Every finding on record at Palliative Care Provider Socal, Inc

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participations regarding Patient Rights was met as follows: --- 1. The Hospice Agency (HA) failed to ensure one of fourteen sampled patients (Patient 8) was informed of the right to choose an attending physician. This failure resulted in violation of patient rights. (Refer to L515). 2. The HA failed to inform seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 8, Patient 9, and Patient 11) about the hospice services they provide and the limitations on these services. This failure resulted in the patient not being aware of the covered hospice services provided as patients certified to receive the hospice benefits. (Refer to L519). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Patient's Rights to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure one of fourteen sampled patients (Patient 8) was informed of the right to choose an attending physician. This failure resulted in a violation of patient rights. --- Findings: A record review of Patient 8s ";Personal Information", indicated a Start of Care (SOC) date of 4/15/2023 with a primary diagnosis including heart disease (several heart conditions that cause decrease blow flow to the heart) unspecified. During a joint home visit on 10/24/2023, at 10:15 a.m., with the Director of Nurses (DON) to Patient 8's home, DON stated she conducted the supervisory visits for Patient 8. During observation, Patient 8 was noted ambulating with walker to the room, sitting at the edge of bed. During a concurrent interview, Care Giver 2 (CG2) stated Patient 8 s insurance (IS) sends NP1 (nurse practitioner), a social service (SS) and a social worker (SW) monthly. CG2 stated Patient 8s medication was checked by the NP1 and took Patient 8s blood. CG2 and Patient 8 stated they have never been told that Patient 8 had six months or less to live. CG2 stated they were unaware of who the HAs staff were. During a telephone in interview on 10/24/2023, at 11:15 a.m., with Patient 8s son, care giver 3 (CG3), CG3 stated that neither him or his mother has ever been told that Patient 8 had six months or less to live. CG3 stated ";I knew she needed help after her fall because she was unable to cook or do anything like that. I dont know how she got involved in a hospice program, maybe because she needed help but not because she was dying." CG3 stated that he had never heard of Medical Director 1 (MD1) or Medical Director 2 (MD2). During a telephone interview on 10/25/2023, at 9:48 a.m., with Patient 8s insurance representative (IR), IR stated that Patient 8 has been seen by NP1 since Patient 8 was released from the hospital in April 2023. IR stated that NP1 oversees Patient 8s medications and blood draws. IR stated he does not see any referrals for hospice services. A record review of the HAs policy and procedure titled, ";Admission Criteria and Process" revised April 2021, indicated ";(HA) will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician, if any... The patients physician must order and approve the provision of hospice care... The patient must desire hospice services and be aware of the diagnosis and prognosis...".

Based on observation, interview and record review, the Hospice Agency (HA) failed to inform seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 8, Patient 9, and Patient 11) were informed about the services they provide and the limitations on these services. This failure resulted in the patients not being aware of the covered hospice services provided as patients certified to receive the hospice benefits. --- Findings: a). A record review of Patient 1s ";Personal Information", indicated a start of care date of 10/26/22, with a primary diagnosis of heart disease ( several heart conditions that decrease the blood flow to the heart), unspecified. During an interview during the home visit on 10/24/23, at 9:50 a.m., Patient 1s caregiver (CG 4) stated she found out about the HA because the agency staff came to church and gave a flyer informing them about a program to help the elderly at home. During an interview on 10/24/23, at 10:20 a.m., Patient 1 stated she did not know what hospice care was. Patient 1 stated ";no" when asked if she had a terminal disease. Patient 1 stated ";no" when asked if a doctor had told her she had 6 months or less to live. Patient 1 stated every time she goes to the doctor, she is told she is doing good. b). A record review of Patient 2s ";Personal Information", indicated a start of care date of 11/11/2022, with a primary diagnosis of hypertensive heart disease without heart failure (( several heart conditions that decrease the blood flow to the heart). During an interview on 10/24/23, at 3:34 p.m., Patient 2s caregiver (CG 5) stated she did not know what hospice care was. CG 5 was asked if a doctor had diagnosed Patient 2 with a terminal illness with a life expectancy of 6 months or less, CG 5 stated ";no". CG 5 stated in Spanish, ";no, no se esta muriendo" (no, hes not dying). CG 5 stated a nurse contacted Patient 2 by telephone informing him she had his discharge paperwork from the hospital and wanted to visit him. CG5 stated after that first visit the nurse started coming once a week. c). A record review of Patient 3s ";Personal Information", indicated a start of care date of 12/30/21, with a primary diagnosis of hypertensive heart disease without heart failure (chronic high blood pressure). During an interview on 10/26/23, at 10:40 a.m., Patient 3s care giver (CG 6) stated Patient 3 was not terminal and did not have a life expectancy of 6 months or less to live. CG 6 stated, ";if a doctor told me that, I think I would have remembered that. That is not something you forget". CG 6 stated Patient 3 had heart surgery in 2021, couldnt move well after that, and thought that was the reason a nurse was seeing her. CG 6 stated a nurse had contacted them to inquire if they needed help at home, which is the reason they agreed to the service. CG 6 stated Patient 3 needed physical therapy, help with moving, and light housekeeping. CG 6 stated, ";did we sign up for the wrong service?" d). A record review of Patient 5s ";Personal Information", indicated a start of care date of 7/29/22, with a primary diagnosis of hypertensive heart disease without heart failure (chronic high blood pressure). During an interview on 10/24/23, at 4:07 p.m., Patient 5 stated she cancelled hospice services a week ago because she's been well, not sick, and does not need the service. Patient 5 stated the HA told her they needed a two week notice to cancel the services. Patient 5 stated she knew that hospice care was for people who were dying, but she was not dying, and a doctor had not told her she had a terminal illness with a life expectancy of 6 months or less to live. Patient 5 stated in Spanish, ";yo no me senti que me estaba muriendo" (I didnt feel I was dying). e). A record review of Patient 8s ";Personal Information", indicated Patient 8s had a Start of Care (SOC) date of 4/15/2023 with a primary diagnosis including heart disease several heart conditions that decrease the blood flow to the heart) unspecified. During a joint home visit on 10/24/2023 at 10:15 a.m. with the Director of Nurses (DON) to Patient 8s home, DON stated she conducts the supervisory visits for Patient 8. Patient 8s was observed ambulating with walker to room, sitting at the edge of bed. Care Giver 2 (CG2) stated Patient 8s insurance (IS) Nurse Practitioner 1 (NP1), a social service (SS) and a social worker (SW) monthly. CG2 stated the NP1 assessed Patient 8, checked Patient 8s medication and took Patient 8s blood. CG2 and Patient 8 stated they have never been told that Patient 8 had six months or less to live. During a telephone in interview on 10/24/2023, at 11:15 a.m., with Patient 8s son, care giver 3 (CG3), CG3 stated that neither him or his mother has ever been told that Patient 8 had six months or less to live. CG3 stated ";I knew she needed help after her fall because she was unable to cook or do anything like that. I dont know how she got involved in a hospice program, maybe because she needed help but not because she was dying." During a telephone interview on 10/25/2023, at 9:48 a.m., with Patient 8s insurance representative (IR), IR stated that Patient 8 has been seen by a doctor since Patient 8 was released from the hospital in April 2023. IR stated that NP1 oversees Patient 8s medications and blood draws. IR stated he does not see any referrals for hospice services. f). A record review of Patient 9s ";Personal Information", indicated a Start of Care (SOC) date of 4/2/2023 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. During an interview on 10/24/2023, at 4:10 p.m., with Patient 9, Patient 9 was asked what hospice services were. Patient 9 stated they bring supplies and sent a nurse to check on me. Patient 9 also stated she was never told that she had six months or less to live by any doctor. Patient 9 stated ";There has never been a doctor that has told me that I was going to die, not even when I was diagnosed with cancer, 16 years ago, melanoma stage III." Patient 9 stated she has a primary doctor, which she saw last in September 2023. Patient 9 stated that she ambulates without assistance, showers, and takes her medication by herself and that she does not use diapers. g). A record review of Patient 11s ";Personal Information", indicated a Start of Care (SOC) date of 11/21/2022 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. During a telephone interview on 10/24/2023, at 4:31 p.m., with Patient 11s Care Giver 1 (CG1), CG1 stated hospice services for Patient 11 included a nurse that came to bathe her and provided diapers and ensure. CG 1 stated they were told by the HA that they would were going to stop their services because Patient 11 had been with them for about two years. CG1 stated Patient 11 did have a primary physician PCP1, which Patient 11 saw within this past year. CG1 stated Patient 11 has never been told that she had six months or less to live. During an interview on 10/24/2023 at 4:40 p.m. with Primary Care Physician Nurse 1, PCP1s Nurse (PN1), PN1 stated Patient 11 saw PCP1 on June 2, 2023. PN1 stated that PCP1 had not referred or given orders for hospice services for Patient 11. During an interview on 10/26/23, at 3 p.m., the Chief Financial Officer (CFO) was informed about Patient 1, Patient 2, Patient 3, Patient 5, Patient 8, Patient 9, Patient 11s reported interview of the patients not knowing what hospice care was. The CFO stated the patients had signed the admission paperwork and asked, ";isnt that evidence they knew about hospice care?" A review of facilitys policy and procedure titled, ";Admission Criteria and Process" revised April 2021, indicated ";4. The patient must desire hospice services and be aware of the diagnosis and prognosis."

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 follows: --- 1. The hospice agency staff failed to conduct and document comprehensive assessment identifying the need for hospice care and services for four of fourteen sampled patients (Patient 1, Patient 2, Patient 3, and Patient 4). These patients did not have life expectancy of six months or less. (Refer to L 522). 2. The hospice agency 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 five calendar days after hospice election for two of fourteen sampled patients (Patient 10 and Patient 13). (Refer to L 523). 3. The hospice agency failed to review all medications patients were taking and update their medication profiles with the currently used medications for two of fourteen sampled patients (Patient 1 and Patient 8). The patients were at risk for medication errors and adverse drug reactions. (Refer to L 530). 4. The hospice agency failed to conduct a bereavement assessment to provide bereavement counseling in accordance with the patient/family's needs for one of fourteen sampled patients (Patient 13), which focused on the social, spiritual, and cultural factors that may affect the ability of the family and other individuals involved in the care, to cope with the patients death. (Refer to L 531). 5. The hospice agency 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 patients and families) met and updated the comprehensive assessment at least every 15 days for eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 8, Patient 9, Patient 11, Patient 12, and Patient 13). (Refer to L 533). The cumulative effect of these systemic practices resulted in the hospice agency admitting patients who did not meet admission criteria and did not qualify for the Medicare hospice benefit.

Based on observation, interview and record review, the Hospice Agency (HA) staff failed to conduct and document comprehensive assessment identifying the need for hospice care and services for four of fourteen sampled patients (Patient 1, Patient 2, Patient 3, and Patient 4). These patients did not have life expectancy of six months or less. This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- Findings: a) A review of Patient 1s ";Personal Information", indicated a start of care (SOC) date of 10/26/2022, with a primary diagnosis of unspecified heart disease. During a home visit on 10/24/2023, at 10:20 a.m., Patient 1 stated she did not know what the hospice care was. When asked Patient 1 if she had a terminal disease, Patient 1 stated, ";No". When asked Patient 1 if a doctor told her that she has six months or less to live, Patient 1 stated, ";No". Patient 1 stated every time she goes to the doctor, she was told she was doing good. Patient 1 stated she did not have or use oxygen, is able to talk without shortness of breath, and does not feel pain or discomfort while lying in her bed. During an interview on 10/25/2023, at 11:09 a.m., the Director of Nurses Designee (DD) stated the LCD (Local Coverage Determination, a tool used to determine hospice admission criteria), was used in the initial comprehensive assessment. DD stated the importance of using the LCD was to determine if the patient was hospice eligible or met the criteria. DD stated, "Ultimately, it was the doctor who decided if patient met criteria". During an interview and concurrent record review on 10/25/2023, at 11:17 a.m., DD reviewed Patient 1s document titled, ";Comprehensive Nursing Assessment", dated 10/26/2022. DD stated the LCD was used during the assessment. The LCD indicated Patient 1 qualified for hospice care because she was ";optimally treated for heart disease with diuretics (medications to get rid of excess water from the body) and vasodilators (medications used to lower blood pressure)", had congestive heart failure (a long-term condition when heart does not pump enough blood to meet body's needs), met the criteria for New York Heart Association (NYHA, a classification system used to classify patients with heart failure) level of 4 (severe limitations, experiences symptoms even at rest, mostly bed bound patients), and had history of unexplained fainting (sudden loss of consciousness). DD stated a NYHA 4 meant the patient was short of breath, or just doing a few steps that causes shortness of breath because the heart disease results in not enough oxygen, causing the shortness of breath. DD stated the HA did not have any medical documents to support the classification of NYHA 4 of heart failure, Patient 1 having a history of fainting, or optimally was treated with diuretics and vasodilators. DD stated Patient 1 qualified for hospice care because she had shortness of breath, was weak, and had co-morbidities (other illnesses). The HA failed to ensure the comprehensive assessment had supportive evidence of Patient 1's heart failure, history of fainting, and history of being optimally treated with diuretics and vasodilators, to validate Patient 1's admission for hospice care. b) A review of Patient 2s ";Personal Information", indicated an SOC date of 11/11/2022, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During an interview on 10/24/2023, at 3:24 p.m., Patient 2s caregiver (CG 5) stated she did not know what hospice care was. When asked CG 5 if a doctor had diagnosed Patient 2 with a terminal illness with a life expectancy of six months or less, CG 5 stated, ";No". CG 5 stated in Spanish, ";No, no se esta muriendo" (no, hes not dying). During an interview and concurrent record review on 10/25/2023, at 12:23 p.m., DD reviewed Patient 2s document titled, ";Comprehensive Assessment", dated 11/11/2022. DD stated the LCD was used during the assessment. The LCD indicated Patient 2 qualified for hospice care because he was optimally being treated for heart disease with diuretics and vasodilators, is unable to be on vasodilators due to medical condition, and had heart failure NYHA level 4. DD stated the LCD was not answered correctly because Patient 2 was not on diuretics and he did not have a medical condition that he cannot have a vasodilator. During an interview and concurrent record review on 10/25/2023, at 12:35 p.m., DD reviewed Patient 2s document titled, ";Comprehensive Assessment", dated 11/11/2022. DD stated there was no evidence Patient 2 had congestive heart failure or NYHA level 4. DD stated the LCD was not answered correctly because Patient 2 did not have a heart failure. During an interview and concurrent record review on 10/25/2023, at 12:37 p.m., DD reviewed Patient 2s document titled, ";Comprehensive Assessment", dated 11/11/2022. DD stated the comprehensive assessment did not accurately reflect Patient 2s condition. DD stated Patient 2 qualified for hospice care because he had shortness of breath and could not walk maximum steps. During an interview on 10/25/2023, at 12:40 p.m., DD stated there were no medical documents, diagnostic tests, and supporting documentation of Patient 2s diagnosis of hypertensive heart disease. c) A review of Patient 3s ";Personal Information", indicated an SOC date of 12/30/2021, with a primary diagnosis of hypertensive heart disease without heart failure. During an interview and concurrent record review on 10/25/2023, at 12:57 p.m., DD reviewed Patient 3s document titled, ";Comprehensive Assessment", dated 12/30/2021. DD stated the LCD was used during the assessment. The LCD indicated Patient 3 qualified for hospice care because she had declined surgical procedures, had congestive heart failure NYHA level 4, and had history of unexplained fainting. DD stated there were no medical documents in Patient 3s record to indicate she was offered surgical procedures, there was no patient interview to indicate Patient 3 declined surgical procedures, there was no medical documents and no diagnostic results to support the findings documented on the LCD. DD stated there was no clinical information to support the diagnosis of congestive heart failure or angina (chest pain or discomfort). Patient 3 did not have edema (swelling), high blood pressure, or have signs of congestive heart failure. DD stated Patient 3 qualified for hospice care because she was weaker and more fatigued. DD stated the assessment did not make sense because the assessment did not support her diagnosis. DD stated Patient 3 was eligible for hospice care because she had a pacemaker (a medical device that helps the heartbeat), she was on medications to thin the blood, and was sure she had other conditions too, but was not documented. There was no documented evidence Patient 3s comprehensive assessment accurately reflected the patient's condition and had clinical evidence of Patient 3s medical condition. d) A review of Patient 4s ";Personal Information", indicated an SOC date of 9/21/2023 with a primary diagnosis of malignant neoplasm of unspecified site of left female breast (breast cancer). During an interview and concurrent .record review on 10/26/2023, at 12:30 p.m., the Director of Nurses (DON) reviewed Patient 4s record titled, ";Comprehensive Assessment", dated 9/21/2023. The DON stated the LCD was used. The record indicated Patient 4 was qualified for hospice care due to a suspicious large tumor and refused to get a definitive diagnosis, she declined in functional status, and had significant, unintentional weight loss. The DON stated the HA did not have supporting documentation that Patient 4 had breast cancer. DON was asked how the agency determined the diagnosis of ";malignant neoplasm of unspecified site of left female breast" if patient did not want to be diagnosed, the DON stated, ";I dont have an answer for that". There was no documented evidence Patient 4s comprehensive assessment accurately reflected the patient's condition and had clinical evidence of Patient 4s medical condition. A record review of the HAs policy and procedure titled, ";Comprehensive Assessment", dated April 2021, indicated, ";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:...X. Laboratory results. Y. Medical, alcohol, and other drug history, BB. Past medical and surgical care including dates of onset/exacerbation..."

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 to support patients and families) complete the comprehensive assessment no later than five calendar days after hospice election for two of fourteen sampled patients (Patient 10 and Patient 13). This deficient practice had the potential to result in patients needs will not be identified in order to receive appropriate hospice care services that could impact their quality of care. --- Findings: a) A review of Patient 10s ";Personal Information", indicated a Start of Care (SOC) date of 10/9/2023 with a primary diagnosis including unspecified heart failure (a chronic condition in which the heart does not pump enough blood to meet body's needs). During an interview and concurrent record review on 10/23/2023, at 11:53 a.m., with the Director of Nurses Designee (DD) of Patient 10s electronic medical record (EMR) form titled ";POC/IDG Review", DD stated there was no initial IDG completed/documented ";yet". DD stated Patient 10s SOC was 10/9/2023 and it should have been completed already. DD stated Patient 10s initial IDG meeting needed to be completed for all disciplines to be aware of Patient10s plan of care and their visit frequencies. b) A review of Patient 13s ";Personal Information", indicated an SOC date of 4/22/2022 and an End of Care (EOC) date of 12/8/2022, with a primary diagnosis including unspecified hypertensive (high blood pressure) heart disease. A review of Patient 13s medical record form titled ";POC (Plan of Care, an individualized care plan for patient)/IDG Review" dated 4/22/2022, indicated sections ";MSW Signature" and Chaplain Signature" were left blank. During an interview and concurrent record review on 10/25/2023 at 12:35 p.m., with the Director of Nurses (DON) of Patient 13s Electronic Medical Record (EMR), medical record form titled ";POC/IDG Review" dated 4/22/2022, the DON stated it was not completed due to missing IDG member signatures. DON stated during the initial IDG meetings is where all HA staff meets to discuss the patients plan of care and any concerns. DON stated that the IDG members signatures indicate their attendance. DON stated that IDG members have 48 to 72 hours to sign the form. A review of the HAs policy and procedure titled, ";Patient Admission Criteria" revised 6/2019, indicated ";Patients are accepted for treatment on the basis of a reasonable expectation that the patients need can be met adequately by Hospice in the patients place of residence. Care follows a written plan of care established by the IDG..." A review of the HAs undated policy and procedure titled, ";Nursing Services", indicated ";Patients receiving nursing services will have appropriate assessments, reassessments, and IDG care planning... A review of facilitys policy and procedure titled ";Admission Criteria and Process", revised 4/2021, indicated ";The hospice registered nurse will contact at least one (1) other member of the interdisciplinary group for input into the plan of care, prior to the delivery of care. The two (2) remaining core services must be contacted and provide input into the plan of care within two (2) days of start of care; this may be in person or by phone. If the patient is accepted for hospice care, a comprehensive assessment of the patient will be performed no later than 5 (five) calendar days after the election of hospice care." A review of facilitys policy and procedure titled ";The Plan of Care", revised 4/2021, indicated ";The Case Manager (or admitting registered nurse) will then notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs. The plan of care will be reviewed prior to care being delivered."

Based on observation, interview, and record review, the Hospice Agency (HA) staff failed to review all medications patients were taking and update their medication profiles with the currently used medications for two of fourteen sampled patients (Patient 1 and Patient 8). This deficient practice had the potential to put the patients at risk for medication errors and adverse drug reactions. --- Findings: a) A review of Patient 1s ";Personal Information", indicated a start of care (SOC) date of 10/26/2022, with a primary diagnosis of unspecified heart disease. During an observation and concurrent interview of the home visit on 10/24/2023, at 9:57 a.m., the Director of Nurses Designee (DD) reviewed the medications Patient 1 was taking at home. DD stated the following medications were not listed in the medication profile: - Gabapentin (treats seizures and nerve pain) 300 mg (mg, a unit of measurement), one capsule at night, for three weeks, then one capsule twice a day. - Naproxen (treats pain) 500 mg, one tablet twice a day as needed for pain. - Calcium (supplement) 500 mg and Vitamin D3 (supplement), 10 mcg (micrograms, a unit of measurement), one tabled by mouth twice daily. - Vitamin B supplements - Insulin Humulin (diabetes [a chronic condition that affects the way the body processes blood sugar] treatment) 70/30, inject 45 units every morning and 25 units every evening. - Albuterol (helps with breathing) 90 mcg, two puffs daily as needed. DD stated medication Tramadol (for pain) was listed on the medication profile but it was not at home. b) A review of Patient 8s ";Personal Information", indicated an SOC date of 4/15/2023 with a primary diagnosis including unspecified heart disease. A review of Patient 8s undated medical record form, titled ";Current Treatment/Medication/DME (durable medical equipment) List", indicated ";Medication B 12 1000 mcg tablet, one tablet orally, once daily, Metformin Hydrochloride (diabetes medication [medication to maintain normal blood sugar]) 850 mg to be taken twice daily, and Metformin Hydrochloride (diabetes medication) 1000 mg to be taken twice daily. During a joint home visit on 10/24/2023, at 10:15 a.m., with the Director of Nurses (DON) at Patient 8s home, DON stated she conducted the supervisory visits for Patient 8. Patient 8 noted ambulating with walker, then sat at the edge of the bed. CG2 stated Patient 8s insurance (IS) sends a doctor (NP1), a social service (SS) and a social worker (SW) monthly. CG2 stated NP1 was there in the morning, assessed Patient 8, checked Patient 8s medications, and took Patient 8s blood. CG2 stated she has been giving Patient 8 fish oil (supplement), complex B (vitamin), vitamin C, and Vitamin D (label on the bottle - 25 mcg, one tablet, every day, filled date of 8/23/2023 for a couple of months). CG2 stated that patient has been taking Alendronate (a medication used to treat a condition when bones become thin, weak, and break easily) 70 mg, every week for a very long time. CG2 stated NP1 discontinued Metformin, added amlodipine (medication to treat high blood pressure), and increased benazepril (medication to treat elevated blood pressure) to 20 mg, this morning during her visit. CG2 stated Patient 8 has not been taking B 12 for the past four months. During a telephone interview on 10/24/2023, at 11:15 a.m., with Patient 8s Care Giver 3 (CG3), CG3 stated that he had never heard of Medical Director 1 (MD1) or Medical Director 2 (MD2). CG3 stated that Patient 8 was being seen by NP1. During a telephone interview on 10/25/2023, at 9:48 a.m., with Patient 8s insurance representative (IR), IR stated that Patient 8 has been seen by NP1 since Patient 8s release from the hospital in April 2023. IR stated that NP1 oversees Patient 8s medications and blood draws. IR stated he does not see any referrals for hospice services. During an interview and concurrent record review on 10/26/2023, at 12:30 p.m., with the Director of Nurses Designee (DD) of Patient 8s medical record form titled ";Current Treatment/Medication/ DME List", DD stated Metformin was increased to 1000 mg on 5/3/2023. DD stated Metformin 850 mg should have been removed from Patient 8s medication list. DD stated, ";It should have been removed from the medication list, to prevent a medication mistake to prevent taking both doses." DD stated that she was unaware of their medication reconciliation policy, but she usually checks patients medications at every visit. A review of facilitys policy and procedure titled ";Medication Reconciliation" revised 6/2019, indicated ";Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication." A review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised 4/2021, indicated ";During the comprehensive patient assessment, all baseline data and other relevant information will be documented...including at least... review of current and related past medications..."

Based on interview and record review, the Hospice Agency (HA) failed to conduct bereavement assessment to provide bereavement counseling in accordance with the patient/family's needs, which focused on the social, spiritual, and cultural factors that may affect the ability of the family and other individuals involved in the care, to cope with the patients death for two of fourteen sampled patients (Patient 10 and Patient 13). This failure had the potential to result in patients family and/or caregivers are not assessed for factors that may place them at risk for a significantly negative bereavement experience. --- Findings: 1) A review of Patient 10s ";Personal Information", indicated Patient 10 had a Start of Care (SOC) date of 10/9/2023 with a primary diagnosis including unspecified heart failure (a chronic condition in which the heart does not pump enough blood to meet body's needs). A review of facilitys form titled ";Audit Log" dated 10/22/2023 to 10/25/2023, indicated the Medical Social Worker (MSW) logged into Patient 10s Electronic Medical Record (EMR) on 10/23/2023. The form indicated ";Module – Bereavement Assess..." was created on 10/23/2023 with a visit date of 10/12/2023. 2) A review of Patient 13s ";Personal Information", indicated an SOC date of 4/22/2022 and an End of Care (EOC) date of 12/8/2022, with a primary diagnosis including unspecified hypertensive (high blood pressure) heart disease. During an interview and concurrent record review on 10/25/2023, at 12:35 p.m., with the Director of Nurses (DON) of Patient 13s Electronic Medical Record (EMR) medical record form titled ";Bereavement", DON stated there was nothing documented. DON stated, ";If a patient declines any discipline, it needs to be documented." DON stated that all their services are offered at every recertification. During an interview and concurrent record review on 10/25/2023, at 12:47 p.m., with the Administrator/Spiritual Counselor (ADM/SC) of Patient 13s EMR medical record form titled ";Bereavement", ADM/SC stated it was not filled out. ADM/SC stated she thought Patient13 declined the bereavement assessment on SOC. ADM/SC stated that she was supposed to ask the patients if they reconsider their assessments within a month of SOC. ADM/SC stated, ";Once they decline, I call them every month to see if they would like to reconsider. There was nothing documented." A record review of the HAs policy and procedure titled, ";Bereavement Assessment", revised 4/2021, indicated ";On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment... the Bereavement Coordinator will review the bereavement risk assessment to determine potential needs of the survivors. Upon completion all bereavement documentation will be filed." A record review of the HAs policy and procedure titled, ";Comprehensive Assessment", revised 4/2021, indicated ";During the comprehensive patient assessment, all baseline data and other relevant information will be documented...including at least... A bereavement assessment..."

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 eleven of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 8, Patient 9, Patient 11, Patient 12, and Patient 13). This deficient practice had potential for the patient's progress toward desired outcomes, including patient's response to care will not be identified causing delay of treatment, intervention, and management of needs of the terminally ill patient. --- Findings: a). A record review of Patient 1s ";Personal Information", indicated a start of care date of 10/26/22, with a primary diagnosis of heart disease, unspecified. During a concurrent interview and record review on 10/26/2023, at 10:30 a.m., the Director of Nurses (DON) reviewed Patient 1s record titled, ";POC/IDG", dated 8/15/2023 and 8/29/2023. The record did not indicate the doctor and spiritual counselor were present to update the comprehensive assessment. The DON stated the signature on the document validated their attendance. The DON stated the documents needed to have documentation about the patients grieving, what kind of stress the patient is going through, and what the spiritual needs of the patient are. The DON stated there was no documentation of such. The DON stated the records did not have the doctors input documented. The DON stated the input of the doctor should be documented because the documents should show the doctor was involved in the plan of care, was aware of the changes of the patient, and what clinical plan needed to be changed. During a concurrent interview and record review on 10/26/2023 at 11:14 a.m., the DON reviewed Patient 1s record titled, ";POC/IDG", dated 9/12/2023. The record did not indicate the doctor and spiritual counselor were present to update the comprehensive assessment. The DON stated there was no documentation about the doctors input. The DON stated the spiritual counselor input indicated he would be available. There was no specific topics or needs documented. During a concurrent interview and record review on 10/26/2023 at 11:15 a.m., the DON reviewed Patient 1s record titled, ";POC/IDG", dated 9/26/2023. The record did not indicate the doctor and spiritual counselor were present to update the comprehensive assessment. The DON stated there was no documentation about the doctors input. The doctors input was important because it showed the involvement in the plan of care, awareness of the changes of the patient, and what clinical plan needed to be changed. The DON stated the spiritual counselor input indicated he would be available. There was no specific topics or needs documented. During a concurrent interview and record review on 10/26/2023 at 11:17 a.m., the DON reviewed Patient 1s record titled, ";POC/IDG", dated 10/10/2023. The record did not indicate the doctor and spiritual counselor were present to update the comprehensive assessment. The DON stated there was no documentation about the doctors input. The DON stated the spiritual counselor input indicated he would be available. There was no specific topics or needs documented. There was no documented evidence the doctor and spiritual counselor updated the comprehensive assessment at least every 15 days. b). A record review of Patient 2s ";Personal Information", indicated a start of care date of 11/11/2022, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During a concurrent interview and record review on 10/26/2023, at 11:18 a.m., the DON reviewed Patient 2s record titled, ";POC/IDG", dated 8/15/2023. The record did not indicate the registered nurse signed the document. The DON stated she had documented the nursing input and had forgotten to sign the document. During a concurrent interview and record review on 10/26/2023, at 11:20 a.m., the DON reviewed Patient 2s record titled, ";POC/IDG", dated 8/29/2023. The record did not indicate the registered nurse signed the document. The DON stated she had documented the nursing input and had forgotten to sign the document. During a concurrent interview and record review on 10/26/2023 at 11:21 a.m., the DON reviewed Patient 2s record titled, ";POC/IDG", dated 9/12/2023. The record did not indicate the registered nurse signed the document. The DON stated she had documented the nursing input and had forgotten to sign the document. The DON stated the signature verified what was documented. During a concurrent interview and record review on 10/26/2023 at 11:22 a.m., the DON reviewed Patient 2s record titled, ";POC/IDG", dated 9/26/2023. The record did not indicate the registered nurse signed the document. The DON stated she had documented the nursing input and had forgotten to sign the document. The DON stated the signature verified what was documented. During a concurrent interview and record review on 10/26/2023 at 11:22 a.m., the DON reviewed Patient 2s record titled, ";POC/IDG", dated 10/10/2023. The record did not indicate the registered nurse signed the document. The record did not indicate the doctor was present: there was no input documented that indicated the doctor participated in the update of the comprehensive assessment. The DON stated she had documented the nursing input and had forgotten to sign the document. The DON stated the signature verified what was documented. There was no documented evidence the doctor, spiritual counselor, and registered nurse updated the comprehensive assessment at least every 15 days. c). A record review of Patient 3s ";Personal Information", indicated a star of care date of 12/30/21, with a primary diagnosis of hypertensive heart disease without heart failure. During a concurrent interview and record review on 10/26/2023 at 11:25 a.m., the DON reviewed Patient 3s record titled, ";POC/IDG", dated 8/15/2023. The record did not indicate the spiritual counselor was present to update the comprehensive assessment. The DON stated the document indicated Patient 3 declined spiritual counseling. Even though it was declined, the spiritual counselor was supposed to participate in the meeting. The DON stated the expectation was for the spiritual counselor to re-evaluate and continue to offer the services because the HA needed to make sure the service continues to be offered, so the patient knows the service is still available. Continued review of the document indicated the registered nurse signature was missing. The DON stated she had forgotten to sign the document. The signature validated attendance and the documentation of the discussion. During a concurrent interview and record review on 10/26/2023, at 11:27 a.m., the DON reviewed Patient 3s record titled, ";POC/IDG", dated 8/29/2023. The record did not indicate the registered nurse and spiritual counselor were present to update the comprehensive assessment. The DON stated the document was missing signatures and the signature validated attendance and discussion. During a concurrent interview and record review on 10/26/2023, at 11:28 a.m., the DON reviewed Patient 3s record titled, ";POC/IDG", dated 9/12/2023. The record did not indicate the registered nurse and spiritual counselor were present to update the comprehensive assessment. The DON stated the document was missing signatures and the signature validated attendance and discussion. During a concurrent interview and record review on 10/26/2023 at 11:29 a.m., the DON reviewed Patient 3s record titled, ";POC/IDG", dated 9/26/2023. The record did not indicate the registered nurse and spiritual counselor were present to update the comprehensive assessment. The DON stated the document was missing signatures and the signature validated attendance and discussion. There was no documented evidence the registered nurse and spiritual counselor updated the comprehensive assessment at least every 15 days. d). A record review of Patient 4s ";Personal Information", indicated a Start of Care date of 9/21/2023 with a primary diagnosis of malignant neoplasm of unspecified site of left female breast (breast cancer). During a concurrent interview and record review on 10/26/2023 at 11:31 a.m., the DON reviewed Patient 4s record titled, ";POC/IDG", dated 8/15/2023. The DON stated the registered nurse and spiritual counselor signature was missing. The signature would validate the attendance in the meeting. The record also indicated ";IDG discussion/Updated Comprehensive Assessment Review...psychosocial. Continue with current plan of care. SW (social worker) will remain available as needed for psychosocial support. The DON stated she was not sure what the psychosocial needs of Patient 4 were because they were not documented. During a concurrent interview and record review on 10/26/2023, at 11:37 a.m., the DON reviewed Patient 4s record titled, ";POC/IDG", dated 8/29/2023. The record indicated ";IDG discussion/Updated Comprehensive Assessment Review...psychosocial. Continue with current plan of care. SW will remain available as needed for psychosocial support. The DON stated she was not sure what the psychosocial needs of Patient 4 were because they were not documented. The expectation was for the specific needs of Patient 4 to be documented in the IDG meetings and plan of care. Continued review of the record indicated the registered nurse and spiritual counselor signatures were missing. The DON stated she had documented the discussion for nursing and spiritual care but had forgotten to sign the document. During a concurrent interview and record review on 10/26/2023 at 11:39 a.m., the DON reviewed Patient 4s record titled, ";POC/IDG", dated 9/26/2023. The DON stated she had documented all the discussions on the record. The DON stated the doctor, registered nurse, medical social worker, and spiritual counselor signatures were missing. The DON stated she did not know what the disciplines contributed to the meeting because patient was just re-admitted. There was no documented evidence the registered nurse and spiritual counselor updated the comprehensive assessment, including the psychosocial needs of the patient at least every 15 days. e). A record review of Patient 5s ";Personal Information", indicated a Start of Care (SOC) date of 7/29/2022, with a primary diagnosis of hypertensive heart disease without heart failure. During a concurrent interview and record review on 10/26/2023, at 11:46 a.m., the DON reviewed Patient 5s record titled, ";POC/IDG", dated 9/12/2023. The DON stated the registered nurse signature was missing because she forgot to sign. The DON stated the psychosocial needs of Patient 5 were not documented and the HA needed to provide what kind of psychosocial support needs to be provided. The DON stated the input of the doctor was not documented either and this was important to document so the team know what changes needed to be done based on the order of the doctor. During a concurrent interview, and record review on 10/26/2023 at 11:51 a.m., the DON reviewed Patient 5s record titled, ";POC/IDG", dated 9/26/2023. The DON stated the registered nurse signature was missing because she forgot to sign. The DON stated the psychosocial needs of Patient 5 were not documented and the HA needed to provide what kind of psychosocial support needs to be provided. The DON stated the input of the doctor was not documented either and this was important to document so the team know what changes needed to be done based on the order of the doctor. The DON stated the spiritual care discussion did not describe the details of Patient 5s spiritual care. During a concurrent interview and record review on 10/26/2023 at 11:53 a.m., the DON reviewed Patient 5s record titled, ";POC/IDG", dated 10/10/2023. The DON stated the registered nurse and doctor signature was missing. The DON stated the psychosocial needs of Patient 5 were not documented and the HA needed to provide what kind of psychosocial support needs to be provided. The DON stated the input of the doctor was not documented either and this was important to document so the team know what changes needed to be done based on the order of the doctor. There was no documented evidence the registered nurse and doctor updated the comprehensive assessment. There was no documented evidence the psychosocial needs of Patient 5 were included in the comprehensive assessment at least every 15 days. f). A record review of Patient 6s ";Personal Information", indicated a Start of Care date of 11/10/2021 with a primary diagnosis of chronic obstructive pulmonary disease. During a concurrent interview and record review on 10/26/2023 at 11:59 a.m., the DON reviewed Patient 6s record titled, ";POC/IDG", dated 11/10/2021. The DON stated Patient 6 had declined Medical Social Worker (MSW) and Spiritual Counseling services. The spiritual counselor (SC) and the MSW did not attend. The DON stated even though Patient 6 had declined the services the MSW and SC were supposed to attend to make sure everyone was discussing the plan of care, any changes, and aware of what is going on with the patient. During a concurrent interview and record review on 10/26/2023, at 12 p.m., the DON reviewed Patient 6s record titled, ";POC/IDG", dated 1/31/2023. The DON stated the MSW and SC signatures were missing. The signature confirmed attendance. During a concurrent interview and record review on 10/26/2023 at 12:09 p.m., the DON reviewed Patient 6s record titled, ";POC/IDG", dated 2/14/2023. The DON stated the MSW and SC signatures were missing. The signature confirmed attendance. During a concurrent interview and record review on 10/26/2023 at 12:10 p.m., the DON reviewed Patient 6s record titled, ";POC/IDG", dated 2/28/2023. The DON stated the SC signature was missing. The DON stated the spiritual care input was missing, and it was important to know what changes were occurring to the patient and what needs to be addressed, so the entire team is aware. There was no documented evidence the MSW and SC updated the comprehensive assessment. The HA failed to ensure the spiritual needs of Patient 6 were included in the comprehensive assessment at least every 15 days. g). A record review of Patient 8s ";Personal Information", indicated a Start of Care (SOC) date of 4/15/2023 with a primary diagnosis including heart disease unspecified. A review of Patient 8s medical record form titled ";POC (plan of care: individualized care plan for patient) /IDG Review" dated 8/15/2023, indicated section ";Chaplain Signature" was left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 8s medical record form titled ";POC (plan of care: individualized care plan for patient) /IDG Review" dated 8/29/2023, indicated section ";Chaplain Signature" was left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 8s medical record form titled ";POC (plan of care: individualized care plan for patient) /IDG Review" dated 9/12/2023, indicated section ";Chaplain Signature" was left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 8s medical record form titled ";POC (plan of care: individualized care plan for patient) /IDG Review" dated 9/26/2023, indicated section ";Chaplain Signature" was left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 8s medical record form titled ";POC (plan of care: individualized care plan for patient) /IDG Review" dated 10/10/2023, indicated sections ";MD Signature" and ";Chaplain Signature" was left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. During a concurrent interview and record review on 10/26/2023 at 12:30 p.m., with the Director of Nurses Designee (DD) of Patient 8s Electronic Medical Record (EMR) medical record form titled ";History of POC/IDG Review" DD stated that Patient 8s IDGs dated 8/15/2023, 8/29/2023, 9/12/2023, 9/26/2023, and 10/10/2023 were not completed. DD stated, ";IDG meetings are important so we can keep track of the patients needs, how do we know if we dont discuss. Based on the meeting everyone came up with what we need to do to meet the patients need." h). A record review of Patient 9s ";Personal Information", indicated a Start of Care (SOC) date of 4/2/2023 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. A review of Patient 9s medical record form titled ";POC (plan of care: individualized care plan for patient) /IDG Review" dated 8/15/2023, indicated section ";Chaplain Signature" was left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 9s medical record form titled ";POC/IDG Review" dated 8/29/2023, indicated section ";Chaplain Signature" was left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 9s medical record form titled ";POC/IDG Review" dated 9/12/2023, indicated section ";Chaplain Signature" was left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 9s medical record form titled ";POC/IDG Review" dated 9/26/2023, indicated sections ";MD Signature" and ";Chaplain Signature" were left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 9s medical record form titled ";POC/IDG Review" dated 10/10/2023, indicated sections ";MD Signature" and ";Chaplain Signature" were left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. During a concurrent interview and record review on 10/26/2023 at 12:30 p.m., with DD of Patient 9s EMR medical record form titled ";History of POC/IDG Review" DD stated that Patient 9s IDGs dated 8/15/2023, 8/29/2023, 9/12/2023, 9/26/2023, and 10/10/2023 were not completed. i). A record review of Patient 11s ";Personal Information", indicated a Start of Care (SOC) date of 11/21/2022 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. A review of Patient 11s medical record form titled ";POC (plan of care: individualized care plan for patient) /IDG Review" dated 8/15/2023, indicated section ";RN (Registered Nurse) Signature" was left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 11s medical record form titled ";POC/IDG Review" dated 8/29/2023, indicated section ";RN Signature" was left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 11s medical record form titled ";POC/IDG Review" dated 9/12/2023, indicated section ";RN Signature" was left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 11s medical record form titled ";POC/IDG Review" dated 9/26/2023, indicated sections ";MD Signature" and ";RN Signature" were left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 11s medical record form titled ";POC/IDG Review" dated 10/10/2023, indicated sections ";MD Signature" and ";RN Signature" were left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. During a concurrent interview and record review on 10/26/2023 at 10:58 a.m. with the Director of Nurses (DON) of Patient 11s EMR medical record form titled ";History of POC/IDG Review" DON stated that Patient 11s IDGs dated 8/15/2023, 8/29/2023, 9/12/2023, 9/26/2023, and 10/10/2023 were not signed by all the IDGs members. j). A record review of Patient 12s ";Personal Information", indicated a Start of Care (SOC) date of 3/11/2023 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. A review of Patient 12s medical record form titled ";POC/IDG Review" dated 9/12/2023, indicated section ";RN Signature" was left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 12s medical record form titled ";POC/IDG Review" dated 9/26/2023, indicated sections ";RN Signature" were left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 12s medical record form titled ";POC/IDG Review" dated 10/10/2023, indicated sections ";MD Signature" and ";RN Signature" were left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. During a concurrent interview and record review on 10/26/2023 at 1:12 p.m. with DD of Patient 12s EMR medical record form titled ";History of POC/IDG Review" DD stated that Patient 12s IDGs dated 9/12/2023, 9/26/2023, and 10/10/2023 were not completed. k). A record review of Patient 13s ";Personal Information", indicated a Start of Care (SOC) date of 4/22/2022 and an End of Care (EOC) date of 12/8/2022, with a primary diagnosis including hypertensive (high blood pressure) heart disease, unspecified. A review of Patient 13s medical record form titled ";POC (plan of care: individualized care plan for patient) /IDG Review" dated 4/22 /2022, indicated sections ";MSW Signature" and ";Chaplain Signature" were left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 13s medical record form titled ";POC/IDG Review" dated 12/6/2022, indicated sections ";MSW Signature" and ";Chaplain Signature" were left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 13s medical record form titled ";POC/IDG Review" dated 11/8/2022, indicated sections ";MSW Signature" and ";Chaplain Signature" were left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. A review of Patient 13s medical record form titled ";POC/IDG Review" dated 11/22/2022, indicated sections ";MSW Signature" and ";Chaplain Signature" were left blank. It also indicated section ";IDG Discussion/Updated Comprehensive Assessment Review – Other / Physician" was left blank. During a telephone interview on 10/25/2023 at 2:20 p.m. with Medical Director 1 (MD1), MD1 stated he attended the IDG meetings usually once or twice a month. MD1 stated, ";Sometimes they want to do it a second time a month, its usually every 2-3 weeks just in case someone cant make it. We try to do it at least once a month." A review of facilitys policy and procedure titled, ";Admission Criteria and Process" revised 4/2021, indicated Eligibility criteria will be continually reviewed on an ongoing basis by the interdisciplinary team to assure appropriateness of hospice care." A record review of the HAs policy and procedure titled, ";Patient Admission Criteria" revised 6/2019, indicated ";Care follows a written plan of are established by the IDG and reviewed at least every 15 days and IDG." A review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised April 2021, indicated ";1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including as least the following information, as relevant: The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days. If no changes are needed, then that must be documented. If there has been a change in the patients condition/status, then the comprehensive assessment must be updated." A review of facilitys policy and procedure titled ";Interdisciplinary Group Meeting" revised 4/2021, indicated ";The patient's plan of care will be updated no less frequently than every 15 days or more frequently if the patient's condition requires: social, cultural, and physical environments presenting obstacles to effective intervention; integration of alternative therapies into medical regime to assist in effectiveness; and any special needs of the patient. 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."

Based on interview and record review the Hospice Agency (HA) failed to ensure all care services furnished followed individualized plans of care (POC – an individualized plan that maps out the needs and services supplied to patient and their care givers) established be the interdisciplinary team (IDT) by not conducting home visits as indicated in the plan of care for three of fourteen sampled patients (Patient 8, Patient 9, and Patient 12 ). This deficient practice resulted in the patients not receiving care/services from the home visits and placed the patients at risk by not being provided care/services when they needed. --- Findings: A record review of Patient 8s ";Personal Information", indicated a Start of Care (SOC) date of 4/15/2023 with a primary diagnosis including heart disease unspecified. A record review of Patient 8s medical record form titled ";POC Summary" indicated ";Frequency of Visits ... SN (skilled nurse) 1 per week..." During a record review on 10/23/2023, at 7:21 p.m., of Patient 8s Electronic Medical Record (EMR) medical record form titled ";Visit Notes" indicated there was no documentation of a visit note written on the week of 6/18/2023. During a concurrent interview and record review on 10/25/2023, at 11:30 a.m., with the Director of Nurses (DON) for Patient 8s EMR medical record form titled ";Visit Notes" DON stated Patient 8 had a Skilled Nurse (SN) visit frequency of 1x/wk (one time/visit per week). DON stated, ";When there is a missed visit, the LVN calls us to tell us the reason for the missed visit, and we document on the communication log. We try to call the patient and communicate to reschedule for the same week. There is nothing documented in the communication." DON stated it was important for staff to be aware of patients missed visits because patients need to be monitored and the HA needs to provide the services stated on the patients POC. A record review of Patient 9s ";Personal Information", indicated a Start of Care (SOC) date of 4/2/2023 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. A record review of Patient 9s medical record form titled ";POC Summary" indicated ";Frequency of Visits ... LVN (License Vocational Nurse) 1 per week..." During a record review on 10/23/2023 at 8:05 p.m. of Patient 9s EMR medical record form titled ";Visit Notes" indicated there was no documentation of a visit note written on the week of 6/18/2023. A record review of Patient 12s ";Personal Information", indicated a Start of Care (SOC) date of 3/11/2023 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. A record review of Patient 12s medical record form titled ";POC Summary" indicated ";Frequency of Visits ... RN 1 per week + 3 PRN (as needed) visits..." During a record review on 10/23/2023 at 8:50 p.m., of Patient 12s EMR medical record form titled ";Visit Notes" indicated there were no documentation of a visit notes written for weeks 2/5/2023, 3/19/2023, 4/9/2023, 8/6/2023, 10/8/2023, and 10/15/2023. During a concurrent interview and record review on 10/26/2023 at 1:12 p.m., with the Director of Nurses Designee (DD) or Patient 12s EMR medical record form titled ";Visit Notes" DD stated Patient 12 had RN (Registered Nurse) visit frequency of 1x/wk. DD stated, ";I dont see their documentation under the communication notes there is nothing that state why there were missed visit for those days." DD stated that nurses are to document their visit notes as soon as possible. DD usually stated a doctors order is placed in the patients EMR when a patient refuses a visit. DD stated there were no orders written. DD stated, ";The nurse has to call the office or MD and tell the reason why, then the POC, there should be an order of the missed visit." A review of facilitys policy and procedure titled ";Interdisciplinary Group Meeting" revised 4/2021, indicated ";An interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes, which may include Increases or decreases in frequency of visits by team members and reason for the change. Missed visits by aides and staff will be explained and adjustment to the POC will be made if appropriate." A review of facilitys policy and procedure titled ";Nursing Services" undated, indicated ";If any RN/ L VN missed visits notify MD to reason for missed visit and do a new MD order for the resumption of visit." A review of facilitys policy and procedure titled ";Admission Criteria and Process" revised 4/2021, indicated ";Provide services as needed and ordered by physician (or other authorized independent practitioner), and incorporate additional needs into the hospice plan of care." A review of facilitys policy and procedure titled ";Patient Admission Criteria" revised 6/2019, indicated ";Care follows a written plan of care established by the IDG..." A review of facilitys policy and procedure titled, ";The Plan of Care" revised 4/2021, indicated ";The Plan of Care will identify the patients needs and services to meet those needs... 8. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments... 14. Care provided to the patient will be in accordance with the plan of care."

Based on interview and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for Core Services as follows: --- 1. The HA failed to ensure a Registered Nurse provided supervision to Licensed Vocational Nurses to ensure three of fourteen sampled patients (Patient 8, Patient 9, and Patient 11) 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) were followed to address patient concerns. (Refer to L591). 2. The HA failed to follow its policy and procedure regarding conducting a bereavement follow-up assessment with the bereaved family, for two of fourteen sampled patients, (Patient 7 and Patient 14), that were deceased. (Refer to L596). 3. The HA failed to ensure one of fourteen sampled patients (Patient 10) received initial spiritual counseling assessments to meet Patient 10's spiritual needs. (Refer to L598). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations to ensure Core Services were provided to all the patients.

Based on interview and record review, the Hospice Agency failed to ensure a Registered Nurse provided supervision to Licensed Vocational Nurses to ensure three of fourteen sampled patients (Patient 8, Patient 9, and Patient 11) 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) were followed to address any patient concerns. This deficient practice had the potential to result in the hospice agency not able to reassess the quality of care and services provided by the nursing personnel, the potential that patient concerns regarding nursing services were not monitored, addressed, and resolved, and could affect the quality of care and services provided to the patients under the hospice agencys care. --- (a) During a review of Patient 8s Personal Information record, the Personal Information record indicated a Start of Care (SOC) date of 4/15/2023 with a primary diagnosis including heart disease unspecified (any condition that affects the structure or function of the heart). During a review of Patient 8s undated 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) Summary, the POC Summary indicated skilled Nurse (SN) had a frequency of one visit per week. During a record review on Patient 8s History of Nursing Assessment, dated 7/15/2023, 8/12/2023, 9/9/2023, and 10/7/2023, the section ";Supervisory Note – LVN Name" in the History of Nursing Assessment was left blank. During a concurrent interview and record review, on 10/25/2023, at 11:30 a.m., with the DON, on Patient 8s EMR medical record form titled ";History of Nursing Assessment", the DON stated, ";SN supervisory visit needs to be completed monthly, to make sure the nurses are doing their job according to their POC. Also, to see if they have any concerns." The DON stated Patient 8s SN supervisory notes were not completed. (b) A record review of Patient 9s ";Personal Information", indicated a Start of Care (SOC) date of 4/2/2023 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. A review of Patient 9s medical record form titled ";POC Summary" indicated LVN had a frequency of one visit per week. During a record review on Patient 9s EMR medical record form titled ";History of Nursing Assessment" dated 7/9/2023, 8/6/2023, 9/3/2023, 9/17/2023, and 10/1/2023, indicated section ";Supervisory Note" were left blank, except for LVN1s name. During a concurrent record review and interview on 10/25/2023 at 11:45 a.m., with DON, of Patient 9s EMR medical record form titled ";History of Nursing Assessment", the DON stated the supervisory visits are important to assess the LVNs monitoring, reporting, communication and to demonstrate they are providing the correct services as outlined in the patient POC. (c ) A record review of Patient 11s ";Personal Information", indicated a Start of Care (SOC) date of 11/21/2022 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. A review of Patient11s medical record form titled ";POC Summary" indicated LVN had a frequency of one visit per week. During a concurrent record review and interview on 10/25/2023 at 1:07 p.m. with DON of Patient 11s EMR medical record form titled ";History of Nursing Assessment" DON stated LVN supervisory notes was not completed monthly. A review of facilitys undated policy and procedure titled ";Nursing Services", indicated, ";Nursing care will be provided in accordance with the patient's IDG plan of care, under the supervision of a registered nurse. Professional nursing service will be provided by a registered nurse and include Supervising L VN/LPNs and paraprofessionals providing services at least every 30 days: Home visit with or without LVN/LPN present.

Based on interview and record review, the Hospice Agency failed to follow its policy and procedure on conducting a bereavement (loss of a loved one) follow-up assessment with the bereaved family, for two of fourteen sampled patients, (Patient 7 and Patient 14), that were deceased. This failure resulted in the patients' family and/or caregivers bereavement need (emotional, psychological, and spiritual) not being supported by the hospice agency. --- (a ) A record review of Patient 7s ";Personal Information", indicated a start of care date of 6/3/2023 and an end of care date of 7/5/2023, with a primary diagnosis of senile degeneration of brain, not elsewhere classified. During an interview on 10/26/2023, at 12:25 p.m., the Administrator/Spiritual Counselor (ADM/SC) stated its the Medical Social Worker (MSW) who follows up with the family once the patient had passed away. The ADM/SC stated her responsibility was to document what the plan was. During an interview on 10/26/2023, at 12:26 p.m., the Director of Nurses (DON) stated she could not find the documentation to indicate the MSW had followed up with Patient 7s family after the death. The DON stated that MSW follow up after the patients death was important to make sure the patients family was provided services post death, to assess whatever their needs were, and what resources can be offered to the family. During an interview on 10/26/2023, at 12:27 p.m., the DON stated she could not find evidence that MSW/ spiritual care follow up was conducted on the bereaved family. The DON stated the spiritual counselor should have followed up to make sure the needs of the family/loved ones that were left behind were met and could have offered guidance and resources. The DON stated if services were not offered by the spiritual counselor and MSW, the grieving family would think there were no support for them, and the hospice agency (HA) had left them alone. b). A record review of Patient 14s ";Personal Information", indicated a Start of Care (SOC) date of 2/20/2023 and an End of Care (EOC) date of 3/5/2023, with a primary diagnosis including senile degeneration of brain, not elsewhere classified. During a record review on 10/23/2023, at 9;03 p.m., of Patient 14s Electronic Medical Record (EMR) form titled ";Post-Death Bereavement Support", the form was not filled out. During a concurrent interview and record review on 10/25/2023, at 12:47 p.m., with the ADM/SC of Patient 14s EMR form titled ";Post-Death Bereavement Support", the ADM/SC stated the Post-Death Bereavement Support form was not filled out and that she did not document the post bereavement assessment. The ADM/SC stated documentation was the proof that the post bereavement was completed. A review of facilitys undated public brochure, indicated ";we specialize in spiritual and emotional support... Chaplains provide spiritual support for you and your loved ones." A review of facilitys undated policy and procedure titled, ";Bereavement / Postmortem Care", indicated ";Hospice staff will coordinate the patients care through dying and death." A review of facilitys policy and procedure titled, ";Bereavement Assessment", revised April 2021, indicated ";after the death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment. The Bereavement Coordinator will develop a plan for intervention based on the findings of the bereavement follow-up assessment."

Based on interview and record review, the Hospice Agency failed to ensure two of fourteen sampled patients (Patient 10 and Patient 13) received initial spiritual counseling assessments to meet their spiritual needs. This failure had the potential to place patients at risk of not receiving the care in accordance with their spiritual beliefs and desires. --- a ) A record review of Patient 10s ";Personal Information", indicated a Start of Care (SOC) date of 10/9/2023 with a primary diagnosis including heart failure, unspecified. A review of facilitys form titled ";Audit Log" dated 10/22/2023 to 10/25/2023, indicated the Administrator/Spiritual Counselor (ADM/SC) logged into Patient 10s Electronic Medical Record (EMR) on 10/25/2023. It also indicated ";module – Spiritual Assess..." was created on 10/25/2023 with a visit date of 10/9/2023. During a concurrent interview and record review on 10/23/2023, at 10:36 a.m., with the Director of Nurses Designee (DD) of Patient 10s Electronic Medical Record (EMR) form titled, ";History of Spiritual Assessment", did not indicate any documentation. The DD stated the initial spiritual assessment should have been completed within five days of admission. During a concurrent interview and record review on 10/25/2023, at 12:47 p.m., with the ADM/SC, of Patient 10s EMR form titled ";History of Spiritual Assessment", the form was blank. The ADM/SC stated she was supposed to ask the patient within one month of SOC if they reconsidered a spiritual assessment. The ADM/SC stated, ";Once they decline, I should call them every month to see if they would like to reconsider." The ADM/SC stated, ";there is nothing documented." b) A record review of Patient 13s ";Personal Information", indicated a Start of Care (SOC) date of 4/22/2022 and an End of Care (EOC) date of 12/8/2022, with a primary diagnosis including hypertensive (high blood pressure) heart disease, unspecified. During a record review on 10/23/2023, at 8:55 p.m., of Patient 13s EMR form titled ";History of Spiritual Assessment", indicated nothing was documented. During a concurrent interview and record review on 10/25/2023, at 12:35 p.m., with the Director of Nurses (DON) of Patient 13s EMR medical record form titled ";History of Spiritual Assessment" indicated, nothing was documented. The DON stated if a patient declines spiritual services, the staff need to document the refusal. DON stated they need to offer all their services at every recertification. During an interview on 10/25/2023, at 12:47 p.m., with the ADM/SC, the ADM/SC stated she completed the initial spiritual assessment within five days of SOC, as needed and at every recertification. The ADM/SC stated the spiritual assessment was important to be completed to provide the spiritual support to the patient and the family. A review of facilitys undated public brochure, indicated, ";We specialize in spiritual and emotional support... Chaplains provide spiritual support for you and your loved ones." A review of facilitys policy and procedure titled, ";Spiritual Assessment", revised April 2021, indicated ";a spiritual assessment will be completed for each patient/family by the Hospice Chaplain. The in-depth spiritual assessment will be performed by the Hospice Chaplain. After the spiritual assessment is performed, ongoing contact will be maintained by phone and/or home visits by the Hospice Chaplain... If the patient and/or family/caregiver refuse these services, the refusal will be documented. The interdisciplinary group members will continue to assess for spiritual needs and offer appropriate services to the patient and/or family/caregiver." A review of facilitys policy and procedure titled, ";Initial Assessment", dated May 2023, indicated ";Admitting registered nurse will determine the other disciplines to complete the appropriate sections of the comprehensive assessment based on identified problems and needs during this initial assessment."

Based on interview and record review the Hospice Agency (HA) failed to conduct a Certified Home Health Aide (CHHA) supervisory visit every 14 days to one of fourteen sampled patients (Patient 11). This failure had the potential to result in patients being taken care of by an unqualified CHHA. --- Findings: A record review of Patient 11s ";Personal Information", indicated a Start of Care (SOC) date of 11/21/2022 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. A record review of Patient 11s medical record form title ";POC Summary" indicated Patient 11s CHHA visit frequency was 3 per week. A record review on 10/23/2023, at 8:32 p.m., of Patient 11s Electronic Medical Record (EMR) medical record form titled ";History of Nursing Assessment" indicated supervisory visits were conducted on 1/18/2023, 3/21/2023, and 9/13/2023. During a telephone interview on 10/24/2023, at 4:31 p.m., with Patient 11s Care Giver 1 (CG1), CG1 stated the HA was providing staff to assist Patient 11 in bathing. During a concurrent interview and record review on 10/25/2023, at 1:07 p.m., with the Director of Nurses (DON) of Patient 11s EMR medical record form titled ";History of Nursing Assessments" DON stated that not all the CHHA supervisory visits were done. During a concurrent interview and record review on 10/26/2023, at 10:58 a.m., with the DON of Patient 11s EMR medical record form titled ";History of Nursing Assessments" DON stated supervisory visits should be completed at least once a month. DON stated it was important to complete. DON stated ";We need to make sure the services they are providing are based on the POC. At least once a month." A review of facilitys policy and procedure titled, ";Hospice Aide Supervisory Visits" revised 4/2021, indicated ";The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days."

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions].and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources programs] for Medical Director was met as follows: --- 1. The HA failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) reviewed patients clinical information to determine hospice (health care that focuses on the palliation [specialized medical care for people living with a serious illness] of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care criteria was met and/or provide an initial written certification that the patient had six months or less to live if the illness runs its normal course for eight of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, and Patient 11). (Refer to L 667). 2. The HA failed to ensure the medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 8 Patient 9, and Patient 11). (Refer to L 668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory (a written law or regulation) mandated compliance with Federal (government) regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) reviewed patients clinical information and current health condition to determine hospice (health care that focuses on the palliation [specialized medical care for people living with a serious illness] of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life), care criteria was met and complete an initial written certification that the patient had six months or less to live if the illness runs its normal course, for eight of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, and Patient 11). This deficient practice resulted in the patients being admitted for hospice care without a written clinical information reviewed and evaluated by the Medical Director to support the terminal illness diagnoses. --- Findings: a. A record review of Patient 1s ";Personal Information", indicated a start of care (SOC) date of 10/26/2022, with a diagnosis of heart disease, unspecified. During a home visit and an interview on 10/24/2023, at 10:20 a.m., at Patient 1's home, Patient 1 stated she did not know what hospice care was. Patient 1 stated ";no" when asked if she had a terminal disease. Patient 1 stated no doctor had told her that she has 6 months or less to live. Patient 1 stated the doctor would tell her that she was doing good every time she went to the doctor. Patient 1 stated she did not use oxygen for breathing, able to talk without shortness of breath, and did not felt pain or discomfort while lying in her bed. During a concurrent interview and record review on 10/25/2023, at 11:17 a.m., with Director of Nurses Designee (DD), Patient 1s ";Comprehensive Nursing Assessment", dated 10/26/2022 was reviewed. DD stated the Local Coverage Determination (LCD, a tool used for criteria to hospice care) indicated Patient 1 qualified for hospice care because she was ";optimally treated for heart disease with diuretics (medications to get rid of excess water from the body) and vasodilators (medications used to lower blood pressure)", had congestive heart failure and met the criteria for New York Heart Association (NYHA-used to classify patients with heart failure) level of 4 (severe limitations. Experiences symptoms even at rest, mostly bed bound patients), and she had history of unexplained fainting. DD stated the HA had no documentations to support the classification of NYHA 4 of heart failure, During a concurrent interview and record review on 10/26/2023, at 12:37 p.m., the Director of Nurses (DON) reviewed Patient 1s ";Physicians Certification for Hospice Benefit" Certification of Terminal Illness (CTI, is the narrative summary, 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), for certification period 10/26/2022 to 1/23/2023. The record indicated the doctor wrote Patient 1 had NYHA 4 heart failure, dependent on multiple activities of daily living (ADL) and got assistance from her family. The DON stated the doctor who certified Patient 1 was no longer working at the HA. The DON stated there was no documented evidence Patient 1 had NYHA level 4 heart failure. There was no documented evidence the CTI had supportive evidence of Patient 1s heart failure to validate an admission to hospice care. b. A record review of Patient 2s ";Personal Information", indicated a start of care date of 11/11/2022, with a primary diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a condition where the heart muscle becomes weak and can't pump blood and oxygen around the body). During an interview on 10/24/2023, at 3:34 p.m., with Patient 2s caregiver (CG 5), CG5 stated she did not know what hospice care was. When CG 5 was asked if a doctor had diagnosed Patient 2 with a terminal illness with a life expectancy of 6 months or less, CG 5 stated ";no". CG 5 stated in Spanish, ";no, no se esta muriendo" (no, hes not dying). During a concurrent interview and record review on 10/25/2023, at 12:23 p.m., DD reviewed Patient 2s ";Comprehensive Assessment", dated 11/11/2022. DD stated the LCD indicated Patient 2 qualified for hospice care because he was optimally being treated for heart disease with diuretics and vasodilators, was unable to be on vasodilators due to medical condition and he had heart failure NYHA level 4. DD stated the LCD was not completed correctly because Patient 2 was not on diuretics, and he did not have a medical condition that he cannot have a vasodilator. During a concurrent interview and record review on 10/25/2023, at 12:35 p.m., DD reviewed Patient 2s ";Comprehensive Assessment", dated 11/11/2022. DD stated there was no evidence Patient 2 had congestive heart failure, or NYHA level 4. DD stated the LCD was not completed correctly because Patient 2 did not have heart failure. During an interview on 10/25/2023, at 12:40 p.m., DD stated there were no documentation, diagnostic tests and supporting documentation of Patient 2s diagnosis of hypertensive heart disease. A record review of Patient 2s record titled, ";Physicians Certification for Hospice Benefit", for certification period 11/11/2022 to 2/8/2022, indicated the physician wrote Patient 2 had a diagnosis of ";heart disease without heart failure...NYHA IV (4) ..." During an interview on 10/25/2023, at 4:05 p.m., with Patient 2s Primary Care Physician (PCP 2), PCP 2 stated she was Patient 2's PCP2 for ";many, many years". PCP 2 stated the last visit with Patient 2 was on 8/17/2023. PCP 2 stated Patient 2 had Alzheimers disease (affects memory) but was stable because he was following his treatment plan. PCP 2 stated she was surprised to learn that Patient 2 was in hospice care. PCP 2 stated she was not aware Patient 2 was in hospice care because Patient 2 has no terminal illness and has a life expectancy greater than 6 months. PCP 2 stated she did not refer Patient 2 to hospice care. There was no documented evidence the CTI had supportive evidence of Patient 2s heart failure to validate an admission to hospice care. c). A record review of Patient 3s ";Personal Information", indicated a star of care date of 12/30/2021, with a primary diagnosis of hypertensive heart disease without heart failure. During a concurrent interview and record review on 10/25/2023, at 12:57 p.m., DD reviewed Patient 3s ";Comprehensive Assessment", dated 12/30/2021. DD stated the LCD indicated Patient 3 qualified for hospice care because she had declined surgical procedures, had congestive heart failure NYHA level 4, and had history of unexplained fainting. DD stated there were no documentation that Patient 3 was offered surgical procedures, and no documentation that Patient 3 declined surgical procedures, there was no diagnostic results, to support the findings documented on the LCD. DD stated there was no clinical information to support a diagnosis of congestive heart failure. Patient 3 did not have edema (swelling) or signs of congestive heart failure. During an interview on 10/26/2023, at 10:40 a.m., with Patient 3s care giver (CG 6), CG 6 stated Patient 3 has no terminal illness and did not have a life expectancy of 6 months or less to live. CG 6 stated, ";if a doctor told me that, I think I would have remembered that. That is not something you forget." A record review of Patient 3s document titled, ";Physicians Certification for Hospice Benefit", for certification period 12/30/2021 to 3/29/2022, indicated the physician wrote Patient 3 had ";hypertensive heart disease without heart failure...NYHA IV (4). There was no documented evidence the CTI had supportive evidence of Patient 3s heart failure to validate an admission to hospice care. d). A record review of Patient 4s ";Personal Information", indicated a Start of Care date of 9/21/2023 with a primary diagnosis of malignant neoplasm (an abnormal cells grow, multiply and spread to other parts of the body) of unspecified site of left female breast. During a concurrent interview and record review on 10/26/2023, at 12:30 p.m. the DON reviewed Patient 4s ";Comprehensive Assessment", dated 9/21/2023. Comprehensive Assessment indicated Patient 4 qualified for hospice care because she had a suspicious large tumor and refused to get a definitive diagnosis, she declined in functional status, and had significant, unintentional weight loss. The DON stated the HA did not have supporting documentation that Patient 4 had breast cancer. When the DON was asked how the agency determined the diagnosis of ";malignant neoplasm of unspecified site of left female breast" if patient did not want to be diagnosed, the DON stated, ";I dont have an answer for that". During a concurrent interview and record review on 10/26/2023, at 1:28 p.m., the Medical Director (MD 1) reviewed Patient 4s ";Physicians Certification for Hospice Benefit" (CTI), for certification period 9/21/2023 to 11/19/2023. The CTI indicated, ";Physician Narrative: Diagnosis of breast cancer, recent hospitalization due to nausea/vomiting...disease course not expected to improve. Patient remains hospice appropriate". MD 1 stated he obtained Patient 4s information from the previous CTIs, the onsite nursing assessment, and patient history. MD 1 stated he did not need to include all the information about her breast cancer in the current CTI because it was documented previously in the other CTIs. MD 1 stated Patient 4s record did not have documents about her previous oncologist (cancer doctor) and medical treatments. There was no documented evidence Patient 4s CTI had documented evidence of Patient 4s breast cancer to validate an admission to hospice care. e). A record review of Patient 8s ";Personal Information", indicated a Start of Care (SOC) date of 4/15/2023 with a primary diagnosis including heart disease unspecified. A record review of Patient 8s ";LCD dated 4/15/2023, indicated ";Heart Disease (1 and 2 must be met) – 2.a. Does this CHF (Congestive Heart Failure – weaken heart condition that cause fluid buildup) or angina patient meet the criteria for NYHA (New York Heart Association – describes functional classification) Class IV (unable to carry out physical activity without discomfort) level? Yes". A record review of Patient 8s ";Physician Certification For Hospice Benefit – Statement for First 90-day period" dated from 4/15/2023 to 7/13/2023, indicated ";Terminal Diagnosis – Heart Disease, Unspecified". The Physician 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." It also indicated Medical Director 2 (MD2) was the referring physician and singed the form electronically. A record review of Patient 8s ";Physician Certification For Hospice Benefit – Certification #1: Statement for First 90-day period." indicated ";Certification is based on: Face to Face encounter." The ";NYHA IV" indicated ";Based on the MD face to face encounter and RN assessment, patient meets the LCD guidelines for hospice and is appropriate for hospice services. Patient has a medical prognosis of 6 months or less if the terminal illness runs its normal course." Lastly form indicated it was signed by MD2 with ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." During a joint home visit on 10/24/2023, at 10:15 a.m., with the Director of Nurses (DON) to Patient 8s home, DON stated she conducts the supervisory visits for Patient 8. Patient 8s care giver (CG2) opened the door and asked us to wait in Patient 8s bedroom. Patient 8 was observed ambulating with walker to room, sat at edge of bed by self. CG2 stated Patient 8 s insurance (IS) sends a doctor (NP1), a social service (SS) and a social worker (SW) monthly. CG2 stated NP1 was there in the morning, assessed Patient 8, checked Patient 8s medication and took Patient 8s blood. CG2 and Patient 8 stated they have never been told that Patient 8 had six months or less to live. During a telephone in interview on 10/24/2023, at 11:15 a.m., with Patient 8s care giver 3 (CG3), CG3 stated that neither him or his mother has ever been told that Patient 8 had six months or less to live. CG3 stated ";I knew she needed help after her fall because she was unable to cook or do anything like that. I dont know how she got involved in a hospice program, maybe because she needed help but not because she was or is dying." During a telephone interview on 10/25/2023, at 9:48 a.m., with Patient 8s insurance representative (IR), IR stated that Patient 8 has been seen by NP1 since Patient 8s release from the hospital in April 2023. IR stated that NP1 oversees Patient 8s medications and blood draws. IR stated he does not see any referrals for hospice services. During a concurrent interview and record review on 10/25/2023, at 11:30 a.m., with the Director of Nurses (DON) of Patient 8s Electronic Medical Record (EMR) DON stated Patient 8 was not incontinent, Patient 8 did not use oxygen, Patient 8 was not a hospice patient based on her home visit yesterday and will be most likely discharged. DON stated she received a call from the Administrator/ Spiritual Counselor (ADM/SC) asking her to complete an initial evaluation. DON stated she evaluated and assessed Patient 8, then called the HA and gave the report to the ADM/SC and was told to document her findings. DON stated she does not speak to the doctors directly. DON stated ADM/SC ";has the direct contact with all the doctors". During a concurrent interview and record review on 10/26/2023 at 10:15 a.m. with ADM/SC of Patient 8s EMR, ADM/SC stated that she was unaware how or who referred Patient 8 to hospice, it was not documented. ADM/SC stated that she learned about Patient 8 when DON called the office to report her assessment findings. During a concurrent interview and record review on 10/25/2023, at 1:46 p.m., with the Medical Director 1 (MD1) of Patient 8s EMR form titled ";Physician – CTI" MD1 stated he did not know how Patient 8 was referred to hospice. MD1 stated that his care begins when he receives a call from Volunteer (VT) with possible admits. MD1 stated he did not know Patient 8 was being followed by NP1. During a concurrent interview and record review on 10/26/2023, at 12:30 p.m., with the Director of Nurses Designee (DD) of Patient 8s EMR medical record form titled ";LCD" dated 4/15/2023, DD stated ";According to the nurse documentation the patient does not meet the qualifications for NYHA IV." f). A record review of Patient 9s ";Personal Information", indicated a Start of Care (SOC) date of 4/2/2023 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. A record review of Patient 9s ";LCD" dated 4/2/2023, indicated ";Heart Disease (1 and 2 must be met) – 2.a. Does this CHF (Congestive Heart Failure – weaken heart condition that cause fluid buildup) or angina patient meet the criteria for NYHA Class IV level? Yes". A record review of Patient 9s ";Physician Certification For Hospice Benefit – Statement for First 90-day period" dated from 4/2/2023 to 6/30/2023, indicated ";Terminal Diagnosis – Hypertensive heart disease without heart failure". Form also 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." It also indicated Medical Director 3 (MD3) was the referring physician and signed the form electronically. A record review of Patient 9s ";Physician Certification for Hospice Benefit – Certification #1: Statement for First 90-day period." Form also indicated ";NYHA IV". It also indicated ";Patient may not last 6 months if the disease runs its normal course." Lastly form indicated it was signed by MD3 with ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." During a concurrent interview and record review on 10/26/2023, at 9:30 a.m., with MD3 of Patient 9s EMR, MD3 stated most of the information he gets from the nurses assessment. MD3 stated he does not use the LCD to determine hospice eligibility. MD3 stated ";I tell nurses to document NYHA IV because that is the level acceptable to hospice." MD3 stated he does not have information such as a diagnostic report for Patient 9s heart disease. During an interview on 10/24/2023 ,at 4:10 p.m., Patient 9 was asked if she knew what hospice services were. Patient 9 stated they brought supplies and sent a nurse to check on me. Patient 9 also stated she was never told that she had six months or less to live by any doctor. Patient 9 stated ";There has never been a doctor that has told me that I was going to die, not even when I was diagnosed with cancer, 16 years ago, melanoma stage III." Patient 9 stated she has a primary doctor, which she saw last in September 2023. Patient 9 stated that she ambulates without assistance, take showers without assistance, and takes her medication by herself and that she does not use diapers. During a concurrent interview and record review on 10/25/2023, at 11:45 a.m., with the DON of Patient 9s EMR DON stated she received a call from ADM/SC asking her to do a home visit and report my assessment findings. DON stated ADM/SC then calls MD, then calls her back to document Patient 9s assessment in the EMR. During a concurrent interview and record review on 10/25/2023, at 12:15 a.m., with the Chief Financial Officer (CFO) of Patient 9s EMR, CFO stated ";It is not documented how she started our services." g). A record review of Patient 10s ";Personal Information", indicated a Start of Care (SOC) date of 10/9/2023 with a primary diagnosis including heart failure, unspecified. A review of Patient 10s ";Physician Certification for Hospice Benefit" dated 10/9/2023 to 12/07/2023, indicated sections ";Physician Narrative" and ";Medical Director – Signature" were left blank. A review of facilitys form titled ";Audit Log" dated 10/22/2023 to 10/25/2023, indicated module ID #1625586 was assigned to module ";Certification MD". Form also indicated the DON accessed Patient 10s EMR medical record form titled ";Certification MD – Physician Narrative: Certifying Physician Summary" on 10/23/2023 3:32:23 p.m. and added the physician narrative onto module ";Certification MD - 1625586". It also indicated module #1625586 was electronically signed by MD1 on 10/20/2023 11:29:41 a.m. During an interview on 10/26/2023, at 10:15 a.m., with ADM/SC, ADM/SC stated she received a call from Patient 10s friend asking to be admitted for hospice services. During an interview on 10/26/2023, at 11:19 a.m., with the CFO, CFO stated Patient 10 is self-referred. CFO stated HA did not receive Patient 10s history and physical. During an interview on 10/26/2023, at 12 p.m., with DD, DD stated that she received a call from VT informing her of a new referral. DD stated she visited Patient 10 and completed her nursing assessment. DD stated she then called ADM/SC and VT to inform them she had admitted Patient 10. DD stated she did not speak with any doctor regarding Patient 10. DD stated she was unaware of who spoke with MD1 about Patient 10 admission, ADM/SC, or VT. h). A record review of Patient 11s ";Personal Information", indicated Patient 11 had a Start of Care (SOC) date of 11/21/2022 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. A record review of Patient 11s ";LCD" dated 11/21/2022, indicated ";Heart Disease (1 and 2 must be met) – 2.a. Does this CHF (Congestive Heart Failure – weaken heart condition that cause fluid buildup) or angina patient meet the criteria for NYHA Class IV level? Yes". A record review of Patient 11s ";Physician Certification For Hospice Benefit – Certification #5: Re-Certification Statement for Next 60-day period" dated from 11/21/2022 to 1/19/2023, indicated ";Terminal Diagnosis – Hypertensive heart disease without heart failure". Form also 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." It also indicated Medical Director 2 (MD2) was the referring physician and singed the form electronically. A record review of Patient 11s ";Physician Certification For Hospice Benefit – Certification #5: Statement for Next 60-day period." Form also indicated ";Certification is based on: Face to Face encounter." Form also indicated ";NYHA IV". It also indicated ";I certify that (P11) has a life expectance of six months or less, if the terminal illness runs its normal course." Lastly form indicated it was signed by MD2 with ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." During a telephone interview on 10/24/2023, at 4:31 p.m., with Patient 11s Care Giver 1 (CG1), CG1 stated hospice services for Patient 11 included a nurse that came to bathe her and provided diapers and Ensure. CG 1 stated they were told by the HA that they would were going to stop their services because Patient 11 had been with them for about two years. CG1 stated Patient 11 did have a primary physician (PCP1), which Patient 11 saw within this past year. CG1 stated Patient 11 has never been told that she had six months or less to live. During an interview on 10/24/2023, at 4:40 p.m., with PCP1s Nurse (PN1), PN1 stated Patient 11 saw PCP1 on June 2, 2023. PN1 stated that PCP1 had not referred or given orders for hospice services for Patient 11. During an interview on 10/26/2023, at 10:15 a.m., with ADM/SC, ADM/SC stated ";The doctor needs to be logged into (EMR) to be aware that they have a new patient. During an interview on 10/26/2023, at 11:19 a.m., with the CFO, CFO stated all the sample patients are self-referred and does not have their H&P (History & Physical). A review of facilitys policy and procedure titled, ";Admission Criteria and Process" revised 4/2021, indicated ";The patients life-limiting illness and prognosis of six (6) months of less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCD). 1. (HA) will admit a patient only on recommendation of the medical director in consultation with, or input from the patients attending physician... 3. The patient must have a life-limiting illness with a life expectancy of six (6) moths or less, as determined by the attending physician... utilizing standard clinical prognosis criteria in the organizations intermediary Local coverage Determination. 4. The patient must desire hospice services and be aware of the diagnosis and prognosis." A review of facilitys policy and procedure titled, ";Certification of Terminal Illness" revised 4/2021, indicated ";When certifying the patient as terminally ill, the hospice medical director...or physician designee must consider at least the diagnosis of the terminal condition of the patient, other health related conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. At the time of admission to hospice, the hospice Medical Director... or the patients attending physician will complete a certification narrative that reflect the patients individual circumstances based on: his/her review of the patients medical record... Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. Tools such as the fiscal intermediarys Local Coverage Determination, along with other supporting documentation, can be used to provide guidance in determining and documenting terminal prognosis." A review of facilitys policy and procedure titled ";Interdisciplinary Group Meeting" revised 4/2021, indicated ";Patient approaching recertification will be reviewed for the appropriateness of continuation of care based on identifiable criteria and progression of the terminal illness."

Based on observation, interview, and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs for recertification of terminal illness for continued hospice care and services, for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 8 Patient 9, and Patient 11). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and services for the management of terminal illness and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life. --- Findings: a. A record review of Patient 1s ";Personal Information", indicated a start of care date of 10/26/2022, with a primary diagnosis of heart disease, unspecified. During a home visit conducted on 10/24/2023, at 10:20 a.m., at Patient 1's home and an interview, Patient 1 stated that she did not know what hospice care was. Patient 1 stated she had no terminal disease (an advanced stage of a disease with an unfavorable prognosis and no known cure). Patient 1 stated the physician did not tell her that she had 6 months or less to live. During a concurrent interview and record review on 10/26/2023, at 8:54 a.m., with the Medical Doctor (MD3), Patient 1s ";Physicians Certification for Hospice Benefit" certification of terminal illness (CTI, is the narrative summary, 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), for certification dates 1/24/2023 to 4/23/2023 was reviewed. MD 3 stated Patient 1s Congestive Heart Failure (CHF, a long-term condition in which the heart can't pump blood well enough to meet your body's needs) diagnosis was determined from reviewing previous documents written by the hospice doctor, medical record form, and the documentation about edema and shortness of breath. MD 3 stated he used the information from the physical assessment done by the nurse to re-certify the patient for hospice care. During a concurrent interview and record review on 10/26/2023, at 9 a.m., with MD3 of Patient 1s ";Physicians Certification for Hospice Benefit" CTI, for certification dates 4/24/2023 to 6/22/2023 were reviewed . Patient 1s ";Physicians Certification for Hospice Benefit" CTI, under Physician Narrative, indicated ";See Attached file". The attached file was titled, ";History and Physical-Progress Note/Face to Face Encounter". The ";Attestation Statement" section were blank and has no documented information, MD 3 stated the attestation should have been included in the note. During a concurrent interview and record review on 10/26/2023, at 12:40 p.m., the Director of Nursing (DON) reviewed Patient 1s ";Physicians Certification for Hospice Benefit" (CTI), for certification dates 1/24/2023 to 4/23/2023. The DON stated, Patient 1s ";Physicians Certification for Hospice Benefit" (CTI) did not have any supporting objective information to validate Patient 1s diagnosis of CHF. During a concurrent interview and record review on 10/26/2023, at 12:42 p.m., Medical Director 1 (MD 1) reviewed Patient 1s ";Physicians Certification for Hospice Benefit" (CTI), for certification dates 6/23/2023 to 8/21/2023. MD 1 stated he recertified Patient 1 for hospice care because Patient 1 needed a lot of help with ADLs, and was experiencing worsening pulmonary symptoms. MD 1 stated the evidence he used to classify Patient 1s NYHA level 4 was due to shortness of breath on rest and history of heart disease. MD 1 stated a lab test called ";probnp" used to support heart failure, along with a heart ultrasound. MD 1 stated the ";probnp" and heart ultrasound information was provided by ";qualified staff"(unknown). MD 1 stated, ";we just take their word for it". MD 1 stated he could not find information of laboratory tests for Patient 1 to support heart failure. During a concurrent interview and record review on 10/26/2023, at 12:55 p.m., MD 1 reviewed Patient 1s ";Physicians Certification for Hospice Benefit" (CTI), for certification dates 8/22/2023 to 10/20/2023. The ";Physician Narrative, indicated that the patient is entering the 5th benefit period...female diagnosed with malignant neoplasm of unspecified site of left female breast...". MD 1 stated, ";Oh no, I see an error on my part." MD 1 stated the information documented on Patient 1s certification belonged to a different patient. MD 1 stated he copied and pasted the information on to the new certification period and made edits to update the information. MD 1 stated he might have accidentally copied and paste the information to the wrong patient. MD 1 stated the CTI needed to be accurate because the document describes the reason, they are in hospice care, it summarizes the doctors findings. During an interview on 10/26/2023, at 12:54 p.m., MD 1 stated he had not recertified Patient 1 for certification period 10/21/20203 to 12/19/2023 because he had an issue with this license. MD 1 stated his designee could have recertified Patient 1. MD 1 stated he did not remember the name of his designee. MD 1 stated the CTI has to be completed by 10/21/2023 and Patient 1 continued on hospice services without a recertification information.There was no documented evidence the MD 1 reviewed the patients clinical information to ensure its accuracy, to validate a recertification to hospice care. b. A record review of Patient 2s ";Personal Information", indicated a start of care date of 11/11/2022, with a primary diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure. During an interview on 10/24/2023, at 3:34 p.m., with Patient 2s caregiver (CG 5), CG5 stated she did not know what hospice care was. CG 5 stated, was asked if a doctor had diagnosed Patient 2 with a terminal illness with a life expectancy of 6 months or less, CG 5 stated ";no". CG 5 stated in Spanish, ";no, no se esta muriendo" (no, hes not dying). During an interview on 10/25/2023, at 12:40 p.m., DD stated there were no medical documents, diagnostic tests and supporting documentation of Patient 2s diagnosis of hypertensive heart disease. During an interview on 10/25/2023, at 4:05 p.m., with Patient 2s Primary Care Physician 2 (PCP 2). PCP 2 stated she was Patient 2's PCP2 for ";many, many years". PCP 2 stated the last visit with Patient 2 was on 8/17/2023. PCP 2 stated Patient 2 had Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills) but was stable because Patient 2 was following his treatment plan. PCP 2 stated she was surprised to learned that Patient 2 was in hospice care. PCP 2 stated she was not aware that Patient 2 was in hospice care because Patient 2 was not terminal (an advanced stage of a disease with an unfavorable prognosis and no known cure) and has a life expectancy greater than 6 months. PCP 2 stated she did not refer Patient 2 to hospice care. During a concurrent interview and record review on 10/26/2023, at 12:59 p.m., with MD 1 reviewed Patient 2s ";Physicians Certification for Hospice Benefit" (CTI), for certification period 5/10/2023 to 7/8/2023. Patient 2s ";Physicians Certification for Hospice Benefit" (CTI), indicated Patient 2 was recertified for hospice care because he continued to decline with increased weakness and fatigue, continues to meet the LCD guidelines, and has NYHA IV (4). MD 1 stated there was no laboratory or diagnostic results for Patient 2 to support heart failure. During a concurrent interview and record review on 10/26/2023, at 1:13 p.m., MD 1 reviewed Patient 2s ";Physicians Certification for Hospice Benefit" (CTI), for certification period 7/9/2023 to 9/6/2023. MD 1 stated the information under ";certifying Physician Summary" was the same as the prior certification period. MD 1 stated he copied and pasted the information from the previous certification onto this one because the information had not changed. c. A record review of Patient 3s ";Personal Information", indicated a star of care date of 12/30/21, with a primary diagnosis of hypertensive heart disease without heart failure. During an interview on 10/26/23, at 10:40 a.m., Patient 3s caregiver (CG 6) stated Patient 3 was not terminal and did not have a life expectancy of 6 months or less to live. CG 6 stated, ";if a doctor told me that, I think I would have remembered that. That is not something you forget". During a concurrent interview and record review on 10/26/2023, at 1:18 p.m., MD 1 reviewed Patient 3s ";Physicians Certification for Hospice Benefit" (CTI), for certification period 6/23/2023 to 8/21/2023. MD 1 stated he recertified Patient 3 for hospice care because she was having worsening weakness and fatigue. During a concurrent interview and record review on 10/26/2023, at 1:20 p.m., MD 1 reviewed Patient 3s ";Physicians Certification for Hospice Benefit" (CTI), for certification period 8/22/2023 to 10/20/2023. MD 1 stated he recertified Patient 3 for hospice care because she was having worsening weakness and fatigue. MD 1 stated he did not tell Patient 3 and family about her prognosis and terminal disease because he assumed the previous provider did it. During a concurrent interview and record review on 10/26/2023, at 1:22 p.m., MD 1 reviewed Patient 3s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for certification period 10/21/2023 to 12/19/2023. The record did not indicate Patient 3 was recertified for hospice care. MD 1 stated he was considering removing her from hospice care because of her stability. MD 1 stated, ";well, I didnt recertify her this time". Patient 3 continued on hospice services without a recertification information from the MD. d. A record review of Patient 5s ";Personal Information", indicated a start of care date of 7/29/22, with a primary diagnosis of hypertensive heart disease without heart failure. During an interview on 10/24/23, at 4:07 p.m., with Patient 5, Patient 5 stated that she canceled hospice services a week ago because she is well, and not sick, and did not need the hospice service. Patient 5 stated the HA told her they needed a two week notice to cancel the services. Patient 5 stated she knew that hospice care was for people who were dying, but she was not dying, and a doctor had not told her she had a terminal illness with a life expectancy of 6 months or less to live. Patient 5 stated in Spanish, ";yo no me senti que me estaba muriendo" (I didnt feel I was dying). During a concurrent interview and record review on 10/26/2023, at 1:33 p.m., MD 1 reviewed Patient 5s ";Physicians Certification for Hospice Benefit" (CTI), for certification period 7/24/2023 to 9/21/2023. MD 1 stated he recertified Patient 5 for hospice care because she declined in status, reviewed the physical findings, and chart review from previous hospice providers. MD 1 stated based on the findings Patient 5 had heart failure. MD 1 stated he did not have any labs or other studies to support the diagnosis of heart failure. During a concurrent interview and record review on 10/26/2023, at 1:35 p.m., MD 1 reviewed Patient 5s ";Physicians Certification for Hospice Benefit" (CTI), for certification period 9/22/2023 to 11/20/2023. MD 1 stated he recertified Patient 5 for hospice care because she declined in status, reviewed the physical findings, and chart review from previous hospice providers. MD 1 stated based on the findings Patient 5 had heart failure. MD 1 stated he did not have any labs or other studies to support the diagnosis of heart failure. e. A record review of Patient 8s ";Personal Information", indicated a Start of Care (SOC) date of 4/15/2023 with a primary diagnosis including heart disease unspecified. A record review on 10/23/2023 of Patient 8s ";Physician Certification For Hospice Benefit" dated 10/12/2023 to 10/10/2023, indicated ";NYHA IV". It also indicated ";I attest/ confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Section ";Medical Director – Signature" was left blank. During a telephone in interview on 10/24/2023, at 11:15 a.m., with Patient 8s son, caregiver 3 (CG3), CG3 stated that neither him or his mother has ever been told that Patient 8 had six months or less to live. CG3 stated ";I knew she needed help after her fall because she was unable to cook or do anything like that. I dont know how she got involved in a hospice program, maybe because she needed help but not because she was dying." During a telephone interview on 10/25/2023, at 9:48 a.m., with Patient 8s insurance representative (IR), IR stated that Patient 8 has been seen by NP1 since Patient 8 was released from the hospital in April 2023. IR stated that NP1 oversees Patient 8s medications and blood draws. IR stated he does not see any referrals for hospice services. During a concurrent interview and record review on 10/25/2023 at 11:30 a.m. with the Director of Nurses (DON) of Patient 8s Electronic Medical Record (EMR) DON stated Patient 8 was not a hospice patient based on her home visit yesterday 10/24/2023 and will be most likely discharged. DON stated she does not speak to the doctors directly. DON stated ADM/SC ";has the direct contact with all the doctors". During a concurrent interview and record review on 10/25/2023 at 1:46 p.m. with MD1 of Patient 8s ";Physician – CTI" MD1 stated he uses the LCD guidelines and the nursing assessment to determine hospice eligibility. MD1 stated Patient 8s hospice eligibility was based on her severe heart disease and shortness of breath while at rest. MD1 stated Patient 8 was an existing patient and kept her heart disease diagnosis. During a concurrent interview and record review on 10/26/2023, at 1:53 p.m., with MD1 of Patient 8s ";CTI #1" and ";CTI#2" MD1 stated they both had the same documentation. MD1 stated that he looks at the previous MD documentation and if there are no changes, he copies and paste. MD1 stated that he did not make any changes to Patient 8s CTI#2. During a concurrent interview and record review on 10/26/2023, at 12:30 p.m., with the Director of Nurses Designee (DD) of Patient 8s ";LCD" dated 7/15/2023 and 10/7/2023, DD stated ";according to the nurse documentation the patient does not meet the qualifications for NYHA IV." During a concurrent interview and record review on 10/26/2023, at 12:30 p.m., with the Director of Nurses Designee (DD) of Patient 8s EMR medical record form titled ";LCD" dated 4/15/2023, DD stated ";according to the nurse documentation the patient does not meet the qualifications for NYHA IV." DD stated Patient 8s CTI #1 and CTI#2 had the same documentation. f. A record review of Patient 9s ";Personal Information", indicated a Start of Care (SOC) date of 4/2/2023 with a primary diagnosis of hypertensive (high blood pressure) heart disease without heart failure. During an interview on 10/24/2023, at 4:10 p.m., with Patient 9, Patient 9 stated the HA brought supplies (unknown) and sent a nurse. Patient 9 stated that she was never told that she had six months or less to live by any doctor. Patient 9 stated ";There has never been a doctor that has told me that I was going to die, not even when I was diagnosed with cancer, 16 years ago, melanoma stage III." Patient 9 stated she had a primary doctor, which she saw last in September 2023. Patient 9 stated that she could walk without assistance, could take showers without assistance, takes her medication by herself, and that she does not use diapers. During a concurrent interview and record review on 10/25/2023, at 11:45 a.m., with DON of Patient 9s EMR, DON stated she received a call from ADM/SC asking her to do a home visit and report her assessment findings. DON stated ADM/SC then calls MD, then calls her back to document Patient 9s assessment in the EMR. During a concurrent interview and record review on 10/25/2023, at 12:15 a.m., with the Chief Financial Officer (CFO) of Patient 9s EMR, CFO stated ";It is not documented how she started our services." During a concurrent interview and record review on 10/25/2023, at 1:32 p.m., with MD1 of Patient 9s ";CTI #3" dated 9/29/2023 to 11/27/2023, MD1 stated Patient 9s qualified for hospice mainly due to her shortness of breath on exertion and the diminished breath sounds based on the RNs assessment documented on 9/17/2023. During a concurrent interview and record review on 10/26/2023 at 1:42 p.m. with MD1 of Patient 9s ";CTI#1" dated 4/2/2023 to 6/30/2023, ";CTI #2" dated from 7/1/2023 to 9/28/2023, and ";CTI #3" dated 9/29/2023 to 11/27/2023, MD1 stated CTI #1, CTI #2, and CTI #3 have the same documentation, from the nurses assessment. MD1 stated ";I used the previous providers template and change it if needed. No, it does not look like I changed anything." MD1 stated that it does not seem Patient 9's condition had decline. MD1 stated, ";the time next certification rolls around they might be DC (discharged) because of their stability." g. A record review of Patient 11s ";Personal Information", indicated a Start of Care (SOC) date of 11/21/2022 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. During a concurrent interview and record review on 10/26/2023, at 1:06 p.m., with DON of Patient 11s ";CTI" dated 9/13/2023, DON stated Patient 11s diagnosis was heart disease without heart failure. DON stated Patient 11 was not taking any diuretics (medications to facilitate fluid output). DON stated Patient 11s LCD was inaccurate because Patient 11 does not take diuretics or has heart failure. During a concurrent interview and record review on 10/26/2023, at 12:54 p.m., with DON of Patient 11s ";CTI" dated 7/19/2023 to 9/16/2023 and 9/17/2023 to 11/15/2023 DON stated both CTIs have the same documentation. During a concurrent interview and record review on 10/26/2023, at 12:54 p.m., with DON of Patient 11s ";CTI" dated 5/20/2023 to 7/18/2023 DON stated the physician's narrative has the same documentation as the Nurse Recertification Assessment dated 3/21/2023. During a telephone interview on 10/24/2023, at 4:31 p.m., with Patient 11s Care Giver 1 (CG1), CG1 stated hospice services included a nurse that came to bathe her and provided diapers and Ensure. CG 1 stated the HA would were stop the hospice services because Patient 11 had been with HA for about two year. CG 1 stated Patient 11's primary care physician 1 (PCP 1) within this past year and had not told that Patient 11 had six months or less to live. During an interview on 10/24/2023, at 4:40 p.m., with PCP1s Nurse (PN1), PN1 stated Patient 11 saw PCP1 on June 2, 2023. PN1 stated that PCP1 had not referred or given orders for hospice services for Patient 11. During a concurrent interview and record review on 10/25/2023, at 1:58 p.m., with MD1 of Patient 11s ";CTI" dated 9/17/2023, MD1 stated he didnt know the hospice criteria used. MD1 stated Patient 11s shortness of breath on exertion and increase activity of daily living assistance would qualified Patient 11 for hospice services. MD1 stated Patient 11s heart was not showing signs of worsening. MD1 stated Patient 11s daughter had mentioned Patient 11 had a primary physician, but he did not contact him because there was no need. MD1 stated the benefits of speaking with Patient 11s primary physician would be to gather information on Patient 11 before treating her. MD1 stated considering discharging her because she is stable. During a concurrent interview and record review on 10/26/2023, at 1:36 p.m., with MD1 of Patient 11s ";CTI" MD1 stated CTI #9 and CTI#10 had the same documentation because Patient 11 did not show ";much of a difference". MD1 stated CTI#8 and Nurse Recertification Assessment dated 3/21/2023 had the same documentation. MD1 stated he copied and paste from the nurses assessment because there was no change. MD1 stated ";By this point the nurses know them more than I have." A review of facilitys policy and procedure titled, ";Admission Criteria and Process" revised April 2021, indicated ";The patients life-limiting illness and prognosis of six (6) months of less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCD). 1. (HA) will admit a patient only on recommendation of the medical director in consultation with, or input from the patients attending physician... 3. The patient must have a life-limiting illness with a life expectancy of six (6) moths or less, as determined by the attending physician... utilizing standard clinical prognosis criteria in the organizations intermediary Local coverage Determination. 4. The patient must desire hospice services and be aware of the diagnosis and prognosis."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Clinical Records was met as follows: --- 1. The HA failed to ensure any amendments (changes), correction or late entries within the electronic health record clearly identified the original content, the modified content, date, and authorship of each record modified, for two of fourteen sampled patients (Patient 9 and Patient 11). (Refer to L679) 2. The HA failed to ensure contents and information in the patients medical records were safeguarded from unauthorized access by the HA staff to make any alterations or modifications. (Refer to L680). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records are safeguarded from unauthorized access by any individuals or hospice staff.

Based on interview and record review, the hospice agency (HA) failed to ensure any amendments (changes), correction or late entries within the electronic health record clearly identified the original content, the modified content, date, and authorship of each record modified, for two of fourteen sampled patients (Patient 9 and Patient 11). This failure had the potential to result in an unauthorized and inaccurate patient information or assessment entered in the patients clinical record that could affect the patients quality of care and well-being. --- a ) A record review of Patient 9s ";Personal Information", indicated Patient 9 had a Start of Care (SOC) date of 4/2/2023 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. A review of facilitys form titled, ";Audit Log", dated 10/22/2023 to 10/25/2023, indicated, Administrator/Spiritual Counselor (ADM/SC), ";created" Patient 9s ";Spiritual Assessment..." for 6/22/2023, 9/15/2023, and on 10/25/2023. During a concurrent interview and record review on 10/25/2023, at 12:55 p.m., with the ADM/SC of Patient 9s Electronic Medical Record (EMR) form titled, ";History of Spiritual Assessment", the ADM/SC stated she documented Patient 9s spiritual assessment for 6/22/2023, 9/15/2023 and on 10/24/2023. The ADM/SC stated, ";I dated them late, it is considered falsification." The ADM/SC stated it is important to document patient records on time because it is part of the regulations and hospice services. b) A record review of Patient 11s ";Personal Information", indicated Patient 11 had a Start of Care (SOC) date of 11/21/2022 with a primary diagnosis including hypertensive (high blood pressure) heart disease without heart failure. A review of Patient 11s ";Plan of care (POC, an individualized care plan for a patient) Summary" indicated the frequency of Health Aide visit is three (3) per week – for ADLs (activity of daily living) and personal care assist." A review of facility form titled, ";Audit Log", dated 10/22/2023 to 10/25/2023, indicated the Director of Nurses (DON) logged in to Patient 11s Electronic Medical Record (EMR) form titled, ";HA (Health Aide) Notes" on 10/24/2023 8:44:35. The Form also indicated the DON filled out form HA notes dated 9/4/2023. During a concurrent interview and record review on 10/26/2023, at 1 p.m., with the DON of Patient 11s EMR form titled, ";HA note", dated 9/4/2023, the DON stated she did not do a home visit on 9/4/2023. The DON stated, ";I wasnt there, I dont know what happened." The DON also stated she noticed the Certified Home Health Aide (CHHA)s visit note documentation was not completed on 9/4/2023. The DON stated she completed part of the CHHAs daily visit note dated 9/4/2023. The CHHA notes need to be completed by the CHHA. They need to document what they have done on the field." On 10/25/2023, at 3 p.m., the facilitys policy and procedure for - EMR Documentation: Time frame, Authentication, Safeguarding, and Authorization were requested, and was not received. A review of the undated facilitys policy and procedure (P&P) titled, ";Patient / Family Bill of Rights", indicated, ";as a patient, you have the right to be assured confidential treatment of personal and clinical records..." A review of facilitys P&P titled, ";Consent for Treatment and Services", revised 6/2019, indicated ";consent for treatment and services will be completed during initial assessment and inform patient of EMR process of documentation during entire hospice care services.

Based on interview and record review, the Hospice Agency (HA) failed to ensure contents and information in the patients medical records were safeguarded from unauthorized access by a volunteer personnel to make any alterations or modifications. This failure had the potential to result in an unauthorized and inaccurate patient information or assessment entered in the patients clinical record that could affect the patients quality of care and well-being. --- During a concurrent observation and interview on 10/23/2023 at 9:35 a.m., the Volunteer (VT) was observed opening the hospice agency (HA). The VT stated she was the VT and will call the Administrator (ADM) to let her know we were there. On 10/23/2023 at 10 a.m. the facilitys current patient census, unduplicated admission for the past 12 months, and the employee list were requested from the VT. On 10/23/2023 at 10:15 a.m., the VT provided facilitys current patient census, unduplicated admission for the past 12 months, and an employee list. All documents had the HAs Electronic Medical Record (EMR) logo on them. During an interview on 10/25/2023 at 1:32 p.m. with the Medical Director 1 (MD1), MD1 stated he speaks mainly to VT. During an interview on 10/25/2023 at 1:32 p.m. with the Chief Financial Officer (CFO), the CFO stated VT is an office staff. During an interview on 10/25/2023 at 1:46 p.m. with MD1, MD1 stated the admitting process starts when he receives a call from VT. During an interview on 10/26/2023 at 9:15 a.m. with MD3, MD3 stated he gets assignments from the nurses, but usually from the VT. During an interview on 10/26/2023 at 9:20 a.m. with MD3, MD3 stated the VT assist him with the HAs EMR while he is in the office. During an interview on 10/26/2023 at 11:05 a.m. with VT, the VT stated that she was not an employee, and that she just helps sometimes verify patient eligibility. The VT stated that she uses the Administrator/Spiritual Counselor (ADM/SC) EMR log in information to log into the HAs EMR system with her (ADM/SC) permission. The VT stated that she assists MD3 log in and navigate the HAs EMR to the Certification of Terminal Illness (CTI) section when he is at the HA. The VT stated that at times, she assists MD3 transcribe his findings into the patients CTI narrative section. The VT stated the Chief Financial Officer (CFO) asks her to check patients eligibility and to call the doctor to let them know they are eligible. The VT stated, once a doctor says yes, she emails the Director of Nurses (DON) to inform her that she needs to go evaluate the patient. The VT stated, the DON returns the call to let her know patient is admitted. The VT stated, sometimes she calls the doctor directly. The VT stated, ";I call the doctor and tell him that the DON went to see the patient and completed the assessment, and I tell the doctor the patient is admitted." The VT stated, the ADM/SC is not a regular staff and that she is a resource person for her. During an interview on 10/26/2023 at 11:19 a.m. with the CFO, the CFO stated usually either him or the VT calls the RN when there is a possible admission. During an interview on 10/26/2023 at 12 p.m. with the Director of Nurses Designee (DD), the DD stated, the VT would inform her of a new admission. The DD stated after the new admission nursing assessment is done, she calls the VT and the ADM/SC to inform them that she had admitted the patient. The DD stated she sent VT the patients medication list and asked her to send to the doctor for approval. The DD stated she was unaware of who would contact the doctor, VT, or ADM/SC. During an interview on 10/26/2023 at 2 p.m. with the CFO, the CFO stated, the VT did not have an employee file. The CFO stated VT had started as a volunteer in the past month. The CFO stated, the VT does not have access to the patients records. The CFO stated he had not run a background check on VT. On 10/25/2023 at 3 p.m., the facilitys policy and procedure for - EMR Documentation: Time frame, Authentication, Safeguarding, and Authorization were requested, but was not received. A review of facilitys undated policy and procedure P&P) titled, ";Patient / Family Bill of Rights", indicated ";as a patient, you have the right to be assured confidential treatment of personal and clinical records..." A review of facilitys P&P titled, ";Consent for Treatment and Services" revised 6/2019, indicated ";Consent for treatment and services will be completed during initial assessment and inform patient of EMR process of documentation during entire hospice care services.