Every finding on record at Panorama Hospice, Inc

Based on observation, interview, and record review, the hospice agency failed to ensure the Condition of Participation for Patients rights was met as follows: The hospice agency, for three of 15 patients, (Patients 1, 8 and 9), failed to: 1. Ensure the patients had their family members listed as the primary responsible contact person. 2. Ensure hospice care (care that focuses on comfort, and quality of life of a person with a serious illness who is approaching the end of life) enrollments had consents signed by the patient and or its family members. 3. Inform and explain what hospice care is, as well as the type of care and services patients will receive under hospice care. This deficient practice resulted in the patients being unaware about hospice care and its covered benefits and had the potential to affect the quality of life the affected patients would have if hospice care was not the services the patients would have wished for. (Refer to L 518). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Patient's Rights to be informed about hospice services. --- .

Based on observation, interview, and record review, for three of 15 patients, (Patients 1, 8 and 9), the hospice agency failed to: 1.Ensure the patients had their family members listed as the primary responsible contact person. 2. Ensure hospice care (care that focuses on comfort, and quality of life of a person with a serious illness who is approaching the end of life) enrollments had consents signed by the patient and or its family members 3. Inform and explain what hospice care is, as well as the type of care and services patients will receive under hospice care. This deficient practice resulted in the patients being unaware about hospice care and its covered benefits and had the potential to affect the quality of life the affected patients would have if hospice care was not the services the patients would have wished for. --- c. A review of Patient 8s Patient Information Sheet indicated a Start of Care (SOC) date of 7/6/2020, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (accumulation of plaque in the arteries that supply blood to the heart muscle) without angina pectoris (chest pain). The Information Sheet indicated that the Board and Care Facility Owner (BCS 2) was the Primary contact/patient caregiver for Patient 8. On 7/19/2023 at 11:30 a.m., a home visit was conducted at Patient 8s board and care facility with Licensed Vocational Nurse (LVN 1). Patient 8 was alert and oriented and lying in bed. Patient 8 was able get up from the bed and walk with a slow gait to a chair and sit down independently. During an interview on 7/19/2023 at 11:40 am, when Patient 8 was asked if he was on a hospice program, Patient 8 stated he did not know what was meant by hospice. When Patient 8 was asked if he had a heart disease or a terminal illness, Patient 8 stated he did not have heart disease and never had a heart attack. Patient 8 stated that a terminal illness is like having cancer, and he did not have a terminal illness. Patient 8 stated he was visited every Thursday by Family Member (FM 2) and that he and FM 2 go to the gym. Patient 8 stated that the Medical Director (MD 1) and the Administrator/Director of Patient Care Services come visit him to do routine checkups. Patient 8 stated that if there was an emergency, FM 2 should be contacted. During an interview on 7/19/2023 at 11:52 am, LVN 1 stated Patient 8s primary contact information was with the Board and Care and if they needed to be contacted, the Board and Care would contact them. During an interview on 7/19/2023 at 12:00 pm, the board and care administrator (BC-ADM 1), stated if Patient 8 had an emergency and had to go to the hospital, they would call FM 2, who was Patient 8s primary/emergency contact. BC-ADM 1 stated that BCS 2 was the owner of the Board and Care facility not Patient 8s primary contact. During an interview on 7/21/2023 at 11:45 am, the Social Worker (SW) stated that she did not know why the primary contacts did not print out on the facesheet because it was in the patients electronic chart. SW stated that FM 2 was Patient 8s primary contact if Patient 8 had an emergency. A further review of Patient 8s electronic chart did not indicate that FM 2 was Patient 8s primary/emergency contact. d. A review of Patient 9s Patient Information Sheet indicated a Start of Care (SOC) date of 7/12/2022 with a primary diagnosis of chronic obstructive pulmonary disease (chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). The Patient Information Sheet indicated that Board and Care Facility Staff (BCS 1) was Patient 9s Primary Contact. A review of Patient 9s Physician Orders for Life-Sustaining Treatment (POLST) dated 7/12/2022 was signed by the Medical Director (MD 1) and BCS 1. The POLST indicated Do not attempt Resuscitation/DNR and to allow natural death. The POLST indicated BCS 1 as the legally recognized decisionmaker. A review of Patient 9s Hospice Consents dated 7/12/2022 showed BCS 1 initialed the documents. On 7/19/2023 at 11:30 am, a home visit was conducted at Patient 9s board and care facility with Licensed Vocational Nurse (LVN 1). Patients 8 and 9 were observed to share a room. Patient 9 was alert, oriented and forgetful as the surveyor had to continually repeat her questions. Patient 9 was lying in bed. LVN 1 performed vital signs and a skilled assessment. When Patient 9 was asked who the Board and Care Facility Staff (BCS 1) were, Patient 9 stated BCS 1 was the lady in the facility who does the cooking. Patient 9 further stated his wife (FM 3) comes to visit every week. During an interview on 7/19/2023 at 11:35 am, with Patient 8, Patient 8 also stated that BCS 1 was the lady who cooked the meals, washed the bedding and clothes, and mopped the floors. During a telephone interview on 7/19/2023 at 5:22 pm, FM 3 stated that Patient 9 was her husband and that she was the board and care primary contact if Patient 9 had an emergency. FM 3 stated she visited Patient 8 almost every weekend and if Patient 9 needed to go to the hospital, she would be the one to take him. FM 3 stated that the board and care had been talking to her about putting Patient 8 in hospice, but she did not want him to die. FM 3 stated that hospice was a sad place where they let people die and exterminate them. FM 3 stated she did not know Patient 9 was a hospice patient and did not sign any documents consenting Patient 9 to enroll in a hospice program. FM 3 stated she makes the decisions for her husband. FM 3 stated that BCS 1 was the person who lived in the house and cooked for the patients. During a telephone interview on 7/20/2023 at 12:03 pm, FM 4 stated she was not aware that Patient 9 was in hospice and was only aware that he was in a board and care facility. FM 4 stated that if there was an emergency, the board and care was to contact FM 3 and that if there were not able to get a hold of FM 3, they would contact her. FM 4 stated FM 3 was the person who made the decisions for Patient 9. During a telephone interview on 7/21/2023 at 9:08 am, BCS 1 stated that she lived and worked at the Board and Care. BCS 1 stated she cooked the meals and was a caregiver for the patients. BCS 1 stated that she did not sign for any patient for hospice and that only the board and care administrator could do that. During a telephone interview on 7/21/202 at 9:17 am, BC-ADM 1 stated that the emergency contact for Patient 9 was FM 3 and that he understood, FM 3 signed Patient 9 up for hospice. BD-ADM stated that he usually speaks to the patients family and is aware if a patient in the facility was going to be enrolled in hospice. BD-ADM 1 stated if there was a case where a family member was too far to sign patient up for hospice and it was urgent, the family would have to give him permission to sign the patient up for hospice. BD-ADM 1 stated that he was not aware that any of the board and care staff had signed consents to enroll a patient in a hospice program. A review of the hospice agencys policy, ";Hospice Election Statement" dated 1/2020 indicated that the individuals or representatives acknowledges that he or she has been given a full understanding of the palliative rather than curative nature of Hospice care, as it relates to the individuals terminal illness. The policy indicated hospice staff will explain the hospice election statement to the patient, patients legal representative, family, and caregiver. The policy indicated that the signing of the Election Statement by the patient/legal representative gives agreement to care. a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 06/09/2023, with diagnosis of heart failure. A review of Patient 1's IDG Conference Note/Update to Plan of Care dated 07/13/2023, indicated that a skilled nurse (SN) was scheduled to visit the patient one time a week for 90 days. A review of Patient 1s Discharge Summary from the general acute care hospital (GACH) dated 02/05/2023 indicated that patient was evaluated by a Psychiatry and deemed incompetent to make decisions. A review of Patient 1s clinical record indicated that there was no documentation that family members were informed regarding hospice services. On 07/19/2023, at 1:30 p.m., a joint home visit with the Licensed Vocational Nurse (LVN 1) was conducted at Patient 1s residence. Patient 1 observed sitting on a wheelchair in the living room with gauze to left lower leg. Hospice folder observed to have patient consents and Physician Orders for Life Sustaining Treatment (POLST) with Patient 1s signature. During an interview with Patient 1 on 07/19/2023 at 1:49 p.m., she stated that she did not sign up for hospice. Patient 1 further stated that hospice are for people who are about to die and that was not her. During an interview the Director of Patient Care Services (DPCS) on 07/21/2023 at 12:01 p.m., she stated that if a patient is deemed incompetent by the psychiatrist, the patient should not be signing for themselves.

Based on interview, observation, and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Initial and Comprehensive Assessment of the Patient was met as evidenced by: 1. The Hospice Agency (HA) failed to conduct an accurate comprehensive assessment assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patients current health status and identified the patients needs for hospice care and services related to eligibility and management of the terminal illness, for three of 15 sampled patients, (Patients 1, 9, and 15). This deficient practice resulted in the provision of hospice services for patients who were not clinically eligible to receive hospice care and services. (Refer to L524). 2. The hospice agency (HA) failed to maintain the current medication profiles for two of 15 sampled patients (Patient 1 and Patient 2). The deficient practice had the potential to put patients at risk for medication errors and adverse drug reactions which can be life threatening. (Refer to L 530). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Patient's Rights to protect and promote the rights of the patient in the hospice agency. --- .

Based on interview, observation, and record review, the hospice agency (HA) failed to conduct an accurate comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patients current health status and identified the patients needs for hospice care and services related to eligibility and management of the terminal illness, for three of 15 sampled patients, (Patients 1, 9, and 15). This deficient practice resulted in the provision of hospice services to patients who were not clinically eligible to receive hospice care and services. --- c. A review of Patient 9s Patient Information Sheet indicated a Start of Care (SOC) date of 7/12/2022 with a primary diagnosis of chronic obstructive pulmonary disease (chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). The Patient Information Sheet indicated that Board and Care Facility Staff (BCS 1) was Patient 9s Primary Contact. A review of Patient 9s Nursing clinical notes from a prior certification indicated Patient 9 had the following normal oxygen levels: On 6/6/2023, oxygen saturation was 95% on room air. On 6/13/2023, oxygen saturation was 97% on room air. On 6/20/2023, oxygen saturation was 95% on room air. On 6/27/2023, oxygen saturation was 96% on room air. On 7/4/2023, oxygen saturation was 98% on room air. A review of Patient 9s Physician Orders for Life-Sustaining Treatment (POLST) dated 7/12/2022 signed by Medical Director (MD 1) and BCS 1 indicated ";Do not attempt Resuscitation/DNR and to allow natural death." The POLST indicated BCS 1 as the legally recognized decision maker. A review of Patient 9s Recertification Comprehensive Hospice Assessment dated 7/7/2023 for certification period 7/7/2023 to 9/4/2023 indicated Patient 9 had pulmonary disease. The assessment indicated Patient 9 had severe chronic lung disease but did not indicate whether Patient 9 was hypoxemic (when oxygen levels in the blood are lower than normal as evidenced by oxygen saturation less than or equal to 88%) and the check box was left blank. The assessment described Patient 9s respiratory status as unlabored with dyspnea (difficulty breathing) and the severity of symptoms as mild with an oxygen saturation level of 94%. The comprehensive assessment was signed by the Administrator/Director of Patient Care Services (ADM/DPCS). On 7/19/2023 at 11:30 am, a home visit was conducted at Patient 9s board and care facility with Licensed Vocational Nurse (LVN 1). Patient 9 was alert, oriented, forgetful and lying-in bed. LVN 1 performed vital signs and a skilled assessment. During an interview with LVN 1 on 7/19/2023 at 11:55 am, LVN 1 stated that Patient 9 has not experienced shortness of breath or COPD exacerbation since he has been in my care. LVN 1 stated that she had been seeing Patient 9 since last year. d. A review of Patient 11s Patient Information Sheet indicated a Start of Care (SOC) date of 4/11/2023 with a primary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen). The Patient Information Sheet indicated that the Board and Care Administrator (BC-ADM 2) was Patient 11s Primary Contact. A review of Patient 11s Recertification Comprehensive Hospice Assessment dated 4/11/2023 for certification period 4/22/2023 to 7/20/2023 indicated Patient 11 had heart disease and had a New York Heart Association classification (NYHA, a simple way of classifying the extent of heart failure) of Class IV [severe symptoms such as fatigue, palpitations (tremors or shivers) chest pain, dyspnea (difficulty breathing), or syncope (fainting) with features of heart failure with minimal physical activity and even at rest] level. e. A review of Patient 15s Patient Information Sheet indicated a Start of Care (SOC) date of 4/22/2023 with a primary diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). The Patient Information Sheet indicated that the Board and Care Administrator (BC-ADM 2) was Patient 15s Primary Contact. A review of Patient 15s Recertification Comprehensive Hospice Assessment dated 4/22/2023 for certification period 4/22/2023 to 7/20/2023 indicated that Patient 15 had Alzheimers Disease. The assessment indicated that Patient 15s Functional Assessment Staging Tool for Dementia and Alzheimer disease (FAST) Score was 7 or above. The assessment indicated that Patient 15s FAST score was 7b (7b-means all intelligible vocabulary lost). The assessment indicated that Patient 15 required considerable assistance and frequent medical care. The assessment indicated that Patient 15 was able to perform the following activities of daily living with no supervision, direction, or personal assistance (bathing, dressing, toileting, transferring, and feeding). The assessment indicated BC-ADM 2 as Patient 15s caregiver who was able/willing to provide all care, follow instructions and assist with activities of daily living and needed care. The comprehensive assessment was signed by the Administrator/Director of Patient Care Services (ADM/DPCS). During a telephone interview on 7/21/2023 at 11:15 am with the hospice social worker (SW) and BC-ADM 2, BC-ADM 2 stated Patient 11 and Patient 15 are husband and wife who lived in the facility. BC-ADM 2 was aware the nurses visited the patients but was not aware that Patient 11 and Patient 15 were in hospice. BC-ADM stated that the facility was independent living and that Patient 15 walks around the house, eats and sits outside, and does everything by herself. BC-ADM 2 stated that Patient 15 knows what day it is and watches television and does not look like she is dying. BC-ADM 2 stated that Patient 15 speaks to other patients, laughs, and jokes, and is able to walk. When asked if BC-ADM 2 was the primary contact or caregiver for Patient 15, BC-ADM 2 stated that the patients in the facility were independent, and she was the Administrator and did not change diapers. BC-ADM 2 stated that she did not know if the patients had a power of attorney, just that they had a referral and came from the hospital. During an interview on 7/21/2023 at 11:50 am, the Administrator/Director of Patient Care Services (ADM/DPCS) indicated that the patients were referred from the General Acute Community Hospital (GACH 1) and the referral order was provided in the History and Physical (H and P, physicians examination of patient) from the GACH. ADM/DPCS stated that the H&P should be uploaded in the patients electronic chart or a hard copy in the patients paper chart. During an interview on 7/21/2023 at 12:25 pm, ADM/DPCS stated while the patients were not actively dying, we provide the patients with palliative services through the hospice agency. The hospice agency was unable to provide patient records, including history and physical, to indicate that the patients had met LCD Hospice Eligibility Determination (Local Coverage Determination - an assessment to determine a patients eligibility for hospice services). A review of the Hospice Agencys undated policy, "Admission Criteria and Process" indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediaries Local Coverage Determinations (LCD). The policy further indicated the HA would admit a patient only on recommendation of the medical director in consultation with, or input from, the patient's attending physician, if any. Findings: a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 06/09/2023, with diagnosis of heart failure. A review of Patient 1's IDG Conference Note/Update to Plan of Care dated 07/13/2023, indicated that a skilled nurse (SN) was scheduled to visit the patient one time a week for 90 days. A review of Patient 1s Discharge Summary from the general acute care hospital (GACH) dated 02/05/2023 indicated that patient desaturated on room air but did not indicate that oxygen saturation was below 88%. A review of Patient 1s Comprehensive Hospice Assessment dated 06/09/2023, indicated that on the section Medicare Guidelines for Non-Cancer Diagnosis Determination for Hospice supportive documentation included oxygen saturation was below 88%.

Based on observation, interview, and record review, the hospice agency (HA) failed to maintain the current medication profiles for two of 15 sampled patients, (Patient 1 and Patient 2). The deficient practice had the potential to put patients at risk for medication errors and adverse drug reactions which can be life threatening. --- Findings: a. A review of Patient 1's Patient Intake Sheet indicated a start of care date (SOC) of 6/9/2023, with diagnosis of heart failure (a chronic condition in which the heart cannot pump or fill adequately). A review of Patient 1's IDG (Interdisciplinary Group is the team responsible for the holistic care of the hospice beneficiary) Conference Note/Update to Plan of Care dated 7/13/2023, indicated that a skilled nurse (SN) was scheduled to visit the patient one time a week for 90 days. On 7/19/2023, at 1:30 p.m., a joint home visit with the Licensed Vocational Nurse (LVN 1) was conducted at Patient 1s residence. A review of Patient 1s Medication Profile provided by the agency indicated that patient was taking: Spironolactone (a medication used for the management of high blood pressure and heart failure) 25 mg (milligram, a unit of measurement) one tablet orally once a day for hypertension (elevated blood pressure). Tylenol (a medication for pain relief) ES (Extra Strength) 500 mg one to two tablet orally every 4 hours as needed for pain. Trazadone (a medication used to treat depression [a mood disorder]) 50 mg two tablets orally once a day as needed for insomnia (difficulty getting to sleep). A review of Patient 1s current medication indicated that the patient did not have Spironolactone 25 mg and Tylenol ES 500 mg. Further review of Patient 1s current medications indicated that patient takes Potassium Chloride (a mineral supplement used to treat low potassium level) ER (extended release, a medication that slowly released into the blood over a period of time ) 20 MEQ (milliequivalent, a measurement unit) one tablet daily and Trazadone 50 mg three tablet daily at bedtime. During an interview with Board and Care Facility Staff (BCS 2) on 7/19/2023 at 1:58 p.m., BCS 2 stated that the only medications she takes are the ones that she had provided. b. A review of Patient 2 s Patient Intake Sheet indicated an SOC date of 3/19/2019 with a primary diagnosis of cerebral infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). On 7/19/2023 at 2:00 p.m., a joint home visit with the Licensed Vocational Nurse (LVN 1) was conducted at Patient 2s residence. A review of Patient 2s Medication Profile provided by the agency indicated that patient was taking gas relief 125 mg one tablet orally every four hours and Nasonex (a nasal spray used to decrease inflammation in the nose and used for allergies) 50 mcg (microgram – unit of measurement) one spray nasal once a day for allergies. A review of Patient 2s current medication indicated that patient takes Fluticasone (a medication that comes as a nasal spray and used to for the treatment of allergy symptoms) 50 mcg, one spray on each nostril once daily. Further review of Patient 2's current medications indicated that Patient 2 was not taking gas relief medication. During an interview with BCS 2 on 7/19/2023 at 2:25 p.m., BCS 2 stated that the only medications she takes are the ones that she had provided. During an interview on 7/21/2023 at 1:12 p.m., the Administrator/Director of Patient Care Services (ADM/DPCS) designee stated that in every visit the nurse should check the medications. A review of agencys undated policy and procedure titled, ";Medication Profile", indicated that medication profile will be updated for each change to reflect current medications and new and/or discontinued medications.

Based on interview and record review, the hospice agency failed to document the plan of care in the Interdisciplinary Group Conference note and update to the Plan of Care for one of 15 sampled patients (Patient 9). This deficient practice placed the patient at risk of not receiving care that would have been identified during the IDG group meetings. --- Findings: A review of Patient 9s Patient Information Sheet indicated a Start of Care (SOC) date of 7/12/2022 with a primary diagnosis of chronic obstructive pulmonary disease (chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Patient 9s Certificate of Terminal Illness for certification period 5/8/2023 to 7/6/2023 indicated Patient 9 had a primary diagnosis of COPD. A review of Patient 9s IDG Conference note/Update to Plan of Care dated 6/29/2023, 6/15/2023, 6/1/2023, and 5/18/2023 did not indicate any problems or plan of care and was blank. The note was signed by the Medical Director (MD 1), Administrator/Director of patient Care Services (ADM/DPCS) designee, Social Worker (SW), and Chaplain (CH). During an interview on 7/21/2023 at 1:37 pm, the Administrator/Director of Patient Care Services (ADM/DPCS) designee stated the IDG documentation should be complete with the frequency of services and the care plan. A review of the HAs (undated) policy titled, ";The Plan of Care," indicated the Plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days. The policy indicated this plan will focus on identified problems, goals, and interventions.

Based on interview and record review, the hospice agency failed to document the frequency of services to be provided in the Interdisciplinary Group Conference note/Update to Plan of Care for five of 15 sampled patients. (Patient 2, 5, 9, 10, and 12). This deficient practice placed the patient at risk for not receiving care from services identified during the IDG group meetings. --- Findings: a. A review of Patient 9s Patient Information Sheet indicated a Start of Care (SOC) date of 7/12/2022 with a primary diagnosis of chronic obstructive pulmonary disease (chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Patient 9s Certificate of Terminal Illness for the certification period of 5/8/2023 to 7/6/2023 indicated Patient 9 had a primary diagnosis of COPD. A review of Patient 9s Certificate of Terminal Illness for the certification period 7/7/2023 to 9/4/2023 indicated Patient 9 had a primary diagnosis of COPD. A review of Patient 9s IDG Conference note/Update to Plan of Care dated 5/18/2023, 6/1/2023, and 6/15/2023 and 7/7/2023 did not indicate the frequency of visits for a home health aide. The IDG note was signed by the Medical Director (MD 1), Administrator/Director of patient Care Services (ADM/DPCS) designee, Social Worker (SW), and Chaplain (CH). A review of Patient 9s Hospice Aide notes dated 5/17/2023, 5/24/2023 and 6/01/2023 indicated Patient 9 was visited by a Home Health Aide. The note indicated the aide provided Patient 9 a shower and cleaned the patients environment. b. A review of Patient 10s Patient Information Sheet indicated a Start of Care (SOC) date of 8/15/2022 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (accumulation of plaque in the arteries that supply blood to the heart muscle) without angina pectoris (chest pain). A review of Patient 10s Certificate of Terminal Illness for certification period 6/11/2023 to 8/9/2023 indicated Patient 10 had a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. A review of Patient 10s IDG Conference note/Update to Plan of Care dated 6/15/2023, 6/29/2023, and 7/13/2023 did not indicate the frequency of visits for any services (skilled nursing, chaplain, medical social worker or aide). The IDG note was signed by the Medical Director (MD 1), Administrator/Director of patient Care Services (ADM/DPCS) designee, Social Worker (SW), and Chaplain (CH). c. A review of Patient 12s Patient Information Sheet indicated a Start of Care (SOC) date of 8/11/2022 with a primary diagnosis of chronic obstructive pulmonary disease. A review of Patient 12s Certificate of Terminal Illness for certification period 6/7/2023 to 8/5/2023 indicated Patient 12 had a primary diagnosis of COPD. A review of Patient 12s IDG Conference note/ Update to Plan of Care dated 6/15/2023, 6/29/2023, and 7/13/2023 did not indicate the frequency of visits for any services (skilled nursing, chaplain, medical social worker or aide). The IDG note was signed by the Medical Director (MD 1), Administrator/Director of patient Care Services (ADM/DPCS) designee, Social Worker (SW), and Chaplain (CH). During an interview on 7/21/2023 at 1:37 pm, the Administrator/Director of Patient Care Services (ADM/DPCS) designee stated the IDG documentation should be complete with the frequency of services and the care plan. A review of the HAs (undated) policy titled, ";Interdisciplinary Group (IDG) Meeting," indicated the IDG group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patient on the hospice program. The policy indicated that the level of services will be reviewed for new and ongoing patients based on hospice team assessment. The group will approve recommendation for a change in the level of care. Findings: a. A review of Patient 2 s Clinical Record indicated a Start of Care (SOC) date of 03/19/2019 with a primary diagnosis of cerebral infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Patient 2s IDG Conference Note/Update to Plan of Care dated 07/13/202 and 6/29/2023 did not indicate the frequency of visits for any services (skilled nursing, chaplain, medical social worker or aide). The note was signed by the Medical Director (MD 1), Administrator/Director of patient Care Services (ADM/DPCS) designee, Social Worker (SW), and Chaplain (CH). b. A review of Patient 5 s Clinical Record indicated a Start of Care (SOC) date of 10/24/2022 with a primary diagnosis of Alzheimer's disease (progressive disease that destroys memory and other important mental functions.) A review of Patient 5's IDG Conference note/Update to Plan of Care dated 06/29/2023, and 07/13/2023 did not indicate the frequency of visits for a home health aide. The IDG note was signed by the Medical Director (MD 1), Administrator/Director of patient Care Services (ADM/DPCS) designee, Social Worker (SW), and Chaplain (CH).

Based on interview and record review, the Hospice Agency (HA) failed to coordinate the recertification of a hospice patient prior to the end of the certification period for one of 15 sampled patients (Patient 15). This deficient practice had the potential to place the patient at risk for not receiving hospice services. --- A review of Patient 15s Patient Information Sheet indicated a Start of Care (SOC) date of 4/22/2023 with a primary diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Patient 15s Certificate of Terminal Illness dated 4/22/2023 indicated a certification period from 4/22/2023 to 7/20/2023. During an interview on 7/21/2023 at 4:45 pm, the Medical Director (MD 1) indicated that Patient 15 was not alert and not able to care for herself. MD 1 stated that Patient 15 was a hospice patient but did not see Patient 15 last week or this week. MD 1 stated she was not aware if Patient 15 was discharged because they did not have an Interdisciplinary Group meeting. MD 1 stated she knows when a patient needs to be recertified because the nurse always notified her. During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) designee on 7/21/2023 at 4:55 pm, the electronic clinical record was reviewed and indicated Patient 15s Certificate of Terminal Illness for the certification period from 4/22/2023 to 7/20/2023 had ended and that there was no discharge summary or recertification of terminal illness for the next period. The ADM/DPCS designee stated here was no CTI starting 7/21/2023 or discharge summary for Patient 15. A review of the HAs (untitled) policy, ";Recertification Process," indicated the organization is responsible for recertifying the hospice patient no earlier than 30 days by the hospice physician and assessed by the Registered nurse not more than two weeks before the end of the Hospice benefit period. A review of the HAs (undated) policy titled, ";Interdisciplinary Group (IDG) Meeting," indicated the IDG group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patient on the hospice program.

Based on interview and record review, the hospice agency failed to review the patients clinical information to determine the terminal illness (an illness or condition which cannot be cured and is likely to lead to someone's death) required to certify a patients certification of terminal illness (CTI, illness with a prognosis of having 6 months of life or less) for one of 15 sampled patients, (Patient 1), for hospice admission eligibility. This deficient practice resulted in patient admission to hospice services who does not have a clinical information or diagnosis of terminal illness. --- A review of Patient 1's clinical record indicated a start of care date (SOC) of 06/09/2023, with diagnosis of heart failure. A review of Patient 1's IDG Conference Note/Update to Plan of Care dated 07/13/2023, indicated that a skilled nurse (SN) was scheduled to visit the patient one time a week for 90 days. A review of Patient 1s Certificate of Terminal Illness for certification period 06/09/2023 to 09/06/2023 indicated that given condition of patients illness and prognosis the primary caregiver/family have opted to palliative comfort care to be provided to patient. It did not indicate a diagnosis of any terminal illness. A review of Patient 1s clinical record indicated that there was no documentation of referral and agency unable to provide any paperwork when requested. On 07/19/2023, at 1:30 p.m., a joint home visit with the Licensed Vocational Nurse (LVN 1) was conducted at Patient 1s residence. Patient 1 observed sitting on a wheelchair in the living room with gauze to left lower leg. On 07/19/2023 at 1:49 p.m., during an interview with Patient 1, Patient 1stated that she did not sign up for hospice. Patient 1 further stated that hospice is for people who are about to die and that was not her. During an interview with Family Member 1 (FM 1) on 07/19/2023 at 3:19 p.m., FM 1 stated that she was not aware that Patient1is under hospice care, and no one had informed her. FM1 further stated that hospice is for patients who have a terminal illness and are dying, and that Patient 1 is not dying. During an interview with the Director of Patient Care Services (DPCS) on 7/21/2023 at 12:01 p.m., she stated that the hospice agency is not licensed for palliative care. The policy and procedure for palliative care was requested and the hospice agency was unable to provide. A review of the hospice agencys (undated) policy titled, ";Certification of Terminal Illness", indicated that at the time a patient and family/caregiver choose hospice, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. It also indicated that patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director.

Based on observation, interview, and record review, the hospice agency failed to ensure the medical director and/or physician designee had the patients clinical information needed to support the diagnoses of terminal illness (illness with a prognosis of having 6 months of life or less to live), to determine recertification (a critical piece of documentation necessary to ensure Medicare payment for the hospice services) for hospice care and services for the two of 15 patients, (Patients 8 and 9). This deficient practice had the potential to result in inappropriate recertification of patients who are not eligible for hospice care and services. --- a. On 7/19/2023 at 11:30 am, a home visit was conducted at Patient 8s board and care facility with Licensed Vocational Nurse (LVN 1). Patient 8 was alert and oriented and lying in bed. Patient 8 was able get up from the bed and walk with slow gait to a chair and sit down independently. Patient 8 was able to have a conversation and answer questions with no shortness of breath. LVN 1 performed vital signs and asked patient if he had pain or problems breathing. Patient 8 denied any pain and shortness of breath. During an interview on 7/19/2023 at 11:40 am, Patient 8 stated he did not have a terminal illness. Patient 8 stated he was visited by Family Member (FM 2) and that he and FM 2 go to the gym every Thursday. A review of Patient 8s Patient Information Sheet indicated a Start of Care (SOC) date of 7/6/2020 with a primary diagnosis that included atherosclerotic heart disease of native coronary artery (accumulation of plaque in the arteries that supply blood to the heart muscle) without angina pectoris (chest pain). The Information Sheet indicated that the Board and Care Facility Owner (BCS 2) was the Primary contact/patient caregiver for Patient 8. A review of Patient 8s Certificate of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less) for certification period 4/22/2023 to 6/20/2023 indicated that Patient 8 was home-bound and required round-the-clock care and supervision. The CTI indicated that the patient had difficulty carrying on a conversation due to shortness of breath and for Patient 8 to continue medications and did not indicate a terminal illness diagnosis. The CTI was signed by the Medical Director (MD 1). A request was made to the hospice agency (HA) for Patient 8s history and physical and hospice referral[EE1] , however, HA was unable to provide the documents requested. b. A review of Patient 9s Patient Information Sheet indicated a Start of Care (SOC) date of 7/12/2022 with a primary diagnosis of chronic obstructive pulmonary disease (chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). The Patient Information Sheet indicated that Board and Care Facility Staff (BCS 1) was Patient 9s Primary Contact. A review of Patient 9s Physician Orders for Life-Sustaining Treatment (POLST, a physician order that helps give seriously ill patients more control over their end-of-life care) dated 7/12/2022 was signed by Medical Director (MD 1) and BCS 1. The POLST indicated Do not attempt Resuscitation/DNR and to allow natural death. The POLST indicated BCS 1 as the legally recognized decision maker. A review of Patient 9s CTI for certification period 7/7/2023 to 9/4/2023 indicated Patient 9 had a primary diagnosis of COPD. The CTI indicated that Patient 9 used oxygen via nasal cannula as needed per physician orders, and that patient and family have opted to hospice palliative care for comfort measures. The CTI also indicated Patient 9s Hospice consents were signed by the patient's caregiver. During a telephone interview on 7/19/2023 at 5:22 pm, FM 3 stated that she was Patient 9s primary contact if Patient 9 had an emergency. FM 3 stated she visited Patient 8 almost every weekend and if Patient 9 needed to go to the hospital, she would be the one to take him. FM 3 stated that the board and care had been talking to her about putting Patient 9 in hospice, but she did not want him to die. FM 3 stated hospice was a sad place where they let people die and exterminate them. FM 3 stated she did not know Patient 9 was a hospice patient and did not sign any documents consenting Patient 9 to enroll in a hospice program. Patient 9 stated that FM 3 makes the decisions for him. FM 3 stated that BCS 1 was the person who lived in the house and cooked for the patients. During an interview on 7/21/2023 at 4:50 pm, MD 1 was asked regarding the hospice agencys (HA) process for admitting a patient. MD 1 stated the HA performs education, cares for patient, conducts interdisciplinary group meetings, makes sure the patient is being taken care of and to do their best for the patient and their families. MD 1 stated they received a referral for hospice and the family can choose to be in the program. MD 1 stated that the regulations the HA follows were Medicare policies. A review of the hospice agencys undated policy and procedure titled, ";Certification of Terminal Illness", indicated Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. The policy indicated that subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient's medical record or, if applicable, examination of the patient. The policy indicated that the hospice physician or nurse practitioner must have a face-to-face encounter with the patient within the 30 days prior to the third benefit period recertification and within 30 days prior to each subsequent recertification.

Based on interview and record review, the hospice agency (HA) failed to complete the discharge summary for two of 15 sampled patients (Patient 7 and 14). This deficient practice resulted in the status of the patients health condition at discharge to be unknown. --- A review of Patient 14s Patient Information Sheet indicated a Start of Care (SOC) date of 7/6/2022 with a primary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen). A review of Patient 14s Discharge Summary dated 1/11/2023 indicated the reason for discharge was "Discharged for cause" and condition on discharge/transfer was ";Unchanged." During an interview on 7/21/2023 at 4:00 pm, the Administrator (ADM)/Director of Patient Care Services (DPCS) designee stated that the discharge summary should be more specific, in this case, the patient was transferred to the hospital so the summary should say, patient revoked for shortness of breath, chest pain and went to the hospital. The ADM/DPCS designee stated the summary should have included time, date and contact person at the at the HA receiving report and where the patient transferred. A review of the HAs (undated) policy titled ";Discharge Summary," indicated that all patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record. The policy indicated that hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include, as appropriate: A. The date of discharge, the date the physician and patient informed of discharge B. The reason for discharge, including the name of the organization to which the patient is being transferred, if applicable C. Patient identifying information D. Contact person receiving report and date and time report given E. Patients physician F. Diagnoses related to discharge G. Significant health history H. Discharge orders, instructions, medication profile and allergies I. The status of problems identified at admission and during the provision of care J. The resolution of identified problems K. Continuing pain and symptom management needs L. The overall status of the patient at discharge M. A summary of the care or services provided and ongoing need that cannot be met N. The patients current plan of care O. The patients latest physician orders P. Presence of Advance Directive Q. End of life decisions a. A review of Patient 7s Clinical Record indicated a Start of Care (SOC) date of 12/30/2022 with a primary diagnosis of atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery). A review of Patient 7s Discharge/Transfer Summary dated 04/20/2023 indicated the reason for discharge was "Revoked" and reason for revocation was ";seek active treatment".

Based on interview and record review, the Hospice Agency (HA) failed to ensure the personnel files of the Administrator/Director of Patient Care Services (ADM/DPCS), Social Worker (SW), and License Vocational Nurse (LVN 1) were current. This deficient practice had the potential to result in the risk of the HA to employ unqualified staff. --- Findings: A review of the ADM/DPCS employee records indicated that the ADM/DPCS Registered Nurse (RN) License/Registration Expiration was 12/31/2022. The ADM/DPCS Cardiopulmonary resuscitation (CPR, a credential that qualifies the holder to perform a life-saving procedure on someone who cannot breathe on their own due to a near-drowning incident, suffocation, or a cardiac event) care was issued on 7/27/2019 and recommended renewal date was 7/2021. The reference check form, new staff orientation and training checklist, and Report of suspected adult/elder abuse forms were incomplete. There were no history and physical or tuberculosis test in the employee records. A review of the SW employee records indicated that the SWs CPR card was issued on 8/14/2020 and was valid for two years (expired 8/2022). There were no history and physical or tuberculosis test in the employee records. A review of LVN 1 employee records indicated there were no history and physical or tuberculosis test. During an interview on 7/21/2023 at 1:57 pm, the ADM/DPCS designee stated that the DCPS is responsible for ensuring the employee records are accurate and up to date. A review of the HAs (undated) policy titled, ";Personnel Record Contents," indicated that the Hospice will maintain current personnel files on all personnel. The policy indicated the content of the personnel files for regular full or part-time personnel will include: General documents: A. Skills and Experience Inventory B. Signed standards of conduct. C. Verified professional licensure or certification. D. CPR certification (professional personnel). New Hire Documents: E. References (2) K. Orientation checklist (completed) The policy indicated that the content of a separate file, which includes health information will contain: 1. Short and long -term disability forms 2. Workers compensation reports and correspondence 3. TB Mantoux test documentation 4. Physicians statement of health.