Every finding on record at Quality Care Hospice, Inc

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of Patients was met as follows: 1. The hospice agency failed to document the patient had an existing pacemaker(small device use to treat irregular heart beat) in the initial comprehensive assessment for one out of 14 sample patients (Patient 1). (Refer to L524). 2. The hospice agency failed to provide an initial bereavement (grief after death) assessment for two of 14 sampled patients (Patients 4 and 10). (Refer to L531). 3. The hospice agency failed to accurately assess the patient's eligibility for hospice services related to palliation (relief of symptoms or suffering cause by a life threatening disease) and management of the terminal illness and related conditions for four out of 14 sampled patients (Patients 1, 2, 3, and 5). (Refer to L532). The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily ( right or legal way) mandated compliance with the Federal regulations for Initial & Comprehensive Assessment of Patients to ensure the highest quality of care is being provided to patients certified to receive the Medicare hospice benefits. --- **

Based on observation, interview and record review, the hospice agency failed to document in their initial comprehensive assessment that one of 14 sample patients had an existing pacemaker (Patient 1). This deficient practice had the potential to result in the lack of required care and monitoring of the pacemaker and identification of problems with the patients pacemaker. --- A review of Patient 1's face sheet indicated Patient 1 was admitted to hospice on 10/21/22, with a primary diagnosis of unspecified alcohol-induced persisting dementia (brain damage cause by drinking to much alcohol for many years). A review of Patient 1's "Plan of Care (POC)" dated 10/21/22, for Benefit period #1, indicated the Skilled Nurse (SN) was to visit Patient 1 once a week. The Medical Social Worker (MSW) was to visit once a month, and the hospice aid (HA) service was declined. On 4/8/23, at 1 p.m., a home visit was conducted at Patient 1's residence accompanied by Administrator 1. Patient 1 was observed walking around the hallway talking to himself in a locked facility. During an interview, with Medication Technician 1 (MT1) on 4/8/23, at 1:05p.m., MT1 was asked about Patient 1's health condition, MT1 stated Patient 1 has a pacemaker and has an appointment with his physician for a pacemaker check up next month. A review of Patient 1's Comprehensive Nursing Assessment dated 10/21/22, indicated the visiting nurse did not document that Patient 1 had an existing pacemaker. On 4/10/23, at 11 a.m., during an interview with the DPCS (Director of Patient Care Services), DPCS stated the visiting nurse should assess and document Patient 1's pacemaker in the initial Comprehensive Nursing Assessment notes.

Based on observation, interview and record review, the hospice agency (HA) failed to: Maintain an accurate, current medication profile for one out of 14 sampled patients (Patient 8). Notify the physician when Patient 7 was given Hydralazine without a physician's order. These failures had the potential to place both Patient 7 and Patient 8 at risk for medication errors and adverse drug reactions. --- A. A review of Patient 7's admission record indicated the Patient 7 was admitted to the hospice agency on 1/20/23, with a primary diagnosis of hemiplegia (paralysis on one side of the body) following cerebral infarct(stroke) affected right dominant side. A review of the "Plan of Care" dated 1/20/23, indicated the SN visit frequency for Patient 7 was initial, recertification and every 14 days if CHHA (certified home health aide) services are given or every 30 days if LVN (licensed vocational nurse) services are given. On 4/8/23, at 3:00 p.m., during a joint home visit with the Registered Nurse (RN 1), Patient 7 was observed lying in a hospital bed and Family member 1 was present. RN 1 proceeded with her home visit. On concurrent medication review, Patient 7 did not have a physician's order for hydralazine as needed for a blood pressure more than 160/80. A review of the Registered Nurse (RN) in-person "Visit Note" dated 4/2/23 Narrative, indicated Family member 1 reported to the RN that Patient 7 had just taken Hydralazine half an hour ago for a blood pressure of 161/89, as well as hydrocodone-acetaminophen 5/325 mg 1 tablet by mouth at 2 :00 p.m. for a headache. RN instructed family member to keep monitoring Patient 7's blood pressure and pain level and to report to the on-call nurse if there were any symptoms that were not controlled by medications. There was no written documentation in the visit note narrative that the physician and the Director of Nursing (DON) were called and notified about the medication error. During an interview and record review with the DON on 4/10/23 at 12:10 p.m., a comparison of the medication profile of what the visiting nurse gave on the date of the home visit and the medication profile printed on this date was done. The DON was asked to verify if there was an order for Hydralazine for Patient 7 and the DON confirmed there was none. The DON while viewing the documentation of the visiting nurse for 4/2/23, the DON stated, where did she get the medication if there was no order? The DON further stated this is considered a medication error and should have been reported to the physician and the supervisor. A review of the HA's policy titled "Ongoing Comprehensive Assessments" indicated the physician will be notified to verify any changes in medications, including over-the-counter medications, and treatment/interventions that require physician's approval. B. A review of Patient 8's admission record indicated Patient 8 was admitted to the hospice agency on 2/4/23, with a primary diagnosis of Alzheimer's disease (a general term for memory loss and other cognitive abilities serious enough to interfere with daily life) early onset. A review of the "Plan of Care" dated 3/28/23, indicated the SN visit frequency for Patient 8 was an initial visit, recertification and a visit every 14 days if CHHA (certified home health aide) services are given or every 30 days if LVN (licensed vocational nurse) services are given. On 4/8/23, at 3:00 p.m., during a joint home visit with the Registered Nurse (RN 1), Patient 8 was observed lying in a hospital bed and Family member 1 was next to the Patient. RN 1 proceeded with her home visit. During Patient 8's medication review with RN1 compared with the medication profile, Losartan Potassium 50 mg(milligrams - a unit of measurement) 1 tablet daily for high blood pressure was not listed on the medication profile. On concurrent review and interview with RN 1, RN 1 confirmed that Patient 7 had the bottle but did not understand why it was not listed on the medication profile. RN stated she will verify with the electronic medical record. During a medication profile review and interview with the Director of Nursing (DON) on 4/10/23 at 12:10 p.m., the DON stated that the admitting nurse should have reviewed the medication bottle with the med list per our policy. A review of the HA's undated policy titled "Medication Reconciliation" indicated the Hospice will reconcile patient's medication at time of admission and on an ongoing basis. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication.

Based on interview and record review, the hospice agency (HA) failed to provide an initial bereavement assessment for two of 14 sampled patients (Patient 4 and Patient 10). This deficient practice had the potential to impact a family members abilities to cope with the patients death. --- Findings: a. A review of Patient 4's admission record indicated a start of care date (SOC) of 7/8/22, with a diagnoses that included hemiplegia (paralysis of one side of the body) following cerebral infarction (also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side. A review of Patient 4s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 7/19/2022, indicated the skilled nurse (SN) was to visit Patient 4 once per week, and the spiritual counselor (SC) was to visit Patient 4 once per month. The medical social worker (MSW), hospice aide (HA) and volunteer visits were declined. A review of Patient 4's clinical record indicated that there was no initial bereavement assessment conducted. b. A review of Patient 10's admission record indicated a SOC of 11/25/2022, with a diagnoses which included atherosclerosis of aorta (a material called plaque [fat and calcium] has built up in the inside wall of a large blood vessel of the heart called the aorta). A review of Patient 10s Plan of Care/Interdisciplinary Group Review, dated 12/06/2022, indicated the skilled nurse (SN) frequency of visits with Patient 10 was to be done once per week, and the spiritual counselor (SC) visit was to be done once per month. The medical social worker (MSW), hospice aide (HA) and volunteer visits were declined. A review of Patient 10's clinical record indicated there was no initial bereavement assessment conducted. On 4/10/2023 at 1:40 p.m., during an interview with the Director of Patient Care Services (DPCS), she stated a bereavement assessment should be conducted on admission. The DPCS further stated Patient 4 and Patient 10 did not have an initial bereavement assessment conducted on admission. A review of the agency's undated policy and procedure titled "Bereavement Assessment," , indicated on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that will be given to the Bereavement Coordinator. The Bereavement Coordinator will review the bereavement risk assessment to determine potential needs of the survivors.

Based on observation, interview, and record review, the hospice agency failed to accurately assess the eligibility ( the right to do something) for hospice ( medical care given to people with life threatening diseases) services related to the palliation ( relief of symptoms and suffering cause by life threatening diseases) and management of the terminal illness and related conditions for four out of 14 sampled patients (Patients 1, 2, 3 and 5 ). This deficient practice had the potential to result in misuse of the hospice services that could result in substandard (below) provision (supplying something for use) of patient care. --- d. A review of Patient 3's clinical record indicated a start of care date (SOC) of 11/13/2022, with diagnoses which included cerebrovascular disease, unspecified (a group of conditions, diseases, and disorders that affect the blood vessels and blood supply to the brain). The record further indicated, the ";referring/attending/patient choice" physician was the Medical Director (MD). A review of Patient 3's Certificate of Terminal Illness (CTI), dated 11/13/22 to 1/11/23, Benefit period #8 indicated the Medical Director signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. A review of Patient 3s form titled, "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" for Stroke and Coma, indicated for stroke, section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 3 had an impairment of functional status. Section 2 was marked ";yes" that Patient 3 had a weight loss greater than 10% in the last 6 months or greater than 7.5% in the last 3 months. A review of Patient3's clinical record indicated there was no documented evidence Patient 3 had a weight loss greater than 10% in the last 6 months or greater than 7.5% in the last 3 months. On 4/10/2023 at 1:40 p.m., during an interview with the Director of Patient Care Services (DPCS), she stated she was not able to find the documented evidence Patient 3 had a weight loss greater than 10% in the last 6 months or greater than 7.5% in the last 3 months. A review of the agency's undated policy and procedure titled, "Admission Criteria and Process", indicated Quality Care Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). a. A review of Patient 1's face sheet indicated admission to hospice on 10/21/22, with primary diagnosis of unspecified with alcohol-induced persisting dementia, and Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 1's Certificate of Terminal Illness (CTI), dated 10/21/22 to 1/18/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 4/8/23, at 1 p.m., a home visit was conducted at Patient 1's residence with Administrator 1. The patient was observed walking around the hallway talking to himself in a locked facility. During a concurrent interview, when Administrator 1 was asked if Patient 1's attending physician referred him to hospice service, she stated, no. Administrator 1 also stated that one of the staff from the hospice agency referred him to this hospice agency. b. A review of Patient 2's face sheet indicated admission to hospice on 4/4/23, with primary diagnosis of Alzheimer's disease, and Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 2's Certificate of Terminal Illness (CTI), dated 4/4/23 to 7/2/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 4/8/23, at 1:30 p.m., a home visit was conducted at Patient 2's residence with Administrator 1. The patient was observed confused, talking to himself while lying in bed with both side rails up. During a concurrent interview, when Administrator 1 was asked if Patient 2's attending physician referred him to hospice service, she stated, no. Administrator 1 also stated that a family friend referred him to this hospice agency. c. A review of Patient 5's face sheet indicated admission to hospice on 9/29/22, with primary diagnosis of Alzheimer's disease, and Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 5's Certificate of Terminal Illness (CTI), dated 9/29/22 to 12/27/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 4/10/23, at 11 a.m., during an interview with the Director of Patient Care Services (DPCS ), she stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. On 4/10/23, at 1 p.m., during a phone interview with Medical Director 1, he stated that he was not the attending physician, and he does not know who the attending physician for Patients 1, 2, 3, 5, 6, 7 and 8. He stated since Patients 1,2,3,5,6,7 and 8 were admitted to their hospice service, he is now the patient's attending physician, that he signed the referral attending physician section because no one would sign it. Medical Director 1 further stated that he did a face-to-face encounter with Patients 1,2,3,5,6,7 and 8 during their admission to the hospice service, but he determined the patients were eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. A review of the agency policy titled, "Admission Criteria and Process", indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination. Emanuel Hospice Inc. will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. The patient's physician must order and approve the provision of hospice care, be willing to sign or have a representative who is willing to sign the death certificate and be willing to discuss the patients resuscitation status with the patient's resuscitation status with the patient and family/caregiver. The patient must desire hospice services and be aware of the diagnosis and prognosis. Eligibility criteria will be continually reviewed by the interdisciplinary team to ensure appropriateness of hospice care.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met as follows: 1. The hospice agency failed to ensure every member of the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) participated in the interdisciplinary group meeting for two of 14 sampled patients, (Patients 3 and Patient 6) (Refer to L541). 2. The Skilled Nurse (SN) failed to develop a written plan of care for pacemaker (a small device that is placed in the chest to help to control the heartbeat) management for one of 14 sampled patients (Patient 1). (Refer to L543). 3. The hospice agency failed to ensure the IDG, including the Medical Director, communicated with the patient's primary physician to verify the patient's eligibility for hospice care services for eight of 14 sampled patients, (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 10). (Refer to L554). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care were provided to the patients who were accurately assessed to receive hospice care and services. --- **

Based on interview and record review, the hospice agency failed to ensure every member of the interdisciplinary group (IDG, team members from different disciplines working collaboratively with a common purpose to set goals, make decisions, and share resources and responsibilities) participated in the interdisciplinary group meeting for two of 14 patients, (Patients 3 and Patient 6). This deficient practice had the potential to result in members of the IDG not contributing to the patients comprehensive and ongoing assessments and care planning process. --- B. A review of Patient 6s admission record indicated Patient 6 was admitted to the HA on 12/28/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD) with acute exacerbation (symptoms of a COPD exacerbation (flare-up) include tiredness or fatigue, more shortness of breath than usual, more coughing, more wheezing than usual, feeling unwell, feeling as if you have a cold, mucus changes, swollen legs or ankles, trouble sleeping, and other). A review of Patient 6s medical record titled, ";POC/IDG Review," did not indicate the Hospice Medical Director had signed and attended the Interdisciplinary group meeting (IDG) on the following dates: 3/28/23, 3/14/23, 2/28/23, 2/14/23, 1/31/23, 1/17/23 and 1/3/23. During a phone interview with the Medical Director on 4/10/23 at 1:10 p.m., the Medical Director stated he usually attends the IDG meeting and has access to the electronic medical record(EMR). When asked if he signs the EMR after the IDG, he stated "Yes" and also stated if he is unable to sign the staff at the agency signs on his behalf. On concurrent record review and interview with the Director of Nursing(DON) on 4/10/23 at 12:10 p.m., the DON stated if it was not signed there was no attendance. The DON further stated the members of the IDG include the medical director should be in attendance. The DON also stated the agency calls the medical director for any concerns with the patient during the IDG. A review of the HA's policy titled "Physician Services-Medical Director" indicated the hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical director will include, but not limited to: reviewing and updating the plan of care every 14 days, or more frequently as needed in conjunction with the attending physician and interdisciplinary group. Attending IDG meetings and working in a team approach with the group. Findings: a. A review of Patient 3's clinical record indicated a start of care date (SOC) of 11/13/2022, with diagnoses which included cerebrovascular disease, unspecified (a group of conditions, diseases, and disorders that affect the blood vessels and blood supply to the brain). The Plan of Care (POC) for the certification period from 11/22/2022 to 3/14/2023 was reviewed. The agency document titled, "POC/IDG Review," dated 11/22/2022, 12/06/2022, 1/03/2023, 1/17/2023, 1/31/2023, 2/14/2023, 2/28/2023 and 3/14/2023, indicated the SOC was begun on 11/13/2022 on routine care. There was no documented evidence the Medical Director (MD) participated in the POC/IDG review for Patient 3 on 11/22/2022, 12/06/2022, 1/03/2023, 1/17/2023, 1/31/2023, 2/14/2023, 2/28/2023 and 3/14/2023. On 4/10/2023 at 1:40 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), she stated that the IDG team meeting should be held every two weeks with participation of all the IDG members (Medical Director, DPCS, MSW and spiritual counselor). The DPCS confirmed there was no documentation the MD participated in the POC/IDG review of Patient 3 on 11/22/2022, 12/06/2022, 1/03/2023, 1/17/2023, 1/31/2023, 2/14/2023, 2/28/2023 and 3/14/2023. A review of the agency's undated policy and procedure titled "Interdisciplinary Group Meeting," indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care. Each patients 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. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor.

Based on observation, interview and record review, the Skilled Nurse (SN) failed to develop a written plan of care for pacemaker (a small device that is placed in the chest to help to control the heartbeat) management for one of 14 sampled patients (Patient 1). This deficient practice placed the patient at risk of having unidentified pacemaker problems or malfunctions. --- A review of Patient 1's undated Face Sheet indicated, Patient 1 was admitted to hospice agency on 10/21/2022, with a primary diagnosis of unspecified alcohol-induced persisting dementia (a type of alcohol-related brain damage). On 4/8/2023 at 1:00 p.m., a home visit was conducted at Patient 1's residence accompanied by Administrator 1. Patient 1 was observed walking around the hallway and talking to himself in a locked facility. During a concurrent interview with Medication Technician 1 (MT1), MT1 stated that Patient 1 had a pacemaker and had an appointment with his physician for pacemaker check up next month. A review of Patient 1's "Plan of Care (POC)" dated 10/21/2022, Benefit period #1, indicated the SN was to visit Patient 1 once a week, the Medical Social Worker (MSW) visit once a month, and the hospice aid (HA) service was declined. There was no care plan developed for management of Patient 1's pacemaker. During an interview with the DPCS (Director of Patient Care Services) on 4/10/2023, at 11:00 a.m., DPCS stated the visiting nurse should have developed a care plan for pacemaker management. A review of the hospice agency's undated policy titled "Interdisciplinary Group Meeting", indicated the patient's plan of care will be updated no less frequently than every 15 days or more frequently if the patient's condition requires. The policy indicated a plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment.

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the nursing staff provided instructions or health teaching to the patient's caregiver (PCG) for one of 14 sampled patients (Patient 7), who complained of not having a bowel movement for five days. This deficient practice had the potential to place Patient 7 at risk that could affect the patient's already compromised clinical status and well being. --- A review of Patient 7's admission record indicated Patient 7 was admitted to the hospice agency on 1/20/23, with a primary diagnosis of hemiplegia (paralysis on one side of the body) following cerebral infarct (stroke) which affected the right dominant side. A review of the "Plan of Care" dated 1/20/23, indicated the SN visit frequency for Patient 7 included an initial, recertification and every 14 days, if CHHA (Certified Home Health Aide) services are given or every 30 days, if LVN (licensed vocational nurse) services are given. On 4/8/23, at 3:00 p.m., during a joint home visit with Registered Nurse (RN 1), Patient 7 was observed lying in a hospital bed and Family member 1 was present. RN 1 proceeded with her home visit. A review of the medication review, at the same date and time, with Family Member 1 and RN 1, revealed the medication profile of Patient 7 had the following for bowel management ordered: Lactulose 10 grams (gm- unit of solid measurement) per 15 milliliters (ml- unit of liquid measurement) every six hours as needed for constipation. Miralax Powder 17gm one packet, mix with fluid daily for constipation. Hold for loose stool. Docusate Sodium 100 milligrams (mg- unit of measurement) one capsule daily for constipation. During an interview with Family Member 1(FM 1), FM 1 one was asked if she administered the lactulose and the Miralax powder today,? FM 1 stated "No, I haven't because I know the nurse is coming today and I wanted to ask her first, even if I called her late at night." During an interview with Registered Nurse 1 ( RN 1) during the home visit on the same date, when asked what she should do when her patient did not have any bowel movement for five days? RN 1 stated, "We will try the Lactulose and the Miralax first, then will call the doctor. if ineffective." During an interview with the Director of Nursing (DON) on 4/10/23, at 12:10 p.m., the DON stated the visiting nurse should have called the doctor already for the change in condition. Per policy if a patient had no bowel movement for three days we call the supervisor." A review of the HA's undated policy titled "Bowel Management" indicated to provide standardized and consistent approach for assessing patient's bowel status. Educate patient and family regarding bowel management such as adequate diet and hydration, medication. The SN(skilled nurse) visiting nurse will report to the RN supervisor for patients who have not have a bowel movement in three days. The RN supervisor or case manager will notify the attending physician or hospice medical director for any bowel regimen medication. Any changes in bowel status will be reported and discussed with the IDG(interdisciplinary group) and a plan of care will be initiated. The visiting nurse (SN) shall monitor the effectiveness of the medication and will document and report to the RN supervisor.

Based on observation, interview and record review, the hospice agency failed to ensure the Interdisciplinary Group (IDG, team members from different disciplines working collaboratively with a common purpose to set goals, make decisions, and share resources and responsibilities), including the Medical Director had communicated with the patients primary physician to verify the patient's eligibility for hospice care services for eight of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 10). This deficient practice resulted in certifying patients for hospice services without clinical evidence to support the diagnoses to qualify to receive the Medicare hospice benefit. --- 6. A review of Patient 6s admission record indicated Patient 6 was admitted to the HA on 12/28/22, with a primary diagnosis of chronic obstructive pulmonary disease with acute exacerbation (symptoms of a COPD exacerbation (flare-up) include tiredness or fatigue, more shortness of breath than usual, more coughing, more wheezing than usual, feeling unwell, feeling as if you have a cold, mucus changes, swollen legs or ankles, trouble sleeping, and other) and the Medical director (MD) was the Referring/Attending /Patient choice doctor. A review of the Benefit period 3/28/23 to 6/25/23 indicated the MD signed the attending physician referral section when the patient was admitted to hospice care on 12/28/22 to indicate Patient 6 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. 7. A review of Patient 7's admission record indicated Patient 7 was admitted to the hospice agency on 1/20/23, with a primary diagnosis of hemiplegia (paralysis on one side of the body) following cerebral infarct(stroke) with affected right dominant side. The MD was the Referring/Attending /Patient choice doctor. A review of the Benefit period 1/20/23 to 4/19/23 indicated the Medical Director signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. 8. A review of Patient 8's admission record indicated Patient 8 was admitted to the hospice agency on 2/4/23, with a primary diagnosis of Alzheimer's disease (a general term for memory loss and other cognitive abilities serious enough to interfere with daily life) early onset and the MD was the Referring/Attending /Patient choice doctor. A review of the Benefit period 2/4/23 to 5/4/23 indicated the MD signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. During a joint home visit with the Registered Nurse (RN) on 4/8/23 at 3:00 p.m., at Patient 7 and 8's home, on concurrent interview with Family Member 1 (FM1), FM 1 stated they were referred to this hospice agency and they are still being seen by their primary care physician to this date aside from the hospice doctor. FM 1 stated he only spoke to the hospice doctor by phone once during the admission of her parents to hospice. On 4/10/23, at 11 a.m., during an interview with the Director of Patient Care Services (DPCS ), she stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. On 4/10/23, at 1 p.m., during a phone interview with MD , he stated he was not the attending physician, and he does not know who the attending physician for Patients 1, 2, 3, 5, 6, 7 and 8 is. He stated since Patients 1, 2, 3, 5, 6, 7 and 8 were admitted to their hospice service. He is now the patient's attending physician, and that he signed the referral attending physician section because no one would sign it. MD further stated he did a face-to-face encounter with Patients 1, 2, 3, 5, 6, 7 and 8 during their admission to the hospice service, but he determined the patients were eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse (RN) upon their initial visit to the patients. d. A review of Patient 3's clinical record indicated a start of care date (SOC) of 11/13/2022, with diagnoses which included cerebrovascular disease, unspecified (a group of conditions, diseases, and disorders that affect the blood vessels and blood supply to the brain). A review of Patient 3's Certificate of Terminal Illness (CTI), dated 11/13/22 to 1/11/23, Benefit period #8 indicated the Medical Director signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documented evidence the hospice medical director communicated with the primary physician, to certify that Patient 10 had a life expectancy of 6 months or less, if the terminal illness runs it normal course. e. A review of Patient 10's admission record indicated a SOC of 11/25/22, with diagnoses which included atherosclerosis of aorta (a material called plaque [fat and calcium] has built up in the inside wall of a large blood vessel of the heart called the aorta). A review of the "Physician's Certification for Hospice Benefit (the patient must be certified as being terminally ill to receive hospice care)" for the benefit period, from 11/25/22 to 1/23/22, indicated Patient 10's terminal diagnosis was Atherosclerosis of aorta. There was no documented evidence the hospice medical director communicated with the primary physician, to certify that Patient 10 had a life expectancy of 6 months or less, if the terminal illness runs it normal course. On 4/10/23, at 1:00 p.m., during a phone interview with Medical Director 1, he stated that he was not the attending physician, and he does not know who the attending physician for Patient 3 and Patient 10. The Medical Director 1 further stated that he determined the patients were eligible for hospice services by reviewing the patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. During an interview with the DPCS, on 4/10/23, at 1:40 p.m., the DPCS was not able to provide the documented evidence that the hospice medical director or the hospice attending physician had communicated with the primary physician of Patient 3 and Patient 10 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of the agency's undated policy and procedure titled, "Admission Criteria and Process", indicated the patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination. Quality Care Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. a. A review of Patient 1's face sheet indicated Patient 1 was admitted to hospice on 10/21/22, with a primary diagnosis of unspecified alcohol-induced persisting dementia, and Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 1's Certificate of Terminal Illness (CTI), dated 10/21/22 to 1/18/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 4/8/23, at 1 p.m., a home visit was conducted at Patient 1's residence with Administrator 1. Patient 1 was observed walking around the hallway talking to himself in a locked facility. During a concurrent interview, when Administrator 1 was asked if Patient 1's attending physician referred him to hospice service, she stated, "No." Administrator 1 also stated one of the staff from the hospice agency referred him to this hospice agency. b. A review of Patient 2's Face Sheet indicated Patient 2 was admitted to hospice on 4/4/23, with a primary diagnosis of Alzheimer's disease, and Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 2's Certificate of Terminal Illness (CTI), dated 4/4/23 to 7/2/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 4/8/23, at 1:30 p.m., a home visit was conducted at Patient 2's residence accompanied by Administrator 1. The patient was observed confused, talking to himself while lying in bed with both side rails up. During a concurrent interview, when Administrator 1 was asked if Patient 2's attending physician referred him to hospice service, she stated, "No." Administrator 1 also stated a family friend referred him to this hospice agency. c. A review of Patient 5's face sheet indicated Patient 5 was admitted to hospice on 9/29/22, with a primary diagnosis of Alzheimer's disease, and Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 5's Certificate of Terminal Illness (CTI), dated 9/29/22 to 12/27/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. On 4/10/23, at 11 a.m., during an interview with the Director of Patient Care Services (DPCS ), she stated in order for a new patient to be admitted to their hospice service there should be a referral from the patient's attending physician. On 4/10/23, at 1 p.m., during a phone interview with Medical Director 1, he stated he was not the attending physician, and he does not know who was the attending physician for Patients 1, 2, 3, 5, 6, 7 and 8. He stated since Patients 1, 2, 3, 5, 6, 7 and 8 were admitted to their hospice service. He is now the patient's attending physician, and that he signed the referral attending physician section because no one would sign it. Medical Director 1 further stated he did a face-to-face encounter with Patients 1, 2, 3, 5, 6, 7 and 8 during their admission to the hospice service, but he determined the patients were eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. A review of the agency policy titled, "Admission Criteria and Process," indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination. The Hospice Agency, will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. The patient's physician must order and approve the provision of hospice care, be willing to sign or have a representative who is willing to sign the death certificate and be willing to discuss the patients resuscitation status with the patient's resuscitation status with the patient and family/caregiver. The patient must desire hospice services and be aware of the diagnosis and prognosis. Eligibility criteria will be continually reviewed by the interdisciplinary team to ensure appropriateness of hospice care.

Based on interview and record review, the hospice agency failed to ensure a performance improvement project (PIP, a concentrated effort on a particular problem in one area of the facility or facility wide involving gathering of information systematically to clarify issues or problems, and intervening for improvements) evaluated outcomes every quarter. This failure had the potential to affect the highest quality of care provided to all the patients under the agency's care. --- A request was made on 4/9/23, at 2:40 p.m., to the Director of Nursing (DON) and the QAPI Coordinator/Volunteer coordinator for the performance improvement projects (PIP) derived from the data collected from the Quality Assurance and Performance Improvement (QAPI, the coordinated application of two mutually‑reinforcing aspects of a quality management system. QAPI takes a systematic, comprehensive, and data‑driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) program. On 4/9/23 at 2:40 p.m., during a concurrent record review and interview with the DON and QAPI/Volunteer Coordinator confirmed that they have their goals and interventions for every quarter of their QAPI plan but did not evaluate the outcome of each goals and interventions of their QAPI plan for the past 2022 and their first quarter QAPI for 2023. Both stated there should be an evaluation or stated outcome for each quarter whether if the evaluation of the goal is met or not met. A review of the agency's QAPI/PIP did not contain any written evidence of each quarters outcome for the year 2022 and the first quarter outcome for the year 2023. A review of the HA's policy titled "Quality Assessment and Performance Improvement Plan and Program" indicated the agency will have an organized system assessing and improving the quality of care and services. This system shall be designed to improve performance on a systematic and continuous basis. The policy stated there should be coordination of performance improvement activities. The QAPI Committee is responsible for evaluating and prioritizing QAPI activities based on the aggregation of analysis of data collected. The QAPI committee has the authority to issue recommendations for action or further study. Under the direction of the QAPI coordinator, the committee issues a quarterly report summarizing QAPI activities and results of actions taken.

Based on interview, observation and record review, the hospice agency (HA) failed to ensure and update a process of tracking, documenting and implementing their policies and procedures regarding Coronavirus disease (COVID 19, a severe respiratory illness caused by virus and spread from person to person) and providing education of infection control to all HA staff, patients and their families vaccinated or non-vaccinated with COVID-19. This deficient practice had the potential to place employees, patients and their families at risk for spreading and/or contracting COVID-19 infection, that could lead to severe respiratory illness, hospitalization and/or death. --- A review of Patient 7's admission record indicated Patient 7 was admitted to the hospice agency on 1/20/23, with a primary diagnosis of hemiplegia(paralysis on one side of the body) following a cerebral infarct(stroke) which affected Patient 7's right dominant side, and MD was the Referring/Attending /Patient choice doctor. A review of Patient 8's admission record indicated Patient 8 was admitted to the hospice agency on 2/4/23, with a primary diagnosis of Alzheimer's disease (a general term for memory loss and other cognitive abilities serious enough to interfere with daily life) early onset. The admission record further indicated the Medical Director (MD) was the Referring/Attending /Patient choice doctor. A joint home visit was conducted with Registered Nurse 2 (RN1) on 4/8/23 at 3:00 p.m., at Patient 7 and 8's residence. On concurrent interview with the family member 1(FM 1) stated their whole family refused to get vaccinated due to its side effects as their family preference. A review of patient 7's RN "Visit Notes COVID-19 Screening" question "Was the patient screened for Covid-19 prior to visit? The reply was " No" on the following dates 1/20/23, 2/28/23, 3/6/23, 3/13/23, 3/20/23, 3/26/23 and 4/2/23. A review of patient 8's RN "Visit Notes COVID-19 Screening" question "Was the patient screened for Covid-19 prior to visit? The reply was " NO" on the following dates 2/4/23, 2/28/23, 3/6/23, 3/14/23, 3/20/23, 3/26/23 and 4/2/23. A request was made to the Director of Nursing (DON) on 4/9/23 for their COVID-19 Mitigation Plan and their COVID-19 tracking sheet. On concurrent review with their COVID-19 tracking sheet, indicated two patients (Patient 7 and 8) were not vaccinated were not listed on their tracking sheet. On 4/10/23 at 12:10 p.m., during an interview with the DON, stated, the infection control tracking sheet is important for continued surveillance for symptom management for COVID-19 and for safety of the visiting nurses. DON also confirmed that they did not have signed waivers for their patients who refused to be vaccinated with the COVID-19 vaccine. A review of the HA's Policy titled "Covid-19 Vaccination Policy" indicated the vaccination is a vital tool to reduce the presence and severity of COVID-19 cases in the workplace, in communities and in the nation as a whole. The policy further indicated the policy on mandatory vaccination is to safeguard the health of its employees from the hazard of COVID-19. There was no indication in the policy that addressed waivers for staff and patients under their care. A review of the HA's Policy titled "Covid-19 Pandemic Infectious disease" indicated when making a home visit, organizations will identify patients at risk for having Covid-19 infections before or immediately upon arrival to the home.