Every finding on record at New Century Hospice Inc

Based on interview and record review, the Hospice Agency (HA) failed to ensure that education and training were provided to the patient/patient’s caregiver related to blood pressure/blood sugar monitoring, logs, bleeding precautions while on anti-coagulant medication (medication that is used to prevent and treat blood clots in blood vessels and the heart), and safety precautions of oxygen therapy use for three of eight sampled patients (Patient 17, Patient 18, and Patient 19).This failure resulted in the HA’s inability to ensure the patient’s/patient caregiver’s understanding of possible risks, safety precautions, and side effects of medication. --- b. During a record review of Patient 18’s medical record form titled “Personal Information” the form indicated Patient 18’s start of care date was 11/6/2024 with a primary diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that cause progressive airflow obstruction and breathing difficulties), unspecified.During a review of Patient 18’s 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: -          Xarelto 10 milligrams (mg, unit of weight) tablet, one tablet, oral (by mouth), once a day for CVA (Cerebrovascular Accidents, are caused by blood clots and broken blood vessels in the brain) prophylaxis (to prevent disease or preserve health. During a review of Patient 18’s POC (Plan of Care,  consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient's needs)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 4/21/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus one PRN (pro re nata, which means “as needed”) visits to promote comfort and symptom management, the Master of Social Work (MSW) to visit once a month to provide psychosocial support to patient and family, Spiritual Counselor (SC) to visit every certification and as needed to identify spiritual needs to support patient/patient’s caregiver (PCG) and Hospice Aide (HA) to visit twice a week for personal care, home making, and to promote comfort. Upon further review, Patient 18’s POC/IDG dated 3/3/2025, 3/17/2025, 3/31/2025, 4/14/2025, and 4/21/2025 did not include a care plan for safety precautions while on oxygen therapy use and bleeding precautions while on anti-coagulant medication. During a home visit on 4/22/2025, at 10:00 a.m., Licensed Vocational Nurse (LVN 2) conducted a home visit with Patient 18.  Patient 18 was lying on her hospital bed, comfortably sleeping, in no apparent distress, on oxygen therapy 2liters (unit of measurement)/minutes via nasal canula (a simple medical device used to deliver supplemental oxygen through the nose, it consists of two flexible prongs that are inserted into the nostrils, connected to a tubing that delivers oxygen from a source) connected from oxygen concentrator (a medical device that separates oxygen from the air, concentrates it, and delivers it to the patient for supplemental oxygen therapy) machine.  Patient 18 has a caregiver on duty (CG9), CG9 stated that she works for Patient 18 during days and there is another caregiver at nighttime as well. CG9 stated that she does not remember if HA provided a signage for safety precautions regarding oxygen use. During a concurrent review of Patient 18’s HA folder at 10:15 a.m., with LVN 2, the signage for safety precautions regarding oxygen use was inside the folder. LVN 2 stated that this was the first time she visited Patient 18, LVN 2 stated that she does not know why the signage was inside the folder and not in a place where it is visible.   During a concurrent interview, and record review, on 4/22/2025, at 10:25 a.m., LVN 2 reviewed the medications Patient 18 was currently taking, using the patient’s record titled, “Current Treatment/Medication/DME List” printed on 4/21/2025.  The medications reviewed include:-          Xarelto 10 mg tablet, one tablet, oral, once a day for CVA prophylaxis.-          Oxygen concentrator 5L (stationary) with E-tank-          Nasal cannula LVN 2 stated that Xarelto is an anticoagulant medication that can cause bleeding, unusual bruising and dark stools. During a concurrent review of Patient 18’s HA folder at 10:30 a.m., with LVN 2, there was no educational materials, or references provided to Patient 18/CG9 regarding what symptoms or side effects to look for while patient is on anticoagulant medication. LVN2 stated that when a patient is on a new medication that is high risk, education and teaching needs to be provided to patients and caregivers to determine bleeding precautions, what symptoms or side effects to look for like blood in stool, and nosebleed. During the interview on 4/22/2025, at 10:48 a.m., with CG9, CG9 stated that she does not remember if HA visiting nurses provided teaching to her regarding bleeding precautions while Patient 18 is on Xarelto. CG9 stated that Patient 18 is still taking Xarelto as ordered. During an interview and concurrent record review of Patient 18’s following clinical records on 4/25/2025, at 2:30 p.m., with the Director of Patient Care Services (DPCS2), The DPCS2 confirmed and stated that Patient 18’s clinical record titled “The Plan of Care (POC)/Interdisciplinary Group (IDG, team consists of the Medical Director, PCA, Social Worker, Spiritual Chaplain and Volunteer Coordinator that work together towards the goal of the patient) Review,” dated 3/3/2025, 3/17/2025, 3/31/2025, 4/14/2025, and 4/21/2025, the POC/IDG Review indicated no  management of potential problems, interventions, goals regarding safety precautions for oxygen therapy use and bleeding precautions while on xarelto anti-coagulant medication. DPCS2 stated that a care plan should have been formulated for Patient 18 since she is bedbound, wheelchair bound and uses oxygen therapy via nasal cannula continuously, DPCS stated that care plan must address potential problems and for the nursing team to be aware of the goals and interventions and current health status of patient. DPCS2 stated that patient teaching must be done at the start of the care and at random, stated that it needs to be documented and needs to provide written education materials. Upon further review, the DPCS2 confirmed and stated that Patient 18’s clinical record titled “Visit Note LVN (Licensed Vocational Nurse),” dated 3/27/2025, 4/3/2025, 4/10/2025, and 4/17/2025, indicated no documentations to validate that visiting nurses provided teachings to Patient 18/Patient’18’s caregivers regarding safety precautions while oxygen therapy use and bleeding precautions while on anti-coagulant medication. c. During a record review of Patient 19’s medical record form titled “Personal Information” the form indicated Patient 19’s start of care date was 4/30/2024 with a primary diagnosis of cerebrovascular (disease that caused by blood clots and broken blood vessels in the brain) disease, unspecified.During a review of Patient 19’s 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:-          Clopidogrel 75 mg, tablet, one tablet, oral, once a day for blood thinner.During a review of Patient 19’s POC (Plan of Care,  consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient's needs)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 4/14/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus one PRN (pro re nata, which means “as needed”) visits to promote comfort and symptom management, the Master of Social Work (MSW) to visit once a month to provide psychosocial support to patient and family, Spiritual Counselor (SC) to visit every certification and as needed to identify spiritual needs to support patient/patient’s caregiver (PCG) and Hospice Aide (HA) to visit twice a week for personal care, home making, and to promote comfort. Upon further review, Patient 19’s POC/IDG dated 2/17/2025, 3/3/2025, 3/17/2025, 3/31/2025, and 4/14/2025, did not include a care plan for bleeding precautions while on anti-coagulant medication. During an interview and concurrent record review of Patient 19’s following clinical records on 4/25/2025, at 2:45 p.m., with the Director of Patient Care Services (DPCS2), The DPCS2 confirmed and stated that Patient 18’s clinical record titled “The Plan of Care (POC)/Interdisciplinary Group (IDG, team consists of the Medical Director, PCA, Social Worker, Spiritual Chaplain and Volunteer Coordinator that work together towards the goal of the patient) Review,” dated 2/17/2025, 3/3/2025, 3/17/2025, 3/31/2025, and 4/14/2025, the POC/IDG Review indicated no  management of potential problems, interventions, goals regarding bleeding precautions while on clopidogrel anti-coagulant medication. . Upon further review, the DPCS2 confirmed and stated that Patient 19’s clinical record titled “Visit Note LVN (Licensed Vocational Nurse),” dated 3/17/2025, 3/24/2025, 3/31/2025, 4/7/2025, and 4/14/2025, did not have documentations to validate that visiting nurses provided teachings to Patient 19/Patient 19’s caregivers regarding bleeding precautions while on anti-coagulant medication. DPCS2 stated that visiting nurses need to provide education and teachings regarding safety precautions and what to look for if patient is using high risk medications like anticoagulant medications and when to report to the HA. DPCS2 stated that teaching must be documented to validate that it was provided to patient and caregivers. DPCS2 stated that a care plan should have been formulated for Patient 19, DPCS stated that care plan must address potential problems and for the nursing team to be aware of the goals and interventions and current health status of patients. DPCS2 stated that patient teaching must be done at the start of the care and at random, stated that it needs to be documented and needs to provide written education materials.  During a review of the HA's Policy and Procedure (P&P) titled, Patient education process, undated, indicated "Patients and family/caregivers will receive education in verbal, visual, and written format, as appropriate. The scope of teaching will be determined by the assessed needs, abilities, learning preferences, and readiness to learn of the patient and family/caregiver, as well as by the plan of care. Education will be the responsibility of each interdisciplinary group member".     During an interview on 4/23/2025 at 1:15pm with the Director of Patient Care Services 2 (DPCS2), the DPCS2 stated not all patients who have a diagnosis of Diabetes (a condition where blood sugar levels become too high) will have an order from the physician to check the patient’s blood sugar level. The DPCS2 continued to state that if the patient does have a physician order to check the blood sugar, then it will state how often to check it and if the SN is to check it or the family/caregiver. The DPCS2 stated if the order indicates for the HA SN to check the blood sugar, then the SN is to check the blood sugar during the home visits and document the level in the nursing visit note. The DPCS2 continued to state that some physician orders can indicate to check the blood sugar twice a day, and if so the nurse will only check it during the scheduled home visits and the other days and second time of the day, will be done by the family/caregiver. The DPCS2 stated if the order indicated for the patient’s family/caregiver to check the blood sugar, then the SN is to monitor the blood sugar level during the home visits. The DPCS2 continued to state that meant the SN is to ask the family/caregiver what the patient’s blood sugar levels were for the week and document it in the nursing visit note. The DPCS2 further stated the SN is to verify if the patient’s family/caregiver is able to monitor the blood sugar level, educate them on how to perform blood sugar monitoring, and provide them with the supplies needed like the glucometer (medical device for measuring the concentration of blood sugar), alcohol pads, lancets (small, sterile needles used to obtain a small drop of blood to monitor blood sugar levels) and testing strips. a. During a review of Patient 17’s medical record titled, Personal Information, undated, indicated a Start of Care (SOC) date of 10/14/2024, with a primary diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).During a review of Patient 17’s medical record titled, Plan of Care/ Interdisciplinary Group (POC/IDG) Review for certification period #6 dated 4/14/2025, indicated order for frequency of visits of the Skilled Nurse (SN) for 2 times per week with 1 as needed (PRN) visit to promote comfort and symptom management. The POC/IDG also indicated Patient 17 is at risk for unstable blood glucose related to Diabetes, and the SN is to assess for sign and symptoms of hypoglycemia (low blood sugar)/ hyperglycemia (high blood sugar) at every visit, instruct the PCG on a healthy diet and lifestyle, assess the PCG’s current knowledge and understanding about the prescribed diet, have the PCG report blood sugar below 60 mg/dl or above 300 mg/dl, instruct the PCG regarding the prescribed medication and side effects, and monitor/assess effectiveness of current medication.During a review of Patient 17’s medical record titled, Current treatment/ medication/ durable medical equipment list, undated, indicated a medication order for:Glipizide/Metformin Hydrochloride (diabetes medication) 5 milligrams (mg- unit of measurement)- 500 mg, 2 tablets (10mg- 100mg) twice a day for in indication of Diabetes ( a condition where blood sugar levels become too high)Blood sugar monitoring to be taken by the family/caregiver twice daily before meal. Primary caregiver (PCG) will manage blood glucose by using glucometer (medical device for measuring the concentration of blood sugar). Note: Report blood sugar level below 60 mg/ deciliter (dl- unit of measurement) and above 400.During a joint home visit on 4/22/2025 at 12:42pm with the Licensed Vocational Nurse 2 (LVN2) at Patient 17’s assisted living facility, Patient 17 was observed sitting up on a wheelchair, awake, alert and oriented self, and able to answer some simple questions with yes or no responses. During a joint home visit on 4/22/2025 at 1:08pm with LVN2 at Patient 17’s assisted living facility, LVN2 was not observed completing Patient 17’s head to toe assessment, and did not assess the patient’s blood sugar level. The LVN2 stated she was done with her assessment, sanitized her equipment and put it away.During an interview on 4/22/2025 at 1:24pm with Patient 17’s medication technician at the assisted living facility, the medication technician stated that as a medication technician in the assisted living facility they are not allowed to check any patient’s blood sugar levels, they just administer the medication to the patients. The medication technician stated he has never seen any of the SN’s from the HA check the patient’s blood sugar levels during their visits. The medication technician stated when he is on shift he has also not seen Patient 17’s family check the patient’s blood sugar levels.During an interview on 4/22/2025 at 1:28pm with LVN2, LVN2 stated she reviewed the patient’s plan of care, and it did not indicate an order to assess the blood sugar level, and that is why she did not assess Patient 17’s blood sugar level and did not bring a glucometer with her. During a concurrent interview and record review on 4/23/2024 at 1:21pm with the DPCS2, Patient 17’s Electronic Medical Record (EMR) was reviewed. The DPCS2 stated and confirmed Patient 17 did have an order to monitor her blood sugar twice a day. Patient 17’s POC/IDG review dated 4/14/2025 was reviewed, and the DPCS2 stated and confirmed that the POC/IDG did not include documented evidence of the order to monitor the patient’s blood sugar twice a day, under the care plan for endocrine. The DPCS2 stated this information was not communicated with the patients SN’s, as it was not transcribed over to the patient’s POC. The DPCS2 stated Patient 17’s POC/IDG did indicate an intervention for the SN to monitor/assess effectiveness of the current medication, and patient caregiver (PCG) to report blood sugar below 60 or above 350. The DPCS2 stated the SN or patient’s family would not have been able to carry out these interventions, like when to report if the blood sugar level was low or high or if the medication was controlling the blood sugar levels, because the order to monitor the blood sugar was missing from the POC/IDG, and it was not being done. The DPCS2 stated because Patient 17 lives in an assisted living facility where the medication technicians do not check blood sugar levels, the HA should have communicated that with the physician and with the SN and the patient’s family. The DPCS2 stated that in Patient 17’s situation, what should have been done is the SN would educate the patient’s family on blood sugar monitoring, provide the supplies needed, and on the scheduled home visits, the SN would assess the patient’s blood sugar levels. The DPCS2 stated it is important that all care staff review the patient’s POC/IDG with current orders to verify all treatment and medications orders are transcribed over to the POC, so all care staff follow the POC, providing the patient with the proper care. The DPCS2 stated it is also important to communicate all orders with the HA SN so they provide the patient and/or family with the education and training needed to that they too can provide the patient with proper care.During a concurrent interview and record review on 4/23/2025 at 1:30 pm with the DPCS2, Patient 17’s medical records titled, visit note LVN for the visit dates of 3/3/2025, 3/7/2025, 3/10/2025, 3/13/2025, 3/17/2025, 3/20/2025, 3/24/2025, 3/27/2025, 3/31/2025, 4/3/2025, 4/7/2025, 4/10/2025, 4/14/2025, 4/17/2025, 4/21/2025, 4/22/205, and 4/24/2205 were reviewed. The DPCS2 stated and confirmed that the Patient 17’s visit notes for the dates of 3/3/2025, 3/7/2025, 3/10/2025, 3/13/2025, 3/17/2025, 3/20/2025, 3/24/2025, 3/27/2025, 3/31/2025, 4/3/2025, 4/7/2025, 4/10/2025, 4/14/2025, 4/17/2025, 4/21/2025, 4/22/205, and 4/24/2205 did not have documented evidence of the patient’s blood sugar level. The DPCS2 stated the SN’s did not document, under the Endocrine section or the narrative section, Patient 17’s blood sugar level or if any education or training was provided to the patient’s family. The DPCS2 further stated if the visit note does not have documentation of the patient’s blood sugar level, then it indicates it was not done.During a telephone interview on 4/24/2025 at 10:56am with Patient 17’s daughter, Patient 17’s daughter stated the patient does live at an assisted living facility and has HA nurses visit her twice a week. Patient 17’s daughter stated she has good communication with the HA nurses, and they call her once a week to give her an update or feedback on Patient 17. Patient 17’s daughter stated she was not told or educated by the HA nurses about monitoring the patient’s blood sugar levels or trained how to do it.During a review of the HA's Policy and Procedure (P&P) titled, Patient education process, undated, indicated "Patients and family/caregivers will receive education in verbal, visual, and written format, as appropriate. The scope of teaching will be determined by the assessed needs, abilities, learning preferences, and readiness to learn of the patient and family/caregiver, as well as by the plan of care. Education will be the responsibility of each interdisciplinary group member".

Based on observation, interview and record review, the Hospice Agency failed to develop an individualized plan of care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver) that includes management of potential problems, interventions, and goals for safety precautions while on oxygen therapy use ( a treatment that provides a patient with extra oxygen to breathe in) and use of anticoagulant (blood thinner medication that can cause serious bleeding) medication for two of eight sampled patients (Patient 18 and Patient 19). This deficient practice resulted in patients with no formulated POC for the   current health status for management of symptoms of terminal illness that is likely to cause delayed care, undetected signs of physical, emotional, and spiritual needs when transitioning to the final stages of dying process. --- Findings:a. During a record review of Patient 18’s medical record form titled “Personal Information” the form indicated Patient 18’s start of care date was 11/6/2024 with a primary diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that cause progressive airflow obstruction and breathing difficulties), unspecified.During a review of Patient 18’s 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: -          Xarelto 10 milligrams (mg, unit of weight) tablet, one tablet, oral (by mouth), once a day for CVA (Cerebrovascular Accidents, are caused by blood clots and broken blood vessels in the brain) prophylaxis (to prevent disease or preserve health. During a review of Patient 18’s POC (Plan of Care,  consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient's needs)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 4/21/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus one PRN (pro re nata, which means “as needed”) visits to promote comfort and symptom management, the Master of Social Work (MSW) to visit once a month to provide psychosocial support to patient and family, Spiritual Counselor (SC) to visit every certification and as needed to identify spiritual needs to support patient/patient’s caregiver (PCG) and Hospice Aide (HA) to visit twice a week for personal care, home making, and to promote comfort. Upon further review, Patient 18’s POC/IDG dated 3/3/2025, 3/17/2025, 3/31/2025, 4/14/2025, and 4/21/2025 did not include a care plan for safety precautions while on oxygen therapy use and bleeding precautions while on anti-coagulant medication. During a home visit on 4/22/2025, at 10:00 a.m., Licensed Vocational Nurse (LVN 2) conducted a home visit with Patient 18.  Patient 18 was lying on her hospital bed, comfortably sleeping, in no apparent distress, on oxygen therapy 2liters (unit of measurement)/minutes via nasal canula (a simple medical device used to deliver supplemental oxygen through the nose, it consists of two flexible prongs that are inserted into the nostrils, connected to a tubing that delivers oxygen from a source) connected from oxygen concentrator (a medical device that separates oxygen from the air, concentrates it, and delivers it to the patient for supplemental oxygen therapy) machine.  Patient 18 has a caregiver on duty (CG9), CG9 stated that she works for Patient 18 during days and there is another caregiver at nighttime as well. CG9 stated that she does not remember if HA provided a signage for safety precautions regarding oxygen use. During a concurrent review of Patient 18’s HA folder at 10:15 a.m., with LVN 2, the signage for safety precautions regarding oxygen use was inside the folder. LVN 2 stated that this was the first time she visited Patient 18, LVN 2 stated that she does not know why the signage was inside the folder and not in a place where it is visible.   During a concurrent interview, and record review, on 4/22/2025, at 10:25 a.m., LVN 2 reviewed the medications Patient 18 was currently taking, using the patient’s record titled, “Current Treatment/Medication/DME List” printed on 4/21/2025.  The medications reviewed include:-          Xarelto 10 mg tablet, one tablet, oral, once a day for CVA prophylaxis.-          Oxygen concentrator 5L (stationary) with E-tank-          Nasal cannula LVN 2 stated that Xarelto is an anticoagulant medication that can cause bleeding, unusual bruising and dark stools. During a concurrent review of Patient 18’s HA folder at 10:30 a.m., with LVN 2, there was no educational materials, or references provided to Patient 18/CG9 regarding what symptoms or side effects to look for while patient is on anticoagulant medication. LVN2 stated that when a patient is on a new medication that is high risk, education and teaching needs to be provided to patients and caregivers to determine bleeding precautions, what symptoms or side effects to look for like blood in stool, and nosebleed. During the interview on 4/22/2025, at 10:48 a.m., with CG9, CG9 stated that she does not remember if HA visiting nurses provided teaching to her regarding bleeding precautions while Patient 18 is on Xarelto. CG9 stated that Patient 18 is still taking Xarelto as ordered. During an interview and concurrent record review of Patient 18’s following clinical records on 4/25/2025, at 2:30 p.m., with the Director of Patient Care Services (DPCS2), The DPCS2 confirmed and stated that Patient 18’s clinical record titled “The Plan of Care (POC)/Interdisciplinary Group (IDG, team consists of the Medical Director, PCA, Social Worker, Spiritual Chaplain and Volunteer Coordinator that work together towards the goal of the patient) Review,” dated 3/3/2025, 3/17/2025, 3/31/2025, 4/14/2025, and 4/21/2025, the POC/IDG Review indicated no  management of potential problems, interventions, goals regarding safety precautions for oxygen therapy use and bleeding precautions while on xarelto anti-coagulant medication. DPCS2 stated that a care plan should have been formulated for Patient 18 since she is bedbound, wheelchair bound and uses oxygen therapy via nasal cannula continuously, DPCS stated that care plan must address potential problems and for the nursing team to be aware of the goals and interventions and current health status of patient. DPCS2 stated that patient teaching has to be done at the start of the care and at random, stated that it needs to be documented and needs to provide written education materials.  b. During a record review of Patient 19’s medical record form titled “Personal Information” the form indicated Patient 19’s start of care date was 4/30/2024 with a primary diagnosis of cerebrovascular (disease that caused by blood clots and broken blood vessels in the brain) disease, unspecified.During a review of Patient 19’s 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:-          Clopidogrel 75 mg, tablet, one tablet, oral, once a day for blood thinner.During a review of Patient 19’s POC (Plan of Care,  consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient's needs)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 4/14/2025, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus one PRN (pro re nata, which means “as needed”) visits to promote comfort and symptom management, the Master of Social Work (MSW) to visit once a month to provide psychosocial support to patient and family, Spiritual Counselor (SC) to visit every certification and as needed to identify spiritual needs to support patient/patient’s caregiver (PCG) and Hospice Aide (HA) to visit twice a week for personal care, home making, and to promote comfort. Upon further review, Patient 19’s POC/IDG dated 2/17/2025, 3/3/2025, 3/17/2025, 3/31/2025, and 4/14/2025, did not include a care plan for bleeding precautions while on anti-coagulant medication. During an interview and concurrent record review of Patient 19’s following clinical records on 4/25/2025, at 2:45 p.m., with the Director of Patient Care Services (DPCS2), The DPCS2 confirmed and stated that Patient 18’s clinical record titled “The Plan of Care (POC)/Interdisciplinary Group (IDG, team consists of the Medical Director, PCA, Social Worker, Spiritual Chaplain and Volunteer Coordinator that work together towards the goal of the patient) Review,” dated 2/17/2025, 3/3/2025, 3/17/2025, 3/31/2025, and 4/14/2025, the POC/IDG Review indicated no  management of potential problems, interventions, goals regarding bleeding precautions while on clopidogrel anti-coagulant medication. DPCS2 stated that a care plan should have been formulated for Patient 19, DPCS stated that care plan must address potential problems and for the nursing team to be aware of the goals and interventions and current health status of patients. DPCS2 stated that patient teaching must be done at the start of the care and at random, stated that it needs to be documented and needs to provide written education materials. During a review of the HA’s policy and procedure, titled “The Plan of Care,” updated, the policy and procedure indicated that a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program.

Based on observation, interview and record review the Hospice Agency (HA) failed to follow the patient’s Plan of Care (POC - an individualized care planned) to monitor and/or assess the effectiveness of current and new medication/treatment, as per physician orders, to help identify patterns for two of eight sampled patients (Patient 17 and Patient 18).This deficient practice resulted in patient’s blood sugar and blood pressure readings not being monitored accordingly, that could have had an effect on the effectiveness of the current medications and treatment administered. --- During an interview on 4/23/2025 at 1:15pm with the Director of Patient Care Services 2 (DPCS2), the DPCS2 stated not all patients who have a diagnosis of Diabetes (a condition where blood sugar levels become too high) will have an order from the physician to check the patient’s blood sugar level. The DPCS2 continued to state that if the patient does have a physician order to check the blood sugar, then it will state how often to check it and if the SN is to check it or the family/caregiver. The DPCS2 stated if the order indicates for the HA SN to check the blood sugar, then the SN is to check the blood sugar during the home visits and document the level in the nursing visit note. The DPCS2 continued to state that some physician orders can indicate to check the blood sugar twice a day, and if so the nurse will only check it during the scheduled home visits and the other days and second time of the day, will be done by the family/caregiver. The DPCS2 stated if the order indicated for the patient’s family/caregiver to check the blood sugar, then the SN is to monitor the blood sugar level during the home visits. The DPCS2 continued to state that meant the SN is to ask the family/caregiver what the patient’s blood sugar levels were for the week and document it in the nursing visit note. The DPCS2 further stated the SN is to verify if the patient’s family/caregiver is able to monitor the blood sugar level, educate them on how to perform blood sugar monitoring, and provide them with the supplies needed like the glucometer (medical device for measuring the concentration of blood sugar), alcohol pads, lancets (small, sterile needles used to obtain a small drop of blood to monitor blood sugar levels) and testing strips.   a. During a review of Patient 17’s medical record titled, Personal Information, undated, indicated a Start of Care (SOC) date of 10/14/2024, with a primary diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).During a review of Patient 17’s medical record titled, Plan of Care/ Interdisciplinary Group (POC/IDG) Review for certification period #6 dated 4/14/2025, indicated order for frequency of visits of the Skilled Nurse (SN) for 2 times per week with 1 as needed (PRN) visit to promote comfort and symptom management. The POC/IDG also indicated Patient 17 is at risk for unstable blood glucose related to Diabetes, and the SN is to assess for sign and symptoms of hypoglycemia (low blood sugar)/ hyperglycemia (high blood sugar) at every visit, instruct the PCG on a healthy diet and lifestyle, assess the PCG’s current knowledge and understanding about the prescribed diet, have the PCG report blood sugar below 60 mg/dl or above 300 mg/dl, instruct the PCG regarding the prescribed medication and side effects, and monitor/assess effectiveness of current medication.During a review of Patient 17’s medical record titled, Current treatment/ medication/ durable medical equipment list, undated, indicated a medication order for:Glipizide/Metformin Hydrochloride (diabetes medication) 5 milligrams (mg- unit of measurement)- 500 mg, 2 tablets (10mg- 100mg) twice a day for in indication of Diabetes ( a condition where blood sugar levels become too high)Blood sugar monitoring to be taken by the family/caregiver twice daily before meal. Primary caregiver (PCG) will manage blood glucose by using glucometer (medical device for measuring the concentration of blood sugar). Note: Report blood sugar level below 60 mg/ deciliter (dl- unit of measurement) and above 400.During a joint home visit on 4/22/2025 at 12:42pm with the Licensed Vocational Nurse 2 (LVN2) at Patient 17’s assisted living facility, Patient 17 was observed sitting up on a wheelchair, awake, alert and oriented self, and able to answer some simple questions with yes or no responses. During a joint home visit on 4/22/2025 at 1:08pm with LVN2 at Patient 17’s assisted living facility, LVN2 was not observed completing Patient 17’s head to toe assessment, and did not assess the patient’s blood sugar level. The LVN2 stated she was done with her assessment, sanitized her equipment and put it away.During an interview on 4/22/2025 at 1:24pm with Patient 17’s medication technician at the assisted living facility, the medication technician stated that as a medication technician in the assisted living facility they are not allowed to check any patient’s blood sugar levels, they just administer the medication to the patients. The medication technician stated he has never seen any of the SN’s from the HA check the patient’s blood sugar levels during their visits. The medication technician stated when he is on shift he has also not seen Patient 17’s family check the patient’s blood sugar levels.During an interview on 4/22/2025 at 1:28pm with LVN2, LVN2 stated she reviewed the patient’s plan of care, and it did not indicate an order to assess the blood sugar level, and that is why she did not assess Patient 17’s blood sugar level and did not bring a glucometer with her. During a concurrent interview and record review on 4/23/2024 at 1:21pm with the DPCS2, Patient 17’s Electronic Medical Record (EMR) was reviewed. The DPCS2 stated and confirmed Patient 17 did have an order to monitor her blood sugar twice a day. Patient 17’s POC/IDG review dated 4/14/2025 was reviewed, and the DPCS2 stated and confirmed that the POC/IDG did not include documented evidence of the order to monitor the patient’s blood sugar twice a day, under the care plan for endocrine. The DPCS2 stated this information was not communicated with the patients SN’s, as it was not transcribed over to the patient’s POC. The DPCS2 stated Patient 17’s POC/IDG did indicate an intervention for the SN to monitor/assess effectiveness of the current medication, and patient caregiver (PCG) to report blood sugar below 60 or above 350. The DPCS2 stated the SN or patient’s family would not have been able to carry out these interventions, like when to report if the blood sugar level was low or high or if the medication was controlling the blood sugar levels, because the order to monitor the blood sugar was missing from the POC/IDG, and it was not being done. The DPCS2 stated because Patient 17 lives in an assisted living facility where the medication technicians do not check blood sugar levels, the HA should have communicated that with the physician and with the SN and the patient’s family. The DPCS2 stated that in Patient 17’s situation, what should have been done is the SN would educate the patient’s family on blood sugar monitoring, provide the supplies needed, and on the scheduled home visits, the SN would assess the patient’s blood sugar levels. The DPCS2 stated it is important that all care staff review the patient’s POC/IDG with current orders to verify all treatment and medications orders are transcribed over to the POC, so all care staff follow the POC, providing the patient with the proper care. The DPCS2 stated it is also important to communicate all orders with the HA SN so they provide the patient and/or family with the education and training needed to that they too can provide the patient with proper care.During a concurrent interview and record review on 4/23/2025 at 1:30 pm with the DPCS2, Patient 17’s medical records titled, visit note LVN for the visit dates of 3/3/2025, 3/7/2025, 3/10/2025, 3/13/2025, 3/17/2025, 3/20/2025, 3/24/2025, 3/27/2025, 3/31/2025, 4/3/2025, 4/7/2025, 4/10/2025, 4/14/2025, 4/17/2025, 4/21/2025, 4/22/205, and 4/24/2205 were reviewed. The DPCS2 stated and confirmed that the Patient 17’s visit notes for the dates of 3/3/2025, 3/7/2025, 3/10/2025, 3/13/2025, 3/17/2025, 3/20/2025, 3/24/2025, 3/27/2025, 3/31/2025, 4/3/2025, 4/7/2025, 4/10/2025, 4/14/2025, 4/17/2025, 4/21/2025, 4/22/205, and 4/24/2205 did not have documented evidence of the patient’s blood sugar level. The DPCS2 stated the SN’s did not document, under the Endocrine section or the narrative section, Patient 17’s blood sugar level or if any education or training was provided to the patient’s family. The DPCS2 further stated if the visit note does not have documentation of the patient’s blood sugar level, then it indicates it was not done.During a telephone interview on 4/24/2025 at 10:56am with Patient 17’s daughter, Patient 17’s daughter stated the patient does live at an assisted living facility and has HA nurses visit her twice a week. Patient 17’s daughter stated she has good communication with the HA nurses, and they call her once a week to give her an update or feedback on Patient 17. Patient 17’s daughter stated she was not told or educated by the HA nurses about monitoring the patient’s blood sugar levels or trained how to do it.During a record review of the HA’s form titled “Statement of Deficiencies and Plan of Corrections” with a completion date of 4/18/2025, indicated "2. HA will review the plan of care for every patient during IDG with the care team. Discussion regarding accuracy and needs of the patients and families are discussed." b. During a record review of Patient 18’s medical record form titled “Personal Information” the form indicated Patient 18’s start of care date was 11/6/2024 with a primary diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that cause progressive airflow obstruction and breathing difficulties), unspecified. During a review of Patient 18’s medical record titled, Current treatment/ medication/ durable medical equipment list, undated, indicated a medication order for:-        Metoprolol Succinate (medication for hypertension), 25 milligrams (mg, unit of weight), one tablet, oral (by mouth), one tablet daily for hypertension (a condition where the force of blood against the artery walls is consistently too high).  During a home visit on 4/22/2025, at 10:00 a.m., Licensed Vocational Nurse (LVN 2) conducted a home visit with Patient 18.  Patient 18 was lying on her hospital bed, comfortably sleeping, in no apparent distress, on oxygen therapy 2liters(unit of measurement)/minutes via nasal canula (a simple medical device used to deliver supplemental oxygen through the nose, it consists of two flexible prongs that are inserted into the nostrils, connected to a tubing that delivers oxygen from a source) connected from oxygen concentrator (a medical device that separates oxygen from the air, concentrates it, and delivers it to the patient for supplemental oxygen therapy) machine.  Patient 18 has a caregiver on duty (CG9), CG9 stated that she works for Patient 18 during days and there is another caregiver at nighttime as well. CG9 stated she monitored Patient 18’s blood pressure readings daily before giving her blood pressure medications. CG9 stated that there were no given parameters when not to give blood pressure medications but stated that Patient 18’s blood pressure readings were always high. CG9 stated that she document in her own log not provided by the HA to write down Patient 18’s daily BP readings and if there were abnormal readings, stated she would call the HA nurse for directions. CG9 stated that Patient 18’s blood pressure readings average as always above 120/80.During a concurrent observation, interview, and record review, on 4/22/2025, at 10:25 a.m., LVN 2 reviewed the medications Patient 18 was currently taking, using the patient’s record titled, “Current Treatment/Medication/DME List” printed on 4/21/2025.  The medications which include: -        Metoprolol Succinate (medication for hypertension), 25 milligrams (mg, unit of weight), one tablet, oral (by mouth), one tablet daily for hypertension (a condition where the force of blood against the artery walls is consistently too high).LVN2 confirmed and stated that there were no given blood pressure parameters prior to administering the medication. LVN2 stated that CG9 was well informed when not giving BP medications. LVN2 stated that HA is supposed to provide a BP log for patient and patient’s caregiver to better monitor the daily BP readings and to determine if BP medications are working well and need to be adjusted. LVN 2 stated that BP parameters prior to administration of BP medication is important to avoid complications, low blood pressure and adverse reactions.During a concurrent interview and record review on 4/24/2024 at 12:34 pm with the DPCS2, Patient 18’s Electronic Medical Record (EMR) titled Patient 18’s “POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient's needs)” form dated 4/21/2025, was reviewed. The POC indicated under “Cardiovascular (pertains to the heart and blood vessels)”, with goal of – “Patient will maintain SBP (systolic blood pressure, when the vessels constrict) not greater than (>) 129 or less than (<)90, DBP (diastolic blood pressure, when vessels relax) or less than (<) 60 within the next 2 weeks and will re-evaluate on the next IDT meeting.” DPCS2 stated that BP parameters needed if patient is taking BP medication to avoid complications such as low blood pressure and should be consistent with the POC and patient/family should be able to monitor BP readings. DPCS2 stated that goal per POC must be followed and if BP not monitored regularly then it would be inconsistent with the IDT’s re-evaluation. DPCS2 stated that patient and patient’s caregiver should have a BP log of their own but the HA can also provide for them. DPCS2 stated that teachings regarding BP readings and ranges/parameter, when it is out of range should be provided and consistently reminded to patient/patient’s caregiver. DPCS stated that teachings provided to patients and patients’ caregivers must be documented on each encounter. DPCS2 stated that POC must include what patient and patients ‘caregiver BP readings need to be reported to HA. DPCS2 stated it is important that all care staff review the patient’s POC/IDG with current orders to verify all treatment and medications orders are transcribed over to the POC, so all care staff follow the POC, providing the patient with the proper care. DPCS2 stated it is also important to communicate all orders with the HA SN so they provide the patient and/or family with the education and training needed to that they too can provide the patient with proper care.During a record review of the HA’s form titled “Statement of Deficiencies and Plan of Corrections” with a completion date of 4/18/2025, indicated "2. HA will review the plan of care for every patient during IDG with the care team. Discussion regarding accuracy and needs of the patients and families are discussed."

Based on observation, interview, and record review, the HA failed to establish a policy and procedure to ensure that patient’s outdated, mislabeled, or unusable medications were disposed in accordance with currently accepted professional practice for one of eight sampled patients (Patient 18). This deficient practice resulted in HA not having a standardized practice of disposing unused patient’s medications and had the potential to put the patient at risk for medication errors and adverse drug reactions. --- Findings:During a review of Patient 18’s “Personal Information” the form indicated Patient 18’s start of care date was 11/6/2024 with a primary diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that cause progressive airflow obstruction and breathing difficulties), unspecified. During a home visit on 4/22/2025, at 10:00 a.m., Licensed Vocational Nurse (LVN 2) conducted a home visit with Patient 18.  Patient 18 was lying on her hospital bed, comfortably sleeping, in no apparent distress, on oxygen therapy 2 liters (unit of measurement)/minutes via nasal cannula (a simple medical device used to deliver supplemental oxygen through the nose, it consists of two flexible prongs that are inserted into the nostrils, connected to a tubing that delivers oxygen from a source) connected from oxygen concentrator (a medical device that separates oxygen from the air, concentrates it, and delivers it to the patient for supplemental oxygen therapy) machine.  Patient 18 has a caregiver on duty (CG9), CG9 stated that she works for Patient 18 during days and there is another caregiver at nighttime as well. During a concurrent observation, interview, and record review, on 4/22/2025, at 10:25 a.m., LVN 2 reviewed the medications Patient 18 was currently taking, using the patient’s record titled, “Current Treatment/Medication/DME List” printed on 4/21/2025.  The following medications were not listed in the form, but the medications were available at Patient 18’s home:LVN 2 stated “Benzonatate” (used to treat cough) was in Patient 18’s medications supply. CG9 stated Patient 8 stopped taking the medication for a long time.LVN 2 stated “Albuterol” (used to treat lung conditions) was in Patient 18’s medications supply. CG9 stated that Patient 18 was no longer using the medication inhaler.LVN 2 stated “Cefpodoxime” (an antibiotic to treat infections) was at home.  CG9 stated the medication was delivered on 4/19/2025 in replacement of the previously ordered antibiotic medication as Patient 18 was allergic to it per the pharmacy. LVN 2 stated “Promethazine” (used to treat cough) was in Patient 18’s medications supply. CG9 stated Patient 18 was no longer using this medication for a long time.LVN 2 stated “Ofloxacin” (an antibiotic eyedrops to treat eye infection) was in Patient 18’s medications supply. CG9 stated Patient 18 was no longer using this eyedrop for a long time. LVN 2 stated “Nystatin” (topical (apply to skin) powder that treats skin problems) was in Patient 18’s medications supply. CG9 stated Patient 18 was no longer using this eyedrop for a long time. LVN 2 stated “Glucose tablets” (chewable tablets to treat low blood sugar) was in Patient 18’s medications supply. CG9 stated Patient 18 use it only if needed for low blood sugar.LVN 2 stated “Loperamide” (anti-diarrheal medication to treat (abnormal loose stools) was in Patient 18’s medications supply. CG9 stated Patient 18 use it only if needed for diarrhea.LVN 2 stated “AZO” (medication to prevent UTI (urinary tract infection, infection in  urinary system) was in Patient 18’s medications supply. CG9 stated Patient 18 use it only if needed if there are symptoms of UTI. During an interview on 4/22/2025, at 10:58 a.m., with LVN 2, LVN 2 stated the medication review and reconciliation was supposed to be done on every visit.  LVN 2 stated that when there were a change of medication, the case manager needed to be called.  The case manager was the one responsible for updating the medication list.  The importance of the medication review was for the care team to know what treatment Patient 18 was receiving and to know if the treatment was working. LVN 2 stated that patient and/or patient’s caregivers (in general) need to be asked if there were any over the counter (OTC) medications or medications that need to be added to active medication lists. LVN 2 stated that patient’s medications need to be checked to ensure that all current medications included prescribed and over the counter medications. LVN 2 stated that new medications and OTC medications need to be brought to doctor’s attention and if approved, then the medications would be entered to patient’s current medication list. LVN 2 stated that if discontinued or unused medications were mixed to active medications, it could create confusion among the caregivers and hospice nurses and could also result in adverse reaction if needed. LVN 2 stated that unused medications need to be discarded and need to be coordinate with the DPCS and HA. During an interview with the Director of Patient Care Services (DPCS2) on 4/25/2025 at 2:18 p.m., the DPCS stated the visiting nurse should have conducted medication reconciliation on every visit, to ensure that patient had all the ordered medications. DPCS2 stated that unused or expired medications should be discarded immediately to prevent unnecessary use of unneeded medications. DPCS2 stated that controlled expired medications should be discarded by two nurses to witness and to ensure proper waste disposal of controlled medications. The survey team requested HA’s policy and procedure regarding disposal of non-controlled, outdated, mislabeled, or unusable medications in accordance with currently accepted professional practice from the DPCS2. At 3:00pm, DPCS2 stated and confirmed  that HA has no established policy and procedure regarding disposal of non-controlled, outdated, mislabeled, or unusable medications.

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participations regarding initial and Comprehensive Assessments of Patients was met as followed: --- 1. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after election of hospice care for five of fourteen sampled patients (Patient 2, Patient 3, Patient 5, Patient 6, and Patient 7). (Refer to L 523). 2. The HA failed to conduct and document a comprehensive assessment that reflected the patient's current and accurate health status and identify the patients' needs for hospice care and services related to hospice eligibility and management of terminal illness for three of fourteen sampled active patients (Patient 1, Patient 2, and Patient 9). As a result, Patient 1, Patient 2, and Patient 9 had the potential to lose their hospice eligibility/hospice benefits, not receive hospice care when needed in the future and had the potential to not receive the necessary care and services that could lead to potential hospitalization and death. (Refer to L524). 3. The HA staff failed to review all medications one of fourteen sampled patients (Patient 8) were taking and update their medication profiles with the currently used medications. (Refer to L 530). 4. The HA failed to ensure one of fourteen sampled patients (Patient 5) receive an initial bereavement assessment. (Refer to L 531). 5. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). (Refer to L 533). The cumulative effect of these systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the patients to ensure the highest quality of care were being provided to patients certified to receive the hospice benefits.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss the patients plan of care, to be able to provide the best individualized care and support to patients and families) completed the comprehensive assessment no later than five calendar days after election of hospice care for five of fourteen sampled patients (Patient 2, Patient 3, Patient 5, Patient 6, and Patient 7). This failure resulted in patients not being properly evaluated which resulted in the patients not being provided individualized focused care. --- 1). During a record review of Patient 2s medical record form titled ";Personal Information" the form indicated Patient 2s start of care date was 12/2/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the bodys organs). During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/2/2024, the assessment indicated Patient 2s diagnoses included hypertensive heart disease with heart failure, and hyperlipidemia (high cholesterol). The Comprehensive Nursing Assessment also indicated Patient 2 had a history of high blood pressure, arthritis (swelling and tenderness of one or more joints), depression (mental health condition causing low mood and loss of interest in activities), a heart attack (blood flow to the heart is blocked) five years ago with three bypass surgery (a surgical procedure to divert blood around the heart), shortness of breath, and wounds on both lower extremities. During a record review of Patient 2s medical record form titled ";POC (plan of care)/IDG (interdisciplinary group) Review" dated 12/2/2024, the POC review did not indicate any problems, interventions, goals, or status for Patient 2. During a record review of Patient 2s medical record form titled ";Audit Log" dated from 1/1/2024 to 12/16/2024, indicated the Administrator / Director of Patient Care Services (ADM/DPCS) updated Patient 2s initial comprehensive assessment to include a plan of care action, target date, and status. During a concurrent interview and record review, on 12/14/2024 at 11;05 a.m. with the Administrator/ Director of Patient Care Services (ADM/DPCS) of Patient 2s Electronic Medical Record (EMR), the ADM/DPCS stated Patient 2s initial comprehensive assessment did not indicate any problems, interventions, goals, or status. The ADM/DPCS stated Patient 2 did not have a plan of care documented. The ADM/DPCS stated a patients care plan is used to plan and monitor their transition to death while in hospice and to offer medication management and pain control. The ADM/DPCS stated patients run risk of not being assessed properly and not receiving their individualized care if their care is not planned. The ADM/DPCS stated Patient 2s comprehensive assessment dated 12/2/2024 was not signed by herself (ADM/DPCS) or the Medical Social Worker (MSW). The ADM/DPCS stated the discipline signatures indicated they assessed and documented the patients assessment. 2. During a record review of Patient 3s medical record form titled ";Personal Information" the form indicated Patient 3s start of care date was 5/14/2024 with a primary diagnosis of Alzheimers Disease (progressive memory loss). During a record review of Patient 3s medical record form titled ";Comprehensive Nursing Assessment" dated 5/14/2024, the Comprehensive Nursing Assessment indicated Patient 3 had a history of Alzheimers Disease, insomnia (sleep disorder that makes it difficult to fall asleep), constipation (infrequent or difficult to pass a bowel), anxiety (a feeling of fear, dread, and uneasiness), and was at risk for falls. During a record review of Patient 3s medical record form titled ";POC/IDG Review" dated 5/14/2024, the form indicated the Registered Nurse (RN) did not sign the form. During a concurrent interview and record review on 12/16/2024 at 12:25 p.m. with the ADM/DPCS of Patient 3s EMR, the ADM/DPCS stated she (the ADM/DPCS) did not sign Patient 3s initial interdisciplinary group meeting forms the day of the meeting. The ADM/DPCS stated all disciplines are to sign the interdisciplinary group meetings the same day of the meeting for patient safety and real time documentation. 3. During a record review of Patient 5s medical record form titled ";Personal Information" the personal information form indicated Patient 5s start of care date was 5/30/2024 and an end of care date of 6/3/2024 with a primary diagnosis of multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). During a record review of Patient 5s medical record form titled ";POC/IDG Review" dated as of 5/30/2024, the form indicated it was not signed by the ADM/DPCS. During a record review of Patient 5s medical record form titled ";Audit log" dated from 5/4/2024 to 12/16/2024, the log indicated the ADM/DPCS signed Patient 5s POC/IDG review dated 5/4/2024 on 6/2/2024. During a record review of Patient 5s medical record form titled ";Audit log" dated from 5/4/2024 to 12/16/2024, indicated Registered Nurse 1 (RN1) signed Patient 5s POC/IDG review dated 5/13/2024 on 7/24/2024, the MD1 signed on 6/2/2024, and the SC signed on 6/3/2024. During a record review of Patient 5s medical record form titled ";Audit log" dated from 5/4/2024 to 12/16/2024, the audit log indicated the MSW signed Patient 5s POC/IDG review dated 5/27/2024 on 5/28/2024, the MD1 signed on 6/2/2024, the SC signed on 6/3/2024, and the ADM/DPCS signed on 6/18/2024. 4. During a record review of Patient 6s medical record form titled ";Personal Information" the form indicated Patient 6s start of care date was 11/6/2024 with a primary diagnosis of Alzheimers Disease. During a record review of Patient 6s medical record form titled ";Comprehensive Nursing Assessment" dated 11/6/2024, indicated Patient 6s diagnoses included Alzheimers Disease, balance impaired, fecal and urine incontinence (loss of bladder and bowel control). The Comprehensive Nursing Assessment also indicated Patient 6 was dependent on a caregiver for her activities of daily living (ADL – task performed to stay healthy and maintain personal care). During a record review of Patient 6s medical record form titled ";POC / IDG Review" dated 11/6/2024, the review did not indicate any problems, interventions, goals, or status for Patient 6. Patient 6s POC/IDG Review also indicated it was not signed by an RN. During a concurrent interview and record review on 12/16/2024 at 1:19 p.m. with the ADM/DPCS of Patient 6s EMR, the ADM/DPCS stated Patient 6s initial comprehensive assessment did not indicate any problems, interventions, goals, or status. The ADM/DPCS stated Patient 6s plan of care should contain directions and ";basically" is what the patient requires of us, the treatment. The ADM/DPCS stated Patient 6s planned care is used for all HA employees to follow to ensure Patient 6s needs are met. 5. During a record review of Patient 7s medical record form titled ";Personal Information" the form indicated Patient 7s start of care date was 10/18/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease without heart failure. During a record review of Patient 7s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for First 90-day period" dated 10/18/2024 to 1/15/2024, indicated under the Physician Narrative section ";Admitted... with terminal diagnosis of hypertensive heart disease with heart failure..." During a record review of Patient 7s medical record form titled ";POC Summary" dated as of 12/12/2024, indicated ";Admit patient... with primary diagnosis of hypertensive heart disease without heart failure...". Patient 7s POC Summary also indicated it was not signed. During a record review of Patient 7s medical record form titled ";POC/IDG Review" dated 10/18/2024, the form indicated Patient 7 had one issue listed ";Pain." Patient 7s POC/IDG Review also indicated it was not signed by an RN. During a concurrent interview and record review on 12/16/2024 at 1:40 p.m. with the ADM/DPCS of Patient 7s EMR, the ADM/DPCS stated Patient 7s POC/IDG meeting dated 10/18/2024 was not complete. The ADM/DPCS stated Patient 7s comprehensive assessment was missing Patient 7s issues, interventions, and goals for his (Patient 7s) blood pressure management, self-care deficit, bereavement risk, high blood pressure, decreased cardiac output, diabetes type II, skin impairment, and risk for falls. The ADM/DPCS also stated Patient 7s comprehensive assessment was missing a registered nurse signature.

Based on observation, interview, and record review, the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to conduct and document a comprehensive assessment (an assessment to identify the physical, psychosocial [the interaction between psychological {mental and emotional} and social {relationship and societal} factors], 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 of the patient) that reflected the patient's current and accurate health status and identify the patients' needs for hospice care and services related to hospice eligibility and management of terminal illness for three of fourteen sampled active patients (Patient 1, Patient 2, and Patient 9). As a result of the noncompliance, Patient 1, Patient 2, and Patent 9 were placed at increased risk for losing their hospice eligibility/hospice benefits, not receiving hospice care when needed in the future, and not receiving the necessary care and services that could lead to potential hospitalization and death. On 12/16 /2024, at 4:08 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agencys Administrator / Director of Patient Care Services (ADM/DPCS) related to failure to ensure to conduct and document an accurate comprehensive assessment 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 two of fourteen sampled active patients (Patient 1 and Patient 2). On 12/17/2024, at 2:15 pm, the Department conducted an exit conference with the ADM/DPCS with the IJ situation not removed. On 2/20/2025, the agency submitted acceptable IJ removal plans as follow: 1.On 12/17/2024, the HA discharged Patient 1 and Patient 9 due to extended prognosis. 2.On 12/15/2024, Patient 2 revoked hospice services voluntarily and opted to seek treatment at a hospital. On 2/21/2025, at 4 pm, the Department removed the IJ situation in the presence of the HA's DPCS after the onsite verifications of the HA's IJ removal plans. --- Findings: During an interview on 12/15/2024, at 9:39 a.m., with the ADM/DPCS, the ADM/DPCS stated the HA did not rely on the Local Coverage Determination (LCD-a tool used to determine if a patient meets hospice care based on specific criteria) to admit a patient (in general) into hospice care. ADM/DPCS stated that the HA relied on the assessment and the doctors referral for hospice patients. During an interview on 12/16/2024, at 10:25 a.m., with the Medical Director 1 (MD1), MD1 stated he (MD 1) relied on the nursing assessment and documentation to certify patients into hospice care. MD1 stated he (MD 1) trusted that the HAs nursing staff (in general) completed the nursing assessment correctly. During a record review of Patient 1s Personal Information, the Personal Information indicated a start of care (SOC-the date on which a patient begins receiving hospice care) date of 7/16/2024 with a primary diagnosis of heart disease (a general term that includes many types of heart problems), unspecified. During a record review of Patient 1s Updated Assessment (a nursing assessment made to determine if a patient continues to qualify for hospice services) dated 12/3/2024, signed by Registered Nurse 1 (RN1), the Updated Assessment indicated Patient 1 ambulated (walked) with a walker (is a type of mobility aid that offers stability and support while walking) and required maximum assist. The Updated Assessment indicated a score of three (3) (maximum assist) for Patient 1s activities of daily living (ADL-basic tasks that patients perform to maintain their health and well-being) including ambulation, toileting, and bathing. The Updated Assessment indicated a level of four (IV -unable to carry out any physical activity without discomfort) on Patient 1s NYHA scale (New York Heart Association – functional classification). The Updated Assessment indicated Patient 1 was assigned a score of 50 (requires considerate assistance and frequent medical care) on the KPS (Karnofsky Performance Scale, evaluate patients ability to perform activities of daily living) and a score of 50 (mainly sit or lie, unable to do any work) on the PPS (Palliative Performance Scale, assessed patients ability to function). The Updated Assessment indicated Patient 1 had ";very limited" mobility and did not indicate Patient 1 had a left eye prosthesis (artificial body part). During a concurrent observation and interview on 12/13/2024, at 11 a.m., with Patient 1, Patient 1 was observed in the house awake, alert, oriented to person, place, and time, and walking using a cane. Patient 1 stated she (Patient 1) was not referred by her (Patient 1) own physician to hospice, and that she (Patient 1) became aware of the HA thru her (Patient 1) family member (Granddaughter in law). Patient 1 stated she (Patient 1) did not have a terminal illness, was not dying, and she (Patient 1) did not expect to die anytime soon. Patient 1 stated the doctors did not tell her (Patient 1) she was terminal or had six months or less to live. Patient 1 stated she (Patient 1) had a left eye prosthesis, used a walker to ambulate when out of her (Patient 1) home, never had issues with edema (fluid buildup in the skin), was able to transfer, bathe, dress, and feed herself (Patient 1). Patient 1 stated she (Patient 1) did not know who RN1 was. During a concurrent interview and record review on 12/16/2024, at 10:47 a.m. with MD1, Patient 1s Updated Assessment dated 12/3/2024 was reviewed. MD1 stated that he (MD1) based Patient 1s Certification of Terminal Illness (CTI - a document that certifies the patient for hospice care by a doctor), on RN1s nursing assessment. MD1 stated nurses were his (MD1) eyes and ears. MD1 stated Patient 1s nursing assessment indicated that Patient 1 had shortness of breath with minimal activities, edema, weakness, and loss of appetite. MD1 stated he (MD1) did not wait or rely on objective findings (factual observations or data gathered through testing) to place patients in hospice care. During a concurrent interview and record review on 12/16/2024, at 11:55 a.m., with the ADM/DPCS, Patient 1s Updated assessment dated 12/3/2024 was reviewed. ADM/DPCS stated that based on Patient 1s updated assessment, Patient 1 required considerable assistance, was mainly sitting, or lying down, and would take a few steps before experiencing shortness of breath. The ADM/DPCS stated she ADM/DPCS transcribed (write) Patient 1s CTI. ADM/DPCS stated that she (ADM/DPCS) was asked to transcribe Patient 1s CTI by MD1. 2. During a record review of Patient 2s Personal Information indicated a SOC date of 12/2/2024, with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organ). During a record review of Patient 2s Comprehensive Nursing Assessment dated 12/2/2024, the Comprehensive Nursing Assessment indicated Patient 2 required maximum assistance with ambulation (movement). The Comprehensive Nursing Assessment indicated Patient 2 was assigned a score of three (3) with her (Patient 2) activities of daily living with ambulation, transfer, and bathing. The Comprehensive Nursing Assessment indicated Patient 2 was assigned a score of 40 (disabled, requires special care and assistance; mainly in bed, unable to do most activities) for both KPS and PPS, and NYHA IV. The Comprehensive Nursing Assessment indicated Patient 2 had a FAST (Functional Assessment Staging Tool, scale for dementia) score of 7C (unable to ambulate independently). The Comprehensive Nursing Assessment indicated there was no signature of the Registered Nurse responsible for completing the assessment. During a record review of Patient 2s Physicians Certification for Hospice Benefit – Statement for first 90-day period, dated from 12/2/2024 to 3/1/2025, the Certification for Hospice Benefit – Statement indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice..." The Physicians Certification for Hospice Benefit – Statement indicated the referring physician was Medical Doctor 2 (MD2). The Physicians Certification for Hospice Benefit – Statement indicated it was not signed by MD2. The form indicated ";signature on file/verified by (ADM/DPCS)". During a record review of Patient 2s Physician Certification for Hospice Benefit – Certification #1: Statement for First 90-day period" dated 12/2/2024 to 3/1/2025, indicated ";In my opinion, this patient has a life expectancy of six (6) months or less if the illness runs its normal course." The Physician Certification for Hospice Benefit indicated it was signed by MD1. During a record review of Patient 2s medical record form titled ";Psychosocial Assessment" dated 12/4/2024, indicated it was not complete and it was not signed. During a concurrent observation and interview on 12/13/2024, at 1 p.m., with Patient 2, Patient 2 was observed in the house awake, alert, oriented to person, place, and time. Patient 2 stated she (Patient 2) was independent until she (Patient 2)developed her (Patient 2) wounds (left leg shin and right outer great toe). Patient 2 stated she (Patient 2) did not have any heart issues and was not expecting to die within six months. Patient 2 stated she (Patient 2) was seen at the General Acute Care Hospital (GACH on 12/5/2024, while receiving hospice services. During a concurrent interview and record review on 12/14/2024, at 8:55 a.m., with Registered Nurse 2 (RN2), Patient 2s Comprehensive Nursing Assessment dated 12/2/2024 was reviewed. RN2 stated she (RN 2) was the admitting nurse who assessed Patient 2 on 12/2/2024. RN2 stated Patient 2 lived alone and mostly would sit on the sofa. RN2 stated she (RN 2) based Patient 2s KPS, PPS, and FAST score on what Patient 2 reported and not on any objective findings. During a concurrent interview and record review on 12/14/2024, at 10:15 a.m., with the ADM/DPCS, Patient 2s Comprehensive Nursing Assessment dated 12/2/2024 was reviewed. ADM/DPCS stated RN2 completed Patient 2s comprehensive nursing assessment dated 12/2/2024 but did not sign it. The ADM/DPCS stated RN2s signature would have indicated she (RN 2) documented Patient 2s nursing assessment. The ADM/DPCS stated Patient 2s hospice admission is based on her (Patient 2) medications, MD 2s referral, and her (Patient 2) diagnosis. The ADM/DPCS stated MD 2 referred Patient 2 for hospice services. During a concurrent interview and record review on 12/14/2024, at 10:25 a.m., with MD2, Patient 2s Comprehensive Nursing Assessment dated 12/2/2024 was reviewed.MD2 stated that he (MD 2) face timed (face to face conversation over the internet using a mobile application) RN2 and Patient 2 on 12/2/2024. MD2 stated he (MD 2) did not use the patients age or medications to determine hospice eligibility. MD 2 stated that MD 2 would determine patient eligibility based on the patients functional status. MD2 stated his (MD 2) assessment and hospice referral for Patient 2 was based on RN2s assessment and Patient 2s responses about her (Patient 2) functional status. MD2 stated he (MD 2) did not observed Patient 2s gait. MD2 stated Patient 2 might have swelling because she (Patient 2) was taking Lasix (medication to remove excess fluid from the body). MD2 stated he (MD 2) was not sure why Patient 2 was taking prednisone (medication to treat asthma, allergic reactions, arthritis, inflammatory bowel disease adrenal, and blood or bone marrow disorders). MD2 stated he (MD 2) was not aware Patient 2 was seen at the GACH on 12/5/2024. MD2 stated Patient 2 lived alone and did not meet her family or caregiver. MD2 stated he recommended Patient 2 for IHSS (In home support services – aids people with disabilities in their home). During an interview on 12/14/2024, at 10:53 a.m., with the Operating Manager (OM), the OM stated Patient 2 was referred by the senior foundation of Patient 2s senior apartment building. The OM stated Patient 2 received home health services (a variety of medical services provided in a patient's home to treat an injury or illness), but Patient 2s wounds were not being treated. The OM stated the only thing Patient 2 wanted was treatment for her (Patient 2) wounds. The OM stated she (OM) asked MD2 to assess Patient 2 for hospice services. The OM stated she (OM) informed Patient 2 that she (OM) was unable to see any other doctors if she decided on hospice care. The OM stated Patient 2 did not mention family or caregiver names or phone numbers. During a concurrent interview and record review on 12/14/2024, at 11:05 a.m., with the ADM/DPCS, Patient 2s Psychosocial Assessment dated 12/4/2024 was reviewed. ADM/DPCS stated she (ADM/DPCS) was unsure if Patient 2 was seen by the Medical Social Worker (MSW) for the initial psychosocial assessment. The ADM/DPCS stated that as of 12/14/2024 the MSW had not evaluated Patient 2. The ADM/DPCS stated Patient 2 lived alone and there were no family or caregiver information in Patient 2s medical records. ADM/ADMS stated the HA did not refer Patient 2 to In-Home Supportive Services (IHSS- is a program that helps low-income, elderly, blind, or disabled individuals pay for services to remain safely in their own homes) because MD2s recommendation were not noted. The ADM/DPCS stated IHSS assisted people with caregivers, food preparation, activities, and cleaning. During a concurrent interview and record review on 12/16/2024, at 10:33 a.m., with MD1, Patient 2s Comprehensive Nursing Assessment dated 12/2/2024 was reviewed. MD1 stated Patient 2s CTI was based on Patient 2s Comprehensive Nursing Assessment dated 12/2/2024. 3.During a review of Patient 9s Face Sheet (admission record), the Face Sheet indicated a SOC date of 11/15/2024, with a terminal diagnosis of Unspecified severe protein-calorie malnutrition (the state of inadequate intake of food). During a review of Patient 9s ";LCD Hospice Eligibility Determination", dated 11/15/2024, the LCD Hospice Eligibility Determination indicated that Patient 9 does not qualify for hospice based on LCD guidelines.[JH1] During a review of Patient 9s ";CTI" for certification period 11/15/2024 to 1/13/202, the CTI indicated, that Patient 9 completely meets LCD guidelines. Documentation completed by MD 1. During a concurrent interview and record review on 12/15/2024, at 9:41 a.m., the ADM/DPCS reviewed Patient 9s record titled, ";LCD Hospice Eligibility Determination," dated 11/15/2024. and Patient 9s ";Comprehensive Assessment," dated 11/15/2024. The ADM/DPCS state that Patient 9s ";Comprehensive Assessment," indicated that Patient 9was eligible for hospice services and met the Local Coverage Determination (LCD) guidelines. The ADM/DPCS stated that Patient 9s ";LCD Hospice Eligibility Determination". indicated that Patient 9 did not qualify for Hospice eligibility per LCD guidelines. The ADM/DPCS stated that MD 1 would need to be contact due to the discrepancies between Patient 9s LCD Hospice Eligibility Determination and Comprehensive Assessment. During a concurrent interview and record review on 12/15/2024, at 9:52 a.m., the ADM/DPCS reviewed Patient 9s medical records and stated there was no history and physical (a medical document that explains the patients past medical history, their current problems/diagnosis, and the plan of care) to support Patient 9s diagnosis of severe protein-calorie malnutrition. The ADM/DPCS stated the information needed to support Patient 9s diagnosis was laboratory studies such as blood studies, and information on other medical conditions causing malnutrition. ADM/DPCS stated there was no blood studies information in Patient 9s medical records. ADM/DPCS stated that ideally, the medical documents to support the diagnosis of Patient 9s severe protein-calorie malnutrition should have been in Patient 9s record on the SOC date of 11/15/2024 to be able to confirm that Patient 9 met the criteria for hospice care. The ADM/DPCS stated Patient 9 was admitted to hospice based on the diagnosis of severe protein-calorie malnutrition. The ADM/DPCS stated that it was a mistake to admit Patient 9 into hospice because the HA needed clinical objective information to support Patient 9s diagnosis of severe protein-calorie malnutrition. During a concurrent interview and record review on 12/15/2024, at 10:08 a.m., the ADM/DPCS reviewed Patient 9s record titled, ";Comprehensive Nursing Assessment", dated 11/15/2024. The ADM/DPCS stated that Patient 9s Comprehensive Nursing Assessment indicated that Patient 9 was eligible for hospice care because Patient 9 met the Local Coverage Determination criteria. The ADM/DPCS stated that based on the verbiage, the assessment was not accurate because the LCD said Patient 9 did not meet eligibility. ADM/DPCS further stated that there was also no clinical information to support Patient 9s diagnosis of severe protein-calorie malnutrition . During an interview on 12/16/2024, at 10:25 a.m., the MD1 stated the LCD is an important document when making the decision of admitting a patient into hospice care because there are criteria that needed to be met to qualify a patient for hospice. MD1 stated that he trusts that the HA nurses had done the LCD and nursing assessment correctly. During a concurrent interview and record review on 12/16/2024, at 11:13 a.m., with MD1, MD1 reviewed Patient 9s record titled, ";LCD Hospice Eligibility Determination", dated 11/15/2024, and ";CTI" for certification period 11/15/2024 to 1/13/202. MD 1 stated that the CTI indicated, ";Patient completely meets LCD guidelines". MD 1 stated that the ";LCD Hospice Eligibility Determination", dated 11/15/2024, indicated ";Patient does not qualify based on LCD guidelines." When asked how come MD1 had documented that Patient 9 met LCD guidelines, the MD1 stated he (MD 1) had made a mistake. During a record review of the HAs document titled, ";Admission Criteria and Process", dated November 2021, indicated, ";Policy...The patients life-limiting illness and prognosis (the predicted outcome or course of a disease or medical condition) if six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys (an institution or individual that acts as a middleman between two parties in a financial transaction) Local Coverage Determinations (LCDs)...3. The patient must have a life-limiting illness with a life expectancy of six (6) months or less as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by LCD. 4. The patient must desire hospice services and be aware of the diagnosis and prognosis. During a record review of the HAs document titled, ";Comprehensive Assessment", dated November 2021, indicated, the document indicated that ";Procedure 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patients clinical record, including at least the following information, as relevant:...K. Patients past and present medical and psychosocial history including pertinent diagnosis and any co-morbid conditions...M Name of the hospital and other agencies or persons involved in the past and present care of the patient...R. Patient and family/caregiver support systems and the care the family/caregiver is available, capable, and willing to provide...S. The patients psychosocial status...X. Laboratory results. Y. Medical...history...BB. Past medical and surgical care, including dates of onset/exacerbation...4. The Clinical Supervisor will be responsible for assuring that the documentation of clinical finding supports the terminal diagnosis...5...C. If there has been a change in the patients condition/status, then the comprehensive assessment must be updated."

Based on observation, interview, and record review, the Hospice Agency (HA) staff failed to review all medications that one of fourteen sampled patients (Patient 8) were taking and to update their medication profiles with their currently used medications. This failure had the potential to result in a risk for medication errors and adverse drug reactions. --- A review of Patient 8s ";Personal Information", document indicated a start of care (SOC) of 3/1/2024, with a terminal diagnosis of Other cerebrovascular disease. During a home visit on 12/13/2024, at 2 p.m., Licensed Vocational Nurse (LVN 1) visited Patient 8. Patient 8 was lying in a hospital bed, awake and alert. Patient 8 was not able to communicate in English or her preferred language, Spanish. Patient 8 smiled and responded to Spanish language communication through eye and eyebrow gestures. During a concurrent observation, interview, and record review, on 12/13/2024, at 2:25 p.m., LVN 1 reviewed the medications Patient 8 was taking, using the patients record titled, ";Current Treatment/Medication/DME List" printed on 12/12/2024. The following medications were listed in the form, but the medications were not available at Patient 8s home: LVN 1 stated ";Amlodipine" (used to treat high blood pressure) was not at the home. Caregiver 7 (CG7) stated Patient 8 stopped taking the medication six months ago. LVN 1 stated ";Albuterol" (used to treat lung conditions) was not at home. Caregiver 6 (CG6) stated the medication was not at home because she had ran out of it. CG 6 stated Patient 8 has not used the medication in the last two months ago. LVN 1 stated ";Cipro" (an antibiotic to treat infections) was not at home. CG 6 stated the last time Patient 8 used the medication was in July 2024. LVN 1 stated ";Promethazine" (used to treat cough) was not at home. CG 6 stated the last time Patient 8 used the medication was 3 months ago. During an interview on 12/13/2024, at 2:58 p.m., LVN 1 stated the medication review and reconciliation was supposed to happen every visit. Whenever a change of medication is seen, the case manager needed to be called. The case manager was the one responsible for updating the medication list. The importance of the medication review was for the care team to know what treatment Patient 8 was receiving and to know if the treatment was working. A record review of the HAs undated document titled, ";Medication Reconciliation" indicated, ";Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications...Medication reconciliation should be completed at every skilled visit and any changes should be documented both in the home medication profile and in the MD (doctor) order."

Based on interview and record review the Hospice Agency (HA) failed to ensure one of fourteen sampled patients (Patient 5) received an initial bereavement assessment. This failure had the potential to result in placing the patients and their family/caregiver at risk of spiritual and emotional distress. --- During a record review of Patient 5s medical record form titled ";Personal Information" , the form indicated Patient 5s start of care date was 5/30/2024 and an end of care date of 6/3/2024, with a primary diagnosis of multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). Patient 5s Personal Information form also indicated Caregiver 2 (CG2) was Patient 5s neighbor. During a record review of Patient 5s undated medical record form titled ";Current Treatment/Medication/DME (durable medical equipment)" indicated Patient 5s level of care was continuous care which was ordered on 5/30/2024. During a record review of Patient 5s medical record form titled ";Comprehensive Nursing Assessment" dated 5/30/2024, the comprehensive assessment indicated Patient 5 was admitted to the HA under continuous level of care. A record review of Patient 5s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #2: Re-Certification Statement for Second 90-day period" dated from 5/30/2024 to 8/27/2024, indicated Patient 5 had severe shortness of breath that required continuous oxygen and was transitioning." The form also indicated it was signed by Medical Director 1 (MD1). During a record review of Patient 5s medical record form titled ";Physician Orders" dated 5/30/2024, , the form indicated ";Level of Care: Continuous Care." During a record review of Patient 5s medical record titled ";Spiritual Assessment" dated 5/31/2024, the assessment indicated the Spiritual Counselor signed the form on 5/31/2024. Patient 5s Spiritual Assessment also indicated ";PCG (patient caregiver) asked to schedule probably for the next month." During a record review of Patient 5s medical record titled ";History of Bereavement Assessment" indicated there were no entries made. During a record review of Patient 5s medical record titled ";History of Bereavement POC (plan of care)" indicated there were no entries made. During a record review of Patient 5s medical record form titled ";Discharge Summary" dated 6/3/2024, indicated Patient 5 was pronounced at 3:34 a.m. The form also indicated Patient 5 was receiving continuous care. During a record review of Patient 5s medical record titled ";Post Death Bereavement" dated 6/10/2024, indicated the Spiritual Counselor signed the form. The Post Death Bereavement also indicated Patient 5s ";daughter" (CG2), which was her main caregiver, was called and was spiritually satisfied. During a record review of Patient 5s medical record titled ";Audit Log" dated from 11/1/2024 to 12/16/2024, indicated the Spiritual Counselor (SC) documented and signed Patient 5s Post Death Bereavement dated 6/10/2024 on 12/12/2024. During a concurrent interview and record review on 12/16/2024 at 1:13 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 5s Electronic Medical Record (EMR), the ADM/DPCS stated the SC spoke with CG2 to offer his services, but that she (CG2) declined. The ADM/DPCS stated the HA needs to offer bereavement services to assist the patients family with the patients passing.

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). This failure resulted in patients not being properly evaluated which resulted in not being provided individualized focused care. --- During an interview on 12/15/2024, at 8:21 a.m., the Administrator and Director of Patient Care Services (ADM/DPCS) stated the comprehensive assessment was used to ensure the plan of care was developed according to the needs of the patient and family members. During an interview on 12/15/2024, at 8:35 a.m., the ADM/DPCS stated the IDG team met to review the patient assessments and update the plan of care every 2 weeks. If there were changes, decline in the patients care, medication changes, the plan of care would be updated to reflect those changes. 1. A record review of Patient 1s medical record form titled ";Personal Information" indicated Patient 1s start of care date was 7/16/2024 with a primary diagnosis of heart disease (general term for a variety of conditions that affect the hears structure and function), unspecified. During a review of Patient 1s Updated Assessment (a nursing assessment conducted to determine if a patient continues to qualify for hospice services) dated 12/3/2024, the Updated Assessment indicated a score of 3 (maximum assist) for Patient 1s activities of daily living including ambulation, toileting, and bathing. The Updated Assessment indicated a level of IV (unable to carry out any physical activity without discomfort) on Patient 1s NYHA scale (New York Heart Association – functional classification). The Updated Assessment indicated Patient 1 had ";very limited" mobility. The Updated Assessment was signed by Registered Nurse 1 (RN1). During a record review of Patient 1s medical record form titled ";POC (plan of care) Summary" dated as of 12/12/2024, indicated ";Interdisciplinary team to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 1s medical record form titled ";Current Treatment / Medication / DME (durable medical equipment)" undated, indicated ";Interdisciplinary team to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 1s undated, medical record form titled ";History of POC (plan of care)/IDG (interdisciplinary group)" indicated the last entry was made on 11/25/2024. During a record review of Patient 1s medical record form titled ";Audit Log" dated from 7/19/2024 to 12/16/2024, indicated Patient 1s IDG meeting dated 12/9/2024 was signed by the Registered Nurse 1 (RN1) and the Spiritual Counselor (SC) on 12/13/2024. The Medical Director 1 (MD1) signed Patient 1s IDG meeting dated 12/9/2024 on 12/14/2024. The Medical Social Worker (MSW) signed Patient 1s IDG meeting dated 12/9/2024 on 12/15/2024. Lastly, Patient 1s IDG meeting form dated 12/9/2024 indicated the Administrator / Director of Patient Care Services (Adm./DPCS) documented Patient 1s summary assessment on 12/13/2024. During a concurrent interview and record review on 12/16/2024 at 11:55 a.m. with the ADM/DPCS of Patient 1s Electronic Medical Record (EMR), the ADM/DPCS stated Patient 1s interdisciplinary meeting was not done on 12/9/2024 and was held sometime after 12/13/2024. The ADM/DPCS stated it was important to hold an interdisciplinary meeting every 14 days to ensure patients plan of care is up to date and to be able to come up with an appropriate plan of care. 2. During a record review of Patient 2s medical record form titled ";Personal Information" the information form indicated Patient 2s start of care date was 12/2/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the bodys organs). During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/2/2024, the assessment indicated Patient 2s diagnoses included hypertensive heart disease with heart failure, and hyperlipidemia (high cholesterol). The Comprehensive Nursing Assessment also indicated Patient 2 had a history of high blood pressure, arthritis (swelling and tenderness of one or more joints), depression (mental health condition causing low mood and loss of interest in activities), a heart attack (blood flow to the heart is blocked) five years ago with three bypass surgery (a surgical procedure to divert blood around the heart), shortness of breath, and wounds on both lower extremities. A record review of Patient 2s medical record form titled ";POC (plan of care) Summary" dated as of 12/12/2024, indicated ";Interdisciplinary team to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 2s undated, medical record form titled ";Current Treatment/Medication/DME (durable medical equipment)" indicated ";Interdisciplinary team to review patients status every 14 days and as needed to evaluate changes in condition." A record review of Patient 2s medical record form titled ";POC (plan of care)/IDG (interdisciplinary group) Review" dated 12/9/2024, indicated the Registered Nurse (RN) and the Medical Social Worker (MSW) did not sign the form. The POC/IDG Review also did not indicate any problems, interventions, goals, or status for Patient 2. During a record review of Patient 2s medical record form titled ";Audit Log" dated from 1/1/2024 to 12/16/2024, the log indicated the ADM/DPCS and the MSW signed Patient 2s POC/IDG Review dated 12/9/2024 on 12/15/2024. During a concurrent interview and record review on 12/14/2024 at 11:05 a.m. with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 2s Electronic Medical Record (EMR), the ADM/DPCS stated Patient 2s POC/IDG Review dated 12/9/2024 did not indicate any problems, interventions, goals, or status. The ADM/DPCS stated Patient 2 did not have a plan of care documented. The ADM/DPCS stated a patients care plan is used to plan and monitor their transition to death while in hospice and to offer medication management and pain control. The ADM/DPCS stated patients run the risk of not being assessed properly and not receiving their individualized care if their care is not planned. The ADM/DPCS stated Patient 2s comprehensive assessment dated 12/9/2024 was not signed by herself (ADM/DPCS) or the Medical Social Worker (MSW). The ADM/DPCS stated the discipline signatures indicated they assessed and documented the patients assessment. 3. A record review of Patient 3s medical record form titled ";Personal Information" indicated Patient 3s start of care date was 5/14/2024 with a primary diagnosis of Alzheimers Disease (progressive memory loss). During a record review of Patient 3s medical record form titled ";Comprehensive Nursing Assessment" dated 5/14/2024, the Comprehensive Nursing Assessment indicated Patient 3 had a history of Alzheimers Disease, insomnia (sleep disorder that makes it difficult to fall asleep), constipation (infrequent or difficult to pass a bowel), anxiety (a feeling of fear, dread, and uneasiness), and was at risk for falls. During a record review of Patient 3s medical record form titled ";POC (plan of care) Summary" dated as of 12/12/2024, the summary indicated ";Interdisciplinary team to review patients status every 14 days and as needed to evaluate changes in condition." A record review of Patient 3s undated, medical record form titled ";Current Treatment/Medication/DME (durable medical equipment)" indicated ";Interdisciplinary team to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 3s medical record form titled ";Audit Log" dated from 5/13/2024 to 12/16/2024, indicated Patient 3s IDG meeting dated 10/28/2024 was signed by the ADM/DPCS on 12/14/2024. During a record review of Patient 3s medical record form titled ";Audit Log" dated from 5/13/2024 to 12/16/2024, indicated Patient 3s IDG meeting dated 11/11/2024 was signed by the ADM/DPCS on 12/14/2024. During a record review of Patient 3s medical record form titled ";Audit Log" dated from 5/13/2024 to 12/16/2024, indicated Patient 3s IDG meeting dated 11/25/2024 was signed by the ADM/DPCS on 12/14/2024. During a record review of Patient 3s medical record form titled ";History of POC (plan of care)/IDG (interdisciplinary group)" the POC indicated the last entry was made on 11/25/2024. During a record review of Patient 3s medical record form titled ";POC/IDG Review" dated 11/25/2024, the review indicated a registered nurse did not sign the form. During a record review of Patient 3s medical record form titled ";Audit Log" dated from 5/13/2024 to 12/16/2024, the audit log indicated Patient 3s IDG meeting dated 12/9/2024 was signed by the ADM/DPCS and the MD1 on 12/14/2024. The MSW signed Patient 3s IDG meeting dated 12/9/2024 on 12/15/2024. Lastly, the SC signed Patient 3s IDG meeting form dated 12/9/2024 on 12/13/2024. During a concurrent interview and record review on 12/16/2024 at 12:25 p.m. with the ADM/DPCS of Patient 3s EMR, the ADM/DPCS stated the last documented IDG meeting for Patient 3 was documented on 11/25/2024. The ADM/DPCS stated Patient 3s IDG meeting dated 12/9/2024 was documented within a few dates from this interview. The ADM/DPCS stated all disciplines are to sign the interdisciplinary group meetings the same day of the meeting for patient safety and real time documentation. 4. During a record review of Patient 4s medical record form titled ";Personal Information" indicated Patients 4 start of care date was 8/30/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure. During a record review of Patient 4s medical record form titled ";Plan of Care" dated as of 12/12/2024, indicated ";Next POC review to be done no later than 14 days from todays date." During a record review of Patient 4s undated, medical record form titled ";Current Treatment / Medication/DME (durable medical equipment)" the form indicated the ";Interdisciplinary team to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 4s medical record form titled ";Audit Log" dated from 8/30/2024 to 12/16/2024, the audit log indicated Patient 4s IDG meeting dated 10/28/2024 was signed by the ADM/DPCS on 12/14/2024. During a record review of Patient 4s medical record form titled ";Audit Log" dated from 8/30/2024 to 12/16/2024, indicated Patient 4s IDG meeting dated 11/11/2024 was signed by the ADM/DPCS on 12/14/2024 and the SC on 12/5/2024. During a record review of Patient 4s medical record form titled ";Audit Log" dated from 8/30/2024 to 12/16/2024, the audit log indicated Patient 4s IDG meeting dated 11/25/2024 was signed by the ADM/DPCS on 12/14/2024 and the SC on 12/5/2024. During a record review of Patient 4s medical record form titled ";Audit Log" dated from 8/30/2024 to 12/16/2024, the audit log indicated Patient 4s IDG meeting dated 12/9/2024 was signed by the ADM/DPCS and the MD1 on 12/14/2024. The MSW signed Patient 4s IDG meeting dated 12/9/2024 on 12/15/2024. Lastly, the SC signed Patient 4s IDG meeting form dated 12/9/2024 on 12/13/2024. 5. During a record review of Patient 5s medical record form titled ";Personal Information" the form indicated Patient 5s start of care date was 5/30/2024 and an end of care date of 6/3/2024 with a primary diagnosis of multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). During a record review of Patient 5s medical record form titled ";POC Summary" dated as of 12/12/2024, the summary indicated ";IDT to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 5s undated, medical record form titled ";Current Treatment/Medication/DME (durable medical equipment)" indicated Patient 5s level of care was continuous care which was ordered on 5/30/2024. During a record review of Patient 5s medical record form titled ";Audit log" dated from 5/4/2024 to 12/16/2024, the audit log indicated the ADM/DPCS signed Patient 5s POC/IDG review dated 5/4/2024 on 6/2/2024. During a record review of Patient 5s medical record form titled ";Audit log" dated from 5/4/2024 to 12/16/2024, the audit log indicated the Registered Nurse 1 (RN1) signed Patient 5s POC/IDG review dated 5/13/2024 on 7/24/2024, the MD1 signed on 6/2/2024, and the SC signed on 6/3/2024. During a record review of Patient 5s medical record form titled ";Audit log" dated from 5/4/2024 to 12/16/2024, the audit log indicated the MSW signed Patient 5s POC/IDG review dated 5/27/2024 on 5/28/2024, the MD1 signed on 6/2/2024, the SC signed on 6/3/2024, and the ADM/DPCS signed on 6/18/2024. 6. During a record review of Patient 6s medical record form titled ";Personal Information" the personal information form indicated Patient 6s start of care date was 11/6/2024 with a primary diagnosis of Alzheimers Disease. During a record review of Patient 6s medical record form titled ";Comprehensive Nursing Assessment" dated 11/6/2024, indicated Patient 6s diagnoses included Alzheimers Disease, balance impaired, fecal and urine incontinence (loss of bladder and bowel control). The Comprehensive Nursing Assessment also indicated Patient 6 was dependent on a caregiver for her (Patient 6) activities of daily living (ADL – task performed to stay healthy and maintain personal care). During a record review of Patient 6s medical record form titled ";POC Summary" dated as of 12/14/2024, the summary indicated ";Level of care – Continuous Care. Skilled nursing services continuously for assessments, clinical care, and support as needed for ongoing evaluation of patients condition." Patient 6s POC Summary also indicated it was not signed by a HA staff. During a record review of Patient 6s undated, medical record form titled ";Current Treatment/Medication /DME (durable medical equipment)" indicated ";Skilled nursing services continuously for assessments, clinical care, and support as needed for ongoing evaluation of patients condition." During a record review of Patient 6s medical record form titled ";POC/IDG Review" dated 12/9/2024, the review indicated a registered nurse did not sign the form. Patient 6s POC/IDG Review also indicated Patient 6s level of care was routine care. During a concurrent interview and record review on 12/16/2024 at 1:19 p.m. with the ADM/DPCS of Patient 6s EMR, the ADM/DPCS stated Patient 6s last POC/IDG meeting was completed on 12/9/2024. The ADM stated the HA did not conduct a POC/IDG meeting to discuss Patient 6s current condition after being placed on continuous care on 12/10/2024. The ADM/DPCS stated Patient 6s plan of care needed to be updated to ensure she (Patient 6) received the proper care from the HAs nurses. 7. During a record review of Patient 7s medical record form titled ";Personal Information" the information form indicated Patient 7s start of care date was 10/18/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease without heart failure. During a record review of Patient 7s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for First 90-day period" dated 10/18/2024 to 1/15/2024, indicated under the Physician Narrative section ";Admitted... with terminal diagnosis of hypertensive heart disease with heart failure...". During a record review of Patient 7s medical record form titled ";POC Summary" dated as of 12/12/2024, indicated ";Admit patient... with primary diagno sis of hypertensive heart disease without heart failure..." Patient 7s POC Summary also indicated it was not signed. During a record review of Patient 7s medical record form titled ";POC/IDG Review" dated 11/11/2024, the review indicated Patient 7s POC/IDG Review was not signed by an RN. During a record review of Patient 7s medical record form titled ";POC/IDG Review" dated 11/25/2024, the review indicated Patient 7s POC/IDG Review was not signed by an RN. During a concurrent interview and record review on 12/16/2024 at 1:40 p.m. with the ADM/DPCS of Patient 7s EMR, the ADM/DPCS stated Patient 7s POC/IDG meetings dated 11/11/2024 and 11/25/2024 were not signed by a registered nurse. 8a. A review of Patient 8s ";Personal Information" document indicated a start of care (SOC) date of 3/1/2024, with a terminal diagnosis of other cerebrovascular disease. During a home visit on 12/13/2024, at 2 p.m., Licensed Vocational Nurse (LVN 1) visited Patient 8. Patient 8 was lying in a hospital bed, awake and alert. Patient 8 was not able to communicate in English or her preferred language, Spanish. Patient 8 smiled and responded to Spanish language communication through eye and eyebrow gestures. During a concurrent observation and interview at the home visit on 12/13/2024, at 2:09 p.m., LVN 1 assessed Patient 8. During the observation of Patient 8s belly, a tube was coming out of Patient 8s belly. LVN 1 stated the tube was a ";G-Tube" (gastrostomy tube, inserted through the belly, to bring nutrition to the stomach) and looked like the size was ";15." LVN 1 proceeded to change the dressing (bandage) covering the G-tube. LVN 1 asked Caregiver (CG 6) if there was normal saline (water with salt) to clean the skin surrounding the G-tube. CG 6 stated she did not have normal saline, and only had hydrogen peroxide (a cleaning solution). CG 6 stated she did not know that she was supposed to use normal saline to clean the G-tube site. During the dressing change and assessment of the G-tube, the LVN did not check for residual (the process of checking how much food is left in the stomach). During a concurrent interview and record review on 12/14/2024, at 11:07 a.m., Registered Nurse 3 (RN 3), reviewed Patient 8s record titled, ";Re-Cert Assessment", dated 10/25/2024. RN 3 stated an assessment of the GI system (gastrointestinal-stomach, and all associated body parts) included assessing the G-tube to see if there was a clog (block), redness around the tube, and foul smell. Teaching the family on how to care for the G-tube, and how to flush it (to prevent it from clogging) was also important. RN 3 stated it was the standard of care to check for residual. Checking for residual was important to make sure the tube was patent (working). RN 3 stated he reviewed the assessment and stated he had not documented residual was assessed. Assessing residual was important to make sure the patient can get everything she needs through the tube. Clogging can cause medication to not fully be absorbed. That is why teaching to the family to flush the tube was important. RN 3 stated he did not document teaching was provided to Patient 8s caregivers. Teaching was important so the family knows how to manage the G-tube, so there are no issues, no clogging, and not to have hospitalizations associated with the G-tube. During a concurrent interview and record review on 12/14/2024, at 11:07 a.m., RN 3, reviewed Patient 8s record titled, ";Re-Cert Assessment", dated 10/25/2024. RN 3 stated he had forgotten to document the size of the G-tube. Documenting the size of the G-tube was important so if something happened to it, the HA could send the right size, and to have it handy. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. During a concurrent interview and record review on 12/14/2024, at 11:50 a.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 11/25/2024. The ADM/DPCS stated the instructions on how to take care of the G-tube were not included in the update of the comprehensive assessment. The instructions for care that needed to be included: to flush before and after medication administration, check for residual, notify the doctor if the residual amount was greater than 60 ml (ml-milliliters, unit of measurement), instructions on what to do if it clogs, and to check to see the proper location. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. During a concurrent interview and record review on 12/14/2024, at 12:08 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 11/11/2024. The ADM/DPCS stated the instructions on how to take care of the G-tube were not included in the update of the comprehensive assessment. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. During a concurrent interview and record review on 12/14/2024, at 12:08 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 10/28/2024. The ADM/DPCS stated the instructions on how to take care of the G-tube were not included in the update of the comprehensive assessment. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. 8b. During a concurrent observation and interview at the home visit on 12/13/2024, at 2:09 p.m., LVN 1 assessed Patient 8. During the observation of Patient 8s back side, LVN 1 stated the skin at the end of the spine (buttocks, coccyx area) was intact (skin present). Patient 8s skin was clean and dry. No skin pressures/ulcers (opening of the skin, due to pressure, friction, rubbing) was observed. During an interview at the home visit on 12/13/2024, at 2:15 p.m., CG 6 stated Patient 8 has not had any issues with the skin. Patient 8s skin had never opened. During a concurrent interview and record review on 12/14/2024, at 11:07 a.m., RN 3, reviewed Patient 8s record titled, ";Re-Cert Assessment", dated 10/25/2024. The record indicated, ";Patient presents with stage 1 pressure ulcer (discoloration of the skin, the mildest form of pressure ulcer) on coccyx area. Wound care per MD orders, cleanse with NS, pat dry...". The record did not include a picture of the pressure ulcer. RN 3 stated he was supposed to take a picture of the wound, but he was rushing that day, so he did not take a picture of Patient 8s pressure wound. RN 3 stated it was the HAs policy to take a picture of the pressure ulcer. During a concurrent interview and record review on 12/14/2024, at 11:50 a.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 11/25/2024. The ADM/DPCS stated the document indicated Patient 8 had pressure ulcer on the coccyx area and would be managed by the wound specialist. The ADM/DPCS stated the HA needed to take pictures to document the progress and assessment of the wound. The ADM/DPCS stated there was no pictures taken of Patient 8s wound. The ADM/DPCS stated the comprehensive assessment was not updated and had to do an internal assessment herself to assess what happened with all the documentation, to make sure it did not happen again. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. During a concurrent interview and record review on 12/14/2024, at 12:08 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG" dated 11/11/2024. The ADM/DPCS stated the document indicated Patient 8 had pressure ulcer on the coccyx area and would be managed by the wound specialist. The ADM/DPCS stated the comprehensive assessment was not updated to reflect the current needs of the patient. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. During a concurrent interview and record review on 12/14/2024, at 12:11 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 10/28/2024. The ADM/DPCS stated the document indicated Patient 8 had a pressure ulcer on the coccyx area and would be managed by the wound specialist. The ADM/DPCS stated the comprehensive assessment was not updated to reflect the current needs of the patient. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. 8c. During a concurrent observation, interview, and record review, on 12/13/2024, at 2:25 p.m., LVN 1 reviewed the medications Patient 8 was taking, using the patients record titled, ";Current Treatment/Medication/DME List", printed on 12/12/2024. The following medications were listed in the form, but the medications were not at Patient 8s home: LVN 1 stated ";Amlodipine" (used to treat high blood pressure) was not at the home. Caregiver 7 (CG7) stated Patient 8 stopped taking the medication six months ago. During a concurrent interview and record review on 12/14/2024, at 11:50 a.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 11/25/2024. The ADM/DPCS stated based on the document Patient 8 was taking ";Amlodipine." The ADM/DPCS was informed CG 7 stated Patient 8 had stopped taking the medication six months ago. The ADM/DPCS stated the update of the comprehensive assessment and plan of care was supposed to be done every 14 days. The importance of this was for patient safety reasons. It can be very detrimental to Patient 8 if her blood pressure drops. The ADM/DPCS stated the comprehensive assessment was not updated to reflect the current needs of the patient. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. During a concurrent interview and record review on 12/14/2024, at 12:08 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 11/11/2024. The ADM/DPCS stated the record indicated Patient 8 was on ";Amlodipine." The ADM/DPCS stated the comprehensive assessment was not updated to reflect the current needs of the patient. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. During a concurrent interview and record review on 12/14/2024, at 12:11 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 10/28/2024. The ADM/DPCS stated the record indicated Patient 8 was on ";Amlodipine." The ADM/DPCS stated the comprehensive assessment was not updated to reflect the current needs of the patient. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. 9. During a review of Patient 9s Face Sheet, the Face Sheet indicated a SOC date of 11/15/2024, with a terminal diagnosis of unspecified severe protein-calorie malnutrition. During an interview on 12/15/2024, at 8:45 a.m., the ADM/DPCS stated the nursing discussion section in the documents titled, ";POC/IDG" were copied from the previous nursing assessment and pasted on the document. During a concurrent interview and record review on 12/15/2024, at 9:58 a.m., the ADM/DPCS reviewed Patient 9s record titled, ";POC/IDG" dated 12/9/2024. The ADM/DPCS stated the document indicated Patient 9 had heart failure NYHA 4 (New York Heart Association-a classification tool for heart failure, unable to do any activity, without discomfort). The ADM/DPCS stated the information was wrong and should not be there. Patient 9 did not have that diagnosis. The ADM/DPCS stated this was not an accurate update of the comprehensive assessment. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. During a concurrent interview and record review on 12/15/2024, at 10:02 a.m., the ADM/DPCS reviewed Patient 9s record titled, ";POC/IDG", dated 11/25/2024. The ADM/DPCS stated the document indicated Patient 9 had heart failure NYHA 4. The ADM/DPCS stated the information was wrong and should not be there. ADM/DPCS stated this was not an accurate update of the comprehensive assessment and was correcting it at this time because it was her mistake. The ADM/DPCS stated she would not copy and paste documentation anymore. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. During a concurrent interview and record review, on 12/15/2024, at 10:06 a.m., the ADM/DPCS reviewed Patient 9s record titled, ";POC/IDG", dated 11/15/2024. The ADM/DPCS stated the document indicated Patient 9 had heart failure NYHA 4. The ADM/DPCS stated the information was wrong and should not be there. The ADM/DPCS stated this was not an accurate update of the comprehensive assessment and was correcting it at this time because it was her mistake. The ADM/DPCS stated she would not copy and paste documentation anymore. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. 10. A review of Patient 10s ";Personal Information" documented indicated an SOC of 12/23/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. During a concurrent interview and record review on 12/15/2024, at 10:26 a.m., the ADM/DPCS reviewed Patient 10s record titled, ";Re-Cert Assessment", dated 10/12/2024. The document indicated Patient 10s indwelling catheter (a tube that drains urine from the bladder) was changed on 7/6/2024. The ADM/DPCS stated she needed to contact the nurse to find out if the catheter was changed recently. The catheter needed to be changed at least monthly, every 30 days and as needed, due to risk of infection, patient comfort, and safety. The longer the catheter is in, the longer the risk of infection. During an interview on 12/15/2024, at 10:36 a.m., Licensed Vocational Nurse 1 (LVN 1), stated she had changed Patient 10s catheter on 11/20/24. LVN 1 stated she usually changed the catheter every 4 to 5 weeks or sooner if the catheter leaked. During a concurrent interview and record review on 12/15/2024, at 10:42 a.m., the ADM/DPCS reviewed Patient 10s records. The ADM/DPCS stated there were no foley catheter orders for the current recertification period of 10/18/2024 to 12/16/2024. The ADM/DPCS stated that for every recertification period, there should be new doctors orders. The last catheter order was written on 4/3/2024 and this order did not say how often to change the catheter. The doctors order needed to include when to change the catheter due to patient safety and risk of infection. The purpose of having a frequency order was for the nurses to follow directions with the patient care and safety of changing the catheter. During a concurrent interview and record review on 12/15/2024, at 11:20 a.m., the ADM/DPCS reviewed Patient 10s record titled, ";POC/IDG" dated 11/11/2024. The ADM/DPCS stated the document indicated Patient 10 had heart failure NYHA 4. The ADM/DPCS stated the information was wrong and should not be there. The ADM/DPCS stated Patient 10 was using an indwelling catheter and there were no interventions for the catheter. The ADM/DPCS stated the document also indicated Patient 10 was on ";Cipro" (an antibiotic used to treat infections), but this was wrong too because the patient did not have an infection. The ADM/DPCS stated this was not an accurate update of the comprehensive assessment. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. During a concurrent interview and record review on 12/15/2024, at 11:41 a.m., the ADM/DPCS reviewed Patient 10s record titled, ";POC/IDG" dated 10/28/2024. The ADM/DPCS stated the document indicated Patient 10 had heart failure NYHA 4. The ADM/DPCS stated the information was wrong and should not be there. The ADM/DPCS stated Patient 10 was using an indwelling catheter and there were no interventions for the catheter. The ADM/DPCS stated the document also indicated Patient 10 was on ";Cipro", but this was wrong too because the patient did not have an infection. The ADM/DPCS stated this was not an accurate update of the comprehensive assessment. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the comprehensive assessment. During an interview on 12/15/2024, at 5:05 p.m. Patient 10s caregiver (CG 8) stated Patient 10 had a catheter. CG 8 stated Patient 10s urine out of nowhere, will turn red in color. They will give her an antibiotic, and it clears up. CG 8 stated he did not know why Patient 10 kept getting the urinary tract infection (UTI). CG 8 stated Patient 10 did not currently have a UTI but did have several UTIs this year. A record review of the HAs document titled, ";Interdisciplinary Group Meeting", dated 11/2021, indicated, ";1. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor...5. A plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment. A record review of the HAs document titled, ";The Plan of Care", dated 11/2021, indicated, ";Policy...The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation regarding care planning and coordination of services for patients was met as follows: --- 1. The HA failed to ensure one of fourteen sampled patients (Patient 6) Plan of Care (POC – individualized care planned) to provide a Certified Home Health Aide Visits as ordered was followed (Refer to L543). 2. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) reviewed and revised ten of fourteen sampled patients (Patient1, Patient 2, Patient 3. Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, patient 9, and Patient 10) plan of care (POC- an individualized care planned). (Refer to L552). 3. The HA failed to ensure one of fourteen sampled patients (Patient 2) care and services were communicated with the hospice team to ensure services were provided as ordered. The HA was not aware the referring Medical Doctor 2 (MD2) ordered In Home Supportive Services (IHSS – program that provided in-home assistance to eligible aged, blind, and disabled individuals) for Patient 2. This failure resulted in the HA staff placing patients at risk for harm by not being aware of patients status. (Refer to L554). The cumulative effect of these systemic practices resulted in the HA not providing the services/care as ordered and had the potential to result in the patients not receiving appropriate healthcare services that could affect their quality of life.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure one of fourteen sampled patients (Patient 6) Plan of Care (POC – individualized care planned) received services as indicated in the plan of care. This failure had the potential to result in unmanaged needs due to not having a plan of care to follow. --- During a record review of Patient 6s medical record form titled ";Personal Information" the personal information form indicated Patient 6s start of care date was 11/6/2024 with a primary diagnosis of Alzheimers Disease. During a record review of Patient 6s medical record form titled ";Comprehensive Nursing Assessment" dated 11/6/2024, indicated Patient 6s diagnoses include Alzheimers Disease, balance impaired, fecal and urine incontinence (loss of bladder and bowel control). The Comprehensive Nursing Assessment also indicated Patient 6 was dependent on a caregiver for her (Patient 6) activities of daily living (ADL – task performed to stay healthy and maintain personal care). The Comprehensive Assessment also indicated under ";Personal Care and Support Needs – Need for Hospice Aide" for grooming, light meal preparation, and linen change. During a record review of Patient 6s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #3: Re-Certification Statement for Next 60-day period" dated from 11/6/2024 to 12/4/2024, indicated Patient 6 needed maximum assist with five out of six ADLs. During a record review of Patient 6s medical record form titled ";POC Summary" dated as of 12/14/2024, the summary indicated a ";Certified home health aide frequency of twice a week for personal and ADL care." During a record review of Patient 6s undated medical record form titled ";Current Treatment/Medication/DME (durable medical equipment)" indicated ";Certified home health aide frequency twice a week for personal and ADL care." During a record review of Patient 6s medical record form titled ";POC/IDG Review" dated 11/6/2024, the form indicated ";Certified home health aide frequency twice a week for personal and ADL care." During a record review of Patient 6s medical record form titled ";History of HA Visits" , the history indicated Patient 6 received CHHA visits on 11/6/2024, 11/13/2024, 11/20/2024, 11/27/2024, and 12/4/2024. During a concurrent interview and record review on 12/16/2024 at 1:19 p.m. with the Administrator/Director of Patient Care services (ADM/DPCS) of Patient 6s EMR, the ADM/DPCS stated Patient 6 was ordered to receive CHHA visits twice per week. The ADM/DPCS stated she (ADM/DPCS) does not know what happened. The ADM/DPCS stated it was important to provide the ordered CHHA frequency and services to assist the patient and family with the life transition.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) reviewed and revised ten of fourteen sampled patients (Patient1, Patient 2, Patient 3. Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, patient 9, and Patient 10) plan of care (POC- an individualized care planned). This failure resulted in patients to not be properly evaluated which resulted in not being provided individualized focused care. --- During an interview on 12/15/2024, at 8:21 a.m., the Administrator and Director of Patient Care Services (ADM/DPCS) stated the comprehensive assessment was used to ensure the plan of care was developed according to the needs of the patient and family members. During an interview on 12/15/2024, at 8:35 a.m., the ADM/DPCS stated the IDG team meets to review the patient assessments and update the plan of care every two weeks. If there were changes, decline in the patients care, medication changes, the plan of care would be updated to reflect those changes. 1. During a record review of Patient 1s medical record form titled ";Personal Information" the form indicated Patient 1s start of care date was 7/16/2024 with a primary diagnosis of heart disease (general term for a variety of conditions that affect the hears structure and function), unspecified. During a review of Patient 1s Updated Assessment (a nursing assessment conducted to determine if a patient continues to qualify for hospice services) dated 12/3/2024, the Updated Assessment indicated a score of 3 (maximum assist) for Patient 1s activities of daily living including ambulation, toileting, and bathing. The Updated Assessment indicated a level of IV (unable to carry out any physical activity without discomfort) on Patient 1s NYHA scale (New York Heart Association – functional classification). The Updated Assessment indicated Patient 1 had ";very limited" mobility. The Updated Assessment was signed by Registered Nurse 1 (RN1). During a record review of Patient 1s medical record form titled ";POC (plan of care) Summary" dated as of 12/12/2024, the summary indicated ";Interdisciplinary team to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 1s undated medical record form titled ";Current Treatment/Medication/DME (durable medical equipment)" indicated ";Interdisciplinary team to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 1s undated medical record form titled ";History of POC (plan of care)/IDG (interdisciplinary group)" indicated the last entry was made on 11/25/2024. During a record review of Patient 1s medical record form titled ";Audit Log" dated from 7/19/2024 to 12/16/2024, the audit log indicated Patient 1s IDG meeting dated 12/9/2024 was signed by Registered Nurse 1 (RN1) and the Spiritual Counselor (SC) on 12/13/2024. The Medical Director 1 (MD1) signed Patient 1s IDG meeting dated 12/9/2024 on 12/14/2024. The Medical Social Worker (MSW) signed Patient 1s IDG meeting dated 12/9/2024 on 12/15/2024. Lastly, Patient 1s IDG meeting form dated 12/9/2024 indicated the Administrator/Director of Patient Care Services (Adm./DPCS) documented Patient 1s summary assessment on 12/13/2024. During a concurrent interview and record review on 12/16/2024 at 11:55 a.m. with the ADM/DPCS of Patient 1s Electronic Medical Record (EMR), the ADM/DPCS stated Patient 1s interdisciplinary meeting was not done on 12/9/2024 and was held sometime after 12/13/2024. The ADM/DPCS stated it was important to hold an interdisciplinary meeting every 14 days to ensure patients plan of care is up to date and to be able to come up with an appropriate plan of care. During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/2/2024, indicated Patient 2s diagnoses include hypertensive heart disease with heart failure, and hyperlipidemia (high cholesterol). The Comprehensive Nursing Assessment also indicated Patient 2 had history of high blood pressure, arthritis (swelling and tenderness of one or more joints), depression (mental health condition causing low mood and loss of interest in activities), a heart attack (blood flow to the heart is blocked) five years ago with three bypass surgery (a surgical procedure to divert blood around the heart), shortness of breath, and wounds on both lower extremities. During a record review of Patient 2s medical record form titled ";POC (plan of care) Summary" dated as of 12/12/2024, the POC indicated ";Interdisciplinary team to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 2s undated, medical record form titled ";Current Treatment/Medication/DME (durable medical equipment)" indicated ";Interdisciplinary team to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 2s medical record form titled ";POC (plan of care)/IDG (interdisciplinary group) Review" dated 12/9/2024, the POC indicated a Registered Nurse (RN) and the Medical Social Worker (MSW) did not sign the form. The POC/IDG Review also did not indicate any problems, interventions, goals, or status for Patient 2. During a record review of Patient 2s medical record form titled ";Audit Log" dated from 1/1/2024 to 12/16/2024, the audit log indicated the ADM/DPCS and the MSW signed Patient 2s POC/IDG Review dated 12/9/2024 on 12/15/2024. During a concurrent interview and record review on 12/14/2024 at 11:05 a.m. with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 2s Electronic Medical Record (EMR), the ADM/DPCS stated Patient 2s POC/IDG Review dated 12/9/2024 did not indicate any problems, interventions, goals, or status. ADM/DPCS stated Patient 2 did not have a plan of care documented. The ADM/DPCS stated a patients care plan is used to plan and monitor their transition to death while in hospice and to offer medication management and pain control. The ADM/DPCS stated patients run risk of not being assessed properly and not receiving their individualized care if their care is not planned. The ADM/DPCS stated Patient 2s comprehensive assessment dated 12/9/2024 was not signed by herself (ADM/DPCS) or the Medical Social Worker (MSW). The ADM/DPCS stated the discipline signatures indicated they assessed and documented the patients assessment. 3. During a record review of Patient 3s medical record form titled ";Personal Information" the form indicated Patient 3s start of care date was 5/14/2024 with a primary diagnosis of Alzheimers Disease (progressive memory loss). During a record review of Patient 3s medical record form titled ";Comprehensive Nursing Assessment" dated 5/14/2024, the Comprehensive Nursing Assessment indicated Patient 3 had history of Alzheimers Disease, insomnia (sleep disorder that makes it difficult to fall asleep), constipation (infrequent or difficult to pass a bowel), anxiety (a feeling of fear, dread, and uneasiness), and was at risk for falls. During a record review of Patient 3s medical record form titled ";POC (plan of care) Summary" dated as of 12/12/2024, indicated ";Interdisciplinary team to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 3s medical record form titled ";Current Treatment/Medication/DME (durable medical equipment)" undated, indicated ";Interdisciplinary team to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 3s medical record form titled ";History of POC (plan of care)/IDG (interdisciplinary group)" indicated the last entry was made on 11/25/2024. During a record review of Patient 3s medical record form titled ";POC/IDG Review" dated 11/25/2024, indicated a registered nurse did not sign the form. During a record review of Patient 3s medical record form titled ";Audit Log" dated from 5/13/2024 to 12/16/2024, the audit log indicated Patient 3s IDG meeting dated 10/28/2024 was signed by the ADM/DPCS on 12/14/2024. During a record review of Patient 3s medical record form titled ";Audit Log" dated from 5/13/2024 to 12/16/2024, the audit log indicated Patient 3s IDG meeting dated 11/11/2024 was signed by the ADM/DPCS on 12/14/2024. During a record review of Patient 3s medical record form titled ";Audit Log" dated from 5/13/2024 to 12/16/2024, the audit log indicated Patient 3s IDG meeting dated 11/25/2024 was signed by the ADM/DPCS on 12/14/2024. During a record review of Patient 3s medical record form titled ";Audit Log" dated from 5/13/2024 to 12/16/2024, the audit log indicated Patient 3s IDG meeting dated 12/9/2024 was signed by the ADM/DPCS and the MD1 on 12/14/2024. The MSW signed Patient 3s IDG meeting dated 12/9/2024 on 12/15/2024. Lastly, the SC signed Patient 3s IDG meeting form dated 12/9/2024 on 12/13/2024. During a concurrent interview and record review on 12/16/2024 at 12:25 p.m. with the ADM/DPCS of Patient 3s EMR, the ADM/DPCS stated the last documented IDG meeting for Patient 3 was documented on 11/25/2024. The ADM/DPCS stated Patient 3s IDG meeting dated 12/9/2024 was documented within a few dates from this interview. The ADM/DPCS stated all disciplines are to sign the interdisciplinary group meetings the same day of the meeting for patient safety and real time documentation. 4. During a record review of Patient 4s medical record form titled ";Personal Information" indicated Patients 4 start of care date was 8/30/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure. During a record review of Patient 4s medical record form titled ";Plan of Care" dated as of 12/12/2024, indicated ";Next POC review to be done no later than 14 days from todays date." During a record review of Patient 4s undated medical record form titled ";Current Treatment/Medication/DME (durable medical equipment)" , the form indicated ";Interdisciplinary team to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 4s medical record form titled ";Audit Log" dated from 8/30/2024 to 12/16/2024, the audit log indicated Patient 4s IDG meeting dated 10/28/2024 was signed by the ADM/DPCS on 12/14/2024. During a record review of Patient 4s medical record form titled ";Audit Log" dated from 8/30/2024 to 12/16/2024, the audit log indicated Patient 4s IDG meeting dated 11/11/2024 was signed by the ADM/DPCS on 12/14/2024 and the SC on 12/5/2024. During a record review of Patient 4s medical record form titled ";Audit Log" dated from 8/30/2024 to 12/16/2024, the audit log indicated Patient 4s IDG meeting dated 11/25/2024 was signed by the ADM/DPCS on 12/14/2024 and the SC on 12/5/2024. During a record review of Patient 4s medical record form titled ";Audit Log" dated from 8/30/2024 to 12/16/2024, the audit log, indicated Patient 4s IDG meeting dated 12/9/2024 was signed by the ADM/DPCS and the MD1 on 12/14/2024. The MSW signed Patient 4s IDG meeting dated 12/9/2024 on 12/15/2024. Lastly, the SC signed Patient 4s IDG meeting form dated 12/9/2024 on 12/13/2024. 5. During a record review of Patient 5s medical record form titled ";Personal Information" the personal information indicated Patient 5s start of care date was 5/30/2024 with an end of care date of 6/3/2024 with a primary diagnosis of multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). During a record review of Patient 5s medical record form titled ";POC Summary" dated as of 12/12/2024, the POC Summary indicated ";IDT to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 5s undated medical record form titled ";Current Treatment/Medication/DME (durable medical equipment)" indicated Patient 5s level of care was continuous care which was ordered on 5/30/2024. During a record review of Patient 5s medical record form titled ";Audit log" dated from 5/4/2024 to 12/16/2024, the audit log indicated the ADM/DPCS signed Patient 5s POC/IDG review dated 5/4/2024 on 6/2/2024. During a record review of Patient 5s medical record form titled ";Audit log" dated from 5/4/2024 to 12/16/2024, the audit log indicated the Registered Nurse 1 (RN1) signed Patient 5s POC/IDG review dated 5/13/2024 on 7/24/2024, the MD1 signed on 6/2/2024, and the SC signed on 6/3/2024. During a record review of Patient 5s medical record form titled ";Audit log" dated from 5/4/2024 to 12/16/2024, the audit log indicated the MSW signed Patient 5s POC/IDG review dated 5/27/2024 on 5/28/2024, the MD1 signed on 6/2/2024, the SC signed on 6/3/2024, and the ADM/DPCS signed on 6/18/2024. 6. During a record review of Patient 6s medical record form titled ";Personal Information" the form indicated Patient 6s start of care date was 11/6/2024 with a primary diagnosis of Alzheimers Disease. During a record review of Patient 6s medical record form titled ";Comprehensive Nursing Assessment" dated 11/6/2024, indicated Patient 6s diagnoses include Alzheimers Disease, balance impaired, fecal and urine incontinence (loss of bladder and bowel control). The Comprehensive Nursing Assessment also indicated Patient 6 was dependent on a caregiver for her (Patient 6) activities of daily living (ADL – task performed to stay healthy and maintain personal care). During a record review of Patient 6s medical record form titled ";POC Summary" dated as of 12/14/2024, the summary indicated ";Level of care – Continuous Care. Skilled nursing services continuously for assessments, clinical care, and support as needed for ongoing evaluation of patients condition." Patient 6s POC Summary also indicated it was not signed by an HA staff. During a record review of Patient 6s undated medical record form titled ";Current Treatment/Medication/DME (durable medical equipment)" indicated ";Skilled nursing services continuously for assessments, clinical care, and support as needed for ongoing evaluation of patients condition." During a record review of Patient 6s medical record form titled ";POC/IDG Review" dated 12/9/2024, the review indicated a registered nurse did not sign the form. Patient 6s POC/IDG Review also indicated Patient 6s level of care was routine care. During a concurrent interview and record review on 12/16/2024 at 1:19 p.m. with the ADM/DPCS of Patient 6s EMR, the ADM/DPCS stated Patient 6s last POC/IDG meeting was completed on 12/9/2024. The ADM stated the HA did not conduct a POC/IDG meeting to discuss Patient 6s current condition after being placed on continuous care on 12/10/2024. The ADM/DPCS stated Patient 6s plan of care needed to be updated to ensure she (Patient 6) received the proper care from the HAs nurses. 7. During a record review of Patient 7s medical record form titled ";Personal Information" the personal information indicated Patient 7s start of care date was 10/18/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease without heart failure. During a record review of Patient 7s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for First 90-day period" dated 10/18/2024 to 1/15/2024, indicated under the Physician Narrative section ";Admitted... with terminal diagnosis of hypertensive heart disease with heart failure...". During a record review of Patient 7s medical record form titled ";POC Summary" dated as of 12/12/2024, the summary indicated ";Admit patient... with primary diagnosis of hypertensive heart disease without heart failure...". Patient 7s POC Summary also indicated it was not signed. During a record review of Patient 7s medical record form titled ";POC/IDG Review" the review dated 11/11/2024, indicated Patient 7s POC/IDG Review was not signed by an RN. During a record review of Patient 7s medical record form titled ";POC/IDG Review" dated 11/25/2024, the review indicated Patient 7s POC/IDG Review was not signed by an RN. During a concurrent interview and record review on 12/16/2024 at 1:40 p.m. with the ADM/DPCS of Patient 7s EMR, the ADM/DPCS stated Patient 7s POC/IDG meetings dated 11/11/2024 and 11/25/2024 were not signed by a registered nurse. 8a. A review of Patient 8s ";Personal Information", document indicated an start of care (SOC) of 3/1/2024, with a terminal diagnosis of other cerebrovascular disease. During an observation of the home visit on 12/13/2024, at 2 p.m., Licensed Vocational Nurse (LVN 1) visited Patient 8. Patient 8 was lying in a hospital bed, awake and alert. Patient 8 was not able to communicate in English or her preferred language, Spanish. Patient 8 smiled and responded to Spanish language communication through eye and eyebrow gestures. During a concurrent observation and interview at the home visit on 12/13/2024, at 2:09 p.m., LVN 1 assessed Patient 8. During the observation of Patient 8s belly, a tube was coming out of Patient 8s belly. LVN 1 stated the tube was a ";G-Tube" (gastrostomy tube, inserted through the belly, to bring nutrition to the stomach) and looked like the size was ";15". LVN 1 proceeded to change the dressing (bandage) covering the G-tube. LVN 1 asked Caregiver (CG 6) if there was normal saline (water with salt) to clean the skin surrounding the G-tube. CG 6 stated she did not have normal saline, and only had hydrogen peroxide (a cleaning solution). CG 6 stated she did not know that she was supposed to use normal saline to clean the G-tube site. During the dressing change and assessment of the G-tube, the LVN did not check for residual (the process of checking how much food is left in the stomach). During a concurrent interview and record review on 12/14/2024, at 11:07 a.m., Registered Nurse 3 (RN 3), reviewed Patient 8s record titled, ";Re-Cert Assessment", dated 10/25/2024. RN 3 stated an assessment of the GI system (gastrointestinal-stomach, and all associated body parts) included assessing the G-tube to see if there was a clog (block), redness around the tube, and foul smell. Teaching the family on how to care for the G-tube, and how to flush it (to prevent if from clogging) was also important. RN 3 stated it was the standard of care to check for residual. Checking for residual was important to make sure the tube was patent (working). RN 3 stated he reviewed the assessment and stated he had not documented residual was assessed. Assessing residual was important to make sure patient can get everything she needs through the tube. Clogging can cause medication to not fully be absorbed. That is why teaching to the family to flush the tube was important. RN 3 stated he did not document teaching was provided to Patient 8s caregivers. Teaching was important so the family knows how to manage the G-tube, so there are no issues, no clogging, and not to have hospitalizations associated with the G-tube. During a concurrent interview and record review on 12/14/2024, at 11:07 a.m., RN 3, reviewed Patient 8s record titled, ";Re-Cert Assessment", dated 10/25/2024. RN 3 stated he had forgotten to document the size of the G-tube. Documenting the size of the G-tube was important so if something happened to it, the HA could send the right size, and to have it handy. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. During a concurrent interview and record review on 12/14/2024, at 11:50 a.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 11/25/2024. The ADM/DPCS stated the instructions on how to take care of the G-tube were not included in the update of the plan of care. The instructions for care needed to be included: to flush before and after medication administration, check for residual, notify the doctor if the residual amount was greater than 60 ml (ml-milliliters, unit of measurement), instructions on what to do if it clogs, and to check to see the proper location. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. During a concurrent interview and record review on 12/14/2024, at 12:08 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 11/11/2024. The ADM/DPCS stated the instructions on how to take care of the G-tube were not included in the update of the plan of care. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. During a concurrent interview and record review on 12/14/2024, at 12:08 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 10/28/2024. The ADM/DPCS stated the instructions on how to take care of the G-tube were not included in the update of the plan of care. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. 8b. During a concurrent observation and interview at the home visit on 12/13/2024, at 2:09 p.m., LVN 1 assessed Patient 8. During the observation of Patient 8s back side, LVN 1 stated the skin at the end of the spine (buttocks, coccyx area) was intact (skin present). Patient 8s skin was clean and dry. No skin pressures/ulcers (opening of the skin, due to pressure, friction, rubbing) was observed. During an interview at the home visit on 12/13/2024, at 2:15 p.m., CG 6 stated Patient 8 has not had any issues with the skin. Patient 8s skin had never opened up. During a concurrent interview and record review on 12/14/2024, at 11:07 a.m., RN 3, reviewed Patient 8s record titled, ";Re-Cert Assessment", dated 10/25/2024. The record indicated, ";Patient presents with Stage 1 pressure ulcer (discoloration of the skin, the mildest form of pressure ulcer) on coccyx area. Wound care per MD orders, cleanse with NS, pat dry...". The record did not include a picture of the pressure ulcer. RN 3 stated he was supposed to take a picture of the wound, but he was rushing that day, so he did not take a picture of Patient 8s pressure wound. RN 3 stated it was the HAs policy to take a picture of the pressure ulcer. During a concurrent interview and record review on 12/14/2024, at 11:50 a.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 11/25/2024. The ADM/DPCS stated the document indicated Patient 8 had a pressure ulcer on the coccyx area and would be managed by the wound specialist. The ADM/DPCS stated the HA needed to take pictures to document the progress and assessment of the wound. The ADM/DPCS stated there was no pictures taken of Patient 8s wound. The ADM/DPCS stated the plan of care was not updated and she had to do an internal assessment herself to assess what happened with all the documentation, to make sure it did not happen again. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. During a concurrent interview and record review on 12/14/2024, at 12:08 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 11/11/2024. The ADM/DPCS stated the document indicated Patient 8 had a pressure ulcer on the coccyx area and would be managed by the wound specialist. The ADM/DPCS stated the plan of care was not updated to reflect the current needs of the patient. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. During a concurrent interview and record review on 12/14/2024, at 12:11 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 10/28/2024. The ADM/DPCS stated the document indicated Patient 8 had a pressure ulcer on the coccyx area and would be managed by the wound specialist. The ADM/DPCS stated the plan of care was not updated to reflect the current needs of the patient. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. 8c. During a concurrent observation, interview, and record review, on 12/13/2024, at 2:25 p.m., LVN 1 reviewed the medications Patient 8 was taking, using the patients record titled, ";Current Treatment/Medication/DME List", printed on 12/12/2024. The following medications were listed in the form, but the medications were not at Patient 8s home: LVN 1 stated ";Amlodipine" (used to treat high blood pressure) was not at the home. Caregiver 7 (CG7) stated Patient 8 stopped taking the medication six months ago. During a concurrent interview and record review on 12/14/2024, at 11:50 a.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 11/25/2024. The ADM/DPCS stated based on the document Patient 8 was taking ";Amlodipine." The ADM/DPCS was informed CG 7 stated Patient 8 had stopped taking the medication six months ago. The ADM/DPCS stated the update of the plan of care was supposed to be done every 14 days. The importance of this was for patient safety reasons. It can be very detrimental to Patient 8 if her blood pressure drops. The ADM/DPCS stated the plan of care was not updated to reflect the current needs of the patient. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. During a concurrent interview and record review on 12/14/2024, at 12:08 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG", dated 11/11/2024. The ADM/DPCS stated the record indicated Patient 8 was on ";Amlodipine." The ADM/DPCS stated the plan of care was not updated to reflect the current needs of the patient. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. During a concurrent interview and record review on 12/14/2024, at 12:11 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG" dated 10/28/2024. The ADM/DPCS stated the record indicated Patient 8 was on ";Amlodipine." The ADM/DPCS stated the plan of care was not updated to reflect the current needs of the patient. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. 9. During a review of Patient 9s Face Sheet, the Face Sheet indicated a SOC date of 11/15/2024, with a terminal diagnosis of unspecified severe protein-calorie malnutrition. During a concurrent interview and record review on 12/15/2024, at 9:58 a.m., the ADM/DPCS reviewed Patient 9s record titled, ";POC/IDG" dated 12/9/2024. The ADM/DPCS stated the document indicated Patient 9 had heart failure NYHA 4 (New York Heart Association-a classification tool for heart failure, unable to do any activity, without discomfort). The ADM/DPCS stated the information was wrong and should not be there. Patient 9 did not have that diagnosis. The ADM/DPCS stated this was not an accurate update of the plan of care. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. During a concurrent interview and record review on 12/15/2024, at 10:02 a.m., the ADM/DPCS reviewed Patient 9s record titled, ";POC/IDG", dated 11/25/2024. The ADM/DPCS stated the document indicated Patient 9 had heart failure NYHA 4. The ADM/DPCS stated the information was wrong and should not be there. The ADM/DPCS stated this was not an accurate update of the plan of care and was correcting it at this time because it was her mistake. The ADM/DPCS stated she would not copy and paste documentation anymore. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. During a concurrent interview and record review on 12/15/2024, at 10:06 a.m., the ADM/DPCS reviewed Patient 9s record titled, ";POC/IDG" dated 11/15/2024. The ADM/DPCS stated the document indicated Patient 9 had heart failure NYHA 4. The ADM/DPCS stated the information was wrong and should not be there. The ADM/DPCS stated this was not an accurate update of the plan of care and was correcting it at this time because it was her mistake. The ADM/DPCS stated she would not copy and paste documentation anymore. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. 10. A review of Patient 10s ";Personal Information" documented indicated a SOC of 12/23/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. During a concurrent interview and record review on 12/15/2024, at 10:26 a.m., the ADM/DPCS reviewed Patient 10s record titled, ";Re-Cert Assessment" dated 10/12/2024. The document indicated Patient 10s indwelling catheter (a tube that drains urine from the bladder) was changed on 7/6/2024. The ADM/DPCS stated she needed to contact the nurse to find out if the catheter was changed recently. The catheter needed to be changed at least monthly, every 30 days and as needed, due to the risk of infection, patient comfort, and safety. The longer the catheter is in, the longer the risk of infection. During an interview on 12/15/2024, at 10:36 a.m., Licensed Vocational Nurse 1 (LVN 1), stated she had changed Patient 10s catheter on 11/20/24. LVN 1 stated she usually changed the catheter every 4 to 5 weeks or sooner if the catheter leaked. During a concurrent interview and record review on 12/15/2024, at 10:42 a.m., the ADM/DPCS reviewed Patient 10s records. The ADM/DPCS stated there were no indwelling catheter orders for the current recertification period of 10/18/2024 to 12/16/2024. The ADM/DPCS stated that for every recertification period, there should be a new doctors order. The last catheter order was written on 4/3/2024 and this order did not indicate how often to change the catheter. The doctors order needed to include when to change the catheter due to patient safety and risk of infection. The purpose of having a frequency order was for the nurses to follow directions with the patient care and safety of changing the catheter. During a concurrent interview and record review on 12/15/2024, at 11:20 a.m., the ADM/DPCS reviewed Patient 10s record titled, ";POC/IDG" dated 11/11/2024. The ADM/DPCS stated the document indicated Patient 10 had heart failure NYHA 4. The ADM/DPCS stated the information was wrong and should not be there. The ADM/DPCS stated Patient 10 was using an indwelling catheter and there were no interventions for the catheter. The ADM/DPCS stated the document also indicated Patient 10 was on ";Cipro" (an antibiotic used to treat infections), but this was wrong too. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. During a concurrent interview and record review on 12/15/2024, at 11:41 a.m., the ADM/DPCS reviewed Patient 10s record titled, ";POC/IDG" dated 10/28/2024. The ADM/DPCS stated the document indicated Patient 10 had heart failure NYHA 4. The ADM/DPCS stated the information was wrong and should not be there. The ADM/DPCS stated Patient 10 was using an indwelling catheter and there were no interventions for the catheter. The ADM/DPCS stated the document also indicated Patient 10 was on ";Cipro", but this was wrong too because the patient did not have an infection. The ADM/DPCS stated this was not an accurate update of the plan of care. Further review of the record did not indicate a Registered Nurse had signed the document to validate their input in the update of the plan of care. During an interview on 12/15/2024, at 5:05 p.m. Patient 10s caregiver (CG 8) stated Patient 10 had a catheter. CG 8 stated Patient 10s urine out of nowhere, would turn red in color. They would give her an antibiotic, and it would clear up. CG 8 stated he did not know why Patient 10 kept getting an urinary tract infection (UTI). CG 8 stated Patient 10 did not currently have a UTI but did had several UTIs this year. A record review of the HAs document titled, ";Interdisciplinary Group Meeting", dated 11/2021, indicated, ";1. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor...5. A plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment. A record review of the HAs document titled, ";The Plan of Care" dated 11/2021, indicated, ";Policy...The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days.

Based on interview and record review, the Hospice Agency (HA) failed to ensure one of fourteen sampled patients (Patient 2) care and services were communicated with the hospice team to ensure services were provided as ordered. The HA was not aware the referring Medical Doctor 2 (MD2) ordered In Home Supportive Services (IHSS – program that provided in-home assistance to eligible aged, blind, and disabled individuals) for Patient 2. This failure resulted in the HA staff placing patients at risk of harm by not being aware of patients status. --- During a record review of Patient 2s medical record form titled ";Personal Information" the Personal Information form indicated Patient 2s start of care date was 12/2/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the bodys organs). During a record review of Patient 2s medical record form titled ";Physicians Certification for Hospice Benefit – Statement for First 90-day period" dated 12/2/2024, the statement indicated Medical Doctor 2 (MD2) referred Patient 2 for hospice services. During a record review of Patient 2s untitled, medical record form which was provided by the Administrator/Director of Patient Care Services (ADM/DPCS) dated 12/2/2024, indicated MD2 signed the form. The untitled form also indicated ";Caregiver: She does not have anyone to help her at home. She needs IHSS." During a record review of Patient 2s undated, medical record form titled ";Current Treatment/Medication /DME (durable medical equipment)" did not indicate IHSS was mentioned. During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/2/2024, the assessment did not indicate IHSS was mentioned. During a record review of Patient 2s medical record form titled ";Psychosocial Assessment" dated 12/4/2024, the Psychosocial Assessment did not indicate IHSS was mentioned. The Psychosocial Assessment indicated it was not signed. During a record review of Patient 2s medical record form titled ";POC (plan of care)/IDG (interdisciplinary group) Review" dated 12/9/2024, the POC did not indicate IHSS was mentioned. During a record review of Patient 2s medical record form titled ";POC (plan of care) Summary" dated as of 12/12/2024, the POC Summary did not indicate IHSS was mentioned. During a concurrent interview and record review on 12/14/2024 at 10:15 a.m. with the ADM/DPCS of Patient 2s Electronic Medical Record (EMR), the ADM/DPCS stated Patient 2s admitting nurse had a FaceTime visit (face to face conversation with someone over the internet using a mobile app) with MD2 after Patient 2s admitting nursing assessment. During a concurrent interview and record review on 12/14/2024 at 10:25 a.m. with MD2 of Patient 2s EMR, MD2 stated she saw Patient 2 while the admitting nurse was assessing her (Patient 2) via face time. MD 2 stated Patient 2 needs help at home; she needs IHSS. During a concurrent interview and record review on 12/14/2024 at 11:05 a.m. with the ADM/DPCS of Patient 2s EMR, ADM/DPCS stated she (ADM/DPCS) ";overlooked" MD2s order for IHSS and Certified Home Health Aide (CHHA) services for Patient 2. The ADM/DPCS stated either the IHSS or CHHA could have provided patient direct assistance. During a concurrent interview and record review on 12/16/2024 at 8:53 a.m. with the Medical Director 1 (MD1) of Patient 2s EMR, MD1 stated he (MD1) did not recall signing any IHSS forms for Patient 2. A record review of the HAs undated document titled, ";Coordination of Care with Contracts/Agreements" indicated, ";Procedure...6. All care provided will be in accordance with the hospice plan of care and documented in the clinical record."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for License Professional Services was met as evidence by: --- 1. The HA failed to provide evidence their licensed providers were authorized and qualified to provide hospice services to one of fourteen sample patients (Patient 2). (Refer to L584). The cumulative effect of these systemic practices resulted in the HA not ensuring their license personnel were providing services/care as required and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life.

Based on interview and record review, the Hospice Agency (HA) failed to provide evidence their licensed providers were authorized and qualified to provide hospice services to one of fourteen sample patients (Patient 2). This failure had the potential to result in patient's being taken care of by unqualified and unauthorized staff. --- During a record review of Patient 2s medical record form titled ";Personal Information" the Personal Information form indicated Patient 2s start of care date was 12/2/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the bodys organs). During a record review of Patient 2s medical record form titled ";Physicians Certification for Hospice Benefit – Statement for First 90-day period" dated 12/2/2024, the statement indicated Medical Doctor 2 (MD2) referred Patient 2 for hospice services. During a record review of Patient 2s untitled medical record form, which was provided by the Administrator/Director of Patient Care Services (ADM/DPCS) dated 12/2/2024, the form indicated MD2 signed the form. The untitled form also indicated ";Caregiver: She does not have anyone to help her at home. She needs IHSS." During a concurrent interview and record review on 12/14/2024 at 10:15 a.m. with the ADM/DPCS of Patient 2s Electronic Medical Record (EMR), the ADM/DPCS stated Patient 2s admitting nurse face time (face to face conversation with someone over the internet using a mobile app) with MD2 after Patient 2s admitting nursing assessment. During a concurrent interview and record review on 12/14/2024 at 10:25 a.m. with MD2 of Patient 2s EMR, MD2 stated she saw Patient 2 while the admitting nurse was assessing her (Patient 2) via face time. MD 2 stated Patient 2 needs help at home; She needs IHSS. During a concurrent interview and record review on 12/14/2024 at 11:05 a.m. with the ADM/DPCS of Patient 2s EMR, ADM/DPCS stated she (ADM/DPCS) ";overlooked" MD2s order for IHSS and Certified Home Health Aide (CHHA) services for Patient 2. The ADM/DPCS stated either the IHSS or CHHA could have provided patient direct assistance. During an interview on 12/17/2024 at 1:03 p.m. with the ADM/DPCS, the ADM/DPCS stated the HA does not have a contract, an employee file, or a background check for MD2 and she (ADM/DPCS) was unable to recall when MD2 started working for the HA. ADM/DPCS stated MD2 was referred by a consulting firm and does not have any of MD2s information to provide. ADM/DPCS stated it was important to have MD2s information for patient safety and to ensure patients are receiving safe and quality care. A record review of the HAs undated document titled, ";Coordination of Care with Contracts/Agreements", indicated, ";Procedure...4. Hospice will evaluate contract facility personnel needs for education and training at least once annually through its performance improvement program and/or corporate compliance program."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Organization and Administration of Services was met as evidence by: --- 1) . The HA failed to ensure the administrator assumed responsibility for the day-to-day operations of the agency for twelve 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, and Patient 12). (Refer to L651). 2. The HA failed to ensure the staff providing care were validated for their competency for one of fourteen sampled patients (Patient 8). (Refer to L663). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Organization and Administration of Services to ensure patients needs are met by qualified individuals.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the administrator assumed responsibility for the day-to-day operations of the agency, for twelve 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, and Patient 12). This failure resulted in the HA not providing quality care as required and resulted in the patients not receiving appropriate healthcare services that could affect their quality of life. --- During an interview on 12/14/2024, at 8:10 a.m., the Administrator and Director of Patient Care Services (ADM/DPCS) stated her role at the agency was Administrator and Director of Patient Care Services. The ADM/DPCS stated she worked part-time as a Nurse Practitioner. (NP) When asked how many hours a week she dedicated in working as an NP, the ADM/DPCS stated 60 hours a week. When asked who was in charge of the day-to-day operation of the HA, the ADM/DPCS stated she was on call 24 hours a day, 7 days a week. The ADM/DPCS stated she was seeing patients every 15 minutes, which gave her flexibility to step out in between patients and call the patients from the HA. The ADM/DPCS stated she had access to her computer 24 hours a day, 7 days a week. The ADM/DPCS stated she was available on the weekends too. On 12/16 /2024 at 4:08 p.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the agencys Administrator/Director of Patient Care Services. The HA failed to conduct and document a comprehensive assessment that reflected the patient's current and accurate health status and identify the patients' needs for hospice care and services related to hospice eligibility and management of terminal illness for three of fourteen sampled active patients (Patient 1, Patient 2, and Patient 9). (Refer to L524). On 12/17 /2024 at 1:37 p.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the agencys Administrator / Director of Patient Care Services. The HA Medical Director failed to document an accurate Certification of Terminal Illness 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 five of 14 sampled active patients (Patient 1, Patient 3, Patient 4, Patient 8, and Patient 10). (Refer to L667). On 12/17 /2024 at 1:44 p.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the agencys Administrator / Director of Patient Care Services. The HA Medical Director failed to document an accurate Certification of Terminal Illness 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 five of 14 sampled active patients (Patient 1, Patient 3, Patient 4, Patient 8, and Patient 10). (Refer to L668).

Based on observation, interview, and record review, the HA failed to ensure the staff providing care were validated for their competency for one of 14 sampled patients (Patient 8). This failure resulted in inaccurate information about the patients condition, which could affect the quality of care provided to them. --- During an interview on 12/14/2024, at 8:39 a.m., the Administrator/Director of Patient Care Services (ADM/DPCS) stated the Nurse Practitioner (NP 1) started working as a NP on 12/1/2023. The ADM/DPCS stated there was no competency evaluation in her employee file. The ADM/DPCS stated a competency evaluation was important to make sure patients are safe, ensures quality of care, and make sure they meet the expectation for their role. The ADM/DPCS stated NP 1 did not have a minimum of (1) year NP experience and was hired because the HA liked her worth ethic as a Registered Nurse. The Medical Director made an exception for the NP1. During an interview on 12/16/2024, at 10:18 a.m., the Medical Director (MD 1) stated he provided supervision of the NP 1 through her notes. MD 1 stated he had not observed her physical assessment skills in person, and all observations had been through the phone, through video conference. MD 1 stated NPs were considered to be independent practitioners. Once they were fully licensed, it was in their scope of care to assess patients and come up with the plan of care. Once the NP was licensed, it was expected for her do these things. MD 1 stated he did not need to go and teach her to do a physical examination and did not need to validate her competency in person. Once the NP was licensed, that was the validation that she was competent. A review of Patient 8s ";Personal Information" document indicated a start of care (SOC) of 3/1/2024, with a terminal diagnosis of other cerebrovascular disease. During a home visit on 12/13/2024, at 2 p.m., Licensed Vocational Nurse (LVN 1) visited Patient 8. Patient 8 was observed laying in a hospital bed, awake and alert. Patient 8 was not able to communicate in English or her preferred language, Spanish. Patient 8 smiled and responded to Spanish language communication through eye and eyebrow gestures. During an interview at the home visit on 12/13/2024, at 2:15 p.m., Patient 8s caregiver (CG 6) stated she and another relative (CG 7) cared for Patient 8 full time. CG 6 stated someone was always with Patient 8 when HA staff visit. CG 6 stated Patient 8 was unable to speak, and only understood the Spanish language. CG 6 stated sometimes Patient 8 would moan or mumble. During an interview, while at the home visit, on 12/13/2024, at 2:43 p.m., CG 7 stated no doctor had come to visit Patient 8 at the house. CG 6 stated no doctor had phoned them to talk to CG 6 and CG 7. CG 6 stated no doctor had contacted them through video telephone communication. CG 7 stated she and CG 6 were always present whenever there was an HA visit. CG 6 stated she had not seen a doctor come to the house, call, or contact them through video-telephone communication. CG 6 stated the nurse who visits Patient 8 calls the doctor and get everything they need. During an interview on 12/14/2024, at 8:56 a.m., CG 6 was asked if a Registered Nurse (RN 3) had come to visit them on 10/25/2024. The name of the RN was provided to CG 6. CG 6 was informed there was RN visits documented by RN 3 on 10/25/2024 by RN 3. CG 6 stated, ";Thats a lie." No one by that name had come visit Patient 8. CG 6 was given the name of the Nurse Practitioner (NP 1) and was asked if the NP had come to visit Patient 8. CG 6 stated a NP had not visited Patient 8, since starting hospice care. During a concurrent interview and record review on 12/14/2024, at 9:30 a.m., NP 1 reviewed Patient 8s record titled, ";F2F Visit Note", dated 10/24/2024. NP 1 stated this was a face-to-face visit for recertification. NP 1 stated she saw Patient 8 in an in-person visit at her home. NP 1 stated no one was present during the visit. NP 1 stated Patient 8 was left alone. NP 1 stated there was a communication barrier, language related. NP 1 stated Patient 8 was speaking a little bit of English. NP 1 stated due to Patient 8s language barrier, Patient 8 was not very talkative that day, but was able to assess her needs with the limited English Patient 8 spoke. During an interview on 12/14/2024, at 9:40 a.m., NP 1 was informed that CG 6 and CG 7 stated they had never met her and have not had any doctor or NP come to their home. NP 1 stated, as mentioned previously, no one was there when she visited Patient 8 on 10/24/2024. During a concurrent interview and record review on 12/14/2024, at 11:07 a.m., RN 3 reviewed Patient 8s record titled, ";Re-Cert Assessment", dated 10/25/2024. RN 3 stated he saw Patient 8 at her house on 10/25/2024, with the purpose to assess the patient for recertification of hospice care. RN 3 stated CG 7 was present during the visit. RN 3 stated Patient 8 did not talk a lot, as she was limited in talking, and was able to speak some English words. RN 3 stated this visit was rushed. During a concurrent interview and record review on 12/16/2024, at 11:05 a.m., MD 1 reviewed Patient 8s record titled, ";CTI", for benefit/certification Period 4, dated 10/27/2024 to 12/25/2024. MD 1 stated he had not seen Patient 8, but NP 1 had seen her. MD 1 stated he recertified Patient 8 based on the face-to-face encounter of NP 1. During an interview on 12/16/2024, at 11:10 a.m., MD 1 was informed that CG 6 and CG 7 had stated they had not had any NP visits. MD 1 stated he did not have anything to say about this. MD 1 stated he did not recall NP 1 calling him about Patient 8. During an interview on 12/16/24 at 2:50 p.m., NP 1 was asked, ";You mentioned patient was alone during the visit on 10/24/2024, correct?" NP 1 stated, unfortunately, she thought she had mixed up the patients. During the RN visit, she asked the nurse to face time during the visit. NP 1 stated she never went to her house. NP 1 stated the face time visit was on 10/24/24 or 10/25/24 whenever the nurse was there. NP1 was asked why she had documented that the face-to-face visit occurred on 10/24/2024? NP 1 stated she thought she forgot the date, it was probably an error on her end. NP 1 stated she could not go back and fix the document once it was submitted. A record review of the HAs document titled, ";Job Descriptions" for NP 1, dated 1995, the document indicted, ";Position Qualifications...4...minimum of one (1) year Nurse Practitioner experience...7.Excellent observation, verbal and written communication skill, problem solving skills, mathematical skills; nursing skills per competency checklist."

Based on observation, interview, and record review, the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA- a program that provides care and support for patients who are terminally ill] and have stopped treatment to cure their disease) failed to ensure the Conditions of Participations (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) regarding initial and Comprehensive Assessments (an assessment to identify the physical, psychosocial [the interaction between psychological {mental and emotional} and social {relationship and societal} factors], 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 of the Patient) of Patients was met as follows: --- 1. The HA Medical Director 1 (MD1) failed to ensure to review and document an accurate Certification of Terminal Illness (CTI- a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician) 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 12 of 14 sampled active patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). As a result of the noncompliance, Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12 were placed at increased risk for losing their hospice eligibility/hospice benefits, not receive hospice care when needed in the future, and had the potential to not receive the necessary care and services that could lead to potential hospitalization and death. (Refer to L667). 2. The HA Medical Director 1(MD1) failed to document an accurate Recertification of Terminal Illness (RTI- a brief narrative for recertification designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician) 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 five of 14 sampled active patients (Patient 1, Patient 3, Patient 4, Patient 8, and Patient 10). (Refer to L668). The cumulative effect of these systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Medical Director to ensure to provide the necessary care and services to the patients.

Based on observation, interview, and record review, the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA, agency providing care to terminally ill patients who have six months or less to live) Medical Director1 (MD 1) failed to ensure to review and document an accurate Certification of Terminal Illness (CTI-a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician) 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 12 of 14 sampled active patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). As a result of the noncompliance described above, Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12 were placed at increased risk for losing their hospice eligibility/hospice benefits, not receive hospice care when needed in the future, and had the potential to not receive the necessary care and services that could lead to potential hospitalization and death. On 12/17 /2024, at 1:37 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agencys Administrator/Director of Patient Care Services (ADM/DPCS) related to failure to ensure MD 1 reviewed and documented an CTI that reflected the patient's current health status and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness for 12 of fourteen sampled active patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). On 12/17/2024, at 2:15 pm, the Department conducted an exit conference with the ADM/DPCS with the IJ situation not removed. On 2/20/2025, the agency submitted acceptable IJ removal plans as follow: 1.On 12/8/2024, Patient 13 revoked hospice services. 2.On 12/15/2024, Patient 2 and Patient 11 revoked hospice services voluntarily and opted to seek treatment at a hospital. 3.On 12/17/2024, the HA discharged Patient 1 and Patient 9 due to extended prognosis. 4.On 12/18/2024, the HA discharged patient 6 due to death. 5.On 12/20/2024, the HA completed accurate assessments for Patient 8. 6.On 12/21/2024, the HA completed a supervisory visit for Patient 10 and the HA determined Patient 10 was hospice eligible. 7.On 12/23/2024, Patient 4 revoked hospice services. 8.On 12/23/2024, the HA discharged Patient 7 due to extended prognosis. 9.On 12/24/2024, the HA completed a supervisory visit for Patient 12 and determined Patient 12 is hospice eligible. 10.As of 1/5/2025, all CTIs were signed by the Medical Director. 11.On 1/9/2025, Patient 3 revoked hospices benefits. 12.On 1/22/2025, the agency conducted a systemic review of all the patients' chart to determine which patients were affected by the findings. 13.On 1/23/2025, all current HA's patients have accurate and timely initial and recertifying Certifications of Terminal Illness. On 2/21/2025, at 4 pm, the Department removed the IJ situations in the presence of the HA's DPCS after the onsite verifications of the HA's IJ removal plans. --- Findings: During an interview on 12/16/2024, at 10:18 a.m. with MD1, MD1 stated he MD1 was a certified hospice medical director. MD1 stated that it is the HA procedure that when admitting a new patient into hospice, the admitting nurse will call MD 1 after completing the patients initial assessment in order to go over the patients diagnosis, medications, and prognosis so that MD 1 can make a determination of a hospice diagnosis and provide any additional necessary orders. MD1 stated that he (MD 1) depended on the nurses initial assessment notes to determine if he (MD 1) would complete a patients initial CTI. MD1 stated patients objective (factual observations or data gathered through testing) information was important but not necessary to determine hospice eligibility and that ";a more symptomatic approach" was used. MD1 stated he (MD 1) trusted the HA admitting nurses to complete the Local Coverage of Determination (LCD-a tool used to determine if a patient meets hospice care based on specific criteria) which was a significant criterion to be met to admit patients for hospice services. MD1 stated if he (MD 1) disagreed with the nurses LCD findings, he would either corrected or request supporting information. MD1 stated he (MD 1) documented the patients Certification of Terminal Illness (CTI - a document that certifies the patient for hospice care by a doctor), within 48 hours of their start of care. MD1 stated he documented the patients CTI on the physician narrative section and did not use a scribe (a person whose job is to copy letters, books, or other written materials). During an interview on 12/16/2024, at 10:25 a.m., with MD1, MD1 stated he (MD 1) would rely on the nursing assessment and documentation for (MD 1) to certify the patients into hospice care. MD1 stated (MD 1) trusted that the HA nurses will conduct the newly admitted patients nursing assessment correctly. MD 1 stated the nurses often called (MD 1) right after leaving the patients house, within a few hours, or within the same day, to review the patients diagnoses, physical assessment, declining status, and medication review. MD 1 stated having objective clinical information about the patient was important but ";not everything". MD 1 stated he (MD 1) would not delay a patients care for not having clinical documents to support their diagnosis. During an interview on 12/16/2024, at 10:25 a.m., with MD1, MD1 stated the LCD tool was significant in deciding to admit a patient into hospice care because there are certain criteria that need to be met. MD 1 stated he (MD 1) trusts that the HA nurses will do the patients LCD assessment correctly. MD 1 stated he (MD 1) is able to see the HA nurses LCD assessments of a patient, and MD 1 will either agree or disagree with the findings. MD 1 stated if he (MD 1) disagreed with an LCD assessment, he (MD 1) will discuss the situation with the HA case manager. MD 1 stated the discussion entails whether the LCD needs to be corrected, if any additional documentation is needed, if there is a need to obtain more supporting material for the diagnosis such as doctors notes, history and physical (a medical document that explains a patient past medical history, current medical problems, and the plan of care), and laboratory (blood) studies, if available. During an interview on 12/16/2024, at 10:25 a.m., with MD1, MD1 stated he (MD 1) documents the CTI in each patients Electronic Medical Record (EMR), within 48 hours of the start of care. MD 1 stated documentation was important because it was used for billing purposes. MD1 stated the information could get lost if MD 1 did not document patient information immediately, and that it was important to document in a timely fashion. MD1 stated it was a requirement not to wait for a long time to document. MD 1 stated he (MD 1) typed his (MD 1) own narrative in the CTI under the section physician narrative. MD 1 stated he (MD 1) liked to put in the notes in his own words. During an interview on 12/16/2024, at 2:04 p.m., the ADM/DPCS, the ADM/DPCS stated the CTI is a doctors document and there were no circumstances when a nurse could document on a doctors document. The ADM/DPCS stated the doctor or medical provider who is certifying that a patient is eligible for hospice services is responsible for completing the CTI form. The ADM/DPCS stated the physician will sign the CTI which is an indication that the physician reviewed, made edits, and agreed with the CTI documentation. During an interview on 12/17/2024, at 10:40 a.m., with the ADM/DPCS, the ADM/DPCS stated patients records titled, ";CTI...Statement for First 90-day period" is the form used from the referring physician (the physician that refers a patient to a hospice agency). The ADM/DPC stated the verbal authorization date is the date the authorization from the physician was made. The ADM/DPCS stated the physician is supposed to fill out the CTI within 24 hours of when a patient was admitted to hospice in order for the HA to start hospice care. 1. During a record review of Patient 1s Personal Information, the Personal Information form indicated a start of care (SOC- the date on which a patient begins receiving hospice care) date of 7/16/2024 with a primary diagnosis of heart disease (a general term that includes many types of heart problems), unspecified. During a record review of Patient 1s Physicians Certification for Hospice Benefit – Statement for first 90-day Period, dated 7/16/2024, Patient 1s Physicians Certification for Hospice Benefit – Statement for first 90-day Period indicated that ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice..." The Physicians Certification for Hospice Benefit indicated the referring physician was MD1. The Physicians Certification for Hospice Benefit form indicated MD1 signed Patient 1s Physicians Certification for Hospice Benefit – Statement for first 90-day Period. During a record review of Patient 1s Physician Certification for Hospice Benefit – Certification #1: Statement for First 90-day period, dated 7/16/2024 to 10/13/2024, Patient 1s Physicians Certification for Hospice Benefit – Statement #1 for first 90-day Period indicated ";In my opinion, this patient has a life expectancy of 6 months or less if the illness runs its normal course." The Physician Certification for Hospice Benefit indicated ";She (Patient 1) has plus one (+1) pitting edema (occurs when excess fluid builds up in the body, causing swelling; when pressure is applied to the swollen area, a ";pit", or indentation, will remain) in bilateral (both) lower extremities (legs)." The Physician Certification for Hospice Benefit indicated MD 1 signed Patient 1s Physicians Certification for Hospice Benefit – Statement #1 for first 90-day. During a record review of Patient 1Audit Log (a document detailing the entries, modifications, and changes done in a medical record), dated from 7/19/2024 to 12/16/2024, the Audit Log indicated that the ADM/DPCS documented and updated Patient 1s CTI dated 7/16/2024 under the Physician Narrative section on 7/24/2024, 8/3/2024, and 8/16/2024. During a record review of Patient 1s Audit Log, dated from 7/19/2024 to 12/16/2024, the Audit Log indicated MD1 signed Patient 1s CTI dated 7/16/2024 on 10/19/2024. During a concurrent observation and interview on 12/13/2024, at 11 a.m., with Patient 1, Patient 1 was observed in the house awake, alert, oriented to person, place, and time; and walking using a cane. Patient 1 stated she (Patient 1) was not referred by her (Patient 1) own physician to hospice. Patient 1 stated that she (Patient 1) became aware of the HA thru her (Patient 1) family member (Granddaughter in law). Patient 1 stated she (Patient 1) did not have a terminal illness, was not dying, and she (Patient 1) did not expect to die anytime soon. Patient 1 stated the doctors did not tell her (Patient 1) she was terminal or had six months or less to live. Patient 1 stated she (Patient 1) had a left eye prosthesis, used a walker to ambulate when out of her (Patient 1) home, never had issues with edema (fluid buildup in the skin), was able to transfer, bathe, dress, and feed herself (Patient 1). Patient 1 stated she (Patient 1) does not know who Registered Nurse 1 (RN1) is. During a concurrent interview and record review on 12/16/2024, at 10:47 a.m. with MD1, Patient 1s Updated Assessment dated 12/3/2024 was reviewed. MD1 stated that he (MD1) based Patient 1s CTI on RN1s nursing assessment. MD1 stated Patient 1s nursing assessment indicated that Patient 1 had shortness of breath with minimal activities, edema, weakness, and loss of appetite. MD1 stated he (MD1) did not wait or rely on objective findings (factual observations or data gathered through testing) to place patients in hospice care. During a concurrent interview and record review on 12/16/2024, at 11:55 a.m., with the ADM/DPCS of Patient 1s EMR, the ADM/DPCS stated she (ADM/DPCS) scribed (write) Patient 1s CTI and was asked to do so by MD1. 2.During a record review of Patient 2s Personal Information form, the Personal Information form indicated Patient 2s SOC date of 12/2/2024, with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organ). During a record review of Patient 2s Comprehensive Nursing Assessment dated 12/2/2024, the Comprehensive Nursing Assessment indicated Patient 2 required maximum assistance with ambulation (movement). The Comprehensive Nursing Assessment indicated Patient 2 was assigned a score of three (3) with her (Patient 2) activities of daily living (ADL-basic tasks that patients perform to maintain their health and well-being) with ambulation, transfer, and bathing. The Comprehensive Nursing Assessment indicated Patient 2 was assigned a score of 40 (disabled, requires special care and assistance; mainly in bed, unable to do most activities) for both Karnofsky Performance Scale (KPS evaluate patients ability to perform activities of daily living) and Palliative Performance Scale (PPS- assessed patients ability to function), and New York Heart Association (NYHA– functional classification). The Updated Assessment indicated Patient 1 was assigned a score of 50 (requires considerate assistance and frequent medical care) four (IV -unable to carry out any physical activity without discomfort). The Comprehensive Nursing Assessment indicated Patient 2 had a Functional Assessment Staging Tool (FAST- scale for dementia) score of 7C (unable to ambulate independently). The Comprehensive Nursing Assessment indicated there was no signature of the registered nurse responsible for completing the assessment. During a record review of Patient 2s Physicians Certification for Hospice Benefit – Statement for first 90-day period, dated from 12/2/2024 to 3/1/2025, the Certification for Hospice Benefit – Statement indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice..." The Physicians Certification for Hospice Benefit – Statement indicated the referring physician was Medical Doctor 2 (MD2). The Physicians Certification for Hospice Benefit – Statement indicated it was not signed by MD2. The form indicated ";signature on file/verified by (ADM/DPCS)". During a record review of Patient 2s Physician Certification for Hospice Benefit – Certification #1: Statement for First 90-day period, dated 12/2/2024 to 3/1/2025, Patient 2s Physician Certification for Hospice Benefit – Certification #1indicated ";In my opinion, this patient has a life expectancy of six (6) months or less if the illness runs its normal course." The Physician Certification for Hospice Benefit indicated ";She (Patient 2) suffers from irregular rhythm. The Physician Certification for Hospice Benefit indicated Patient 2s Physician Certification for Hospice Benefit – Certification #1 was signed by MD1. During a record review of Patient 2s Audit Log, dated from 5/6/2024 to 12/16/2024, indicated that ADM/DPCS, documented the Physician Narrative section of Patient 2s CTI dated 12/2/2024 on 12/11/2024. During a record review of Patient 2s Audit Log, dated from 7/19/2024 to 12/16/2024, the audit log indicated MD1 signed Patient 2s CTI dated 12/2/2024 on 12/12/2024. The Audit Log indicated MD1 did not access Patient 2s CTI physician narrative section. During a concurrent home visit observation and interview on 12/13/2024, at 1 p.m., with Patient 2, Patient 2 was observed at home, awake, alert, oriented to person, place, and time. Patient 2 stated she (Patient 2) was independent until she (Patient 2) developed her wounds (left leg shin and right outer great toe). Patient 2 stated she (Patient 2) did not have any heart issues and was not expecting to die within six months. Patient 2 stated she (Patient 2) was seen at a hospital on 12/5/2024, while receiving hospice services. During a concurrent interview and record review on 12/14/2024, at 8:55 a.m., with Registered Nurse 2 (RN2), Patient 2s Comprehensive Nursing Assessment dated 12/2/2024 was reviewed. RN2 stated she (RN 2) was the admitting nurse who assessed Patient 2 on 12/2/2024. RN2 stated Patient 2 lived alone and mostly would sit on the sofa. RN2 stated she (RN 2) based Patient 2s KPS, PPS, and FAST score on what Patient 2 reported and not on any objective findings. During a concurrent interview and record review on 12/14/2024, at 10:15 a.m., with the ADM/DPCS, Patient 2s Comprehensive Nursing Assessment dated 12/2/2024 was reviewed. ADM/DPCS stated RN2 completed Patient 2s comprehensive nursing assessment dated 12/2/2024 but did not sign it. The ADM/DPCS stated RN2s signature would have indicated she (RN 2) documented Patient 2s nursing assessment. The ADM/DPCS stated Patient 2s hospice admission is based on her (Patient 2) medications, MD 2s referral, and her (Patient 2) diagnosis. The ADM/DPCS stated MD 2 referred Patient 2 for hospice services. During a concurrent interview and record review on 12/14/2024, at 10:25 a.m., with MD2, Patient 2s Comprehensive Nursing Assessment dated 12/2/2024 was reviewed.MD2 stated that he (MD 2) face timed (face to face conversation over the internet using a mobile application) RN2 and Patient 2 on 12/2/2024. MD2 stated he (MD 2) did not use the patients age or medications to determine hospice eligibility. MD 2 stated that MD 2 would determine patient eligibility based on the patients functional status. MD2 stated his (MD 2) assessment and hospice referral for Patient 2 was based on RN2s assessment and Patient 2s responses about her (Patient 2) functional status. MD2 stated he (MD 2) did not observed Patient 2s gait. MD2 stated Patient 2 might have swelling because she (Patient 2) was taking Lasix (medication to remove excess fluid from the body). MD2 stated he (MD 2) was not sure why Patient 2 was taking prednisone (medication to treat asthma, allergic reactions, arthritis, inflammatory bowel disease adrenal, and blood or bone marrow disorders). MD2 stated he (MD 2) was not aware Patient 2 was seen at the GACH on 12/5/2024. MD2 stated Patient 2 lived alone and did not meet her family or caregiver. During an interview on 12/14/2024, at 10:53 a.m., with the Operating Manager (OM), the OM stated Patient 2 was referred by the senior foundation of Patient 2s senior apartment building. The OM stated Patient 2 received home health services (a variety of medical services provided in a patient's home to treat an injury or illness), but Patient 2s wounds were not being treated. The OM stated the only thing Patient 2 wanted was treatment for her (Patient 2) wounds. The OM stated she (OM) asked MD2 to assess Patient 2 for hospice services. The OM stated she (OM) informed Patient 2 that she (OM) was unable to see any other doctors if she decided on hospice care. During a concurrent interview and record review on 12/16/2024, at 10:33 a.m., with MD1, Patient 2s Comprehensive Nursing Assessment dated 12/2/2024 was reviewed. MD1 stated Patient 2s CTI was based on Patient 2s Comprehensive Nursing Assessment dated 12/2/2024. 3. During a record review of Patient 3s Personal Information indicated a SOC date of 5/14/2024 with a primary diagnosis of Alzheimers Disease (progressive memory loss). During a record review of Patient 3s Physician Certification for Hospice Benefit – Certification #1: Statement for First 90-day period, dated 5/14/2024 to 8/11/2024, Patient 3s Physician Certification for Hospice Benefit – Certification #1indicated ";In my opinion, this patient has a life expectancy of six (6) months or less if the illness runs its normal course." The Physician Certification for Hospice Benefit indicated ";Patient has KPS 40 percent (%-unit of measure), PS score of 40%, FAST score 7C." The Physician Certification for Hospice Benefit indicated MD1 signed the form. During a review of Patient 3s Audit Log, dated from 5/6/2024 to 12/16/2024, the Audit Log indicated the ADM/DPCS documented and updated Patient 3s CTI dated 5/14/2024 section ";Physician Narrative" on 7/8/2024 and 8/14/2024. During a review of Patient 3s Audit Log dated from 7/19/2024 to 12/16/2024, the Audit Log indicated MD1 signed Patient 3s CTI dated 5/14/2024 on 11/29/2024. During an interview on 12/14/2024, at 9:43 a.m., with Nurse Practitioner 1 (NP1), NP1 stated that Patient 3 was admitted to hospice care due to dementia (a decline in mental ability severe enough to interfere with daily life) and that according to Patient 3s family, Patient 3 has been losing weight. During an interview on 12/16/2024, at 11:58 a.m., with Patient 3s daughter/caregiver (CG3), CG3 stated taking Patient 3 to see her primary doctor (MD3) was difficult for her (CG3) because she (CG3) needed equipment that she (CG3) did not have. CG3 stated Patient 3 last saw her (CG3) Primary Care Physician (Medical Doctor 3 [MD 3]) about 10 months to one year ago. CG3 stated she (CG3) did not tell MD3 that Patient 3 was receiving hospice services. CG3 stated, ";I mean it is none of his business. (MD3) he does not know if she (Patient 3) has six months or less to live." 4. During a review of Patient 4s Personal Information, the Personal Information indicated a start of care date of 8/30/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure. During a review of Patient 4s Physicians Certification for Hospice Benefit – Statement for first 90-day Period" dated 8/30/2024, indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice..." The Physicians Certification for Hospice Benefit indicated the referring physician was MD1. The Physicians Certification for Hospice Benefit was signed by MD1. During a review of Patient 4s Physician Certification for Hospice Benefit – Certification #1: Statement for First 90-day period, dated 8/30/2024 to 11/27/2024, indicated ";In my opinion, this patient has a life expectancy of six (6) months or less if the illness runs its normal course." The Physician Certification for Hospice Benefit indicated ";Patient requires maximum assistance with ADLs. Patient 4 had a KPS score of 50%, PPS score of 50% and is NYHA class IV." The Physician Certification for Hospice Benefit was signed by MD1. During a review of Patient 4s Audit Log" dated from 5/6/2024 to 12/16/2024, the Audit Log indicated the ADM/DPCS, documented and updated Patient 4s CTI, dated 8/30/2024 section ";Physician Narrative" on 9/3/2024. During a review of Patient 4s Audit Log dated from 7/19/2024 to 12/16/2024, the Audit Log indicated the MD1 signed Patient 4s CTI dated 8/30/2024 on 10/19/2024. During an interview on 12/15/2024, at 9:36 a.m., with Patient 4s daughter/caregiver (CG4), CG4 stated Patient 4 visited a podiatrist (doctor who focuses on feet) a week ago. CG4 stated Patient 4 could shop by himself (Patient 4) and that all he (Patient 4) needed was someone to take him (Patient 4) to the store. CG4 stated Patient 4 lived alone, could use the restroom by himself (Patient 4), and he (Patient 4) was able to put ";his frozen food," in the microwave. CG4 stated Patient 4 last saw his primary doctor sometime in the Spring of 2024. GC4 stated that Patient 4 has never been told that he (Patient 4) had six months or less to live by any physician, including his (Patient 4) primary physician. 5. During a review of Patient 5s Personal Information, the Personal Information form indicated a start of care date of 5/30/2024 and an end of care date of 6/3/2024 with a primary diagnosis of multiple sclerosis (MS, a progressive disease involving damage to the nerve cells in the brain and spinal cord) During a review of Patient 5s Comprehensive Nursing Assessment dated 5/30/2024, the Comprehensive Nursing Assessment indicated Patient 5 was admitted to the HA under continuous level of care (a type of hospice care that provides around-the-clock nursing care for patients with severe symptoms). During a review of Patient 5s Physicians Certification for Hospice Benefit – Certification #2... with a verbal authorization date of 5/30/2024, indicated Patient 5s referring physician was MD2. The Physicians Certification for Hospice Benefit indicated the ADM/DPCS signed the form which stated ";Signature on file verified by (ADM/DPCS). It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to Ho spice." During a review of Patient 5s Physicians Certification for Hospice Benefit – Certification #2..." dated from 5/30/2024 to 8/27/2024, indicated that Patient 5s Physicians Certification for Hospice Benefit – Certification #2 was signed by MD1. During a review of Patient 5s Discharge Summary dated 6/3/2024, the Discharge Summary indicated Patient 5 received continuous care. During a review of Patient 5s Audit Log" dated from 11/2/2024 to 12/16/2024, the Audit Log indicated the ADM/DPCS, documented and updated Patient 5s CTI, dated 5/30/2024 under section ";Physician Narrative" on 7/25/2024. During a review of Patient 5s Audit Log dated from 5/30/2024 to 12/17/2024, the Audit Log indicated MD1 signed Patient 5s CTI dated 5/30/2024 on 10/20/2024. During a concurrent interview and record review on 12/16/2024, at 1:07 p.m., with the ADM/DPCS, reviewed Patient 5s CTI dated 5/30/2024. ADM/DPCS stated MD2 referred Patient 5 to hospice services. The ADM/DPCS stated she (ADM/DPCS) signed Patient 5s referral CTI for MD2. The ADM/DPCS stated she (ADM/DPCS) was unable to verify MD2s signature, background check, and required licenses because the HA did not have an employee file for MD2. The ADM/DPCS stated it was a ";mistake" on her (ADM/DPCS) part and the MD2 should have signed Patient 5s CTI because he (MD 2) documented the form and certified Patient 5 for hospice services. The ADM/DPCS stated the HA required an employee file for MD2 to verify his credentials. During an interview on 12/17/2024, at 1:03 p.m., with the ADM/DPCS, the ADM/DPCS stated the HA did not have a contract with MD2. The ADM/DPCS stated she (ADM/DPCS) thought the HA did not need an employee file or contract for MD2 since the HA did not use MD2 often. The ADM/DPCS stated she (ADM/DPCS) did not know if MD2 had a medical license, did not know MD 2s credentials, or what MD 2s background check was. The ADM/DPCS stated an employee file was needed for MD2 for patient safety and to make sure patients received safe and quality care. 6. During a review of Patient 6s Personal Information, Patient 6s Personal Information indicated a SOC date of 11/6/2024 with a primary diagnosis of Alzheimers Disease, unspecified (gradual memory loss). During a review of Patient 6s Physician Certification for Hospice Benefit – Certification #3: Re-certification Statement for Next 60-day period" dated 11/6/2024 to 1/4/2025, Patient 6s Physician Certification for Hospice Benefit – Certification #3 indicated ";In my opinion, this patient has a life expectancy of six months or less if the illness runs its normal course." The Physician Certification for Hospice Benefit was signed by MD1. During a review of Patient 6s Audit Log dated from 11/6/2024 to 12/17/2024, the Audit Log indicated the ADM/DPCS, documented the Physician Narrative section of Patient 6s CTI dated 11/16/2024 on 11/14/2024. During a review of Patient 6s Audit Log dated from 11/6/2024 to 12/17/2024, indicated MD1 signed Patient 6s CTI dated 11/6/2024 on 12/12/2024 and 12/14/2024. 7. During a review of Patient 7s Personal Information, Patient 7s Personal Information indicated a SOC date of 10/18/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease without heart failure. During a review of Patient 7s Physician Certification for Hospice Benefit – Certification #1: Statement for First 90-day period dated 10/18/2024 to 1/15/2025, Patient 7s Physician Certification for Hospice Benefit – Certification #1 indicated ";In my opinion, this patient has a life expectancy of six months or less if the illness runs its normal course." The form also indicated ";Admitted ... with terminal diagnosis of hypertensive heart disease with heart failure..." the Physician Certification for Hospice Benefit was signed by MD1. During a review of Patient 7s Audit Log" dated from 7/19/2024 to 12/16/2024, indicated MD1 signed Patient 7s CTI dated 10/18/2024 on 10/29/2024. During an interview on 12/17/2024, at 12:43 p.m., with Patient 7s daughter/caregiver (CG5), CG5 stated Patient 7 last saw her (Patient 7) Primary Physician (MD4) on September 2024. CG5 stated Patient 7 had not been informed by MD4 or any other physician that Patient 7 had six months or less to live. CG5 stated the HA asked CG5if Patient 7 needed help. CG5 stated that the HA interviewed Patient 7 then informed CG5that they would let CG5know if Patient 7 qualified for hospice care. CG 5 stated, ";Next thing we knew they were setting her (Patient 7) up" (admitting Patient 7 to the HA). CG5 stated Patient 7 was independent but needed assistance. CG5 stated the last time Patient 7 went out socially was ";recently" with family and friends. 8. During a review of Patient 8s Personal Information, Patient 8s Personal Information indicated a start of care (SOC) of 3/1/2024, with a terminal diagnosis of other cerebrovascular disease (a term for a group of conditions that affect the blood vessels and blood supply to the brain). During a record review of Patient 8s CTI, for certification/benefit period 1, dated 3/1/2024 to 5/29/2024, Patient 8s CTI indicated MD 1 certified Patient 8 for hospice care on 3/1/2024. During a concurrent interview and record review on 12/16/2024, at 1:55 p.m., the ADM/DPCS reviewed Patient 8s Audit Log dated 2/29/2024 to 12/16/2024. The Audit Log indicated the ADM/DPCS documented in Patient 8s CTI dated 3/1/2024, under the physician narrative. The ADM/DPCS stated there were times when MD 1 told ADM/DPCS to write things for MD 1, as a scribe. The ADM/DPCS stated Audit Log indicated MD 1 signed Patient 8s CTI dated 3/1/2024on 8/27/2024. During a review of Patient 8s Audit Log, dated 2/29/2024 to 12/17/2024, Patient 8s Audit Log indicated MD 1 completed Patient 8s ";CTI...Statement for First 90-day period", dated 3/1/2024, on 8/27/2024. 9. During a review of Patient 9s Face Sheet (admission record), the Face Sheet indicated a SOC date of 11/15/2024, with a terminal diagnosis of Unspecified severe protein-calorie malnutrition (the state of inadequate intake of food). During a review of Patient 9s ";CTI", for certification/benefit period three (3), dated 11/15/2024 to 1/13/2024, Patient 9s ";CTI", for certification/benefit period three was signed MD 1 had on 11/15/2024. During a concurrent interview and record review on 12/15/2024, at 9:52 a.m., the ADM/DPCS reviewed Patient 9s medical records and stated there was no history and physical (a medical document that explains the patients past medical history, their current problems/diagnosis, and the plan of care) to support Patient 9s diagnosis of severe protein-calorie malnutrition. The ADM/DPCS stated the information needed to support Patient 9s diagnosis was laboratory studies such as blood studies, and information on other medical conditions causing malnutrition. ADM/DPCS stated there was no blood studies information in Patient 9s medical records. ADM/DPCS stated that ideally, the medical documents to support the diagnosis of Patient 9s severe protein-calorie malnutrition should have been in Patient 9s record on the SOC date of 11/15/2024 to be able to confirm that Patient 9 met the criteria for hospice care. The ADM/DPCS stated Patient 9 was admitted to hospice based on the diagnosis of severe protein-calorie malnutrition. The ADM/DPCS stated that it was a mistake to admit Patient 9 into hospice because the HA needed clinical objective information to support Patient 9s diagnosis of severe protein-calorie malnutrition. During a concurrent interview and record review on 12/16/2024, at 11:13 a.m., with MD1, MD1 reviewed Patient 9s record titled, ";LCD Hospice Eligibility Determination", dated 11/15/2024, and ";CTI" for certification period 11/15/2024 to 1/13/202. MD 1 stated that the CTI indicated, ";Patient completely meets LCD guidelines". MD 1 stated that the ";LCD Hospice Eligibility Determination", dated 11/15/2024, indicated ";Patient does not qualify based on LCD guidelines." When asked how come MD1 had documented that Patient 9 met LCD guidelines, the MD1 stated he (MD 1) had made a mistake. During a concurrent interview and record review on 12/16/2024, at 2:04 p.m., the ADM/DPCS reviewed Patient 9s audit log, dated 11/15/2024 to 12/16/2024. Patient 9s audit log indicated the ADM/DPCS had entered the physician narrative for the CTI (benefit/certification period 3), dated 11/15/2024 to 12/16/2024, on 11/25/2024. The ADM/DPCS stated she (ADM/DPCS) had entered the documentation in the physicians narrative, as a scribe, as directed by MD 1. The audit log indicated MD 1 did not change the entries made by the ADM/DPCS and signed the CTI dated 11/15/2024 on 12/12/2024 at 12:23 p.m. During a review of Patient 9s Audit Log, dated 11/1/2024 to 12/17/2024, indicated MD 1 completed the ";CTI...Statement for First 90-day period", dated 11/15/2024, on 11/29/2024. 10. During a review of Patient 10s Personal Information, Patient 10s Personal Information indicated an SOC of 12/23/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, is a disease that damages the lungs in ways that make it hard to breathe). During a review of Patient 10s ";CTI," for certification/benefit period 1, 12/23/2023 to 3/21/2024, indicated MD 1 certified Patient 10 for hospice care on 12/23/2023. During a concurrent interview and record review on 12/16/2024, at 2:10 p.m., the ADM/DPCS reviewed Patient 10s Audit Log, dated 12/28/2023 to 12/16/2024. The ADM/DPC stated the Audit Log indicated that ADM/DPCS entered the physician narrative for Patient 10s CTI (benefit/certification period 1), dated 12/23/2023 to 3/21/2024, on 2/15/2024. The ADM/DPCS stated she (ADM/DPCS) entered the documentation in the physicians narrative, as a scribe, as directed by MD 1. The audit log indicated MD 1 signed Patient 10s CTI dated 12/23/2023on 3/16/2024. During a review of Patient 10s Audit Log, dated 12/28/2023 to 12/16/2024, indicated MD 1 completed the ";CTI...Statement for First 90-day period", dated 12/23/2023, on 3/16/2024. 11. During a review of Patient 11s Personal Information, Patient 11s Personal Information indicated an SOC of 11/9/2024, with a terminal diagnosis of other cerebrovascular disease. During a record review of Patient 11s CTI, for certification/benefit period 1, 11/9/2024 to 2/6/2024, Patient 11s CTI indicated MD 1 had certified Patient 11 for hospice care on 11/9/2024. During a concurrent interview and record review on 12/16/2024, at 2:15 p.m., the ADM/DPCS reviewed Patient 11s audit log, dated 11/7/2024 to 12/16/2024. The ADM/DPCS stated the Audit Log indicated the ADM/DPCS entered the physician narrative for Patient 11s CTI (benefit/certification period 1), dated 11/9/2024 to 2/6/2024, on 11/25/2024. The ADM/DPCS stated she (ADM/DPCS) entered the documentation in the physicians narrative, as a scribe, as directed by MD 1. During a review of Patient 11s Audit Log, dated 11/7/2024 to 12/17/2024, Patient 11s Audit Log indicated MD 1 completed the ";CTI...Statement for First 90-day period", dated 11/9/2024, on 11/29/2024. 12. During a review of Patient 12s Personal Information, Patient 12s Personal Information indicated an SOC of 10/15/2024, with a terminal diagnosis of malignant neoplasm (cancer) of unspecified site of left female breast. During a review of Patient 12s CTI, for certification/benefit period 1, 10/15/2024 to 1/12/2025, indicated MD 1 certified Patient 12 for hospice care on 10/15/2024. During a concurrent interview and record review on 12/16/2024, at 2:18 p.m., the ADM/DPCS reviewed Patient 12s Audit Log, dated 10/15/2024 to 12/16/2024. The ADM/DPCS stated Patient 12s Audit Log indicated the ADM/DPCS entered the physician narrative for the CTI (benefit/certification period 1), dated 10/15/2024 to 1/12/2025, on 11/2/2024. The ADM/DPCS stated she (ADM/DPCS) entered the documentation in the physicians narrative, as a scribe, as directed by MD 1. The ADM/DPCS stated the Audit Log indicated MD 1 signed and completed Patient 12s CTI dated 10/15/2024 on 11/4/2024. During an interview on 12/17/2024, at 12:23 p.m., MD 1 was informed of the audit log information for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12. When asked why MD 1 had signed the CTIs for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12 after each patients start of care date, MD 1 stated he (MD 1) was waiting for some information to include in the CTI because (MD 1)tried to have the most relevant information so there can be the best CTI. MD 1 stated the physician narratives always had information entered. MD 1 stated he (MD 1) would go back into the physician narrative, edit the document, and sign it when it was completed. MD 1 was informed that the ADM/DPCS stated MD 1 had instructed her (ADM/DPCS) to write in the physician narrative portion of the CTI. MD 1 stated he (MD 1) did not instruct anyone to scribe for MD 1 or asked anyone to write the CTI. During an interview on 12/17/2024, at 1:06 p.m., the ADM/DPCS was asked what could happen to patients if they do not qualify for hospice care. The ADM/DPCS stated patients could lose their hospice services in the future due to overuse of inappropriate hospice services. The ADM/DPCS stated the largest amount paid to the HA for hospice services occurred in the first certification. During a review of the HAs undated document titled, ";Certification of Terminal Illness", indicated, ";Policy: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patients attending physician, if any, will certify the patients terminal illness...Procedure 1. At the time of admission to hospice, the hospice Medical Director or the patients attending physician will complete a certification narrative that reflects the patients individual circumstances based on his/her review of the patients medical record or, if applicable, examination of the patient. 2. 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. During a record review of the HAs document titled, ";Admission Criteria and Process", dated November 2021, indicated, ";Policy...The patients life-limiting illness and prognosis (the predicted outcome or course of a disease or medical condition) if six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys (an institution or individual that acts as a middleman between two parties in a financial transaction) Local Coverage Determinations (LCDs)...3. The patient must have a life-limiting illness with a life expectancy of six (6) months or less as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by LCD. 4. The patient must desire hospice services and be aware of the diagnosis and prognosis. During a record review of the HAs document titled, ";Comprehensive Assessment", dated November 2021, indicated, the document indicated that ";Procedure 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patients clinical record, including at least the following information, as relevant:...K. Patients past and present medical and psychosocial history including pertinent diagnosis and any co-morbid conditions...M Name of the hospital and other agencies or persons involved in the past and present care of the patient...R. Patient and family/caregiver support systems and the care the family/caregiver is available, capable, and willing to provide...S. The patients psychosocial status...X. Laboratory results. Y. Medical...history...BB. Past medical and surgical care, including dates of onset/exacerbation...4. The Clinical Supervisor will be responsible for assuring that the documentation of clinical finding supports the terminal diagnosis...

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) Medical Director 1 (MD1) failed to review and document an accurate Recertification of Terminal Illness 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 five of 14 sampled active patients (Patient 1, Patient 3, Patient 4, Patient 8, and Patient 10). As a result of the noncompliance, Patient 1, Patient 3, Patient 4, Patient 8, and Patient 10 were placed at increased risk for losing their hospice eligibility/hospice benefits, not receiving hospice care when needed in the future, and had the potential to not receive the necessary care and services that could lead to potential hospitalization and death. On 12/17 /2024, at 1:44 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Administrator/Director of Patient Care Services (ADM/DPCS) related to failure to ensure MD1 reviewed and documented the Recertification of Terminal Illness (RTI- a brief narrative designed to recertify the explanation of clinical findings that support a life expectancy of six months or less which is composed by the hospice physician) 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 five of 14 sampled active patients (Patient 1, Patient 3, Patient 4, Patient 8, and Patient 10). On 12/17/2024, at 2:15 pm, the Department conducted an exit conference with the ADM/DPCS with the IJ situation not removed. On 2/20/2025, the agency submitted acceptable IJ removal plans as follow: 1.On 12/8/2024, Patient 13 revoked hospice services. 2.On 12/15/2024, Patient 2 and Patient 11 revoked hospice services voluntarily and opted to seek treatment at a hospital. 3.On 12/17/2024, the HA discharged Patient 1 and Patient 9 due to extended prognosis. 4.On 12/18/2024, the HA discharged patient 6 due to death. 5.On 12/20/2024, the HA completed accurate assessments for Patient 8. 6.On 12/21/2024, the HA completed a supervisory visit for Patient 10 and the HA determined Patient 10 was hospice eligible. 7.On 12/23/2024, Patient 4 revoked hospice services. 8.On 12/23/2024, the HA discharged Patient 7 due to extended prognosis. 9.On 12/24/2024, the HA completed a supervisory visit for Patient 12 and determined Patient 12 is hospice eligible. 10.On 1/5/2025, the HA's Contracted Consultant provided in-services to the licensed staff including the Medical Director regarding the importance of timely and accurate CTI submission to prevent recurrence of such issues, appropriateness of hospice patients' eligibility, and hospice Regulations. 11.As of 1/5/2025, all CTIs were signed by the Medical Director. 12.On 1/9/2025, Patient 3 revoked hospices benefits. 13.As of 1/23/2025, the HA's active patients now have accurate and timely CTIs and all pertinent information is up to date. On 2/21/2025, at 4 pm, the Department removed the IJ situations in the presence of the HA's DPCS after the onsite verifications of the HA's IJ removal plans. --- Findings: During an interview on 12/15/2024, at 8:21 a.m., the ADM/DPCS stated a comprehensive assessment (an assessment to identify the physical, psychosocial [the interaction between psychological {mental and emotional} and social {relationship and societal} factors], 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 of the patient) was needed for the recertification periods for the purpose to reassess if there were any changes from the baseline assessment and to see if patients still met hospice eligibility. During an interview on 12/16/2024, at 10:25 a.m., with MD1, MD1 stated he (MD1) relied on the nursing assessment and documentation for him to recertify the patients into hospice care. MD1 stated he trusted the nurses (in general) had done the nursing assessment correctly. MD 1 stated he focused on the nursing recertification assessments and the IDG (Interdisciplinary Group-meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) meetings to recertify patients for hospice care. MD 1 stated after the second recertification, he relied on the Nurse Practitioner (NP) visit notes, the declines the NP documents, and the nursing reassessment notes. MD 1 stated he read every single word of those notes. During an interview on 12/16/2024, at 10:25 a.m., with MD1, MD1 stated he documented the CTI in each patients Electronic Medical Record (EMR), within 48 hours of the start of care. MD 1 stated documentation was important because it was used for billing purposes. MD1 stated the information could get lost and that it was important to document timely. MD1 stated it was a requirement not to wait for a long time to document. MD 1 stated he typed his own narrative in the CTI, under the section physician narrative. MD 1 stated he liked to put in the notes in his own words. During an interview on 12/16/2024, at 2:04 p.m., with the ADM/DPCS, the ADM/DPCS stated the CTI was a doctors document and there were no circumstances when a nurse could document on a doctors document. The ADM/DPCS stated the doctor or medical provider who was certifying the patient for hospice services was the one who was supposed to document. The ADM/DPCS stated the signature on the CTI document meant the doctor had reviewed, made edits, and agreed with the document. 1.During a record review of Patient 1s Personal Information indicated a start of care (SOC the date on which a patient begins receiving hospice care) date of 7/16/2024 with a primary diagnosis of heart disease, unspecified. During a review of Patient 1s Updated Assessment (a nursing assessment conducted to determine if a patient continues to qualify for hospice services) dated 12/3/2024, the Updated Assessment indicated Patient 1 ambulated (waled) with a walker and required maximum assist. The Updated Assessment indicated a score of 3 (maximum assist) for Patient 1s activities of daily living including ambulation, toileting, and bathing. The Updated Assessment indicated a level of IV (unable to carry out any physical activity without discomfort) on Patient 1s NYHA scale (New York Heart Association – functional classification). Patient 1 was assigned a score of 50 (requires considerate assistance and frequent medical care) on the KPS (Karnofsky Performance Scale – evaluate patients ability to perform activities of daily living) and a score of 50 (mainly sit or lie, unable to do any work) on the PPS (Palliative Performance Scale – assessed patients ability to function). The Updated Assessment indicated Patient 1 had ";very limited" mobility. The updated Assessment did not indicate Patient 1 had a left eye prosthesis (artificial body part). The Updated Assessment was signed by Registered Nurse 1 (RN1). During a review of Patient 1s Physicians Certification for Hospice Benefit – Statement for first 90-day Period" dated 7/16/2024, indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice..." The Physicians Certification for Hospice Benefit indicated the referring physician was the MD1. The Physicians Certification for Hospice Benefit indicated MD1 signed it. During a review of Patient 1s Physician Certification for Hospice Benefit – Certification #1: Statement for First 90-day period, dated 7/16/2024 to 10/13/2024, indicated ";In my opinion, this patient has a life expectancy of 6 months or less if the illness runs its normal course." The Physician Certification for Hospice Benefit indicated ";She has +1 pitting edema (fluid buildup in the skin) in bilateral (both) lower extremities (legs)." The Physician Certification for Hospice Benefit indicated MD1 signed it. During a review of Patient 1s Audit Log, dated from 7/19/2024 to 12/16/2024, the Audit Log indicated the ADM/DPCS, documented and updated Patient 1s CTI, dated 7/16/2024 section ";Physician Narrative" on 7/24/2024, 8/3/2024, and 8/16/2024. During a review of Patient 1s Audit Log" dated from 7/19/2024 to 12/16/2024, the Audit Log indicated MD1 signed Patient 1s CTI dated 7/16/2024 on 10/19/2024. During a concurrent observation and interview on 12/13/2024, at 11 a.m., with Patient 1, Patient 1 was observed in the house awake, alert, oriented to person, place, and time, and walking using a cane. Patient 1 stated she (Patient 1) was not referred by her (Patient 1) own physician to hospice, and that she (Patient 1) became aware of the HA thru her (Patient 1) family member (Granddaughter in law). Patient 1 stated she (Patient 1) did not have a terminal illness, was not dying, and she (Patient 1) did not expect to die anytime soon. Patient 1 stated the doctors did not tell her (Patient 1) she was terminal or had six months or less to live. Patient 1 stated she (Patient 1) had a left eye prosthesis, used a walker to ambulate when out of her (Patient 1) home, never had issues with edema (fluid buildup in the skin), was able to transfer, bathe, dress, and feed herself (Patient 1). Patient 1 stated she (Patient 1) did not know who RN1 was. During a concurrent interview and record review on 12/16/2024, at 10:47 a.m. with MD1, Patient 1s Updated Assessment dated 12/3/2024 was reviewed. MD1 stated that he (MD1) based Patient 1s Certification of Terminal Illness (CTI - a document that certifies the patient for hospice care by a doctor), on RN1s nursing assessment. MD1 stated nurses were his (MD1) eyes and ears. MD1 stated Patient 1s nursing assessment indicated that Patient 1 had shortness of breath with minimal activities, edema, weakness, and loss of appetite. MD1 stated he (MD1) did not wait or rely on objective findings (factual observations or data gathered through testing) to place patients in hospice care. During a concurrent interview and record review on 12/16/2024 at 11:55 a.m., with the ADM/DPCS of Patient 1s EMR, the ADM/DPCS stated she scribed Patient 1s CTI as asked by MD1. 2.During a review of Patient 3s Personal Information indicated a start of care date of 5/14/2024 with a primary diagnosis of Alzheimers Disease (progressive memory loss). During a review of Patient 3s Physician Certification for Hospice Benefit – Certification #1: Statement for First 90-day period" dated 5/14/2024 to 8/11/2024, indicated ";In my opinion, this patient has a life expectancy of 6 months or less if the illness runs its normal course." The form indicated ";Patient has KPS 40%, PS score of 40%, FAST score 7C." The Physician Certification for Hospice Benefit indicated MD1 signed it. During a review of Patient 3s Audit Log dated from 5/6/2024 to 12/16/2024, indicated the ADM/DPCS, documented and updated Patient 3s CTI dated 5/14/2024 section ";Physician Narrative" on 7/8/2024 and 8/14/2024. During a review of Patient 3s Audit Log dated from 7/19/2024 to 12/16/2024, indicated MD1 signed Patient 3s CTI dated 5/14/2024 on 11/29/2024. During a concurrent interview and record review on 12/14/2024, at 9:43 a.m., with Nurse Practitioner 1 (NP1) of Patient 3s EMR, NP1 stated Patient 3 was admitted due to her dementia (a decline in mental ability severe enough to interfere with daily life) and that according to Patient 3s family, Patient 3 had been losing weight. During an interview on 12/16/2024, at 11:58 a.m., with Patient 3s daughter/caregiver (CG3), CG3 stated taking Patient 3 to see her primary doctor was difficult for her (CG3) because she needed equipment that she did not have. CG3 stated Patient 3 last saw her Primary Physician (MD3) about 10 months to a year ago. CG3 stated she has not told MD3 that Patient 3 was receiving hospice services. CG3 stated, ";I mean it is none of his business. (MD3) he does not know if she has six months or less to live." 3. During a review of Patient 4s Personal Information indicated a start of care date of 8/30/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure. During a review of Patient 4s Physicians Certification for Hospice Benefit – Statement for first 90-day Period" dated 8/30/2024, indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice..." The Physicians Certification for Hospice Benefit indicated the referring physician was the MD1. The Physicians Certification for Hospice Benefit indicated MD1 signed. During a review of Patient 4s Physician Certification for Hospice Benefit – Certification #1: Statement for First 90-day period" dated 8/30/2024 to 11/27/2024, indicated ";In my opinion, this patient has a life expectancy of 6 months or less if the illness runs its normal course." The form also indicated ";Patient requires maximum assistance with 4/6 ADLs (Activities of daily living). Patient has KPS score of 50%, PPS score of 50% and is NYHA class IV." Lastly, the form indicated it was signed by MD1. During a review of Patient 4s Audit Log, dated from 5/6/2024 to 12/16/2024, the Audit Log indicated the ADM/DPCS, documented and updated Patient 4s CTI, dated 8/30/2024 section ";Physician Narrative" on 9/3/2024. During a review of Patient 4s Audit Log, dated from 7/19/2024 to 12/16/2024, indicated MD1 signed Patient 4s CTI dated 8/30/2024 on 10/19/2024. During an interview on 12/15/2024, at 9:36 a.m., with Patient 4s daughter/caregiver (CG4), CG4 stated Patient 4 belonged to a Medical Group 1 (MG1) and was seen by their podiatrist (doctor who focuses on feet) a week ago. CG4 stated Patient 4s MG1 was not providing the home services he required. CG4 stated Patient 4 could shop by himself and that all he needed was someone to take him to the store. CG4 stated Patient 4 lived alone, could use the restroom by himself, and he was able to put ";his frozen food," in the microwave. CG4 stated Patient 4 last saw his primary doctor sometime in the Spring of 2024 but has never been told he had six months or less to live by any physician, including his primary physician. 4. During a review of Patient 8s Personal Information, indicated an start of care (SOC) of 3/1/2024, with a terminal diagnosis of other cerebrovascular disease. During a home visit observation and interview on 12/13/2024, at 2 p.m., with Licensed Vocational Nurse1 (LVN 1) visited Patient 8. Patient 8 was lying in a hospital bed, awake, and alert. Patient 8 was not able to communicate in English or her preferred language, Spanish. Patient 8 smiled and responded to Spanish language communication through eye and eyebrow gestures. During an interview at the home visit on 12/13/2024, at 2:15 p.m., Patient 8s caregiver (CG 6) stated she and another relative (CG 7) cared for Patient 8 full time. CG 6 stated someone was always with Patient 8 when HA staff visited Patient 8. CG 6 stated Patient 8 was unable to speak, and only understood Spanish language. CG 6 stated sometimes Patient 8 would moan or mumble. During an interview at the home visit on 12/13/2024, at 2:43 p.m., CG 7 stated no doctor had come to visit Patient 8 to the house. CG 6 stated no doctor had phoned them to talk to CG 6 and CG 7. CG 6 stated no doctor had contacted them through video telephone communication. CG 7 stated she and CG 6 were always present whenever there was an HA visit. CG 6 stated she had not seen a doctor come to the house, call, or contact them through video-telephone communication. During an interview on 12/14/2024, at 8:56 a.m., CG 6 was asked if Registered Nurse (RN 3) went to visit Patient 8 on 10/25/2024. The name of RN 3 was provided to CG 6. CG 6 was informed there was RN visits documented by RN 3 on 10/25/2024 by RN 3. CG 6 stated, ";thats a lie". No one by that name had come visit Patient 8. CG 6 was given the name of the Nurse Practitioner (NP 1) and was asked if NP1 had come to visit Patient 8. CG 6 stated an NP had not visited Patient 8, since starting hospice care. During a concurrent interview and record review on 12/14/2024, at 9:30 a.m., NP 1 reviewed Patient 8s record titled, ";F2F Visit Note," dated 10/24/2024. NP 1 stated this was a face-to-face visit for recertification. NP 1 stated she saw Patient 8 in an in-person visit at her home. NP 1 stated no one was present during the visit. NP 1 stated Patient 8 was left alone. NP 1 stated there was a communication barrier, language related. NP 1 stated Patient 8 was speaking a little bit of English. NP 1 stated due to Patient 8s language barrier, Patient 8 was not very talkative that day, but was able to assess her needs with the limited English Patient 8 spoke. During an interview on 12/14/2024, at 9:40 a.m., NP 1 was informed that CG 6 and CG 7 stated they had never met her and have not had any doctor or NP come to their home. NP 1 stated, as mentioned previously, no one was there when she visited Patient 8 on 10/24/2024. During a concurrent interview and record review on 12/14/2024, at 11:07 a.m., RN 3 reviewed Patient 8s record titled, ";Re-Cert Assessment", dated 10/25/2024. RN 3 stated he (RN3) saw Patient 8 at Patient 8s house on 10/25/2024, with the purpose to assess Patient 8 for recertification of hospice care. RN 3 stated CG 7 was present during the visit. RN 3 stated Patient 8 did not talk a lot, as she was limited in talking, and was able to speak some English words. RN 3 stated this visit was rushed. During a concurrent interview and record review on 12/16/2024, at 11:05 a.m., MD 1 reviewed Patient 8s record titled, ";CTI", for benefit/certification period 4, dated 10/27/2024 to 12/25/2024. MD 1 stated he had not seen Patient 8, but NP 1 had seen her. MD 1 stated he recertified Patient 8 based on the face-to-face encounter of NP 1. During an interview on 12/16/2024, at 11:10 a.m., MD 1 was informed that CG 6 and CG 7 had stated they had not had any NP visits. MD 1 stated he did not have anything to say about this. MD 1 stated he did not recall NP 1 calling him about Patient 8. During an interview on 12/16/24 at 2:50 p.m., NP 1 was asked, ";You mentioned patient was alone during the visit on 10/24/2024, correct?" NP 1 stated, unfortunately, she thought she had mixed up the patients. During the RN visit, she asked the nurse to face time during the visit. NP 1 stated she never went to her house. NP 1 stated the face time visit was on 10/24/24 or 10/25/24 whenever the nurse was there. NP1 was asked why she had documented that the face-to-face visit occurred on 10/24/2024? NP 1 stated she thought she forgot the date; it was probably an error on her end. NP 1 stated she could not go back and fix the document once it was submitted. During an interview on 12/16/2024, at 11:10 a.m., MD 1 stated he documented all of the CTIs for Patient 8. During a concurrent interview and record review on 12/16/2024, at 1:55 p.m., the ADM/DPCS reviewed Patient 8s audit log dated 2/29/2024 to 12/16/2024. The audit log indicated the ADM/DPCS had entered notes in the physician summary section of the CTI for re-certification period beginning 10/27/2024 on 11/4/2024. The ADM/DPCS stated she had entered the notes, based on MD 1s direction, as a scribe. The audit log indicated MD 1 signed the recertification CTI for period beginning 10/27/2024, on 12/1/2024. The ADM/DPCS stated MD 1 was supposed to sign the CTI on 10/27/2024. The ADM/DPCS stated the HA continued hospice care without a recertification of terminal illness from MD 1. 5. During a review of Patient 10s Personal Information indicated an SOC of 12/23/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, is a disease that damages the lungs in ways that make it hard to breathe). During a concurrent interview and record review on 12/15/2024, at 10:18 a.m., the ADM/DPCS reviewed Patient 10s Re-Cert Assessment, dated 10/12/2024. The ADM/DPCS stated the record was a recertification assessment to recertify Patient 10 for certification period beginning on 10/18/2024. The Re-Cert Assessment indicated Patient 10 had heart failure (heart unable to pump blood effectively) NYHA (New York Heart Association-a classification tool for heart failure) level 4 (unable to do any activity, without discomfort). The ADM/DPCS stated she reviewed Patient 10s medical records and there was no evidence Patient 10 had heart failure. During a concurrent interview and record review on 12/15/2024, at 11:03 a.m., the ADM/DPCS reviewed Patient 10s record titled, ";Re-Cert Assessment", dated 10/12/2024. The record indicted Patient 10 was eligible to be recertified for hospice care because the LCD (Local Coverage Determination-a tool used that indicates if patient is eligible for hospice care based on specific criteria) indicated Patient 10 was having increased visits to the emergency room, was having respiratory failure (lungs not exchanging oxygen effectively) and was experiencing unintentional weight loss. The ADM/DPCS stated there was no documents in Patient 10s record about the emergency room visits, respiratory failure, and Patient 10s weight remained the same from the SOC date to date. The ADM/DPCS stated that based on the baseline assessment, Patient 10 had not experienced weight loss. The ADM/DPCS stated the recertification assessment was not accurate. The ADM/DPCS stated the importance of having an accurate assessment was to make sure the patients (in general) received the care they needed, and they met the criteria for recertification. The ADM/DPCS stated according to Patient 10s clinical record, Patient 10 did not qualify for recertification of hospice care. During an interview on 12/15/2024, at 5:05 p.m., Patient 10s caregiver (CG 8) stated Patient 10 had gained weight since returning from the hospital a year ago. CG 8 stated, Patient 10 had always been petite, and now had a ";little gut" because she was eating ";really well." During a concurrent interview and record review on 12/16/2024, at 11:17 a.m., MD 1 reviewed Patient 10s record titled, ";CTI", for re-certification period 10/18/2024 to 12/16/2024. MD 1 stated Patient 10 was recertified for hospice care because there was a decline in her condition. Patient 10 was experiencing shortness of breath at rest and activity, she was mostly in bed due to worsening weakness, decreased food and fluid intake, and poor appetite. MD 1 stated he obtained the information from NP1, during the face-to-face visit. MD 1 stated he diagnosed Patient 10 with heart failure due to her symptoms. MD 1 was informed about CG 8s report of Patient 10 gaining weight. MD 1 stated it could be that NP 1 was documenting history of weight loss. MD 1 though NP 1 needed to document this better. MD1 stated It could be that the weight loss is improving. MD 1 stated ";maybe the rate of decline has slowed down." MD1 stated NP 1 could do a better job of wording Patient 10s condition better. During a review of Patient 10s recertification ";CTI", dated 10/18/2024 to 12/16/2024, indicated MD 1 recertified Patient 10 for hospice care on 10/18/24. The recertification CTI indicated MD 1 had composed the physician narrative. During a concurrent interview and record review on 12/16/2024, at 2:10 p.m., the ADM/DPCS reviewed Patient 10s audit log, dated 12/28/2023 to 12/16/2024. The document indicated the ADM/DPCS had entered the physician narrative for the CTI (benefit/certification period 5), dated 10/18/24-12/16/24, on 11/4//2024. The ADM/DPCS stated she had entered the documentation in the physicians narrative, as a scribe, as directed by MD 1. The audit log further indicated MD 1 signed the CTI on 12/12//2024. During an interview on 12/17/2024, at 12:23 p.m. MD 1 was informed of the audit log information for Patient 1, Patient 3, Patient 4, Patient 8, and Patient 10. When asked why he had signed the CTIs on later dates, MD 1 stated he was waiting for some information to include in the CTI because he tried to have the most relevant information so there can be the best CTI. MD 1 stated the physician narratives always had information entered. MD 1 stated he would go back into the physician narrative, edit the document, and sign it when it was complete. MD 1 was informed that the ADM/DPCS stated MD 1 had instructed her to write in the physician narrative portion of the CTI. MD 1 stated every CTI was done from scratch, he deleted everything and type the CTI himself. MD 1 stated he did not instruct anyone to scribe for him or asked anyone to write the CTI. During an interview on 12/17/2024, at 1:06 p.m., the ADM/DPCS was asked what could happen to patients if they do not qualify for hospice care. The ADM/DPCS stated patients could lose their hospice services in the future due to overuse of inappropriate hospice services. The ADM/DPCS stated the largest amount paid to the HA for hospice services occurred in the first certification. During a review of the HAs undated document titled, ";Certification of Terminal Illness", indicated, ";Procedure...4 A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on review of the patients medical record or, if applicable, examination of the patient. A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than two (2) weeks prior or two (2) calendar days after the first day of each period...5. The hospice physician or nurse practitioner must have a face-to-face encounter with the patient within the 30 days prior to the third benefit period recertification and within 30 dys prior to each subsequent re certification...Tools such as the fiscal intermediarys Local Coverage Determinations, along with other supporting documentation, can be used to provide guidance in determining and documenting terminal policy."

Based on interview and record review the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA- a program that provides care and support for patients who are terminally ill] and have stopped treatment to cure their disease) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) on Clinical Records was met as follows: --- 1.The HA failed to ensure physician orders were documented in two of fourteen sampled patients records (Patient 3 and Patient 5). Patient 3 did not have a recertification for hospice services and Patient 5 did not have an order for oxygen treatment. (Refer to L678). This failure resulted in Patient 3 and Patient 5 to receive treatment and medications without a physician order. 2. The HA failed to ensure the clinical records of three of 14 sampled patients (Patient 8, Patient 9, and Patient 10) were complete and reflected any amendments, corrections, and or late entries. (Refer to L679). This failure had the potential to affect the quality of care for Patient 8, Patient 9, and Patient 10. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated (written law) compliance with Federal regulations for Clinical Records to ensure patients medical records are safeguarded from unauthorized access by any individuals or hospice staff.

Based on interview and record review the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA- a program that provides care and support for patients who are terminally ill] and have stopped treatment to cure their disease) failed to ensure physician orders were documented in two of fourteen sample patients records (Patient 3 and Patient 5). Patient 3 did not have a recertification for hospice services and Patient 5 did not have an order for oxygen treatment. This failure resulted in Patient 3 and Patient 5 to receive treatment and medications without a physician order. --- Findings: 1. During a review of Patient 3s Personal Information, the Personal Information indicated a start of care (SOC-the date on which a patient begins receiving hospice care) date of 5/14/2024 with a primary diagnosis of Alzheimers disease (progressive memory loss). During a review of Patient 3s undated Current Treatment/Medication/DME (durable medical equipment), indicated the last recertification order was written on 8/6/2024 for the second benefit period from 8/12/2024 to 11/9/2024. During a review of Patient 3s Plan of Care (POC) Summary, dated as of 12/12/2024, the POC Summary indicated the last recertification order was written on 8/6/2024 for the second benefit period from 8/12/2024 to 11/9/2024. The POC Summary indicated it was not signed. During a concurrent interview and record review on 12/14/2024, at 9:43 a.m., with Nurse Practitioner 1 (NP1) of Patient 3s Electronic Medical Record (EMR), NP1 stated Patient 3 needed a recertification order for her current hospice service episode. NP1 stated she (NP1) assessed Patient 3 and determined she (Patient 3) needed to continue to receive hospice services. NP1 stated there was an error and that Patient 3 needed a recertification order. During a concurrent interview and record review on 12/14/2024, at 11:35 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 3s EMR, the ADM/DPCS stated Patient 3 did not have a recertification order in her (Patient 3) EMR. The ADM/DPCS stated the HA was unable to treat Patient 3 without a physicians consent and order. The ADM/DPCS stated Medical Director 1 (MD1) had to assess Patient 3 to determine if Patient 3 met the hospice criteria. During a concurrent interview and record review on 12/16/2024, at 11 a.m., with MD1 of Patient 3s EMR, MD1 stated Patient 3 was currently on her third hospice episode. MD1 stated he (MD1) did not write a recertification order for Patient 3. MD1 stated it was important for Patient 3 to have a recertification order for billing and to certify Patient 3 continue to require hospice care. During a concurrent interview and record review on 12/16/2024 at 12:25 a.m. with the ADM/DPCS of Patient 3s EMR, the ADM/DPCS stated Patient 3 did not have a recertification order for her (Patient 3) third benefit period. The ADM/DPCS stated it was important to have a physician order to carry on with hospice care with the physicians consent. 2. During a review of Patient 5s Personal Information, the Personal Information indicated patient 5s SOC date was 5/30/2024 and an end of care date of 6/3/2024 with a primary diagnosis of multiple sclerosis (MS- a disease involving damage to the nerve cells in the brain and spinal cord). During a review of Patient 5s Comprehensive Nursing Assessment, dated 5/30/2024, indicated under section Respiratory that Patient 5 used two to five liters of oxygen as needed. The Comprehensive Nursing Assessment also indicate under the narrative and disease trajectory section ";Patient has episodes of dyspnea (shortness of breath) at rest, relieved with supplemental oxygen..." During a review of Patient 5s Physicians Certification for Hospice Benefit – Certification #2: Re-Certification Statement for Second 90-day period, dated from 5/30/2024 to 8/27/2024, indicated under section Physician Narrative ";requires use of 02 (oxygen) nasal cannula (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) continuously." During a review of Patient 5s undated Current Treatment/Medication/DME (durable medical equipment), did not indicate there was an oxygen treatment ordered. During a review of Patient 5s POC/IDG (Interdisciplinary Group- which is a team of healthcare professionals who work together to provide comprehensive care for hospice patients. IDGs are responsible for developing and reviewing a patient's plan of care, and they meet regularly to discuss care plans, communicate updates, and more. IDGs typically include members from the following professions: Doctor of medicine or osteopathy, Registered nurse, Social worker, and Pastoral or other counselor) Review" dated 5/30/2024, indicated Patient 5s plan of care section ";Respiratory" did not mention supplemental or continuous oxygen administration. During a review of Patient 5s Physician Orders, dated 5/30/2024 and 6/3/2024, did not indicate there was an oxygen treatment ordered. During a review of Patient 5s POC Summary, dated as of 12/12/2024, did not indicate there was an oxygen treatment ordered. During a interview and record review on 12/16/2024, at 1:13 p.m., with the ADM/DPCS of Patient 5s EMR, the ADM/DPCS stated Patient 5 used oxygen without a physician order for oxygen treatment. The ADM/DPCS stated it was important to have medication and treatment orders for the patients safety. The ADM/DPCS stated it was not within her (ADM/DPCS) scope of practice to follow through without physician orders. During a review of the HAs document titled, ";Verification of Physician Orders", dated 11/2021, indicated, ";Policy Orders will be obtained from a licensed physician. This includes...any changes to the plan of care and/or assessment."

Based on interview and record review the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA, a program that provides care and support for patients who are terminally ill] and have stopped treatment to cure their disease) failed to ensure the clinical records of three of 14 sampled patients (Patient 8, Patient 9, and Patient 10) were completed and reflected any amendments and or corrections or late entries. This failure had the potential to affect the quality of care for Patient 8, Patient 9, and Patient 10. --- Findings: 1.During a review of Patient 8s Personal Information, the Personal Information indicated an start of care (SOC, the date on which a patient begins receiving hospice care) of 3/1/2024, with a terminal diagnosis of other cerebrovascular disease. During a concurrent interview and record review on 12/14/2024, at 11:50 a.m., with the ADM/DPCS reviewed Patient 8s record titled, Plan of Care Interdisciplinary (POC/IDG-Interdisciplinary Group- which is a team of healthcare professionals who work together to provide comprehensive care for hospice patients. IDGs are responsible for developing and reviewing a patient's plan of care, and they meet regularly to discuss care plans, communicate updates, and more. IDGs typically include members from the following professions: Doctor of medicine or osteopathy, Registered nurse, Social worker, and Pastoral or other counselor) dated 11/25/2024. The ADM/DPCS stated the record did not indicate a Registered Nurse had signed the document. During a concurrent interview and record review on 12/14/2024, at 12:08 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG," dated 11/11/2024. The ADM/DPCS stated the record did not indicate a Registered Nurse (unidentified) had signed the document. During a concurrent interview and record review on 12/14/2024, at 12:11 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";POC/IDG," dated 10/28/2024. The ADM/DPCS stated the record did not indicate a Registered Nurse had signed the document. During an interview on 12/14/2024, at 12:19 p.m., the Administrator and Director of Patient Care Services (ADM/DPCS) stated nursing staff (in general) was supposed to complete their documentation within 48 to 72 hours, with the purpose to prevent inappropriate care, safety, and to show what care was provided. During a concurrent interview and record review on 12/14/2024, at 12:19 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";Visit Note LVN (Licensed Vocational Nurse)," dated 12/4/2024. The ADM/DPCS stated the record was not signed by the author of the note. During a concurrent interview and record review on 12/14/2024, at 12:23 p.m., the ADM/DPCS reviewed Patient 8s record titled, ";Psychosocial Assessment," dated 12/9/2024. The ADM/DPCS stated the record was not signed by the author of the note. 2. During a review of Patient 9s Face Sheet, the Face Sheet indicated a SOC date of 11/15/2024, with a terminal diagnosis of unspecified severe protein-calorie malnutrition. During a concurrent interview and record review on 12/15/2024, at 9:58 a.m., the ADM/DPCS reviewed Patient 9s record titled, ";POC/IDG," dated 12/9/2024. The ADM/DPCS stated the document did not indicate a Registered Nurse had signed the document. During a concurrent interview and record review on 12/15/2024, at 10:02 a.m., the ADM/DPCS reviewed Patient 9s record titled, ";POC/IDG," dated 11/25/2024. The ADM/DPCS stated the Registered Nurse (unidentified) had not signed the document. During a concurrent interview and record review on 12/15/2024, at 10:06 a.m., the ADM/DPCS reviewed Patient 9s record titled, ";POC/IDG", dated 11/15/2024. The ADM/DPCS stated the document indicated Patient 9 had heart failure NYHA 4. The ADM/DPCS stated the information was wrong and should not be there. The ADM/DPCS stated the record did not indicate a Registered Nurse (unidentified) signed the document. 3. During a review of Patient 10s Personal Information, the Personal Information indicated an SOC of 12/23/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, is a disease that damages the lungs in ways that make it hard to breathe). During a concurrent interview and record review on 12/15/2024, at 11:20 a.m., the ADM/DPCS reviewed Patient 10s record titled, ";POC/IDG", dated 11/11/2024. The ADM/DPCS stated the document did not indicate a Registered Nurse (unidentified) signed the document. During a concurrent interview and record review on 12/15/2024, at 11:41 a.m., the ADM/DPCS reviewed Patient 10s record titled, ";POC/IDG," dated 10/28/2024. The ADM/DPCS stated the document did not indicate a Registered Nurse had signed the document. During a review of the HAs document titled, ";Clinical/Service Data Collection", dated 11/2021, indicated, ";Policy...Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided...7. The clinical/service note will include:...E. Signature of clinician/technician and his/her credentials."

Based on interview and record review the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA- a program that provides care and support for patients who are terminally ill] and have stopped treatment to cure their disease) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Drugs and Biologicals, medical supplies, and durable medical equipment was met as follows: --- 1.The HA failed to ensure the licensed nurses (in general) transcribed (write), verified, and carried out the physician orders for one of 14 sampled patients (Patient 2). (Refer to L690). This failure placed Patient 2 at risk for receiving the wrong treatments/medications that could cause harm. The cumulative effect of these systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with federal regulation for Drugs and Biologicals, medical supplies, and durable medical equipment drugs to ensure to provide the necessary care and services to the patient.

Based on interview and record review the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA- a program that provides care and support for patients who are terminally ill] and have stopped treatment to cure their disease) Agency (HA, a program that provides care and support for patients who are terminally ill] and have stopped treatment to cure their disease) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Drugs and Biologicals, medical supplies, and durable medical equipment was met as follows: 1.The HA failed to ensure the licensed nurses (in general) transcribed (write), verified, and carried out the physician orders for one of 14 sampled patients (Patient 2). This failure placed Patient 2 at risk for receiving the wrong treatments/medications that could cause harm. --- Findings: During a review of Patient 2s Personal Information, the Personal Information indicated Patient 2s start of care date (SOC, the date on which a patient begins receiving hospice care) was 12/2/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organ). During a review of Patient 2s undated Current Treatment / Medication /DME (durable medical equipment), the Current Treatment / Medication /DME indicated ";Left anterior (front) lower leg traumatic ulceration (cut on the skin): cleanse the wound with cleanser and pat dry..." During a review of Patient 2s Audit Log dated from 1/1/2024 to 12/16/2024, the Audit Log indicated the Intake Coordinator (IC) created, entered, verified, reconciliated (the process of comparing a patient's medication orders to all of the medications that the patient has been taking), and updated Patient 2s Physician order ";Left anterior lower leg traumatic ulceration: cleanse the wound with cleanser and pat dry..." dated 12/12/2024 on 12/13/2024. During an interview on 12/16/2024, at 12:22 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated she (ADM/DPCS) received and transcribed the physician orders. The ADM/DPCS stated that if the HAs intake personnel received a physician order, they were instructed to inform her (ADM/DPCS) so that she (ADM/DPCS) could contact the physician to clarify and write the order. The ADM/DPCS stated the HAs intake personnel were not able to write physician orders because they were not nurses. The ADM/DPCS stated, ";If a non-nursing personnel writes an order the risk for error is very high and it can harm the patient by placing, not knowing the clinical knowledge to know what they are writing." During an interview on 12/17/2024, at 10:37 a.m., with the IC, the IC stated she was not a Registered Nurse or a licensed nurse. The IC stated she was the intake coordinator and not clinical. The IC stated she (IC) did not receive or transcribe the physician orders because there was a possibility that she (IC) might transcribe the order wrong. During a concurrent interview and record review on 12/17/2024, at 11 a.m., with the ADM/DPCS of Patient 2s medical record form titled ";Audit Log" dated from 1/1/2024 to 12/16/2024, the ADM/DPCS stated the IC was not able to transcribe any physician order because the physician orders should be taken by a licensed person. During a review of the HAs document titled, ";Verification of Physician Orders", dated 11/2021, indicated, ";Policy...A qualified individual will review each order or prescription before care is provided...2...The verbal order will be documented by the staff receiving the order, indicated by staff signature and credentials, and cosigned by the physician per policy and/or state licensure requirement."

Based on interview and record review the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA- a program that provides care and support for patients who are terminally ill] and have stopped treatment to cure their disease) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Personnel Qualification was met as follows: --- 1. The HA failed to ensure to keep a personnel file for Medical Director 2 (MD2) and to ensure MD2 was qualified and licensed to provide patient care for one of fourteen sampled patients (Patient 2). (Refer to L784). 2. The HA failed to provide the criminal background check for the Medical Director 2 (MD2) before providing care and services for one of fourteen sampled patients (Patient 2). (Refer to L795). These failures placed Patient 2 at risk for harm. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated (written law) compliance with Federal regulations to ensure the patients were being cared for by qualified personnel.

Based on interview and record review the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA- a program that provides care and support for patients who are terminally ill] and have stopped treatment to cure their disease) failed to ensure to keep a personnel file for Medical Director 2 (MD2) and to ensure MD2 was qualified and licensed to provide patient care for one of fourteen sampled patients (Patient 2). This failure placed Patient 2 at risk for harm. --- Findings: During a review of Patient 2s Personal Information, the Personal Information indicated Patient 2s start of care date (SOC, the date on which a patient begins receiving hospice care) was 12/2/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the bodys organs). During a review of Patient 2s Physicians Certification for Hospice Benefit – Statement for First 90-day period" dated 12/2/2024, indicated MD2 referred Patient 2 for hospice services. During a review of Patient 2s medical record form untitled, which was provided by the Administrator/Director of Patient Care Services (ADM/DPCS) dated 12/2/2024, indicated MD2 signed the form. The untitled form also indicated ";Caregiver: She does not have anyone to help her at home. She needs IHSS (In-home Supportive Services)" During a concurrent interview and record review on 12/14/2024, at 10:15 a.m., with the ADM/DPCS of Patient 2s Electronic Medical Record (EMR), the ADM/DPCS stated Patient 2s admitting nurse face time (face to face conversation with someone over the internet using a mobile app) with MD2 after Patient 2s admitting nursing assessment. During a concurrent interview and record review on 12/14/2024, at 10:25 a.m., with MD2 of Patient 2s EMR, MD2 stated she (MD2) saw Patient 2 while the admitting nurse was assessing her (Patient 2) via face time. MD 2 stated Patient 2 needed help at home and needed IHSS. During a concurrent interview and record review on 12/14/2024, at 11:05 a.m., with the ADM/DPCS of Patient 2s EMR, ADM/DPCS stated she (ADM/DPCS) ";overlooked" MD2s order for IHSS and Certified Home Health Aide (CHHA) services for Patient 2. The ADM/DPCS stated either the IHSS or CHHA could have provided patient direct assistance. During an interview on 12/17/2024 at 1:03 p.m. with the ADM/DPCS, the ADM/DPCS stated the HA did not have a contract, an employee file, or a background check for MD2 and she (ADM/DPCS) was unable to recall when MD2 started working for the HA. The ADM/DPCS stated MD2 was referred by a consulting firm and did not have any of MD2s information to provide. The ADM/DPCS stated it was important to have MD2s information for patient safety and to ensure patients received safe quality care. During a review of the HAs undated document titled, ";Coordination of Care with Contracts/Agreements", indicated, ";Procedure...4. Hospice will evaluate contract facility personnel needs for education and training at least once annually through its performance improvement program and/or corporate compliance program."

Based on interview and record review the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA- a program that provides care and support for patients who are terminally ill] and have stopped treatment to cure their disease) failed to provide the criminal background check for the Medical Director 2 (MD2) before providing care and services for one of fourteen sampled patients (Patient 2). This failure placed Patient 2 at risk for harm. --- Findings: During a review of Patient 2s Personal Information, the Personal Information indicated Patient 2s start of care date (SOC, the date on which a patient begins receiving hospice care) was 12/2/2024 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the bodys organs). During a review of Patient 2s Physicians Certification for Hospice Benefit – Statement for First 90-day period" dated 12/2/2024, indicated MD2 referred Patient 2 for hospice services. During a review of Patient 2s medical record form untitled, which was provided by the Administrator/Director of Patient Care Services (ADM/DPCS) dated 12/2/2024, indicated MD2 signed the form. The untitled form also indicated ";Caregiver: She does not have anyone to help her at home. She needs IHSS (In-home Supportive Services)" During a concurrent interview and record review on 12/14/2024, at 10:15 a.m., with the ADM/DPCS of Patient 2s Electronic Medical Record (EMR), the ADM/DPCS stated Patient 2s admitting nurse face time (face to face conversation with someone over the internet using a mobile app) with MD2 after Patient 2s admitting nursing assessment. During a concurrent interview and record review on 12/14/2024, at 10:25 a.m., with MD2 of Patient 2s EMR, MD2 stated she (MD2) saw Patient 2 while the admitting nurse was assessing her (Patient 2) via face time. MD 2 stated Patient 2 needed help at home and needed IHSS. During a concurrent interview and record review on 12/14/2024, at 11:05 a.m., with the ADM/DPCS of Patient 2s EMR, ADM/DPCS stated she (ADM/DPCS) ";overlooked" MD2s order for IHSS and Certified Home Health Aide (CHHA) services for Patient 2. The ADM/DPCS stated either the IHSS or CHHA could have provided patient direct assistance. During an interview on 12/17/2024 at 1:03 p.m. with the ADM/DPCS, the ADM/DPCS stated the HA did not have a contract, an employee file, or a background check for MD2 and she (ADM/DPCS) was unable to recall when MD2 started working for the HA. The ADM/DPCS stated MD2 was referred by a consulting firm and did not have any of MD2s information to provide. The ADM/DPCS stated it was important to have MD2s information for patient safety and to ensure patients received safe quality care. During a review of the HAs undated document titled, ";Coordination of Care with Contracts/Agreements", indicated, ";Procedure...4. Hospice will evaluate contract facility personnel needs for education and training at least once annually through its performance improvement program and/or corporate compliance program."