Every finding on record at Rosewood Hospice & Palliative Care, Inc

Observed in Record Review. In 3 of 7 patient records reviewed, for active patients it was noted by the nurse surveyor that for RRHV#3, RRNHV#2, and RRNHV#3 there were blank Revocation Forms signed by the patient/caregiver and slipped into the back of flap of the binder of the paper medical record. Finding was validated by the office manager who stated it must have been a mistake. Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor during the patient interview for RRHV#1 that the patient stated he did not know he was on Hospice until several months ago even though he had signed an Election of Benefits over a year ago. Finding was validated by the Field Supervisor who was present during the visit. Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge for extended prognosis, it was noted by the nurse surveyor that for RRDC#3 the patient/patient’s representative was not issued a Notice of Medicare Non-coverage (NOMNC) at least two days prior to of discharge as required. Finding was verified by the Office Manager.

Observed in Record Review. In 5 of 7 patient records reviewed, it was noted by the nurse surveyor that the initial bereavement risk assessment had not been documented for active patients RRHV#2, RRHV#3, RRNHV#2, RRNHV#3, and RRNHV#4. It was agency policy for the Social Worker/Bereavement Coordinator to complete the Bereavement Risk assessments but there was no provision as to who was going to complete them if the patient/family refused Chaplain/Bereavment services. Finding was verified by the Office Manager and DPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, it was noted by the nurse surveyor that the patient did not receive education on medication administration. During RRHV#1, the patient repeatedly asked about what one of his medications were for. The skilled nurse said he was not sure and did not try to look up the medication or provide the patient with an answer. During RRHV#2, the skilled nurse asked the patient about her medications and how often she was taking them. The patient stated she was not sure about why she was taking a few of the medications on her medication profile. Findings were noted by the Field Supervisor who was present during the home visits.

Observed in Record Review. In 7 of 7 patient records reviewed, for active home hospice patients the nurse surveyor noted that the goals were not consistently measurable. For example, “Following and administering pharmacological regimen safely” and “Pain will be controlled at a level acceptable to patient”. Additionally, goals were mostly the same from patient to patient with minimal individualization. There were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, or safety and there were no time frames for completion of goals. Findings were discussed with the DPCS Designee on day two and later with the DPCS during record review.

Observed in Record Review. In 7 of 7 patient records reviewed, for active patients, it was noted by the nurse surveyor that the patient plans of care were all the same, requiring the assessment of the patient with no individualized orders to manage or control symptoms. For example, for RRHV#2 and RRHV#3, both patients were going to out-patient dialysis three times a week. Both of their care plans were no different than the other active patients. Additionally, their care plans did not show any coordination with the dialysis centers or specialized care or assessment of their shunts. Findings were discussed with the DPCS.

Observed in Surveyor review but corrected onsite pending acceptable Evidence of Standards Compliance. In 7 of 7 patient records reviewed, for active patients, it was noted by the nurse surveyor that for RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, and RRNHV#4 there was no documentation of progress toward goals to indicate that the ordered interventions were having the desired outcomes. Findings were reviewed with the DPCS.

Observed in Tracer Activities. It was noted by the nurse surveyor that Leadership was unable to demonstrate any improvement in indicators related to palliative outcomes or hospice services. There was not any data regarding the monitoring of falls, PIP data, or indicators. Two PIP projects were documented; however, they were ended over eight months ago with no continued monitoring. A PIP project to decrease infections was noted in the QAPI Quarterly minutes for third Quarter 2023, but there was no such PIP project documented or monitored after that.

Observed in Data Session. It was noted by the nurse surveyor that the hospice did not use the results of data analysis to identify improvement opportunities. For example, since data analysis of falls did not occur, there were no related improvement opportunities identified as a result of data analysis. Finding was confirmed with the DPCS. Observed in Data Session. It was noted that the hospice did not analyze and compare internal data over time to identify levels of performance, patterns, trends, and variations. For example, there was no fall data collected so that the information could be tracked and trended over time. Finding was confirmed with the DPCS.

Observed in Tracer Activities. It was noted by the nurse surveyor that performance improvement activities did not track and analyze adverse events as evidenced by a CTI narrative that stated frequent falls by the patient, yet there was no record of the falls or that any event data had been collected. Finding was validated by the Director of Patient Care Services.

Observed in Data Session. It was noted by the nurse surveyor that there had been two performance improvement projects over the past year that were now complete. Both projects were related to documentation. There was also an infection control project identified in the QAPI minutes and was to start third quarter 2023, however, there was no data to support that this project was started. There currently are no performance projects being worked on. Finding was confirmed with the DPCS.

Observed in Data Session. It was noted that there were three performance improvement projects identified over the last year. The two documentation projects did not include the reasons for conducting the projects. The performance improvement project for wound infections did not include the necessary documentation regarding the project itself, the reason for conducting the project, and measurable progress achieved on the project. Finding was validated with the DPCS.

Observed in Patient Home. In 3 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per “Hand Hygiene Policy No. 9-009.1”. For example, during RRHV#1 the skilled nurse used liquid alcohol to wash his hands with water in the patient’s kitchen sink. He then did not perform hand hygiene again at any time during visit while taking vital signs, assessing the patient, or documenting. During RRHV#2, the skilled nurse washed her hands in the patient’s kitchen sink with soap an water upon entering the home, she then donned gloves but did not perform hand hygiene upon removal of the gloves or at another time during the visit. She did wipe her hands off with a Lysol wipe after cleaning her equipment. During RRHV#3 with the social worker, he did not perform hand hygiene prior to entering the home, after entering the home, or during the visit. Findings were also observed by the Field Supervisor who was present during each of the visits. Observed in Patient Home. In 1 of 3 home visits conducted, it was observed by the nurse surveyor that clinical staff did not clean their equipment per agency policy, “Bag Technique Policy No. 9-014.2”. For RRHV#2 the skilled nurse cleaned their equipment (BP cuff, stethoscope, thermometer, pulse oximeter) with Lysol wipes. The policy states that equipment is to be cleaned with alcohol. Finding was observed by the Field Supervisor who was present during the visit.

Observed in Tracer Activities. It was noted by the nurse surveyor that Medical Social Work services was being provided under contract by a Social Services Company providing that core service to the HOSPICE. The contract was effective May of 2023. Finding was validated by the Office Manager and Owner.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation review, and staff interviews: §418.64, §418.100, §418.102, §418.116, §418.56, §418.58, and §418.52.

Observed in HR File Review. In 2 of 9 HR files reviewed, It was noted by the nurse surveyor that competency was not assessed as required as part of orientation. HR#6 (Chaplain/Bereavement Coordinator), his competency was not assessed at time of orientation almost four months ago. HR#8 (Volunteer Coordinator), his competency was not assessed during orientation almost four months ago.Finding was verified by Office Manager.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that for RRHV#1, the initial Certification of Terminal illness (CTI) did not match the patient’s condition. The patient said that he was not dying and that he had not been dying to his knowledge when he was first admitted to Hospice. The CTI noted that the patient was very short of breath and needed assistance with ADLs and oxygen. The patient stated that he had not ever been on oxygen and that he was independent in his ADLs. Finding was noted by the Field Supervisor present on the home visit.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that for RRHV#1, the CTI documented at recertification did not reflect the patient’s current condition. The most recent Certifiation of Terminal Illness stated that the patient was able to ambulate short distances but was still limited by chest tightness and shortness of breath. Complained of increased fatigue and needed assistance with activities of daily living. Fair to poor appetite which requires prompting. During the home visit patient was up and about without any shortness of breath and was able to attend to his own ADL’s. He stated that he drove himself where he wanted to go and took care of his own business. The patient was making a cup of tea when the nurse arrived. He stated he eats whenever he feels like it. Finding was noted by the Field Supervisor present on the home visit.

Observed in Patient Home. In 2 of 3 home visits conducted, it was noted by the surveyor that the medication profile was inaccurate. During RRHV#1, the skilled nurse reviewed the medications with the patient utilizing the medication profile and noted that he was taking Robitussin as needed for a cough at night along with medicated cough drops, and Arthritis Strength Tylenol for pain. These medications were not on his medication profile. Additionally, he patient was no longer taking his antidepressant and his blood pressure medication had been decreased to one time a day, these changes were not reflected on the medication profile in the EMR. For RRHV#2, during review of her medications, the patient told the nurse that three of the medications on her medication profile had been discontinued by the dialysis clinic three months ago. They were here antidepressant, her blood pressure medication, and a multivitamin. Findings were validated by the Field Supervisor who was present on the visit.

Observed in Document Review. In 2 of 2 contracts reviewed, providing direct patient care services, it was noted by the nurse surveyor that the contracts providing Therapy Services (PT/OT/ST) and Social Work Services did not include the statement that criminal background checks would be checked and maintained by the Contractor. Findings were validated by the Office Manager and Owner.

Observed in Tracer Activities. It was noted by the surveyor that a Change of Ownership (CHOW) occurred in June of 2022, however, the CHOW license owner and Administrator has not been updated with the State of California. Additionally, the organization changed its office location, and the old address has not been updated with the State and is still on their current State License for Hospice. Observed in Tracer Activities. During discussion with the surveyor regarding the provision of patient care, it was noted by the owner that for RRHV#1, the patient was receiving weekly nursing visits and medications as approved by the IDT, however, they were not billing for care. The patient understood that at this time he was under HOSPICE and had signed an EOB.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Condition of Participation on Patients' rights was met as follows: 1. The Hospice Agency (HA) failed to ensure that 3 of 14 sampled patients (Patients 11, 12 and 14) named a legal representative to make medical decisions for them. This deficient practice has the potential to cause Patients 11, 12, and 14 to receive a delay or inadequate care if there is no one to make medical decisions for the patients. (Refer to L 507) 2. The HA failed to ensure the patients were informed and the agency explained all the Medicare (federal health insurance for people 65 or older) and non Medicare coverage for hospice service that patient could receive, and that the patient understand the information provided, for two of 14 patients (Patient 1 and 8). This deficient practice resulted in the patients being misinformed about hospice care and services covered benefits. (Refer to L 518). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Patient's Rights to protect and promote the rights, of the patient in the hospice agency. --- .

Based on interview and record review, the Hospice Agency (HA) failed to ensure that 3 of 14 sampled patients (Patients 11, 12 and 14) named a legal representative to make medical decisions for them. This deficient practice has the potential to cause Patients 11, 12, or 14 to receive a delay or inadequate care if there is no one to make medical decisions for the patients. --- a. A review of Patient 11s Face Sheet (patient information sheet) indicated a start of care (SOC) date of 12/15/22 and is currently on certification period 8/12/2023 to 10/10/2023. Patient 11 had a primary diagnosis of benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty) and a secondary diagnosis of hypertensive heart disease without heart failure (heart problems that occurs due to high blood pressure). On the same document only the patient and a caregiver 1(CG1) are listed as contacts. A review of Patient 11s initial assessment dated 12/15/2023, indicated that their ";Mental Status" was confused, forgetful, withdrawn and agitated, wit impaired long term and short term memory. Under ";Psychosocial Status" it did not indicate who the patient lives with and there is no emergency contact listed. The document also indicated that they did not have an Advanced Directive (a legal document that spells out your decisions about end-of-life care and decide who will make decisions for you when you cannot.) During an interview on 10/4/2023, at 11:30am, CG1 stated that he owns the home that Patient 11 rents a room in. CG1 stated that he provided another caregiver to care for Patient 11 on a daily basis. CG 1 stated that he makes medical decisions for Patient 11. CG1 Stated that Patient 11 has a brother, but the brother no longer wanted to care for Patient 11 so he gave CG1 consent to make medical decisions for him. b. A review of Patient 12s Face Sheet indicated a start of care (SOC) date of 12/13/2022 and is currently on certification period 8/10/2023 to 10/8/2023. Patient 12 had a primary diagnosis of chronic obstructive pulmonary disease (COPD: a group of lung diseases that block airflow and make it difficult to breathe). On the same document only the patient and a caregiver 1(CG1) are listed as contacts. A review of Patient 12s initial assessment dated 12/15/2023, indicated that their ";Mental Status" was oriented, forgetful and lethargic, with impaired short term memory. Under ";Psychosocial Status" it did not indicate who the patient lives with and there is no emergency contact listed. The document also indicated that Patient 12 did not have an Advanced Directive. c. A review of Patient 14s Face Sheet indicated a SOC date of 5/3/2023 and is currently on certification period 8/1/2023 to 9/29/2023. Patient 14 had a primary diagnosis of COPD and a secondary diagnosis of hypertensive heart disease without heart failure. On the same document only the patient and a caregiver 1(CG1) are listed as contacts. A review of Patient 14s initial assessment dated 5/3/2023, did not have any information filled out for ";Mental Status". Under ";Psychosocial Status" it did not indicate who the patient lives with and there is no emergency contact listed. The assessment did not indicate that Patient 14 had an Advanced Directive. During an interview on 10/4/2023, at 11:30am, CG1 stated that he owns the home that Patient 12 and 14 rents a room in. CG1 stated that he provided another caregiver to care for Patient 12 and 14 on a daily basis. CG1 stated that Patient 12 and 14 do not have any family or a Power of Attorney (POA: a legal document that allows one person to appoint another person to act on their behalf.) but if the HA needs anything, then they call him. During a congruent interview and record review on 10/5/2023, at 2:18pm, Patient 11, 12, and 14 charts were reviewed and the Director of Patient Care Services (DPCS) stated that she could not find a document indicating that CG1 could make medical decisions on behalf of Patients 11, 12 and 14. The DPCS stated that the HA should have some sort of document advanced listing CG1 as the decision maker. The HA should have it for legal purposes because they are making medical decisions. The DPCS stated that the patients should have delegated someone to make medical decision for them, so they know what the patients wants are. A review of the HAs policy titled ";Admission Criteria and Process", dated 2019, indicated that the patient must identify a family member/caregiver or legal representative who agrees to be primary support caregiver if and when needed. Exceptions may be made for patients without such an identified individual and who are independent in their activities of daily living (ADLs). These individuals will require a specific plan to be developed at time of admission with the social worker to plan for when they are no longer independent.

Based on observation, interview and record review, the hospice agency failed to inform and explain all the Medicare (federal health insurance for people 65 or older) and non Medicare coverage for hospice service that patient could receive, and that the patient understand the information provided, for two of seven patients (Patient 1 and 8). This deficient practice resulted in the patients being misinformed about hospice care and services covered benefits. --- Findings: a. A review of Patient 1s Patient Information Sheet indicated a Start of Care (SOC) date of 3/23/2023 with a primary diagnosis of end stage heart failure (terminal end stage of heart disease in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). A review of Patient 1s Election of Medicare Hospice Benefit, dated 3/23/2023, indicated that the patient was given an explanation and had a full understanding of the purpose of hospice care indicated that the nature of hospice care is to relieve pain and other symptoms related to Patient 1s terminal illness. A review of Patient 1s Certification of Plan of Care (POC) for certification period 9/19/2023 to 11/17/2023 (6th 60 days) indicated that for Skilled Nurse (SN) visit for the first week: one visit and one PRN (pro re nata, meaning "as needed") visit for pain and symptom management and the following weeks: one visit/week and one PRN visit for symptom management. On 10/3/2023 at 10:30 a.m., a joint home visit was conducted with Licensed Vocational Nurse 1 (LVN 1) at Patient 1s home residence. Patient 1 was observed to be alert and oriented, and breathing room air oxygen, and able to use a walker with assistance from bedroom to living room and sit in chair in the living room. LVN 1 asked if patient was short of breath and needed oxygen, but Family Member (FM 1), stated he did not need oxygen. LVN 1 performed vitals signs, skills assessment and checked Patient 1s medications. Patient 1 sat in the chair, answered the LVN 1s questions and was not observed short of breath. During a telephone interview on 10/04/2023 at 11:54 a.m., Family Member (FM 1) stated that a member of her church recommended Patient 1 for hospice. FM 1 stated that hospice was for those that needed comfort, have pain, and cannot take care of themselves. FM 1 stated she understood that Hospice was like home health care where they have a nurse that visits and checks on Patient 1. When FM 1 was asked what terminal illness Patient 1 had, FM 1 stated Patient had problem with his prostate (small walnut shape organ below the bladder), but it was curable, arthritis (swelling of the joints), and had back pain that did not go away. FM 1 further stated that the Hospice Medical Doctor (MD 1) did not say Patient 1 had a terminal illness and that Patient 1 is not dying yet, just has a lot of pain, and would not be dying in six months. A review of the HAs policy, "Hospice Election Statement", dated 2019, indicated the purpose was to ensure that patients and/or legal guardians/caregivers understand the Medicare Part A or Medicaid coverage for hospice care and agree to this program. B. A Review of Patient 8s Patient Face Sheet (patient information sheet) indicated a start of care (SOC) date of 1/7/2023 and on certification period 9/4/2023 to 11/2/2023. Patient 8 had a primary diagnosis of atherosclerotic heart disease of native coronary artery (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery leading to decreased blood floor to the heart) without angina pectoris (chest pain) and a secondary diagnosis of hypertensive heart disease (heart disease caused by high blood pressure) without heart failure. A review of Patient 8s "Election of Medicare Hospice Benefit", dated 1/7/2023, indicated that the Patient 8 was given an explanation and had a full understanding of the purpose of hospice care indicated that the nature of hospice care is to relieve pain and other symptoms related to their terminal illness. During an interview on 10//4/2023, at 1:30 p.m., Patient 8 stated she does not know what term hospice is. Patient 8 stated that the nurses come to help her medically, help her health and to help her when she is not feeling well. During an interview on 10/4/2023, at 1:49 p.m., Family member 2 (FM 2) stated that he does not know what hospice is. He just knows that the nurse comes to check on her and to get her medications. During an interview on 10/4/2023, at 2:10 p.m., Licensed Vocational Nurse 1 (LVN 1) stated that patients should be educated on what hospice is during admission. The nurse needs to make sure that the patient fully understands what hospice is and know what to expect during the end of life and know what services the agency provides to make them comfortable. A review of the HAs policy titled, "Hospice Election Statement", dated 2019, indicated the purpose was to ensure that patients and/or legal guardians/caregivers understand the Medicare Part A or Medicaid coverage for hospice care and agree to this program.

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 healthcare organizations must meet in order to begin and continue participating in the Medicare [a government health insurance for people 65 or older] and Medicaid [a joint government and state program that gives health coverage to some people with limited income and resources] programs) of the Patient was met as evidenced by: 1. The HA failed to conduct a comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patients current health status and identified the patients needs for hospice care and services related to eligibility and management of the terminal illness, for five of 14 sampled patients, (Patient 1, Patient 2, Patient 8, Patient 11, and Patient 14). This deficient practice resulted in the provision of hospice services who were not clinically eligible to receive hospice care and services and had the potential to cause delay of patient care for Patient 1, Patient 2, Patient 8, Patient 11, and Patient 14. (Refer to L524). 2. The HA failed to review all the medications and update the medication profiles with the currently used medications for three of 14 sampled patients, (Patient 1, Patient 2, and Patient 8). This deficient practice resulted for Patient 1, Patient 2, and Patient 8 not to receive medications as ordered by the physician and had a potential to result for Patient 1, Patient 2, and Patient 8 to experience adverse side effects (any unwanted effects of medications). (Refer to L 530). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (State law) compliance with Federal Regulations for Initial and Comprehensive Assessment of Patient to ensure highest quality health care is provided to patients assessed to receive hospice services. --- .

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to conduct an accurate comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patients current health status and identified the patients needs for hospice care and services related to eligibility and management of the terminal illness, for five of 14 sampled patients, (Patients 1, 2, 8, 11, and 14). This deficient practice resulted in the provision of hospice services who were not clinically eligible to receive hospice care and services and had the potential to cause delay of patient care for Patient 1, Patient 2, Patient 8, Patient 11, and Patient 14. --- c. A Review of Patient 8s Patient Face Sheet (patient information sheet) indicated a start of care (SOC) date of 1/7/2023 and on certification period 9/4/2023 to 11/2/2023. The Patient Face Sheet indicated Patient 8 had a primary diagnosis of atherosclerotic heart disease of native coronary artery (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery leading to decreased blood floor to the heart) without angina pectoris (chest pain) and a secondary diagnosis of hypertensive heart disease (heart disease caused by high blood pressure) without heart failure. A review of Patient 8s Hospice Referral, dated 1/7/2023, written by the HAs Medical Director (MD1) indicated there was no indication there was a primary Medical Doctor involved in the hospice certification of Patient 8. A review of Patient 8s Initial Orders and Plan of Care, for certification period 1/7/2023 to 4/6/2023 indicated under ";Medical History," that Patient 8 had a hospice diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. There was no documentation for co-morbidities (other diseases), pertinent medical history/test/labs, or of their last hospital admission. A review of Patient 8s Certification of Terminal Illness dated 9/1/2023, indicated a Karnofsky Performance Status Scale (KPS: an assessment tool for functional impairment. It is used to improve understanding of patient needs ability to carry out daily activities and to assess patient progress) score of 40, indicating Patient 8 was disabled, required special care and assistance. Patient 8 was unable to care for self, required equivalent of institutional or hospital care; diseases may be progressing rapidly. The same document indicated a New York Heart Association (NYHA: a classification system that provides a simple way of classifying the extent of heart failure.) score of IV, indicating severe limitations, experiences symptoms even while at rest. Mostly bedbound patients. The Physician Brief Narrative note indicated Patient 8 required maximum assistance with all activities of daily living (ALDs) and had fair to poor appetite and required prompting and assistance. During an observation and interview on 10/4/2023, at 1:10pm, during a home visit at Patient 8s house, Patient 8 was observed alert and oriented and denied pain. Patient 8 stated she had arthritis pain (tenderness of one or more joints), and the pain came when it was cold. Patient 8 stated she would get dizzy if she walked for long periods of time. Patient 8 stated she did not use oxygen. Patient 8 stated she would go out of the house to go to church and to visit her family. Patient 8 stated she could shower and feed herself and had a good appetite. Patient 8 stated her diagnoses included ear infection, headaches, body aches, and high blood pressure. Patient 8 stated the last time she was admitted to a hospital was in the year 2000. Patient 8 stated a woman (unidentified) from her church referred her to the HA. During a record review on 10/5/2023, at 12:26 pm, Patient 8s medical records (all in general) were reviewed with the Director of Patient Care Services (DPCS). The DPCS stated she was unable to find any documentation to verify Patient 8s terminal diagnosis. The DPCS stated there were no doctors notes or hospital records. During an interview on 10/5/2023, at 4:16pm, MD1 stated to ensure a patient (in general) qualified for hospice, he would look at the referral from their primary MD or hospital, the patients diagnosis, and the nursing assessment. MD 1 stated if the patient did not have a primary MD, the HA would see if the patient had any recent hospitalizations and would try to get the records because they needed to have a way to verify the patients diagnosis. d. A review of Patient 11s Face Sheet) indicated a start of care (SOC) date of 12/15/2022 and was currently on the certification period 8/12/2023 to 10/10/2023. Patient 11 had a primary diagnosis of benign prostatic hyperplasia (BPH: age-associated prostate gland enlargement that can cause urination difficulty) and a secondary diagnosis of hypertensive heart disease without heart failure (heart problems that occurs due to high blood pressure). A review of Patient 11s hospice referral, dated 12/14/2022, was written by MD1 and indicated there was no indication there was a primary MD involved in the hospice certification of Patient 11. A review of Patient 11s Initial Comprehensive Assessment, dated 12/15/2022, indicated a hospice diagnosis of BPH, but also had Dementia/Alzheimers (a progressive disease that destroys memory and other important mental functions). The nursing summary stated the patients primary diagnosis was early onset of Alzheimers disease. During an interview on 10/5/2023, at 1:27pm, the DPCS stated BPH was not a terminal diagnosis, and the HA should have put hypertensive heart disease. The DPCS stated she could not find any supportive documents to verify Patient 11s diagnoses. Patient 11s medical record was reviewed, the DPCS stated there was no history and physical or doctor/hospital records found that listed the patients diagnosis. e. A review of Patient 14s GACH (general acute care hospital) records, dated 3/9/2018, indicated a medical history of auditory hallucinations (when you hear voices or noises that do not exist in reality), ovarian cyst (a solid or fluid filled sac on the surface of an ovary [reproductive organ]), paranoia (a mental illness where you feel threatened in some way, when there is no evidence to support it), schizophrenia (a mental disorder that affects a persons ability to think, feel, and behave clearly), and psychosis ( a mental disorder characterized by a disconnection from reality). A review of Patient 14s Admission Record indicated Patient 14 had a prior admission from 4/15/2023 to 4/27/2023, with a diagnosis of end stage heart failure (when the heart can no longer effectively pump blood throughout the body). A review of Patient 14s Initial Comprehensive Assessment, dated 5/3/2023 with a diagnosis of Chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and hypertensive heart disease. A review of Patient 14s Face Sheet indicated a SOC date of 5/3/2023 and was currently on certification period 8/1/2023 to 9/29/2023. Patient 14 had a primary diagnosis of COPD and a secondary diagnosis of hypertensive heart disease without heart failure. A review of Patient 14s medication profile for election period 8/1/2023 to 9/29/2023, indicated there were no medications listed that would treat heart disease. During a concurrent interview and record review on 10/5/2023, at 2 p.m. the DPCS could not explain why Patient 14 had two different terminal diagnoses for her two different admission. DPCS stated she was not able to find any supporting documents to verify Patient 14s terminal diagnosis. During an interview on 10/5/2023, at 2:26pm, the DPCS stated to help validate hospice eligibility (in general) the HA would review the hospital records, labs (blood work that shows how the body is functioning) and past medical history (H&P). The DPCS stated it was important to have an H& P because it would give a picture of how the patient (in general) was before the admission to the HA. The DPCS stated the H&P would help the patient qualify for hospice care and identify the patients' needs. Findings: a. A review of Patient 1s Patient Information Sheet indicated a Start of Care (SOC) date of 3/23/2023 with a primary diagnosis of end stage heart failure (the heart muscle is unable to pump enough blood to meet the bodys needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). A review of Patient 1s Initial Assessment, dated 3/23/2023 indicated a Hospice diagnosis of end stage heart failure. The assessment indicated in Patient 1s Cardiovascular assessment the following: Heart sound- regular and within normal limits (WNL), Pulses-WNL, edema (swelling)-none, and did not indicate chest, dizziness, and palpitations. The assessment indicated in Patient1s Respiratory assessment the following: indication of shortness of breath-yes, respirations-WNL, no cough, lung sounds- clear, oxygen saturation (amount of oxygen in the blood) on room air 95% (95% to 100 % normal), and dyspnea (difficulty breathing) on exertion (physical activity). The Nutrition/Hydration assessment indicated Patient 1 had a normal appetite and a regular diet as tolerated. The assessment indicated Patient 1 had a NYHA Class III (marked limitation of physical activity, comfortable at rest, less than ordinary activity causes fatigue, palpitation, shortness of breath or chest pain). The initial assessment did not indicate a prognosis guideline (Local Coverage Determination, LCD, guidelines used to identify any Medicare beneficiary whose current clinical status and anticipated progression of disease is more likely than not to result in a life expectancy of six months or less) included in the assessment. The assessment indicated the eligibility assessment as evidenced by decreased cognitive status, decreased pulmonary function, and decreased cardiac function. The assessment indicated no care problems identified. A review of Patient 1s Nursing Recertification Assessment, dated 7/7/2023, indicated a Hospice Primary diagnosis of Hypertensive Heart Disease (heart conditions caused by high blood pressure) without heart failure. The assessment indicated Patient 1 was alert and oriented to name/person and place. The assessment indicated in Patient 1s respiratory assessment the following: dyspnea with exertion, clear lung fields and oxygen saturation of 96% on room air. The assessment indicated in Patient 1s cardiovascular assessment the following: heart sounds regular, did not indicate chest pain, dizziness, or edema, and pulses with no significant findings. The assessment indicated in the Nutritional/Hydration assessment Patient 1 had a fair appetite, ate three meals a day and had a regular diet as tolerated. The assessment indicated the eligibility assessment as evidenced by decreased cognitive status, decreased pulmonary function, and decreased cardiac function. The assessment indicated no care problems identified. A review of Patient 1s Nursing Recertification Assessment, dated 8/25/2023, indicated a Hospice Primary diagnosis of Hypertensive Heart Disease without heart failure. The assessment indicated Patient 1 was alert and oriented to name/person and place. The assessment indicated in Patient 1s respiratory assessment the following: dyspnea with exertion, clear lung fields and oxygen saturation of 96% on room air. The assessment indicated in Patient 1s cardiovascular assessment the following: heart sounds regular, fatigues easily, no indication of chest pains, dizziness, no edema, and pulses with no significant findings. The assessment indicated in the Nutritional/Hydration assessment Patient 1 had a good appetite, ate three meals a day, and had a regular diet as tolerated. The assessment indicated the eligibility assessment as evidenced by increased weakness, decreased pulmonary function, and decreased cardiac function. The assessment indicated no care problems identified. A review of Patient 1s Nursing Clinical Note, dated 9/1/2023, indicated Patient 1 was alert and oriented to name/person, time, place, and situation/current events. The assessment indicated in Patient 1s respiratory assessment the following: no significant findings and oxygen saturation of 96% on room air. The assessment indicated in Patient 1s cardiovascular assessment the following: heart sounds regular, no indication of chest pains or dizziness, no edema, and strong pulses. The assessment indicated in the Nutritional/Hydration assessment Patient 1 had a good appetite, ate three meals a day and had a regular diet as tolerated. The assessment indicated no care problems identified. A review of Patient 1s Nursing Clinical Note, dated 9/8/2023, indicated Patient 1 was alert and oriented to name/person, time, place, and situation/current events. The assessment indicated in Patient 1s respiratory assessment the following: no significant findings and oxygen saturation of 97% on room air. The assessment indicated in Patient 1s cardiovascular assessment the following: heart sounds regular, no indication of chest pains or dizziness, no edema, and strong pulses. The assessment indicated in the Nutritional/Hydration assessment Patient 1 had a good appetite, ate three meals a day and had a regular diet as tolerated. The assessment indicated no care problems identified. A review of Patient 1s Nursing Clinical Note, dated 9/15/2023, indicated Patient 1 was alert and oriented to name/person, time, place, and situation/current events. The assessment indicated in Patient 1s respiratory assessment the following: no significant findings and oxygen saturation of 96% on room air. The assessment indicated in Patient 1s cardiovascular assessment the following: heart sounds regular, no indication of chest pains or dizziness, no edema, and strong pulses. The assessment indicated in the Nutritional/Hydration assessment Patient 1 had a good appetite, ate three meals a day and had a regular diet as tolerated. The assessment indicated no care problems identified. A review of Patient 1s Certification of Terminal Illness (CTI), dated 9/18/2023, indicated Patient 1 had New York Heart Association classification (NYHA, a simple way of classifying the extent of heart failure) of Class IV [severe symptoms such as fatigue, palpitations (tremors or shivers), chest pain, dyspnea (difficulty breathing), or syncope (fainting) with features of heart failure with minimal physical activity and even at rest] level and mainly bedbound patients). During a concurrent observation and interview on 10/3/2023, at 10:30 a.m., during a joint home visit with Licensed Vocational Nurse 1 (LVN 1) at Patient 1s home residence, Patient 1 was alert and oriented. Patient 1 used a walker (a mobility aid that offers stability and support while walking) to walk from a bedroom to the living room and sat in a chair in the living room. LVN 1 asked if Patient 1 was short of breath and needed oxygen, Family Member 1 (FM 1), who was present during the visit, stated Patient 1 did not need oxygen. Patient 1 sat in a chair, answered LVN 1s questions and was not observed short of breath. FM 1 stated Patient 1 would leave the house during the week to go to church. During a telephone interview on 10/4/2023, at 11:54 a.m., with FM 1, FM 1 stated Patient 1 did not have a terminal illness. During a concurrent interview and record review, on 10/5/2023, at 2:28 p.m., with the Director of Patient Care Services (DPCS), Patient 1s Recertification Assessments dated 7/7/2023 and 8/25/2023, and the Nursing Clinical Notes from 7/2023 through 9/2023 were reviewed. The Recertification Assessments indicated Patient 1 had a hospice primary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure), without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). The DPCS stated the diagnosis from the Recertification Assessment and the Nursing Clinical Notes did not reflect the diagnosis on Patient 1s CTI. The DPCS stated the recertification assessment, and the Nursing Clinical Notes did not show a decline of Patient 1 and did not support the diagnosis of a patient with heart failure. b. A review of Patient 2s Patient Information Sheet indicated a Start of Care (SOC) date of 3/23/2023 with a primary diagnosis of cerebral infarction (a stroke; a condition that occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to unspecified occlusion or stenosis of unspecified cerebral (brain) artery. A review of Patient 2s Initial Assessment, dated 3/23/2023 indicated a Hospice Diagnosis of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery. The assessment indicated in Patient 1 was confused and lethargic (lack of energy). The musculoskeletal assessment indicated the following: within normal limits. The cardiovascular assessment indicated Patient 2s Heart sound- regular and within normal limits (WNL), Pulses-WNL, edema-none, and did not indicate chest, dizziness, palpitations. The assessment indicated in Patient 2s Respiratory assessment the following: indication of shortness of breath-yes, Respirations-WNL, no cough, lung sounds- clear, oxygen saturation on room air 95%, and dyspnea-on exertion. The Nutrition/Hydration assessment indicated Patient 2 had a normal appetite, a regular diet as tolerated and no dysphagia (problem with swallowing). The initial assessment did not indicate a prognosis guideline (Local Coverage Determination, LCD, guidelines used to identify any Medicare beneficiary whose current clinical status and anticipated progression of disease is more likely than not to result in a life expectancy of six months or less) included in the assessment. The assessment indicated the eligibility assessment as evidenced by decreased cognitive status, decreased weakness, and increased need for services. The assessment indicated no care problems identified. The narrative indicated the patient was mostly in bed these days needing assistance of a patient caregiver with activities of daily living and was weak with poor appetite. A review of Patient 2s Nursing Clinical Notes dated 5/26/2023 indicated Patient 2s mental status was alert and oriented to name/person, time, place and situation. The assessment indicated in Patient 2s cardiovascular assessment the following: heart sounds regular, no indication of chest pains, dizziness, no edema, and strong pulses. The assessment indicated in the Nutritional/Hydration assessment that Patient 2 had a good appetite, ate three meals a day and had a regular diet as tolerated. The assessment indicated that Patient 2 had hand grasp that were equal strength in both hands. The assessment indicated no care problems identified. A review of Patient 2s Nursing Recertification Assessment, dated 6/18/2023, indicated a Hospice Primary diagnosis of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery. The assessment indicated that Patient 2 was forgetful and oriented to place. The assessment indicated in Patient 1s neurological assessment that there were no significant findings. The assessment indicated in Patient 1s respiratory assessment the following: dyspnea with exertion, clear lung fields and oxygen saturation of 96% on room air. The assessment indicated in Patient 1s cardiovascular assessment the following: heart sounds regular, no indicated of chest pains, dizziness, no edema, pulses with no significant findings. The assessment indicated in the Nutritional/Hydration assessment that Patient 1 had a fair appetite, ate three meals a day and had a regular diet as tolerated. The assessment indicated that that eligibility assessment as evidenced by decreased cognitive status, decreased pulmonary function, and decreased cardiac function. The assessment indicated no care problems identified. A review of Patient 2s Nursing Clinical Notes dated 8/11/2023 indicated Patient 2s mental status was alert and oriented to name/person, time, place and situation. The assessment indicated in Patient 2s cardiovascular assessment the following: heart sounds regular, fatigues easily, no indication of chest pains, dizziness, no edema, and strong pulses. The assessment indicated in the Nutritional/Hydration assessment that Patient 2 had a good appetite, ate three meals a day and had a regular diet as tolerated. The assessment indicated Patient 2 had hand grasp that were equal strength in both hands. The assessment indicated no care problems identified. A review of Patient 2s Nursing Recertification Assessment, dated 9/17/2023, indicated a Hospice Primary diagnosis of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery. The assessment indicated that Patient 2 was alert, forgetful and oriented to name/person, time, place, and situation/Current events. The assessment indicated in Patient 1s neurological assessment that there were no significant findings. The assessment indicated in Patient 1s respiratory assessment the following: no significant findings, clear lung fields and oxygen saturation of 97% on room air. The assessment indicated in Patient 2s cardiovascular assessment the following: heart sounds regular, pulses with no significant findings, and no indication of chest pain, dizziness, or edema. The assessment indicated in the Nutritional/Hydration assessment that Patient 1 had a fair appetite, ate three meals a day and had a low saturated fat and cholesterol diet. The assessment indicated Patient 2 had equal strength in both hands. The assessment indicated that that eligibility assessment as evidenced by decreased cognitive status, decreased cardiac function, and increased weakness. A review of Patient 2s Certificate of Terminal Illness (CTI), dated 9/18/2023 indicated a diagnosis of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery. A review of Patient 2s Nursing Clinical Notes dated 9/22/2023 indicated Patient 2s mental status was lethargic and oriented to name/person, time, and place. The assessment indicated in Patient 2s cardiovascular assessment the following: heart sounds regular, no indication of chest pains, dizziness, no edema, and strong pulses. The assessment indicated in the Nutritional/Hydration assessment that Patient 2 had a fair appetite, ate three meals a day and had a regular diet as tolerated. The assessment indicated that Patient 2 had a strong right-hand grasp and a weal left hand grasp. The assessment indicated no care problems identified. During a concurrent observation and interview on 10/3/2023 at 1 p.m., a joint home visit was conducted with the DPCS at Patient 2s home residence. Patient 2 was alert and oriented and walked with an unsteady gait from the door to the living room using the wall for assistance as she walked. Patient 2 stated she came back from dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Patient 2 stated she would take ride hailing service (where a rider ";hails" or hires a personal driver to take them exactly where they need to go) by herself to her dialysis appointment three times a week, on Tuesdays, Thursdays, and Saturdays. When Patient 2 was asked when she had a stroke, Patient 2 stated she had a stroke in 2013. Patient 2 stated she had no problems swallowing and was waiting for FAM 2 to finish cooking lunch so she could eat and then go to sleep. During a record review and interview on 10/5/2023 at 10:26 a.m., with the DPCS, Patient 2s Initial Comprehensive Assessment dated 3/23/2023, and Recertification Assessments dated 6/18/2023 were reviewed and indicated Patient 2 had a Karnofsky Performance Status (KPS, an assessment tool intended to assist clinicians and caretakers in gauging a patient's functional status and ability to carry out activities of daily living) of 40% (Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly; disabled; requires special care and assistance). The DPCS stated Patient 2 was more of a KPS of 50% because the patient would go to dialysis three times a week, was able to care for most of her personal needs, and although her energy levels varied, Patient 2 could do some grooming and change her clothes. The DPCS stated the assessments did not show residual from a stroke diagnosis such as contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) or problems with speech. During an interview and record review on 10/5/2023 at 2:43 p.m., with the DPCS, Patient 2s clinical record was reviewed. The DPCS stated that the documentation to support the Patient 2s CVA terminal diagnosis was not in the patients record. The DCPS stated it was important to have the history and physical and information from the hospital because it was the basis for the diagnosis of the patient and to identify the patient's needs. The DPCS stated it should have been in the agency in the patients chart. A further review of Patient 2s the DPCS stated the Initial and Recertification assessment and Nursing Clinical Notes did not indicate an assessment of Patient 2s arteriovenous fistula (AV) fistula (a connection made by a vascular surgeon, of an artery to a vein) used for dialysis. The DPCS stated the HA was unable to provide patient records, including history and physical, to indicate Patient 2 had met LCD Hospice Eligibility Determination (Local Coverage Determination - an assessment to determine a patients eligibility for hospice services). A review of the Hospice Agencys policy, titled "Admission Criteria and Process," dated 2019, indicated hospice will admit any patient with a life-limiting illness that meets the admission criteria. The policy indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediaries Local Coverage Determinations (LCD). The policy further indicated the HA would admit a patient only on recommendation of the medical director in consultation with, or input from, the patient's attending physician, if any.

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 review three of 14 sampled patients (Patients 1, 2, and 8) medications and ensure Patients 1, 2, and 8 had updated medication profiles. This deficient practice had the potential for Patients 1, 2, and 3 to experience medication errors (any preventable event that may cause or lead to inappropriate medication use or patient harm) and adverse drug reactions (harmful or unpleasant reaction related to the use of a medication). --- C. A Review of Patient 8s Patient Face Sheet (patient information sheet) indicated a start of care (SOC) date of 1/7/2023 and on certification period 9/4/2023 to 11/2/2023. Patient 8 had a primary diagnosis of atherosclerotic heart disease of native coronary artery (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery leading to decreased blood floor to the heart) without angina pectoris (chest pain) and a secondary diagnosis of hypertensive heart disease (heart disease caused by high blood pressure) without heart failure. A review of Patient 8s medication profile for election period 9/4/2023 to 11/2/2023 listed he following medications: 1. Tylenol (pain relief medication) 500 milligram (mg-unit of measurement), by mouth (PO), every six hours as needed (PRN) with an order date of 1/7/23. 2. Losartan (blood pressure medication) 10mg, PO, one tablet (tab) daily. Order date of 8/25/23. 3. Gabapentin (medication to treat nerve pain) 10mg, PO, two times daily. Order date 8/25/23. 4. Atorvastatin (high cholesterol [fatty substance found in the blood] medication) 10mg, PO, one tab daily before bedtime. Order date 8/25/23. 5. Aspirin (medicine to treat pain and reduce risk for heart attack) 81 mg, PO, daily as needed. On 10/4/2023, at 1:10 p.m., a home visit was conducted with Licensed Vocational Nurse (LVN 1). Patient 8s medications were reviewed, and the following discrepancies were found. 1. Patient 8 was no longer taking the gabapentin or Losartan. 2. Patient 8 was taking three new medications: a. Methyl salicylate camphor plus menthol, 50ml, external use for gas pain. Rub on stomach as needed. b. Claritin (allergy medication) 10mg, PO, daily. c. Fluocinolone Acetonide oil 0.01% (medicine to reduce swelling, redness and itching on the ear). The fill date on the bottle was 10/23/20. During an interview on 10/4/2023, at 1:30 p.m, Patient 8 stated that she was no longer taking Gabapentin nor Losartan because she does not need it. Patient 8 was unable to state when the last time she took the. medications. No bottle for Losartan was found in the home. During an interview on 10/4/2023, at 1:49 p.m., Family member 2 (FM 2) stated that Patient 8 does not take any medications for her blood pressure. FM 2 stated that the nurse that visits weekly always checks her blood pressure, and it is fine. During an interview on 10/5/2023, at 1:20 p.m., the Director of Patient Care Services (DPCS) stated that medication reconciliation should be done every visit. The nurse needs to make sure the patient knows why they take it and if they need more teaching. Nurse should ask why the patient is no longer taking this medication. Any medication change should reported after the visit. The nurse needs to notify the DPCS of any medication changes, and will need to call the MD. A review of the HAs policy titled ";Medication Profile", dated 2019, indicated that patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications... Deviations in taking medications as ordered will be documented in the clinical notes, and the physician (or other authorized licensed independent practitioner) will be notified. a. A review of Patient 1s Patient Information Sheet indicated a Start of Care (SOC) date of 3/23/2023 with a primary diagnosis of end stage heart failure (terminal end stage of heart disease in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). A review of Patient 1s Certification of Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for certification period 9/19/2023 to 11/17/2023 (6th 60 days) indicated that for Skilled Nurse (SN) visit for the first week: one visit and one PRN (pro re nata, meaning "as needed") visit for pain and symptom management and the following weeks: one visit/week and one PRN visit for symptom management. A review of Patient 1s Medication Profile indicated for the following: Travatan 0.004% (eye drops are used to lower pressure in the eye) Ophthalmic (relating to eye) Solution, one drop to every eye once in the evening. Oyster Calcium (supplement), one tablet, oral, daily for supplement. Lovastatin (medication to help lower cholesterol) 10 milligrams (mg, unit of measurement) one tablet, oral, daily in the evening for hyperlipidemia (high cholesterol). Losartan (medication to help control high blood pressure), 50 mg, one tablet, oral, daily for hypertension (high blood pressure). Fish Oils, 1200 mg, one capsule, oral daily for supplement. Benzonatate (medication to help control cough), 100 mg cup, by mouth, three times daily as needed for cough. During a joint home visit observation and interview on 10/3/2023 at 10:30 a.m., with Licensed Vocational Nurse 1 (LVN 1) at Patient 1s home residence, Patient 1 was alert and oriented, on room air, and able to use a walker (a type of mobility aid that offers stability and support while walking) from bedroom to living room and sat in chair in the living room. LVN 1 asked if patient was short of breath and needed oxygen, Family Member (FM 1), stated he did not need oxygen. Patient 1 sat in the chair, answered the LVN 1s questions and was not observed short of breath. LVN 1 performed vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and checked Patient 1s medications. Family Member (FM 1) was present during the visit and stated Patient 1 had lower back pain and bilateral (both) calf pain and used Salonpas (pain relief patches), Lidocaine 4%, Pain relieving gel, Maximum Strength, for the pain. FM 1 stated Patient 1 stopped taking Losartan last month. FM 1 stated Patient 1 would leave the house during the week to go to church. When asked if Patient 1 had a cough, FM 1 stated he had a cough several months ago, but no longer had a cough. During an observation and interview 10/3/2023 at 10:50 a.m., with LVN 1 and FM 1, LVN 1 checked Patient 1s medications with the Medication Profile and it was observed Patient 1 did not have Travatan, Oyster Calcium, and Fish oil, and the bottle of Lovastatin, ordered 9/14/2023, was for 40 mg, one tablet, oral, daily in the evening. FM 1 stated Patient 1 stopped taking Losartan last month. LVN 1 stated the medications Patient 1 did not have, needed to be refilled and the old order for the Lovastatin 10 mg should have been discontinued. LVN 1 stated the pain relief patch medication, Salonpas, Patient 1 was using should have been added to the medication profile. b. A review of Patient 2s Patient Information Sheet indicated a Start of Care (SOC) date of 3/23/2023 with a primary diagnosis of cerebral infarction (a condition that occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to unspecified occlusion or stenosis of unspecified cerebral (brain) artery. A review of Patient 2s Certification of Plan of Care dated 9/19/2023 to 11/17/2023 (3rd 60 days) indicated for Skilled Nurse (SN) visit for the first week: one visit and one PRN (as needed) visit for pain and symptom management and the following weeks: one visit/week and one PRN visit for symptom management. A review of Patient 2s Medication Profile indicated for the following medications: Voltaren 1%, Topical Gel, 1% topical, twice daily for moderate pain. Metoprolol Tartrate (medication to help control high blood pressure), 50 milligrams (mg, unit of measurement), one tablet by mouth twice daily for hypertension. Hydralazine (medication to help control high blood pressure), 100 mg, one tablet by mouth three times daily for hypertension. Amlodipine (medication to help control high blood pressure), 10 mg, one tablet, oral, daily for hypertension. On 10/3/2023 at 1 p.m., a joint home visit was conducted with the Director of Patient Care Services (DPCS) at Patient 2s home residence. Patient 2 was alert and oriented, hard of hearing, walked with an unsteady gait from the door to the living room using the wall for assistance. Patient 2 stated she just came back from dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). The DPCS performed vital signs and checked Patient 2s medications. Patient 2 stated her blood pressure medications were discontinued last week because of her low blood pressure and stopped using the Voltaren gel two weeks ago. The last time she was visited by a nurse was on 9/29/2023. The DPCS stated Patient 2's medications needed to be reviewed to prevent any medication errors and adverse reactions.

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 healthcare organizations must meet in order to begin and continue participating in the Medicare [a government health insurance for people 65 or older] and Medicaid [a joint government and state program that gives health coverage to some people with limited income and resources] programs) for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, Coordination of Services was met as follows: 1.Hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed for 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) to develop an individualized care plan for three of eleven sampled patients (Patient 2, Patient 11, and Patient 14). (Refer to 543). 2. The HA failed to ensure its IDG reviewed, revised, and document the individualized plan of care every 15 days in consultation with the physician, social worker and chaplain (provide spiritual and emotional support to patients and their families during end-of-life care) for two of 14 sampled patients (Patients 1 and Patient 2). (Refer to L552). The cumulative effect of these systemic practices resulted in the failure of the HA to delivery statutorily mandated compliance with the Federal regulations for Interdisciplinary group, Care planning, and Coordination of services of patients to ensure hospice care and services were provided to meet the patient's care goals. --- ,

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 for 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) to develop an individualized care plan for three of eleven sampled patients (Patient 2, Patient 11, and Patient 14). This deficient practice placed the patient at risk of not receiving necessary care (in general) based on the patient care needs. --- b. A record review of Patient 11s Patient Information sheet indicated a start of care (SOC) date of 12/15/2022 certification period 8/12/2023 to 10/10/2023 with diagnoses of benign prostatic hyperplasia (BPH, age-associated prostate gland [male reproductive system that is located just below the bladder helps to control urination] enlargement that can cause urination difficulty) and hypertensive heart disease without heart failure (heart problems that occurs due to high blood pressure). A record review of Patient 11s medication profile for election period 8/12/2023 to 10/10/2023, indicated Patient 1 taking the following psychotropic medication (medications that affect the mind, emotions, and behavior) medications. There was no documentation of care plan for Patient 11 used of the following medications 1. Quetiapine fumarate (used to treat certain mental/mood conditions) 300 milligrams (mg, unit of measurement) per os (PO, by mouth) one tablet daily. 2. Olanzapine (primarily used to treat schizophrenia [disorder that affects a person's ability to think, feel, and behave clearly]and bipolar disorder [mental health condition that causes extreme mood swings ]) 20g, PO, half a tablet twice a day. 3. Invega Sustenna (used to treat symptoms of schizophrenia, a mental illness with disturbances in thinking, feelings and behaviour) 234 mg, intramuscular (IM, a medication administered into a muscle), ever four weeks. c. A record review of Patient 14s Patient Information sheet indicated a SOC date of 5/3/2023 and certification period 8/1/2023 to 9/29/2023, with diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and hypertensive heart disease without heart. A review review of Patient 14s medication profile for election period 8/1/23 to 9/29/2023, indicated that they were taking the following psychotropic medications... 1. Trazodone Hydrochloride (drug used for depression [a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily) 100mg, PO two tablets at bedtime. 2. Risperidone (antipsychotic) 1mg, PO, one tablet twice a day. 3. Bupropion Hydrochloride (antidepressant) 150mg, PO, daily. A review of Patient 14s Plan of Care, dated 8/1/2023 to 9/29/2023, was blank, no care plan was developed. During an interview on 10/5/23, at 2:23 p.m., 2:23 p.m., the Director of Patient Care Services (DPCS) stated the IDG should have develop a care plan so nursing knows how to care for patient. DPCS stated there should be a care plan for the antidepressant and antipsychotic medication so the nurses know what adverse reaction to look for while Patient 14 is taking the medications. A review of the HAs policy titled, ";The Plan of Care," dated 2019, indicated the Plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days. The policy indicated this plan will focus on identified problems, goals, and interventions. Findings: a. A review of Patient 2s Patient Information Sheet indicated a Start of Care (SOC) date of 3/23/2023 with a primary diagnosis of cerebral infarction (a stroke; a condition that occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to unspecified occlusion or stenosis of unspecified cerebral (brain) artery. A review of Patient 2s Initial Certification of Plan of Care (POC) for certification period 3/23/2023 to 6/20/2023 (1st 90 days) indicated for Skilled Nurse (SN) visit for the first week: one visit and one PRN (as needed) visit for pain and symptom management and the following weeks: one visit/week and one PRN visit for symptom management. The POC indicated ";No Care Problems identified." A review of Patient 2s Certification of Plan of Care dated 9/19/2023 to 11/17/2023 (3rd 60 days) indicated that for Skilled Nurse (SN) visit for the first week: one visit and one PRN (as needed) visit for pain and symptom management and the following weeks: one visit/week and one PRN visit for symptom management. The POC did not indicate physical indicators of disease progression. The POC indicated that for Skilled Nurse (SN) visit for the first week: one visit and one PRN (as needed) visit for pain and symptom management and the following weeks: one visit/week and one PRN visit for symptom management. The POC indicated ";No Care Problems identified" and that the Interdisciplinary Group (IDG) and Physician determined that the client is eligible for Hospice Services. On 10/3/2023 at 1 p.m., a joint home visit was conducted with the Director of Patient Care Services (DPCS) at Patient 2s home residence. Patient 2 was alert and oriented, walked with an unsteady gait from the door to the living room using the wall for assistance as she walked. Patient 2 stated she just came back from dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Patient 2 stated she took a ride hailing service (where a rider ";hails" or hires a personal driver to take them exactly where they need to go) by herself to her dialysis appointment three times a week, on Tuesday, Thursday and Saturday. The DPCS performed vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), performed skills assessment, and checked Patient 2s medications. The DPCS assessed Patient 2s Arteriovenous (AV fistula, a connection between your artery and your vein that is created by a surgeon) and checked for bruit (an audible vascular sound associated with turbulent blood flow) and thrill (vibration felt upon palpation of a blood vessel). During an interview and record review on 10/5/2023 at 10:26 a.m. with the DPCS, the Comprehensive assessment, dated 3/23/2023, was reviewed and indicated that the blood pressure taken was from the left arm (where the Patient 1's fistula located). The DPCS stated the blood pressure should have been taken on the right arm. The DPCS stated that it was important to take the blood pressure on the correct location because the Patient 2 had a dialysis access on the left upper arm and if taken there, can damage the dialysis access and restrict blood flow to the limb. During an interview and record review on 10/5/2023 at 1:30 p.m. with the Director of Patient Care Services (DCPS), Patient 2s Interdisciplinary Group Meeting/Care Plan Update dated 9/8/2023 was reviewed. The DPCS stated there was no care plan for the Patient 1's fistula and that it should be assessed every visit when the nurse visits the patient. The DPCS stated the nurse should assess for bruit and thrill, bleeding, signs of infection, capillary refill, and pulses. The DPCS stated the assessment of the AV fistula was important to ensure the circulation was good, the access was protected and not leaking because it would require intervention right away. A review of the HAs policy titled, ";The Plan of Care," dated 2019, indicated the Plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days. The policy indicated this plan will focus on identified problems, goals, and interventions.

Based on 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 its interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) reviewed and revised the patient's care plans in consultation with the physician, social worker and chaplain (provide spiritual and emotional support to patients and their families during end-of-life care) for three of 14 sampled patients (Patients 1 and Patient 2). This deficient practice had a potential to result in not to identify changes in the patient's overall health status and delayed of care during the end of life process. --- Findings: a. A record review of Patient 1s Patient Information Sheet indicated a Start of Care (SOC) date of 3/23/2023 with a primary diagnosis of end stage heart failure (end stage of heart disease in which the heart muscle is unable to pump enough blood to meet the bodys needs). A record review of Patient 1s Certification of Plan of Care (POC) for certification period 9/19/2023 to 11/17/2023 (6th 60 days) indicated for Skilled Nurse (SN) visit for the first week: one visit and one PRN (pro re nata, meaning "as needed") visit for pain and symptom management and the following weeks: one visit/week and one PRN visit for symptom management. The POC indicated for Physical Indicators of Disease Progression to collaborate with Interdisciplinary Team (IDT)/facility staff/Family regarding nutrition/hydration/medication/treatment/DME and care needs. The POC indicated ";No Care Problems identified" and that the Interdisciplinary Group (IDG) and Physician determine client is eligible for Hospice Services. A record review of Patient 1s IDG Meeting/Care Plan Update has no documentation of meetings held from 4/07/2023 through 9/08/2023. During a joint home visit on 10/3/2023 at 10:30 a.m., conducted with Licensed Vocational Nurse 1 (LVN 1) at Patient 1s home residence, Patient 1 was observed, alert, oriented, and was able to walk with the use of walker with assistance from bedroom to living room and sit in chair in the living room. During an interview on 10/5/2023 at 11:28 a.m., the Director of Patient Care Services (DPCS) stated, there was no documentation of IDG meetings prior to 9/22/2023 for Patient 1. The DPCS stated, the IDG meetings should have been documented and signed by the team present in the IDG meeting and filed in the patients chart or signed in the electronic chart. b. A record review of Patient 2s Patient Information Sheet indicated a Start of Care (SOC) date of 3/23/2023 with a primary diagnosis of cerebral infarction (a stroke; a condition that occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to unspecified occlusion or stenosis of unspecified cerebral (brain) artery. A record review of Patient 2s Certification of Plan of Care dated 9/19/2023 to 11/17/2023 (3rd 60 days) indicated that for Skilled Nurse (SN) visit for the first week: one visit and one PRN (as needed) visit for pain and symptom management and the following weeks: one visit/week and one PRN visit for symptom management. The POC has no documentation of physical indicators of disease progression and was left blank. The POC indicated ";No Care Problems identified" and the IDG and Physician determine client was eligible for Hospice Services. A record review of Patient 2s IDG Meeting/Care Plan Update has no documentation of meetings held from 4/07/2023 through 8/25/2023 and 9/22/2023. During a joint home visit conducted with the Director of Patient Care Services (DPCS) on 10/3/2023 at 1 p.m., at Patient 2s home residence. Patient 2 was observed alert, oriented, walked with an unsteady gait from the door to the living room held on the wall when walking. During an interview and record review on 10/5/2023 at 11:24 a.m. with the DCPS, the Patient 2s IDG meeting notes dated 9/8/2023 was reviewed. The DPCS stated the IDG meeting minutes was not recorded and should have been documented and signed by the IDG team present in the meeting and filed in the patients chart or signed in the electronic chart. A review of the hospice agency's policy titled, ";Interdisciplinary Group Meeting", dated 2019, indicated that interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. The policy indicated that each patient's 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 patient's condition requires.

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 follow their policy to ensure that the Department was notified in writing of the agency's change of location (CHOL) of the agency. This deficient practice had the potential to result in the agency operating with unqualified ownership, lack of office personnel, and unauthorized location with inadequate physical space, no adequate provision to protect patient confidentiality, inadequate patient care supplies, and misinformation to the patients and their family. --- Findings: A review of the Hospice Agency's State of California Department of Public Health License, effective 11/23/2021 indicated the address: 1241 S. Glendale Ave, Suite 301C, Glendale, CA 91205-3386. On 10/2/2023 at 11:40 a.m., an unannounced complaint investigation visit was conducted at the agency's address on record: 1241 S. Glendale Ave, Suite 301C, Glendale, CA 91205. During an observation on 10/2/2023 at 11:41 a.m., the sign on the door read ";Rosewood Hospice & Palliative Care, Inc., NOTICE, Due to Covid, We are working remotely" and to call the hospice agency phone number. The rooms in the agency were empty and there were no employees present. During an interview on 10/2/2023 at 11:45 a.m., the Building Owner (BO 1) stated that the tenants of Suite 301C moved out recently, about two weeks ago and are still in the process of moving. BO 1 stated that Administrator (ADM) is the owner. During a telephone interview on 10/2/2023 at 11:49 a.m., ADM stated that the agency recently moved to 207 East Los Feliz Road, Suite 207C in Glendale, California. During an interview on 10/2/2023 at 12:10 p.m., the ADM stated there was a Change of Ownership (CHOW) of the hospice agency that was sent on 11/2022 and the agency moved to this location in 7/2023. A request was made for the CHOW and the Change of Location (CHOL) of the hospice agency. The ADM stated he was the owner of the hospice agency. A review of the HAs Organizational Chart from the CHOW, dated 12/1/2022 did not indicate the ADM as the Administrator or the DPCS as the Director of Patient Care Services. The Organizational chart indicated that the ADM was the Chief Financial Officer (CFO) /50% owner and another board member as Chief Executive Officer (CEO)/50% Owner. A review of the HAs organizational work chart (undated) provided 10/2/2023 by the ADM, indicated the ADM was the only member of the Governing Board with title of Chief Executive Officer (CEO), board member (100%), and Administrator. The work chart indicated that the Director of Patient Care Services was also the ADM designee. A review of the California Department of Public Health letter address to the ADM, dated 7/10/2023, provided by the ADM, indicated that the application for a change of stock transfer, governing board, administrator, director of patient care services, administrator designee, director of patient care services designee, and medical director for the hospice agency was deemed incomplete for failure to provide required documentation by the Centralized Applications Branch (CAB). The letter further stated that on 6/5/2023, a 30-day correction letter was sent outlining the pending items needed to complete the report of change. During an interview on 10/5/2023 at 4:47 p.m., The ADM stated that the agency officially moved here (207 East Los Feliz Road, Suite 207C, Glendale, California) effective 9/10/2023. When the ADM was asked again for a copy of the CHOL, the ADM stated that the CHOL application would be submitted this week. The ADM stated that the application for the change of administrator and director of patient care services was submitted by mail in July or August 2023. There was no documented evidence indicating that Licensing and the Department was notified of a change of location or change of Administrator or Director of Patient Care Services. A review of the Hospice Agency's undated policy titled, ";Reporting of Changes", indicated that it was the policy of the Hospice Agency to notify the California Department of Public Health, Centers of Medicare and Medicaid (CMS) of any changes in the hospice agency's ownership, name, mailing address, location, principal officer of the governing board, Administrator, Director of Patient Care Services, and addition or deletion of services. The policy further stated that the owner or designee will, within 10 days, notify the Department in writing of the following...b. the change of location and/or address of the hospice agency...f. change of the Administrator including the name and mailing address of the administrator, the date office was assumed, and a brief description of qualifications and background of the Administrator, g. Change of Director of Patient Care Services including the name and mailing address, the date office was assumed, and a brief description of qualification and background of the Director of Patient Care Services.

Based on observation, interview, and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows: 1. The hospice agencys Medical Director failed to review the patient clinical information to determine the certification for eligibility for admission to the hospice program for two of 14 sampled patients (Patient 1 and Patient 2). This deficient practice resulted in the provision of hospice services with anticipation of life expectancy of six months or less to patients who were not clinically eligible to receive hospice services. (Refer to L668) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for Medical Director services to ensure the highest quality of patient care are provided to the patients certified to receive hospice services. --- .

Based on observation, interview, and record review, the hospice agency failed to ensure the Medical Director and/or physician designee had the patients clinical information needed to support the diagnoses of terminal illness (illness with a prognosis of having six months of life or less to live), to determine recertification (a critical piece of documentation necessary to ensure Medicare payment for the hospice services) for hospice care and services for two of 14 sampled patients (Patients 1 and Patient 2). This deficient practice had the potential to result in inappropriate recertification of patients who are not eligible for hospice care and services. --- Findings: a. A review of Patient 1s Patient Face Sheet indicated a Start of Care (SOC) date of 3/23/2023 with a primary diagnosis of end stage heart failure (terminal end stage of heart disease in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). A review of Patient 1s Certification of Plan of Care (POC) for certification period 9/19/2023 to 11/17/2023 (6th 60 days) indicated, Skilled Nurse (SN) visit for the first week: one visit and one as needed (PRN means "as need") visit for pain and symptom management and the following weeks: one visit per week and one as needed (PRN) visit for symptom management. The POC indicated for Physical Indicators of Disease Progression to collaborate with Interdisciplinary Team (IDT, a group of professionals from various disciplines who work together to attend to the holistic needs of hospice patients and their families)/facility staff/Family regarding nutrition/hydration/medication/treatment/DME (DME, durable medical equipment) and care needs. The POC indicated Changes in Symptoms as Not Applicable. The POC indicated ";No Care Problems identified" and that the Interdisciplinary Group (IDG, a group of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families) and Physician determine client is eligible for Hospice Services. A review of Patient 1s Certification of Terminal Illness (CTI), dated 9/18/2023, indicated that Patient 1 had New York Heart Association classification (NYHA, a simple way of classifying the extent of heart failure) of Class IV [severe symptoms such as fatigue, palpitations (tremors or shivers), chest pain, dyspnea (difficulty breathing), or syncope (fainting) with features of heart failure with minimal physical activity and even at rest level. The CTI was signed by the Hospice Medical Director (MD 1). A review of Patient 1s Interdisciplinary Group Meeting/Care Plan Update indicated no documented evidence of meetings held from 4/07/2023 through 9/08/2023. On 10/3/2023 at 10:30 a.m., a joint home visit was conducted with Licensed Vocational Nurse 1 (LVN 1) at Patient 1s home residence. Patient 1 was alert and oriented, on room air, and able to use a walker with assistance from bedroom to the living room and sit in the chair in the living room. LVN 1 asked if patient was short of breath and needed oxygen, but Family Member (FM 1), stated he did not need oxygen. LVN 1 performed vital signs, skills assessment, and checked Patient 1s medications. Patient 1 sat in the chair, answered LVN 1s questions, and was not observed having short of breath. During a telephone interview on 10/04/2023 at 11:54 a.m., Family Member (FM 1) stated that a member of her church recommended Patient 1 for hospice. FM 1 stated that hospice was for those that needed comfort, have pain, and cannot take care of themselves. FM 1 stated she understood that hospice was like home health care where they have a nurse that visits and checks on Patient 1. When FM 1 was asked what terminal illness Patient 1 had, FM 1 stated Patient 1 had problem with his prostate (a male reproductive organ), but it was curable, arthritis (inflammation of joints), and had back pain that did not go away. FM 1 further stated that the Hospice Medical Doctor (MD 1) did not say that Patient 1 had a terminal illness and that Patient 1 is not dying yet, just has a lot of pain, and would not be dying in six months. During an interview and record review on 10/5/2023 at 2:28 p.m. with the Director of Patient Care Services (DPCS), Patient 1s Recertification Assessments dated 7/7/2023 and 8/25/2023 and Clinical Nurses notes from 7/2023 through 9/2023 were reviewed and indicated, Patient 1 had a hospice primary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure), without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). The DPCS stated that the diagnosis from the Recertification Assessment and the nurses notes did not reflect the diagnosis on Patient 1s CTI. The DPCS further stated that the recertification assessment and the nurses notes did not show a decline of the patient nor did it support the diagnosis of a patient with heart failure. During an interview and record review on 10/5/2023 at 2:45 p.m. with the DPCS, Patient 1s clinical record was reviewed. The DPCS stated that there was no documentation to support that Patient 1 had heart failure. b. A review of Patient 2s Patient Face Sheet indicated a Start of Care (SOC) date of 3/23/2023 with a primary diagnosis of cerebral infarction (a stroke, a condition that occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to unspecified occlusion or stenosis of unspecified cerebral (brain) artery (narrowing of an artery in the brain). A review of Patient 2s Certification of Plan of Care dated 9/19/2023 to 11/17/2023 (3rd 60 days) indicated, Skilled Nurse (SN) visit for the first week: one visit and one as needed (PRN) visit for pain and symptom management and the following weeks: one visit per week and one as needed (PRN) visit for symptom management. The POC did not indicate physical indicators of disease progression and was left blank. The POC indicated ";No Care Problems identified" and that the Interdisciplinary Group (IDG) and Physician determine client is eligible for Hospice Services. A review of Patient 2s Interdisciplinary Group (IDG, a group of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families) Meeting/Care Plan Update indicated no documented evidence of meetings held from 4/07/2023 through 8/25/2023 and 9/22/2023. A review of Patient 2s Certificate of Terminal Illness (CTI), dated 9/18/2023, indicated a diagnosis of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery. The Hospice Medical Director (MD 1) signed the attestation that ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and /or examination of the patient." The CTI indicated that patient had a Karnofsky Palliative score (an assessment tool intended to assist clinicians in measuring a patient's functional status and ability to carry out activities of daily living) of 40 percent (unable to care for self; disabled; requires special care and assistance) and a Palliative Performance Scale (PPS, a tool used to assess patient's ability to function and determine how to move toward the end of life) of 40% (mainly in bed, cannot do any work, die to extensive disease, and mainly needed assistance in self-care). On 10/3/2023 at 1:00 p.m., a joint home visit was conducted with the Director of Patient Care Services (DPCS) at Patient 2s home residence. Patient 2 was alert and oriented, walked with an unsteady gait from the door to the living room using the wall for assistance during walking. Patient 2 stated she just came back from dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys [two bean shaped organs to filter blood] stop working properly). Patient 2 stated she takes a ride hailing service (where a rider ";hails" or hires a personal driver to take them exactly where they need to go) by herself to her dialysis appointment three times a week, on Tuesday, Thursday, and Saturday. When Patient 2 was asked when she had a stroke, Patient 2 stated she had a stroke in 2013. Patient 2 stated she had no problems swallowing and was waiting for her son to finish cooking lunch so she could eat and then go to sleep. During a record review and interview on 10/5/2023 at 10:26 a.m. with the DPCS, Patient 2s Initial Comprehensive Assessment dated 3/23/2023, and Recertification Assessments dated 6/18/2023 reviewed and indicated that Patient 2 had a Karnofsky Performance Status (KPS, an assessment tool intended to assist clinicians and caretakers in gauging a patient's functional status and ability to carry out activities of daily living) of 40 percent (unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly; disabled; requires special care and assistance). The DPCS stated that Patient 2 was more of a KPS of 50 because the patient goes to dialysis three times a week, is able to care for most of her personal needs, and that although her energy levels vary, Patient 2 can do some grooming and change her clothes. The DPCS further stated that the assessments did not show residuals from a stroke diagnosis such as contractures or problems with speech. During an interview and record review on 10/5/2023 at 2:43 p.m., with the DPCS, Patient 2s clinical record was reviewed. The DPCS stated that the documentation to support the Patient 2s CVA terminal diagnosis was not in the patients folder. The DCPS stated it was important to have the history and physical and information from the hospital because it is the basis for the diagnosis of the patient. The DPCS stated it should have been in the agency in the patients chart. During a telephone interview on 10/5/2023 at 4:16 p.m., the Medical Director (MD 1) stated that to qualify a patient for hospice, the patient would need a referral from a doctor or from the hospital. MD 1 stated that he participates in biweekly interdisciplinary group meetings, does face to face with patients in person or via zoom and documents it in the computer system in the notes section. MD 1 stated that if there is no primary doctor, he tries to see if there was a recent hospitalization and tries to get those records to verify the patient diagnosis. MD 1 stated that he reviews the documentation and returns it to the nurse and that the patients hospital documentation is kept with the agency and uploaded into the computer system or kept with the patients chart. When MD 1 was asked to discuss one of the HAs patients, MD 1 stated that he was not able to help because he did not have access to the patients records at this time. A review of the hospice agencys undated policy and procedure titled, ";Certification of Terminal Illness", dated 2019, indicated Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. The policy indicated that clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed with the medical records with the written certification. The policy indicated that a subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director.

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 background checks were performed on all employees and filed with the employee records. This deficient practice had the potential to allow someone with a criminal background to work at the agency and cause harm to the patients. --- Findings: a. On 10/2/2023, a review of the Administrators (ADM) employee record was conducted. The employee record for the ADM was incomplete and did not contain the following documentation: history and physical, a purified protein derivative (PPD, a skin test is a method used to diagnose silent [latent] tuberculosis [TB] infection) test or chest x-ray, or a background check. b. On 10/2/2023, a review of the Director of Patient Care Services (DPCS)s employee record was conducted. The employee record for the DPCS was incomplete and did not contain a history and physical or background check. c. On 10/2/2023, a review of the Bereavement Counselors (BC) employee record was conducted. The employee record for BC was incomplete and did not contain a background check. During an interview and record review on 10/2/2023 at 3:18 p.m. with the DPCS, the employee records were reviewed and did not contain a background check. The DPCS stated all the employee files should have a background check. The DPCS stated it was important to check for criminal records to be eligible to be employed by the hospice agency. A review of the HAs policy titled ";Human Resources", dated 2019, indicated that prior to hire, the organization will secure multiple reference checks, health reports as required by the state or policy, criminal record checks when required by law, and proof of citizenship or documentation of resident status.