Every finding on record at Pure Love Hospice, Inc

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live), failed to ensure that the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Patient Rights was met as followed: --- the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure patients rights to be informed of the services the HA provides and the limitations of these services for two out of 14 sampled patients (Patients X and 6) certified to receive hospice care and services. ( Refer to L519) This deficient practice had the potential for misinformation, misunderstanding and miscommunication of hospice care and services provided for the patients. s

Based on observation, interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure to inform four out of 14 sampled patients (Patients 1, Patient 2, Patient 3, and Patient 6), about the services the HA provided and the limitations of those services. This deficient practice resulted in Patients 1, Patient 2, Patient 3, and Patient 6, not aware about the care and services the HA provided and had the potential for misinformation, misunderstanding and miscommunication of hospice care and services provided for the patients. ( Refer to L519). --- A review of Patient 6s record titled, ";Physician's Certification for Hospice Benefit", indicated a start of care date on 9/21/2023 with a primary diagnosis of hypertensive heart disease with heart failure (is a long-term condition that develops over many years in people who have high blood pressure). During a concurrent phone interview with Patient 6 on 5/18/2024 at 9:00 a.m., Patient 6 stated he complained about this hospice because the agency promised him they will send him ensure and toiletries if he signs the consent forms. Patient 6 stated he signed the consent forms but the agency did not send what they promised so he complained and the agency stopped their services after a month when they found out I complained. Patient 6 stated "they did not tell me that they were a hospice agency. I was not seen by a doctor and there were 2 people knocking door to door at our building telling them of the same thing. Patient 6 stated he could not remember who were the people who went to his apartment. During an interview with the Director of Patient Care Services Designee (DD) on 5/19/2024 at 12:21 p.m., DD stated that she comes once a month or as needed when the agency owner calls her. DD stated that the admission process starts when they get referrals from patients friends, or community referrals. DD stated then they explain the hospice benefits, look at their prognosis and decline and look into medical records if they have it. DD stated they ask the medical director (MD) when the patients referred to your agency especially if these patients had not seen or visited their primary doctors and the MD will be the referring and the attending doctor for that patient. DD stated that she knows that the agency owners hire marketers to find patients for admission for hospice. DD stated she does not know who the marketers were. A review of the agency's document tilted " Admission Information" revised 2/2022 indicated To provide patients with accurate information to make informed decisions regarding care or services. The scope of services: Nursing, Hospice aide and homemaker services, Physical therapy, occupational therapy, Speech language pathology, Social Worker, Physician services, volunteers, counselors, dietary counseling, home medical equipment related to terminal illness, drugs and biologicals related to terminal illness, short tern inpatient care, respite care, continuous care, bereavement counseling and medical supplies. At time of initial assessment, Hospice will provide each patient with a statement of the scope of services provided directly and/or through contractual/written agreement. Patients will also be provided the following information: Care/service limitations, eligibility criteria, charges or patient liability for care/services, information regarding the Medicare Hospice benefit. a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 2/4/2024, with a terminal diagnosis of chronic systolic congestive heart failure (a specific type of heart failure that occurs in the heart's left ventricle). During a review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 4/22/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. On 5/19/2024, at 10 a.m. during a phone interview with Patient 1, she stated she did not have an idea what hospice services was about. Patient 1 stated the HA would send a nurse (unidentified) to come visit her every week to take her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). Patient 1 also stated she was not sick and that she was not dying in the next six months. b. During a review of Patient 2s admission record indicated a start of care (SOC) date of 1/17/2024 with a terminal diagnosis of chronic systolic congestive heart failure (a specific type of heart failure that occurs in the heart's left ventricle). During a review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 4/22/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week plus 1 prn (or pro re nata, which means as needed) visits, the spiritual counselor (SC) and social worker (MSW) to visit monthly and 1 prn visit. During a joint home visit, on 5/18/2024 at 1 p.m., with the licensed vocational nurse (LVN 1) at Patient 2s residence, Patient 2 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device. During an interview, Patient 2 stated no doctors or nurses told her that she had terminal illness and had 6 months or less to live, what hospice service was, and that nobody explained to her that what she signed up for was for hospice care and service. c. During a review of Patient 3s admission record indicated a start of care (SOC) date of 2/15/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (a condition which affects the arteries that supply the heart wit blood). During a review of Patient 3's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 4/22/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week plus 1 prn (or pro re nata, which means as needed) visits, the spiritual counselor (SC) and social worker (MSW) to visit monthly and 1 prn visit. During a joint home visit, on 5/18/2024 at 12 p.m., with the licensed vocational nurse (LVN 1) at Patient 3s residence, Patient 3 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device. During an interview, Patient 3 stated nobody explained to her that what she signed up for was for hospice care. She further stated that she was referred by a friend and she was not dying in 6 months. During an interview on 5/19/2024 at 1:20 p.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated the visiting nurses should have explained to the patient and to the patients family the kind of service they provide and the limitations of these services. During a review of the agencys undated policy and procedure titled, ";Rights/Responsibilities", indicated each patient will be an active, informed participant in his/her plan of care. The patient will be informed during the initial assessment visit, in advance of furnishing care, of the hospice philosophy and program of care, the organizations mission and care and services provided directly or through contractual arrangements, and the goals of hospice, the interventions that support those goals and the identification of the staff providing service.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) regarding Initial and Comprehensive Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process of the Patient) was met as follows: The hospice agency failed to conduct and document a comprehensive assessment that reflected the patient's current health status and identify patients' needs for hospice care and services related to hospice eligibility and management of terminal illness for four of 14 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 6). (Refer to L524) The hospice agency failed to maintain a current medication profile for one of 14 sampled patients (Patient 8). (Refer to L530) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live)) failed to conduct and document a 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 four of 14 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 6). This deficient practice had the potential to result for the patients not to receive appropriate healthcare services that could affect their quality of life. --- a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 2/4/2024, with a terminal diagnosis of chronic systolic congestive heart failure (a specific type of heart failure). During a review of Patient 1's Initial Comprehensive Assessment dated 2/4/2024, the Initial Comprehensive Assessment indicated Patient 1 was awake, alert, oriented x 3 (person, place, time), had cardiac-related pain, normal respirations, moderate dyspnea (difficult or labored breathing) with mild exertion, and required maximum assistance with ambulation, toileting, and transfer. During a review of Patient 1's Re-Cert Assessment dated 5/3/2024, the Re-Cert Assessment indicated Patient 1 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure and met the Local Coverage Determinations (LCD guidelines for hospice eligibility). During a review of Patient 1s LCD Hospice Eligibility Determination form for heart disease, dated 5/3/2024, the LCD Hospice Eligibility Determination form indicated Patient 1 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 1 had been optimally treated for heart disease on vasodilators due to medical condition. Section 2 was marked "yes" that Patient 1s Congestive heart Failure or angina met the criteria for NYHA Class IV level (unable to carry out any physical activity without discomfort). During a review of Patient 1's undated Certification of Terminal Illness (CTI), dated 5/3/2024, the CTI indicated Physician 1 indicated Patient 1 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. The CTI indicated the hospice's Medical Director did not communicate with the patients primary physician to certify Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. During a telephone interview on 5/19/2024, at 10 a.m., with Patient 1, Patient 1 stated she did not have an idea what hospice services was about. Patient 1 stated the HA would send a nurse (unidentified) to come visit her every week to take her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). Patient 1 also stated she was not sick and that she was not dying in the next six months. During a review of Patient 1's clinical record, and an interview on 5/19/2024, at 11 a.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated she was not able to find documented evidence that Patient 1 had been treated for heart disease on vasodilators (medication to open the blood vessels). The DPCS stated there was no documented evidence Patient 1 was on complete rest, confined to a bed or chair, or any physical activity limitations, or that Patient 1 had an ejection fraction of less than 20 (heart failure b. During a review of Patient 2s admission record indicated a start of care (SOC) date of 1/17/2024 with a terminal diagnosis of chronic systolic congestive heart failure (heart failure). During a review of Patient 2's Initial Comprehensive Assessment, dated 1/17/2024, the Initial Comprehensive Assessment indicated Patient 2 was awake, alert, oriented x 3 (person, place, time), had cardiac-related pain, normal respirations, moderate dyspnea (difficult or labored breathing) with mild exertion, and requires maximum assistance with ambulation, toileting, and transfer. During a review of Patient 2's Re-Cert Assessment, dated 4/17/2024, the Re-Cert Assessment indicated Patient 2 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure and met LCD guidelines for hospice eligibility. During a review of Patient 2's CTI, dated 4/17/2024, Physician 1 indicated Patient 2 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. The CTI indicated the hospice's Medical Director did not communicate with the patients primary physician to certify Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. During a review of Patient 2s LCD Hospice Eligibility Determination form for Heart Disease, dated 4/17/2024, indicated Patient 2 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 2 had been ruled out as a candidate for surgical procedures due to medical condition. Section 2 was marked "yes" that Patient 2s Congestive heart Failure or angina (chest pain) met the criteria for NYHA Class IV level. During a joint home visit observation, and interview, on 5/18/2024, at 1 p.m., with Licensed Vocational Nurse 1 (LVN 1) at Patient 2s residence, Patient 2 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory (able to walk) without using an assistive device. Patient 2 stated that no doctors or nurses told her that she had terminal illness and had six months or less to live, or what hospice service was, and that nobody explained to her that what she signed up for was for hospice care and services. During a review of Patient 1's clinical record, and an interview on 5/19/2024, at 11 a.m., with the DPCSD, the DPCSD stated she was not able to find evidence that Patient 2 had been ruled out (excluded) as a candidate for surgical procedures due to medical condition. The DPCSD stated there was no documented evidence Patient 2 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest, or had an ejection fraction of less than 20. c. During a review of Patient 3s admission record indicated a start of care (SOC) date of 2/15/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (a condition which affects the arteries that supply the heart with blood). During a review of Patient 3's Initial Comprehensive Assessment dated 2/15/2024, the Initial Comprehensive Assessment indicated Patient 3 was awake, alert, oriented x 3 (person, place, time), had cardiac-related pain, normal respirations, moderate dyspnea (difficult or labored breathing) with mild exertion, and requires maximum assistance with ambulation, toileting, and transfer. Patient 3 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure and met LCD guidelines for hospice eligibility. During a review of Patient 3's CTI, dated 2/15/2024, the CTI indicated Physician 1 indicated Patient 3 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. During a review of Patient 3s LCD Hospice Eligibility Determination form for Heart Disease, dated 2/15/2024, indicated Patient 3 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 3 had been ruled out as a candidate for surgical procedures due to medical condition. Section 2 was marked "yes" that Patient 3s Congestive heart Failure or angina met the criteria for NYHA Class IV level. During a joint home visit observation, and an interview, on 5/18/2024, at 12 p.m., with Licensed Vocational Nurse 1 (LVN 1) at Patient 3s residence, Patient 3 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory (able to walk) without using an assistive device. Patient 3 stated no one explained to her that what she signed up for was for hospice care. Patient 3 stated she was referred by a friend and she was not dying in six months. During an interview on 5/19/2024, at 11 a.m., with the DPCSD, the DPCSD stated she was not able to find documented evidence that Patient 1, Patient 2, and Patient 3 had a disabling dyspnea (shortness of breath) at rest, were poorly responsive or unresponsive to bronchodilators (medications to help with breathing) prior to hospice admission. The DPCS stated there was no documented evidence Patient 3 had been ruled out as a candidate for surgical procedures due to medical condition. The DPSC stated there was no documented evidence Patient 3 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest, or had an ejection fraction of less than 20. During a review of the agencys undated policy and procedure titled "Admission Criteria and Process", indicated Bless Care Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Bless Care Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician, if any. During a review of the agencys undated policy and procedure titled ";Certification of Terminal Illness", indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. During a review of Patient 6s record titled, ";Physician's Certification for Hospice Benefit," the Physician's Certification for Hospice Benefit indicated a start of care date on 9/21/2023 with a primary diagnosis of hypertensive heart disease with heart failure (is a long-term condition that develops over many years in people who have high blood pressure). A review of Patient 6's Physicians Certification for Hospice Benefit, dated 9/21/2023 to 12/19/2023, the Physicians Certification for Hospice Benefit indicated the Medical Director signed the attending physician referral section to indicate Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a concurrent phone interview with Patient 6 on 5/18/2024, at 9 a.m., Patient 6 stated the agency promised him they would send him ensure and toiletries if he would sign the consent forms. Patient 6 stated he signed the consent forms, but the agency did not send what the HA promised, and the agency stopped their services after a month when they found out Patient 6 complained. Patient 6 stated "they did not tell me that they were a hospice agency. I was not seen by a doctor and there were two people knocking door to door at our building telling us the same thing." During an interview on 5/19/2024, at 12:21 p.m., with the Director of Patient Care Services Designee (DD), the DD stated she would go to the HA once a month and as needed and stated that she was notified by the assistant administrator (AA) that she needed to be at the HA. The DD stated in general, the admission process started when the HA would get community referrals, referrals by their friends, then they would explain the hospice benefits, look at their prognosis and decline and look into the medical records if they have it. The DD stated that they also would ask the medical director when the patients referred to the agency especially if these patients had not seen or visited their primary doctors and the MD would be the referring and the attending MD. During an interview with the Medical Director (MD) on 5/19/2024, at 2:12 p.m., the MD stated that in general he became the patients' attending after they would be admitted to the hospice. MD stated that he would call the attending physician only as necessary. When asked if he obtained laboratory works and history and Physical (H/P) for his patients, MD responded " if they do not have the H/P (history and physical) and lab works then it will be hard for us to determine that they are going to be admitted to the program." A review of the agency's undated document titled " Medical Director Job Description" indicated A Medical Director, or Clinical Medical Director, is responsible for overseeing daily operations of a healthcare facility Their duties include reviewing healthcare laws and regulations to implement on daily practices, monitoring facility or department budgets and developing strategies to improve communication between medical professionals and patients. Ensuring that the medical staff and facility comply with the federal rules, regulations and codes. A review of the agency's document tilted " Admission Information" revised 2/2022 indicated To provide patients with accurate information to make informed decisions regarding care or services. The scope of services: Nursing, Hospice aide and homemaker services, Physical therapy, occupational therapy, Speech language pathology, Social Worker, Physician services, volunteers, counselors, dietary counseling, home medical equipment related to terminal illness, drugs and biologicals related to terminal illness, short tern inpatient care, respite care, continuous care, bereavement counseling and medical supplies. At time of initial assessment, Hospice will provide each patient with a statement of the scope of services provided directly and/or through contractual/written agreement. Patients will also be provided the following information: Care/service limitations, eligibility criteria, charges or patient liability for care/services, information regarding the Medicare Hospice benefit. Patient referrals ma be made by anyone including the family, physician, discharge planners, healthcare :workers, friends, relatives or the patient. When a telephone or verbal referral is received by Hospice, a referral form is completed by a RN. Referrals may also be received by fax in person or in the mail. The referral form includes at least the following information from the attending physician; • Patient identification information, e.g., name, address, telephone number, date of birth, sex, Medicare or social security number, insurance information, emergency contact and telephone number.• Physician's name, address and telephone number and alternative physician to contact is attending is no􀂲 available.• Referral source. i• Primary admitting terminal diagnosis and other diagnosis( es).• Medications and !treatments required, including orders for treatments and symptom management.• Date of hospital discharge, if applicable.• Care or treatments to be provided, including frequency and duration.• Dietary restrictions.• Any other information reported, e.g., medical management of conditions unrelated to the terminal illness and current medical findings.

Based on observation, interview, and record review, the hospice agency (HA) failed to maintain a current medication profile for one of 14 sampled patients (Patient 3). This deficient practice had the potential to place Patient 3 at risk for medication errors and adverse drug reactions (harmful, unintended result caused by taking medication). --- During a review of Patient 3s admission record indicated a start of care (SOC) date of 2/15/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (a condition which affects the arteries that supply the heart with blood). During a review of Patient 3's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 4/22/2024, the POC/IDG indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week plus one prn (as needed) visits to administer and monitor the effectiveness of medication, and to instruct the patient caregiver (PCG) regarding prescribed medication and side effects (are unwanted undesirable effects). During a joint home visit observation, on 5/18/2024 at 12 p.m., with the licensed vocational nurse (LVN 1) at Patient 3s residence, Patient 3 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory (able to walk) without using an assistive device. During a review of Patient 3s current medication, and an interview, on 5/18/2024, at 12:20 p.m., with LVN 1, there was an empty bottle of Metoprolol (medication to help lower the blood pressure) 25 milligram (mg, a unit of measure) one tablet oral daily. However, Patient 3s current medication profile provided by the HA indicated patient was taking the medication. Patient 3 stated she ran out of the Metoprolol medication for two weeks. During an interview on 5/19/2024, at 1:20 p.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated the visiting nurse needed to review patients current medication on every visit and update the medication profile in the patients clinical record. During a review of the hospice agencys undated policy and procedure titled, ";Medication Profile," indicated patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for IDG, Care Planning, Coordination, and Quality of Care was met as follows: --- 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 and updated the comprehensive assessment at least every 15 days for 14 out of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14). ( Refer to L539) This deficient practice had potential for the patients progress toward desired outcomes, including the patient's response to care will not be identified, causing delay of treatment, intervention, and management of needs of the terminally ill patient. w

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG, group of healthcare professionals [Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor ] working together to provide residents with the care they need) met and performed their assigned tasks (functions) for the thirteen of 14 sampled patients, (Patients 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, and 14). This deficient practice had the potential the necessary care, and services necessary to maintain the highest practicable physical, mental and psychosocial wellbeing of the affected patients will not be assessed and provided. --- 6. A review of Patient 6s record titled, ";Patient Face Sheet", indicated a start of care date on 9/21/2023 with a primary diagnosis of hypertensive heart disease with heart failure (is a long-term condition that develops over many years in people who have high blood pressure). During a concurrent interview with Patient 6 on 5/18/2024 at 9:00 a.m., Patient 6 stated he complained about this hospice because the agency promised him they will send him ensure and toiletries if he signs the consent forms. Patient 6 stated he signed the consent forms but the agency did not send what they promised so he complained and the agency stopped their services after a month when they found out I complained. On concurrent review of Patient 6's EMR (electronic medical record- are a digital version of the paper charts in the clinician's office) on 5/18/2024 showed that the discharge summary (the summary of the patient's stay on hospice, all current orders and plans of care, and any other clinical documentation to provide a coordinated discharge plan if requested by the receiving organization) was not signed by the medical director and the registered nurse (RN), there was no discharge assessment conducted by the RN, there was no bereavement assessment and no psychosocial assessment and the IDG (The Interdisciplinary Group (IDG) is the team responsible for the holistic care of the hospice beneficiary. It is this team which is responsible for development and review of the beneficiary's plan of care) for the following dates: 9/21/2023, 9/25/2023, 10/9/2023, 10/2023 was not signed by the medical director (MD), RN, Medical Social Worker (MSW) and the Chaplain. 7. A review of Patient 7's "Personal Information" indicated the patient was admitted to hospice on 7/23/2023 with the diagnosis of hypertensive heart disease with heart failure and benign prostatic hyperplasia (enlarged prostate). On concurrent review of Patient 7's EMR on 5/18/2024 revealed that the discharge summary dated 12/22/2023 was not signed by the MD and the RN. IDG for the following dates: 7/26/2023, 7/31/2023, 8/14/2023, 8/28/2023 had no MD, MSW and chaplain signatures. On 9/11/2023, 9/25/2023, 10/9/2023, 10/23/2023, 11/6/2023, 11/20/2023, 12/4/2023, 12/18/2023 revealed that only the RN signed IDG , No MD, MSW, Chaplain signatures. 8. A review of Patient 8's "Personal Information" indicated that patient was admitted to hospice on 9/21/2023 with the diagnosis of hypertensive heart disease with heart failure. On concurrent review of Patient 8's EMR on 5/18/2024 revealed the IDG on the following dates: 9/25/2023, 10/3/2023 had no MSW and chaplain signatures. On 10/31/2023, 3/11/2024 and 3/25/2024 there was no MD, no MSW and no chaplain signatures. on 11/6/2023 to 2/26/2024 no MSW and no chaplain signatures. 9. A review of Patient 9's "Personal Information" indicated that patient was admitted to hospice on 9/22/1013 with the diagnosis of hypertensive heart disease with heart failure. On concurrent review of Patient 9's EMR on 5/19/2024 revealed that the following dates: 5/6/2023, 4/22/2023, 4/8/2023, 3/25/2023, 3/11/2023, 2/26/2023, 2/12/2023, 1/29/2024, 1/15/2024 and 1/1/2024 had no MSW and no chaplain signatures. 10. A review of Patient 10's "Personal Information" on 5/19/2024 indicated that the patient was admitted to hospice on 5/23/2023 with the medical diagnosis of senile degeneration of brain (also called Dementia - is an umbrella term for a group of conditions that affect the ability to think, concentrate, or remember). On concurrent review of Patient 10's EMR indicated that the IDG on the following dates: 5/6/2024, 4/22/2024, 4/8/2024, 4/8/2024, 3/25/2024, 3/11/2024, 2/26/2024, 2/12/2024, 1/29/2024, 1/15/2024 and 1/1/2024 revealed there was no MSW and no chaplain signatures. 11. A review of Patient 12's "Personal Information" on 5/19/2024 indicated that the patient was admitted to hospice on 2/15/2024 with the diagnosis of atherosclerotic heart disease (The usual cause is the build-up of plaque. This causes coronary arteries to narrow, limiting blood flow to the heart). On concurrent review of Patient 12's EMR indicated that the IDG on the following dates:2/15/2024, 2/26/2024, 3/11/2024, 3/25/2024, 4/8/2024, 4/22/2024 and 5/6/2024 no chaplain signature present. 12. A review of Patient 13's "Personal Information" on 5/19/2024 indicated that the patient was admitted to hospice on 9/10/2023 with the diagnosis of ischemic cardiomyopathy (ineffective blood pumping by the heart as a result of ischemic damage to the myocardium. It is a common condition and a significant cause of morbidity and mortality). On concurrent review of Patient 13's EMR on 5/19/2024 revealed that there was no MSW and chaplain signatures on 5/6/2024, 4/22/2024, 4/8/2024, 3/25/2024, 3/11/2024, 2/26/2024, 2/12/2024, 1/19/2024 and 1/1/2024. No MSW notes on 4/20/2024, 3/20/2024, 2/18/2024, 1/15/2024, 12/16/2023, 11/15/2023 and 10/14/2023. 13. A review of Patient 14's "Personal Information" on 5/19/2024 indicated that the patient was admitted to hospice on 11/16/2023 with the diagnosis of cancer of the prostate. On concurrent record review on 5/19/2023 showed that there was no notes for MSW and chaplain when order stated services were offered monthly. During an interview with the ADM on 5/18/2024 at 1:10 p.m., ADM stated that the IDG members comprises of the MD, MSW, DPCS, DD, the visiting nurse , volunteer and or other ancillary services if any and all attend virtually. ADM further stated that all has access to the EMR and should be able to sign the IDG after each meeting. ADM stated if it is not signed means its not done. A review of the agency's document titled " IDG Care Planning process" revised 2/2022 indicated Hospice has designated an interdisciplinary group which, in consultation with the patient's attending physician, Prepares a written plan of care for each patient. The group consists of: A physician member who is the Hospice Medical Director or another Hospice physician who is employed by or under contract with Hospice (the physician must be a doctor of medici11ib or osteopathy).Registered nurse. Social worker . Pastoral or another counselor. The IDG works together to meet the physical, medical, psychosocial, emotional and spiritual needs of Hospice patients and families facing terminal illness and bereavement. IDG members provide the care and services offered by Hospice. IDG supervises the care and services. a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 2/4/2024, with a terminal diagnosis of chronic systolic congestive heart failure (a specific type of heart failure that occurs in the heart's left ventricle). On concurrent review of Patient 1's EMR (electronic medical record) indicated the following IDG meetings on dates 2/4, 2/12, 2/26/24, 3/11, 3/25/24, 4/8, 4/22/24 and 5/6/24, revealed that medical director, social worker and chaplain's signatures were missing. b. During a review of Patient 2s admission record indicated a start of care (SOC) date of 1/17/2024 with a terminal diagnosis of chronic systolic congestive heart failure (a specific type of heart failure that occurs in the heart's left ventricle). On concurrent review of Patient 2's EMR indicated the following IDG meetings on dates 1/17, 1/29/24, 2/1, 2/26/24, 3/11, 3/25/24, 4/8, 4/22/24 and 5/6/24, revealed that medical director, social worker and chaplain's signatures were missing. c. During a review of Patient 3s admission record indicated a start of care (SOC) date of 2/15/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (a condition which affects the arteries that supply the heart wit blood). On concurrent review of Patient 3's EMR indicated the following IDG meetings on dates 2/15, 2/28/24, 3/11, 3/25/24, 4/8, 4/22/24 and 5/6/24, revealed that medical director, social worker and chaplain's signatures were missing. d. During a review of Patient 4s admission record indicated a start of care (SOC) date of 12/22/2023 with a terminal diagnosis of congestive heart failure (a condition in which the heart does not pump blood as well as it should). On concurrent review of Patient 4's EMR indicated the following IDG meetings on dates 2/15, 2/28/24, 3/11, 3/25/24, 4/8, 4/22/24 and 5/6/24, revealed that medical director, social worker and chaplain's signatures were missing.

Based on observation, interview and record review, the visiting nurse failed to notify the physician regarding one of 14 sampled patients (Patient 3), who ran out of hypertensive (high blood pressure) medication for two weeks. This deficient practice placed the patient at risk to have hypertensive crisis episodes. --- Findings: A review of Patient 3s admission record indicated a start of care (SOC) date of 2/15/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (a condition which affects the arteries that supply the heart with blood). A review of Patient 3's Plan of Care (POC)/Interdisciplinary Group (IDG, group of healthcare professionals [Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor ] working together to provide residents with the care they need) form, dated 4/22/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week plus 1 prn (as needed) visit to administer and monitor the effectiveness of medication, and to instruct the patient caregiver (PCG) regarding prescribed medication and side effects (undesirable effects). During a joint home visit, on 5/18/2024 at 12 p.m., with LVN 1 at Patient 3s residence, Patient 3 was observed awake, alert, oriented x 3 (to person, place, and time). Patient 3 was ambulatory without using an assistive device. A review of Patient 3s current medication with LVN 1 during the home visit was conducted on 5/18/2024 at 12:20 p.m. and an empty bottle of Metoprolol 25 milligram (mg, a unit of measure) 1 tablet oral daily was observed. Patient 3s current medication profile provided by the HA indicated Patient 3 was currently taking the medication (Metoprolol 25 mg.). When asked, Patient 3 stated she ran out of this medication for two weeks. A review of Patient 3's electronic medical records did not indicate documented evidence of a communication note that the physician was notified by LVN 1 regarding Patient 3s Metoprolol medication that had ran out for two weeks. During an interview on 5/19/2024 at 11:20 a.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated she could not find any documentation that LVN 1 notified the physician nor it was reported to her (DPCSD) that Patient 3 ran out of Metoprolol medication for two weeks. A review of agency's undated policy and procedure titled, "Change of Condition," indicated the clinician is responsible for any specific treatment and would notify the attending physician of significant changes in the patient's condition.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to measure the results and document evidence of a Quality Assessment and Performance Improvement (QAPI, quality improvement) program based upon identified or negative patient care outcomes, measurable indicators to evaluate changes in policy, procedure, and intervention. This deficient practice had the potential for the HA not to be able to assess and evaluate possible negative patient care outcomes, infection control program surveillance, and the HA's operations. --- A request was made on 5/17/2024, at 2 p.m., to the Assistant Administrator (AA) for the performance improvement projects (PIP) derived from the data collected from the QAPI program. During a concurrent interview with the AA on 5/17/2024, at 2 p.m., the AA stated she did not know where the QAPI/PIP book was. The AA stated that it was a learning experience for her that she should know where these books were. During an interview with the Administrator on 5/18/2024, at 1:10 p.m., the Administrator stated the members of the QAPI team were the Administrator, Medical director, Licensed staff, Medical Social Worker, Chaplain, and ancillary services if any. During a review of the agency document titled "Quarterly Report," for the period of January to March 2024, indicated that QAPI department conducted a utilization review for volunteers, quarterly complaint log, fall risk assessment, infection control and satisfaction survey form. On concurrent interview with the Administrator on 5/18/2024, at 1:30 p.m., the Administrator stated there was only one quarter reviewed for QAPI with no stated results and could not explain how she gathered the data for her QAPI. A review of the agency's policy titled "QAPI Plan" 2023-2024, indicated the monitoring and evaluation process will provide the QAPI committee with additional information concerning trends and patterns of care/service. The QAPI Chairman will present a quarterly report that will include a summary of the previous three months QAPI activities, problems identified, problem resolved, as well as recommendations for policy/procedural changes. The following representatives will make up the QAPI Committee: governing board, medical director, administrator, Nursing services, Social Services, spiritual counselor. Frequency of collection: Data is collected monthly and trended and analyzed every quarter. The QAPI committee will meet quarterly. QAPI activities and outcomes will be on the agenda of every staff meeting. The minutes from all meetings will be available online. The QAPI committee will report all activities to the governing board. The QAPI committee will have responsibility for reviewing data, suggestions, and input from patients, staff, family members, and other stakeholders. The QAPI committee will prioritize opportunities for improvement and determine which performance improvement projects will be initiated. When an issue or problem is identified that is not systemic and does not require a performance improvement project, the QAPI committee will decide how to correct the issue or problem. Thebe corrections may include an easy decision, corrective action plan or rapid improvement cycle.

Based on interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide evidence that Hospice Aide 1 (HA1) had the training and qualifications needed to provide patient care for all patients (20 of 20 active patients) admitted in their program. This deficient practice had the potential to cause harm and injury to the patients. --- During a review of the employee files on 5/18/2024 indicated that there was only one hospice aide active on file. During a review of the agency's document titled "2023-2024 In-Service," log (Annual) indicated topics for the in-services that the hospice aide should have taken for the past year. There was no written evidence of a lesson plan and attendance sheet and who presided the training for the hospice aide. During an interview on 5/18/2024, at 1:10 p.m., with the Administrator (ADM), the ADM stated she started working in the agency last January 2023. The Administrator stated, "Honestly, I had not looked into the hospice aide training program." On concurrent record review of the "Hospice Aide Hub" logbook with the Administrator, the Administrator stated the agency did not have evidence of in-services or accumulated training hours for hospice aides (HA 1.) During an interview with the Director of Patient care Designee (DD) on 5/19/2024, at 12:21 p.m., the DD stated she would go to the HA at least once a month or when the agency called her. The DD stated she functioned as the Director of Patient care (DPCS). The DD stated she would help manage with clinical, help with the program, any issues with the patient, call that needed the nurses and acted as back up to find out what was going on, if the DPCS was not available, the designee was the back up. A review of the agency's undated document titled "Clinical Director (DPCS) Job Description" indicated The DPCS Designee is responsible for assisting the Director of Patient Care Services in the overall planning, direction, management hand and supervision of all clinical operations. The DPCS Designee works hand in hand in assuring quality of care by reviewing and assessing services and overall compliance. Evaluates performance of clinical managers. Assists clinical managers to develop skills and techniques in evaluating the performance of clinicians. Hires, evaluates and terminates clinical organization personnel. Conducts clinician performance evaluations annually and more frequently if indicated. A review of the agency's undated document with no title indicated The Administrator is responsible for the overall direction of the hospice services. They ensure the employment of qualified personnel and are responsible for the provision of hospice services, hospice personnel evaluations and for ensuring that standards of care comply with federal, state and professional guidelines. They also ensure that the provision of services is consistent with the agency's mission, vision and philosophy.

Based on interview and record review the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure volunteer services were offered to all patients (20 active patients) on a continuous basis. This deficient practice had the potential not to facilitate services to the patients. --- A review of the agency's "Volunteer Services Program" was conducted in the presence of the Administrator (ADM) on 5/18/2024, at 2 p.m., revealed the volunteer training program details, there was no written specifications noted for the cost saving plan, volunteer duties utilized and specified number of hours and training for their volunteer. During a concurrent interview on 5/18/2024, at 2 p.m., with the ADM, ADM stated the HA had one volunteer in the HA's volunteer program. The ADM stated the volunteer did not come to the office and would usually call the patients from home. A review of the agency's document titled " An Overview of Volunteer Services: Policies, procedures and Regulations" indicated volunteer coordinators or volunteers must actively participate in the interdisciplinary care planning process. Documentation of volunteer services on the plan of care is required for all patients receiving volunteer services. Individualized plans must be reviewed, revised, and documented as frequently as the patient's condition requires, but no less frequently than every 15 days. The plan of care must include a detailed statement of the scope and frequency of services to meet the patient's and family's needs. When volunteers are involved in a patient's care, the scope, frequency, and updates must be documented just as for all other disciplines. The use of "PRN" (as needed} may not be used as a standalone visit frequency on the plan of care. Direct patient care hours encompass all hands-on, direct time spent with patients, families, or hospice survivors, including: Telephone calls to patients, families, or survivors. Travel time to patient homes, if travel time is also considered for staff hours. Time spent receiving orientation to a specific patient, such as infection control procedures during an introductory visit. ime spent training volunteers for particular administrative tasks, like clerical duties in the office. Direct patient care hours include but are not limited to:In-home/in-person family time.Telephone contact.Art at the bedside for individual patients.Music at the bedside for individual patients.Providing companionship.Transportation, e.g., doctor visits, shopping, errands.Respite care.Pet therapy for individual patients.Companion vigils (11th hour volunteers).Life review and life history discussions. The policy indicated Volunteers must provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff.The hospice must maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked. Routine Administrative Duties Volunteers may assist in routine administrative tasks that support direct patient care activities. These duties may include: Answering telephones. Filing and organizing documents. Assisting with patient and family mailings. Data entry for administrative purposes. Routine Direct Patient Care Hospice may utilize volunteers to provide direct patient care services or assist patients and families with household chores, shopping, transportation, and companionship. Examples of direct patient care services include: Mowing a patient's lawn. Walking a patient's dog. Providing companionship and emotional support. The policy indicated the hospice must use volunteers to the extent specified in paragraph (e) of this section. These volunteers must be used in defined roles and under the supervision of a designated hospice employee. Training: The hospice must maintain, document, and provide volunteer orientation and training that is Pure Love Hospice Inc. consistent with hospice industry standards.

Based on interview and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for Organization and Administration of Services as follows: --- 1. The hospice agency (HA) failed to ensure the governing body and administrator, assumed full responsibility for the day-to-day operation of the hospice services and provision of care. (Refer to L651) 2. The hospice agency (HA) failed to assess the skills and competencies of all individuals furnishing care, including volunteers furnishing services, and, as necessary, to provide required in-service training and education programs. (Refer to L663) This deficient practice resulted in the HAs substandard quality of care.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the governing body and Administrator assumed full responsibility for the day-to-day operation and the provision of hospice care and services. --- Findings: During an observation of the agency on 5/17/2024 at 1:00 p.m., there was only one staff present in the office. During an interview with the Office Manager (OM) on 5/17/2024 at 1:10 p.m., OM stated that he just started two months ago, and he is still trying to learn their business operations. Assistant Administrator (AA) arrived in the office on 5/17/2024 at 2:00 p.m. Requested AA to provide employee files, QAPI (resource that assists a hospice provider with implementation and maintenance of their quality improvement program and activities), Staff In-services, hospice aide training program, volunteer services program, and the governing body minutes book. During a concurrent interview with the AA, the AA stated that she is unable to provide the requested files and documents and stated that she will have it ready by the next day. AA further stated that she understands that she should know where to find HAs books and these books should be present in the office. During an interview on 5/18/2024, at 1:10 p.m., the Administrator (ADM) stated she will try to call the Director of Patient Care Services (DPCS) and the DPCS Designee (DD) to come to the office for the survey. ADM also stated that she studied nursing, but she is not licensed to practice. ADM further stated that she has remote access to the electronic medical records. During an interview with the Director of Patient Care Services Designee (DD) on 5/19/2024 at 12:21 p.m., DD stated that she comes once a month or as needed when the agency calls her. DD further stated that the DPCS is out of town and will not be able to come to the office for the survey. When asked if she is familiar with patients, DD stated she would have to review the chart for any information the department may need. A review of the agency's untitled and undated document indicated the Administrator is responsible for the overall direction of the hospice services. The document indicated: - They ensure the employment of qualified personnel and are responsible for the provision of hospice services, hospice personnel evaluations, and for ensuring that standards of care comply with federal, state and professional guidelines. - They also ensure that the provision of services is consistent with the agency's mission, vision, and philosophy. - Assumes responsibility for the day-to-day administration of hospice program. - Organizing and directing the organization's ongoing operations to assure the availability and provision of care and services. - Implementing governing body directives and organizational policies and procedures. This includes ensuring the development, implementation, and enforcement of agency policies and procedures. - Planning, developing, implementing, administering, and evaluating programs. A review of the agency's undated document titled " Hospice Administrator Designee Job Description" indicated, the Hospice Administrator Assistant/Designee will: - Assist the Administrator in managing all aspects of the hospice program including staffing, financial management, interaction with patients and families, community relations, and regulatory compliance. - Oversee and manage all aspects of hospice operations, including patient care, staff management, budgeting, and compliance with regulations. - Develop and implement policies and procedures to ensure the delivery of quality care services that align with industry best practices and regulatory requirements. Ensure compliance with all applicable laws, regulations, and accreditation standards, maintaining accurate and up-to-date documentation as required.

Based on interview, and record review, the hospice agency (HA) failed to assess the skills and competencies of all individuals furnishing care, including volunteers furnishing services, and, as necessary, to provide required in-service training and education programs. This deficient practice resulted in the HAs substandard quality of care. --- A review of the HAs personnel files on 5/17/2024, indicated that all the field staff had their performance evaluations during their initial hire date. There was no other documented evidence in all personnel files of yearly performance evaluations. A further review of the hospice agency's personnel files indicated, the Director of Patient Care Services (DPCS), two registered nurses (RN), chaplain/volunteer coordinator, two Licensed Vocational Nurses (LVN) had no Basic Life Support (BLS, a level of medical care which is used for patients with life-threatening illnesses or injuries until they can be given full medical care by advanced life support providers) training. Medical Director (MD) and Medical Social Worker's (MSW) had expired BLS certificates. During an interview with the Administrator (ADM) on 5/18/2024 at 1:10 p.m., the ADM stated that she had not looked into the employee files recently. A review of the agency's untitled and undated document indicated the Administrator is responsible for the overall direction of the hospice services. The document indicated: They ensure the employment of qualified personnel and are responsible for the provision of hospice services, hospice personnel evaluations, and for ensuring that standards of care comply with federal, state and professional guidelines. They also ensure that the provision of services is consistent with the agency's mission, vision, and philosophy. Assumes responsibility for the day-to-day administration of hospice program. Organizing and directing the organization's ongoing operations to assure the availability and provision of care and services. Planning, developing, implementing, administering, and evaluating programs. Ensuring adequate staff orientation and staff education. Staff development including orientation, in-services, continuing education, competency testing and performance improvement. A review of the agency's undated document titled " Hospice Administrator Designee Job Description" indicated the Hospice Administrator Assistant/Designee will assist the Administrator in managing all aspects of the hospice program including: Staffing, financial management, interaction with patients and families, community relations, and regulatory compliance. Oversee and manage all aspects of hospice operations, including patient care, staff management, budgeting, and compliance with regulations. Develop and implement policies and procedures to ensure the delivery of quality care services that align with industry best practices and regulatory requirements. Ensure compliance with all applicable laws, regulations, and accreditation standards, maintaining accurate and up-to-date documentation as required. Recruit, train, and supervise a team of healthcare professionals, ensuring they have the necessary skills and resources to provide compassionate and effective care.

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 hospice agency failed to ensure the agency staff submitted complete clinical notes in a timely manner, and pertinent clinical records were included to reflect the care and assessment provided for four of 14 sampled patients (Patients 1, 2, 3 and 4). (Refer to L672) 2. The hospice agency (HA) failed to ensure that the visiting nurse document the efforts for missed visits for three out of 14 sampled patients (Patient 8,10 and 14). (Refer to L674). 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 were safeguarded from unauthorized access by any individual or hospice staff and were maintained complete and accurate.

The hospice agency failed to ensure the agency staff submitted complete clinical notes in a timely manner, and pertinent clinical records were included to reflect the care and assessment provided for four of 14 sampled patients (Patients 1, 2, 3 and 4). This failure resulted in patients incomplete clinical record that could lead to misinformation and non-continuity of care and services information provided to the patient. --- a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 2/4/2024, with a terminal diagnosis of chronic systolic congestive heart failure (a specific type of heart failure that occurs in the heart's left ventricle). On concurrent review of Patient 1's EMR (electronic medical record) indicated the following clinical notes on dates 5/6/2024 and 5/13/2024, revealed to be missing. b. During a review of Patient 2s admission record indicated a start of care (SOC) date of 1/17/2024 with a terminal diagnosis of chronic systolic congestive heart failure (a specific type of heart failure that occurs in the heart's left ventricle). On concurrent review of Patient 2's EMR indicated the following clinical notes on dates 2/22/2024, 4/4/2024, 4/11/2024, 4/18/2024, 4/25/2024, 5/2/2024, 5/9/2024, and 5/16/2024, revealed to be missing. c. During a review of Patient 3s admission record indicated a start of care (SOC) date of 2/15/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (a condition which affects the arteries that supply the heart wit blood). On concurrent review of Patient 3's EMR indicated the following clinical notes on dates 3/1/2024, 3/8/2024, 3/15/2024, 3/22/2024, 3/29/2024, 4/5/2024, 4/12/2024, 4/19/2024, 4/22/2024, 4/25/2024, 5/3 and 5/10/2024, revealed to be missing. d. During a review of Patient 4s admission record indicated a start of care (SOC) date of 12/22/2023 with a terminal diagnosis of congestive heart failure (a condition in which the heart does not pump blood as well as it should). On concurrent review of Patient 4's EMR indicated the following clinical notes on dates 3/25/2024, 4/13/2024, 4/20/2024, 4/22/2024, 4/27/2024, 5/4/2024, and 5/11/2024, revealed to be missing. During an interview on 5/19/2024, at 11:45 a.m., with the DPCSD (director of patient care services), she stated that she calls the QA and calls the caregivers and field staff to complete their notes for QA review. She also stated that the field staff are required to submit their notes within 48 to 72 hours after their home visit, that the QA will review the notes and will resend the noted to the field staff for signature. She further stated that it has been an ongoing problem that the staff were not submitting their notes on time for the QA to review it. A review of facilitys undated policy and procedure titled, ";Clinical/Service Data Collection", indicated a clinical/service record will be initiated and maintained for each patient and will include at a minimum: Pertinent medical history... Current patient status and progress toward goals... Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided... Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. The clinical/service note will include: the date the service was provided... signature of clinician/technician and his/her credentials."

Based on observation, interview and record review, The hospice agency (HA) failed to ensure that the visiting nurse document the efforts for missed visits for three out of 14 sampled patients (Patient 8,10 and 14) This failure had the likelihood to cause patient harm or injury and the delay of necessary services required in the patients care. --- 1. A review of Patient 8's "Personal Information" indicated that patient was admitted to hospice on 9/21/2023 with the diagnosis of hypertensive heart disease with heart failure ( long term medical condition resulted from unmanage high blood pressure). A review of Patient 8's "Communication Log" dated 1/16/2024 at 5:10 p.m., and 2/21/2024 at 2:31 p.m., indicated that the nurse called the patients number on file doesn't ring and auto-disconnects. There was no other documented evidence indicating what the agency did after the attempt to call the patient during those dates. 2. A review of Patient 10's "Personal Information" on 5/19/2024 indicated that the patient was admitted to hospice on 5/23/2023 with the medical diagnosis of senile degeneration of brain (also called Dementia - is an umbrella term for a group of conditions that affect the ability to think, concentrate, or remember). A review of Patient 10's "Communication Log" dated 2/21/2024 at 2:11 p.m., indicated that the nurse called the patients number and was directed to a home care that was unavailable and left a voice message. There was no documented evidence in the patient's chart the nurse followed up. 3. A review of Patient 14's "Personal Information" on 5/19/2024 indicated that the patient was admitted to hospice on 11/16/2023 with the diagnosis of cancer of the prostate ( a form of cancer that begins in the gland cells prostate (small walnut size gland) found in males only). A review of Patient 14s "Communication Log" dated 1/16/2024, at 4:26 p.m., 2/27/2024 at 4:43 p.m., and indicated that the nurse called the patient but was unavailable and left a voice message. On 5/14/2024 at 4:12 p.m., nurse documented that the patients daughter stated the patient was out of the country for the past 2 months and no definite date of return yet. There was no documented evidence that the patient was discharged and agency still continued services for the certification period. On 5/18/2024 at 1:10 p.m., during an interview with the Administrator (ADM), ADM stated that the agency should call back again when they are attempting a phone call and make sure that the nurse should do a wellness check if there is a missed home visit and should notify the agency and document the results in the electronic medical record. A review of the agency's document titled " Documentation Standards" revised 7/2020 indicated Our processes are outlined in this document which meet the requirements of State and Federal laws, as well as accreditation standards. We will update standards based on audits and system changes.100% of Documentation is completed at the point of care and accurate. Every home care visit note is closed and completed within 24 hours and every IPU note is closed at the end of each shift. A closed visit note is your electronic signature and protects you from changes to your documentation. Computers are synchronized at least every morning and every evening so that everyone has the latest information to all patient encounters (i.e. visits, phone calls, etc.) need to be recorded in the electronic medical record (EMR). Utilize this resource. Ask for help when needed from your preceptor or supervisor.