Every finding on record at Prestige Hospice Care

Based on interview and record review the Hospice Agency (HA) failed to ensure one of 15 sample patients (Patient 10) and the care giver were informed of the State toll-free hotline number to lodge complaints including their hours of operations. This failure had the potential to result in the violation of the patient's rights to be informed of the home health hotline number and its purpose. --- During a record review of Patient 10s medical record form titled ";Personal Information" indicated a start of care date of 2/26/2023 with a primary diagnosis of chronic kidney failure (kidneys unable to function properly". During a joint home visit on 3/13/2024 at 9:15 a.m., with Registered Nurse 2 (RN2) to Patient 10s home, we were greeted by Patient 10s care giver (CG2). CG2 stated she was not informed by the HA of the State toll free complaint number and its contact information. CG 2 stated, ";no one ever told me." RN2 stated that patients and their family need to be provided and informed of the State complaint number in case they suspect and must report abuse. During a record review of HAs policy and procedure titled ";Patient Bill of Rights/Responsibilities" revised 4/20219, indicated ";The patient bill of rights/responsibilities statement defines the right of the patient to: Use the district office of the Department hotlines to lodge complaints..."

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participations regarding Initial and Comprehensive Assessments of Patients was met as follows: --- 1. The HA failed to conduct and accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for nine of 15 sample selected patients (Patient 1, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 12, Patient 13, and Patient 14). (Refer to L 522). 2. The HA failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met to complete and document patients comprehensive assessment within 5 calendar days after their start of care for eight of 15 sampled patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 9, and Patient 10). (Refer to L 523). 3. The HA failed to review all medications the patients were taking and update their medication profiles with the currently used medications for two of 15 sample selected patients (Patient 3 and Patient 10). The patients were at risk for medication errors and adverse drug reactions. (Refer to L 530). 4. The HA failed to conduct or attempt to conduct an initial bereavement assessment to provide bereavement counseling in accordance with the patient/family/caregivers needs for four of 15 sample selected patients (Patient 2, Patient 3, Patient 4, and Patient 9). (Refer to L531). 5. The HA failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met to discuss and update four out of 15 sample selected patients (Patient 3, Patient 8, Patient 9, and Patient 10) comprehensive assessments at least every 15 days. (Refer to L 533). The cumulative effect of these systemic practices resulted in the failure of the Hospice agency to deliver mandated compliance with the Federal regulations for Initial and Comprehensive Assessment of Patients to ensure provision of the highest quality of care to patients certified to receive the hospice benefits.

Based on observation, interview, and record, the registered nurse (RN) staff failed to conduct and accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for nine of 15 sample selected patients (Patient 1, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 12, Patient 13, and Patient 14). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential to result of the patients not receiving appropriate healthcare services that could affect their quality of life. --- 1. During a record review of Patient 1s ";Personal Information", indicated a start of care on 2/1/2023, with a primary diagnosis of hemiplegia following cerebral infarction, affected right dominant side (right sided weakness due to brain attack). The record further indicated an end of care date on 1/17/2024 with reason of revocation of hospice. During a concurrent interview and record review on 3/14/2023, at 12:07 p.m., the Director of Nurses (DON) reviewed Patient 1s record titled, ";Comprehensive Nursing Assessment", dated 2/1/2024. The DON stated the LCD (Local Coverage Determination, a tool used to determine if patient meets criteria to be in hospice care) was a requirement to admit the patient into hospice care. The DON stated, "Patient 1 did not have an LCD assessment completed and the doctor needed to be asked if his admission to hospice care was appropriate". During a record review of Patient 1s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for the 1st certification 2/1/2023 to 5/12023, indicated, ";Physician Narrative: Based on RNs (Registered Nurse) assessment, Patient qualifies for hospice." There was documented evidence Patient 1s comprehensive assessment included the LCD to accurately reflect the criteria the patient met to be admitted into hospice care. 2. During a record review of Patient 3s ";Personal Information", indicated a start of care on 1/31/2024, with a primary diagnosis of unspecified systolic congestive heart failure (heart is not working well). The record indicated this was a re-admission, with a second certification period. During a record review of Patient 3s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for the 2nd certification 1/31/2024 to 4/29/2024, indicated, ";Physician Narrative: Based on RNs (Registered Nurse) assessment, Patient qualifies for hospice." During an observation of the home visit on 3/13/2024, at 10 a.m., with Licensed Vocational Nurse 1 (LVN 1), Patient 3 was sitting in the living room sofa, awake, alert and oriented. Patient 3 was talking to the nurse with an unlabored breathing pattern and no use of oxygen. During an observation of the home visits on 3/13/2024, at 10:20 a.m., LVN 1 asked Patient 3 about her appetite. Patient 3 stated she went out to eat to Applebees and was able to eat an entire salad because it was good, but only ate about ¼ of the dinner because she was already full of the salad. During an interview at the home visit on 3/13/2024, at 10:22 a.m., Patient 3s daughter (CG 3) stated they asked to be referred to the agency due to Patient 3 having been hospitalized after experiencing a heart attack 2-3 months ago. CG 3 stated they were aware of the agency a year ago, when Patient 3 experienced a heart attack. CG 3 stated the reason they requested hospice was because Patient 3 was too weak to go to the doctors appointments and she really needed help at home. CG 3 stated a doctor had not told her Patient 3 was terminal or that she had 6 months or less to live. CG 3 stated Patient 3 was getting better and eating more. CG 3 stated Patient 3 needed oxygen at the beginning, used it for a short period of time, but she doesnt need it anymore. During an observation of the home visits on 3/13/2024, at 10:30 a.m., Patient 3 walked to the kitchen, without the use of a cane or walker. During ambulation (walking) Patient 3s breathing was unlabored, not using oxygen, lips were pink, and there was no change in her skin color. During a concurrent interview and record review on 3/14/2024, at 12:13 p.m., the DON reviewed Patient 3s record titled, ";Comprehensive Nursing Assessment", dated 1/31/2024. The DON stated the LCD was used and indicated Patient 3 met hospice criteria because of NYHA IV (4) (New York Heart Association, a tool used to classify the degree of heart failure). The DON stated NYHA 4 meant a patient is not able to perform any activities, laying down, and not doing anything. The Patient would be having symptoms at rest such as shortness of breath even without any activity, increase discomfort with any activity, and they would require continuous oxygen. During a continued record review of the ";Comprehensive Nursing Assessment", dated 3/14/2024, indicated Patient 3 was ";ambulatory", wheelchair was selected and ";non-ambulatory", bed bound was selected. Sections ";Cardiovascular" (heart and circulation) and ";Respiratory" (lungs) of the assessment were also reviewed with the DON. The DON stated the respiratory assessment was documented incorrectly. It should say patient was on 2 liters of oxygen continuously. The DON stated the document indicated Patient 3 used oxygen as needed. Patient 3s oxygen saturation was 92% (%-percentage of oxygen in the blood) on room air (breathing without the use of oxygen). The DON stated the cardiovascular assessment was normal. The DON stated the assessment was documented incorrectly. Based on the assessment Patient 3 did not qualify for hospice. The DON stated the physical assessment done to admit Patient 3 into hospice care, did not meet the NYHA IV criteria. 3. During a record review of Patient 4s ";Personal Information", indicated a start of care on 2/17/2024, with a primary diagnosis of Hypertensive heart disease without heart failure (high blood pressure). The record further indicted this was Patient 4s 5th certification period, and the admission type was a ";Re-Admit". During a record review of Patient 4s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for the 5th certification 2/17/2024 to 4/16/2024, indicated, ";Physician Narrative: Based on RNs (Registered Nurse) assessment, Patient qualifies for hospice." During a concurrent interview and record review on 3/14/2024, at 12:26 p.m., the DON reviewed Patient 4s record titled, ";Comprehensive Nursing Assessment", dated 2/17/2024. The DON stated the LCD was used and indicated Patient 4 met hospice criteria because of NYHA IV. The DON reviewed sections ";Cardiovascular" and ";Respiratory" of the document and stated, the heart and lung assessment was normal. Patient 4s oxygen saturation was 95% room air, and he did not have shortness of breath. The DON stated the assessment did not qualify him for a NYHA IV. The DON stated there was no diagnostic reports or history and physical (a document that indicates the past and current medical conditions, and plan of care) to support Patient 4 had heart failure NYHA 4. 4. During a record review of Patient 5s ";Personal Information", indicated a start of care on 6/3/2023, with a primary diagnosis of heart disease, unspecified. The record further indicted this was Patient 5s 1st certification period. During a record review of Patient 5s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for the 1st certification 6/3/2023 to 8/31/2023, indicated, ";Physician Narrative: Based on RNs (Registered Nurse) assessment, Patient qualifies for hospice." During a concurrent interview and record review on 3/14/2024, at 12:30 p.m., the DON reviewed Patient 5s record titled, ";Comprehensive Nursing Assessment", dated 6/13/2023. The DON stated the LCD was used and indicated Patient 5 met hospice criteria because of NYHA IV. The DON reviewed sections ";Cardiovascular" and ";Respiratory" of the document and stated, the heart and lung assessment was normal. Patient 5s oxygen saturation was 93% room air and he did not have shortness of breath. The DON stated the assessment did not qualify her for a NYHA IV. The DON stated there was no diagnostic reports or history and physical (a document that indicates the past and current medical conditions, and plan of care) to support Patient 5 had heart failure NYHA 4. The DON stated the LCD was marked incorrectly. 5. During a record review of Patient 6s record titled, ";Personal Information", indicated a start of care on 12/16/2023 with a primary diagnosis of Chronic obstructive pulmonary disease, unspecified (a lung condition that makes breathing difficult). The record further indicated this was Patient 6s 1st certification period. During a record review of Patient 6s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for the 1st certification 12/16/2023 to 3/14/2024, indicated, ";Physician Narrative... meets LCD guidelines for hospice eligibility. Based on patient current status...team assessment...patient qualifies for hospice..." During a concurrent interview and record review on 3/14/2024, at 12:38 p.m., the DON reviewed Patient 6s record titled, ";Comprehensive Nursing Assessment", dated 12/16/2023. The DON stated the LCD was used and indicated Patient 6 met hospice criteria because ";yes" was marked to ";Documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, less than 30% predicted (if available)?" (a lung test to see how the lungs work), ";yes" was marked to ";Increasing physician home visits (prior to hospice admission)?, and ";yes" to O2 (oxygen) Sats (saturation) less than or equal to 88% determined either by arterial blood gases or O2 saturation monitors? (these values may be obtained from recent hospital records). Continued review of the record indicated Patient 6s oxygen saturation on the day of assessment was 92% on room air. The DON stated there was no history and physical or any other medical record to support the ";yes" answers to the LCD. The DON stated she assumed the information on the assessment was correct, but the LCD was filled out incorrectly. There was no documented evidence Patient 6s comprehensive assessment indicated the accurate condition of the patient to qualify for hospice care. 6. During a record review of Patient 7s record titled, ";Personal Information", indicated a start of care on 10/16/2023, with a primary diagnosis of Unspecified cirrhosis of liver (liver not working well). The record further indicated the 3rd certification period, and ";Admit Type Re-Admit". During a concurrent interview and record review on 3/14/2024, at 12:46 p.m., the DON reviewed Patient 7s record titled, ";Comprehensive Nursing Assessment", dated 10/16/2023. The DON stated the LCD was used and indicated Patient 6 met hospice criteria because ";yes" was marked to the following lab tests: ";Prothrombin time prolonged more than 5 seconds over control?", International Normalized Ration (INR) > 1.5?", and ";Serum albumin < 2.5 gm/dl?" ";Yes" was marked to ";Ascites, refractory to treatment or patient non-compliant?". The DON stated there was no record of lab results history and physical, or any other medical documents to support Patient 7s diagnosis. The DON stated the assessment of Patient 7s abdomen was documented as normal. If she had ascites (toxin build up in the belly, due to liver failure), the DON would measure the abdomen and document it. The DON stated Patient 7s skin assessment was documented as normal. The DON stated the expectation based on ascites and labs including jaundiced skin color. The DON stated the LCD was documented incorrectly. There was no documented evidence Patient 7s comprehensive assessment indicated the accurate condition of the patient to qualify for hospice care. 7. During a record review of Patient 12s ";Personal Information", indicated a start of care on 12/6/2023, with a primary diagnosis of Alzheimers Disease (progressive memory loss). During a record review of Patient 12s record titled, ";Physicians Certification for Hospice Benefit", for the 1st certification 12/6/2023 to 3/4/2024, indicated, ";Based on RNs assessment, Patient qualifies for hospice." During a concurrent interview and record review on 3/15/2023, at 12:40 p.m., with the DON of Patient 12s EMR medical record form titled, ";LCD Hospice Eligibility Determination", dated 12/6/2023, the DON stated Patient 12s LCD was incorrect because she was able to bathe, eat, and get dressed with minimal assistance. DON stated Patient 12 did not have a urinary catheter (soft hollow tube inserted into the urinary bladder through the urethra) and was able to ambulate to the restroom. DON also stated Patient 12 was able to communicate and had lost weight but did not know how much weight was lost. There was no documented evidence Patient 12s initial nursing assessment included an accurate LCD that reflect the criteria the patient met to qualify for hospice care. 8. During a record review of Patient 13s ";Personal Information", indicated a start of care on 12/6/2023, with a primary diagnosis of senile degeneration of brain (progressive memory loss). During a record review of Patient 13s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for the 1st certification 12/6/2023 to 3/4/2024, indicated, ";Physician Narrative: Based on RNs (Registered Nurse) assessment, Patient qualifies for hospice." During a record review of Patient 13s record titled, ";LCD Hospice Eligibility Determination" dated 12/6/2023, indicated the form was left blank. The form also indicated ";Patient does not qualify per LCD guidelines." During a concurrent interview and record review on 3/15/2023, at 12:45 p.m., the DON of Patient 13s electronic medical record (EMR) medical record form titled, ";Nursing Assessment" dated 12/6/2024, the DON stated Patient 13 did not have an LCD assessment completed. DON stated Patient 13s nursing assessment was inaccurate. DON stated that according to her narrative Patient 13 did not qualify for hospice services. Patient 13s initial nursing assessment did not include the LCD to accurately reflect the criteria the patient met to be admitted into hospice care. 9. During a record review of Patient 14s ";Personal Information", indicated a start of care on 6/21/2023, with a primary diagnosis of hypertensive (high blood pressure) without heart failure. During a record review of Patient 14s record titled, ";Physicians Certification for Hospice Benefit", for the 1st certification 6/21/2023 to 9/18/2023, indicated, ";Physician Narrative... meets LCD guidelines for hospice eligibility. Based on patient current status, medical condition...team assessment...patient qualifies for hospice..." During a concurrent interview and record review on 3/15/2023, at 12:30 p.m., with the DON of Patient 14s electronic medical record (EMR) medical record form titled, ";LCD Hospice Eligibility Determination", dated 6/21/2023. The DON stated the LCD was a requirement to admit the patient into hospice care. The DON stated that according to Patient 14s LCD, he met the hospice criteria, but that it was inaccurate because Patient 14 did not have discomfort without activity. DON stated Patient 14 did not meet hospice criteria. Patient 14 was called at number on HAs file on 3/13/2024 at 1:01 p.m., with no answer. Patient 14s initial nursing assessment did not include an accurate LCD that reflect the criteria the patient met to qualify for hospice care. During a record review of HAs policy and procedure titled ";Initial Assessment" revised 4/2019, indicated ";An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care unless otherwise specified by the physician, patient or representative to be completed in less than 48 hours.

Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met to complete and document patients comprehensive assessment within 5 calendar days after their start of care for eight of 15 sampled patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 9, and Patient 10). This failure resulted in the HA not identifying patients need for hospice services/care and claiming reimbursement for patients who did not need hospice service to manage their terminal illness. It also had the potential to result to patients not receiving appropriate healthcare services that could affect their health and quality of life. --- 1. During a record review of Patient 2s record titled, ";Personal Information", indicated a start of care on 10/20/2023 with a primary diagnosis of senile degeneration of brain. The record further indicated an end of care date of 12/17/2023 with a reason of death. During a record review of Patient 2s medical records, on 3/14/2024, did not indicate the MSW had done a Psychosocial Assessment. 2a. During a record review of Patient 3s ";Personal Information", indicated a start of care on 1/31/2024, with a primary diagnosis of unspecified systolic congestive heart failure (heart is not working well). The record indicated this was a re-admission, with a second certification period. During an interview at the home visit on 3/13/2024, at 10:22 a.m., Patient 3 stated she had never been visited or called by an MSW. Caregiver 4 (CG 4) stated MSW had not come to Patient 3s home nor had she called Patient 3 over the phone. During a concurrent interview and record review on 3/15/2024, at 1:03 p.m., the Director of Nurses (DON) reviewed Patient 3s record titled ";Psychosocial Assessment", dated 2/3/2024. The record indicated, ";MSW completed an initial assessment over the phone per patient`s request. Necessary assessment of the patient`s condition and needs were completed. Patient declined MSW care, so will offer in next benefit period." Further review of the record indicated the form was empty. The DON stated the assessment was incomplete and the assessment was not done. During a record review of Patient 3s audit log (a report that shows who made changes, additions, or modifications to an electronic medical record), dated 1/31/2024 to 3/15/2024, indicated the MSW added the narrative ";MSW completed an initial assessment over the phone..." on 3/12/2024. The record indicated the previous value was empty (nothing documented). During the survey, the MSW was not available for an interview. 2b. During a concurrent interview and record review on 3/15/2024, at 1:09 p.m., the DON reviewed Patient 3s record titled ";Spiritual Assessment", dated 2/2/2024. The record indicated, ";SC completed an initial assessment over the phone per patient`s request. Necessary assessment of the patient`s condition and needs were completed. Patient declined SC care, so will offer in next benefit period." Further review of the record indicated the form was empty. The DON stated the assessment was incomplete and the assessment was not done. During a record review of Patient 3s audit log, dated 1/31/2024 to 3/15/2024, indicated the SC added the narrative, ";SC completed an initial assessment over the phone per patients request..." on 3/12/2024. During the survey, the SC was not available for an interview. 3a. During a record review of Patient 4s ";Personal Information", indicated a start of care on 2/17/2024, with a primary diagnosis of Hypertensive heart disease without heart failure (high blood pressure). The record further indicted this was Patient 4s 5th certification period, and the admission type was a ";Re-Admit". During a concurrent interview and record review on 3/15/2024, at 1:05 p.m., the DON reviewed Patient 4s record titled ";Psychosocial Assessment", dated 2/18/2024. The record indicated, ";Provided Initial assessment, but patient declined the further visit. Will offer in next period." The DON stated the assessment was completely empty and the assessment had not been done. 3b. During a concurrent interview and record review on 3/15/2024, at 1:10 p.m., the DON reviewed Patient 4s record titled ";Spiritual Assessment", dated 2/19/2024. The record indicated, ";SC completed an initial assessment over the phone per patient`s request. Necessary assessment of the patient`s condition and needs were completed. Patient declined SC care, so will offer in next benefit period." There was no evidence SC completed the spiritual assessment 4 within 5 days of the start of care. 4a. During a record review of Patient 5s ";Personal Information", indicated a start of care on 6/3/2023, with a primary diagnosis of heart disease, unspecified. The record further indicted this was Patient 5s 1st certification period. During a concurrent interview and record review on 3/15/2024, at 1:06 p.m., the DON reviewed Patient 5s record titled ";Psychosocial Assessment", dated 6/5/2024. The record indicated, ";MSW visited patient to provide initial psychosocial assessment. Patients living environment is clean, safe and appropriate. MSW provided emotional support to patient through active listening, encouraged her to express feelings, thoughts and to utilize coping techniques to relief sadness and frustration. MSW found no concerns. MSW encouraged patient to call hospice if any changes in condition or if any concerns. MSW offered psychosocial care, but patient declined. Will offer Psychosocial Care for next benefit period." The DON stated the assessment was completely empty and the assessment had not been done. Based on the document, the HA did not know what the needs of Patient 5 were. there was no evidence MSW completed the within 5 days of the start of care. 4b. During a concurrent interview and record review on 3/15/2024, at 1:11 p.m., the DON reviewed Patient 5s record titled ";Spiritual Assessment", dated 6/7/2023. The record indicated, ";Chaplain visited the patient. Patient was alert and oriented, verbal, able to converse and communicate his spiritual and emotional needs..." The DON stated the assessment was incomplete, and as a result, the HA did not know what the spiritual needs of patient 5 were. The SC assessment was not completed within 5 days of the start of care. 5a. During a record review of Patient 6s record titled, ";Personal Information", indicated a start of care on 12/16/2023 with a primary diagnosis of Chronic obstructive pulmonary disease, unspecified (a lung condition that makes breathing difficult). The record further indicated this was Patient 6s 1st certification period. During a concurrent interview and record review on 3/15/2024, at 1:07 p.m., the DON reviewed Patient 6s record titled ";Psychosocial Assessment", dated 12/19/2023. The record indicated, ";MSW visited patient to provide initial psychosocial assessment...MSW offered psychosocial care, but patient declined. Will offer Psychosocial Care for next benefit period." The DON stated the assessment was incomplete and was not considered done. Based on the document, the HA did not know what the needs of Patient 6 were. 5b. During a concurrent interview and record review on 3/15/2024, at 1:11 p.m., the DON reviewed Patient 6s record titled ";Spiritual Assessment", dated 12/20/2023. The record indicated, ";Chaplain contacted the patient caregiver and they agreed for a chaplain visit...". The DON stated the assessment was not done because the form was empty. Based on the document, the HA did not know what the spiritual needs of Patient 6 were. 6a. During a record review of Patient 7s record titled, ";Personal Information", indicated a start of care on 10/16/2023, with a primary diagnosis of Unspecified cirrhosis of liver (liver not working well). The record further indicated the 3rd certification period, and ";Admit Type Re-Admit". During a record review on 3/15/2024, Patient 7s record titled, ";Psychosocial Assessment", dated 10/18/2024, indicated, ";MSW visited patient to provide initial psychosocial assessment...Patient and caregiver declined psychosocial care. Will offer next benefit period". Further review of the record did not have documented evidence of a detailed psychosocial assessment. Many areas of the document were blank and incomplete. There was no documented evidence the MSW completed a psychosocial assessment within 5 days of the start of care. 6b. During a record review on 3/15/2024, Patient 7s record titled, ";Spiritual Assessment", dated 10/19/2023, indicated, ";Chaplain visited the patient for spiritual comprehensive assessment and support...Patient declined spiritual care and support. Chaplain will offer in next benefit period." Further review of the record did not have documented evidence of a detailed spiritual assessment. Many areas of the document were blank and incomplete. There was no documented evidence the SC completed a spiritual assessment within 5 days of the start of care. 7a. During a record review of Patient 9s medical record form titled ";Personal Information" indicated a start of care date of 11/7/2023 and an end of care date of 11/13/2023, with a primary diagnosis of unspecified combined systolic and diastolic congestive heart failure (weak left heart ventricle). During a record review of Patient 9s medical record form titled ";POC/IDG Review" dated 11/7/2023, indicated it was not signed by the Registered Nurse (RN). During a telephone interview on 3/13/2024 at 1:54 p.m. with Patient 9s care giver/son (CG1), CG1 stated he was Patient 9s care giver. CG1 stated Patient 9 never received care from HA. CG1 stated his brother (S1) takes care of his mother because it was difficult to take care of both their mother and father in the same home. CG1 stated the owner of HA called him on behalf of his brother, but that he never signed up with the HA. 7b. During a record review of Patient 9s medical record form titled ";POC Summary" dated as of 3/12/2024, indicated ";SC (spiritual Counselor) 1 – per month +1 PRN visit for support and counseling." During a record review of Patient 9s electronic medical record (EMR) medical record form titled ";History of Spiritual Assessment" indicated there were no entries. There was documented evidence an initial spiritual assessment was completed within 5 days of the start of care. 7c. During a record review of Patient 9s medical record form titled ";POC Summary" dated as of 3/12/2024, indicated an order for ";MSW visits – 1 per month +1 PRN (as needed) visits for support and counseling – to provide psychosocial support to patient and family." During a record review of Patient 9s electronic medical record titled ";History of Psychosocial Assessment" indicated there were no entries. The HA failed to complete an initial psychosocial assessment within 5 days of the start of care for Patient 9. During a record review of Patient 9s medical record form titled ";POC Summary" dated as of 3/12/2024, indicated an order for ";Bereavement Coordination to assess and evaluate bereavement and grieving risk factor within 5 days of admission." During a record review of Patient 9s electronic medical record titled ";History of Bereavement Assessment" indicated there were no entries. The HA failed to complete an initial bereavement assessment within 5 days of the start of care for Patient 9. 8. During a record review of Patient 10s medical record form titled ";Personal Information" indicated a start of care date of 2/26/2023 with a primary diagnosis of chronic kidney failure (kidneys unable to function properly". During an interview on 3/13/2024 at 9:15 a.m., with Patient 10s care giver (CG2), CG2 stated she has not been contacted by the MSW. During an interview on 3/14/2024 at 11:03 a.m., with the DON, the DON stated the Medical Social Worker (MSW) needs to see patients within five days of admission to make sure patient and their family have all the resources available to them. DON stated the spiritual assessment also needs to be completed within five days of admission by the Spiritual Counselor (SC) to be able to assist the patient and their family during the difficult time and to provide spiritual help. DON stated the MSW is responsible for the bereavement assessment. DON stated the bereavement assessment needs to be completed within 5 days start of care. DON stated that the bereavement assessment is important for patients and families. DON stated, ";Bereavement assessment, is basically when they are getting close to end of life and just to make sure, to assess the mental status pretty much how the patient and family are coping with everything." SC was called on 3/14/2024 at 1:29 p.m., with no answer. Message with call back number left. MSW was called on 3/14/2024 at 1:30 p.m. with no answer. Message with call back number left. IC was asked to call the SC and MSW on 3/14/2024 at 1:32 p.m. IC stated neither answered and that she left a call back number. IC was asked to call the SC and MSW on 3/15/2024 at 10:54 a.m. IC stated neither are answering her calls. During a record review of HAs policy and procedure titled ";Initial Assessment" revised 4/2019, indicated ";Admitting registered nurse will determine the other disciplines to complete the appropriate sections of the comprehensive assessment based on identified problems and needs during this initial assessment." During a record review of HAs policy and procedure titled ";Ongoing Assessment" revised 4/2019, indicated ";During each home visit, the Case Manager or the other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. The nurse will assess each patient on each visit for: functional status. During a record review of HAs policy and procedure titled ";Comprehensive Assessment" revised 4/2019, indicated ";A comprehensive assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. The assessment should determine: probable prognosis of six (6) months or less. The organization must assure that the data elements allow for measurement of outcomes. The Clinical Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but an a minimum every 15 days. If no changes are needed, then that must be documented. If there has been a change in the patients condition/status, then the comprehensive assessment must be updated." During a record review of HAs policy and procedure titled ";Interdisciplinary Group Meeting" revised 4/2019, indicated ";Each patient plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. The hospice Medical Director and all hospice interdisciplinary group members will be present... Members at the interdisciplinary group meeting will sing an attendance from that will be kept by the hospice Clinical Supervisor.

Based on observation, interview and record review, the Hospice Agency (HA) staff failed to review all medications the patients were taking and update their medication profiles with the currently used medications for two of fifteen sample selected patients (Patient 3 and Patient 10). This deficient practice had the potential risk to result in medication errors and adverse drug reactions jeopardizing the health and safety of the hospice patients. --- During an interview on 3/14/2024, at 11:37 a.m., the Director of Nurses (DON) stated medication reconciliation/review should be done every visit to make sure the patient had the right medications that they should be taking. 1. During a record review of Patient 3s ";Personal Information", indicated a start of care on 1/31/2024, with a primary diagnosis of unspecified systolic congestive heart failure (heart is not working well). The record indicated this was a re-admission, with a second certification period. On 3/13/2024, at 10 a.m., a home visit was conducted with the Licensed Vocational Nurse 1 (LVN 1) at Patient 3's home. On 3/13/2024, at 10:26 a.m., LVN 1 reviewed the medications Patient 3 was taking at home, using Patient 3s record titled, ";Current Treatment/Medication/DME list", printed on 3/12/2024. Medication ";Baclofen" (to treat muscle pain) had the wrong dose listed. The bottle at home indicated to take 10 mg (mg-milligram unit of measurement) tablet 3 times a day. The record indicated to take 5 mg tablet 3 times a day. On 3/13/2024, at 10:30 a.m., LVN 1 reviewed the medications Patient 3 was taking at home, using Patient 3s record titled, ";Current Treatment/Medication/DME list". The following medications were in Patient 3s home but not listed on the record: Nitrofurantoin (an antibiotic to treat and prevent urinary tract infections). Ibuprofen (for pain). Carvedilol (for heart failure). Patient 3s medication profile updated to accurately reflect the medications being taken at home. 2a. During a record review of Patient 10s medical record form titled ";Personal Information" indicated a start of care date of 2/26/2023 with a primary diagnosis of chronic kidney failure (kidneys unable to function properly". During a record review of Patient 10s medical record form titled ";Current Treatment/Medication /DME List" indicated the following medications were listed multiple times: Gabapentin (pain medication), Hydrocodone & Norco (pain medication), and Zolpidem Tartrate & Ambien (sleep aid medication). During a joint home visit on 3/13/2024 at 9:15 a.m. with Registered Nurse 2 (RN2) to Patient 10s home, we were greeted by Patient 10s care giver (CG2). RN2 stated medication reconciliation is done every month and a half. RN2 stated it was important to reconcile patients medications to be able to notify the doctor when there is a new or discontinued medication. RN2 stated she was not sure who needed to reconcile Patient 10s medications, but she will call the HA to inform them. RN2 reconciled Patient 10s medication with discrepancies found as follows: The Medication list indicated: Zolpidem Tartrate & Ambien - same sleep aid medication listed three times: --Ambien 10mg once a day --Zolpidem Tartrate 10mg at bedtime --Zolpidem Tartrate 10mg one tablet by mouth every night. The Medication bottle indicated: Ambien 10 mg at bedtime During a concurrent interview with CG2 stated she was told by the License Vocational Nurse 2 (LVN2) on 3/11/2024, who had the doctor over the phone, to give patient half a tab of Ambien 5 mg instead of 10mg. 2b. Medication list: Lasix (diuretic) 20mg 1 tab at bedtime CG2 stated she was told by LVN2, who had the doctor over the phone to give Lasix every other day instead of everyday. 2c. Medication list: Same pain medication listed twice. Gabapentin 100mg 1 capsule every night. Gabapentin 100mg at bedtime Medication label: Gabapentin 100mg one tablet every evening 2d. Medication list: Same narcotic pain medication listed twice. Norco 5mg-325mg one tablet every 6 hours as needed for mild to moderate pain. Hydrocodone Bitartrate/acetaminophen 5mg-325mg four times a day as needed for severe pain. Medication label: Norco 5mg-325mg one tablet every six hours as needed. 2e. Medication list: Vitamin B-12 (supplement) 1000mcg once a day CG2 stated Patient 10 has not taken B12 for one or two months. CG2 requested RN2 to ask the doctor is she needs to start taking it again. 2f. Medication list: Vitamin D (supplement) 1000 units Medication label: Vitamin D3 2g. Medication list: Ofloxacin 0.3% ottic solution (ear drops) CG2 stated Patient 10 used that medication for 7 days last year, starting 11/7/2023. 2h. Medication list: Zithromax Z-PAK (anti biotic) CG2 stated Patient 10 used this medication for 5 days, starting 2/27/2024. 2i. There was a medication bottle for patient that was not on the HAs medication list: Tramadol 50mg one tablet three times per day as needed for pain. CG2 stated she only gives that to Patient 10 occasionally. Patient 10s medication profile was not updated to reflect the medications being taken at home. During an interview on 3/14/2024 at 11:24 a.m., with the DON stated, patients home medications should be reconciliated during every Skilled Nurse (SN) visit to prevent errors. During a record review of HAs policy and procedure titled ";Ongoing Assessment" revised 4/2019, indicated ";ongoing comprehensive assessments should focus on: changes in patients condition, level of deterioration; changes in patients diagnoses/prognosis. The physician will be notified to verify any changes in medications, including over the counter medication, and treatment/interventions that require physician approval." During a record review of HAs policy and procedure titled ";Ongoing Assessment" revised 4/2019, indicated ";The physician will be notified to verify any changes in medications, including over the counter medication, and treatment/interventions that require physician approval."

Based on interview and record review the Hospice Agency (HA) failed to conduct an initial bereavement assessment to provide bereavement counseling in accordance with the patient/family/caregivers needs for four of 15 sample selected (Patient 2, Patient 3, Patient 4, and Patient 9). This deficient practice had the potential for the patient/family/caregiver not being provided social, spiritual, and cultural support related to the patient's pending death, to be able to cope with the patients death. --- During an interview on 3/14/2024, at 11:08 a.m., the Director of Nursing stated the Medical Social Worker (MSW) was supposed to do the initial bereavement assessment within 5 days of the start of care. The assessment was important because it was part of the hospice program, to make sure the patient have help, assess the mental status, assess how the patient and family is coping with everything, and to provide resources based on their needs. 1. During a record review of Patient 2s record titled, ";Personal Information", indicated a start of care on 10/20/2023 with a primary diagnosis of senile degeneration of brain. The record further indicated an end of care date of 12/17/2023 with a reason of death. During a record review on 3/15/2024, Patient 2s clinical record was reviewed. There was no documented evidence an initial bereavement assessment was conducted by MSW. 2. During a record review of Patient 3s ";Personal Information", indicated a start of care on 1/31/2024, with a primary diagnosis of unspecified systolic congestive heart failure (heart is not working well). The record indicated this was a re-admission, with a second certification period. On 3/12/2024, at 1:38 p.m., there was no initial bereavement assessment in Patient 3s medical records. On 3/14/2024, revealed there was a bereavement assessment initiated on 2/2/2024, signed by the spiritual counselor, however there was nothing documented. During a concurrent interview and record review on 3/15/2024, at 1:13 p.m., the DON reviewed Patient 3s document titled, ";Bereavement Assessment", dated 2/2/2024. The record was signed by the Spiritual Counselor", but there was no information entered. The DON stated the assessment was not done because there was nothing documented. 3. During a record review of Patient 4s ";Personal Information", indicated a start of care on 2/17/2024, with a primary diagnosis of Hypertensive heart disease without heart failure (high blood pressure). The record further indicted this was Patient 4s 5th certification period, and the admission type was a ";Re-Admit". On 3/12/2024, at 12:58 p.m., Patient 4s records were reviewed. There was no documented evidence an initial bereavement assessment was done. 4. During a record review of Patient 9s medical record form titled ";Personal Information" indicated a start of care date of 11/7/2023 and an end of care date of 11/13/2023, with a primary diagnosis of unspecified combined systolic and diastolic congestive heart failure (weak left heart ventricle). During a record review of Patient 9s medical record form titled ";POC Summary" dated as of 3/12/2024, indicated an order for ";Bereavement Coordination to assess and evaluate bereavement and grieving risk factor within 5 days of admission." During a record review of Patient 9s electronic medical record titled ";History of Bereavement Assessment" indicated there were no entries. During a telephone interview on 3/13/2024 at 1:54 p.m. with Patient 9s care giver/son (CG1), CG1 stated he was Patient 9s care giver. CG1 stated Patient 9 never received care from HA. CG1 stated his brother (S1) takes care of his mother because it was difficult to take care of both their mother and father in the same home. CG1 stated the owner of HA called him on behalf of his brother, but that he never signed up with the HA. During an interview and record review on 3/12/2023 at 1 p.m. with the Administrator (ADM) of the HAs Electronic Medical Record (EMR), while she was printing sample patients requested documents. ADM stated, ";If the form was not there, it was not done." During an interview on 3/14/2024 at 11:03 a.m., with the DON, DON stated the MSW was responsible for the bereavement assessment. DON stated the bereavement assessment needs to be completed within 5 days start of care. DON stated that the bereavement assessment is important for patients and families. DON stated, ";Bereavement assessment, was basically when they are getting close to end of life and just to make sure, to assess the mental status pretty much how the patient and family are coping with everything."

Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met to discuss and update four out of 14 sample selected patients (Patient 3, Patient 8, Patient 9, and Patient 10) comprehensive assessments at least every 15 days. This failure resulted in the IDG not knowing the patients current status, their identified needs, interventions, and significant changes in the patients' condition. --- During an interview on 3/14/2024, at 10:49 a.m., the Director of Nurses (DON) stated the MD, SC, MSW, and RN met in the office, and some on the phone, every two weeks to go over the care of all the patients. The DON stated each individual discipline was responsible in documenting their input under their own discipline in the IDG meeting form. The disciplines had to document the same day and sign by the end of the day. The signature on the document meant they were present, they participated in the meeting, and the input they documented were theirs. During an interview on 3/14/2024, at 11 a.m., the DON stated she had signed a lot of documents the day prior, on 3/13/2024. The DON stated the date of the IDG meeting is what appears next to the signature line, not the date the form was signed. 1. During a record review of Patient 3s ";Personal Information", indicated a start of care on 1/31/2024, with a primary diagnosis of unspecified systolic congestive heart failure (heart is not working well). The record indicated this was a re-admission, with a second certification period. During a concurrent observation, interview, and record review, on 3/13/2024, at 10:30 a.m., Licensed Vocational Nurse 1 (LVN 1) reviewed the medications Patient 3 was taking at home, using Patient 3s record titled, ";Current Treatment/Medication/DME list". The following medications were in Patient 3s home but not listed on the record: Nitrofurantoin (an antibiotic to treat and prevent urinary tract infections). During an interview at the home visit on 3/13/2024, at 10:55 a.m., Patient 3s daughter (CG 3) stated Patient 3 had frequent urinary tract infections (UTI) and requested a blood and urine test. During a concurrent interview and record reviews on 3/15/2024, at 12:57 p.m., the DON reviewed Patient 3s records titled, ";POC/IDG Review", for dated 2/5/2024, 2/19/2024, and 3/4/2024. The DON stated the records did not indicate the IDG team had discussed Patient 3s lab results and discussion about her UTIs. The DON stated laboratory tests were done on 2/28/2024 and 3/4/2024. The labs showed her renal (kidney) panel was out of range. The DON stated there was no notes that the doctor was aware of the labs. There were no notes the doctor prescribed a new treatment or there was a need to modify the plan of care. The DON stated it was the nurses responsibility to notify the doctor of the lab results. The DON stated the doctor was notified, but it was not documented. The DON stated the IDG discussed Patient 3s labs and UTI but it was not documented. The DON stated, in theory, it was not documented, that the IDG discussed the status of the patient. 2. During a record review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 1/9/2023 and an end of care date of 1/19/2024, with a primary diagnosis of chronic kidney disease. During a record review of Patient 8s medical record form titled ";POC Summary" dated as of 3/12/2024, indicated ";IDT to review patient status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 8s medical record form titled ";POC/IDG Review" dated 1/22/2024, indicated it was not signed by the RN. 3. During a record review of Patient 9s medical record form titled ";Personal Information" indicated a start of care date of 11/7/2023 and an end of care date of 11/13/2023, with a primary diagnosis of unspecified combined systolic and diastolic congestive heart failure (weak left heart ventricle). During a record review of Patient 9s medical record form titled ";POC Summary" dated as of 3/12/2024, indicated ";IDT to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 9s medical record form titled ";POC/IDG Review" dated 11/7/2023, 11/9/2023, and 11/13/2023, indicated it was not signed by the Registered Nurse (RN). During a telephone interview on 3/13/2024 at 1:54 p.m., with Patient 9s care giver/son (CG1), CG1 stated he was Patient 9s care giver. CG1 stated Patient 9 never received care from HA. CG1 stated his brother (S1) takes care of his mother because it was difficult to take care of both their mother and father in the same home. CG1 stated the owner of HA called him on behalf of his brother, but that he never signed up with the HA. During an interview on 3/14/2024 at 11:03 a.m. with the DON stated she signed Patient 9s IDGs dated 11/7/2023, 11/9/2023, and 11/13/2023, ";possible yesterday". 4. During a record review of Patient 10s medical record form titled ";Personal Information" indicated a start of care date of 2/26/2023 with a primary diagnosis of chronic kidney failure (kidneys unable to function properly". During a record review of Patient 10s medical record form titled ";POC Summary" dated as of 3/12/2024, indicated ";IDT to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 10s medical record form titled ";POC/IDG Review" dated 3/4/2024, indicated it was not signed by the Registered Nurse (RN). During a concurrent interview and record review on 3/14/2024 at 11:24 a.m., with the DON of Patient 10s EMR, the DON stated the last documented recertification comprehensive assessment for Patient 10 was on 2/26/2023. During an interview on 3/12/2024 at 11 a.m., with the Administrator (ADM), the ADM stated patients had both an electronic medical record and a physical medical record. ADM stated that patients physical medical record only contained their consent duplicates. During an interview on 3/14/2024 at 10:38 a.m., with the DON stated the MSW, SC, MD, and DON have their IDG meetings every two weeks in the office and sometimes over the phone to go over patients to make sure all patients are receiving quality care. DON stated the members discuss patients goals to make sure they are being met. DON stated each discipline document on their discussion section. DON stated all disciplines have till the end of the meeting day to sign and document their findings on their EMR. DON stated they did not have any physical sign in sheet for the IDG meetings. DON stated the discipline signatures indicated they were present and verified their documentation. During a record review of HAs policy and procedure titled ";Ongoing Assessment" revised 4/2019, indicated ";Based on the assessments, the plan of care including problems, needs, goals, and outcomes will be reviewed and updated by the interdisciplinary group members responsible for the case. The physician will be notified to verify any changes in medications, including over the counter medication, and treatment/ interventions that require physician approval." During a record review of HAs policy and procedure titled ";Interdisciplinary Group Meeting" revised 4/2019, indicated ";Each patient plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. The hospice Medical Director and all hospice interdisciplinary group members will be present... Members at the interdisciplinary group meeting will sing an attendance from that will be kept by the hospice Clinical Supervisor.

Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure one of 15 sample patients (Patient 10) was provided information of care provided as indicated in the plan of care. This failure has the potential to result in patient/caregiver inability to be informed and participate in the care and services provided by the hospice. --- During a record review of Patient 10s medical record form titled ";Personal Information" indicated a start of care date of 2/26/2023 with a primary diagnosis of chronic kidney failure (kidneys unable to function properly". During a joint home visit on 3/13/2024 at 9:15 a.m., with Registered Nurse 2 (RN2) to Patient 10s home. Patient 10s care giver (CG2) was present during the visit. During an interview CG2 stated she was not informed by the HA that Patient 10 had an individualized care plan. CG2 stated, ";I did not know what a plan of care was. I dont have her plan of care, I need one." RN2 stated that patients plan of care need to be provided to patients. RN2 stated that patients and their caregivers need to know the information in their plan of care, the discipline, and their frequencies. RN2 stated she told CG2 that she will let the HA know of her request for Patient 10s plan of care. During a record review of HAs policy and procedure titled ";Patient Bill of Rights/Responsibilities" revised 4/20219, indicated ";Each patient will be an active, informed participant in his/her plan of care. The patient bill of rights/responsibilities statement defines the right of the patient to: Be informed in advance of service about the care to be furnished... Use the district office of the Department hotlines to lodge complaints... Be informed of disciplines furnishing care and the frequency of visits.

Based on interview and record review the Hospice Agency (HA) failed to provide bereavement services for one of 15 sample selected patients (Patient 2) and their family/caregiver. This failure resulted in grieving family/caregiver did not receive bereavement services after their family member passed away. --- During a record review of Patient 2s record titled, ";Personal Information", indicated a start of care on 10/20/2023 with a primary diagnosis of senile degeneration of brain. The record further indicated an end of care date of 12/17/2023 with a reason of death. During an interview on 3/15/2024 at 2:07 p.m., the Director of Nurses (DON) reviewed Patient 2s medical records. The DON stated there was no Bereavement Plan of Care (POC) and no bereavement letters. The DON stated the bereavement POC was supposed to be done when the patient passed away. The importance of the POC was to see how the family was coping after the death and to provide resources for the family. The DON stated a Registered Nurse was supposed to complete the POC. Regarding the post bereavement letters, the DON stated a letter was supposed to be done once only, within the week of when the patient passed away. The DON stated the importance of the letters was for the grieved to know the agency is there for them, to remind them the HA is thinking of them. During an interview on 3/14/2024 at 11:03 a.m., with the DON stated the MSW is responsible for the bereavement assessment. DON stated the bereavement assessment needs to be completed within 5 days start of care. DON stated that the bereavement assessment is important for patients and families. DON stated, ";Bereavement assessment, is basically when they are getting close to end of life and just to make sure, to assess the mental status pretty much how the patient and family are coping with everything."

Based on interview and record review the Hospice Agency (HA) failed to ensure five of 15 sampled patients (Patient 3, Patient 4, Patient 6, Patient 7, and Patient 9) receive spiritual counseling services to meet their spiritual needs. This failure had the potential to result in not providing patients and their caregivers the spiritual assistance to provide comfort in the dying process. --- 1. During a record review of Patient 3s ";Personal Information", indicated a start of care on 1/31/2024, with a primary diagnosis of unspecified systolic congestive heart failure (heart is not working well). The record indicated this was a re-admission, with a second certification period. During a concurrent interview and record review on 3/15/2024, at 1:09 p.m., the DON reviewed Patient 3s record titled ";Spiritual Assessment", dated 2/2/2024. The record indicated, ";SC completed an initial assessment over the phone per patient`s request. Necessary assessment of the patient`s condition and needs were completed. Patient declined SC care, so will offer in next benefit period." Further review of the record indicated the form was empty. The DON stated the assessment was incomplete and the assessment was not done. During a record review of Patient 3s audit log, dated 1/31/2024 to 3/15/2024, indicated the SC added the narrative, ";SC completed an initial assessment over the phone per patients request..." on 3/12/2024. During the survey, the SC was not available for an interview. 2. During a record review of Patient 4s ";Personal Information", indicated a start of care on 2/17/2024, with a primary diagnosis of Hypertensive heart disease without heart failure (high blood pressure). The record further indicted this was Patient 4s 5th certification period, and the admission type was a ";Re-Admit". During a concurrent interview and record review on 3/15/2024, at 1:10 p.m., the DON reviewed Patient 4s record titled ";Spiritual Assessment", dated 2/19/2024. The record indicated, ";SC completed an initial assessment over the phone per patient`s request. Necessary assessment of the patient`s condition and needs were completed. Patient declined SC care, so will offer in next benefit period." 3. During a record review of Patient 6s record titled, ";Personal Information", indicated a start of care on 12/16/2023 with a primary diagnosis of Chronic obstructive pulmonary disease, unspecified (a lung condition that makes breathing difficult). The record further indicated this was Patient 6s 1st certification period. During a concurrent interview and record review on 3/15/2024, at 1:11 p.m., the DON reviewed Patient 6s record titled ";Spiritual Assessment", dated 12/20/2023. The record indicated, ";Chaplain contacted the patient caregiver and they agreed for a chaplain visit...". The DON stated the assessment was not done because the form was empty. Based on the document, the HA did not know what the spiritual needs of Patient 6 were. 4. During a record review of Patient 7s record titled, ";Personal Information", indicated a start of care on 10/16/2023, with a primary diagnosis of Unspecified cirrhosis of liver (liver not working well). The record further indicated the 3rd certification period, and ";Admit Type Re-Admit". During a record review on 3/15/2024, Patient 7s record titled, ";Spiritual Assessment", dated 10/19/2023, indicated, ";Chaplain visited the patient for spiritual comprehensive assessment and support...Patient declined spiritual care and support. Chaplain will offer in next benefit period." Further review of the record did not have documented evidence of a detailed spiritual assessment. Many areas of the document were blank and incomplete. 5. During a record review of Patient 9s medical record form titled ";Personal Information" indicated a start of care date of 11/7/2023 and an end of care date of 11/13/2023, with a primary diagnosis of unspecified combined systolic and diastolic congestive heart failure (weak left heart ventricle). During a record review of Patient 9s medical record form titled ";POC Summary" dated as of 3/12/2024, indicated ";SC (spiritual Counselor) 1 – per month +1 PRN visit for support and counseling." During a record review of Patient 9s electronic medical record (EMR) medical record form titled ";History of Spiritual Assessment" indicated there were no entries. The SC was called on 3/14/2024 at 1:29 p.m. with no answer. Message with call back number left. The MSW was called on 3/14/2024 at 1:30 p.m. with no answer. Message with call back number left. The IC called the SC and MSW on 3/14/2024 at 1:32 p.m. IC stated neither answered and that she left a call back number. The IC again called SC and MSW on 3/15/2024 at 10:54 a.m. IC stated neither are answering her calls. During a review of HAs policy and procedure titled ";Initial Assessment" revised 4/2019, indicated ";Admitting registered nurse will determine the other disciplines to complete the appropriate sections of the comprehensive assessment based on identified problems and needs during this initial assessment." During a review of HAs policy and procedure titled ";Ongoing Assessment" revised 4/2019, indicated ";During each home visit, the Case Manager or the other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. The nurse will assess each patient on each visit for: functional status. During a review of HAs policy and procedure titled ";Comprehensive Assessment" revised 4/2019, indicated ";A comprehensive assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. The assessment should determine: probable prognosis of six (6) months or less. The organization must assure that the data elements allow for measurement of outcomes. The Clinical Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but a minimum every 15 days. If no changes are needed, then that must be documented. If there has been a change in the patients condition/status, then the comprehensive assessment must be updated." During a review of HAs policy and procedure titled ";Interdisciplinary Group Meeting" revised 4/2019, indicated ";Each patient plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. The hospice Medical Director and all hospice interdisciplinary group members will be present... Members at the interdisciplinary group meeting will sing an attendance from that will be kept by the hospice Clinical Supervisor.

Based on interview and record review the Hospice Agency (HA) failed to ensure the Condition of Participation for Medical Director was met as evidenced by: --- 1.The HA failed to ensure the Medical Director conducted an accurate assessment, review, and verify the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services, for eleven of 15 sample selected patients (Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). (Refer to L667) 2. The HA failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for seven of 15 sample selected patients (Patient 5, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13). (Refer to L 668 ). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on interview and record review the Hospice Agency (HA) failed to ensure the Medical Director conducted an accurate assessment, review, and verify the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services, for eleven of 15 sample selected patients (Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). These deficient practices resulted in the hospice medical director certifying these patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- During an interview on 3/15/24 at 2 p.m., the Director of Nurses (DON) stated she did not enter the narratives and did not know who did. The DON initially stated had not given anyone her log in information to the electronic medical record (EM), then later stated she gave someone (did not identify who) her log in information at the beginning because she was new to hospice care and needed help with the computer. 1. During a record review of Patient 3s ";Personal Information", indicated a start of care on 1/31/2024, with a primary diagnosis of unspecified systolic congestive heart failure (heart is not working well). The record indicated this was a re-admission, with a second certification period. During a record review of Patient 3s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for certification period 1/31/2024 to 4/29/2024, indicated a physician note was entered. The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". Further review of the record indicated, ";Physician Narrative: Based on RNs (Registered Nurse) assessment, Patient qualifies for hospice." The doctors signature was present. During a record review of Patient 3s record titled ";Audit Log", dated 1/31/24 to 3/15/24, indicated the Director of Nurses (DON) entered the physician note of 1/31/2024, on 2/13/2024. The doctor signed the document on 2/13/2024. The Medical Director (MD 1) signed the document attesting he certified Patient 3 for hospice care, even though the narrative was composed by the DON. 2. During a record review of Patient 4s ";Personal Information", indicated a start of care on 2/17/2024, with a primary diagnosis of Hypertensive heart disease without heart failure (high blood pressure). The record further indicted this was Patient 4s 5th certification period, and the admission type was a ";Re-Admit". During a record review of Patient 4s, ";Physicians Certification for Hospice Benefit" (CTI), for certification period 2/17/2024 to 4/16/2024, indicated a physician note was entered. The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". Further review of the record indicated, ";Physician Narrative: Based on RNs (Registered Nurse) assessment, Patient qualifies for hospice." The doctors signature was present. During a record review of Patient 4s, ";Audit Log", dated 2/17/24 to 3/15/24, indicated the DON entered the physician note of 2/17/2024 on 3/6/24. The doctor signed the CTI on 2/23/24, even though there was no physician narrative documented on 2/23/2024. MD 1 certified Patient 4 for hospice care on 2/23/2024, without a narrative explaining the reasons Patient 4 qualified for hospice care. 3. During a record review of Patient 5s ";Personal Information", indicated a start of care on 6/3/2023, with a primary diagnosis of heart disease, unspecified. The record further indicted this was Patient 5s 1st certification period. During a record review of Patient 5s, ";Physicians Certification for Hospice Benefit" (CTI), for 1st certification period 6/3/2023 to 8/31/2023, indicated a physician note was entered. The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". Further review of the record indicated, ";Physician Narrative: Based on RNs (Registered Nurse) assessment, Patient qualifies for hospice." The doctors signature was present. During a record review of Patient 5s ";Audit Log", dated 6/2/2023 to 3/15/24, indicated the DON entered the physician note for CTI 6/3/2023, on 6/16/2023. The record further indicated the doctor signed the CTI for 6/3/2023 on 6/19/2023. Patient 5 was admitted to hospice care on 6/3/2023, without being certified by MD 1. 4. During a record review of Patient 6s record titled, ";Personal Information", indicated a start of care on 12/16/2023 with a primary diagnosis of Chronic obstructive pulmonary disease, unspecified (a lung condition that makes breathing difficult). The record further indicated this was Patient 6s 1st certification period. During a record review of Patient 6s, ";Physicians Certification for Hospice Benefit" (CTI), for 1st certification period 12/16/2023 to 3/14/2024, indicated a physician note was entered. The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". The record further indicated, ";Physician Narrative; meets LCD guidelines for hospice eligibility. Based on patient current status...team assessment...patient qualifies for hospice...". The doctor signed the record. During a record review of Patient 6s, ";Audit Log", dated 12/18/24 to 3/15/24, indicated the DON entered the physician note for 12/16/2023 on 1/11/2024. The document also indicated the MD signed the document on 1/11/2024. Patient 6 was admitted to hospice care on 12/16/2023, without being certified by MD 1. 5. During a record review of Patient 7s record titled, ";Personal Information", indicated a start of care on 10/16/2023, with a primary diagnosis of Unspecified cirrhosis of liver (liver not working well). The record further indicated the 3rd certification period, and ";Admit Type Re-Admit". During a record review of Patient 7s, ";Physicians Certification for Hospice Benefit", (CTI), for 3rd certification period 10/16/2023 to 12/14/2023, indicated a physician note was entered. The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". Further review of the record indicated a doctors signature. During a record review of Patient 7s, ";Audit Log", dated 10/17/23 to 3/15/24, indicated the (DON) entered the physician note for 10/16/2023 on 10/30/2023. The document also indicated the MD signed the document on 10/30/2023. Patient 7 was admitted to hospice care on 10/16/2023, without being certified by MD 1. 6. During a record review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 1/9/2023 and an end of care date of 1/19/2024, with a primary diagnosis of chronic kidney disease. During a record review of Patient 8s medical record form titled ";Physician Certification for Hospice Benefit" dated from 1/9/2023 to 4/8/2023, indicated a physician note was entered. The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". Further review of the record indicated, ";Physician Narrative: Based on RNs (Registered Nurse) assessment, Patient qualifies for hospice." The doctors signature was present. During a record review of Patient 8s medical record form titled ";Audit Log" dated from 1/9/2023 to 3/15/2024, indicated MD1 signed Patient 8s CTI dated 1/9/2023 on 3/16/2023. During a concurrent interview and record review on 3/15/2024 at 11:20 a.m. with the DON of Patient 8s Electronic Medical Record (EMR), DON stated Patient 8 was not eligible for hospice services. DON stated she mistakenly documented wrong information on Patient 8s renal disease LCD. DON stated Patient 8 was able to ambulate with a walker and that Patient 8 did not require extensive assistance. During a telephone interview on 3/13/2024 at 3:55 p.m. with Patient 8, Patient 8 stated she had a liver transplant in 1999 and was told then that she had six months to live. Patient 8 stated that since then there has not been a doctor that has told her she had six months or less to live. Patient 8 stated she was out of town but continues her dialysis (purification of blood when kidneys are not working) treatments three times per week but will be back home soon. Patient 8 stated she has been receiving dialysis treatment since 10/2022. Patient 8 was admitted to hospice care on 1/9/2023, without being certified by MD 1 until 3/16/2023. 7. During a record review of Patient 9s medical record form titled ";Personal Information" indicated a start of care date of 11/7/2023 and an end of care date of 11/13/2023, with a primary diagnosis of unspecified combined systolic and diastolic congestive heart failure (weak left heart ventricle). During a record review of Patient 9s Electronic Medical Record (EMR), medical record form titled ";Transfer papers" indicated Patient 9 was admitted on 8/6/2022 to HA2 after being discharge from HA3. On 11/7/2023 Patient 9 was discharge from HA2 and admitted to HA. The form also indicated Patient 9s son 1 (S1) was listed as his beneficiary. During a record review of Patient 9s EMR, medical record form titled ";F2F Visit Notes List" EMR indicated there were no entries. During a record review of Patient 9s medical record form titled ";Physician Certification for Hospice Benefit" dated from 11/8/2023 to 1/6/2024, indicated a physician note was entered. The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". Further review of the record indicated, ";Physician Narrative: Based on RNs (Registered Nurse) assessment, Patient qualifies for hospice." The doctors signature was present. During a record review of Patient 9s medical record form titled ";Audit Log" dated from 11/6/2023 to 3/15/2024, indicated MD1 signed Patient 9s CTI dated 11/8/2023 on 12/7/2023. During a telephone interview on 3/13/2024 at 1:54 p.m. with Patient 9s care giver/son (CG1), CG1 stated he was Patient 9s care giver. CG1 stated Patient 9 never received care from HA. CG1 stated his brother (S1) takes care of his mother because it was difficult to take care of both their mother and father in the same home. CG1 stated the owner of HA called him on behalf of his brother (S1), but that he never signed up with the HA. During an interview on 3/14/2024 at 11:03 a.m. with the DON, the DON stated Patient 9s LCD was not documented correctly. DON stated Patient 9 did not meet the criteria because he did not have discomfort while at rest. Patient 9 was admitted to hospice care on 11/7/2023, without being certified by MD 1 until 12/7/2023. 8. During a record review of Patient 10s medical record form titled ";Personal Information" indicated a start of care date of 2/26/2023 with a primary diagnosis of chronic kidney failure (kidneys unable to function properly". During a record review of Patient 10s medical record form titled ";Audit Log" dated from 3/1/2023 to 3/15/2024, indicated MD1 signed Patient 10s CTI dated 2/26/2023 on 3/29/2023. Patient 10 was admitted to hospice care on 2/26/2023, without being certified by MD 1 until 3/29/2023. 9. During a record review of Patient 11s ";Personal Information", indicated a start of care on 8/15/2023, with a primary diagnosis of intervertebral disc degeneration, lumbar region (low back pain). During a record review of Patient 11s medical record form titled ";Physician Certification for Hospice Benefit" dated 8/15/2023 to 11/12/2023, indicated ";Physician Narrative: Based on RNs assessment, Patient qualifies for hospice". During a record review of Patient 11s medical record forms titled ";LCD Hospice Eligibility Determination" dated 8/15/2023, indicated it was left blank. The form also indicated ";patient does not qualify per LCD Guidelines." During a record review of Patient 11s medical record form titled ";Audit Log" dated from 8/10/2023 to 3/15/2024, indicated MD1 signed Patient 11s CTI dated 8/15/2023 on 8/28/2023. During a concurrent interview and record review on 3/14/2024 at 11:50 a.m. with the DON of Patient 11s EMR, the DON stated Patient 11s LCD was part of her assessment which was not documented. DON stated a nursing assessment was important to complete to understand what their needs are and to verify hospice eligibility. During a telephone interview on 3/15/2024 at 10:50 a.m. with Patient 11, Patient 11 stated the HA has been calling him the last couple of days. Patient 11 stated he sees his primary doctor but does not feel comfortable providing me his name and number. Patient 11 stated has not been told by his primary doctor that he has a life expectancy of six months or less. Patient 11 stated he has not been seen by the HAs doctors. Patient 11 stated he needed to get off the phone because he was going to run some errands. Patient 11 stated that he was ambulatory. Patient 11 was admitted to hospice care on 8/15/2023, without being certified by MD 1 until 8/28/2023. 10. During a record review of Patient 12s ";Personal Information", indicated a start of care on 12/6/2023, with a primary diagnosis of Alzheimers Disease (progressive memory loss). During a record review of Patient 12s medical record form titled ";Physician Certification for Hospice Benefit" dated 12/6/2023 to 3/4/2024, indicated ";Physician Narrative: Based on RNs assessment, Patient qualifies for hospice". During a record review of Patient 12s medical record form titled ";LCD Hospice Eligibility Guidelines" dated 12/6/2023, indicated ";Dementia due to Alzheimers - 1 must be met and at least one of the conditions in 2; 1. ADL all in this section should be met; 2. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during previous six months or serum albumin <2.5gm/dl. The form indicated a ";yes" was documented for all criteria in section 1 and section 2. The form indicated 1h. is unable to consistently have meaningful verbal communication... 1g. urinary and fecal incontinence is intermittent or constant/dependent on catheter or ostomy care. 1f. unable to bathe without assistance. 1e. unable to dress without assistance. 1d. unable to ambulate without assistance..." During a record review of Patient 12s record titled, ";Audit Log", dated 12/6/2023 to 3/15/2024, indicated the MD signed the CTI dated 12/6/2023 on 12/20/2023. The form also indicated the DON documented on the Physician narrative: Certifying Physician Summary for CTI dated 12/6/2023 on 12/19/2023, 1/13/2024, and 3/12/2024. During a concurrent interview and record review on 3/15/2024 at 12:45 p.m. with the DON of Patient 12s EMR, the DON stated there was no LCD documented for Patient 12. DON stated her nursing assessment dated 12/6/2023 was inaccurate because it does not ";match the patient". DON stated Patient 12 lost weight but does know how much. DON stated Patient 12 was able to communicate, bathe, eat, and dress with little assistance. DON stated Patient 12 did not have a urinary catheter (soft hollow tube inserted into the urinary bladder to facilitated drainage), and that she was able to use the restroom by herself. DON stated Patient 12 did not meet hospice criteria based on the LCD guidelines. 11. During a record review of Patient 13s ";Personal Information", indicated a start of care on 12/6/2023, with a primary diagnosis of senile degeneration of brain (progressive memory loss). During a record review of Patient 13s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for the 1st certification 12/6/2023 to 3/4/2024, indicated, ";Physician Narrative: Based on RNs (Registered Nurse) assessment, Patient qualifies for hospice." During a record review of Patient 13s record titled, ";LCD Hospice Eligibility Determination" dated 12/6/2023, indicated the form was left blank. The form also indicated ";Patient does not qualify per LCD guidelines." During a record review of Patient 13s record titled, ";Audit Log", dated 12/6/2023 to 3/15/2024, indicated the MD signed the CTI dated 12/6/2023 on 12/20/2023. During a concurrent interview and record review on 3/15/2023, at 12:45 p.m., the DON of Patient 13s electronic medical record (EMR) medical record form titled, ";Nursing Assessment" dated 12/6/2024, the DON stated Patient 13 did not have an LCD assessment completed. DON stated Patient 13s nursing assessment was inaccurate. DON stated that according to her narrative Patient 13 did not qualify for hospice services. During a telephone interview on 3/14/2024 at 12;22 p.m. with the Medical Director (MD1), MD1 stated he has been the HAs MD less than a year. MD1 stated not to ask him questions if all the patient information was at the HA. MD1 stated he does not go to patients home after the pandemic. MD1 stated the admitting nurse calls him on the phone when there is a new patient. MD1 stated he reviews patients information to determine if they are eligible for hospice services in the HAs Electronic Medical Record (EMR). MD1 stated he does not document anything on the HAs EMR. MD1 stated he does not know how to log in or document in the HAs EMR. MD1 stated ";the girl" in the office logs in for him and that he does not know his log in information. MD1 stated, ";They sign for me when I say ok, I dont know how to sign on the computer." MD1 stated he did not know what LCD is. MD1 stated, ";If I see the patient and they tell me the patient has COPD, Alzheimers, or heart disease and they tell me the patient is 85 or 90. Usually the patient already signs to be in hospice, and they tell me if they are sick enough to be in hospice." MD1 was asked who they were. MD1 stated ";they" meant the girls in the office. During an interview on 3/14/2024 at 1:06 p.m., with the Intake Coordinator (IC), IC stated MD1 attends the IDG meetings every two weeks in the office. IC stated that either her or the Administrator (ADM) assist him in finding information in their EMR system. IC stated MD1 sometimes shows her his EMR log in information for her to log in for him. During a record review of HAs policy and procedure titled ";Comprehensive Assessment" revised 4/2019, indicated ";A comprehensive assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. The assessment should determine: probable prognosis of six (6) months or less. The organization must assure that the data elements allow for measurement of outcomes. The Clinical Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. During a record review of HAs policy and procedure titled ";Interdisciplinary Group Meeting" revised 4/2019, indicated ";Referrals and admissions will be reviewed to establish appropriateness for hospice care. Adm ission will be reviewed to ensure compliance with hospice policies and procedures."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the medical director and/or physician designee (who is a hospice employee or under contract with the hospice) conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for seven of 15 sample selected patients (Patient 5, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13). These deficient practices resulted in the hospice medical director and/or physician designee certifying the patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses and patients not receiving appropriate healthcare services that could affect their quality of life. --- During an interview on 3/15/24 at 2 p.m., the Director of Nurses (DON) stated she did not enter the narratives and did not know who did. The DON initially stated had not given anyone her log in information to the electronic medical record (EM), then later stated she gave someone (did not identify who) her log in information at the beginning because she was new to hospice care and needed help with the computer. 1. During a record review of Patient 5s ";Personal Information", indicated a start of care on 6/3/2023, with a primary diagnosis of heart disease, unspecified. The record further indicted this was Patient 5s 1st certification period. During a record review of Patient 5s, ";Physicians Certification for Hospice Benefit", for 4th certification period 1/29/2024 to 3/28/2024, indicated a physician note was entered. The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". Physician signature present. During a record review of Patient 5s ";Audit Log", dated 6/2/2023 to 3/15/24, indicated the DON entered the physician note for CTI 1/29/2024 on 2/9/2024. The record further indicated the doctor signed the CTI for 1/29/2024, on 2/23/2024. Medical Doctor 1 (MD 1) did not recertify Patient 5 for continuation of hospice care for certification period beginning 1/29/2024, until 2/23/2024. 2. During a record review of Patient 7s record titled, ";Personal Information", indicated a start of care on 10/16/2023, with a primary diagnosis of Unspecified cirrhosis of liver (liver not working well). The record further indicated the 3rd certification period, and ";Admit Type Re-Admit". During a record review of Patient 7s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for 5th certification period 2/13/2024 to 4/12/2024, did not indicate a doctors narrative. The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". The record further indicated a doctors signature. During a record review of Patient 7s record titled, ";Audit Log", dated 10/17/23 to 3/15/24, indicated the MD signed the document for 2/13/2024 on 2/13/2024, even though no doctor narrative was entered. 3. During a record review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 1/9/2023 and an end of care date of 1/19/2024, with a primary diagnosis of chronic kidney disease. During a record review of Patient 8s medical record form titled ";Physicians Certification for Hospice Benefit" dated 11/5/2023 to 1/3/2024, indicated certification was based on face-to-face encounter. During a record review of Patient 8s medical record form titled ";Physicians Certification for Hospice Benefit" dated 1/4/2024 to 3/3/2024, indicated certification was based on face-to-face encounter. During a record review of Patient 8s Electronic Medical Record (EMR), EMR indicated there were three entries in section ";Physician – F2F (face to face) visit note" dated 11/5/2023, 9/6/2023, and 7/8/2023. EMR also indicated all three forms were not signed by Medical Doctor 1 (MD1) and form dated 9/6/2023 was left blank. During a record review of Patient 8s medical record form titled ";Audit Log" dated from 1/9/2023 to 3/15/2024, indicated MD1 signed Patient 8s CTI dated 1/9/2023 on 3/16/2023. MD1 signed Patient 8s CTI dated 4/9/2023 on 4/27/2023. MD1 signed Patient 8s CTI dated 7/8/2023 on 1/12/2024. MD1 signed Patient 8s CTI dated 9/6/2023 on 1/12/2024. MD1 signed Patient 8s CTI dated 11/5/2023 on 1/12/2024. MD1 signed Patient 8s CTI dated 1/4/2024 on 1/12/2024. During a concurrent interview and record review on 3/14/2024 at 10:38 a.m. with the DON of Patient 8s Electronic Medical Record (EMR), DON stated that MD1 documents in the CTIs and on the Face to Face. DON stated that Patient 8s Face to Face documents were not completed and she did not know if the documentation on the documents were auto populated or completed by MD1 because they were not signed. During a telephone interview on 3/13/2024 at 3:55 p.m. with Patient 8, Patient 8 stated she had a liver transplant in 1999 and was told then that she had six months to live. Patient 8 stated that since then there has not been a doctor that has told her she had six months or less to live. Patient 8 stated she was out of town but continues her dialysis (purification of blood when kidneys are not working) treatments three times per week. Patient 8 stated she did not see the HAs MD1 while receiving their care. 4. During a record review of Patient 10s medical record form titled ";Personal Information" indicated a start of care date of 2/26/2023 with a primary diagnosis of chronic kidney failure (kidneys unable to function properly". During a record review of Patient 10s medical record form titled ";Physician Certification for Hospice Benefit" dated 2/21/2024 to 4/20/2024, indicated the RN prognosis summary and the physician narratives were left blank. During a record review of Patient 10s medical record form titled ";F2F Visit Notes" dated 8/25/2023, 10/24/2023, and 12/23/2023 were not signed by MD1. The forms dated 10/24/2023 and 12/23/2023 were left blank. During a record review of Patient 10s medical record form titled ";LCD Hospice Eligibility Determination" dated 2/17/2024, indicated the form was left blank. The form also indicated ";Patient does not qualify per LCD guidelines." During a record review of Patient 10s medical record form titled ";Audit Log" dated from 3/1/2023 to 3/15/2024, indicated MD1 signed Patient 10s CTI dated 8/25/2023 on 10/12/2023. MD1 signed Patient 10s CTI dated 4/27/2023 on 1/12/2024. MD1 signed Patient 10s CTIs dated 6/26/2023, 10/24/2023, and 12/23/2023 on 1/12/2024. It also indicated DON entered the Physician Narrative: Certifying Physician Summary for: CTIs dated 8/25/2023 on 1/14/2024 and CTI dated 12/23/2023 on 1/14/2024. Lastly, the form also indicated DON entered the Physician Narrative: Face to Face Summary for CTI dated 12/23/2023 on 1/14/2024. During a concurrent interview and record review on 3/14/2024 at 11;24 a.m. with the DON of Patient 10s EMR, DON stated there were no face to face documented for Patient 10. DON stated Patient 10s last recertification nursing assessment was on 2/26/2023. DON stated patients need to be reassessed every 60 days to verify hospice eligibility. During a concurrent interview and record review on 3/15/2024 at 11:50 a.m. with the DON of Patient 10s EMR, DON stated Patient 10 has been stable and not declining since start of care. DON stated Patient 10 does not meet LCD guidelines. 5. During a record review of Patient 11s ";Personal Information", indicated a start of care on 8/15/2023, with a primary diagnosis of intervertebral disc degeneration, lumbar region (low back pain). During a record review of Patient 11s medical record form titled ";Physician Certification for Hospice Benefit" dated 8/15/2023 to 11/12/2023, indicated ";Physician Narrative: Based on RNs assessment, Patient qualifies for hospice". During a record review of Patient 11s medical record form titled ";Physician Certification for Hospice Benefit" dated 2/11/2024 to 4/10/2024, indicated ";RN Prognosis Summary and Physician Narratives" were left blank. The form also indicated ";certification was based on Face to Face". During a record review of Patient 11s EMR indicated there were no notes documented under section ";F2F (face to face) visit note list." During a record review of Patient 11s medical record forms titled ";LCD Hospice Eligibility Determination" dated 8/15/2023 and 2/13/2024, indicated they were left blank. The forms also indicated ";patient does not qualify per LCD Guidelines." During a record review of Patient 11s medical record form titled ";Audit Log" dated from 8/10/2023 to 3/15/2024, indicated MD1 signed Patient 11s CTI dated 8/15/2023 on 8/28/2023. During a concurrent interview and record review on 3/14/2024 at 11:50 a.m., with the DON of Patient 11s EMR, the DON stated Patient 11s LCD was part of her assessment which was not documented. DON stated a nursing assessment was important to complete to understand what their needs are and to verify hospice eligibility. During a telephone interview on 3/15/2024 at 10:50 a.m., with Patient 11, Patient 11 stated the HA has been calling him the last couple of days. Patient 11 stated he sees his primary doctor but does not feel comfortable providing me his name and number. Patient 11 stated has not been told by his primary doctor that he has a life expectancy of six months or less. Patient 11 stated he has not been seen by the HAs doctors. Patient 11 stated he needed to get off the phone because he was going to run some errands. Patient 11 stated that he was ambulatory. 6. During a record review of Patient 12s ";Personal Information", indicated a start of care on 12/6/2023, with a primary diagnosis of Alzheimers Disease (progressive memory loss). During a record review of Patient 12s medical record form titled ";Physician Certification for Hospice Benefit" dated 3/5/2024 to 6/2/2024, indicated ";RN Prognosis Summary and Physician Narrative" sections were left blank. The form also indicated it was signed by MD1. During a record review of Patient 12s record titled, ";Audit Log", dated 12/6/2023 to 3/15/2024, indicated the MD signed the CTI dated 3/5/2024 on 3/6/2024. During a concurrent interview and record review on 3/15/2024 at 12:45 p.m. with the DON of Patient 12s EMR, the DON stated Patient 10s recertification nursing assessment was due on 3/5/2024 and that it was not completed/documented yet. DON stated a reassessment identifies if the patient continues to qualify for hospice services. 7. During a record review of Patient 13s ";Personal Information", indicated a start of care on 12/6/2023, with a primary diagnosis of senile degeneration of brain (progressive memory loss). During a record review of Patient 13s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for the 1st certification 3/5/2024 to 6/2/2024, indicated, ";RN Prognosis Summary and Physician Narrative" were left blank. The form also indicated it was signed by MD1. During a record review of Patient 13s record titled, ";LCD Hospice Eligibility Determination" dated 12/6/2023, indicated the form was left blank. The form also indicated ";Patient does not qualify per LCD guidelines." During a record review of Patient 13s record titled, ";Audit Log", dated 12/6/2023 to 3/15/2024, indicated the MD signed the CTI dated 3/5/2024 on 3/6/2024. During a concurrent interview and record review on 3/15/2023, at 12:45 p.m., with the DON of Patient 13s EMR, the DON stated Patient 13 did not have an LCD assessment completed. DON stated Patient 13s recertification nursing assessment was due on 3/5/2024 and that it was not completed/documented yet. DON stated a reassessment identifies if the patient continues to qualify for hospice services. During an interview on 3/12/2024 at 11 a.m., with the Administrator (ADM), the ADM stated patients had both an electronic medical record and a physical medical record. ADM stated that patients physical medical record only contained their consent duplicates. During a telephone interview on 3/14/2024 at 12:22 p.m., with the Medical Director (MD1), MD1 stated he has been the HAs MD less than a year. MD1 stated not to ask him questions if all the patient information was at the HA. MD1 stated he does not go to patients home after the pandemic. MD1 stated the admitting nurse calls him on the phone when there is a new patient. MD1 stated he reviews patients information to determine if they are eligible for hospice services in the HAs Electronic Medical Record (EMR). MD1 stated he does not document anything on the HAs EMR. MD1 stated he does not know how to log in or document in the HAs EMR. MD1 stated ";the girl" in the office logs in for him and that he does not know his log in information. MD1 stated, ";They sign for me when I say ok, I dont know how to sign on the computer." MD1 stated he did not know what LCD is. MD1 stated, ";If I see the patient and they tell me the patient has COPD, Alzheimers, or heart disease and they tell me the patient is 85 or 90. Usually the patient already signs to be in hospice, and they tell me if they are sick enough to be in hospice." MD1 was asked who they were. MD1 stated ";they" meant the girls in the office. During an interview on 3/14/2024 at 1:06 p.m., with the Intake Coordinator (IC), IC stated MD1 attends the IDG meetings every two weeks in the office. IC stated that either her or the Administrator (ADM) assist him in finding information in their EMR system. IC stated MD1 sometimes shows her his EMR log in information for her to log in for him. During a record review of HAs policy and procedure titled ";Comprehensive Assessment" revised 4/2019, indicated ";A comprehensive assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. The assessment should determine: probable prognosis of six (6) months or less. The organization must assure that the data elements allow for measurement of outcomes. The Clinical Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. During a record review of HAs policy and procedure titled ";Interdisciplinary Group Meeting" revised 4/2019, indicated ";Referrals and admissions will be reviewed to establish appropriateness for hospice care. Admission will be reviewed to ensure compliance with hospice policies and procedures."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Clinical Records was met as follows: --- 1. The HA failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for nine of 15 sample selected patients (Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 12, and Patient 14). (Refer to L679). 2. The HA failed to ensure contents and information in the patients medical records were safeguarded from unauthorized access by HA staff and/or contracted staff to make any alterations or modifications. (Refer to L680). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records are safeguarded from unauthorized access by any individuals or hospice staff.

Based on interview and record review, the Hospice Agency (HA) failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification nine of 15 sample selected patients (Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 12, and Patient 14). This failure has the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients clinical record that could affect the patients quality of care and well-being. --- During an interview on 3/15/24 at 2:00 p.m., the Director of Nurses (DON) stated she did not enter the narratives and did not know who did. The DON initially stated had not given anyone her log in information to the electronic medical record (EM), then later stated she gave someone (did not identify who) her log in information at the beginning because she was new to hospice care and needed help with the computer. 1. During a record review of Patient 3s ";Personal Information", indicated a start of care on 1/31/2024, with a primary diagnosis of unspecified systolic congestive heart failure (heart is not working well). The record indicated this was a re-admission, with a second certification period. During a record review of Patient 3s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for certification period 1/31/2024 to 4/29/2024, indicated a physician note was entered. The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". Further review of the record indicated, ";Physician Narrative: Based on RNs (Registered Nurse) assessment, Patient qualifies for hospice." The doctors signature was present. During a record review of Patient 3s record titled ";Audit Log", dated 1/31/24 to 3/15/24, indicated the Director of Nurses (DON) entered the physician note of 1/31/2024, on 2/13/2024. The doctor signed the document on 2/13/2024. Patient 3s records did not accurately reflect the author of the ";Physician Narrative". 2. During a record review of Patient 4s ";Personal Information", indicated a start of care on 2/17/2024, with a primary diagnosis of Hypertensive heart disease without heart failure (high blood pressure). The record further indicted this was Patient 4s 5th certification period, and the admission type was a ";Re-Admit". During a record review of Patient 4s, ";Physicians Certification for Hospice Benefit" (CTI), for certification period 2/17/2024 to 4/16/2024, indicated a physician note was entered. The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". Further review of the record indicated, ";Physician Narrative: Based on RNs (Registered Nurse) assessment, Patient qualifies for hospice." The doctors signature was present. During a record review of Patient 4s, ";Audit Log", dated 2/17/24 to 3/15/24, indicated the DON entered the physician note of 2/17/2024 on 3/6/24. The doctor signed the CTI on 2/23/24, even though there was no physician narrative documented on 2/23/2024. Patient 4s records did not accurately reflect the author of the ";Physician Narrative". 3. During a record review of Patient 5s ";Personal Information", indicated a start of care on 6/3/2023, with a primary diagnosis of heart disease, unspecified. The record further indicted this was Patient 5s 1st certification period. During a record review of Patient 5s, ";Physicians Certification for Hospice Benefit" (CTI), for 1st certification period 6/3/2023 to 8/31/2023, indicated a physician note was entered. The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". Further review of the record indicated, ";Physician Narrative: Based on RNs (Registered Nurse) assessment, Patient qualifies for hospice." The doctors signature was present. During a record review of Patient 5s ";Audit Log", dated 6/2/2023 to 3/15/24, indicated the DON entered the physician note for CTI 6/3/2023, on 6/16/2023. The record further indicated the doctor signed the CTI for 6/3/2023 on 6/19/2023. Patient 5s records did not accurately reflect the author of the ";Physician Narrative". 4. During a record review of Patient 6s record titled, ";Personal Information", indicated a start of care on 12/16/2023 with a primary diagnosis of Chronic obstructive pulmonary disease, unspecified (a lung condition that makes breathing difficult). The record further indicated this was Patient 6s 1st certification period. During a record review of Patient 6s, ";Physicians Certification for Hospice Benefit" (CTI), for 1st certification period 12/16/2023 to 3/14/2024, indicated a physician note was entered. The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". The record further indicated, ";Physician Narrative; meets LCD guidelines for hospice eligibility. Based on patient current status...team assessment...patient qualifies for hospice...". The doctor signed the record. During a record review of Patient 6s, ";Audit Log", dated 12/18/24 to 3/15/24, indicated the DON entered the physician note for 12/16/2023 on 1/11/2024. The document also indicated the MD signed the document on 1/11/2024. Patient 6s records did not accurately reflect the author of the ";Physician Narrative". 5. During a record review of Patient 7s record titled, ";Personal Information", indicated a start of care on 10/16/2023, with a primary diagnosis of Unspecified cirrhosis of liver (liver not working well). The record further indicated the 3rd certification period, and ";Admit Type Re-Admit". During a record review of Patient 7s, ";Physicians Certification for Hospice Benefit", (CTI), for 3rd certification period 10/16/2023 to 12/14/2023, indicated a physician note was entered. The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". Further review of the record indicated a doctors signature. During a record review of Patient 7s, ";Audit Log", dated 10/17/23 to 3/15/24, indicated the (DON) entered the physician note for 10/16/2023 on 10/30/2023. The document also indicated the MD signed the document on 10/30/2023. Patient 7s records did not accurately reflect the author of the ";Physician Narrative". 6. During a record review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 1/9/2023 and an end of care date of 1/19/2024, with a primary diagnosis of chronic kidney disease. During a record review of Patient 8s medical record form titled ";Discharge (DC) Summary" dated 1/19/2024, indicated ";discharge from (HA) due to seeking aggressive treatment." The form also indicated it was not signed by the author. During a concurrent interview and record review on 3/14/2024 at 10:38 a.m. with the DON of Patient 8s medical record form titled DC summary dated 1/19/2024, the DON stated she was the person who documented the narrative but did not sign it. DC summary indicated it was not signed by the author. DON stated that the authors name should be documented in the form to be able to know what discipline filled it out. Patient 8s records did not accurately reflect the author of the ";Discharge Summary". 7. During a record review of Patient 9s medical record form titled ";Personal Information" indicated a start of care date of 11/7/2023 and an end of care date of 11/13/2023, with a primary diagnosis of unspecified combined systolic and diastolic congestive heart failure (weak left heart ventricle). During a record review of Patient 9s medical record form titled ";Discharge (DC) Summary" dated 11/13/2023, indicated Patient 9 called the HA and stated he was moving out of the area. The form also indicated it was not signed by the author. During an interview on 3/14/2024 at 11:03 a.m. with the DON, the DON stated Patient 9s DC summary was not completed because it was not signed. DON state she did not know who completed the discharge summary. Patient 9s records did not accurately reflect the author of the ";Discharge Summary". 8. During a record review of Patient 12s ";Personal Information", indicated a start of care on 12/6/2023, with a primary diagnosis of Alzheimers Disease (progressive memory loss). During a record review of Patient 12s record titled, ";Physicians Certification for Hospice Benefit (CTI)", for the 2nd certification 3/5/2024 to 6/2/2024, indicated sections RN prognosis summary, and Physician narrative were left blank. The form also indicated it was signed by Medical Director 1 (MD1). The HA failed to ensure Patient 12s CTI was completed. 9. During a record review of Patient 14s ";Personal Information", indicated a start of care on 6/21/2023, with a primary diagnosis of hypertensive (high blood pressure) without heart failure. During a record review on 3/12/2024 of Patient 14s medical record form titled ";Re-Certification Assessment" dated 2/14/2024, indicated the form was left blank. During a record review of Patient 14s medical record form titled ";LCD (Local Coverage Determination, a tool used to determine if patient meets criteria to be in hospice care) Hospice Eligibility Determination" dated 2/14/2024, indicated form was left blank. During a concurrent interview and record review on 3/15/2023, at 12:30 p.m. with the Director of Nurses (DON) of Patient 14s electronic medical record (EMR) the DON stated both the LCD and Re-Certification Assessment were supposed to be documented by 2/14/2024. DON stated the Re-Certification Assessment was documented on 3/12/2024 in the evening or on 3/13/2024 in the morning. The HA failed to ensure Patient 14s LCD and Re-Certification Assessment were completed when required.

Based on interview and record review the Hospice Agency (HA) failed to ensure contents and information on one of 15 sample patient (Patient 10) medical record was safeguarded from unauthorized access by HA staff to make any alterations or modifications. This failure has the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients clinical record that could affect the patients quality of care and well-being. --- During a record review of Patient 10s medical record form titled ";Personal Information" indicated a start of care date of 2/26/2023 with a primary diagnosis of chronic kidney failure (kidneys unable to function properly". During a record review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefit" dated 2/26/2023, indicated ";Certification #3: Re-Certification Statement for Next 60-day period". During a record review of Patient 10s medical record form titled ";Audit Log" dated 3/1/2023 to 3/15/2024, indicated the Intake Coordinator (IC) logged into their Electronic Medical Record (EMR) and accessed Patient 10s medical record module ";Certification MD" on 3/3/2023 at 11:02 a.m. and at 12:44 p.m., and deleted the record both times. During a telephone interview on 3/14/2024 at 12:22 p.m., with the Medical Director (MD1), MD1 stated he has been the HAs MD less than a year. MD1 stated not to ask him questions if all the patient information was at the HA. MD1 stated he does not go to patients home after the pandemic. MD1 stated the admitting nurse calls him on the phone when there is a new patient. MD1 stated he reviews patients information to determine if they are eligible for hospice services in the HAs Electronic Medical Record (EMR). MD1 stated he does not document anything on the HAs EMR. MD1 stated he does not know how to log in or document in the HAs EMR. MD1 stated ";the girl" in the office logs in for him and that he does not know his log in information. MD1 stated, ";They sign for me when I say ok, I dont know how to sign on the computer." MD1 stated he did not know what LCD is. MD1 stated, ";If I see the patient and they tell me the patient has COPD, Alzheimers, or heart disease and they tell me the patient is 85 or 90. Usually the patient already signs to be in hospice, and they tell me if they are sick enough to be in hospice." MD1 was asked who they were. MD1 stated ";they" meant the girls in the office. During an interview on 3/14/2024 at 1:06 p.m., with the Intake Coordinator (IC), IC stated MD1 attends the IDG meetings every two weeks in the office. IC stated that either her or the Administrator (ADM) assist him in finding information in their EMR system. IC stated MD1 sometimes showed her MD1's EMR log in information for her to log in for MD1. During an interview on 3/15/24 at 2 p.m., the Director of Nurses (DON) stated she did not enter the narratives and did not know who did. The DON initially stated had not given anyone her log in information to the electronic medical record (EMR), then later stated she gave someone (did not identify who) her log in information at the beginning because she was new to hospice care and needed help with the computer.

Upon patient record review 1 of 5 records (Patient #5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 5: On SOC Patient declined MSW and SC services. There was no evidence of a psychosocial or spiritual assessment in the record.

Upon patient record review, 1 of 5 records (Patient #3) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient 3: On SOC 4/13/2022 documentation included pain as an active problem, ranging from 4-8 least to worst, with a pain goal of 0-2. Current pain meds adequate and needed 2-3 x per day. Care plan included Assess for pain and assess response to medications. There was no evidence in the record the patient was given or prescribed any pain medication, and no documentation as to why not.

Upon client record review, 2 of 2 applicable records (Patients #4, #5) did not have evidence that the discharge summary includes all required information. Patients 4 and 5: The summary states See attached Care Plan, physician notified and copy sent, no care plan is attached, does not name physician or what was sent specifically. There was no evidence of latest physician orders.