Every finding on record at Paradise Rays Hospice, Inc

Based on observation, interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Conditions of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) regarding Patients Rights was met as follows: --- 1. The HA failed to ensure patients' rights to be informed of the services the HA provides and the limitations of these services for four out of 14 sampled patients (Patient 8, Patient 9, Patient 10, and Patient 12) certified to receive hospice care and services. (Refer to L 519). The cumulative effect of this systemic practice resulted in the failure of the hospice agency to deliver statutorily (written law) mandated Federal (government) compliance for Patients Rights to ensure their rights were not violated and patients received quality hospice care and services.

Based on observation, interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure patients' rights to be informed of the services the HA provides and the limitations of these services for four out of 14 sampled patients (Patients 8, Patient 9, Patient 10, and Patient 12) certified to receive hospice care and services. This deficient practice resulted in the patients' rights being violated for not being fully informed about the purpose of the hospice care services and its limitations. --- a. A review of Patient 8s admission record indicated an admission date of 11/6/2023 with the terminal diagnosis of hypertensive heart disease with heart failure (hypertensive heart disease refers to changes in the heart structure as a result of chronic blood pressure elevation, which increases the workload on the heart inducing structural and functional changes). A review of Patient 8s ";Current Treatment/Medication/DME (Durable Medical Equipment) List" dated 11/6/2023, indicated Patient 8's physician orders included: "Skilled nurse (SN) to assess Vital Signs (VS) during every visit (VS, temperature, blood pressure, heart rate (HR), oxygen saturation [oxygen level in the blood], respiration rate [rate of breathing]), and patient's pain level. SN to educate Patent, PCG (patient caregivers)/Family regarding plan of care, disease process, medication regimen management, pain and symptom management, emergency measures, infection, fall precautions and safety measures, and hotline for hospice. SN to visit patient once a week to promote comfort and symptom management... SN may pronounce death." On 1/20/2024 at 11:15 a.m., a home visit was conducted with the licensed vocational nurse 1 (LVN 1) at Patient 8s apartment. Patient 8 was a 79-year-old woman who answered and opened the door. Patient 8 was observed to be alert and oriented to name, place, time, and person. Patient 8 was able to walk with the assistance of a four-wheel walker and was able to make needs known. Patient 8 currently lives alone in her apartment. LVN 1 initiated her visit. During a concurrent interview with Patient 8, Patient 8 stated that she can still drive and still goes out when she needs groceries or need to go to her doctor for her knee checkup. b. A review of Patient 9's admission record indicated a start of care date (SOC) date of 11/5/2023, with a terminal diagnosis of hypertensive heart disease with heart failure. A review of Patient 9s undated ";Current Treatment/Medication/DME List" indicated the following physician orders: "Skilled nurse (SN) to assess Vital Signs (VS) during every visit (temperature, blood pressure, heart rate, oxygen saturation, respiration rate), and patient's pain level. SN to educate Patient, PCG (patient caregiver)/Family regarding plan of care, disease process, medication regimen management, pain and symptom management, emergency measures, infection, fall precautions and safety measures, and hotline for hospice... SN may pronounce death." During a phone interview on 1/21/2024, at 9:02 a.m., with family member 4 (FM 4), FM 4 was notified that the hospice nurse visited Patient 9's home yesterday and that there was no answer at the patient's door. Informed FM 4 that Patient 9 was admitted to the hospice agency since 11/5/2023 to present date, that the nurse last time visited Patient 9 on 1/15/2024, and that the agency informed the patient and family members about the purpose of the hospice care services. FM 4 got upset and stated he did not know that his mother was on hospice. FM 4 stated that he is in charge of the patient's care and did not consent to the hospice services. FM 4 stated that he was not notified of the service and asked who took the patients information to be admitted to the hospice. FM 4 further stated that he does not know the doctor listed on the HA's information and stated that there was no nurse that comes and visits the patient as stated. FM 4 stated that he is not a doctor and denied that he called the agency for the patient's medications. During an interview and concurrent record review with the Director of Nursing Designee( DOND) and the Administrator (ADM) on 1/21/2024, at 12:00 p.m., ADM stated that the patient's son is a doctor and he called the agency on 11/19/2023 to discontinue the medications. During a concurrent review of the HA's "Communication Log" dated 11/19/2024, indicated that the DOND wrote: "Received a call from patient stating her son is a doctor came to visit and he is the doctor, so he took out medications that he doesn't want to take all meds. Patient does not want to take aspirin (anti-inflammatory drug with different indications) and atorvastatin (medication to treat high blood cholesterol [fat] level) and also the son gave her Diltiazem (medication used to treat high blood pressure), but is not sure of the dosage. Medication was taken from Pharmacy 1. Dr. (doctor) notified. LVN notified to update the dosage of Diltiazem. All IDG (Interdisciplinary Group, the team responsible for the holistic care of the hospice beneficiary) members notified." c. A review of Patient 10s admission record indicated an admission date of 11/7/2023 with the terminal diagnosis of atherosclerotic heart disease (the build-up of fats, cholesterol, and other substances in and on the artery walls). A call attempt was made to Patient 10 on 1/19/2024 and 1/20/2024 and left message to conduct interview. Attempted to conduct a home visit in Patient 10's residence on 1/20/2024, knocked on his door, there was no answer. d. A review of Patient 12's admission record indicated an SOC date of 10/23/2023 with the terminal diagnosis of congestive heart failure (long-term condition in which heart is unable to pump blood well enough to meet the body's needs). A review of Patient 12s undated ";Current Treatment/Medication/DME List" indicated the following physician orders: "Skilled nurse (SN) to assess Vital Signs (VS) during every visit (temperature, blood pressure, heart rate, oxygen saturation, respiration rate), and patient's pain level. SN to educate Patient, PCG (patient caregiver)/Family regarding plan of care, disease process, medication regimen management, pain and symptom management, emergency measures, infection, fall precautions and safety measures, and hotline for hospice... SN may pronounce death. During an interview with FM 5 on 1/21/2024 at 3:30 p.m., FM 5 stated that Patient 12 still goes to his appointments and she is the person who drives the patient to his appointments. FM 5 stated Patient 12 still is able to walk to the bathroom using his walker, is alert and oriented to name, place and person, and had no issues with eating and taking medication. FM 5 stated someone came to her home asking for the patients information for admission which she thought was home health service. FM 5 stated that she thought it was a continuation of the home health because Patient 12 was on home health service before. When asked FM 5 if she has the book left by the agency person, FM 5 stated, "Yes, and a nurse comes to visit the patient once a week and gives her supplies and everything." FM 5 stated that Patient 12 does not have a terminal illness and is not expected to die anytime soon. FM 5 confirmed that he does not know the doctor mentioned by the hospice agency and that Patient 12 is still actively going to the primary doctors which are the patient's urologist (a doctor who specializes in diagnosing and treating diseases of the urinary system) and nephrologist (a doctor who specializes in the kidney [an organ that removes waste from the blood] care and treating diseases of the kidneys) for consultation. A review of the HA's policy titled " Patient Education Process" revised April 2016, indicated that patients and family/caregivers will receive education in verbal, visual, and written format, as appropriate. The scope of teaching will be determined by the assessed needs, abilities, learning preferences, and readiness to learn of the patient and family/caregiver, as well as by the plan of care. Education will be the responsibility of each interdisciplinary group member and will focus on, as appropriate. A review of the HA's policy titled "Physicians' Services: Attending Physician's Role" revised April 2016, indicated "The medical care of each patient admitted to the hospice agency, will be the responsibility of the patient's attending physician. Communication between the attending physician and other members of the interdisciplinary group will be ongoing and documented in the hospice clinical record. When the attending physician is absent, the attending physician must designate another physician to oversee care for the hospice patient, according to his/her medical group's departmental procedure. The attending physician or designee will approve the referral of the patient and family/caregiver to the hospice program, and provide written initial certification of the terminal illness. Supportive documentation will be included. The attending physician will inform the patient and family/caregiver about the prognosis of six (6) months or less and about the hospice program. The physician will make known to the patient and family/caregiver that the goals of the hospice program are palliative, not curative, and that no care will be provided to artificially prolong life. The physician will explain DNR/DNI (Do not resuscitate/Do not Intubate) status to the patient and family/caregiver and document DNR/DNI, if chosen, status for the clinical record, if appropriate. It will also be explained that the focus of patient and family/caregiver care is in the home, and may include short-term inpatient hospital stays or respite (short-term relief for primary caregivers) care as appropriate.

Based on observation, interview, and record review, the hospice agency failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of Patients was met as followed: --- The hospice agency (HA) failed to conduct accurate comprehensive assessment for two of 14 sampled patients (Patient 10 and Patient 12). Refer to L524 The hospice agency (HA) failed to ensure the accurate labeling, disposal, and administering of all drugs and biologicals in accordance to professional standards and manufacturers recommendations to meet the needs of 1 out of 14 sampled patients (Patients 9 and Patient 10). Refer to L530 The cumulative effects of these systemic practices resulted in the delay in the progress and delivery of the plan of care. 3. The hospice agency failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status, and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness for five out of 14 sampled patients (Patients 1, 2, 3, 6 and 7). This deficient practice resulted in patients admitted for hospice care were not appropriately evaluated by the health care professionals and certified to receive the benefits. (Refer to L532).

Based on observation, interview, and record review, the hospice agency (HA) failed to conduct accurate comprehensive assessment for two of 14 sampled patients (Patient 10 and Patient 12). This deficient practice had the potential for the delay in the progress of Patient 10 and 12s delivery of the plan of care. --- a. A review of Patient 10s admission record indicated an admission date of 11/7/2023 with the terminal diagnosis of atherosclerotic heart disease (the build-up of fats, cholesterol [bad fat], and other substances in and on the artery walls) and Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar). A review of Patient 10's "Current Treatment/Medications" for the period of 11/7/2023 to 2/4/2024, indicated: "Skilled Nurse (SN) to assess Vital Signs (VS) during every visit (temperature, blood pressure, heart rate, oxygen saturation [oxygen level in the blood], respiration rate [rate of breathing]), and patient's pain level. SN to educate Patient, PCG (patient caregiver)/Family regarding plan of care, disease process, medication regimen management, pain and symptom management, emergency measures, infection, fall precautions and safety measures, and hotline for hospice. The Fingerstick (a blood test) blood sugar check via glucometer (a medical device used to determine concentration of the glucose (blood sugar) in the blood) twice daily before meals by caregiver. SN may ask the blood glucose level for signs and symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). Report blood glucose levels more than 350 mg/dl (milligrams per deciliter, a unit of measurement of blood sugar) or below 60 mg/dl to hospice. Patient/caregiver is able/willing and competent with blood sugar check, insulin (a treatment for diabetes) administration, and weekly glucometer calibration (a process of checking the device). Return demonstration done at admission. SN may pronounce death. During a record review for Patient 10's electronic medical record (EMR) on 1/21/2024 at 7:45 a.m., the EMR indicated that the skilled nurse had no documentation on the "Endocrine (an organ system involved in the development of diabetes) Tab" and nurse's narrative for the patient's blood sugar every home visit on the following dates: 11/10/2023, 11/11/2023, 11/18/2023, 11/25/2023, 12/2/2023, 12/13/2023, 12/20/2023, 12/21/2023, 12/27/2023, 1/3/2024 and 1/10/2024. b. A review of Patient 12s admission record indicated an admission date of 10/23/2023 with the terminal diagnosis of congestive heart failure (long-term condition in which heart is unable to pump blood well enough to meet body's needs) and Type 2 Diabetes (a condition that affects the way the body processes blood sugar [glucose]). A review of Patient 12's "Current Treatment/Medications" for the period of 1/21/2024 to 3/20/2024, indicated: "Skilled Nurse (SN) to assess Vital Signs (VS) during every visit (temperature, blood pressure, heart rate, oxygen saturation, respiration rate), and patient's pain level. SN to educate Patient, PCG (patient caregiver)/Family regarding plan of care, disease process, medication regimen management, pain and symptom management, emergency measures, infection, fall precautions and safety measures, and hotline for hospice. Fingerstick blood sugar check via glucometer twice daily before meals by caregiver. SN may ask the blood glucose level for signs and symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). Report blood glucose levels more than 350 mg/dl or below 60 mg/dl to hospice. Patient/caregiver is able/willing and competent with blood sugar check, insulin administration, and weekly glucometer calibration. Return demonstration done at admission. SN may pronounce death. A review of Patient 12's electronic medical record (EMR) on 1/21/2024 at 7:45 a.m., the EMR indicated that the skilled nurse had no documentation on the "Endocrine tab" and the nurse's narrative for the patient's blood sugar every home visit on the following dates: 10/26/2023, 10/30/2023, 11/6/2023, 11/13/2023, 11/20/2023, 11/27/2023, 12/3/2023, 12/10/2023, 12/17/2023, 12/24/2023, 1/17/2024 and 1/14/2024. During an interview with the Director of Nursing Designee (DOND) on 1/21/2024 at 12:00 p.m., the DOND stated that the nurse should always add the blood sugar result when the SN do the home visit. The DOND stated it should be placed on the endocrine section or in the narrative for the patient to monitor the patient's blood sugar results and to report it as needed. A review of the HA's policy titled " Medication Monitoring" revised April 2016, indicated the clinician will assess the effect of medications on the patient. The assessment will identify drug interactions, duplicative drug therapy, and noncompliance with drug therapy. The clinical response to medication will be monitored according to the clinical needs of the patient and will include: evaluating the patient's and family/caregiver's perceptions about side effects and efficacy, physical assessment at each visit, Referencing other relevant data, such as laboratory findings and diagnostic studies. The policy indicated the findings, conclusions, and recommendations of medication monitoring will be included in the comprehensive assessment and updates will be made, if needed. The policy further indicated the information obtained through patient medication monitoring will be documented in the patient's clinical record and, if applicable, in the pharmacy record.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the accurate labeling, disposal, and administering of all drugs and biologicals in accordance to professional standards and manufacturers recommendations to meet the needs of one out of 14 sampled patients (Patients 8). These deficient practice had the potential to result in inconsistent medication administration, risks of physical and chemical incompatibilities between the medications and patient altered drug responses. --- A review of Patient 8s admission record indicated an admission date of 11/6/2023 with the terminal diagnosis of hypertensive heart disease with heart failure (hypertensive heart disease refers to changes in the heart structure as a result of chronic blood pressure elevation, which increases the workload on the heart inducing structural and functional changes). A review of Patient 8s ";Current Treatment/Medication/DME (Durable Medical Equipment) List" dated 11/6/2023, indicated Patient 8's physician orders included: "Skilled Nurse (SN) to assess Vital Signs (VS) during every visit (temperature, blood pressure (BP), heart rate (HR), oxygen saturation [oxygen level in the blood], respiration rate [rate of breathing]), and patient's pain level. SN to educate Patent, PCG (patient caregivers)/Family regarding plan of care, disease process, medication regimen management, pain and symptom management, emergency measures, infection, fall precautions and safety measures, and hotline for hospice. SN to visit patient once a week to promote comfort and symptom management. On 1/20/2024 at 11:15 a.m., a home visit was conducted with the licensed vocational nurse 1 (LVN 1) at Patient 8s apartment. Patient 8 was a 79-year-old Caucasian woman who answered and opened the door. Patient 8 was observed to be alert and oriented to name, place, time, and person. Patient 8 was able to walk with the assistance of a four-wheel walker and was able to make needs known. Patient 8 currently lives alone in her apartment. LVN 1 initiated her visit. On 1/20/2024 at 11:15 a.m., during the medication review with LVN 1, the following medication discrepancies were noted: 1. Congestion spray (a medicine helps to relief nasal congestion/stuffy nose), one bottle, once a day as needed for nasal congestion was listed on the agency's medication profile (a written summary/list of all the medications patient takes regularly [current list], including over the counter and complementary medicines). Patient 8 stated she has Fluticasone (prescription nasal spray) spray with no label in her medication box. 2. Diclofenac (a medication used to treat pain) cream was not listed in the agency's medication profile and had no label. Patient 8 stated she is using it for her knee pain. Patient 8 stated she applies two "thumb full" and rubs on her knee and leg. Patient 8 stated she threw the box after it was delivered. During an interview with the Director of Nursing Designee (DOND) on 1/21/2024 at 12:00 p.m., DOND stated that the nurse should perform medication reconciliation every home visit between the medication profile, the medication bottles at the patient's home and call the office and the doctor to confirm the dosage and frequency of the medications not listed. A review of the HA's policy titled "Medication Monitoring", revised April 2016, indicated ongoing patient medication monitoring will use a collaborative approach among the clinicians, physicians, pharmacists, and patients and family/caregivers. The results of medication monitoring will be used to improve the patient's medication regimen. The ongoing monitoring will occur in accordance with the established goals of therapy and be used to: Evaluate the continued use of a medication in the current regimen. Evaluate patient adherence to the prescribed medication regimen. The clinician will assess the effect of medications on the patient. The assessment will identify drug interactions, duplicative drug therapy, and noncompliance with drug therapy. The clinical response to medication will be monitored according to the clinical needs of the patient. A review of the HA's policy titled "Medication Profile", revised April 2016, indicated patients receiving medications by hospice will have a current, accurate profile in the clinical record. The policy indicated the medication profile will be updated for each change to reflect current medications and new and/or discontinued medications.

Based on observation, interview, and record review, the hospice agency (HA) failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status, and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness for five out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, and Patient 7). This deficient practice resulted in patients admitted for hospice care were not appropriately evaluated by the health care professionals and certified to receive the benefits. --- a. A review of Patient 1s admission record indicated a start of care (SOC) date of 12/1/2023, with a terminal diagnosis of hypertensive heart disease (changes in the heart structure and function as a result of chronic blood pressure elevation). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 12/1/2023 to 2/28/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a joint home visit on 1/20/2024, at 12:00 p.m., with LVN 2 at Patient 1s residence, Patient 1 was lying in bed and was sleeping. During an interview on 1/20/2024, at 12:30 p.m., with family member (FM 1), the FM 1 stated Patient 1 had no attending physician and FM 1 referred her to the hospice agency. FM 1 further stated that the agency offered to provide free medical supplies such as lotions, incontinent pads, and shampoo upon patient admission to their hospice service. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 10/26/2023, with a terminal diagnosis of hypertensive heart disease. A review of Patient 2's Physicians Certification for Hospice Benefit, dated 10/26/2023 to 1/23/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit on 1/20/2024, at 1:30 p.m., with LVN 2 at Patient 2s residence, Patient 2 was lying in bed with +2 (a grading system for edema [swelling]) edema on both lower extremities. During an interview on 1/20/2024, at 1:45 p.m., with FM 2, the FM 2 stated Patient 2 had no attending physician and she referred her to the hospice agency. FM 2 also stated that Patient 2 was very weak from old age and needed a nurse to monitor her health condition regularly. c. A review of Patient 3s admission record indicated an SOC date of 12/26/2023, with a terminal diagnosis of COPD (Chronic Obstructive Pulmonary Disease, a group of lung diseases that block airflow and make it difficult to breath). A review of Patient 3's Physicians Certification for Hospice Benefit, dated 12/26/2023 to 3/24/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a phone interview on 1/19/2024, at 2:45 p.m., with FM 3, the FM 3 stated that Patient 3 was not sick and not dying in six months. FM 3 further stated Patient 3 had no attending physician and their family friend referred the patient to the hospice agency. d. A review of Patient 6's admission record indicated an SOC date of 11/4/2023, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other mental functions). A review of Patient 6's Physicians Certification for Hospice Benefit, dated 11/4/2023 to 2/1/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. e. A review of Patient 7's admission record indicated an SOC date of 11/23/2023, with a terminal diagnosis of COPD. A review of Patient 7's Physicians Certification for Hospice Benefit, dated 11/23/2023 to 2/20/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 1/21/2024, at 1:30 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated in order for a new patient to be admitted to their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital from where the patient gets discharged. On 1/29/2024, at 12:30 p.m., during a phone interview with Physician 1, Physician 1 stated that she was not the attending physician, and did not know who the attending physicians were for Patients 1, 2, 3, 6, and 7. Physician 1 stated since Patients 1, 2, 3, 6, and 7 were admitted for hospice service, she became patients' attending physician and signed the referral attending physician section because no one would sign it. Physician 1 further stated that she determined patients' eligibility for hospice services by reviewing patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of six months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. A review of the agency's undated policy and procedure titled "Physician Services-Attending Physician's Role", indicated the attending physician or designee will approve the referral of the patient and family/caregiver to the hospice program, and provide written initial certification of the terminal illness. The policy indicated supportive documentation will be included.

Based on interview and record review, the hospice agency (HA) failed to: a). Ensure the visiting nurse coordinated with the hospice agency efforts to reschedule the missed nursing visits for 1 out of 14 sampled patients, (Patient 14) b). Notify the attending physician regarding edema (swelling) present on both lower extremities for one of 14 sampled patients, (Patient 2). These failures had the potential to result in poor quality care that can affect the affected patients' quality of life. --- a). A review of Patient 14's Patient Profile indicated, a start of care (SOC) date of 9/15/2023, with a diagnosis of chronic obstructive pulmonary disease (COPD- narrowing of the airways making it hard for the patient to breathe) During a review of Patient 14's "Visit Calendar" for the re-certification period from 12/14/2023 to 3/12/2024, the visit calendar included the order for skilled nurse (SN) to visit once a week for nine weeks. to promote comfort and symptom management. A review of the Patient 14s ";Visit Notes" indicated Patient 14 had a missed home visit on 9/25/2023. The Licensed Vocational Nurse (LVN) indicated on her narrative notes, "prior to visit SN gave a call to Patient 14 about the upcoming visit. When SN arrived at Patient 14s residence, Patient 14 did not open the door. Hospice office was notified. A review of the HA's "Communication Notes" by the Director of Nursing Designee (DOND) who received the call from the LVN, the DONDs notes indicated, ";received a call form LVN stating that she called Patient 14 to visit her but Patient 14 requested to reschedule the visit for next week. All interdisciplinary group members (IDG, group of healthcare professionals working together to provide residents with the care they need) was notified. There was no written documentation of efforts made to communicate with Patient 14 regarding the requested reschedule of visit. During an interview with DOND on 1/21/2024 at 12:00 p.m., the DOND stated that the nurse had to document what happened and should have called the family and asked why Patient 14 did not answer the door during her home visit. The DOND stated that the visiting nurse should have coordinated with the Administrator, supervisor and notified the doctor of the missed visits and performed a wellness visit to verify what happened to Patient 14. Several efforts should have been made to reschedule the nurse visit and should have been documented on Patient 14s clinical record. A review of the HHAs policy and procedure titled, ";Missed Visits", revised April 2016, indicated that if a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled, the clinician will notify the physician and the clinical supervisor of the missed visit and the reason for missed visit. Document in the patient's clinical record the following information: 1. Patient name 2. Date and type of visit that was missed 3. Reason for the missed visit 4. Description of any unmet needs and how the patient's needs were met 5. Any other follow-up needed 6. Other person(s) that were notified of the missed visit 7. Signature of staff member reporting the information The clinical supervisor will track the number of missed visits to assess patterns and to assure that the plan of care contained the correct number of planned visits. b). A review of Patient 2s admission record indicated a start of care (SOC) date of 10/26/23, with a terminal diagnosis of hypertensive heart disease (changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation). During a review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG - a team responsible for the holistic care of the hospice beneficiary) form dated 7/24/2023, indicated the frequency of visits for skilled nurse (SN) was once per week plus one prn (as needed) visits for symptom management and support and for any change of patients condition. During a review of Patient 2's License Vocational Nurse (LVN) Visit Note dated 1/18/24, indicated the patient had a pitting edema (+1) at both ankles. During a joint home visit on 1/20/24, at 1:30 p.m., with LVN 2 at Patient 2s residence, Patient 2 was lying in bed with +2 edema (swelling of about 3–4 millimeters deep when the skin is pressed and goes back up in 15 seconds or less) on both lower extremities. LVN 2 was observed touching for the pedal pulses (pulse on top of foot) of both lower legs if it's present. On 1/20/24, at 1:50 p.m., during an interview with LVN 2, LVN 2 stated the Patient 2's both lower legs were edematous (swollen). On 1/21/24, at 11 a.m., during a further review of Patient 2's clinical record, indicated no documented evidence of a communication note that LVN 2 notified the physician regarding the patient's newly identified pitting edema +2 on both lower legs. On 1/21/24, at 1:30 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated she was not aware of Patient 2's new edema found on both lower legs. The DPCS further stated that she could not find any documented evidence that LVN 2 notified the physician of Patient 2's change of condition. A review of the facilitys undated policy and procedure titled, "Monitoring Patient's Response/Reporting To Physician," indicated during each hospice visit, the clinician will notify the patient's physician or the hospice medical director on the same day when there are changes in the patient's condition

Based on interview and record review, the Hospice Agency failed to ensure governing body (designated persons responsible for the management of the hospice agency) meetings were done, and the hospice agencies policies were signed. This deficient practice had the potential to result in the hospice agency not operating its day-to-day operations according to regulations and can affect the continuous quality assessment and performance improvement projects of the agency. --- On 1/21/2024 at 1:40 p.m., a request was made to the Administrator to review their governing body minutes. During a concurrent interview and record review of the agency's governing body minutes on 1/21/2024, at 1:41 p.m., with the Director of Nursing Designee (DOND) and the Administrator (Admin), the DOND and Admin stated that the governing body meets regularly and signs the attendance. When asked about the progress of the meeting, the Admin and DOND showed that the policies were not dated and signed on the date the governing bodys meeting was done. The Admin and DOND stated the agency will update their policies on the next meeting and will make sure they will sign the attendance sheet and the policy sheet. The DOND and Admin agreed that the goals, interventions, and the outcome should be stated and reviewed if it was mentioned in the governing body meeting. A review of the HAs policy and procedure titled, ";Appointment of Executive Director/Administrator", dated 4/2016, indicated the Executive Director/ Administrator of hospice will take reasonable steps to ensure that... hospice complies with applicable law and regulation... Action is taken on reports and recommendations of any authorized planning or regulatory inspection agency.

Based on observation, interview, and record review, the Hospice Agency failed to ensure the Condition of Participation for Medical Director was met as evidenced by: --- 1. 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 an assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (a hospice physician narrative designed to explain the clinical findings that support a life expectancy of six months or less), to qualify for hospice care and services (health care that focuses on the palliation to ease the symptoms without curing the underlying disease of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) for five of 14 sampled patients (Patients 1, 2, 3, 6 and 7). (Refer to L667) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory mandated (state law) compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was 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 conducted an assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (a hospice physician narrative designed to explain the clinical findings that support a life expectancy of six months or less), to qualify for hospice care and services (health care that focuses on the palliation to ease the symptoms without curing the underlying disease of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) for five of 14 sampled patients (Patients 1, 2, 3, 6 and 7). This deficient practice resulted in the Medical Director certifying these patients without clinical documentation to receive the hospice benefits. --- a. A review of Patient 1s admission record indicated a start of care (SOC) date of 12/1/23, with a terminal diagnosis of hypertensive heart disease (changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 12/1/23 to 2/28/23, benefit period number (#) 1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit on 1/20/24, at 12 p.m., with Licensed Vocational Nurse (LVN) 2 at Patient 1s residence, Patient 1 was lying in bed asleep. During an interview on 1/20/24, at 12:30 p.m., with Family Member (FM 1), FM 1 stated Patient 1 had no attending physician and FM 1 referred her to the hospice agency. FM 1 further stated that the agency offered to provide free medical supplies such as lotions, incontinent pads, and shampoo upon patient admission to their hospice service. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 10/26/23, with a terminal diagnosis of hypertensive heart disease (changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 10/26/23 to 1/23/24, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit on 1/20/24, at 1:30 p.m., with LVN 2 at Patient 2s residence, Patient 2 was lying in bed with +2 edema (swelling of about 3–4 millimeters deep when the skin is pressed and goes back up in 15 seconds or less) on both lower extremities. During an interview on 1/20/24, at 1:45 p.m., with FM 2, FM2 stated Patient 2 had no attending physician and she referred her to the hospice agency. She also stated that Patient 2 was very weak from old age and needed a nurse to monitor her health condition regularly. c. A review of Patient 3s admission record indicated a start of care (SOC) date of 12/26/23, with a terminal diagnosis of COPD (chronic obstructive pulmonary disease). A review of Patient 3's Physicians Certification for Hospice Benefit, dated 12/26/23 to 3/24/24, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a phone interview on 1/19/24, at 2:45 p.m., with FM 3, she stated Patient 3 was not sick and not dying in six months. She further stated the patient had no attending physician and their family friend referred the patient to the hospice agency. d. A review of Patient 6's admission record indicated an SOC date of 11/4/23, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other other mental functions). A review of Patient 6's Physicians Certification for Hospice Benefit, dated 11/4/23 to 2/1/24, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. e. A review of Patient 7's admission record indicated an SOC date of 11/23/23, with a terminal diagnosis of COPD. A review of Patient 7's Physicians Certification for Hospice Benefit, dated 11/23/23 to 2/20/24, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 1/21/24, at 1:30 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital from where the patient gets discharged. On 1/29/24, at 12:30 p.m., during a phone interview with Physician 1, Physician 1 stated that she was not the attending physician, and did not know who the attending physicians were for Patients 1, 2, 3, 6 and 7. Physician 1 stated since Patients 1, 2, 3, 6 and 7 were admitted for hospice service, she now becomes the patient's attending physician, signed the referral attending physician section because no one would sign it. Physician 1 further stated that she determined the patients' eligibility for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. A review of the agencys undated policy and procedure titled ";Physician Services-Medical Director", indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care.

Upon patient client record review, 5 of 5 (Patient #1, #2, #3, #4 and #5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1-5 There was white out applied on the Election of Benefit form with agency name handwritten in ink over the white out area.

Upon policy and procedure review, there was no evidence that hospice had developed written policies and procedures to ensure that all personnel are fully vaccinated for COVID19. The policies and procedures include, at a minimum, the following components: • A process for ensuring all personnel specified in 42 CFR 418.60(d)(1) (except for those personnel who have pending requests for, or who have been granted, exemptions to the vaccination requirements of 42 CFR 418.60(d), or those personnel for whom COVID-19 vaccination must be temporarily delayed, as recommended by CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to personnel providing any care, treatment, or other services for the Hospice and/or its patients; • A process for ensuring that all personnel specified in 42 CFR 418.600(d)(1) are fully vaccinated, except for those personnel who have been granted exemptions to the vaccination requirements of 418.60(d), or those personnel for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations. • A process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19, for all personnel who are not fully vaccinated for COVID-19. • A process for tracking and securely documenting the COVID-19 vaccination status of all personnel specified in 42 CFR 418.60(d)(1). • A process for tracking and securely documenting the COVID-19 vaccination status of any personnel who have obtained any booster doses as recommended by CDC. • A process by which personnel may request an exemption from the personnel COVID-19 vaccination requirements based on an applicable federal law. • A process for tracking and securely documenting information provided by those personnel who have requested, and for whom the Hospice has granted, an exemption from the personnel COVID-19 vaccination requirements. • A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines, and which supports personnel requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local laws, and for further ensuring that such documentation contains: • All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the personnel member to receive and the recognized clinical reasons for the contraindications; and • A statement by the authenticating practitioner recommending that the personnel member be exempted from the Hospice's COVID-19 vaccination requirements for personnel based on the recognized clinical contraindications. • A process for ensuring the tracking and secure documentation of the vaccination status of personnel for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and • Contingency plans for personnel who are not fully vaccinated for COVID-19. The Policies and Procedures: COVID-19 ETS is not current. This policy requires organization with > 100 employees to be fully vaccinated or elect to undergo regular COVID testing and wearing face mask in lieu of the vaccination requirement.