Every finding on record at Odyssey Hospice Care, Inc.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of Patients was met as follows: The hospice agency failed to accurately assess the patient's eligibility for hospice care for the management of the terminal illness and related conditions for five out of eight sampled patients, (Patients 2, 3, 4, 5 and 6). This deficient practice had the potential to result in the misuse of the hospice of services that could result in a substandard provision of patient care. (Refer to L532). The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily (right or legal way) mandated compliance with the Federal regulations for Initial & Comprehensive Assessment of Patients to ensure the highest quality of care is being provided to patients certified to receive the Medicare hospice benefits. --- .

Based on observation, interview and record review, the hospice agency failed to accurately assess the patient's eligibility for hospice care for the management of the terminal illness and related conditions for five out of eight sampled patients, (Patients 2, 3, 4, 5 and 6). This deficient practice had the potential to result in the misuse of the hospice of services that could result in a substandard provision of patient care. --- c. A review of Patient 4's face sheet indicated admission to hospice on 2/6/23, with primary diagnosis of chronic obstructive pulmonary disease (a lung disease that block airflow and make it difficult to breathe), and Physician 2 was the Referring/Attending /Patient choice doctor. A review of Patient 4's Certificate of Terminal Illness (CTI), dated 2/6/23 to 5/15/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section to indicate Patient 4 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 4/20/23, at 12 p.m., during a phone interview with Physician 2, he stated that he was not the attending physician for Patient 2 and someone was just using his name and license for hospice services. d. A review of Patient 5's face sheet indicated admission to hospice on 3/2/23, with primary diagnosis of huntington's disease ( a condition in which nerve cells in the brain break down over time), and Physician 3 was the Referring/Attending /Patient choice doctor. A review of Patient 5's Certificate of Terminal Illness (CTI), dated 3/2/23 to 5/30/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 4/19/23, at 12 p.m., during a home visit at Patient 5's residence at an assisted living facility with RN 1, Patient 5 was observed sitting on his bed eating by himself. When Patient 5 was asked if Physician 3 was his attending physician, he stated no and he does not see any physician at all. On 4/20/23, at 1 p.m., during an interview with Physician 3, he stated he was not Patient 5's attending physician. He also stated that Medical Director 1 sent him to do a face to face encounter with Patient 5 after he was admitted hospice agency. e. A review of Patient 6's face sheet indicated admission to hospice on 3/13/23, with primary diagnosis of end stage renal disease (when the kidneys can no longer the body's needs). A review of Patient 6's Certificate of Terminal Illness (CTI), dated 3/13/23 to 6/10/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section to indicate Patient 6 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 4/19/23, at 1 p.m., during a home visit at Patient 6's residence at an assisted living facility with RN 1, Patient 6 was observed sitting on her bed. When Patient 6 was asked if Physician 3 was her attending physician, she stated no and the hospice nurses did not explain to her why she was in hospice service. She also stated that she is not dying in six months and she does not feel sick at all. On 4/20/23, at 1 p.m., during an interview with Physician 3, he stated he was not Patient 6's attending physician. He also stated that Medical Director 1 sent him to do a face to face encounter with Patient 6 after she was admitted hospice agency. On 4/20/23, at 2 p.m., during a phone interview with Medical Director 1, he stated that he was not the attending physician, and he does not know who the attending physician for Patients 2, 3, 4, 5, 6 and 8. He stated since Patients 2,3,4,5,6 and 8 were admitted to their hospice service, he is now the patient's attending physician, but he did not sign the referral attending physician section and someone was signing without my consent. Medical Director 1 further stated that he did not do a face-to-face encounter with the patients during their admission to the hospice service, but he determined the patients were eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. On 4/20/23, at 2:30 p.m., during an interview with the Director of Patient Care Services (DPCS ), he stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. A review of the agency's policy titled, "Admission Criteria and Process", indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination. Findings: a. A review of Patient 2's clinical record indicated Patient 2 was admitted to the hospice agency on 2/13/2023, with a primary diagnosis of senile degeneration of brain, not elsewhere classified (the mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age). The record further indicated, the ";referring/attending/patient choice" physician was Physician 3. A review of Patient 2's Physicians Certification for Hospice Benefit, dated 2/13/2023 to 5/13/2023, Benefit period #2, indicated Physician 3 was the referring physician that Patient 2 has a life expectancy of six months or less, if the terminal illness runs its normal course. The form was not signed by Physician 3. There was no documentation for laboratory test result, imaging data, and history and physical that showed evidence to support the terminal illness diagnosis. On 4/20/2023, at 2:00 p.m., during an interview with Physician 3, he stated he was not the primary attending physician for Patient 2. Physician 3 stated he was just contracted by the hospice agency to conduct an initial evaluation to see if Patient 2 was hospice appropriate. A review of Patient 2s form titled, "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" for Dementia due to Alzheimers, indicated section 1 must be met and at least one of the conditions must be met in section 2. Section 2 was marked ";yes" that Patient 2 had 10% weight loss during the previous 6 months or serum albumin less than 2.5 grams per deciliter (gm/dL). A review of Patient 2's clinical record indicated there was no documented evidence Patient 2 had a weight loss of 10% during the previous 6 months or serum albumin less than 2.5 gm/dL. On 4/20/23, at 1:20 p.m., during an interview with the Director of Patient Care Services (DPCS), DPCS stated he was not able to find documented evidence Patient 2 had 10% weight loss during the previous 6 months or serum albumin of less than 2.5 gm/dL. b. A review of Patient 3's clinical record indicated she was admitted to the hospice agency on 2/07/2023, with a diagnosis including chronic obstructive pulmonary disease, unspecified (COPD, a group of lung diseases that block airflow and make it difficult to breathe). The record further indicated, the ";referring/attending/patient choice" physician was Physician 2. A review of Patient 3's CTI, dated 2/07/2023 to 5/07/2023, Benefit period #1, indicated the Medical Director signed the attending physician referral section that Patient 3 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. A review of the form of "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" of Pulmonary Disease, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 3 had a disabling dyspnea (shortness of breath) at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways), resulting in decreased functional capacity. Section 2 was mark ";yes" that Patient 3 had O2 sat (Oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 95–100%) less than or equal to 88% determined by O2 sat monitors. A review of Patient 3's clinical record indicated there was no documented evidence Patient 3 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators or had O2 saturation of 88% or less. On 4/19/23, at 11:10 a.m., during a joint home visit to Patient 3's home, a Board and Care Facility, with the Registered Nurse (RN 1), Patient 3 was observed sleeping in bed, but easily arousable, alert, and oriented to name only. Patient 3 was observed not using supplemental oxygen, breathing normally, and not showing any signs and symptoms of pulmonary disease. During an interview with the patients caregiver (PCG 1), PCG 1 stated Patient 3 seldom used oxygen, and have no shortness of breath when just lying in bed. On 4/19/2023, at 1:45 p.m., during an interview with Physician 4, he stated he was the attending physician while Patient 3 was in a skilled nursing facility (SNF 1) prior to admission in hospice care. Physician 4 stated he did not refer Patient 3 to hospice care and services. On 4/20/23, at 1:20 p.m., during an interview with the Director of Patient Care Services (DPCS), DPCS stated he was not able to find documented evidence Patient 3 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators or had O2 saturation of 88% or less.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met as follows: The hospice agency failed to: 1. Educate the patient and/or patients family regarding safe and effective use of oxygen equipment and supplies for one of eight sampled patients, (Patient 7). This deficient practice had the potential to result in the patient to develop a respiratory infection. (Refer to L544) 2. Provide a "Comfort Kit" (a prescribed set of medications that are kept in a patient's home in the event of an emergency) as per physician orders for two of eight sampled patients, (Patients 3 and 6). This failure had the potential to result in patients not receiving their comfort medications on a timely basis. L549 3. Ensure the Interdisciplinary Group (IDG, team members from different disciplines working collaboratively with a common purpose to set goals, make decisions, and share resources and responsibilities), including the Medical Director had communicated with the patient's primary physician to verify the patient's eligibility for hospice care services for five of eight sampled patients (Patient 2, 3, 4, 5 and 6). This deficient practice resulted in certifying patients for hospice services without clinical evidence to support the diagnoses to qualify to receive the Medicare hospice benefit. (Refer to L554) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care was provided to the patients who were accurately assessed to receive hospice care and services. --- .

Based on observation, interview, and record review, the hospice agency failed to educate patient and/or patients family regarding safe and effective use of oxygen equipment and supplies for one of eight sampled patients, (Patient 7). This deficient practice had the potential to result in the patient to develop a respiratory infection. --- A review of Patient 7's clinical record indicated that Patient 7 was admitted to the hospice agency on 3/09/2023, with a diagnosis that included acute myeloblastic leukemia (a type of cancer of the blood and bone marrow). A review of Patient 7's "Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) /Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Review," dated 3/16/2023, indicated the skilled nurse (SN) was to visit the patient once a week and as needed for three times, and hospice aide (HA) was to visit twice a week. The POC Summary indicated to administer oxygen inhalation at two (2) liters per minute and may increase five liters per minute via a nasal cannula (oxygen tubing, a device that delivers supplemental oxygen) was ordered on 3/09/2023. There was no documented evidence that the patient or the patients family received any education as to when and how often to change the oxygen humidifier (a device used to make supplemental oxygen moist), and nasal cannula. During a joint home visit with the Licensed Vocational Nurse (LVN 1), on 4/19/2023, at 10:00 a.m., Patient 7 was observed sitting on a recliner, awake, alert and oriented, with a family member (FM 1) next to her. Patient 7 was on oxygen at 4 liters per minute via a nasal cannula attached to an oxygen humidifier. Both humidifier and the nasal cannula were undated. On 4/19/2023, at 10:20 a.m., during an interview with FM 1, he stated, ";I have not changed the oxygen tubing and humidifier since we started her on oxygen maybe about three or four weeks ago. I have no idea that we need to change it often, nobody instructed me about it." On 4/20/2023, at 1:20 p.m., during an interview with the Director of Patient Care Services (DPCS), DPCS stated oxygen tubing and supplies should be changed weekly for infection control purposes. A review of the agency's policy and procedure titled "Safe/Effective Use of Equipment and Supplies," revised April 2018, indicated patients will receive information regarding the safe and effective use of home medical equipment (HME) in accordance with applicable hospice policies. When medical equipment is supplied by another organization, hospice personnel will be supportive in the patients teaching role. Hospice will maintain generic patient teaching tools from the company for common pieces of HME found in the home, including but not limited to oxygen, humidifiers, oxygen concentrators and oxygen cylinders. A review of the agency's policy and procedure titled "Patient Education Process," revised April 2018, indicated 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. Unless otherwise ordered by the physician, the patient and family/caregiver will receive verbal, and as appropriate written instruction on hospice philosophy and the nature of the palliative care, the patients disease process and prognosis, medication management and administration, and the medical regimen.

Based on observation, interviews and record review, the hospice agency failed to ensure physician orders were implemented by failing to provide a "Comfort Kit" (a prescribed set of medications that are kept in a patient's home in the event of an emergency) for two out of eight sampled patients (Patients 3 and 6). This failure had the potential to result in patients not receiving their comfort medications on a timely basis. --- Findings: a. A review of Patient 3's clinical record indicated she was admitted to the hospice agency on 2/07/23, with a diagnosis including chronic obstructive pulmonary disease, unspecified (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 2/07/23 to 5/07/23, the space "Physician Summary" indicated Patient 3 has reported weight loss, poor activity tolerance due to dyspnea (shortness of breath) on exertion, mostly bedbound, and completely dependent on caregivers for bathing, dressing, toileting, transfer, mobility and feeding. It also indicated Patient 3 has a medical prognosis of 6 months or less if the terminal illness runs its normal course. A review of Patient 3's "Plan of Care" (POC) Summary, dated 2/07/23, indicated Skilled Nurse (SN) frequency of visit to once a week plus 3 prn (as needed) visit for pain and symptom management, Certified Home Health Aide (CHHA) was to visit two times a week for grooming, hygiene, and bathing, MSW (Social worker) and SC (Spiritual Counselor) to visit once for assessment, and Volunteer was declined. There was a physician order to provide Comfort Kit medications to Patient 3. On 4/19/23, at 11:10 a.m., during a joint home visit to Patient 3's home, a Board and Care Facility, with the License Vocational Nurse (LVN 1), Patient 3 was observed sleeping in bed, but easily arousable, alert, and oriented to name only. On 4/19/23, at 11:35 a.m., during a joint interview with LVN 1 and the patients caregiver (PCG 1), PCG 1 was asked to provide the Comfort kit for Patient 3 but PCG 1 stated, "we dont have it." LVN 1 stated there was a physician order for Patient 3 to have a comfort kit at home but stated it was not available. On 4/20/23, at 1:20 p.m., during an interview with the Director of Patient Care Services (DPCS), DPCS was notified and acknowledged the finding. DPCS stated there was a physician order for Patient 3 to have a comfort kit at home and it should have been provided according to the plan of care. A review of the agency's policy and procedure titled "The Plan of Care", revised April 2018, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The plan of care will identify the patients needs and services to meet those needs, including management of pain and discomfort and symptom relief. A review of Patient 6's face sheet indicated admission to hospice on 3/13/23, with primary diagnosis of end stage renal disease (when the kidneys can no longer the body's needs). A review of Patient 6's "Plan of Care" (POC) Summary, dated 3/13/23, indicated Skilled Nurse (SN) frequency of visit to once a week plus 3 prn (as needed) visit for pain and symptom management, Certified Home Health Aide (CHHA) was to visit two times a week for grooming, hygiene, and bathing, MSW (Social worker) and SC (Spiritual Counselor) to visit once for assessment, and Volunteer was declined. There was a physician order to provide Comfort Kit medications to Patient 6. On 4/19/23, at 1 p.m., during a joint home visit to Patient 6's home, an assisted living facility, with RN 1 (registered nurse), Patient 6 was observed sitting on her bed, easily arousable, alert, and oriented to name only. On 4/19/23, at 1:35 p.m., during a joint interview with RN 1 and Med Tech 1 (medical technician) the patients caregiver (PCG 1), Med Tech 1 was asked to provide the Comfort kit for Patient 6 but Med Tech 1 stated, "we dont have it." RN 1 stated there was a physician order for Patient 6 to have a comfort kit but she will call pharmacy to bring it to the facility as soon as possible. On 4/20/23, at 1:20 p.m., during an interview with the Director of Patient Care Services (DPCS), he stated there was a physician order for Patient 6 to have a comfort kit at the assisted living facility and it should have been provided according to the plan of care.

Based on observation, interview and record review, the hospice agency failed to ensure the Interdisciplinary Group (IDG, team members from different disciplines working collaboratively with a common purpose to set goals, make decisions, and share resources and responsibilities), including the Medical Director had communicated with the patient's primary physician to verify the patient's eligibility for hospice care services for five of eight sampled patients (Patient 2, 3, 4, 5 and 6). This deficient practice resulted in certifying patients for hospice services without clinical evidence to support the diagnoses to qualify to receive the Medicare hospice benefit. --- b. A review of Patient 2's clinical record indicated Patient 2 was admitted to the hospice agency on 2/13/2023, with a primary diagnosis of senile degeneration of brain, not elsewhere classified (the mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age). A review of Patient 2's Certificate of Terminal Illness (CTI), dated 2/13/2023 to 5/13/2023, Benefit period #2, indicated Physician 2 was the referring physician that Patient 2 has a life expectancy of six months or less, if the terminal illness runs its normal course. The form was not signed by Physician 2. On 4/20/2023, at 2:00 p.m., during an interview with Physician 2, he stated he was not the primary physician for Patient 2. Physician 2 stated he was just contracted by the hospice agency to conduct an initial evaluation to see if Patient 2 was hospice appropriate. c. A review of Patient 3's clinical record indicated she was admitted to the hospice agency on 2/07/2023, with a diagnosis including chronic obstructive pulmonary disease, unspecified (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's CTI, dated 2/07/2023 to 5/07/2023, Benefit period #1, indicated the Medical Director signed the attending physician referral section that Patient 3 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 4/19/2023, at 1:45 p.m., during an interview with Physician 3, he stated he was the attending physician while Patient 3 was in a skilled nursing facility prior to admission in hospice care. Physician 3 stated he did not refer Patient 3 to hospice care and services. During an interview on 4/20/2023 at 12:00 p.m., the DPCS was not able to provide the documented evidence that the hospice medical director or hospice attending physician had communicated with the primary physician of Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 of having life expectancy of six months or less, if the terminal illness runs its normal course. During a phone interview on 4/20/2023 at 12:25 p.m., the MD 1 stated he was not the attending physician, and he does not know who the attending physician for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 were. MD 1 stated he sent Physician 2 to do face-to-face encounter with Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 during their admission to the hospice service, and determined the patients were eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by Physician 2 and registered nurse upon their initial visit to the patients. MD 1 stated there should be a primary physician referral before the agency admit a patient. A review of the agency's policy and procedure titled "Admission Criteria and Process", revised April 2018, indicated Odyssey Hospice care, Inc will admit any patient with a life-limiting illness that meets the admission criteria. The organization will utilize referral information provided by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician offices in the determination of eligibility for admission to the program. If the request for service is not made by the patients physician, he/she will be consulted prior to the evaluation visit/initiation of services. c. A review of Patient 4's face sheet indicated admission to hospice on 2/6/23, with primary diagnosis of chronic obstructive pulmonary disease (a lung disease that block airflow and make it difficult to breathe), and Physician 2 was the Referring/Attending /Patient choice doctor. A review of Patient 4's Certificate of Terminal Illness (CTI), dated 2/6/23 to 5/15/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section to indicate Patient 4 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 4/20/23, at 12 p.m., during a phone interview with Physician 2, he stated that he was not the attending physician for Patient 2 and someone was just using his name and license for hospice services. d. A review of Patient 5's face sheet indicated admission to hospice on 3/2/23, with primary diagnosis of huntington's disease ( a condition in which nerve cells in the brain break down over time), and Physician 3 was the Referring/Attending /Patient choice doctor. A review of Patient 5's Certificate of Terminal Illness (CTI), dated 3/2/23 to 5/30/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 4/19/23, at 12 p.m., during a home visit at Patient 5's residence at an assisted living facility with RN 1, Patient 5 was observed sitting on his bed eating by himself. When Patient 5 was asked if Physician 3 was his attending physician, he stated no and he does not see any physician at all. On 4/20/23, at 1 p.m., during an interview with Physician 3, he stated he was not Patient 5's attending physician. He also stated that Medical Director 1 sent him to do a face to face encounter with Patient 5 after he was admitted hospice agency. e. A review of Patient 6's face sheet indicated admission to hospice on 3/13/23, with primary diagnosis of end stage renal disease (when the kidneys can no longer the body's needs). A review of Patient 6's Certificate of Terminal Illness (CTI), dated 3/13/23 to 6/10/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section to indicate Patient 6 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 4/19/23, at 1 p.m., during a home visit at Patient 6's residence at an assisted living facility with RN 1, Patient 6 was observed sitting on her bed. When Patient 6 was asked if Physician 3 was her attending physician, she stated no and the hospice nurses did not explain to her why she was in hospice service. She also stated that she is not dying in six months and she does not feel sick at all. On 4/20/23, at 1 p.m., during an interview with Physician 3, he stated he was not Patient 6's attending physician. He also stated that Medical Director 1 sent him to do a face to face encounter with Patient 6 after she was admitted hospice agency. On 4/20/23, at 2 p.m., during a phone interview with Medical Director 1, he stated that he was not the attending physician, and he does not know who the attending physician for Patients 2, 3, 4, 5, 6 and 8. He stated since Patients 2,3,4,5,6 and 8 were admitted to their hospice service, he is now the patient's attending physician, but he did not sign the referral attending physician section and someone was signing without my consent. Medical Director 1 further stated that he did not do a face-to-face encounter with the patients during their admission to the hospice service, but he determined the patients were eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. On 4/20/23, at 2:30 p.m., during an interview with the Director of Patient Care Services (DPCS ), he stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. A review of the agency's policy titled, "Admission Criteria and Process", indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination.

Upon patient record review 6 of 11 records (Patients #1, #2, #3, #5, #9, #11) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, 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. Patient #1: The record did not contain evidence that a psychosocial assessment was completed. Patients #2 and 3: The record indicated that spiritual care was declined on initial nurse visit and there was not evidence of comprehensive assessment for spiritual needs. Patients #5, 9, 11: The record indicated that social work and spiritual care was declined on initial nurse visit and there was not evidence of comprehensive assessment for psychosocial and spiritual needs.

Upon patient record review, 1 of 11 records (Patient #7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #7: The record contained order for systane balance lubricant drops 4 timers per day to affected eye as needed for dryness however, did not specify which eye(s). [corrected on site]

Upon patient record review, 2 of 11 records (Patients #4 and #9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #4: The record did not contain evidence of plan of care update to include problems/goals/interventions for bactrim order on 6/26 for UTI and wound on coccyx 6/6 and 6/15 and 7/20. [corrected on site] Patient #9-The record indicated patient was admitted for Huntington's disease however, there was no evidence of neurological problems/interventions/goals on plan of care at start of care.

Upon patient record review, 1 of 11 records (Patient #7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #7: The record contained order for systane balance lubricant drops 4 timers per day to affected eye as needed for dryness however, did not specify which eye(s) on the plan of care. [corrected on site]

Upon patient record review, 3 of 11 (Patients #7, #9, #10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #7: The record indicated patient had a hospital bed and shower chair however, these were not listed on the plan of care. [corrected on site] Patient #9: The record indicated patient had a hospital bed, over the bed table, and walker however, these were not listed on the plan of care. [corrected on site] Patient #10: The record indicated patient had a walker and shower chair however, these were not listed on the plan of care. [corrected on site]

Upon client record review, 1 of 11 records (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The visit frequency orders for nursing was 1 per week and 3 PRN and social work 1 per month and 1 PRN however, the record contained evidence that the nurse visited twice the week of 10/10/21 on 10/11 and 10/14 both as scheduled visits and the social worker visited twice the month of November on 11/16 and 11/22 both as scheduled visits.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Home visit #1: On visit, observed RN remove glove several times while assessing patient and noted twice that RN did not sanitize hands following glove removal per agency policy. Home visit #2: On visit, observed LVN remove glove several times while assessing patient and noted twice that LVN did not sanitize hands following glove removal per agency policy.

Upon patient record review 3 of 9 applicable (Patients #1, #3, #6) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: The record indicated visit frequency for aide was 3 times per week to begin 07/08/2022 however, there was not evidence of aide visits until the following week. [corrected on site] Patient #3: The record indicated visit frequency for aide was 3 times per week however, the week of 09/26/2021 the record only contained evidence of visits on 09/27 and 10/01/2021. Patient #6: The record indicated visit frequency for aide was 2 times per week however, the aide completed visits 3 times per week in months of June and July.

Upon personnel record review, 2 of 8 applicable (Personnel #6, #9) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #6: The record did not contain evidence of skills competency for the bereavement coordinator role. Personnel #9: The record did not contain evidence of skills competency for the volunteer role.