Every finding on record at Saba Hospice Care, Inc

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Conditions of Participations regarding Patient Rights was met as followed: --- 1.The HA failed to ensure one of fourteen sampled patients (Patient 3) was aware of the hospice services (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease). This deficient practice resulted in Patient 3 not being aware of the hospice services and had the potential to affect the patient's quality of care. (Refer to L518). The cumulative effect of these systemic practices resulted in patient not knowing the hospice services with limitations and rights as hospice patient and had the potential to affect the patient's quality of care.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure one of fourteen sampled patients (Patient 3) was aware of the hospice services (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease). This deficient practice resulted in Patient 3 not being aware of the hospice services and had the potential to affect the patient's quality of care. --- Findings During a review of Patient 3s untitled admission record, the admission record indicated a start of care date on 4/15/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). The admission record indicated Family Member 1 (FM1) was listed as an emergency contact for Patient 3. During a review of Patient 3s Comprehensive Assessment, dated 4/15/2024, the Comprehensive Assessment indicated Patient 3 was dependent with the Activities of Daily Living (ADL, activities related to personal care which include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) ambulation (walking), toileting, transfer, dressing, and bathing. During a review of Patient 3s Physicians Certification for Hospice Benefit, with a date of certification of 4/15/2024 to 7/13/2024, the Physicians Certification for Hospice Benefit indicated Patient 3 required maximal assist with five of six ADLs which included ambulation, toileting, transfer, dressing, and feeding due to generalized weakness and easily fatigued. The Physicians Certification for Hospice Benefit indicated Patient 3 had progressive generalized body weakness, ambulated with a walker (is a type of mobility aid that offers stability and support while walking). The Physicians Certification for Hospice Benefit indicated Patient 3 had episodes of dyspnea (difficulty in breathing) upon exertion (physical or mental effort), resulting in decrease functional capacity. During a review of Patient 3s clinical record titled ";Informed Consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure) and Treatment Authorization," indicated the Informed Consent and Treatment authorization was signed on 4/15/2024. During a telephone interview on 5/30/2024, at 11:04 a.m., with Patient 3, Patient 3 was able to tell the surveyor her name, date of birth, and stated she did not know FM1 who was listed as her emergency contacts in the admission record. Patient 3 stated she did not know her personally and did not meet her, stated she was referred to the HA by her friend that moved out of the State. Patient 3 stated she was at the hospital watching for her ninety-year-old aunt to make sure she would not fall from the bed. Patient 3 stated she would go to the hospital to stay with her aunt six hours a day. Patient 3 stated she was the only immediate family of her aunt. Patient 3 stated she used the Lyft ride (transportation services) to take her to the hospital and to go home. Patient 3 stated she could still walk. Patient 3 stated she did not use oxygen and she could still go out. Patient 3 stated she was under hospice care but stated she did not have a terminal illness and it was not explained or mentioned to her by the nurses (in general) or by the doctors (in general). Patient 3 stated from what she understood about hospice was to manage her pain and medications only. Patient 3 stated she could take care of herself and did not need help with going to the bathroom, changing clothes, eating, and taking showers. Patient 3 stated she did not know about her diagnosis of heart failure, and stated she had problems with her blood sugar and blood pressure. Patient 3 stated she signed the informed consent document with the nurse (unidentified) during her admission to the HA and the nurse did not explain about her terminal illness. Patient 3 stated she did not know that she had six months or less to live and her diagnosis. During a telephone interview on 5/31/2024, at 12:20 p.m., with the Medical Director (MD), the MD stated he determined the patients (in general) hospice eligibility and terminal illness such as heart failure through previous clinical records, history and physical, laboratory tests and diagnostic procedures. MD stated that previous clinical records that were reviewed should be in the patients electronic medical records (EMR, includes information about a patient's health history, such as diagnoses, medicines, tests, allergies, immunizations, and treatment plans) or office files. MD stated that he was disappointed with the communication and coordination of care between the doctors, nurses, HAs staff and patients. MD stated for a patient that had a heart failure, the patient should be resting as it was difficult to do physical activity without discomfort, stated Patient 3 needed to be resting at home as it will be difficult for her to move around. During a telephone interview on 5/31/2024, at 1 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated she was not aware Patient 3 was in the hospital helping Patients 3 aunt. The DPCS stated according to Patient 3s documented assessments it was unusual for a hospice patient to go out and watch for her aunt in the hospital, and it did not reflect her health status. During a concurrent interview and record review, on 5/31/2024, at 1:30 p.m., with the Director of Patient Care Services Designee (DPCSD), Patient 3s medical record was reviewed. The DPCSD stated she was unaware Patient 3 was in the hospital taking care of her aunt. The DPSD stated it should have been communicated to the hospice agency and with Patient 3s condition, it would be difficult for her and uncommon for a hospice patient to take care or watch someone. The DPCSD stated Patient 3 could be confused and the hospice services and programs were explained to Patient 3 during her admission. The DPCSD stated that the documented assessments did not reflect Patient 3s current status in relation to Patient 3s stated activities. During a review of hospice agencys policy and procedure titled ";Rights/Responsibilities," with a revised date of November 2022, indicated that the patient, authorized decision-maker or legal representative will be informed during the initial assessment visit, in advance of furnishing care of, which include the right to be informed of his/her condition, to participate in all aspects of care including development on their plan of care, and the right to refuse all or part of his/her care to the extent permitted by law.

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 regarding Initial and Comprehensive Assessment of the Patient was met as follows: --- 1. The HA failed to conduct and document a comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for three of fourteen sampled patients (Patient 2, Patient 3, and Patient 11). (Refer to L524). This deficient practice had the potential for Patient 2, Patient 3, and Patient 11 not to receive care and services. 2. The HA failed to conduct an initial bereavement (is the physical and mental impact of losing a loved one) assessment for one of fourteen sampled patients (Patient 3). (Refer to L531). This deficient practice had the potential not to meet Patient 3's and family needs. 3. The HA failed to ensure the interdisciplinary group (IDG, meeting where the Registered Nurse [RN], Medical Social Worker [MSW, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) conducted biweekly (twice a week) meetings to update the comprehensive assessment of patients and reflected current health status, for ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 11, Patient 12, Patient 13 ). (Refer to L533). This deficient practice resulted in patients not being evaluated and had the potential to affect the patients' care. The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to conduct and document a comprehensive assessment that reflected the patient's current health status and identify the patients' needs for hospice care and services related to hospice eligibility and management of terminal illness for three of fourteen sampled patients (Patient 2, Patient 3, and Patient 11). This deficient practice had the potential for Patient 2, Patient 3, and Patient 11 not to receive care and services. --- A review of Patient 11s admission sheet, indicated a start of care date of 10/2/2024 with diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure with heart failure (heart not pumping enough blood for the body). A review of Patient 11s ";Comprehensive Nursing Assessment," dated 5/6/2024, indicated that Patient 11 required a walker or wheelchair for movement with maximum assist, has shortness of breath with minimal exertion, clear lung sounds and edema (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body) in bilateral lower extremities. Patient 11s ";Comprehensive Nursing Assessment," did not have a signature of the clinician. During an interview with on 5/29/2024 at 1:15pm with Patient 11, Patient 11 stated her Primary Care Physician who Patient 11 sees regularly is PCP 1. During an observation on 5/29/2024 at 1:20 p.m. at Patient 11s home with DPCSD, Patient 11 was observed with no signs or symptoms of edema. DPCSD was observed conducting vital signs for Patient 11 and Patient 11 blood pressure was 138/84 mmHg (millimeter of mercury a manometric unit of pressure used to measure blood pressure), oxygen saturation (the amount of oxygen in the blood) of 95% on room air. During a phone interview on 5/29/2024 at 2:00 p.m., with Primary Care Physician 1 (PCP 1) stated he had been the primary care physician for Patient 11 since 2019 and sees Patient 11 once a month. PCP 1 stated he was unaware Patient 11 has been enrolled in Hospice. PCP 1 stated Patient 11 is not a candidate for Hospice and does not have a terminal illness. PCP 1 stated Patient 11 is ambulatory, has no shortness of breath, doesnt have heart failure, doesnt use a walker or cane to walk and exercises 5 times a week. PCP 1 stated Patient 11 was hospitalized in April for Pneumonia for a few days but has been back in his office since the hospitalization on 4/23/2024. PCP 1 stated the active diagnosis for Patient 11 are hypertension (high blood pressure), controlled asthma (a respiratory condition marked by spasms in the bronchi of the lungs causing difficulty in breathing), and hyperlipidemia (high cholesterol levels in the blood). PCP1 stated Patient 11 is not on any diuretics (medication that causes the kidney to make more urine) under his care and does not have any issues with shortness of breath or edema (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body). During a record review of office visit for Patient 11 from PCP 1s office, dated 4/23/2024, indicated Patient 11 is ambulatory without dyspnea (shortness of breath). The record further indicated, ";Physical Activity, on average, how many days per week do you engage in moderate to strenuous exercise (like a brisk walk): 5 days a week. On average, how many minutes do you engage in exercise at this level?: 30 minutes. Total minutes per week: 150." The document further indicated a cardiovascular (related to or involving the heart and blood vessels) assessment with normal heart sounds and no edema. The document further included respiratory (related to or involving the lungs and breathing) assessment of normal breath sounds in all lung fields. The medication list provided from PCP 1s office did not have any diuretics. During a record review of an email from PCP 1s office, dated 5/29/2024, indicated, ";Per, PCP 1, Patient 11 is not a candidate for Hospice." A review of Patient 11s ";LCD Hospice Eligibility Determination" (local coverage determination for Hospice eligibility used by national government services used to determine guidelines for terminally ill patients and if they have a life expectancy of six months or less), dated 5/6/2024, indicated for NYHA classification under A. Does this CHF (congestive heart failure, the heart's capacity to pump blood cannot keep up with the body's need the term congestive refers to the resulting buildup of fluids in the ankles and feet, arms, lungs, and or other organs), or angina patient meet the criteria for NYHA Class 4 (New York Heart Association classification of heart failure, with class 4 being the most severe stage of heart failure and indicates that patient is unstable to perform any physical activity without discomfort. Patients with Class 4 heart failure experience symptoms even when resting or with minimal exertion, and any physical activity increases their discomfort) level? Yes." During a phone interview on 5/30/2024 at m 1:42pm, with Medical Director (MD), when asked how MD certifies patients for hospice, MD stated, ";the patient has to meet LCD criteria, has to have a terminal diagnosis and sudden decline, has less than 6 months to live." When asked if the primary care physician of the patient is contacted, MD stated, ";if there is a community referral, we absolutely communicate with primary care physician (PCP)." When asked if MD reviews any clinical documents for the patients before certifying for hospice, MD stated, ";yes, I review hospital records, history and physical, labs, diagnostic tests, evaluation from nurse. I look at the entire picture. I speak to PCP, conduct a face to face if available." When asked what info do you need to diagnose a patient with heart disease, MD stated "; I look at the functional status, how far the patient can ambulate without having shortness of breath, I look for symptoms of heart failure, history of heart disease, symptoms of edema, fluid in lungs, objective results such as echo (a scan used to look at the heart and nearby blood vessels) if possible, BNP (Brain natriuretic peptide, blood test that measures the levels of a protein hormone in your bloodstream which is produced by the heart and blood vessels and higher levels and indicate heart inability to pump blood throughout the body or heart failure), changes in labs." When asked what criteria is used to determine NYHA class 4, MD stated, ";NYHA 4 is more of symptomatic assessment." When asked for Patient 11, what criteria was used to determine heart failure and NYHA 4, MD 1 stated, ";Patient 11 has frequent shortness of breath, difficulty with ambulation. I think Patient 11 is more of NYHA 3 not NYHA 4, Patient 11 also has severe osteoarthritis (degenerative joint disease), really bad shortness of breath, chronic pain, hypertension, hyperlipemia. ";When asked what criteria was used to diagnose heart failure, MD 1 stated, ";I based it on the edema, dependency on diuretics, inability to ambulate without shortness of breath." When asked for patient 11, if the PCP was contacted for information and coordination, MD stated," I dont believe I ever communicated with Patient 11s PCP." When asked if MD reviewed any objective data or clinical records to diagnose patient 11 with heart failure, MD stated, ";I cannot recall, if we have them it should be in the office. We should have reviewed it to diagnose patient 11 with heart failure. Check with the office." During a concurrent interview and record review on 5/31/2024 at 2:30 p.m. with DPCSD, of Patient 11s file, there were no labs, diagnostic tests available for review, DPCSD stated, ";we dont have any documents for Patient 11, no labs, no diagnostic data." When asked what criteria was used to determine Patient 11 fits the NYHA 4 classification for heart failure, DPCSD stated, ";Patient 11s symptoms of shortness of breath with ambulation, and lower leg edema." During a concurrent interview and record review on 5/31/2024 at 2:35 p.m. of Patient 11's clinical record titled Comprehensive Assessment, dated 5/6/2024 with DPCSD there is no clinician signature. DPCSD stated, ";Patient 11s comprehensive assessment doesnt have a clinician signature. If its not signed we cant tell who did it or if it was done." A review of the facility's policy and procedure (P&P) titled, "Medicaid Hospice Benefit," dated November 2022, indicated, ";The benefit is available to patients. who: 7. Adherence to LCD for eligibility." A review of the facilitys policy titled, ";Contents of Clinical Record," dated November 2022, indicated, ";The clinical record will contain sufficient information to identify the patient, describe patient problems/needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel." The policy further indicated, ";the clinical record will be dated and signed, including title and credentials, by the person providing the care/service." A. A review of Patient 2s untitled admission sheet, indicated a start of care date on 10/19/2024 with a primary diagnosis of chronic diastolic heart failure (heart not pumping blood properly). A review of Patient 2s clinical record titled ";Comprehensive Assessment", dated 10/19/2023, indicated in the ADL (Activities of Daily Living, activities related to personal care which include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) Assessment the total number of activities with complete dependence (0-6) was 3 out six, which Patient 2 is dependent to ambulation, transfer and bathing. It also indicated that Patient 2 required a cane or walker for movement with maximum assist, has moderate dyspnea (difficulty in breathing) with mild exertion, diminished lung sounds, normal respirations, and edema (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body) in bilateral lower extremities. A review of Patient 2s clinical record titled ";Physicians Certification for Hospice Benefit", with date of certification of 4/16/2024 to 6/14/2024, indicated in the ";LCD (is a decision made by a Medicare Administrative Contractor (MAC) on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the area that the MAC oversees) Determination Status section", -KPS (or Karnofsky Performance Status, is used to determine understanding of patient needs, ability to carry out daily activities and to assess patient prognosis, scores range from 0 to 100, a higher score means the patient is better able to carry out daily activities) still determined at 50%, A review of Patient 2s ";LCD Hospice Eligibility Determination" (local coverage determination for Hospice eligibility used by national government services used to determine guidelines for terminally ill patients and if they have a life expectancy of six months or less), dated 5/16/2024, indicated for NYHA classification under A. Does this CHF (congestive heart failure, the heart's capacity to pump blood cannot keep up with the body's need the term congestive refers to the resulting buildup of fluids in the ankles and feet, arms, lungs, and or other organs), or angina patient meet the criteria for NYHA Class 4 (New York Heart Association classification of heart failure, with class 4 being the most severe stage of heart failure and indicates that patient is unstable to perform any physical activity without discomfort. Patients with Class 4 heart failure experience symptoms even when resting or with minimal exertion, and any physical activity increases their discomfort) level? Yes." During an observation on 5/29/2024 at 11:00 a.m. at Patient 2s home with DPCSD, Patient 2 was observed with no shortness of breath when ambulate to open the entrance door, talks clearly and does not stop in between sentences. DPCSD was observed conducting vital signs for Patient 2 with blood pressure of 142/84 mmHg (millimeter of mercury a manometric unit of pressure used to measure blood pressure), oxygen saturation (the amount of oxygen in the blood) of 92% on room air, Patient 2 appears to have no apparent respiratory distress. During an observation on 5/29/2024 at 11:00 a.m. at Patient 2s home with DPCSD, Patient 2 was observed with no shortness of breath when ambulate to open the entrance door, talks clearly and does not stop in between sentences. DPCSD was observed conducting vital signs for Patient 2 with blood pressure of 142/84 mmHg (millimeter of mercury a manometric unit of pressure used to measure blood pressure), oxygen saturation (the amount of oxygen in the blood) of 92% on room air, Patient 2 appears to have no apparent respiratory distress. B. A review of Patient 3s untitled admission sheet, indicated a start of care date on 4/15/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). A review of Patient 3s clinical record titled ";Comprehensive Assessment", dated 4/15/2024, indicated in the ADL (Activities of Daily Living, activities related to personal care which include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) Assessment the total number of activities with complete dependence (0-6) was 5 out six, which Patient 3 is dependent to ambulation, toileting, transfer, dressing and bathing. It also indicated that Patient 3 required a walker for movement with maximum assist, has mild dyspnea (difficulty in breathing) with mild exertion, clear lung sounds, normal respirations, and no edema (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body). Patient 3s ";Comprehensive Nursing Assessment," did not have a signature of the clinician. A review of Patient 3s ";LCD Hospice Eligibility Determination" (local coverage determination for Hospice eligibility used by national government services used to determine guidelines for terminally ill patients and if they have a life expectancy of six months or less), dated 5/13/2024, indicated for NYHA classification under A. Does this CHF (congestive heart failure, the heart's capacity to pump blood cannot keep up with the body's need the term congestive refers to the resulting buildup of fluids in the ankles and feet, arms, lungs, and or other organs), or angina patient meet the criteria for NYHA Class 4 (New York Heart Association classification of heart failure, with class 4 being the most severe stage of heart failure and indicates that patient is unstable to perform any physical activity without discomfort. Patients with Class 4 heart failure experience symptoms even when resting or with minimal exertion, and any physical activity increases their discomfort) level? Yes." A review of Patient 3s clinical record titled ";Physicians Certification for Hospice Benefit", with date of certification of 4/15/2024 to 7/13/2024, indicated in the ";LCD (is a decision made by a Medicare Administrative Contractor (MAC) on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the area that the MAC oversees) Determination Status section", -KPS (or Karnofsky Performance Status, is used to determine understanding of patient needs, ability to carry out daily activities and to assess patient prognosis, scores range from 0 to 100, a higher score means the patient is better able to carry out daily activities) of 40%, -PPS (Palliative Performance Scale, is a useful tool for measuring the progressive decline of a patient. It has five functional dimensions: ambulation, activity level and evidence of disease, self-care, oral intake, and level of consciousness, hospice care may be appropriate for patients with a PPS score of less than 70%) of 40%, -NYHA IV (New York Heart Association is the accepted measure of functional capacity in patient with heart failure, in NYHA IV, a patient is unable to carry out any physical activity without discomfort, tired and short of breath even at rest, if any physical activity is undertaken, discomfort increased), -Patient requires maximal assist with 5/6 ADLs (5 out of 6 of Activities of Daily Living which includes ambulation, toileting, transfer, dressing, feeding and bathing) due to generalized weakness and easily fatigued. -Patient has progressive generalized body weakness; ambulates with walker -Patient has episodes of dyspnea (difficulty in breathing) upon exertion, resulting in decrease functional capacity. During a telephone interview with Patient 3 (P3) on 5/30/2024, at 11:04 a.m., P3 verified her name, date of birth, stated she does not know of Family Member 1 (FM1) listed as her emergency contacts, stated she does not know her personally and did not meet her, stated she was referred to hospice agency by her friend that moved out of state already. P3 stated she is at the hospital watching for her 90-year-old aunt to make sure she will not fall from the bed. P3 stated she does not do lifting or turning for her aunt, she calls the nurse if her aunt needed help. P3 stated she come to the hospital to stay with her aunt 6 hours a day for a week now, stated she is the only immediate family of her aunt. P3 stated she uses Lyft ride to bring her to the hospital and to go home. P3 stated she can still walk; she uses walker sometimes. P3 stated she does not use oxygen, stated sometimes she has shortness of breath, chest tightness and weakness but she is still can go out. P3 stated she is under hospice care but stated she does not have a terminal illness and it was not explained or mentioned to her by the nurses. P3 stated from what she understood about hospice is to manage her pain and medications only. P3 stated she can still walk with use of walker sometimes, stated she takes care of herself and does not need help with going to the bathroom, changing clothes, eating, and taking showers. P3 stated she does not know about her diagnosis of heart failure, but stated she has problems with her blood sugar and blood pressure, stated it was not explained to her by the hospice nurses or doctor. P3 stated she signed an informed consent document with the nurse during her admission to hospice, but the nurse did not explained about her terminal illness or diagnosis. P3 stated she signed an informed consent document with the nurse during her admission to hospice but the nurse did not explained about her terminal illness that she has six months or less to live and her diagnosis. During telephone conversation with P3, she has no difficulty in breathing, speaks clearly and does not stop in between sentences. During a phone interview on 5/31/2024 at 12:20 p.m., with Medical Director (MD), MD stated, ";the patient has to meet LCD criteria, has to have a terminal diagnosis and sudden decline, has less than 6 months to live, stated ";if there is a community referral, we absolutely communicate with primary care physician (PCP)." MD stated, ";I review hospital records, history and physical, labs, diagnostic tests, evaluation from nurse. I look at the entire picture. I speak to PCP, conduct a face to face if available." MD stated "; I look at the functional status, how far the patient can ambulate without having shortness of breath, I look for symptoms of heart failure, history of heart disease, symptoms of edema, fluid in lungs, objective results such as echo (a scan used to look at the heart and nearby blood vessels) if possible, BNP (Brain natriuretic peptide, blood test that measures the levels of a protein hormone in your bloodstream which is produced by the heart and blood vessels and higher levels and indicate heart inability to pump blood throughout the body or heart failure), changes in labs. MD stated, ";NYHA 4 is more of symptomatic assessment." MD stated, ";I cannot recall where are the patients clinical records, if we have them it should be in the office. We should have reviewed it to diagnose patients with heart failure. I am disappointed with the lack of coordination of care and communication between the office, nurses and patients ." During an interview and concurrent interview and record review on 5/31/2024 at 2:40 p.m. with DPCSD, DPCSD stated, ";Patient 3 s comprehensive assessments have no clinician signature. DPCSD stated that she did the assessments but forgot to sign it.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to provide initial bereavement (is the physical and mental impact of losing a loved one) assessment for one of fourteen sampled patients (Patient 3). This deficient practice had the potential not to meet Patient 3's and family needs. --- Findings: During a review of Patient 3s untitled admission sheet, indicated a start of care date on 4/15/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 3s Current Treatment/Medication/DME(Durable Medical Equipment) List, dated 4/15/2024, indicated and order of ";Bereavement Coordination to Assess and Evaluate Bereavement and Grieving Risk Factor within 5 (five) days of Admission." During a review of the hospice agencys employee list indicated the Spiritual Chaplain (SC) was listed as the Bereavement Coordinator. During an interview and concurrent review of Patient 3s clinical records with the Director of Patient Care Services Designee (DPCSD), on 5/31/2024 at 2:10 p.m., the DPCSD stated that there was no initial bereavement risk assessment conducted and Patient 3s clinical record page, titled ";History of Bereavement Assessment," was blank. The DPCSD stated there were no other documented evidence that an Initial Bereavement Assessment was conducted for Patient 3. The DPCSD stated a bereavement assessment needed to be conducted within five days of admission. The DPCSD stated Patient 3 did not have an initial bereavement assessment conducted based on the clinical records and the Spiritual Chaplain (SC) should have been completed it. During a telephone interview with the SC on 5/31/22024, at 11:50 a.m., the SC stated he was the Bereavement Coordinator and usually did the bereavement assessment for patients and ensure that it was conducted. SC stated he forgot to enter his documentations for Patient 3s bereavement assessment. The SC stated he should have done it as soon as he completed his assessment. A review of the agency's policy and procedure titled "Bereavement Assessment", revised November 2022, indicated that on admission, the social worker, chaplain or hospice registered nurse will complete a bereavement risk assessment that will be given to the Bereavement Coordinator, the Bereavement Coordinator will review the bereavement risk assessment to determine potential needs of the survivors.

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live)The HA failed to ensure the interdisciplinary group (IDG, meeting where the Registered Nurse [RN], Medical Social Worker [MSW, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) conducted biweekly (twice a week) meetings to update the comprehensive assessment of patients and reflected current health status, for ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 11, Patient 12, Patient 13 ). This deficient practice resulted in patients not being evaluated and had the potential to affect the patients' care. --- A. A review of Patient 1s untitled admission sheet, indicated a start of care date on 2/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). B. A review of Patient 2s untitled admission sheet, indicated a start of care date on 10/19/2024 with a primary diagnosis of chronic diastolic heart failure (heart not pumping blood properly). C. A review of Patient 3s untitled admission sheet, indicated a start of care date on 4/15/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). D. A review of Patient 4s untitled admission sheet, indicated a start of care date on 3/11/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a concurrent interview and record review on 5/31/2024 at 2:17 p.m. with the Director of Patient Care Services Designee (DPCSD) of the Electronic Medical Record (EMR) for the following patients: -Patient 1, Plan of Care/Interdisciplinary Group Review (POC/IDG) dates of 3/4/2024 and 3/18/2024, there were no nursing, physician, or Masters of Social Work (MSW) signatures, POC/IDG dates of 4/1/2024, 4/15/2024 and 4/29/2024, there were no signatures from any of the disciplines on the IDGs and no documented evidences that IDGs were done on 5/13/2024 and 5/27/2024. DCPSD stated, ";there were no signatures on the IDG for nursing, doctor, and MSW and any of the disciplines on 3/4/2024 to 4/29/2024. DCSD stated that she doesnt know what happened, it may be a system glitched. DPCSD was unable to provide any documented evidence that IDG meetings were held by all the disciplines. DPCSD stated that the importance of documentation is to update the care plan and have proof that it was done, if there were no signatures it was not done. -Patient 2, POC/IDG dates of 2/26/2024, 3/11/2024, 3/25/2024, 4/8/2024 and 4/22/2024 there were no signatures from any discipline. DCPSD stated, ";there were no signatures from any discipline on any of the IDGs. The importance of documentation is to update the care plan and have proof that it was done. If there are no signatures it wasnt done. -Patient 3, no documented evidence that POC/IDG meetings were done since admission on 4/15/2024, P3s clinical record page titled ";History of POC/IDG" page was blank. DCPSD stated she does not know what happened, stated she remembered P3 is included from their last IDG meetings but stated she was unsure why it was not documented in P3s clinical records. DPCSD stated that the importance of documentation is to update the care plan and have proof that it was done, if there were no signatures or entry records, it was not done. -Patient 4, POC/IDG dates of 3/11/2024, 3/14/2024, 3/28/2024, 4/11/2024, 4/25/2024, 5/9/2024 and 5/23/2024 indicated that there were no signatures from any discipline the IDG. DCPSD stated there were no IDG members signatures from the dates mentioned and if not signed then it is not done. DPCSD stated that there were no attendance form to sign by the IDG discipline for every meeting conducted, stated there should have one to provide evidence that meeting and attendance of IDG members were validated. A review of the hospice agencys policy and procedure titled, ";Interdisciplinary Group Meeting", revised November 2022, the policy and procedure indicated, ";Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor". A review of Patient 12s medical record, untitled admission sheet, indicated a start of care date of 5/1/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris with spasms (build up of fats, cholesterol in artery walls, that affects the heart vessels with chest pain and involuntary, abnormal muscular contraction). During a concurrent interview and record review on 5/31/2024 at 3:00 p.m. with DPCSD of Patient 12s Clinical record, titled Initial Comprehensive Assessment and dated 5/8/2024 and 5/22/2024, there were no signature indicating who completed the document. The DPCSD stated, ";LVN 1 did not sign the visit note for Patient 12 on 5/8/2024 and 5/22/2024". Further review of Patient 12s Electronic Medical Record (EMR) indicated there were no signatures for the IDGs on 5/1/2024, 5/4/2024, and 5/18/2024. The DPCSD stated, ";There are missing signatures for the MD, MSW, RN and Chaplain for these IDGs dated 5/1/2024, 5/4/2024, and 5/18/2024." A review of Patient 13s medical record, untitled admission sheet, indicated a start of care date of 4/23/2024 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) without heart failure. During a concurrent interview and record review on 5/31/2024 at 3:05 p.m. with DPCSD of Patient 13s clinical record, titled ";Initial Comprehensive Assessment" and dated 4/23/2024, there were no signature indicating who completed the document. The DPCSD stated, ";There is no RN signature for the Initial Comprehensive Assessment for Patient 13 on 4/23/2024. I am not sure who documented it." Further review of Patient 13s EMR indicated there were no signatures for the IDGs on 4/23/2024, 4/26/2024, 5/10/2024, and 5/24/2024. The DPCSD stated, ";These IDGs are also missing signatures for the MD, MSW, RN and Chaplain dated 4/23/2024, 4/26/2024, 5/10/2024 and 5/24/2024." E . A review of Patient 6s record untitled admission sheet, indicated a start of care date on 1/30/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). F. A review of Patient 7s record untitled admission sheet, indicated a start of care date on 3/7/2024 with a primary diagnosis of heart disease unspecified (a chronic disease of the heart). G. A review of Patient 8s record untitled admission sheet, indicated a start of care date on 1/22/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. H. A review of Patient 11s record untitled admission sheet, indicated a start of care date on 5/6/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) without heart failure (heart not pumping enough blood for the body). During a concurrent interview and record review on 5/31/2024 at 1:50 p.m. with DPCSD of the Electronic Medical Record (EMR) for Patient 6 IDG dates 1/30/2024-4/29/2024, there were no nursing, physician, or Masters of Social Work (MSW) signatures, from 3/1/2024 to 4/29/2024 there were no signatures from any of the disciples on the IDGs and the IDGs stop on 4/29/2024. DCPSD stated, ";there are no signatures on the IDG for nursing, doctor, and MSW and any of the disciplines after 3/1/2024. And I see how there is no documentation after 4/29/2024. I dont know what happened. The importance of documentation is to update the care plan and have proof that it was done. If there are no signatures it wasnt done." During a concurrent interview and record review on 5/31/2024 at 2:00 p.m. with DPCSD of the Electronic Medical Record (EMR) for Patient 7, IDG dates 3/07/2024-5/19/2024, there were no signatures from any discipline. DCPSD stated, ";there are no signatures from any discipline on any of the IDGs. The importance of documentation is to update the care plan and have proof that it was done. If there are no signatures it wasnt done." During a concurrent interview and record review on 5/31/2024 at 2:05 p.m. with DPCSD of the Electronic Medical Record (EMR) for Patient 8 the IDG dates 1/22/2024-4/29/2024, there were no nursing and MSW signatures, from 1/22/2024 to 3/18/2024, from 4/1/2024 to 4/29/2024 there were no signatures from nursing, physician, and MSW, and the IDGs stop on 4/29/2024. DCPSD stated, ";there are no signatures on the IDG for nursing, and MSW from start of care to 3/18/2024 and only a signature from the chaplain from 4/1/2024 to 4/29/2024. And I see how there is no documentation after 4/29/2024. I dont know what happened. The importance of documentation is to update the care plan and have proof that it was done. If there are no signatures it wasnt done." During a concurrent interview and record review on 5/31/2024 at 2:30 p.m. with DPCSD of the Electronic Medical Record (EMR) for Patient 11 the IDG entry page was blank. DCPSD stated, ";there is no IDG entry period for Patient 11. Not recorded not done." During record review of HAs policy and procedure titled, ";Interdisciplinary Group Meeting", dated November 2022, the policy and procedure indicated, ";The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. 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 an interview, and record review, the Hospice agency (HA) failed to ensure the Condition of Participation for Interdisciplinary Group, Care Planning, and Coordination of Services was met as follows: 1). The HA failed to ensure the Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 11, Patient 12 and Patient 13), were reviewed and updated by interdisciplinary group (IDG, group of healthcare professionals working together to provide patients with the care they need). (Refer to L551) 2). The HA failed to ensure Skilled Nursing Services were provided weekly to one of fourteen sampled patient (Patient 11). (Refer to L584) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the quality of care was provided to the patients who were assessed to receive hospice care and services.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 11, Patient 12, and Patient 13), were reviewed and updated by interdisciplinary group (IDG, group of healthcare professionals working together to provide patients with the care they need). This deficient practice had the potential to affect the quality of care and services needed by the affected patients --- A. A review of Patient 1s untitled admission sheet, indicated a start of care date on 2/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). B. A review of Patient 2s untitled admission sheet, indicated a start of care date on 10/19/2024 with a primary diagnosis of chronic diastolic heart failure (heart not pumping blood properly). C. A review of Patient 3s untitled admission sheet, indicated a start of care date on 4/15/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). D. A review of Patient 4s untitled admission sheet, indicated a start of care date on 3/11/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a concurrent interview and record review on 5/31/2024 at 2:17 p.m. with the Director of Patient Care Services Designee (DPCSD) of the Electronic Medical Record (EMR) for the following patients: -Patient 1, Plan of Care/Interdisciplinary Group Review (POC/IDG) dates of 3/4/2024 and 3/18/2024, there were no nursing, physician, or Masters of Social Work (MSW) signatures, POC/IDG dates of 4/1/2024, 4/15/2024 and 4/29/2024, there were no signatures from any of the disciplines on the IDGs and no documented evidences that IDGs were done on 5/13/2024 and 5/27/2024. DCPSD stated, ";there were no signatures on the IDG for nursing, doctor, and MSW and any of the disciplines on 3/4/2024 to 4/29/2024. DCSD stated that she doesnt know what happened, it may be a system glitched. DPCSD was unable to provide any documented evidence that IDG meetings were held by all the disciplines. DPCSD stated that the importance of documentation is to update the care plan and have proof that it was done, if there were no signatures it was not done. -Patient 2, POC/IDG dates of 2/26/2024, 3/11/2024, 3/25/2024, 4/8/2024 and 4/22/2024 there were no signatures from any discipline. DCPSD stated, ";there were no signatures from any discipline on any of the IDGs. The importance of documentation is to update the care plan and have proof that it was done. If there are no signatures it wasnt done. -Patient 3, no documented evidence that POC/IDG meetings were done since admission on 4/15/2024, P3s clinical record page titled ";History of POC/IDG" page was blank. DCPSD stated she does not know what happened, stated she remembered P3 is included from their last IDG meetings but stated she was unsure why it was not documented in P3s clinical records. DPCSD stated that the importance of documentation is to update the care plan and have proof that it was done, if there were no signatures or entry records, it was not done. -Patient 4, POC/IDG dates of 3/11/2024, 3/14/2024, 3/28/2024, 4/11/2024, 4/25/2024, 5/9/2024 and 5/23/2024 indicated that there were no signatures from any discipline the IDG. DCPSD stated there were no IDG members signatures from the dates mentioned and if not signed then it is not done. DPCSD stated that there were no attendance form to sign by the IDG discipline for every meeting conducted, stated there should have one to provide evidence that meeting and attendance of IDG members were validated. A review of the hospice agencys policy and procedure titled, ";Interdisciplinary Group Meeting", revised November 2022, the policy and procedure indicated, ";Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor". A review of Patient 12s medical record, untitled admission sheet, indicated a start of care date of 5/1/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris with spasms (build up of fats, cholesterol in artery walls, that affects the heart vessels with chest pain and involuntary, abnormal muscular contraction). During a concurrent interview and record review on 5/31/2024 at 3:00 p.m. with DPCSD of Patient 12s Clinical record, titled Initial Comprehensive Assessment and dated 5/8/2024 and 5/22/2024, there were no signature indicating who completed the document. The DPCSD stated, ";LVN 1 did not sign the visit note for Patient 12 on 5/8/2024 and 5/22/2024". Further review of Patient 12s Electronic Medical Record (EMR) indicated there were no signatures for the IDGs on 5/1/2024, 5/4/2024, and 5/18/2024. The DPCSD stated, ";There are missing signatures for the MD, MSW, RN and Chaplain for these IDGs dated 5/1/2024, 5/4/2024, and 5/18/2024." A review of Patient 13s medical record, untitled admission sheet, indicated a start of care date of 4/23/2024 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) without heart failure. During a concurrent interview and record review on 5/31/2024 at 3:05 p.m. with DPCSD of Patient 13s clinical record, titled ";Initial Comprehensive Assessment" and dated 4/23/2024, there were no signature indicating who completed the document. The DPCSD stated, ";There is no RN signature for the Initial Comprehensive Assessment for Patient 13 on 4/23/2024. I am not sure who documented it." Further review of Patient 13s EMR indicated there were no signatures for the IDGs on 4/23/2024, 4/26/2024, 5/10/2024, and 5/24/2024. The DPCSD stated, ";These IDGs are also missing signatures for the MD, MSW, RN and Chaplain dated 4/23/2024, 4/26/2024, 5/10/2024 and 5/24/2024." E . A review of Patient 6s record untitled admission sheet, indicated a start of care date on 1/30/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). F. A review of Patient 7s record untitled admission sheet, indicated a start of care date on 3/7/2024 with a primary diagnosis of heart disease unspecified (a chronic disease of the heart). G. A review of Patient 8s record untitled admission sheet, indicated a start of care date on 1/22/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. H. A review of Patient 11s record untitled admission sheet, indicated a start of care date on 5/6/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) without heart failure (heart not pumping enough blood for the body). During a concurrent interview and record review on 5/31/2024 at 1:50 p.m. with DPCSD of the Electronic Medical Record (EMR) for Patient 6 IDG dates 1/30/2024-4/29/2024, there were no nursing, physician, or Masters of Social Work (MSW) signatures, from 3/1/2024 to 4/29/2024 there were no signatures from any of the disciples on the IDGs and the IDGs stop on 4/29/2024. DCPSD stated, ";there are no signatures on the IDG for nursing, doctor, and MSW and any of the disciplines after 3/1/2024. And I see how there is no documentation after 4/29/2024. I dont know what happened. The importance of documentation is to update the care plan and have proof that it was done. If there are no signatures it wasnt done." During a concurrent interview and record review on 5/31/2024 at 2: 00 p.m. with DPCSD of the Electronic Medical Record (EMR) for Patient 7, IDG dates 3/07/2024-5/19/2024, there were no signatures from any discipline. DCPSD stated, ";there are no signatures from any discipline on any of the IDGs. The importance of documentation is to update the care plan and have proof that it was done. If there are no signatures it wasnt done." During a concurrent interview and record review on 5/31/2024 at 2:05 p.m. with DPCSD of the Electronic Medical Record (EMR) for Patient 8 the IDG dates 1/22/2024-4/29/2024, there were no nursing and MSW signatures, from 1/22/2024 to 3/18/2024, from 4/1/2024 to 4/29/2024 there were no signatures from nursing, physician, and MSW, and the IDGs stop on 4/29/2024. DCPSD stated, ";there are no signatures on the IDG for nursing, and MSW from start of care to 3/18/2024 and only a signature from the chaplain from 4/1/2024 to 4/29/2024. And I see how there is no documentation after 4/29/2024. I dont know what happened. The importance of documentation is to update the care plan and have proof that it was done. If there are no signatures it wasnt done." During a concurrent interview and record review on 5/31/2024 at 2:30 p.m. with DPCSD of the Electronic Medical Record (EMR) for Patient 11 the IDG entry page was blank. DCPSD stated, ";there is no IDG entry period for Patient 11. Not recorded not done." During record review of HAs policy and procedure titled, ";Interdisciplinary Group Meeting", dated November 2022, the policy and procedure indicated, ";The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. 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 interview and record review, the HA failed to ensure skilled nursing services were rendered to one of fourteen sample patients (Patient 11). The deficient practice had the potential to result in patient not receiving necessary nursing care and affect the quality of care. --- A review of Patient 11s record untitled admission sheet, indicated a start of care date on 5/06/2024 with a primary diagnosis of hypertensive heart disease with heart failure (a heart condition caused by long term unmanaged high blood pressure which leads to the inability of the heart to blood pump throughout the body). During a concurrent interview and record review on 5/18/2024 at 2:25 p.m. with Director of Patient Care Services Designee (DPCSD) of the Electronic Medical Record (EMR) for Patient 13 the Skilled Nursing entry visit history page there was no record of skilled nursing visits conducted on the week of 5/13/2024 t0 5/19/20204. DCPSD stated, ";there are no skilled nursing visit notes for Patient 11 for that week. Not sure what happened. We missed this and there are no missed visits documented either." During record review of HAs policy and procedure titled, ";Missed Visits", dated November 2022, the policy and procedure indicated, ";Missed visits will be communicated to the Interdisciplinary Group at the IDG Meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record." The policy further indicated, ";1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor of the missed visit and reason for missed visit B. Document in the patient's clinical record the following information: 1. Patient name 2. Date and type of visit that was missed 3. Reason for the missed visit 4. Description of any unmet needs and how the patient's needs were met 5. Any other follow-up needed 6. Other person(s) that were notified of the missed visit 7. Signature of staff member reporting the information 4. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits."

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Core Services was met as follows: The HA failed to ensure one of fourteen sampled patients (Patient 11) terminal illnesses (an irreversible or incurable disease condition from which death is expected) were coordinated with the primary care physician. (Refer to L590). The cumulative effect of these systemic practices resulted in the HA not providing the core services/care as required and had the potential for the patients not to receive healthcare services that could affect their quality of life.

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure one of fourteen sampled patients (Patient 11) terminal illnesses (an irreversible or incurable disease condition from which death is expected) were coordinated with the primary care physician. This failure resulted in patients receiving hospice services without being certified for hospice care and without the primary care physician coordination which had the potential for patients to receive hospice services when they are not terminally ill. --- A review of Patient 11s admission sheet, indicated a start of care date of 10/2/2024 with diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure with heart failure (heart not pumping enough blood for the body). A review of Patient 11s Electronic Medical Record (EMR) ";Discharge Summary" dated 4/6/2024, indicated Patient 11 was discharged from hospice for Hospitalization. The discharge summary section is blank. There is no signature from any discipline on the document indicating who completed the form. A review of Patient 11s admission sheet, indicated a start of care date of 5/6/2024 with diagnosis of hypertensive heart disease with heart failure. A review of Patient 11's record titled, "Physician's Certification for Hospice Benefit Certification #1: Statement for First 90-day period" dated 5/6/2024,," indicated Certification is based on medical history, record and patient status, and team assessment. During an interview with on 5/29/2024 at 1:15pm with Patient 11, Patient 11 stated her Primary Care Physician who Patient 11 sees regularly is PCP 1. During an observation on 5/29/2024 at 1:20 p.m. at Patient 11s home with Director of Patient Care Services Designee (DPCSD), Patient 11 was observed with no signs or symptoms of edema. DPCSD was observed taking Patient 11's vital signs and Patient 11 blood pressure was 138/84 mmHg (millimeter of mercury a manometric unit of pressure used to measure blood pressure), oxygen saturation (the amount of oxygen in the blood) of 95% on room air. During a phone interview on 5/29/2024 at 2:00 p.m., with Primary Care Physician 1 (PCP 1) stated he had been the primary care physician for Patient 11 since 2019 and sees Patient 11 once a month. PCP 1 stated he was unaware Patient 11 has been enrolled in Hospice. PCP 1 stated Patient 11 is not a candidate for Hospice and does not have a terminal illness. PCP 1 stated Patient 11 is ambulatory, has no shortness of breath, doesnt have heart failure, doesnt use a walker or cane to walk and exercises 5 times a week. PCP 1 stated Patient 11 was hospitalized in April for Pneumonia for a few days but has been back in his office since the hospitalization on 4/23/2024. PCP 1 stated the active diagnosis for Patient 11 are hypertension (high blood pressure), controlled asthma (a respiratory condition marked by spasms in the bronchi of the lungs causing difficulty in breathing), and hyperlipidemia (high cholesterol levels in the blood). PCP1 stated Patient 11 is not on any diuretics (medication that causes the kidney to make more urine) under his care and does not have any issues with shortness of breath or edema (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body). During a record review of office visit for Patient 11 from PCP 1s office, dated 4/23/2024, indicated Patient 11 is ambulatory without dyspnea (shortness of breath). The record further indicated, ";Physical Activity, on average, how many days per week do you engage in moderate to strenuous exercise (like a brisk walk) : 5 days a week. On average, how many minutes do you engage in exercise at this level ? : 30 minutes. Total minutes per week: 150." The document further indicated a cardiovascular (related to or involving the heart and blood vessels) assessment with normal heart sounds and no edema. The document further included respiratory (related to or involving the lungs and breathing) assessment of normal breath sounds in all lung fields. The medication list provided from PCP 1s office did not have any diuretics. During a record review of an email from PCP 1s office, dated 5/29/2024, indicated, "; Per, PCP 1, Patient 11 is not a candidate for Hospice." During a phone interview on 5/30/2024 at m 1:42pm, with Medical Director (MD), when asked how MD certifies patients for hospice, MD stated, ";the patient has to meet lcd criteria, has to have a terminal diagnosis and sudden decline, has less than 6 months to live." When asked if the primary care physician of the patient is contacted, MD stated, ";if there is a community referral, we absolutely communicate with primary care physician (PCP)." When asked if MD reviews any clinical documents for the patients before certifying for hospice, MD stated, ";yes, I review hospital records, history and physical, labs, diagnostic tests, evaluation from nurse. I look at the entire picture. I speak to PCP, conduct a face to face if available." When asked what info do you need to diagnose a patient with heart disease, MD stated "; I look at the functional status, how far the patient can ambulate without having shortness of breath, I look for symptoms of heart failure, history of heart disease, symptoms of edema, fluid in lungs, objective results such as echo (a scan used to look at the heart and nearby blood vessels) if possible, BNP (Brain natriuretic peptide, blood test that measures the levels of a protein hormone in your bloodstream which is produced by the heart and blood vessels and higher levels and indicate heart inability to pump blood throughout the body or heart failure), changes in labs." When asked what criteria is used to determine NYHA class 4 (New York Heart Association classification of heart failure, with class 4 being the most severe stage of heart failure and indicates that patient is unstable to perform any physical activity without discomfort. Patients with Class 4 heart failure experience symptoms even when resting or with minimal exertion, and any physical activity increases their discomfort), MD stated, ";NYHA 4 is more of symptomatic assessment." When asked for Patient 11, what criteria was used to determine heart failure and NYHA 4, MD 1 stated, ";Patient 11 has frequent shortness of breath, difficulty with ambulation. I think Patient 11 is more of NYHA 3 not NYHA 4, Patient 11 also has severe osteoarthritis (degenerative joint disease), really bad shortness of breath, chronic pain, hypertension, hyperlipemia. ";When asked what criteria was used to diagnose heart failure, MD stated, ";I based it on the edema, dependency on diuretics, inability to ambulate without shortness of breath." When asked for patient 11, if the PCP was contacted for information and coordination, MD stated," I dont believe I ever communicated with Patient 11s PCP." When asked if MD reviewed any objective data or clinical records to diagnose patient 11 with heart failure, MD stated, ";I cannot recall, if we have them it should be in the office. We should have reviewed it to diagnose patient 11 with heart failure. Check with the office." During an concurrent interview and record review on 5/31/2024 at 2:30 p.m. with DPCSD, of Patient 11s file, there were no labs, diagnostic tests available for review, and DPCSD stated, ";we dont have any documents for Patient 11, no labs, no diagnostic data." A review of the facility's policy and procedure (P&P) titled, "Medicaid Hospice Benefit," dated November 2022, indicated that an eligibility requirement is to have the attending physician certify prognosis of terminal illness for the first election period. A review of the facility's P & P titled, "Admission Criteria and Process, " dated November 2022, indicated that the HA will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician, if any. The information can be obtained from the hospice nurse or others sharing the attending physicians knowledge of the patient. The patient's physician (or other authorized licensed independent practitioner) must order and approve the provision of hospice care, be willing to sign or have a representative who is willing to sign the death certificate and be willing to discuss the patient's resuscitation status with the patient and family/caregiver.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live), failed to meet the Condition of Participation for organization and administration of services as follows: --- 1.The HA failed to ensure the Director of Patient Care Services Designee (DPCSD) met the requirements and qualifications as indicated in the hospice agencys job description to assumed full responsibility, in the absence of the Director of Patient Care Services (DPCS), for the clinical services and provision of care, for ten of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 11, Patient 12 and Patient 13). 2.The HA failed to ensure that the skilled nurse met the requirements and qualifications as indicated in the agencys job description for the care, services, and continuous assessment of patient health status were provided to ten of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 11, Patient 12 and patient 13) assessed to receive hospice care. (Refer to L651). The cumulative effect of these systemic practices resulted in Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 11, Patient 12 and Patient 13 to not have a continued assessment of the care being provided and had the potential to not identify changes in patients conditions that could affect patients well being. The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Federal regulations for organization and administration of services for patients assessed to received care and services.

Based on interview and record review the Hospice Agency (HA) failed to: 1. Ensure the Director of Patient Care Services Designee (DPCSD) met the requirements and qualifications as indicated in the agencys job description to assumed full responsibility, in the absence of the Director of Patient Care Services (DPCS), for the clinical services and provision of care, for ten of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 11, Patient 12 and Patient 13). 2. Ensure that the skilled nurse met the requirements and qualifications as indicated in the hospice agencys job description for the care, services, and continuous assessment of patient health status were provided to ten of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 11, Patient 12 and patient 13) assessed to receive hospice care. This deficient practice resulted in Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 11, Patient 12 and Patient 13 to not have a continued assessment of the care being provided and had the potential to not identify changes in patients conditions could potentially affect the patients well being. --- Findings: 1a. A review of Patient 1s untitled admission sheet, indicated a start of care date on 2/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). b. A review of Patient 2s untitled admission sheet, indicated a start of care date on 10/19/2024 with a primary diagnosis of chronic diastolic heart failure (heart not pumping blood properly). c. A review of Patient 3s untitled admission sheet, indicated a start of care date on 4/15/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). d. A review of Patient 4s untitled admission sheet, indicated a start of care date on 3/11/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). e . A review of Patient 6s record untitled admission sheet, indicated a start of care date on 1/30/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). f. A review of Patient 7s record untitled admission sheet, indicated a start of care date on 3/7/2024 with a primary diagnosis of heart disease unspecified (a chronic disease of the heart). g. A review of Patient 8s record untitled admission sheet, indicated a start of care date on 1/22/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. h. A review of Patient 11s record untitled admission sheet, indicated a start of care date on 5/6/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) without heart failure (heart not pumping enough blood for the body). i. A review of Patient 12s medical record, untitled admission sheet, indicated a start of care date of 5/1/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris with spasms (build up of fats, cholesterol in artery walls, that affects the heart vessels with chest pain and involuntary, abnormal muscular contraction). j. A review of Patient 13s medical record, untitled admission sheet, indicated a start of care date of 4/23/2024 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) without heart failure. A review of the hospice agencys ";Job Descriptions for Job Title/Position: Clinical Director/Director of Patient Care Services Designee", revised April 2017, indicated position qualifications which include three years of management experience within the last five years in a hospice or related health care organization, at least one year of which was a supervisory or administrative capacity and a registered nurse with four years experience within the last five years in a hospice agency, primary care clinic or health facility, at least one year of which was in a supervisory or administrative capacity. A review of the DPCSD resume in the ";work experience" section, indicated ";New Me MedSpa Head Nurse," with work date from 10/2022 to current. The DPCSD resume indicated that there was no other indication of nursing work experiences related to home health, hospice, or clinical/health facility settings. A review of DPCSDs certificate from the State of California, Board of Registered Nursing, indicated the date of 5/28/2020. During an interview with the DPCSD on 5/31/2024 at 1:12 p.m., she stated that she obtained her licensed as a registered nurse on 5/2020. DPSCD stated that her first nursing job is at the Medical Spa clinic (beauty enhancement clinic). DPCSD stated that she was hire at the hospice agency as a registered nurse on 1/3/2023 and appointed as DPCS designee last month. DPCSD stated that she was not aware of the hospice agencys job requirements and qualifications which she did not meet. DPCSD stated that she has no other nursing or management work experience in home health/hospice or health facility settings for the past five years. DPCSD stated that the management did not discuss with her regarding the job qualifications and requirements. During a telephone interview with the Director of Patient Care Services on 5/31/2024 at 1:31 p.m., the DPCS stated the DPCSD was not qualified based on the agencys job description, the DPCS stated, ";I dont think so." DPCS stated the management has to review the current DPCSDs qualifications to ensure that clinical operations and patient care were not affected. 2. During a review of LVN 1s ";Job Title/Position: Licensed Practical/Vocational Nurse Job Description" dated April 2017, the Job Description indicated, ";Position Qualification of three years nursing experience. Community health/hospice or medical/surgical experience is preferred." During a review of LVN 1s ";Application for Employment" dated 8/29/2022, the employee start date indicated, ";8/29/2022. During a review of LVN 1s ";Board of Vocational Nursing and Psychiatric Technicians Licensing Details" dated 9/1/2022, the Licensing Details indicated, ";issuance date [of] 8/23/2022." On 5/31/2024, at 12:01 p.m., a call was made to LVN1. LVN1 did not answer the call and left message to return the call. During an interview on 5/31/2024 at 1:31 p.m., with the DPCS, the DPCS stated that LVN 1 was not qualified based on the job description. The DON stated, ";I dont think so."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Medical Director was met as follow: --- 1. The HA failed to ensure, the medical director conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial certifications for three of fourteen sampled patients (Patient 2, Patient 3, and Patient 11) to support diagnosis of the patients' terminal illnesses (a health condition that cannot be cured) and to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The HA failed to ensure there were documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice care and services. (Refer to L667). 2. The HA failed to ensure medical director conducted a review and verified the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for one of fourteen sampled patients (Patient 11). (Refer to L 668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory (written law) mandated compliance with Federal regulation for Medical Director services to ensure quality of patient care are provided to the patients certified to receive hospice services.

Based on observation, interview and record review the HA failed to ensure the Medical Director conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial Certification of illness (CTI) to support diagnosis of the patients' terminal illnesses and to qualify for hospice care for three of fourteen sample patients (Patient 2, Patient 3, and Patient 11). The HA has no documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice care and services. The deficient practice resulted in patient being enrolled in hospice and receiving care without a proper verification of patient eligibility and had the potential for Patient 2, Patient 3, and Patient 11 not to received necessary care and healthcare resources to meet their care goals. --- A review of Patient 11s untitled admission sheet, indicated a start of care date of 10/2/2024 with diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure with heart failure (heart not pumping enough blood for the body). During a record review of Patient 11s Electronic Medical Record (EMR) document titled, ";Physicians Certification for Hospice benefit Certification #1: Statement for First 90-day period", dated 10/2/2023 indicated patient was certified to hospice with diagnosis of hypertensive heart disease with heart failure. During a record review of Patient 11s Electronic Medical Record (EMR) ";Discharge Summary" dated 4/6/2024, indicated Patient 11 was discharged from hospice for Hospitalization. The discharge summary section is blank. There is no signature from any discipline on the document indicating who completed the form. During a record review of Patient 11s second untitled admission sheet, indicated a start of care date of 5/6/2024 with diagnosis of hypertensive heart disease with heart failure. During a record review of Patient 11s EMR document titled, ";Physicians Certification for Hospice benefit Certification #1: Statement for First 90-day period" dated 5/6/2024, indicated patient certified for hospice with diagnosis of hypertensive heart disease with heart failure. During record review of Patient 11's EMR document titled, "Physician's Certification for Hospice Benefit Certification #1: Statement for First 90-day period" dated 5/6/2024,," indicated Certification is based on medical history, record and patient status, and team assessment. During an interview with on 5/29/2024 at 1:15pm with Patient 11, Patient 11 stated her Primary Care Physician who Patient 11 sees regularly is PCP 1. During an observation on 5/29/2024 at 1:20 p.m. at Patient 11s home with DPCSD, Patient 11 was observed with no signs or symptoms of edema. DPCSD was observed conducting vital signs for Patient 11 and Patient 11 blood pressure was 138/84 mmHg (millimeter of mercury a manometric unit of pressure used to measure blood pressure), oxygen saturation (the amount of oxygen in the blood) of 95% on room air. During a phone interview on 5/29/2024 at 2:00 p.m., with Primary Care Physician 1 (PCP 1) stated he had been the primary care physician for Patient 11 since 2019 and sees Patient 11 once a month. PCP 1 stated he was unaware Patient 11 has been enrolled in Hospice. PCP 1 stated Patient 11 is not a candidate for Hospice and does not have a terminal illness. PCP 1 stated Patient 11 is ambulatory, has no shortness of breath, doesnt have heart failure, doesnt use a walker or cane to walk and exercises 5 times a week. PCP 1 stated Patient 11 was hospitalized in April for Pneumonia for a few days but has been back in his office since the hospitalization on 4/23/2024. PCP 1 stated the active diagnosis for Patient 11 are hypertension (high blood pressure), controlled asthma (a respiratory condition marked by spasms in the bronchi of the lungs causing difficulty in breathing), and hyperlipidemia (high cholesterol levels in the blood). PCP1 stated Patient 11 is not on any diuretics (medication that causes the kidney to make more urine) under his care and does not have any issues with shortness of breath or edema (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body). During a record review of office visit for Patient 11 from PCP 1s office, dated 4/23/2024, indicated Patient 11 is ambulatory without dyspnea (shortness of breath). The record further indicated, ";Physical Activity, on average, how many days per week do you engage in moderate to strenuous exercise (like a brisk walk) : 5 days a week. On average, how many minutes do you engage in exercise at this level ? : 30 minutes. Total minutes per week: 150." The document further indicated a cardiovascular (related to or involving the heart and blood vessels) assessment with normal heart sounds and no edema. The document further included respiratory (related to or involving the lungs and breathing) assessment of normal breath sounds in all lung fields. The medication list provided from PCP 1s office did not have any diuretics. During a record review of an email from PCP 1s office, dated 5/29/2024, indicated, "; Per, PCP 1, Patient 11 is not a candidate for Hospice." A review of Patient 11s ";LCD Hospice Eligibility Determination" (local coverage determination for Hospice eligibility used by national government services used to determine guidelines for terminally ill patients and if they have a life expectancy of six months or less), dated 5/6/2024, indicated for NYHA classification under A. Does this CHF (congestive heart failure, the heart's capacity to pump blood cannot keep up with the body's need the term congestive refers to the resulting buildup of fluids in the ankles and feet, arms, lungs, and or other organs), or angina patient meet the criteria for NYHA Class 4 (New York Heart Association classification of heart failure, with class 4 being the most severe stage of heart failure and indicates that patient is unstable to perform any physical activity without discomfort. Patients with Class 4 heart failure experience symptoms even when resting or with minimal exertion, and any physical activity increases their discomfort) level? Yes." During a phone interview on 5/30/2024 at m 1:42 p.m., with Medical Director (MD), when asked how MD certifies patients for hospice, MD stated, ";the patient has to meet LCD criteria, has to have a terminal diagnosis and sudden decline, has less than 6 months to live." When asked if the primary care physician of the patient is contacted, MD stated, ";if there is a community referral, we absolutely communicate with primary care physician (PCP)." When asked if MD reviews any clinical documents for the patients before certifying for hospice, MD stated, ";yes, I review hospital records, history and physical, labs, diagnostic tests, evaluation from nurse. I look at the entire picture. I speak to PCP, conduct a face to face if available." When asked what info do you need to diagnose a patient with heart disease, MD stated "; I look at the functional status, how far the patient can ambulate without having shortness of breath, I look for symptoms of heart failure, history of heart disease, symptoms of edema, fluid in lungs, objective results such as echo (a scan used to look at the heart and nearby blood vessels) if possible, BNP (Brain natriuretic peptide, blood test that measures the levels of a protein hormone in your bloodstream which is produced by the heart and blood vessels and higher levels and indicate heart inability to pump blood throughout the body or heart failure), changes in labs." When asked what criteria is used to determine NYHA class 4 (New York Heart Association classification of heart failure, with class 4 being the most severe stage of heart failure and indicates that patient is unstable to perform any physical activity without discomfort. Patients with Class 4 heart failure experience symptoms even when resting or with minimal exertion, and any physical activity increases their discomfort), MD stated, ";NYHA 4 is more of symptomatic assessment." When asked for Patient 11, what criteria was used to determine heart failure and NYHA 4, MD stated, ";Patient 11 has frequent shortness of breath, difficulty with ambulation. I think Patient 11 is more of NYHA 3 not NYHA 4, Patient 11 also has severe osteoarthritis (degenerative joint disease), really bad shortness of breath, chronic pain, hypertension, hyperlipemia. ";When asked what criteria was used to diagnose heart failure, MD stated, ";I based it on the edema, dependency on diuretics, inability to ambulate without shortness of breath." When asked for patient 11, if the PCP was contacted for information and coordination, MD stated," I dont believe I ever communicated with Patient 11s PCP." When asked if MD reviewed any objective data or clinical records to diagnose patient 11 with heart failure, MD stated, ";I cannot recall, if we have them it should be in the office. We should have reviewed it to diagnose patient 11 with heart failure. Check with the office." During a phone interview on 5/30/2024 at 1:50 p.m., with Medical Director (MD), MD was asked about Patient 11s initial physicians certification for hospice benefit, certification #1:first 90 day certification period dated 10/02/2023, then Patient 11 was again certified on 5/6/2024 for physicians certification for hospice benefit, certification #1:first 90 day certification period for a second time , MD stated, ";I am not sure what happened. This is wrong. This was not supposed to be listed as the first 90-day period, since this period was used already. Patient 11 was certified for hospice for a first 90-day period on 10/2/2024. This period was already used, so when Patient 11 was readmitted, the next 60-day certification should have been used for a fourth certification period. This should have been caught." During an interview and concurrent interview and record review on 5/31/2024 at 2:30 p.m. with DPCSD, of Patient 11s file, there were no labs, diagnostic tests available for review, DPCSD stated, ";we dont have any documents for Patient 11, no labs, no diagnostic data." A review of the facility's policy and procedure (P&P) titled, "Medicaid Hospice Benefit," dated November 2022, indicated that an eligibility requirement is to have the attending physician certify prognosis of terminal illness for the first election period. A review of the facility's P & P titled, "Admission Criteria and Process, " dated November 2022, indicated that the HA will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician, if any. The information can be obtained from the hospice nurse or others sharing the attending physicians knowledge of the patient. The patient's physician (or other authorized licensed independent practitioner) must order and approve the provision of hospice care, be willing to sign or have a representative who is willing to sign the death certificate and be willing to discuss the patient's resuscitation status with the patient and family/caregiver. During record review of HAs policy and procedure titled, ";Certification of Terminal Illness", dated November 2022, the policy and procedure indicated, ";At the time of admission to hospice, the hospice Medical Director, physician member of the interdisciplinary team and/or the patient's attending physician will complete a certification narrative that reflects the patients individual circumstances based on: his/her review of the patients medical record or, if applicable, examination of the patient. (The hospice Medical Director, physician member of the interdisciplinary team and/or the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms.) The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election statement." The policy further indicated, ";Tools such as the fiscal intermediary's Local Coverage Determinations, along with other supporting documentation, can be used to provide guidance in determining and documenting terminal prognosis." A. A review of Patient 2s untitled admission sheet, indicated a start of care date on 10/19/2024 with a primary diagnosis of chronic diastolic heart failure (heart not pumping blood properly). A review of Patient 2s clinical record titled ";Comprehensive Assessment", dated 10/19/2023, indicated in the ADL (Activities of Daily Living, activities related to personal care which include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) Assessment the total number of activities with complete dependence (0-6) was 3 out six, which Patient 2 is dependent to ambulation, transfer and bathing. It also indicated that Patient 2 required a cane or walker for movement with maximum assist, has moderate dyspnea (difficulty in breathing) with mild exertion, diminished lung sounds, normal respirations, and edema (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body) in bilateral lower extremities. A review of Patient 2s clinical record titled ";Physicians Certification for Hospice Benefit", with date of certification of 4/16/2024 to 6/14/2024, indicated in the ";LCD (is a decision made by a Medicare Administrative Contractor (MAC) on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the area that the MAC oversees) Determination Status section", -KPS (or Karnofsky Performance Status, is used to determine understanding of patient needs, ability to carry out daily activities and to assess patient prognosis, scores range from 0 to 100, a higher score means the patient is better able to carry out daily activities) still determined at 50%, A review of Patient 2s ";LCD Hospice Eligibility Determination" (local coverage determination for Hospice eligibility used by national government services used to determine guidelines for terminally ill patients and if they have a life expectancy of six months or less), dated 5/16/2024, indicated for NYHA classification under A. Does this CHF (congestive heart failure, the heart's capacity to pump blood cannot keep up with the body's need the term congestive refers to the resulting buildup of fluids in the ankles and feet, arms, lungs, and or other organs), or angina patient meet the criteria for NYHA Class 4 (New York Heart Association classification of heart failure, with class 4 being the most severe stage of heart failure and indicates that patient is unstable to perform any physical activity without discomfort. Patients with Class 4 heart failure experience symptoms even when resting or with minimal exertion, and any physical activity increases their discomfort) level? Yes." During an observation on 5/29/2024 at 11:00 a.m. at Patient 2s home with DPCSD, Patient 2 was observed with no shortness of breath when ambulate to open the entrance door, talks clearly and does not stop in between sentences. DPCSD was observed conducting vital signs for Patient 2 with blood pressure of 142/84 mmHg (millimeter of mercury a manometric unit of pressure used to measure blood pressure), oxygen saturation (the amount of oxygen in the blood) of 92% on room air, Patient 2 appears to have no apparent respiratory distress. During an observation on 5/29/2024 at 11:00 a.m. at Patient 2s home with DPCSD, Patient 2 was observed with no shortness of breath when ambulate to open the entrance door, talks clearly and does not stop in between sentences. DPCSD was observed conducting vital signs for Patient 2 with blood pressure of 142/84 mmHg (millimeter of mercury a manometric unit of pressure used to measure blood pressure), oxygen saturation (the amount of oxygen in the blood) of 92% on room air, Patient 2 appears to have no apparent respiratory distress. B. A review of Patient 3s untitled admission sheet, indicated a start of care date on 4/15/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). A review of Patient 3s clinical record titled ";Comprehensive Assessment", dated 4/15/2024, indicated in the ADL (Activities of Daily Living, activities related to personal care which include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) Assessment the total number of activities with complete dependence (0-6) was 5 out six, which Patient 3 is dependent to ambulation, toileting, transfer, dressing and bathing. It also indicated that Patient 3 required a walker for movement with maximum assist, has mild dyspnea (difficulty in breathing) with mild exertion, clear lung sounds, normal respirations, and no edema (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body). A review of Patient 3s ";LCD Hospice Eligibility Determination" (local coverage determination for Hospice eligibility used by national government services used to determine guidelines for terminally ill patients and if they have a life expectancy of six months or less), dated 5/13/2024, indicated for NYHA classification under A. Does this CHF (congestive heart failure, the heart's capacity to pump blood cannot keep up with the body's need the term congestive refers to the resulting buildup of fluids in the ankles and feet, arms, lungs, and or other organs), or angina patient meet the criteria for NYHA Class 4 (New York Heart Association classification of heart failure, with class 4 being the most severe stage of heart failure and indicates that patient is unstable to perform any physical activity without discomfort. Patients with Class 4 heart failure experience symptoms even when resting or with minimal exertion, and any physical activity increases their discomfort) level? Yes." A review of Patient 3s clinical record titled ";Physicians Certification for Hospice Benefit", with date of certification of 4/15/2024 to 7/13/2024, indicated in the ";LCD (is a decision made by a Medicare Administrative Contractor (MAC) on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the area that the MAC oversees) Determination Status section", -KPS (or Karnofsky Performance Status, is used to determine understanding of patient needs, ability to carry out daily activities and to assess patient prognosis, scores range from 0 to 100, a higher score means the patient is better able to carry out daily activities) of 40%, -PPS (Palliative Performance Scale, is a useful tool for measuring the progressive decline of a patient. It has five functional dimensions: ambulation, activity level and evidence of disease, self-care, oral intake, and level of consciousness, hospice care may be appropriate for patients with a PPS score of less than 70%) of 40%, -NYHA IV (New York Heart Association is the accepted measure of functional capacity in patient with heart failure, in NYHA IV, a patient is unable to carry out any physical activity without discomfort, tired and short of breath even at rest, if any physical activity is undertaken, discomfort increased), -Patient requires maximal assist with 5/6 ADLs (5 out of 6 of Activities of Daily Living which includes ambulation, toileting, transfer, dressing, feeding and bathing) due to generalized weakness and easily fatigued. -Patient has progressive generalized body weakness; ambulates with walker -Patient has episodes of dyspnea (difficulty in breathing) upon exertion, resulting in decrease functional capacity. During a telephone interview with Patient 3 (P3) on 5/30/2024, at 11:04 a.m., P3 verified her name, date of birth, stated she does not know of Family Member 1 (FM1) listed as her emergency contacts, stated she does not know her personally and did not meet her, stated she was referred to hospice agency by her friend that moved out of state already. P3 stated she is at the hospital watching for her 90-year-old aunt to make sure she will not fall from the bed. P3 stated she does not do lifting or turning for her aunt, she calls the nurse if her aunt needed help. P3 stated she come to the hospital to stay with her aunt 6 hours a day for a week now, stated she is the only immediate family of her aunt. P3 stated she uses Lyft ride to bring her to the hospital and to go home. P3 stated she can still walk; she uses walker sometimes. P3 stated she does not use oxygen, stated sometimes she has shortness of breath, chest tightness and weakness but she is still can go out. P3 stated she is under hospice care but stated she does not have a terminal illness and it was not explained or mentioned to her by the nurses. P3 stated from what she understood about hospice is to manage her pain and medications only. P3 stated she can still walk with use of walker sometimes, stated she takes care of herself and does not need help with going to the bathroom, changing clothes, eating, and taking showers. P3 stated she does not know about her diagnosis of heart failure, but stated she has problems with her blood sugar and blood pressure, stated it was not explained to her by the hospice nurses or doctor. P3 stated she signed an informed consent document with the nurse during her admission to hospice, but the nurse did not explained about her terminal illness or diagnosis. P3 stated she signed an informed consent document with the nurse during her admission to hospice but the nurse did not explained about her terminal illness that she has six months or less to live and her diagnosis. During telephone conversation with P3, she has no difficulty in breathing, speaks clearly and does not stop in between sentences. During a phone interview on 5/31/2024 at 12:20 p.m., with Medical Director (MD), MD stated, ";the patient has to meet LCD criteria, has to have a terminal diagnosis and sudden decline, has less than 6 months to live, stated ";if there is a community referral, we absolutely communicate with primary care physician (PCP)." MD stated, ";I review hospital records, history and physical, labs, diagnostic tests, evaluation from nurse. I look at the entire picture. I speak to PCP, conduct a face to face if available." MD stated "; I look at the functional status, how far the patient can ambulate without having shortness of breath, I look for symptoms of heart failure, history of heart disease, symptoms of edema, fluid in lungs, objective results such as echo (a scan used to look at the heart and nearby blood vessels) if possible, BNP (Brain natriuretic peptide, blood test that measures the levels of a protein hormone in your bloodstream which is produced by the heart and blood vessels and higher levels and indicate heart inability to pump blood throughout the body or heart failure), changes in labs. MD stated, ";NYHA 4 is more of symptomatic assessment." MD stated, ";I cannot recall where are the patients clinical records, if we have them it should be in the office. We should have reviewed it to diagnose patients with heart failure. I am disappointed with the lack of coordination of care and communication between the office, nurses and patients ." During an interview and concurrent interview and record review on 5/31/2024 at 2:40 p.m. with DPCSD, of Patient 2 and Patient 3s file, there were no labs, diagnostic tests available for review, DPCSD stated, ";we dont have any documents for Patients 2 and 3, no labs, no diagnostic data." When asked what criteria was used to determine Patients 2 and 3 fit the NYHA 4 classification for heart failure, DPCSD stated, ";Patients symptoms of shortness of breath with ambulation, and lower leg edema." DPCSD stated, ";Patient 3s comprehensive assessments have no clinician signature. DPCSD stated that she did the assessments but forgot to sign it.

Based on interview and record review the Hospice Agency (HA) failed to ensure initial Certification of illness (CTI, the narrative summary, a brief narrative designed to explain clinical findings that support a life expectancy of six months or less) had a physician narrative and was signed by hospice physician for one of fourteen sample patients (Patient 11). The deficient practice resulted in patient being enrolled in hospice and receiving care without a physician authorization, and had the potential for lack of care and services to meet care goals needs. --- Findings: A review of Patient 11s record untitled admission sheet, indicated a start of care date on 10/2/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) without heart failure (heart not pumping enough blood for the body). During a concurrent interview and record review on 5/28/2024 at 2:20 p.m., with DPCSD, Patient 11s Electronic Medical Record (EMR) for Physicians Certification for Hospice benefit Certification was reviewed. Patient 11's EMR Physicians Certification for Hospice benefit Certification indicated that there was no physician signature on the Physicians Certification for Hospice benefit Certification #3: Re-certification Statement for Next 60-day period. During an interview, the DCPSD stated, ";There is no signature on the third certification period CTI by the physician for Patient 11. If its not signed its not done." During a telephone interview on 5/30/2024 at 1:55 p.m., with the Medical Director (MD), the MD stated, ";There is no signature or a physician narrative on the third certification period by a physician for Patient 11. This is not good. There has to be a signature on the Physicians Certification for Hospice benefit by a physician in order to certify for hospice. This should have been caught." During record review of HAs policy and procedure titled, ";Certification of Terminal Illness", dated November 2022, the policy and procedure indicated, ";5. A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient's medical record or, if applicable, examination of the patient. A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than fifteen {15) calendar days prior or two (2) calendar days after the first day of each period. The signed and dated certification must be present prior to billing for each recertification period. 6. The hospice physician or nurse practitioner must have a face-to-face encounter with the patient within the 30 days prior to the 3rd benefit period recertification and within 30 days prior to each subsequent benefit period recertification."

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 the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [is a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) on Clinical Records was met as follows: --- 1. The HA failed to ensure the clinical records for five of fourteen sampled patients (Patient 3, Patient 7, Patient 11, Patient 12, and Patient 13) had signatures on initial comprehensive assessment by the Registered Nurse (RN). (Refer to L679) 2. The HA failed to ensure Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) meetings were signed by all the IDG members for ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 11, Patient 12, and Patient 13). (Refer to L679) 3. The HA failed to ensure the clinical records for one of fourteen sampled patients (Patient 11) had a discharge summary and signature on discharge summary by the RN (Refer to L679, L682). 4. The HA failed to ensure the clinical records for one of fourteen sampled patients (Patient 11) had a signature on the CTI (Certification of Terminal Illness, a hospice physician narrative [brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less]) by the Physician. (Refer to L679) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records were being accurate, complete, signed, and dated by the disciplines furnishing services.

Based on interview and record review, the Hospice Agency (HA) failed to have record entries that were dated and signed in accordance with currently accepted standards of practice and hospice agency policy: 1. The HA failed to ensure the clinical records for five of fourteen sampled patients (Patient 3, Patient 7, Patient 11, Patient 12, and Patient 13) had signatures on initial comprehensive assessment by the Registered Nurse (RN). (Refer to L679) 2. The HA failed to ensure Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) meetings were signed by all the IDG members for ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 11, Patient 12, and Patient 13). (Refer to L679) 3. The HA failed to ensure the clinical records for one of fourteen sampled patients (Patient 11) had a discharge summary and signature on discharge summary by the RN (Refer to L679, L682). 4. The HA failed to ensure the clinical records for one of fourteen sampled patients (Patient 11) had a signature on the CTI, a hospice physician narrative (brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less) by the Physician. (Refer to L679) The deficient practice resulted in patients medical records not being accurate, complete, signed, and dated by the disciplines furnishing services. --- A review of Patient 12s medical record, untitled admission sheet, indicated a start of care date of 5/1/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris with spasms (build up of fats, cholesterol in artery walls, that affects the heart vessels with chest pain and involuntary, abnormal muscular contraction). During a concurrent interview and record review on 5/31/2024 at 3:00 p.m. with DPCSD of Patient 12s Clinical record, titled Initial Comprehensive Assessment and dated 5/8/2024 and 5/22/2024, there were no signature indicating who completed the document. The DPCSD stated, ";LVN 1 did not sign the visit note for Patient 12 on 5/8/2024 and 5/22/2024". Further review of Patient 12s Electronic Medical Record (EMR) indicated there were no signatures for the IDGs on 5/1/2024, 5/4/2024, and 5/18/2024. The DPCSD stated, ";There are missing signatures for the MD, MSW, RN and Chaplain for these IDGs dated 5/1/2024, 5/4/2024, and 5/18/2024." A review of Patient 13s medical record, untitled admission sheet, indicated a start of care date of 4/23/2024 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) without heart failure. During a concurrent interview and record review on 5/31/2024 at 3:05 p.m. with DPCSD of Patient 13s clinical record, titled ";Initial Comprehensive Assessment" and dated 4/23/2024, there were no signature indicating who completed the document. The DPCSD stated, ";There is no RN signature for the Initial Comprehensive Assessment for Patient 13 on 4/23/2024. I am not sure who documented it." Further review of Patient 13s EMR indicated there were no signatures for the IDGs on 4/23/2024, 4/26/2024, 5/10/2024, and 5/24/2024. The DPCSD stated, ";These IDGs are also missing signatures for the MD, MSW, RN and Chaplain dated 4/23/2024, 4/26/2024, 5/10/2024 and 5/24/2024." A. A review of Patient 1s untitled admission sheet, indicated a start of care date on 2/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). B. A review of Patient 2s untitled admission sheet, indicated a start of care date on 10/19/2024 with a primary diagnosis of chronic diastolic heart failure (heart not pumping blood properly). C. A review of Patient 3s untitled admission sheet, indicated a start of care date on 4/15/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). D. A review of Patient 4s untitled admission sheet, indicated a start of care date on 3/11/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a concurrent interview and record review on 5/31/2024 at 2:17 p.m. with the Director of Patient Care Services Designee (DPCSD) of the Electronic Medical Record (EMR) for the following patients: -Patient 1, Plan of Care/Interdisciplinary Group Review (POC/IDG) dates of 3/4/2024 and 3/18/2024, there were no nursing, physician, or Masters of Social Work (MSW) signatures, POC/IDG dates of 4/1/2024, 4/15/2024 and 4/29/2024, there were no signatures from any of the disciplines on the IDGs and no documented evidences that IDGs were done on 5/13/2024 and 5/27/2024. DCPSD stated, ";there were no signatures on the IDG for nursing, doctor, and MSW and any of the disciplines on 3/4/2024 to 4/29/2024. DCSD stated that she doesnt know what happened, it may be a system glitched. DPCSD was unable to provide any documented evidence that IDG meetings were held by all the disciplines. DPCSD stated that the importance of documentation is to update the care plan and have proof that it was done, if there were no signatures it was not done. -Patient 2, POC/IDG dates of 2/26/2024, 3/11/2024, 3/25/2024, 4/8/2024 and 4/22/2024 there were no signatures from any discipline. DCPSD stated, ";there were no signatures from any discipline on any of the IDGs. The importance of documentation is to update the care plan and have proof that it was done. If there are no signatures it wasnt done. -Patient 3, no documented evidence that POC/IDG meetings were done since admission on 4/15/2024, P3s clinical record page titled ";History of POC/IDG" page was blank, clinical record titled ";Comprehensive Assessment", dated 4/15/2024 indicated no clinician signature. DCPSD stated Patients comprehensive assessment has no signature, she does not know what happened, stated she remembered P3 is included from their last IDG meetings but stated she was unsure why it was not documented in P3s clinical records. DPCSD stated that the importance of documentation is to update the care plan and have proof that it was done, if there were no signatures or entry records, it was not done. -Patient 4, POC/IDG dates of 3/11/2024, 3/14/2024, 3/28/2024, 4/11/2024, 4/25/2024, 5/9/2024 and 5/23/2024 indicated that there were no signatures from any discipline the IDG. DCPSD stated there were no IDG members signatures from the dates mentioned and if not signed then it is not done. DPCSD stated that there were no attendance form to sign by the IDG discipline for every meeting conducted, stated there should have one to provide evidence that meeting and attendance of IDG members were validated. A review of the hospice agencys policy and procedure titled, ";Interdisciplinary Group Meeting", revised November 2022, the policy and procedure indicated, ";Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor". E. A review of Patient 6s record untitled admission sheet, indicated a start of care date on 1/30/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). During a concurrent interview and record review on 5/31/2024 at 1:50 p.m. with DPCSD of the Electronic Medical Record (EMR) for Patient 6 IDG dates 1/30/2024-4/29/2024, there were no nursing, physician, or Masters of Social Work (MSW) signatures, from 3/1/2024 to 4/29/2024 there were no signatures from any of the disciples on the IDGs and the IDGs stop on 4/29/2024. DCPSD stated, ";there are no signatures on the IDG for nursing, doctor, and MSW and any of the disciplines after 3/1/2024. And I see how there is no documentation after 4/29/2024. I dont know what happened. The importance of documentation is to update the care plan and have proof that it was done. If there are no signatures it wasnt done." F. A review of Patient 7s record untitled admission sheet, indicated a start of care date on 3/7/2024 with a primary diagnosis of heart disease unspecified (a chronic disease of the heart). During a concurrent interview and record review on 5/31/2024 at 2:00 p.m. with DPCSD of the Electronic Medical Record (EMR) for Patient 7, IDG dates 3/07/2024-5/19/2024, there were no signatures from any discipline. DCPSD stated, ";there are no signatures from any discipline on any of the IDGs. The importance of documentation is to update the care plan and have proof that it was done. If there are no signatures it wasnt done." During further review of Patient 7s clinical record titled Comprehensive Assessment, dated 3/7/2024, there was no signature on from a clinician. DPCSD stated, ";Patient 7s comprehensive assessment doesnt have a clinician signature. If its not signed we cant tell who did it or if it was done." G. A review of Patient 8s record untitled admission sheet, indicated a start of care date on 1/22/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. During a concurrent interview and record review on 5/31/2024 at 2:05 p.m. with DPCSD of the Electronic Medical Record (EMR) for Patient 8 the IDG dates 1/22/2024-4/29/2024, there were no nursing and MSW signatures, from 1/22/2024 to 3/18/2024, from 4/1/2024 to 4/29/2024 there were no signatures from nursing, physician, and MSW, and the IDGs stop on 4/29/2024. DCPSD stated, ";there are no signatures on the IDG for nursing, and MSW from start of care to 3/18/2024 and only a signature from the chaplain from 4/1/2024 to 4/29/2024. And I see how there is no documentation after 4/29/2024. I dont know what happened. The importance of documentation is to update the care plan and have proof that it was done. If there are no signatures it wasnt done." H. A review of Patient 11s record untitled admission sheet, indicated a start of care date on 5/6/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) without heart failure (heart not pumping enough blood for the body). During a concurrent interview and record review on 5/28/2024 at 2:20 p.m. with DPCSD of Patient 11s Electronic Medical Record (EMR) there was no physician signature on the Physicians Certification for Hospice benefit Certification #3: Re-certification Statement for Next 60-day period. DCPSD stated, ";There is no signature on the third certification period CTI by the physician for Patient 11. If its not signed its not done." During a phone interview on 5/30/2024 at 1:55 p.m. with MD, MD stated, ";There is no signature or a physician narrative on the third certification period by a physician for Patient 11. This is not good. There has to be a signature on the Physicians Certification for Hospice benefit by a physician in order to certify for hospice. This should have been caught." During a concurrent interview and record review on 5/31/2024 at 2:30 p.m. with DPCSD of Patient 11s EMR, the IDG entry page was blank. DCPSD stated, ";there is no IDG entry period for Patient 11. Not recorded not done." During a concurrent interview and record review on 5/31/2024 at 2:33pm with DPCSD, Patient 11s EMR ";Discharge Summary" dated 4/6/2024, indicated Patient 11 was discharged from hospice for Hospitalization. The discharge summary section is blank. There is no signature from any discipline on the document indicating who completed the form. DPCSD stated, ";there is no discharge summary or clinician signature on Patient 11s discharge summary. This was missed. Not documented not done." During a concurrent interview and record review on 5/31/2024 at 2:35 p.m. of Patient 11's clinical record titled Comprehensive Assessment, dated 5/6/2024 with DPCSD there is no clinician signature. DPCSD stated, ";Patient 11s comprehensive assessment doesnt have a clinician signature. If its not signed we cant tell who did it or if it was done." A review of the facilitys policy titled, ";Contents of Clinical Record," dated November 2022, indicated, ";The following information will be available in the clinical record, as applicable to care and services provided: Y. Discharge summary and other summary reports sent to the physician, as required by law, regulation, and organization policy." A review of the facilitys policy titled, ";Entries Into the Clinical Record", dated November 2022, the policy indicated, ";1. A clinical record will be initiated and maintained for each patient receiving care services, according to the organization policies found in the manual, and will include at a minimum: D. initial plan of care, updated plan of care initial, comprehensive and updated comprehensive assessment and clinical notes E. Dates, times, and types of interventions, assessments, and coordination of care." The policy further indicated, ";7. Signature authorization of clinical documentation will include the staff members name and credentials as specified on professional licenses and or certification documents. 8. Initials will be used on forms where authentication signature space is designated on the form. 9. All entries in the clinical record will reflect the date care was provided, including the month, day, and year."

The HA failed to ensure the clinical records for one of fourteen sampled patients (Patient 11) had a discharge summary and signature on discharge summary by the RN. The deficient practice resulted in patient's medical records not being accurate, complete, signed, and dated by the discipline furnishing services. --- A review of Patient 11s admission sheet, indicated a start of care date of 10/2/2024 with diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure with heart failure (heart not pumping enough blood for the body). A review of Patient 11s Electronic Medical Record (EMR) ";Discharge Summary", dated 4/6/2024, indicated Patient 11 was discharged from hospice for Hospitalization. The discharge summary section was blank. There was no signature from any discipline on the document indicating who completed the form. During an interview on 5/31/2024 at 2:33 p.m. with the DPCSD, the DPCSD stated, ";There is no discharge summary or clinician signature on Patient 11s discharge summary. This was missed. Not documented, not done." A review of the facilitys policy titled, ";Contents of Clinical Record," dated November 2022, indicated, ";The following information will be available in the clinical record, as applicable to care and services provided: Y. Discharge summary and other summary reports sent to the physician, as required by law, regulation, and organization policy." A review of the facilitys policy titled, ";Entries Into the Clinical Record", dated November 2022, the policy indicated, ";1. A clinical record will be initiated and maintained for each patient receiving care services, according to the organization policies found in the manual, and will include at a minimum: D. initial plan of care, updated plan of care initial, comprehensive and updated comprehensive assessment and clinical notes; E. Dates, times, and types of interventions, assessments, and coordination of care." The policy further indicated, ";7. Signature authorization of clinical documentation will include the staff members name and credentials as specified on professional licenses and or certification documents. 8. Initials will be used on forms where authentication signature space is designated on the form. 9. All entries in the clinical record will reflect the date care was provided, including the month, day, and year."

Observed in Tracer Activities. The organization did not protect the privacy of health information. During contract review, it was noted that contracts did not have a HIPAA business associate agreement where the contracted organization would have access to HIPAA protected patient information. This was confirmed by the QAPI director.

Observed in Individual Tracer. The organization did not asses and manage the patient's pain. During home visit 2 it was observed that the nurse did not assess the patients level of pain or assess the patient's desired level of pain relief. This was confirmed by the RN.

Observed in Record Review. The written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. During review of the record associated with home visit 1, it was noted that the goals were dated to be met ten and a half months after the admission date. This was confirmed by the QAPI Director.

Observed in Record Review. In 8 of 15 patient records reviewed, The plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: - Interventions to manage pain and symptoms - A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs - Measurable outcomes anticipated from implementing and coordinating the plan of care - Medications and treatment necessary to meet the patient’s needs - Medical supplies and appliances necessary to meet the patient’s needs During review of the records associated with home visits 2 and 3 and records 4, 5, 6, 7, 8,and 10 it was noted that the care plan did not include all interventions and goals to manage the patient's symptoms. For example, in the record associated with home visit 2, the patient who had a primary diagnosis of CHF had no cardiac intervention or goals in the plan of care and in record 4, the patient who had dyspnea had no respiratory goals or interventions in the plan of care. This was confirmed by the QAPI Director.

Observed in Record Review. In 3 of 3 patient records reviewed, The patient record was not complete, and promptly and accurately documented. During review of discharge records 12, 13,and 14 it was noted that all the patients were discharged with revocation and documentation reflected a stable patient. The reason documented for revocation was to pursue aggressive treatment. Prior to the discharge date there was no documentation of discussion with the patient and family as to desire for aggressive treatment and all visits for these patients in the two months leading up to discharge demonstrated patients being comfortable and stable. There was no documentation explaining the changes leading up to desire for aggressive treatment such as symptom crises or desire for non-palliative approaches. This was confirmed by the Office Manager.

Observed in Record Review. The hospice did not inform the attending physician of the availability of a discharge summary. The discharge summary is provided to the practitioner upon the their request and includes the patient's medical and health status at the time of discharge, During review of discharge record 11 it was noted that there was no documentation of the discharge summary being provided to the physician. This was confirmed by the Office Manager.

Observed in Record Review. In 2 of 7 patient records reviewed, the hospice interdisciplinary group did not update the comprehensive care plan at least every 15 days. Upon review of RR#2 documentation was noted in the record of issues with sleeplessness and the subsequent IDG did not address the issue. Further in RR#2 and RR#4 the IDG summaries by the RN were noted to be extensive and nearly identical each IDG, making it difficult to note any update in the comprehensive assessment discussed with the IDG team. These observations were discussed with the MSW and Office Manager.

Observed in Individual Tracer. In 3 of 3 patient records reviewed, the hospice did not advise patients upon admission of non covered items, services, and or drugs. Based on a review of the consent forms completed by RR#1, RR#2, and RR#3- they did not document that these patients were given the option to be notified or decline notification of non covered items. By the conclusion of the survey, the manager secured a blank copy of the correct consent form for non covered items and the declination form. These observations were discussed with the director.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, the hospice did not perform a bereavement risk assessment upon admission to the program. RR#1 did not have a bereavement risk assessment completed in the record. This observation was discussed with the director.

Observed in Individual Tracer. In 3 of 3 patient records reviewed, the hospice interdisciplinary group did not update the comprehensive care plan at least every 15 days. RR#2 had a change in a cardiac medication, and the subsequent IDG did not describe the effectiveness of the new medication. Additionally, there were multiple IDG(s) that were not attended by either the MD, MSW, Chaplain, or the RN in RR1, RR#2 and RR#3. This was based on a review of the IDG signature pages that were missing the signatures of this core group. These observations were discussed with the director.

Observed in Individual Tracer. In 1 of 1 home visits conducted, the hospice care plan/update to care plan did not reflect the medication that the patient was currently taking. Per the daughter of RR#1 a medication for constipation and a cardiac medication were discontinued over two weeks ago. The patient was being seen at least weekly by a nurse and the care plan was not updated. This observation was discussed with the director.

Observed in Individual Tracer. In 1 of 1 patient records reviewed, the hospice RN did not supervise the hospice aide at least every 14 days. RR#2 had an aide but no documentation of the supervision of the aide for a two month period. This was discussed with the director.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: 418.100, 418.102, 418.52, 418,54 418.76, and 418.104

Observed in Individual Tracer. In 3 of 3 patient records reviewed, the hospice did not obtain objective medical data to support the hospice diagnosis. For example, there was no history and physical from the referring doctor, copy of lab results, and or xrays for RR#1, RR#2, and RR#3. These observations were discussed with the director.

Observed in Individual Tracer. In 3 of 3 patient records reviewed, the LVN did not appropriately authenticate her visit notes as per policy # 5-006.1 titled Entries Into the Clinical Record. There were multiple visit notes identified in RR#1, RR#2, and RR#3 that were not signed by the LVN who made the visits. These visits occurred over a month ago. The surveyor noted in RR#3, a RN signed off on behalf of the LPN effective the date of the survey. This visit was made by the LPN three weeks ago.