants. DPCS stated that written instructions provided to patients and their caregivers will help them of symptoms to look for and when to seek immediate care. a. During a review of Patient 15s Personal Information, the Personal Information indicated that Patient 15 was admitted to the HA on 6/8/2024 with a primary diagnosis of secondary malignant neoplasm of liver and intrahepatic bile duct (cancer of the liver [the largest solid organ in the body that removes toxins from the body's blood supply] and bile duct [a tube that carries bile from the liver and gallbladder, through the pancreas, and into the small intestine]). During a review of Patient 15s Current Treatment/Medication/DME List (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living), the Current Treatment/Medication/DME List indicated that Patient 15 was on Pradaxa (a medication that can treat and prevent blood clots, reducing the risk of stroke) 110 mg (milligram, a unit) capsule, one capsule, twice a day, for blood thinner. During a joint home visit with the Director of Patient Care Services (DPCS) on 9/25/2024 at 9 a.m., Patient 15 was observed sitting on a chair, alert, awake, and oriented. A medication review with the DPCS was completed during the home visit. During an interview with Patient 15 on 9/25/2024 at 9:50 a.m., Patient 15 stated he was taking Pradaxa to prevent stroke. When asked regarding the side effects of Pradaxa, Patient 15 stated it could cause bruises and bleeding. During a concurrent record review and interview with the DPCS on 9/26/2024 at 11:15 a.m., the DPCS reviewed Patient 15s 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 9/19/2024. The DPCS stated that Patient 15 should have had bleeding precautions included in his POC/IDG Review, so the visiting nurse could monitor if he experienced signs and symptoms of bleeding as a side effect of Pradaxa. The DPCS stated the bleeding precautions would also guide the HA staff to provide teaching to the patient and his family. A review of the HAs policy and procedure, titled ";Patient Education Process," revised November 2020, indicated that patient and family/caregiver education will be interdisciplinary and interactive as appropriate to the plan of care. At interdisciplinary group meetings, patient education and learning needs/processes will be discussed by all clinicians involved with the care.

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 content of clinical record was accurate for one of eight sampled patients (Patient 4). This deficient practice had the potential to patients assessed needs not met and communication between health care providers involved in the patients care impaired. --- During a review of Patient 4s Personal Information, the Personal Information indicated Patient 4 was admitted to the HA on 3/27/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation (or flare-up, occurs when COPD respiratory symptoms become much more severe). During a review of Patient 4s LCD Hospice Eligibility Determination (Local Coverage Determination, guidelines used by hospice providers to determine eligibility of beneficiaries for hospice benefits), dated 6/25/2024, the LCD indicated that Patient 4s oxygen saturation level (the amount of oxygen circulating in blood) was less than or equal to 88 (an ideal oxygen level would be between 95% to 100%) percent (%). During a review of Patient 4s Re-Cert Assessment, dated 6/25/2024, completed by Registered Nurse 2 (RN 2), the Re-Cert Assessment indicated that Patient 4s oxygen saturation level was 95% on room air (without supplemental oxygen), however, the narrative section indicated that RN 2 instructed the caregiver to use oxygen inhalation at 2-5 liter per minute via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) as needed for shortness of breath. During a review of Patient 4s Visit Note RN, dated 8/17/2024, 8/24/2024, 8/31/2024, and 9/7/2024, the Visit Note RN indicated that Patient 4s oxygen saturation levels were between 95% to 97% on room air. The narrative section of the Visit Note RN did not mention the use of supplemental oxygen. During a phone interview with Family Member 1 (FM 1) on 9/25/2024 at 3:54 p.m., FM 1 stated that she had the durable power of attorney (DPOA, the authority to make medical, legal, or financial decisions for another person) for Patient 4. FM 1 stated that Patient 4 is oxygen dependent. FM 1 stated that Patient 4 is continuously using oxygen concentrator (a device that concentrates the oxygen from a gas supply by selectively removing nitrogen to supply an oxygen-enriched product gas stream) at home. FM 1 stated she did not remember the setting for the oxygen concentrator, but per FM 1, Patient 4 would have severe shortness of breath without supplemental oxygen. On 9/26/2024, at approximately 12:30 p.m., the survey team requested to interview RN 2. During an interview with the Director of Patient Care Services (DPCS) on 9/26/2024 at 1:10 p.m., the DPCS stated that Patient 4 needed to use supplemental oxygen continuously due to severe shortness of breath. The DPCS stated the documentation in the Visit Note RN, dated 8/17/2024, 8/24/2024, 8/31/2024, and 9/7/2024, that indicated Patient 4s oxygen saturation levels were between 95% to 97% on room air was inaccurate. The DPCS stated that accurate documentation in patients clinical record was important to make sure that patients needs are met and to facilitate communication between health care providers involved in the patients care. A review of the HAs policy and procedure, titled ";Contents of the Clinical Record," revised November 2020, indicated that the clinical record will contain sufficient information to identify the patient problems/needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel.

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 obtain a physician's discharge order for one of eight sampled patients (Patient 17). This deficient practice had the potential to result in patient being discharge without sufficient resources, potentially contributing to unsafe discharge. --- During a review of Patient 17s Personal Information, the Personal Information indicated that Patient 17 was admitted to the HA on 6/13/2024 with a primary diagnosis of end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids). The Personal Information indicated that Patient 17 was discharged from the HA on 9/1/2024 due to hospitalization. During a review of Patient 17s Discharge Summary, dated 9/1/2024, Patient 17s family member stated that patient was brought to the hospital due to diarrhea (loose, watery stools that occur more frequently than usual). During a concurrent interview and record review with the HAs Director of Patient Care Services (DPCS) on 9/24/2024 at 12:25 p.m., the survey team requested for a physician order for Patient 17s discharge. After reviewing Patient 17s clinical record, the DPCS stated there was no physician's order for Patient 17s discharge. The DPCS stated the HAs Medical Director was notified regarding Patient 17s hospitalization and gave a verbal discharge order, but it was not documented. The DPCS also stated there was no communication note regarding physician notification on Patient 17s hospitalization. When the DPCS was asked why a physician was required for patient discharge, the DPCS stated without a written physician order for the discharge, the patient was not formally discharged from the agency. A review of the HAs policy and procedure, titled ";Discharge From Hospice Program," revised November 2020, indicated there were seven discharge criteria from the hospice program. Hospitalization was not listed among the seven criteria in the policy and procedure.

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 ensure the Conditions of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) regarding Patients Rights was met as follows: 1. The HA failed to provide information of their rights and responsibilities in a language preferred and understood by the patients provided hospice care services for five of 14 sampled patients (Patient 3, Patient 7, Patient 8, Patient 9, and Patient 10). (Refer to L502) 2. The HA failed to inform about the services the HA provided and its specific limitations of these services five of 14 sampled patients (Patient 3, Patient 7, Patient 8, Patient 9, and Patient 10). (Refer to L519) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily (written law) mandated federal compliance for Patients Rights to ensure their rights are not violated and receive the quality of hospice care and services. --- .

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 provide six of fourteen sampled patients (Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) information regarding their rights as a hospice patient in a language that would be understood and preferred by the patient. This deficient practice resulted in the patient not informed and lack of understanding of the HAs care and services, available for the patients and their family, and patients not able to exercise their right to decline the hospice services. --- d. A review of Patient 8s admission record indicated a start of care (SOC) date of 12/22/2023 with a primary diagnosis of hypertensive heart disease with heart failure (a group of medical problems like heart failure and irregular heartbeats that can happen when an individuals high blood pressure (hypertension) is unmanaged). A review of Patient 8s ";Physician Certification for Hospice Benefit" dated 3/21/2024 to 6/18/2024, indicated Patient 8 was completely dependent in 2 of 6 activities: ambulation and bathing. Patient 8's KPS was 50 (Karnofsky Performance Status – measure the level of patient activity – 50%: requires considerable assistance and frequent medical care), and the PPS was 50 (Palliative Performance Scale - tool to assess a patient's ability to function – 40%: mainly in bed, unable to do most activities). The NYHA IV classification (New York Heart Association) indicated Patient 8 was Class IV level (Class IV – inability to carry on any physical activity without discomfort, experiences symptoms even while at rest). It also indicated that Hospice Physician (MD2) electronically signed the form dated 3/7/2024. A review of Patient 8s ";Re-cert Assessment" with visit date of 3/7/2024, indicated in the ";ADL (Activities of Daily Living) Assessment" section that Patient 8 was completely dependent in 6 of 6 activities: ambulation, toileting, transfer, dressing, feeding and bathing. During a telephone interview on 4/12/2024 at 12:13 p.m., (with the assistance of County Interpreter #403228), with Patient 8 and Patient 8's Family Member 1 (FM1) only speak Spanish language. FM1 stated Patient 8 "was not under any hospice services, I am not aware of that." Patient 8 stated ";I have a heart condition, but I have a doctor that I see and I am awaiting for a heart surgery procedure, I do not know that I am in any hospice program and no other doctors or nurses that visits me from hospice, I was never told that I had six months or less to live. FM1 stated, ";I wasnt told that. Thats new to me. No, there has not been a doctor that told Patient 8 had six months or less to live, and Patient 8 walks well and able to drive, he does basically everything with very little help sometimes. We havent seen the agencys doctor or nurses either. Patient 8 is seen by his primary doctor, I take care of my father and as far as we know he is not under hospice care, they have not heard of this agency, we are waiting for my fathers (Patient 8) heart surgery procedure." e. A review of Patient 10s admission record indicated a start of care (SOC) date of 11/8/2023 with a primary diagnosis of senile degeneration of brain (a brain disorder that decrease in ability to think, concentrate or remember, slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). During a telephone interview on 4/11/2024 at 12:30 p.m. with the assistance of County Interpreter #403090, with Patient 10, only speak Spanish language, was asked what hospice services were. Patient 10 stated, ";I dont know about that, and I am not under any hospice services, I am not aware of that." Patient 10 stated ";I had a fall months ago related to job injury and was hospitalized for few days but it was minor, I live alone and take care of myself, I do not have any memory problems, I do not know that I am in any hospice program and no other doctors or nurses that visits me from hospice, I was never told that I had six months or less to live." Patient 10 stated "; I walk around our neighborhood, going to nearby store for my grocery and church, I used my walker but it was provided to me by my primary doctor, I feel good and I am not sick, I only take medication for my blood pressure, my primary doctor lives locally and I am his patient for around 6 to 7 years now, I dont remember he referred me to any hospice services. Patient 10 stated ";no nurses or doctor that call or visit me because I am not sick, I go to my doctors office which is few blocks away from where I live, sometimes police officers come to our neighborhood to do a welfare check on everyone but not nurses." During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 4/12/2024 at 11 a.m., the DPCS reviewed the forms signed by Patient 8, and Patient 10 upon admission to the HA. DPCS stated that if the patient only speaks Spanish, then the documents should have been written in Spanish. The DPCS stated that since Patient 8 and Patient 10 only speak Spanish, the nurses who visited them should have used a Spanish interpreter to communicate with the patients. The DPCS stated there was a phone number the nurses could call for a Spanish interpreter. The DPCS stated the documents such as ";Patients Bills of Rights and Responsibilities" for Patient 8 and Patient 10 should have been in Spanish. f. A review of Patient 6s admission record indicated a start of care (SOC) date of 8/28/2023 with a primary diagnosis of heart disease, unspecified (a disease that affects the heart or the blood vessels which is a tube that circulates in the body). During a telephone interview on 4/10/2024 at 1:30 p.m., with Patient 6, Patient 6 stated ";I am not aware that I am under hospice program, I am healthy and I am not sick, I walk around our neighborhood, there is no doctor or nurse that talks or visits me and I dont need it". During a concurrent interview and record review on 4/12/2024 at 11:25 a.m. with the DPCS, Patient 6's has no indication of documentations for hospice physician face-to-face encounter regarding Patient 6s ";Physician Certification for Hospice Benefit" for third benefit recertification period from February 2024 to current date. The DPCS stated, ";I am not sure why the ";Physician Certification Benefit" for this period was not in patients clinical records." The DPCS stated, ";probably the doctor did not submit the signed documents yet, the recertification has to be signed by the medical director before a new recertification period starts." The DPCS stated, ";It is important that it was done appropriately in a timely manner for billing purposes and for the consistency of patients clinical records. DPCS stated ";the medical director or hospice doctor should conduct a face to face in person with the patient to determine if the patient is still eligible to continue for the hospice services". The DPCS stated ";Patient 6s terminal illness is Heart Disease, the medical director came up with the diagnosis because of his symptoms and review of Patient 6s medical records". A request of Patient 6s previous medical records and H & P (History and physical) from the DPCS prior to hospice admission but the hospice agency was unable to provide it. a. A review of Patient 3's ";Personal Information" indicated Patient 3 was admitted on 12/22/2023 with a primary diagnosis of senile degeneration of brain (symptoms affecting memory, thinking and social abilities). During a telephone interview on 4/9/2024 at 1:50 p.m., with Patient 3, conducted by a Spanish-speaking supervisor, Patient 3 stated she was referred to the HA by her neighbor, who was a patient of the HA. Patient 3 stated that hospice service was a service to help people by providing things such as walker and medications. Patient 3 stated that a representative from the HA came to her house and filled out the paperwork for her. Patient 3 stated she did not know what paperwork it was. Patient 3 stated the nurse who had been visiting her did not speak Spanish. During a joint home visit with Registered Nurse 1 (RN 1) that was conducted through a video call on 4/10/24 at 12:15 p.m., Patient 3 was observed alert and oriented. RN 1 did not speak Spanish, and Family Member 1 (FM 1), who was present during the visit via video, served as a translator. A review of the HAs documents, titled ";Patients Bill of Rights and Responsibilities" and ";Release of Information and Consent for Patient," signed by Patient 3 on 12/22/2023, indicated the documents were written entirely in English and was not in Spanish language. b. A review of Patient 7's ";Personal Information" indicated Patient 7 was admitted on 2/20/2024 with a primary diagnosis of atherosclerosis (plaque build-up made of cholesterol, fat, and calcium inside the artery [blood vessel] walls) of native coronary artery without angina pectoris (chest pain). During a telephone interview on 4/10/24 at 12:43 p.m., with Patient 7 which was done with the assistance of a county Spanish interpreter, Patient 7 stated that he received a brochure of the HA from the market where he bought his food. Patient 7 stated the person at the market told him to call the phone number in the brochure so that he could receive free things. Patient 7 stated he did as he was told when he got home, and he was informed that he had been approved. Patient 7 was not sure what he had been approved for. Patient 7 stated that he thought the HA was the clinic near his house that he regularly visited. Patient 7 stated the nurse who had been visiting him did not speak Spanish and that he could not understand. A review of the HAs documents, titled ";Patients Bill of Rights and Responsibilities" and ";Release of Information and Consent for Patient," signed by Patient 7 on 2/20/24, indicated the documents were written entirely in English. c. A review of Patient 9's ";Personal Information" indicated Patient 9 was admitted on 7/9/2023 with a primary diagnosis of atherosclerosis (plaque build-up made of cholesterol, fat, and calcium inside the artery [blood vessel] walls) of native coronary artery with angina pectoris (chest pain) with spasms (sudden, involuntary muscle contractions). During a telephone interview with Patient 9 on 4/11/24 at 10:34 a.m., which was done with the assistance of a county Spanish interpreter, Patient 9 stated that she did not remember who referred her to the HA. Patient 9 stated she did not know what hospice service was. Patient 9 stated that her nurse did not speak Spanish, so Patient 9 did not understand what the nurse told her. A review of the HAs documents, titled ";Patient/Family Bill of Rights" and ";Admission Agreement," signed by Patient 9 on 7/9/23, indicated the documents were written entirely in English – a language Patient 3 did not understand. During a concurrent record review and interview on 4/12/2024 at 11 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed the forms signed by Patient 3, Patient 7, and Patient 9 upon admission to the HA. The DPCS stated since Patient 3 had a diagnosis of senile degeneration of brain/dementia, she should not have signed the forms, because based on her diagnosis she did not have the cognitive capabilities to make a decision. DPCS stated if the patient only speaks Spanish, then the documents should have been written in Spanish. The DPCS stated that since Patient 7 and Patient 9 only speak Spanish, the nurses who visited them should have used a Spanish interpreter to communicate with them. The DPCS stated there was a phone number the nurses could call for a Spanish interpreter. The DPCS stated the documents such as ";Patients Bills of Rights and Responsibilities" for Patient 3, Patient 7, and Patient 9 should have been in Spanish. A review of the HAs policy, titled ";Rights/Responsibilities," revised November 2020, indicated The Patient Rights and Responsibilities statement will be explained and distributed to the patient prior to the initiation of organization services. This explanation will be in a language or communication method the patient can reasonably expected to understand.

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 inform six of 14 sampled patients (Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) about the services the HA provided and the limitations of these services. This deficient practice resulted in Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10 was be fully informed about the purpose of the hospice care services provided. --- d. A review of Patient 8s admission record indicated a start of care (SOC) date of 12/22/2023 with a primary diagnosis of hypertensive heart disease with heart failure (a group of medical problems like heart failure and irregular heartbeats that can happen when an individuals high blood pressure (hypertension) is unmanaged). A review of Patient 8s ";Physician Certification for Hospice Benefit" dated from 3/21/2024 to 6/18/2024, indicated Patient 8 was completely dependent in 2 of 6 activities: ambulation and bathing. Patient 8's KPS was 50 (Karnofsky Performance Status – measure the level of patient activity – 50%: requires considerable assistance and frequent medical care), and the PPS was 50 (Palliative Performance Scale - tool to assess a patient's ability to function – 40%: mainly in bed, unable to do most activities). The NYHA IV classification (New York Heart Association) indicated Patient 8 was Class IV level (Class IV – inability to carry on any physical activity without discomfort, experiences symptoms even while at rest). It also indicated that Hospice Physician (MD2) electronically signed the form dated 3/7/2024. A review of Patient 8s ";Re-cert Assessment" with visit date of 3/7/2024, indicated in the ";ADL (Activities of Daily Living) Assessment" section that Patient 8 was completely dependent in 6 of 6 activities: ambulation, toileting, transfer, dressing, feeding and bathing. During a telephone interview on 4/12/2024 at 12:13 p.m. with the assistance of County Interpreter #403228, with Patient 8, and his daughter (Family Member 1/FM1) only speak Spanish language, was asked about hospice services. FM1 stated, ";Patient 8 is not under any hospice services, I am not aware of that." Patient 8 stated ";I have a heart condition, but I have a doctor that I see and I am awaiting for a heart surgery procedure, I do not know that I am in any hospice program and no other doctors or nurses that visits me from hospice, I was never told that I had six months or less to live. FM1 stated, ";I wasnt told that. Thats new to me. No, there has not been a doctor that told Patient 8 had six months or less to live, my father walks well and able to drive, he does basically everything with very little help sometimes. We havent seen the agencys doctor or nurses either. Patient 8 is seen by his primary doctor, I take care of my father and as far as we know he is not under hospice care, they have not heard of this agency, we are waiting for my fathers (Patient 8) heart surgery procedure." e. A review of Patient 10s admission record indicated a start of care (SOC) date of 11/8/2023 with a primary diagnosis of senile degeneration of brain (a brain disorder that decrease in ability to think, concentrate or remember, slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). During a telephone interview on 4/11/2024 at 12:30 p.m. with the assistance of County Interpreter #403090, Patient 10, only speak Spanish language, was asked what hospice services were. Patient 10 stated, ";I dont know about that, and I am not under any hospice services, I am not aware of that." Patient 10 stated ";I had a fall months ago related to job injury and was hospitalized for few days but it was minor, I live alone and take care of myself, I do not have any memory problems, I do not know that I am in any hospice program and no other doctors or nurses that visits me from hospice, I was never told that I had six months or less to live." Patient 10 stated "; I walk around our neighborhood, going to nearby store for my grocery and church, I used my walker but it was provided to me by my primary doctor, I feel good and I am not sick, I only take medication for my blood pressure, my primary doctor lives locally and I am his patient for around 6 to 7 years now, I dont remember he referred me to any hospice services. Patient 10 stated ";no nurses or doctor that call or visit me because I am not sick, I go to my doctors office which is few blocks away from where I live, sometimes police officers come to our neighborhood to do a welfare check on everyone but not nurses." During a concurrent record review and interview on 4/12/24 at 11 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed the forms signed by Patient 8, and Patient 10 upon admission to the HA. DPCS stated if the patient only speaks Spanish, then the documents should have been written in Spanish. The DPCS stated that since Patient 8 and Patient 10 only speak Spanish, the nurses who visited them should have used a Spanish interpreter to communicate with them. The DPCS stated there was a phone number the nurses could call for a Spanish interpreter. The DPCS stated the documents such as ";Patients Bills of Rights and Responsibilities" for Patient 8 and Patient 10 should have been in Spanish. f. A review of Patient 6s admission record indicated a start of care (SOC) date of 8/28/2023 with a primary diagnosis of heart disease, unspecified (a disease that affects the heart or the blood vessels which is a tube that circulates in the body). During a telephone interview with Patient 6 on 4/10/2024 at 1:30 p.m., Patient 6 stated ";I am not aware that I am under hospice program, I am healthy and I am not sick, I walk around our neighborhood, there is no doctor or nurse that talks or visits me and I dont need it". During a concurrent interview and record review on 4/12/2024 at 11:25 a.m. with the DPCS, there is no indication of clinical records or documentations for hospice physician's face-to-face encounter regarding Patient 6s ";Physician Certification for Hospice Benefit" for third benefit recertification period from February 2024 to current date. The DPCS stated, ";I am not sure why the ";Physician Certification Benefit" for this period was not in patients clinical records." The DPCS stated, ";Probably the doctor did not submit the signed documents yet, the recertification has to be signed by the medical director before a new recertification period starts." The DPCS stated, ";It is important that it was done appropriately in a timely manner for billing purposes and for the consistency of patients clinical records. DPCS stated ";the medical director or hospice doctor should conduct a face to face in person with the patient to determine if the patient is still eligible to continue for the hospice services". The DPCS stated ";Patient 6s terminal illness is Heart Disease, the medical director came up with the diagnosis because of his symptoms and review of Patient 6s medical records". A request of Patient 6s previous medical records and History and physical (H & P) from the DPCS prior to hospice admission but the HA could not provide the requested information. a. A review of Patient 3's ";Personal Information" indicated Patient 3 was admitted on 12/22/2023 with a primary diagnosis of senile degeneration of brain (symptoms affecting memory, thinking and social abilities). A review of Patient 3's Plan of Care (POC)/Interdisciplinary Group Review (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 3/22/2024, indicated the frequency of visits as follows: - Skilled Nurse (SN; a licensed nurse in general): one visit per week plus two as needed visits. - Registered nurse (RN): once every 14 days. - Social worker (MSW): one as needed. - Bereavement Counselor (BC): one as needed. Physician/NP: once before the third recertification thereafter. A review of Patient 3s ";Physicians Certification for Hospice Benefit," dated 3/7/2024, indicated per LCD Guideline (Local Coverage Determination; coverage criteria by Medicare that determines whether service is covered or not) that Patient 3 had dementia due to Alzheimers. During a joint home visit with Registered Nurse 1 (RN 1) that was conducted through a video call on 4/10/24 at 12:15 p.m., Patient 3 was observed alert and oriented. During a telephone interview on 4/10/2024 at 12:47 p.m., which was done with the assistance of a Spanish-speaking surveyor, Patient 3 stated she had never been diagnosed with dementia or Alzheimer. Patient 3 stated that her physician never told her she had 6 months or less to live. Patient 3 stated she was referred to the HA by her neighbor, who was also a patient of the HA. Patient 3 stated as far as she understood, a hospice service was a service that helped her by providing free things such as walker, milk, and medications. b. A review of Patient 7's ";Personal Information" indicated Patient 7 was admitted on 2/20/2024 with a primary diagnosis of atherosclerosis (plaque build-up made of cholesterol, fat, and calcium inside the artery [blood vessel] walls) of native coronary artery without angina pectoris (chest pain). A review of Patient 7's POC/IDG Review, dated 3/22/2024, indicated the frequency of visits for SC, MSW, RN, and Licensed Vocational Nurse (LVN) was left blank. A review of Patient 7s clinical record, titled ";Physicians Certification for Hospice Benefit," dated 2/20/2024, indicated per LCD Guideline that Patient 7 had heart disease. During a telephone interview on 4/11/2024 at 12:43 p.m., which was done with the assistance of a county Spanish interpreter, with Patient 7, Patient 7 stated he did not have heart disease. Patient 7 stated his physician never told him that he had 6 months or less to live. Patient 7 stated the HA never informed him that hospice service was for dying people. Patient 7 stated he received a brochure about the HA from a vendor at the market where he bought food from, and somebody at the market told him if he called the phone number in the brochure, he would receive free things. Per Patient 7, he called the number in the brochure when he got home, and he was told that he had been approved. Patient 7 stated, ";Approved for what, Im not sure." c. A review of Patient 9's ";Personal Information" indicated Patient 9 was admitted on 7/9/2023 with a primary diagnosis of atherosclerosis (plague build-up made of cholesterol, fat, and calcium inside the artery [blood vessel] walls) of native coronary artery with angina pectoris (chest pain) with spasms (sudden, involuntary muscle contractions). A review of Patient 9's POC/IDG Review, dated 3/22/2024, indicated the frequency of visits as follows: - Skilled Nurse (SN; a licensed nurse in general): one visit per week plus one as needed visit. - Registered nurse (RN): once every 14 days. - Social worker (MSW): declined. - Spiritual Counselor (SC): declined. - Physician: once before the third recertification thereafter. A review of Patient 9s ";Physicians Certification for Hospice Benefit," dated 1/3/2024, indicated per LCD Guideline that Patient 9 had heart disease. During a telephone interview on 4/11/24 at 10:34 a.m., with Patient 9, (Spanish speaking only) conducted with the assistance of a county Spanish interpreter, Patient 9 stated she did not remember who referred her to the HA. Patient 9 stated she did not know what hospice service was for. Patient 9 stated she had never been diagnosed with heart disease. Patient 9 also stated her physician had never told her she had 6 months or less to live. During an interview with the DPCS on 4/12/24 at 2:50 p.m., the DPCS stated the HA staff had to explain about hospice services to patient and/or family upon admission to make sure they understood about the hospice service. A review of the HAs policy, titled ";Rights/Responsibilities," revised November 2020, indicated that each patient will be an active, informed participant in his/her plan of care. The policy indicated the patient will be informed during the initial assessment visit, in advance of furnishing care, of the right to be informed of his/her condition, to participate in all aspects of care including development on their plan of care, and the right to refuse all or part of his/her care to the extent permitted by law.

Based on observation, interview and record review, the hospice agency failed to ensure the Conditions of Participations regarding initial and Comprehensive Assessments of Patients was met as followed: 1. Conduct an initial comprehensive assessment for Patients 14 within 48 hours. (Refer to L 522) 2. Conduct an updated comprehensive assessment during recertification for Patient 2. (Refer to L533) 3. Identify medical condition and medications upon recertification assessment for Patient 3. (Refer to L524) 4. Review all of the Patient 3s prescription and over-the-counter medications. (Refer to L530). The cumulative effect of these systemic practices resulted in delayed care, unmonitored medication use, and undetected signs of physical, emotional, spiritual needs when transitioning to the final stages of dying process.

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 conduct and document an initial 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)) that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for one (1) of 14 sample selected patients (Patient 14). This deficient practice had the potential to cause delay of patient care, uncontrolled patient pain, and undetected signs of physical, emotional, and spiritual needs when transitioning to final stages of dying process. --- A review of Patient 14s admission record indicated a start of care (SOC) date of 12/24/2023 and an end of care (EOC) date of 12/24/2023 with a primary diagnosis of Chronic Obstructive Pulmonary Disease with acute exacerbation (COPD, a group of diseases that cause airflow blockage and breathing related problems). During a concurrent interview and record review on 4/12/2024 at 11:15 a.m., with the Director of Patient Care Services (DPCS), Patient 14s initial comprehensive assessment was reviewed. The DPCS stated, ";We dont have Patient 14s initial and comprehensive assessment, in Patient 14s clinical records." The DPCS stated, ";The nurses did not submit any of these documents yet, Patient 14 expired on the same day of her recertification, usually we give them specific number of days to submit since they have so many patients." The DPCS stated, ";The nurses just communicate with each other and do the home visits" without initial assessment and plan of care. The DPCS stated the nurse that conducted an initial assessment was a Registered Nurse (RN). The DPCS was unable to remember who was the registered nurse that visited Patient 14, and was unable to provide documented evidence of Patient 14s Comprehensive Assessment and/or Skilled Nurse Visit notes for the recertification date of 12/24/2024. The DPCS stated the initial assessment for Patient 14 should have been done within 24-48 hours of admission. The DPCS stated the plan of care would not be generated without a complete initial assessment. DPCS stated for not doing the initial comprehensive assessment within 48 hours could cause inconsistencies with the coordination of care among the team. A review of the agencys policy, titled ";Comprehensive Assessment," revised November 2020, indicated that a comprehensive assessment will be performed by the hospice Interdisciplinary Group (IDG) no later than 5 calendar days after the election of hospice care in consultation with attending physician.

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 identify the medication required to manage the respiratory symptoms for one of 14 sampled patients (Patient 3). This deficient practice had the potential to result in failure to promote the hospice patients well-being, comfort, and dignity throughout the dying process. --- A review of Patient 3's ";Personal Information" indicated Patient 3 was admitted on 12/22/2023 with a primary diagnosis of senile degeneration of brain (symptoms affecting memory, thinking and social abilities). A review of Patient 3s recertification assessment, dated 3/7/2024, completed by Registered Nurse 1 (RN 1), indicated that Patient 3 had labored breathing, which was managed with breathing treatments. A review of Patient 3s ";Current Treatment/Medication/DME List" indicated there were no breathing treatments being used. A review of Patient 3's Plan of Care (POC)/Interdisciplinary Group Review (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 3/22/2024, indicated that respiratory issues for Patient 3 were unresolved. During a telephone interview with RN 1 on 4/11/2024 at 12:16 p.m., RN 1 stated that Patient 3 was using an inhaler from Mexico; hence RN 1 did not document the name of the inhaler/breathing treatment. RN 1 stated she could not remember the name of the inhaler from Mexico. When asked if medications obtained outside the United States needed to be documented in the patients chart, RN 1 did not answer. During an interview with the Director of Patient Care Services (DPCS) on 4/12/2024 at 10:35 a.m., the DPCS stated that all medications taken by patient needed to be documented, both prescription and over the counter, so the hospice could monitor the effectiveness, the side effects, and provide teaching to the patient or family. A review of the HAs policy, titled ";Comprehensive Assessment," revised November 2020, indicated that during the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including review of current and related past medications, including prescription and over the counter medications.

Based on interview and record review, the hospice agency (HA) staff failed to review all the medications and update the medication profile with the currently used medications for one of 14 sampled patients (Patient 3). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. --- A review of Patient 3's ";Personal Information" indicated Patient 3 was admitted on 12/22/2023 with a primary diagnosis of senile degeneration of brain (symptoms affecting memory, thinking and social abilities). A review of Patient 3s recertification assessment, dated 3/7/2024, completed by Registered Nurse 1 (RN 1), indicated that Patient 3 had labored breathing, which was managed with breathing treatments. A review of Patient 3s ";Current Treatment/Medication/DME List" indicated there were no breathing treatments being used. During a telephone interview with RN 1 on 4/11/2024 at 12:16 p.m., RN 1 stated that Patient 3 was using an inhaler from Mexico; hence RN 1 did not document the name of the inhaler/breathing treatment. RN 1 stated she could not remember the name of the inhaler from Mexico. When asked if medications obtained outside the United States needed to be documented in the patients chart, RN 1 did not answer. During an interview with the Director of Patient Care Services (DPCS) on 4/12/2024 at 10:35 a.m., the DPCS stated that all medications taken by patient needed to be documented, both prescription and over the counter, so the hospice staff could monitor the effectiveness, the side effects, and provide teaching to the patient or family. A review of the HAs policy, titled ";Medication Profile," revised November 2020, indicated that for accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patients current medications upon the patients entry to the organization.

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 an updated comprehensive assessment during two recertifications for one of 14 sampled patients (Patient 2). This deficient practice may result in failure to identify changes in patients needs and inability to provide the care and services necessitated by the change. --- A review of Patient 2's ";Personal Information" indicated Patient 2 was admitted on 10/18/2023 with a primary diagnosis of senile degeneration of brain (symptoms affecting memory, thinking and social abilities). The HA was not able to provide the most recent comprehensive assessment as requested by the survey team on 4/9/2024. The administrator assistant (AA) stated the Registered Nurse (RN) who did the recertification assessment had not submitted the notes. A review of ";History of Nursing Assessment" for Patient 2 indicated there was only one comprehensive assessment done, which was on 10/18/2023. During an interview with the Director of Patient Care Services (DPCS) on 4/12/2024 at 12:05 p.m., the DPCS stated the RN was required to conduct a comprehensive assessment upon admission and on every recertification. The DPCS stated that Patient 2 was currently in her third episode, which meant she should have had two recertification assessment done by a Registered Nurse. The DPCS stated that Patient 2 had had two the recertification assessments done on 1/16/24 and 4/5/24; however there was no documented evidence of these assessments were completed. DPCS stated recertification assessment must be documented so that all disciplines involved in the patients care had access to it and could use the information to modify the plan of care. A policy regarding recertification assessment was not provided by the HA.

Based on observation, interview, and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met as evidenced by: --- 1. The hospice agency failed to ensure the IDG disciplines were held by all the members of interdisciplinary group to discuss and contribute the patients updated, ongoing assessments and care planning process for 14 of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L541). 2. The hospice agency failed to ensure care and services were being followed in accordance with the Plan of Care for two (2) of 14 sampled patients (Patient 3 and Patient 9). (Refer to L543). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care was provided to the patients who were assessed to receive hospice care and services.

Based on interview and record review, the hospice agency (HA) failed to ensure the Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) disciplines were held by all the members to discuss and contribute the patients updated, ongoing assessments and care planning process for 14 of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This deficient practice had the potential for the patients' needed care and services will not be provided timely and/or supervised leading to an increased discomfort and delay in mitigating the symptoms related to their terminal illnesses. --- a. A review of Patient 1s admission record indicated a start of care (SOC) date of 3/25/2024 with a primary diagnosis of Senile Degeneration of Brain (A brain disorder that decrease in ability to think, concentrate or remember, slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). A review of Patient 1s electronic medical record (EMR- An electronic health record is the systematized collection of patient and population electronically stored health information in a digital format) titled, ";Plan of Care/Interdisciplinary Group (POC- a nursing care plan provides direction on the type of nursing care the individual/family/community may need. The main focus of a nursing care plan is to facilitate standardized, evidence-based and holistic care.)/IDG (the team responsible for the holistic care of the hospice beneficiary) Review", indicated that the following IDG members did not sign on the IDG dates as follow: Hospice Medical Director (MD), Medical Social Worker (MSW), Registered Nurse (RN) and Spiritual Chaplain (SC) on 3/25/2024 and 4/5/2024. b. A review of Patient 4s admission record indicated a start of care (SOC) date of 3/27/2024 with a primary diagnosis of Chronic Obstructive Pulmonary Disease with acute exacerbation (COPD, a group of diseases that cause airflow blockage and breathing – related problems). A review of Patient 4s electronic medical record (EMR- An electronic health record is the systematized collection of patient and population electronically stored health information in a digital format) titled, ";Plan of Care/Interdisciplinary Group (POC- a nursing care plan provides direction on the type of nursing care the individual/family/community may need. The main focus of a nursing care plan is to facilitate standardized, evidence-based and holistic care.)/IDG (the team responsible for the holistic care of the hospice beneficiary) Review", indicated that the following IDG members did not sign on the IDG date as follows: Hospice Medical Director, Medical Social Worker, Registered Nurse and Spiritual Chaplain on 3/27/2024. c. A review of Patient 6s admission record indicated a start of care (SOC) date of 8/28/2023 with a primary diagnosis of Heart Disease, unspecified (A disease that affects the heart or the blood vessels which is a tube that circulates in the body). A review of Patient 6s electronic medical record (EMR- An electronic health record is the systematized collection of patient and population electronically stored health information in a digital format) titled, ";Plan of Care/Interdisciplinary Group (POC- a nursing care plan provides direction on the type of nursing care the individual/family/community may need. The main focus of a nursing care plan is to facilitate standardized, evidence-based and holistic care.)/IDG (the team responsible for the holistic care of the hospice beneficiary) Review", indicated that the following IDG members did not sign on the IDG dates as follow: Hospice Medical Director and Registered Nurse on 1/26/2024, 2/9/2024, 2/23/2024, 3/8/2024 and 3/22/2024. d. A review of Patient 8s admission record indicated a start of care (SOC) date of 12/22/2023 with a primary diagnosis of Hypertensive Heart Disease with Heart Failure (is a long-term condition that develops over many years in people who have high blood pressure, it is a group of medical problems like heart failure and irregular heartbeats that can happen when an individuals high blood pressure (hypertension) is unmanaged). A review of Patient 8s electronic medical record (EMR- An electronic health record is the systematized collection of patient and population electronically stored health information in a digital format) titled, ";Plan of Care/Interdisciplinary Group (POC- a nursing care plan provides direction on the type of nursing care the individual/family/community may need. The main focus of a nursing care plan is to facilitate standardized, evidence-based and holistic care.)/IDG (the team responsible for the holistic care of the hospice beneficiary) Review", indicated that the following IDG members did not sign on the IDG dates as follow: Hospice Medical Director, Medical Social Worker and Spiritual Chaplain on 12/22/2023, Medical Social Worker and Spiritual Chaplain on 1/26/2024, Medical Social Worker on 2/23/2024, 3/8/2024 and 3/22/2024. e. A review of Patient 10s admission record indicated a start of care (SOC) date of 11/8/2023 with a primary diagnosis of Senile Degeneration of Brain (A brain disorder that decrease in ability to think, concentrate or remember, slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). A review of Patient 10s electronic medical record (EMR- An electronic health record is the systematized collection of patient and population electronically stored health information in a digital format) titled, ";Plan of Care/Interdisciplinary Group (POC- a nursing care plan provides direction on the type of nursing care the individual/family/community may need. The main focus of a nursing care plan is to facilitate standardized, evidence-based and holistic care.)/IDG (the team responsible for the holistic care of the hospice beneficiary) Review", indicated that the following IDG members did not sign on the IDG dates as follow: Hospice Medical Director, Medical Social Worker, Registered Nurse and Spiritual Chaplain on 2/9/2024, 3/8/2024, 2/23/2024 and 3/22/2024. f. A review of Patient 13s admission record indicated a start of care (SOC) date of 1/2/2024 and an end of care (EOC) date of 1/5/2024, with a primary diagnosis of Hypertensive Heart Disease with Heart Failure (is a long-term condition that develops over many years in people who have high blood pressure, it is a group of medical problems like heart failure and irregular heartbeats that can happen when an individuals high blood pressure (hypertension) is unmanaged). A review of Patient 13s electronic medical record (EMR- An electronic health record is the systematized collection of patient and population electronically stored health information in a digital format) titled, ";Plan of Care/Interdisciplinary Group (POC- a nursing care plan provides direction on the type of nursing care the individual/family/community may need. The main focus of a nursing care plan is to facilitate standardized, evidence-based and holistic care.)/IDG (the team responsible for the holistic care of the hospice beneficiary) Review", indicated that the following IDG members did not sign on the IDG dates as follow: Medical Social Worker and Spiritual Chaplain on 1/2/2024 and 1/5/2024. g. A review of Patient 14s admission record indicated a start of care (SOC) date of 12/24/2023 and an end of care (EOC) date of 12/24/2023 with a primary diagnosis of Chronic Obstructive Pulmonary Disease with acute exacerbation (COPD, a group of diseases that cause airflow blockage and breathing related problems). A review of Patient 14s electronic medical record (EMR- An electronic health record is the systematized collection of patient and population electronically stored health information in a digital format) indicated no records of ";Plan of Care/Interdisciplinary Group (POC- a nursing care plan provides direction on the type of nursing care the individual/family/community may need. The main focus of a nursing care plan is to facilitate standardized, evidence-based and holistic care.)/IDG (the team responsible for the holistic care of the hospice beneficiary) Review. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 4/12/2024 at 10:40 a.m., the DPCS stated the agency holds IDG meetings every two weeks. The DPCS stated the IDG members attending the meetings include the RN, MSW, MD, and SC. The DPCS stated the IDG members are expected to sign the IDG Plan of Care after the meeting because their signature means they attended the meeting. A concurrent review of the Interdisciplinary Team (IDT) Attendance Sheet with the DPCS indicated that on dates of 2/9/2024 and 2/23/2024, the IDG members signed in for attendance and on 3/8/2024, the MD and DPCS signed in for the attendance. The DPCS was not able to provide documented evidence all the IDG members had participated in the IDG meetings on the other scheduled dates of the meetings. DPCS stated that the MD, SC, RN and the MSW attended those dates with the missing signatures, however they missed signing in the documents to validate their attendance, some of them attended via video conference/zoom meeting, DPCS stated they should be signing in to validate their attendance as members of the IDG team and to validate the documentations, discussions and collaborations of the patients plan of care. During a review of the agency's policy and procedure titled, "Interdisciplinary Group Meeting," revised November 2020, indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor. h. A review of Patient 2's ";Personal Information" indicated Patient 2 was admitted on 10/18/23 with a primary diagnosis of senile degeneration of brain (symptoms affecting memory, thinking and social abilities). A review of Patient 2s ";POC/IDG Review," dated 26/1/24, 2/9/24, 2/23/24, and 3/8/24, indicated the space for the Registered Nurse (RN) signature was left blank. There was no documented evidence that nursing had any input in the POC/IDG Review dated 26/1/24, 2/9/24, and 3/8/24, as the nursing section in the ";IDG Discussion/Updated Comprehensive Assessment Review" was left blank. i. A review of Patient 3's ";Personal Information" indicated Patient 3 was admitted on 12/22/23 with a primary diagnosis of senile degeneration of brain (symptoms affecting memory, thinking and social abilities). A review of Patient 3s ";POC/IDG Review," dated 26/1/24, 2/9/24, and 2/23/24, indicated the spaces for the physician (MD), social worker (MSW), RN, and Chaplain signatures were left blank. There was no documented evidence that MD, MSW, RN, and Chaplain had any input, as the ";IDG Discussion/Updated Comprehensive Assessment Review" was left entirely blank. A review of Patient 3s ";POC/IDG Review," dated 3/8/24 and 3/22/24, indicated that only the Chaplain signed the ";POC/IDG Review." There was no documented evidence that MD, MSW, and RN had any input, as the ";IDG Discussion/Updated Comprehensive Assessment Review" was left blank. j. A review of Patient 5's ";Personal Information" indicated Patient 5 was admitted on 9/13/23 with a primary diagnosis of heart disease (refers to several types of heart conditions, such as coronary artery disease, which affects the blood flow to the heart). The HA did not provide the last 5 ";POC/IDG Review" for Patient 5 as requested by the survey team. k. A review of Patient 7's ";Personal Information" indicated Patient 7 was admitted on 2/20/24 with a primary diagnosis of atherosclerosis (plague build-up made of cholesterol, fat, and calcium inside the artery [blood vessel] walls) of native coronary artery without angina pectoris (chest pain). A review of Patient 7s ";POC/IDG Review," dated 3/22/24, indicated the spaces for the MD, MSW, RN, and Chaplain signatures were left blank. There was no documented evidence that MSW had any input in the ";POC/IDG Review," as the psychosocial section in the ";IDG Discussion/Updated Comprehensive Assessment Review" was left blank. l. A review of Patient 9's ";Personal Information" indicated Patient 9 was admitted on 7/9/23 with a primary diagnosis of atherosclerosis (plague build-up made of cholesterol, fat, and calcium inside the artery [blood vessel] walls) of native coronary artery with angina pectoris (chest pain) with spasms (sudden, involuntary muscle contractions). A review of Patient 9s ";POC/IDG Review," dated 1/26/24, 2/9/24, 2/23/24, and 3/8/24, indicated the spaces for the MD, MSW, and RN, signatures were left blank. There was no documented evidence the IDG members, except for the Chaplain, had any input in the ";POC/IDG Review," as the nursing, psychosocial, and physician sections in the ";IDG Discussion/Updated Comprehensive Assessment Review" were left blank. m. A review of Patient 11's ";Personal Information" indicated Patient 11 was admitted on 9/9/23 with a primary diagnosis of chronic systolic congestive heart failure (a specific type of heart failure that occurs in the heart's left ventricle). A review of Patient 11s ";POC/IDG Review," dated 1/26/24, 2/9/24, and 2/23/24, indicated the spaces for the MD and RN signatures were left blank. A review of Patient 11s ";POC/IDG Review," dated 3/5/24, indicated the spaces for the MD, MSW, and RN signatures were left blank. n. A review of Patient 12's ";Personal Information" indicated Patient 12 was admitted on 10/27/23 with a primary diagnosis of heart disease. A review of Patient 12s ";POC/IDG Review," dated 1/26/24 and 2/9/24, indicated the space for the Chaplain signature was left blank. A review of Patient 12s ";POC/IDG Review," dated 3/8/24, indicated the spaces for the MD and RN signatures were left blank. There was no documented evidence the MD and RN had any input in the ";POC/IDG Review," as the nursing and physician sections in the ";IDG Discussion/Updated Comprehensive Assessment Review" were left blank.

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 follow a written plan of care (POC) related to blood sugar monitoring for two of 14 sampled patients (Patient 3 and Patient 9). This deficient practice resulted in the HAs inability to ensure that Patient 3's and Patient 9's blood sugar remained in the desired range, which had the potential for diabetes complications such as hypoglycemia or hyperglycemia crisis that could lead to a serious harm. --- a. A review of Patient 3's ";Personal Information" indicated Patient 3 was admitted on 12/22/2023 with a primary diagnosis of senile degeneration of brain (symptoms affecting memory, thinking, and social abilities). A review of Patient 3s clinical record, titled ";Physicians Certification for Hospice Benefit," dated 3/7/2024, indicated Patient 3 had Diabetes Mellitus Type 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) as one of her comorbidities (the existence of more than one disease or condition within ones body at the same time). A review of Patient 3s ";Plan of Care (POC)/Interdisciplinary Group Review" (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 3/22/2024, indicated the endocrine system (an organ system that consists of the tissues [mainly glands] that create and release hormones) goal was to keep the blood sugar as normal as possible (90 to 110 mg/dL [milligram/deciliter]) without serious high or low blood sugars. A review of Patient 3s ";Current Treatment/Medication/DME (Durable Medical Equipment) List" indicated Patient 3 was on Metformin Hydrochloride (a medication to treat diabetes) 500 mg, half a tablet daily. During a joint home visit with Registered Nurse 1 (RN 1) that was conducted through a video call on 4/10/2024 at 12:15 p.m., Patient 3 was observed alert and oriented. During the home visit, Patient 3 stated she did not check her blood sugar. Patient 3 further stated the HA did not provide her with a blood sugar log. A review of ";Visit Note RN" for Patient 3, dated 3/1/2024, 3/8/2024, 3/15/2024, and 3/22/2024, indicated the space to document the blood sugar was marked ";none" by the RN. b. A review of Patient 9's ";Personal Information" indicated Patient 9 was admitted on 7/9/2023 with a primary diagnosis of atherosclerosis (plague build-up made of cholesterol, fat, and calcium inside the artery [blood vessel] walls) of native coronary artery with angina pectoris (chest pain) with spasms (sudden, involuntary muscle contractions). A review of Patient 9s clinical record, titled ";Physicians Certification for Hospice Benefit," dated 1/3/2024, indicated Patient 9 had Diabetes Mellitus Type 2 as one of her comorbidities. A review of Patient 9s ";POC/IDG Review", dated 3/22/2024, indicated the endocrine system goal was to keep the blood sugar as normal as possible (90 to 110 mg/dL) without serious high or low blood sugars. A review of Patient 9s ";Current Treatment/Medication/DME List" indicated Patient 9 took Lantus SoloStar (an injectable medication help to manage blood sugar levels) 100 units/mL pre-filled pen solution for injection, inject 50 units in the morning and 20 units at bedtime to manage her diabetes. A review of ";Visit Note RN" for Patient 9, dated 2/29/2024, 3/1/2024, 3/8/2024, and 3/15/2024, indicated the space to document the blood sugar was marked ";none" by the RN. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 4/12/2024 at 11:35 a.m., the DPCS reviewed the ";Visit Note RN" and ";POC/IDG Review ";for Patient 3 and Patient 9. The DPCS confirmed there were no blood sugar readings documented for both patients. When asked how the HA could monitor and ensure both patients blood sugar levels were in the normal range as indicated in the POC, the DPCS stated that since the RN did not report it to her, both patients blood sugar was fine. However, the DPCS stated that it should have been documented. The DPCS stated if the patient did not check the blood sugar, the HA would need to notify the doctor and discuss it during the IDG. A review of the HAs policy, titled ";The Plan of Care," revised November 2020, indicated that the care provided to the patient must be in accordance with the 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 ensure the Condition of Participation for Medical Director was met as evidenced by: 1. The HA failed to ensure the medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care for three of fourteen sample selected patients (Patient 5, Patient 6 and Patient 9). (Refer to L 668). 2. The hospice agency failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospice patient care program, that included, conducting an assessment, review, and verifying patient clinical information to consistently meet the needs of six of fourteen sampled patients (Patient 3, Patient 6, Patient 7, Patient 8, Patient 9 and Patient 10 ). (Refer to L 669). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for three of fourteen sampled patients (Patient 5, Patient 6 and Patient 9). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- a. A review of Patient 6s admission record indicated a start of care (SOC) date of 8/28/2023 with a primary diagnosis of Heart Disease, unspecified (A disease that affects the heart or the blood vessels which is a tube that circulates in the body). During a telephone interview with Patient 6 on 4/10/2024 at 1:30 p.m., Patient 6 stated ";I am not aware that I am under hospice program, I am healthy and I am not sick, I walk around our neighborhood, there is no doctor or nurse that talks or visits me and I dont need it". During a concurrent interview and record review on 4/12/2024 at 11:25 a.m. with the Director of Patient Care Services (DPCS), there is no indication of clinical records or documentations for hospice physician's face-to-face encounter regarding Patient 6s ";Physician Certification for Hospice Benefit" for third benefit recertification period from February 2024 to current date. The DPCS stated, ";I am not sure why the ";Physician Certification Benefit" for this period was not in patients clinical records." The DPCS stated, ";Probably the doctor did not submit the signed documents yet, the recertification has to be signed by the medical director before a new recertification period starts." The DPCS stated, ";It is important that it was done appropriately in a timely manner for billing purposes and for the consistency of patients clinical records. DPCS stated ";the medical director or hospice doctor should conduct a face to face in person with the patient to determine if the patient is still eligible to continue for the hospice services". The DPCS stated ";Patient 6s terminal illness is Heart Disease, the medical director came up with the diagnosis because of his symptoms and review of Patient 6s medical records". A request of Patient 6s previous medical records and H & P (History and physical) from the DPCS prior to hospice admission but the hospice agency was unable to provide it. During a telephone interview with the hospice agencys Medical Director (MD) on 4/12/2024 at 12:30 p.m., MD stated "; I will do a face to face visit with the patients to determine their hospice eligibility, the agency provided me the copies of patients H & P and medical records to review hospice eligibility, the registered nurses also help me for patients assessment, I am still completing my face to face visit with the patients around the local area and when I am done, I will start the face to face visit or set a video visit with patients live in central and northern California". A review of the hospice agencys policy and procedure titled ";Certification of Terminal Illness", revised November 2020, indicated that when certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, the certification maybe completed no more than fifteen (15) calendar days prior to the effective date of the hospice election statement, if written certification cannot be obtained within two (2) calendar days following the start of care, verbal certification must be obtained and documented in the clinical record within two (2) days following initiation of care, written certification must be obtained before the hospice submits a claim for payment and current relevant information supporting the diagnosis and the hospice physician or nurse practitioner must have face-to-face encounter with the patient within the 30 days prior to the third benefit period recertification and within 30 days prior to each subsequent recertification. A review pf the hospice agencys policy and procedure titled ";Physician Services – Medical Director, revised November 2020, indicated that the duties and responsibilities of the Medical Director will include, but not limited to the following: (7.) Providing written certification of the terminal illness including a short clinical narrative for all subsequent benefit periods and provide a face-to-face encounter visit with patient prior to third hospice benefit period and subsequent benefit periods. b. A review of Patient 5's ";Personal Information" indicated Patient 5 was admitted on 9/13/23 with a primary diagnosis of heart disease (refers to several types of heart conditions, such as coronary artery disease, which affects the blood flow to the heart). A review of Patient 5s clinical record, titled ";Physicians Certification for Hospice Benefit (CTI)," dated 12/10/2024, indicated that Patient 9 had a New York Heart Association (NYHA) class IV (a stage in heart failure that has severe limitations, experiences symptoms even while at rest). The physician narrative section for face to face summary in the CTI was left blank. A review of the ";F2F (Face to Face) Notes List" for Patient 5 indicated that Patient 5 had never had a face to face visit with a physician or physician designee despite being in his third episode of the hospice service. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 4/12/24 at 2:40 p.m., the DPCS reviewed the CTI and ";F2F Notes List." The DPCS stated that Patient 5 should have had a face to face encounter with a physician before the start of the third episode of the hospice benefit. c. A review of Patient 9's ";Personal Information" indicated Patient 9 was admitted on 7/9/23 with a primary diagnosis of atherosclerosis (plague build-up made of cholesterol, fat, and calcium inside the artery [blood vessel] walls) of native coronary artery with angina pectoris (chest pain) with spasms (sudden, involuntary muscle contractions). A review of Patient 9s clinical record, titled ";Physicians Certification for Hospice Benefit (CTI)," dated 1/3/2024, indicated that Patient 9s family member was the historian due to the patient exhibiting shortness of breath even at rest. The CTI indicated that Patient 9 was walker dependent and could only walk 7 to 9 steps. The physician narrative section for face to face summary in the CTI was left blank. During a telephone interview with Patient 9 on 4/11/24 at 10:34 a.m., the surveyor noted that Patient 9 spoke clearly and did not exhibit any shortness of breath throughout the interview, which lasted more than 30 minutes. Patient 9 denied being walker dependent. A review of the ";F2F (Face to Face) Notes List" for Patient 9 indicated that patient 9 had never had a face to face visit with a physician or physician designee despite being in her fourth episode of the hospice service. During an interview with the Director of Patient Services (DPCS) on 4/12/24 at 11 a.m., the DPCS stated that Patient 9 had a face to face encounter with Nurse Practitioner 1 (NP 1). When the survey team requested for the documentation of the face to face encounter, the DPCS stated she was going to look for it. At 2:35 p.m., the DPCS stated she could not find any documentation for the face to face encounter. During a telephone interview with NP 1 on 4/12/24 at 1:22 p.m., NP 1 stated she had never seen or assessed Patient 9. NP 1 stated the HA asked her to visit Patient 9, but the patient was always unavailable every time NP 1 tried to schedule an appointment to see her. NP 1 stated, ";I informed the agency that I had problem scheduling an appointment with her, and also with the other patients in Fresno. They always had something to do, or somewhere to go. These patients are supposed to be homebound."

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 medical director or physician designee assumed responsibility for the medical component of the hospice patient care program, that included, conducting an assessment, review, and verifying the patient clinical information to consistently meet the needs for six of 14 sampled patients (Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). This failure resulted in the hospice medical director and/or the hospice attending physicians to certify patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses and this could result in a lack of, and inappropriate care being provided to the patients. --- d. A review of Patient 3's ";Personal Information" indicated Patient 3 was admitted on 12/22/23 with a primary diagnosis of senile degeneration of brain (symptoms affecting memory, thinking and social abilities). A review of Patient 3s clinical record, titled ";Physicians Certification for Hospice Benefit (CTI)," dated 3/7/2024, indicated per LCD Guideline (Local Coverage Determination; coverage criteria by Medicare that determines whether service is covered or not) that Patient 3 had dementia due to Alzheimers. A review of Patient 3s ";LCD Hospice Eligibility Determination," dated 3/7/24, indicated that Patient 3 did not qualify per LCD guidelines. A review of Patient 3s recertification assessment, dated 3/7/24, completed by Registered Nurse 1 (RN 1), indicated Patient 3 had labored breathing. However, the respiratory section indicated Patient 3 had an oxygen saturation (the percentage of blood saturated with oxygen, 95% or higher is considered normal) of 98% at room air (not requiring supplemental oxygen). The recertification assessment also indicated that Patient 3 could only walk 3 to 5 steps with maximum assistance (75% of the work is done by the person providing assistance). The assessment also indicated that Patient 3 had memory disruptions at all times, decreased alertness, had slurred speech, and was confused. A review of Patient 3s ";Current Treatment/Medication/DME List" indicated there were no breathing treatments being used. During a joint home visit with RN 1 that was conducted through a video call on 4/10/24 at 12:15 p.m., Patient 3 was observed alert and oriented. Patient 3 spoke clearly with no slurred speech observed. The surveyor did not observe labored breathing. Family Member 1 (FM 1) was present via video call during the home visit. During a telephone interview on 4/10/24 at 12:47 p.m., which was conducted by a Spanish-speaking supervisor at Los Angeles County Department of Public Health, Patient 3 stated she was never diagnosed with Alzheimer. Patient 3 also stated her physician never informed her she had 6 months or less to live. During an interview with FM 1 on 4/11/24 at 11:32 a.m., FM 1 stated that Patient 3 was using a walker but was able to walk without another persons assistance. According to FM 1, Patient 3 was able to walk to the market or fast food restaurant near her house. FM 1 stated Patient 3 was never confused, never had breathing problems, or slurred speech. FM 1 stated Patient 3 was never diagnosed with Alzheimer. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 4/12/24 at 2:40 p.m., the DPCS reviewed Patient 3s CTI, LCD Hospice Eligibility Determination, and recertification assessment. The DPCS stated she could not find any clinical records that indicated Patient 3 having Alzheimer or senile degeneration of the brain. e. A review of Patient 7's ";Personal Information" indicated Patient 7 was admitted on 2/20/24 with a primary diagnosis of atherosclerosis (plague build-up made of cholesterol, fat, and calcium inside the artery [blood vessel] walls) of native coronary artery without angina pectoris (chest pain). A review of Patient 7s clinical record, titled ";Physicians Certification for Hospice Benefit," dated 2/20/2024, indicated per LCD Guideline that Patient 7 had heart disease. The certifying physician summary indicated that Patient 7 manifested shortness of breath just by talking. A review of Patient 7s ";LCD Hospice Eligibility Determination," dated 2/20/24, indicated Patient 7 had a New York Heart Association (NYHA) class IV heart failure (a stage in heart failure that has severe limitations, experiences symptoms even while at rest), had been ruled out as a candidate for surgical procedures, and had declined surgical procedures. During a telephone interview on 4/11/24 at 12:43 p.m., which was done with the assistance of a county Spanish interpreter, Patient 7 stated he did not have heart disease. Patient 7 stated his physician never told him that he had 6 months or less to live. Patient 7 stated the HA never informed him that hospice service was for dying people. Patient 7 stated he received a brochure about the HA from a vendor at the market where he bought food from, and somebody at the market told him if he called the phone number in the brochure, he would receive free things. Per Patient 7, he called the number in the brochure when he got home, and he was told that he had been approved. Patient 7 stated, ";Approved for what, Im not sure." The surveyor did not note any shortness of breath throughout the phone conversation, which lasted for 30 minutes. f. A review of Patient 9's ";Personal Information" indicated Patient 9 was admitted on 7/9/23 with a primary diagnosis of atherosclerosis (plague build-up made of cholesterol, fat, and calcium inside the artery [blood vessel] walls) of native coronary artery with angina pectoris (chest pain) with spasms (sudden, involuntary muscle contractions). A review of Patient 9s clinical record, titled ";Physicians Certification for Hospice Benefit," dated 1/3/2024, indicated per LCD Guideline that Patient 9 had heart disease. The certifying physician summary indicated that Patient 9 exhibited shortness of breath ";even at rest", when talking, and performing any task. A review of Patient 9s recertification assessment, dated 3/4/24, completed by RN 1, indicated Patient 9 had labored breathing. However, the respiratory section indicated Patient 9 had an oxygen saturation (the percentage of blood saturated with oxygen, 95% or higher is considered normal) of 98% at room air (not requiring supplemental oxygen). The recertification assessment also indicated that Patient 9 had memory disruptions at all times, slurred speech, and was confused. During a telephone interview with Patient 9 on 4/11/24 at 10:34 a.m., which was done with the assistance of a county Spanish interpreter, Patient 9 stated she did not remember who referred her to the HA. Patient 9 stated she did not know what hospice service was for. Patient 9 stated she had never been diagnosed with heart disease. Patient 9 also stated her physician had never told her she had 6 months or less to live. The surveyor did not note any shortness of breath during the interview, which lasted more than 30 minutes. Patient 9 spoke clearly with no slurred speech noted. Patient 9 was noted to be alert and oriented, not confused. During an interview with the Director of Patient Care Services (DPCS) on 4/12/24 at 10:35 a.m., the DPCS stated that for every terminal diagnosis, the HA had the clinical records to support it, which usually came from the physician who referred the patient to the HA. During a concurrent interview and record review with the DPCS on 4/12/24 at 2:40 p.m., the DPCS reviewed the CTI, LCD Hospice Eligibility Determination, and recertification assessment for Patient 7 and Patient 9. When asked for the clinical records or documentation that supported the diagnoses for Patient 7 and patient 9, the DPCS was not able to fulfil the request. The DPCS stated there were no supporting documents or H & P (history and physical – a record where a physician documents his/her findings which were obtained from a thorough medical history from the patient and a physical examination) to support the heart disease diagnosis for Patient 7 and Patient 9, or that they had NYHA class IV, had been ruled out for surgical procedures, or had declined surgical procedures related to their terminal conditions. a. A review of Patient 6s admission record indicated a start of care (SOC) date of 8/28/2023 with a primary diagnosis of Heart Disease, unspecified (A disease that affects the heart or the blood vessels which is a tube that circulates in the body). During a telephone interview with Patient 6 on 4/10/2024 at 1:30 p.m., Patient 6 stated ";I am not aware that I am under hospice program, I am healthy and I am not sick, I walk around our neighborhood, there is no doctor or nurse that talks or visits me and I dont need it". During a concurrent interview and record review on 4/12/2024 at 11:25 a.m. with the Director of Patient Care Services (DPCS), there is no indication of Patient 6s ";Physician Certification for Hospice Benefit" for third recertification period from February 2024 to current date. The DPCS stated, ";I am not sure why the ";Physician Certification Benefit" for this period was not in patients clinical records." The DPCS stated, ";Probably the doctor did not submit the signed documents yet, the recertification has to be signed by the medical director before a new recertification period starts." The DPCS stated, ";It is important that it was done appropriately in a timely manner for billing purposes and for the consistency of patients clinical records. DPCS stated ";the medical director or hospice doctor should conduct a face to face in person with the patient to determine if the patient is still eligible to continue for the hospice services". The DPCS stated ";Patient 6s terminal illness is Heart Disease, the medical director came up with the diagnosis because of his symptoms and review of Patient 6s medical records". A request of Patient 6s previous medical records and H & P (History and physical) from the DPCS prior to hospice admission but the hospice agency was unable to provide it. b. A review of Patient 8s admission record indicated a start of care (SOC) date of 12/22/2023 with a primary diagnosis of Hypertensive Heart Disease with Heart Failure (is a long-term condition that develops over many years in people who have high blood pressure, it is a group of medical problems like heart failure and irregular heartbeats that can happen when an individuals high blood pressure (hypertension) is unmanaged). A review of Patient 8s medical record form titled, ";Physician Certification for Hospice Benefit" dated from 3/21/2024 to 6/18/2024, indicated Patient 8 was completely dependent in 2 of 6 activities: ambulation and bathing. Patient 8's KPS was 50 (Karnofsky Performance Status – measure the level of patient activity – 50%: requires considerable assistance and frequent medical care), and the PPS was 50 (Palliative Performance Scale - tool to assess a patient's ability to function – 40%: mainly in bed, unable to do most activities). The NYHA IV classification (New York Heart Association) indicated Patient 8 was Class IV level (Class IV – inability to carry on any physical activity without discomfort, experiences symptoms even while at rest). It also indicated that Hospice Physician (MD2) electronically signed the form dated 3/7/2024. A review of Patient 8s medical record form titled ";Re-cert Assessment" with visit date of 3/7/2024, indicated in the ";ADL (Activities of Daily Living) Assessment" section that Patient 8 was completely dependent in 6 of 6 activities: ambulation, toileting, transfer, dressing, feeding and bathing. During a telephone interview on 4/12/2024 at 12:13 p.m. with the assistance of County Interpreter #403228, Patient 8, and his daughter (Family Member 1/FM1) was asked what hospice services were. FM1 stated, ";My father (Patient 8) is not under any hospice services, I am not aware of that." Patient 8 stated ";I have a heart condition, but I have a doctor that I see and I am awaiting for a heart surgery procedure, I do not know that I am in any hospice program and no other doctors or nurses that visits me from hospice, I was never told that I had six months or less to live. FM1 stated, ";I wasnt told that. Thats new to me. No, there has not been a doctor that told my father (Patient 8) had six months or less to live, my father walks well and able to drive, he does basically everything with very little help sometimes. We havent seen the agencys doctor or nurses either. My father (Patient 8) is seen by his primary doctor, I take care of my father and as far as we know he is not under hospice care, they have not heard of this agency, we are waiting for my fathers (Patient 8) heart surgery procedure." c. A review of Patient 10s admission record indicated a start of care (SOC) date of 11/8/2023 with a primary diagnosis of Senile Degeneration of Brain (A brain disorder that decrease in ability to think, concentrate or remember, slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). During a telephone interview on 4/11/2024 at 12:30 p.m. with the assistance of County Interpreter #403090, Patient 10, was asked what hospice services were. Patient 10 stated, ";I dont know about that, and I am not under any N S hospice services, I am not aware of that." Patient 10 stated ";I had a fall months ago related to job injury and was hospitalized for few days but it was minor, I live alone and take care of myself, I do not have any memory problems, I do not know that I am in any hospice program and no other doctors or nurses that visits me from hospice, I was never told that I had six months or less to live." Patient 10 stated "; I walk around our neighborhood, going to nearby store for my grocery and church, I used my walker but it was provided to me by my primary doctor, I feel good and I am not sick, I only take medication for my blood pressure, my primary doctor lives locally and I am his patient for around 6 to 7 years now, I dont remember he referred me to any hospice services. Patient 10 stated ";no nurses or doctor that call or visit me because I am not sick, I go to my doctors office which is few blocks away from where I live, sometimes police officers come to our neighborhood to do a welfare check on everyone but not nurses." During a telephone interview on 4/11/2024 at 1:30 p.m. with Medical Assistant (MA1), MA1 stated ";I know Patient 10 for a long time, I help her with the language interpretation with her doctor". MA1 stated ";I am working with Patient 10s primary doctor and we are located here locally, Patient 10 has been under their care for around 7 years now, her primary doctor is not available for interview as he is seeing patients." MA1 stated ";The clinic and her primary doctor are not aware that she is under hospice care, she is not sick, her memory is still sharp and intact, she comes to her appointment by herself riding on a bus, as far as I know our clinic did not refer her to any hospice services." MA1 stated ";I never heard of NS hospice agency and our clinic is not affiliated in any home health or hospice agencies." During a concurrent interview and record review on 4/12/2024 at 11:45 a.m. with the Director of Patient Care Services (DPCS), there is no indication of Patient 6s ";Physician Certification for Hospice Benefit" for third recertification period from February 2024 to current date. The DPCS stated, ";I am not sure why the ";Physician Certification Benefit" for this period was not in patients clinical records." The DPCS stated, ";Probably the doctor did not submit the signed documents yet, the recertification has to be signed by the medical director before a new recertification period starts." The DPCS stated, ";It is important that it was done appropriately in a timely manner for billing purposes and for the consistency of patients clinical records. DPCS stated ";the medical director or hospice doctor should conduct a face to face in person with the patient to determine if the patient is still eligible to continue for the hospice services". The DPCS stated ";Patient 6s terminal illness is Heart Disease, the medical director came up with the diagnosis because of his symptoms and review of Patient 6s medical records". A request of Patient 6, Patient 8 and Patient 10s previous medical records and H & P (History and physical) from the DPCS prior to hospice admission but the hospice agency was unable to provide it. DPCS stated ";The Medical Director (MD) reviews patients medical records and H & P to determine patients eligibility to the hospice program, I am not aware about the other patients not understanding the hospice program or not aware that they are under hospice, I honestly not know." DPCS stated ";our agency must ensure that hospice benefits and programs were fully explained to the patients to avoid confusion." During a telephone interview with the hospice agencys Medical Director (MD) on 4/12/2024 at 12:30 p.m., MD stated "; I will do a face to face visit with the patients to determine their hospice eligibility, the agency provided me the copies of patients H & P and medical records to review hospice eligibility, the registered nurses also help me for patients assessment, I am still completing my face to face visit with the patients around the local area and when I am done, I will start the face to face visit or set a video visit with patients live in central and northern California". MD stated ";I am not aware about the other patients that live in central and northern California that they do not know about hospice program, I certify them base on the nurses assessments, medical records and H&P."

Based on 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 Condition of Participation on Clinical Records were met as follows: The hospice agency failed to: 1). Ensure contents and information in the patients medical records were safeguarded against unauthorized access, alterations and modifications, by staffs not involved in providing direct patient care for four of 14 sampled patients (Patient 3, Patient 4, Patient 7, and Patient 9). This failure had the potential to result in an inaccurate patient information entered in the patients clinical record that could affect the patients quality of care and well-being. (Refer to L680). 2). Ensure discharge summary was available in the electronics medical record, in one of fourteen sampled patients (Patient 14). This deficient practice had the potential that continuity of care necessary in the care and wellbeing of the affected patient will be jeopardized. (Patient 14). (Refer to L684). The cumulative effects 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. --- .

Based on 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 contents and information in the patients medical records were safeguarded against unauthorized access, alterations and modifications, by staffs not involved in providing direct patient care, for four of 14 sampled patients, (Patient 3, Patient 4, Patient 7, and Patient 9). This failure had the potential to result in an inaccurate patient information entered in patients' clinical record that could affect the patients quality of care and well-being. --- a). A review of Patient 3's ";Personal Information" indicated Patient 3 was admitted to the hospice agency on 12/22/23 with a primary diagnosis of senile degeneration of brain (symptoms affecting memory, thinking and social abilities). A review of Patient 3s printed ";Audit Log" dated 4/8/2024 to 4/12/2024 which included ";all staff" and ";all modules," indicated the Registered Nurse 1 (RN 1) had made 16 electronic updates on Patient 3s records on 4/9/24, from 2:12 p.m. to 2:19 p.m., from Internet Protocol (IP, set of rules governing the format of data sent via the internet or local network, and IP addresses- the identifier that allows information to be sent between devices on a network which contains location information and makes devices accessible for communication) address, 120.28.193.13. A search on IP lookup tool (a type of domain that provides the IP address owner's contact information, the regional Internet registry [RIR] who assigned the IP, the assigned owner, location, and abuse reporting details) indicated the IP address was located in the Philippines. b). A review of Patient 4s admission record indicated a start of care (SOC) date of 3/27/2024 with a primary diagnosis of Chronic Obstructive Pulmonary Disease with acute exacerbation (COPD, a group of diseases that cause airflow blockage and breathing problems). A review of Patient 4s printed ";Audit Log" dated from 3/31/2024 to 4/1/2024, which included ";all staff", indicated that RN 2 made 80 document modifications with an IP address 49.146.164.136. When the IP address was searched, it indicated an IP location of Masbate, Philippines. During a concurrent interview and record review on 4/12/2024 at 2:00 p.m. with the Director of Patient Care Services (DPCS), Patient 4s ";Audit Log" was reviewed. The DPCS stated that RN 2 is a nursing staff who lives in Central California and had not been to the office. The DPCS stated that she (RN2) was involved in patient admissions around the local area that hospice agency is servicing. The DPCS stated RN2 contacts her (DPCS) via the telephone. The DPCS stated that RN2 logs into Electronic Medical Record (EMR) system to document when needed. The audit log was explained to the DPCS. The DPCS stated that all staff should safeguard their credentials and not permit others to log in, to document and to sign on behalf of a staff. The DPCS stated that RN2 was not on vacation on 3/31/2024 to 4/1/2024. The DPCS stated she was unsure why other staff in the Philippines had documented for RN2. On 4/12/2024 at 2:35 p.m., a request was made from the DPCS to call RN2 for a telephone interview, but she stated RN 2 was not available at this time and was on her other job. On 4/12/2024 at 2:40 p.m., during an interview with the Office Manager (OM), she stated according to her records, RN2 was not outside of the country on 3/31/2024-4/1/2024. c). A review of Patient 7's ";Personal Information" indicated Patient 7 was admitted to the hospice agency on 2/20/2024 with a primary diagnosis of atherosclerosis (plague build-up made of cholesterol, fat, and calcium inside the artery [blood vessel] walls) of native coronary artery without angina pectoris (chest pain). A review of Patient 7s printed ";Audit Log" dated 4/8/24 to 4/12/24 which included ";all staff" and ";all modules," indicated that on 4/9/2024, RN 1 had made 11 updates on Patient 4s electronic records from IP address 120.28.193.13. A search on IP lookup tool indicated the IP address was located in the Philippines. d). A review of Patient 9's ";Personal Information," indicated Patient 9 was admitted to the hospice agency on 7/9/23 with a primary diagnosis of atherosclerosis of native coronary artery with angina pectoris (chest pain) with spasms (sudden, involuntary muscle contractions). A review of Patient 9s printed ";Audit Log" dated 4/8/24 to 4/12/24, which included ";all staff" and ";all modules," indicated that on 4/9/24, RN 1 had made 25 updates on Patient 9s electronic records from IP address 120.28.193.13. A search on IP lookup tool indicated the IP address was located in the Philippines. The updates made by RN 1 for Patient 3, Patient 7, and Patient 9 were done on 4/9/2024 between 3:56 a.m. and 2:20 p.m. in the Philippines. However, the facility records indicated that RN 1, was making home visits to patients in Fresno, California on 4/10/2024, including a joint home visit at noon with the surveyor from the California Department of Public Health. During a concurrent interview and record review with the DPCS on 4/12/2024 at 2:55 p.m., the audit logs for Patient 3, Patient 7, and Patient 9 were reviewed. The DPCS confirmed that RN 1 worked at the hospice agency on 4/9/2024, and RN1 was not in the Philippines. During an interview with the Administrator (ADM) on 4/12/2024 at 3:30 p.m., the ADM stated the hospice agency had a contract with a third-party quality assurance (QA) company based in the Philippines. The ADM stated the QA companys role was to audit the charts or notes to see if the nurses had completed them. If the notes were not completed, the QA company would notify the hospice agency, so the hospice agency could have their nurse complete the notes. The ADM stated the QA company was not supposed to add, delete, or modify the charts or notes in any way. The ADM stated she was not aware the QA company had been modifying the patients charts. The ADM stated she did not know how the QA company was able to access the patients records using the nursing staffs credentials. During a request, the hospice agency was unable to provide a policy related to securing patients protected health information (PHI).

Based on 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 discharge summary was available in the electronics medical record, for one of fourteen sampled patients (Patient 14). This deficient practice had the potential that continuity of care necessary in the care and wellbeing of the affected patient, will be jeopardized. --- A review of Patient 14s admission record indicated a start of care (SOC) date of 12/24/2023 and an end of care (EOC) date of 12/24/2023 with a primary diagnosis of Chronic Obstructive Pulmonary Disease with acute exacerbation (COPD, a group of diseases that cause airflow blockage and breathing related problems). A review of Patient 14s clinical records titled ";Post Death Bereavement", dated 12/28/2023 indicated Patient 14s date of death was 12/24/2023. On 4/12/2024, at 2:30 p.m., during a concurrent interview and record review with the DPCS (Director of Patient Care Services), there was no documented discharge summary in Patient 14s clinical record. The DPCS stated that she was not aware that discharge summary was not completed. The DPCS stated the discharge summary it should have been completed at least 72 hours after the patient was discharge from hospice services. The DPCS acknowledged there was no discharge summary in the patients clinical record. A review of the hospice agency's policy and procedure titled, ";Discharge Summary", dated 11/ 2020, indicated that each patient discharged from a service and from hospice, will have a discharge summary completed and filed in the clinical record. Hospice personnel who provide care will complete a discharge summary at the time the discipline was discontinued, and should be completed and submitted within 72 hours of discharge from the service.

Based on observation and interview, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to implement state administrative policy when agency was seen to be operating with another entity inside their current location. This failure had resulted in having no written administrative policy for space/location developed and reviewed made available if necessary and the potential for violation of information privacy and confidentiality of patients in which the entity serves in this location. --- An unannounced complaint validation survey visit was conducted on 4/9/2024 at 11:00 a.m., at this proposed unapproved location, 517 E Wilson Ave, Suite 105A Glendale, CA 91206. (Unapproved proposed location). On 4/9/2024 at 11:10 a.m., during a quick facility tour and interview with the Administrator (ADM), Upon observation, this hospice agency was found to be sharing with a separate room in another entity a home health agency, there is one entrance door with signages suite 105 for Happy Life Home Health Care Inc. and suite 105A for NS Hospice, Inc. Inside the office location, there is one receptionist and reception area, there is a separate room within, with door signage of NS Hospice, Inc. and adjacent to the room is a separate conference room which also accessible by the other agency and one reception area. There is a separate staff and office equipment for both entities. On 4/9/2024 at 11:20 a.m., during an interview with ADM, she stated that there was only one entrance for both Suite 105 and Suite 105a, there is no other entrance or exit doors with one reception area, one receptionist for both agencies and conference room is shared by both agencies. ADM stated that the home health agency came to the suite first 8 months ago then the hospice agency came into suite 6 months ago. ADM stated that they have separate staff, and they dont share patients information of the two agencies and observe patients privacy of their health records. When asked, ADM was unable to provide a policy and procedure in relation to hospice agency as a separate entity to operate. A review of the state ";Administrative Policies Article 6.2 (A)(1) Policies-Administrative Policies" indicated that written administrative policies shall be developed and shall be reviewed as necessary and, if indicated, revised. These policies shall be made available to patients/families or their agents upon request. A review of the state ";Administrative Policies Article 6.2 (A)(2)(f) Policies-Administrative Policies" indicated These policies shall include, but not limited to: f. Patient care policies and procedures that govern record keeping and all services provided shall be established and followed. A review of the State regulation Title 22 Article 2. License. 72201 Application required" indicated Separate licenses shall be required for facilities which are maintained on separate premises even though they are under the same management. Separate licenses shall not be required for separate buildings on the same or adjacent grounds.