Every finding on record at Santa Yekaterina Hospice, Inc.

Based on observation, interview and record review, the hospice staff failed to review all medications the patients were taking and update the medication profiles with the currently used medications for one of eight sampled patients (Patient 13). This deficient practice had the potential to place the patient at risk for adverse drug reactions medication errors. --- A review of Patient 13's clinical record indicated Patient 13 was admitted to the hospice agency on 8/22/2022, with diagnoses that included Carcinoma of the left bronchus and lung. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 9/21/2022 indicated the following: 1). Skilled Nurse (SN) to visit Patient 13 once a week and three additional visits as needed. 2). Medical Social Worker (MSW) to visit once a month and two additional visits as needed. 3). Chaplain to visit once a month and two additional visits as needed. 4). Hospice aide service was declined. On 10/18/2022, at 12:40 p.m., Patient 13's home visit was conducted with Registered Nurse 1 (RN 1) at Patient 13's home. Patient 13 was sitting in a chair, and Family member 1 was next to the patient. At 1:30 p.m., during Patient 13's medication review with RN 1 and a comparison with the "Current treatment/Medication/DME list", the following discrepancies were noted between the actual medications and the "Current treatment/Medication/DME list." 1. Patient 13 had a bottle of Levothyroxine 100 microgram (mcg) on hand while Levothyroxine 125 mcg was listed on the medication profile. During an interview with Patient 13 and Family Member at the same time, they stated the Levothyroxine dosage had been lowered from 125 mcg to 100 mcg three months ago. 2. Patient 13 had a bottle of Valsartan 40 mg dated 5/13/2022, which noted to take one tablet once a day while on the medication profile it indicated to take Valsartan 40 mg twice a day. During an interview with Patient 13 and the Family member at the same time, they stated Patient 13 had been taking Valsartan 40 mg one tablet once a day since 5/13/2022. 3. Patient 13 did not have Vitamin B 12 1000 mg on hand, but it was indicated on the medication profile to take one tablet daily. During an interview with Patient 13 and the Family member at the same time, both stated Vitamin B12 had been discontinued four months ago. During an interview with RN 1 on 10/18/2022, at 1:40 p.m., he stated he had not checked Patient 13's medications compared with the "Current treatment/Medication/DME list" since Patient 13s admission. He stated he should have checked the medications each visit and clarified with the physician. A review of the agency's policy titled "Medication Profile" revised in November 2021 indicated the medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen.

Based on interview and record review, the hospice agency failed to ensure the interdisciplinary group (IDG) developed a plan of care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for two of eight sampled patients, (Patient 2, 14) by failing to: a. Develop the discharge POC for Patient 2 to assess the needs and assist the patient for a safe discharge. b. Develop a plan of care in the care and management of Patient 14 who has dialysis schedules and an AV (arteriovenous, a vascular access surgically created in the vein used during hemodialysis). This deficient practice had the potential to result in inappropriate and unsafe discharge, and poor-quality care and services, which can potentially affect the highest practicable physical, mental and psychosocial well-being of the affected patients. --- a. A review of Patient 2's clinical record indicated Patient 2 was admitted to the hospice agency on 7/19/2022, with diagnoses of hypertensive heart disease with heart failure and discharged on 10/5/2022. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 9/21/2022 indicated the Skilled Nurse (SN) was to visit once a week and three visits as needed, the Medical Social Worker (MSW) was to visit once a month and two visits as needed, the chaplain service was declined. The hospice aide service was not indicated. A review of the Comprehensive Nursing Assessment dated 7/19/2022 indicated Patient 2 was an 86 years old female, alert and oriented x 3 with episodes of forgetfulness, was able to make her needs known. Patient 2 had episodes of chest pains that were relieved by rest and medication, and had mild shortness of breath with light activities. A review of the Discharge Summary dated 10/5/2022 indicated Patient 2 was an 86 years old female, alert and oriented x 3 with episodes of forgetfulness, and was able to make her needs known. Patient 2 had episodes of chest pains that were relieved by rest and the medication, and had mild shortness of breath with light activities. Patient 2 was having conflict with her family at the moment. Patient's family member would like to discontinue the hospice services until further notice. A review of Patient 2's record indicated there was no documented evidence Patient 2's discharge plan was developed from the admission to the discharge. On 10/19/2022, at 1:30 p.m., during an interview with the Director of Patient Care Services (DPCS), she was not able to provide the documented evidence Patient 2's discharge plan was developed, and stated it should have been developed before discharge. A review of the agency's policy titled "Discharge from Hospice Program" revised in November 2021 indicated the hospice Interdisciplinary group will develop a discharge plan which includes the possibility that a patient's condition might stabilize or change such that the patient cannot be certified as terminally ill. b. A review of Patient 14s clinical records indicated the start of care date was 7/26/22, with terminal diagnosis of Hypertensive heart disease with heart failure (is a condition that develops over many years in people who have high blood pressure, heart failure and conduction arrhythmias or irregular heart rhythms) and comorbidities which includes renal failure (is a condition in which one or both of the kidneys are no longer work on their own), hyperlipidemia (means the blood has too many lipids or fats, such as cholesterol and triglycerides), GERD (Gastroesophageal reflux disease, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach esophagus), Chronic Diarrhea ( three or more loose stools daily for at least several weeks with many possible causes) and hypercalcemia ( is a condition in which the calcium level in your blood is above normal). A review of Patient 14s Recertification Assessment dated 9/21/22, indicated in the nurses narrative notes that patient 14 has dialysis scheduled on Tuesdays, Thursdays, Saturdays and has an AV shunt port (A vascular access is a surgically created vein used to remove and return blood during hemodialysis) located on left arm. A review of Patient 14s ";Plan of care (POC)/ Interdisciplinary Group (IDG)" dated 10/5/22, indicated an SN visit frequency of once a week and three visit as needed for shortness of breath, change of condition or severe pain, Medical Social Worker visit once a month and two as needed visits for psychosocial issues and Spiritual Counselor (SC) visit once a month and two as needed visits for spiritual issues. However, the POC did not indicate about dialysis (is a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly, It often involves diverting blood to a machine to be cleaned) and AV shunt management such as ongoing assessment of port site, appearance, bruits (a rumbling sound that can hear on AV shunt location by using a stethoscope) and thrills (a rumbling sensation that can feel when palpate), proper site to check blood pressure. During an interview with the Director of Patient Care Services (DPCS) on 10/19/22, at 2:00 p.m., she was not able to provide the documented evidence dialysis and AV shunt care management was included in the POC. The DPCS stated the dialysis and AV shunt care management should have been included in the POC. A review of the agency's policy and procedure titled "The Plan of Care", undated, indicated the plan of care will identify the patient's needs and services to meet those needs.

Based on observation, interview and record review the hospice agency failed to ensure "Comfort Kits" (hospice emergency kit) were made available at the patients homes and appropriate medication refills were provided for two (2) of eight (8) sampled patients, (Patient 13 and 15). This failure had the potential to result in the delay in the management of the affected patients emergency, and the potential for the affected patients not to receive their medications timely and as ordered by the physician. --- b. A review of Patient 13's clinical record indicated Patient 13 was admitted to the hospice agency on 8/22/2022, with diagnoses of Carcinoma of left bronchus and lung. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 9/21/2022 indicated the Skilled Nurse (SN) was to visit once a week and three visits as needed, the Medical Social Worker (MSW) was to visit once a month and two visits as needed, the chaplain was to visit once a month and two visits as needed, and the hospice aide service was declined. A review of Patient 13's "Current treatment/Medication/DME list" indicated there was a physician's order (dated 8/22/2022) for Comfort kit including following: 1. Atropine 1 % solution 5 milliliters (ml) 2 drops every 4 hours for excess secretion. 2. Bisacodyl - suppository 10 milligram (mg) one rectally as needed for constipation.3. Compazine 25 mg one suppository every 12 hours as needed for nausea/vomiting4. Morphine Sulfate (20 mg/ml) 0.25 to 0.5 ml orally every 3-4 hours as needed for moderate to severe pain and breathlessness.5. Tylenol 650 mg suppository every 4-6 hours as needed for pain/temperature of 100 degree Fahrenheit (F) and above. On 10/18/2022, at 12:40 p.m., Patient 13's home visit was conducted with Registered Nurse 1 (RN 1) at Patient 13's home.Patient 13 was sitting in a chair, and Family member 1 was next to the patient. At 1:30 p.m., when Patient 13's medications were reviewed with RN 1, the Comfort kit was not found at the patient's house. During an interview with RN 1, Patient 13 and Family member 1 at the same time, they stated the agency did not provide a Comfort Kit to Patient 13. RN 1 stated the Comfort kit was not provided to Patient 13 because Patient 13 did not need it, and it could be dangerous to leave the Comfort kit at Patient 13's home due to possible misuse by other persons at home. During an interview with the Director of Patient Care Services (DPCS) on 10/19/2022, at 1:30 p.m., she stated the Comfort kit should have been provided to all the patients upon admission including Patient 13. A review of the agency's policy titled "Hospice Comfort Kits" updated May 2022 indicated the hospice nurse performing the hospice admission will contact the Hospice Medical Director at the time of admission for orders about specific emergency medications to be supplied in a Comfort kit for every patient admitted to the agency. The pharmacy will fill orders for Comfort kits. The hospice primary nurse will follow with education to the patient and family and ensure the Comfort kit medications are listed on the medication list in the patient's chart. a. A review of patient 15s admission record indicated the patient was admitted to the Hospice Agency (HA) on 7/26/22, with a primary diagnosis of Cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). A review of patient 15s plan of care (POC)/Interdisciplinary group (IDG) Review dated 10/5/22 indicated a Skilled Nurse (SN) routine visit once a week and additional 3 PRN (as needed) visits, Medical Social Worker (MSW) visit once a month and additional 2 PRN visits and declined Spiritual counselor (SC) visit. On 10/18/2022, at 2:00 p.m., during a joint home visit with Registered Nurse 2 (RN 2), Patient 15 was observed sitting on a chair, alert, awake and oriented, well-groomed, and pleasant. When asked about comfort kit medications, Patient 15 stated that she never received her comfort kit medications. A review of patient15's medications compared with the medication profile indicated following medications were not found and had empty bottles at the patient's residence. 1. Lorazepam 0.5 mg, one tablet orally every 8 hours as needed for anxiety. 2. Amlodipine 5 mg, one tablet orally daily for hypertension/angina. 3. Aspirin chewable 81 mg, one tablet orally daily for prophylaxis for Cerebrovascular accident/stroke 4. Clopidogrel 75 mg, one tablet orally daily at morning for blood thinner. 5. Folic acid 1mg, one tablet orally daily for supplement. 6. Hydrocodone-acetaminophen 5/325 mg, one tablet orally every 6 hours as needed not to exceed 4 grams in 24 hours for moderate to severe pain. 7. Levothyroxine 137 mcg (microgram), one tablet orally daily for thyroid hormone. 8. Trazadone 50mg, one tablet orally at bedtime for restlessness. 9. Melatonin 5mg, one capsule orally at bedtime as needed. 10. Zolpidem 10 mg, one tablet orally daily at bedtime as needed for insomnia if melatonin is ineffective. During an interview on 10/18/22 at 2:30 p.m., with patient 15, stated that she is out of those medications that have empty bottles for several days but unsure for how many exact days, and did not know regarding comfort kit. Patient 15 stated that she did not receive the comfort kit since her admission to hospice care. During an interview on 10/19/22 at 10:00 a.m., RN 2 stated that he does medication reconciliation during each visit. RN 2 stated from his last visit dated 10/13/22, there were few medications left on the empty bottles and RN 2 stated that he called hospice agency office to order for patient 15s medication refills but there were no documented evidences that medication refills were made on 10/13/22 to 10/17/22. RN 2 stated that patient should have a comfort kit but unsure why patient 15 was not provided a comfort kit. RN 2 stated that he should have included comfort kit in his medication reconciliation. During an interview on 10/19/22 at 10:30 a.m., with the Director of Patient Care Services (DPCS), DPCS stated that the agency nurse should have checked the medications in the comfort kit and should have educated patient 15 to notify the office if she has not received any of her medications yet. DPCS stated that the nurses usually call the office for patients medication refills and office will fax request of medication refills to contracted pharmacy to process. A review of contracted pharmacy delivery receipt indicated that last delivery was made on 9/22/22 with patient 15s proof of receipt signature for the following medications: Melatonin 5 mg capsule quantity of 30 capsules, Zolpidem 10 mg tablet quantity of 30 tablets, and Lorazepam 0.5 mg tablet quantity of 60 tablets. The hospice agency was unable to provide documented policy and procedure related to medication refills.

Based on observation, interview, and record review, the hospice agency failed to ensure that the Condition of Participation regarding Patients' rights was met as follows: 1. The hospice agency failed to inform two of 12 patients, (Patients 8 and 10) of their rights by providing written information before admission. These patients had their own primary care physician but were admitted to the hospice agency by the attending physician from hospice without explanation or being offered the choice of retaining their own primary care physicians. The primary care physicians were not consulted regarding the patient's life expectancy, lack of terminal illness, and qualifications for the Medicare hospital benefit (refer to L521) The cumulative effect of these systemic practices resulted in the hospice agency's failure to protect the rights of admitted patients, who did not qualify for the Medicare hospice benefits.

Based on observation, interview, and record, the hospice agency failed to conduct an accurate comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patient's current health status, patients' need for hospice care and services related to hospice eligibility and management of terminal illness for two of 12 sampled patients, (Patients 8 and 10). These deficient practices resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential that patients are not receiving the appropriate healthcare services that could affect their quality of life. Findings: a. A review of Patient 8's electronic clinical record indicated a start of hospice care date of 11/17/2020, with a terminal diagnosis of Hypertensive heart disease without heart failure ( a heart condition caused by high blood pressure which causes the heart to work under ncreased pressure.) . A review of Patient 8's "Physician's Certification for Hospice Benefit" for the tenth 60- day recertification period from 7/10/2022 to 9/7/2022, indicated Patient 8's hypertensive heart disease without heart failure. There was no documented evidence the hospice agency's medical director or the hospice attending physician had communicated with the patient's primary physician to certify that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course." A review Patient 8's "Initial Nursing Assessment" visit by the Registered Nurse (RN), dated 11/17/2020, indicated Patient 8 was alert, requires bed, wheelchair bound and requires maximum assistance with standing, requires oxygen at two (2) liters per minute (LPM) as needed, with activities up as tolerated. A review of Patient 8's "Initial orders and Plan of Care" dated 11/17/2021, indicated the Skilled Nurse (SN) visit frequency was once a week and two visits as needed for symptom management, oxygen at 2 LPM as needed, and for the SN to check oxygen saturation as needed for shortness of breath (SOB), to call MD if oxygen saturation less than 88% (per cent), nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/caregiver care plan/intervention in collaboration with interdisciplinary team (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities). The RN completed the patient's initial orders and Plan of Care, but there was no signature of the agency's physician, that would indicate that the plan of care and initial orders was reviewed by the agency's physician. A review of Patient 8's "Local Coverage Determination Hospice Eligibility Determination" form (LCD, provides guidance in determining medical necessity of services) indicated that Patient 8 has a history of unexplained syncope/fainting. b. A review of Patient 10's electronic clinical record, indicated a start of hospice care date 7/22/2022, with terminal diagnoses of heart failure unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet body needs). A review of patient 10's "Physician's Certification Hospice Benefit'' for the first 90 -day period, from 7/22/2022 to 10/19/2022, indicated, Patient 10's terminal diagnoses was atherosclerosis (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow). There was no documented evidence the hospice agency's attending physician communicated with the patient's primary physician, to certify that Patient 10 had a life expectancy of 6 months or less, "if the terminal illness runs it normal course." A review of Patient 10's "Initial Nursing Assessment" by RN dated 7/22/2022, indicated Patient 10 was oriented, but forgetful at times, able to do most of her activities of Daily living (ADL) but someone has to be with her at all times, with episodes of chest pain at least twice a week and per daughter, Patient 10 has lost a lot of weight but how much, was unknown. A review of patient 10's "Initial orders and Plan of Care" dated 11/17/2021, indicated the SN visit frequency was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). The RN completed Patient 10's admission orders for the initial orders and Plan of Care, but has no signature of the agency's physician that would indicate that the agency's physician review and verify the patient clinical information. A review of patient 10's LCD Hospice Eligibility determination indicate patient 10 had a history of unexplained syncope/fainting. . On 9/12/22 at 2:02 a.m., during a telephone interview with the hospice agency's Medical Doctor (MD) in the conference room, regarding determining hospice criteria, he stated he reviews the supporting evidence to determine hospice eligibility from records from the admitting Registered Nurse (RN). The Hospice agency's MD conducts a face to face visit and based on the documentation from the skilled nurse assessment, in the patients chart, and his assessment, qualifies the patients for hospice. The hospice agency's MD stated, he has not viewed the hospital records from primary doctors, labs, diagnostic records, reviews the chart and that maybe, they need to incorporate that procedure, before admitting the patients to hospice. The MD stated, he thought the staff notified the patient's primary physician. During an interview and concurrent patient record review with the CFO (Chief Financial Officer) and DPCS in the hospice agency's conference room on 9/16/2022, at 3:30 p.m., regarding determining hospice criteria, they stated they receive supporting evidence from the hospital or primary physician which consist of the hospital, records from primary doctors, labs, diagnostic records, reviews the chart to ensure the patients meet the hospice criteria. On 9/16/2022 at 3:40 p.m., this surveyor had requested the DPCS and CFO to provide all supporting evidence, such as labs, records from the primary doctor, diagnostic results that the MD stated he reviewed for the sample patients, but the DPCS and the CFO were unable to find the requested documents. A review of the hospice agency's policy and procedure on " Admission Criteria and process revised April 2018, stipulates, " Referral information provide by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician office will assist in the determination of eligibility for admission to the program. If the request for services is not made by the patient's physician, he/she will be consulted prior to the evaluation visit/initiation of services."

Based on interview and record review, the hospice agency failed to ensure that the governing body or the Administrator assumed full legal responsibility for the management of the hospice, the provision of all hospice services, continuous quality assessment and performance improvement, and appointed a qualified administrator and Director of Patient Care Services designee to run the day to day operation of the hospice. Findings: On 9/12/22, at 10:45 a.m., during an interview with the Chief Financial Officer(CFO)/ Human Resource staff stated the hospice agency does not have an active Administrator and the DPCS designee hired few months ago has not been appointed by the governing body. The CFO stated the CEO was in the process of appointing her as the administrator however, he is out of the country and she was has not taken the training to be qualified as the administrator at this time. The CFO and the DPCS, stated the hospice agency did not have governing body or a quality assessment and performance improvement program. Review of the hospice agency's job description of Executive Director/Administrator dated 11/2017, stipulates, "The Executive Director/Administrator is responsible for the overall direction of the day to day operations of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy."

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows: 1. The hospice agency failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, reviewing, and verifying patient clinical information necessary for initial certification and recertification of terminal illness for four of 12 sampled patients (Patient 2, 3, 8, and 10). (Refer L 669) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on observation, interview and record review, the hospice agency failed to ensure, the agency's medical director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, review, and verify patient clinical information necessary for initial certification and recertification of terminal illness. This deficient practice resulted in the hospice medical director and/or the hospice attending physician certifying patients with inaccurate terminal diagnoses, without documentation of clinical evidence to support the diagnoses, as required by the Federal regulations. Findings: a. A review of Patient 3's Personal Information Sheet (Face Sheet) indicated a start of care (SOC) date of 7/19/22, with a primary diagnosis of Hypertensive heart disease (high blood pressure) without heart failure. There is no other diagnosis listed on the Face Sheet. A review of Patient 3's Comprehensive Nursing Assessment, dated 7/19/22, under the section "Nature and Condition of Terminal Illness/LCD Eligibilty", indicated that Patient 3's terminal illness of heart disease was reported by the patient, no medical history was used as evidence. It also stated that Patient 3 did not have any ER visits or hospitalizations in the last 12 months and does not need any assistance with walking, toileting, transfers, dressing, feeding, or bathing. A review of Patient 3's Physician's Certification for Hospice Benefit (CIT), for the first 90 day period from 7/19/22-10/16/22, indicated that the medical doctor (MD) certified that Patient 3 has a life expectancy of six months or less, if the illness runs its normal course. There are three options that the MD can check off to identify what the certification is based on ... 1. Medical history, record and patient status 2. Team Assessment 3. Face to face encounter None of the options are checked off and there is no physician narrative note indicating that a face to face visit was conducted. A review of Patient 3's Local Coverage Determination (LCD)Hospice Eligibility Determination sheet, (undated), indicated that Patient 3 has a history of treatment-resistant symptomatic supraventricular or ventricular arrhythmias (irregular heart rhythms that can cause symptoms such as chest pain, dizziness, pounding heartbeat, lightheadedness, and shortness of breath) and unexplained fainting. Although, there was no documentation found in Patient 3's medical record to support the stated history. b. A review of Patient 2's Face Sheet indicated a SOC of 7/19/22, with a diagnosis of hypertensive heart disease with heart failure (chronic condition where heart does not pump blood as well as it should). A review of Patient 2's Comprehensive Nursing Assessment, dated 7/19/22, under the section "Nature and Condition of Terminal Illness/LCD Eligibilty", indicated that Patient 3's terminal illness of heart disease was reported by the patient and family, no medical history was used as evidence. It also stated that Patient 3 did not have any ER visits or hospitalizations in the last 12 months. Patient 2 needs assistance with walking, toileting, transfers, dressing, feeding, or bathing. A review of Patient 2's Physician's Certification for Hospice Benefit (CIT), for the first 90 day period from 7/19/22-10/16/22, indicated that the medical doctor (MD) certified that Patient 3 has a life expectancy of six months or less, if the illness runs its normal course. There are three options that the MD can check off to identify what the certification is based on ... 1. Medical history, record and patient status 2. Team Assessment 3. Face to face encounter None of the options are checked off and there is no physician narrative note indicating that a face-to-face visit was conducted. A review of Patient 2's Local Coverage Determination (LCD) Hospice Eligibility Determination sheet, (undated), indicated that Patient 2 has a history of of unexplained fainting. Although, there was no documentation found in Patient 3's medical record to support the stated history. h. A review of Patient 8's electronic clinical record indicated a start of hospice care date of 11/17/2020, with a terminal diagnosis of Hypertensive heart disease without heart failure ( a heart condition caused by high blood pressure which causes the heart to work under ncreased pressure.) . A review of Patient 8's "Physician's Certification for Hospice Benefit" for the tenth 60- day recertification period from 7/10/2022 to 9/7/2022, indicated Patient 8's hypertensive heart disease without heart failure. There was no documented evidence the hospice agency's medical director or the hospice attending physician had communicated with the patient's primary physician to certify that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course." A review Patient 8's "initial Nursing Assessment" visit by the RN, dated 11/17/2020, indicated Patient 8 was alert, requires bed/wheelchair bound and requires maximum assistnce , with standing, requires oxygen at 2 liters per minute (LPM) as needed, with activities up as tolerated/ A review of Patient 8's "Initial orders and Plan of Care" dated 11/17/2021, indicated the SN visit frequency was once a week and two visits as needed for symptom management, oxygen at 2 LPM as needed, and for the SN to check oxygen saturation as needed for shortness of breath (SOB), to call MD if oxygen saturation, less than 88% nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). The RN completed the patient's initial orders and Plan of Care, but there has no signature of the agency's physician, that would indicate that the plan of care and initial orders was reviewed by the agency's physician. A review of Patient 8's " LCD Hospice Eligiblility Determination indicated pthat patient 8 has a history of unesplained syncope/fainting. i. . A review of Patient 10's electronic clinical record, indicated a start of hospice care date 7/22/2022, with terminal diagnoses of heart failure unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet body needs). A review of patient 10's "Physician's Certification Hospice Benefit'' for the first 90 -day period, from 7/22/2022 to 10/19/2022, indicated, patient 10's terminal diagnose was atherosclerosis(the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow). There has no documented evidence the hospice agency's attending physician communicated with the patient's primary physician, to certify that patient 10 had a life expectancy of 6 months or less, "if the terminal illness runs it normal course." A review of patient 10's "initial Nursing Assessment" by RN dated 7/22/2022, indicated patient 10 was oriented x 3 , but forgetful at times, able to do most of her activities of Daily living (ADL) but someone has to be with her at all times, with episodes of chest pain at least twice a week and per daughter patient 10 has lost a lot of weight but how much unknown. A review of patient 10's "Initial orders and Plan of Care" dated 11/17/2021, indicated the SN visit frequency was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). The RN completed Patient 10's admission orders the initial orders and Plan of Care, but has no signature of the agency's physician that would indicate that the agency's physician review and verify the patient clinical information. A review of patient 10's LCD Hospice Eligibility determination indicate patient 10 had a history of unexplained syncope/fainting. On 9/12/22 at 2:02 p.m., during a telephone interview with the hospice agency's Medical Doctor (MD) in the conference room of the hospice agency regarding determining hospice criteria, he stated he reviews the supporting evidence to determine hospice from records from the admitting Registered Nurse (RN). The Hospice agency's MD conducts a face to face visit and based on the documentation from the skilled nurse assessment in the patients chart and his assessment, qualifies the patients for hospice. The hospice agency's MD stated, he has not viewed the hospital, records from primary doctors, labs, diagnostic records, reviews the chart and that maybe they need to incorporate that procedure, before admitting the patients to hospice. The MD stated, he thought the staff notified the patient's primary physician. During an interview and concurrent patient record review with the CFO and DPCS in the hospice agency's conference room on 9/16/2022, at 3:30 p.m., regarding determining hospice criteria, they stated they receive supporting evidence from the hospital or primary physician which consist of the hospital, records from primary doctors, labs, diagnostic records, reviews the chart to ensure the patients meet the hospice criteria. On 9/16/2022 at 3:40 p.m., requested the DPCS and CFO to provide all supporting evidence, such as labs, records from the primary doctor, diagnostic results that the MD stated he reviewed for the sample patients, but the DPCS and the CFO were unable to find the requested documents. A review of the hospice agency's policy and procedure on " Admission Criteria and process revised April 2018, stipulates, " Referral information provide by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician office will assist in the determination of eligibility for admission to the program. If the request for services is not made by the patient's physician, he/she will be consulted prior to the evaluation visit/initiation of services."

Based on observation and interview, the hospice agency failed to ensure RN 1 provided a sanitary environment by following current standards of practice of placing a protective barrier between his backpack,changing gloves and washing his hands and re-gloving, while providing care to 2 of 12 sample residents ( Patient 1 and 11) and sanitizing his equipment. This deficient practice had the potential for increase in transmission of infection and communicable diseases. Findings: a. A review of Patient 1's Personal Information sheet (Face Sheet) indicated a start of care (SOC) date of 2/25/22, with a primary diagnosis of chronic kidney disease (CKD), stage 4 (kidneys are severely damaged and are not working as well as they should to filter waste from the blood). A review of Patient 1's Physician's Certification for Hospice Benefit, for the 3rd certification period from 8/24/22-10/22/22, indicated a terminal diagnosis of CKD, stage 4 and requires care for all activities of daily living. A review of Patient 1's Plan of Care, dated 9/8/22, indicated that the patient will receive visits from the skilled nursing (SN) once a week and three as needed visits for shortness of breathe, chang of condition, and severe pain. On 9/8/22, at 10:00 am a skilled nursing visit was conducted at the skilled nursing facility where Patient 1 lives. The registered nurse (RN 1) was observed preforming a physical assessment on Patient 1. RN 1 used his own equipment to preform the assessment which included a blood pressure machine, thermometer and oxygen saturation monitor. After use, RN 1 did not clean his equipment before placing back in his carrying case. b. On 9/12/22, a review of Patient 11's electronic clinical record, indicated a start of hospice care date of 5/21/2022, with terminal diagnoses of Liver cell carcinoma. A review of Patient 11's "Physician's Certification Hospice Benefit'' for the 8th 60 -day period, from 8/4/22 to 10/22/22, indicated Patient 11's terminal diagnosis was Liver cell carcinoma prognosis and worsening co-morbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted those services of hospice comfort care, pain management and symptom management only." A review of the Patient 11's "initial Nursing Assessment" visit by RN dated 5/1/2022, , indicated Patient 11 was oriented, wheelchair bound with left below the knee amputee and right above the knee amputee and requires assistance for his personal hygiene and needs. A review of Patient 11's " Plan of Care" dated 9/8/22, indicated the SN visit frequency was twice a week and three visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). A review of Patient 11's " Summary/Plan/Support Diagnosis, indicated " Patient was admitted to hospice under routine level of care for comfort, pain management and symptom management . During a joint home visit with RN 1 and the Director of patient care services (DPCS) at the skilled nursing facility . RN 1 was observed laying his backpack directly with no protective barrier inbetween, on patient 11's bedside table, washing his hands, putting gloves on , taking patient 11's vital signs/skin assessment and then wiping his stethoscope, temperature monitor, O@ saturation device with alcohol and the same gloves he did the assessment of patient 11 and placing his equipment back in his bag while still wearing the same gloves. During an interview with the DPCS on 9/122022, at 3:30 p.m., she stated RN one should have used a protective barrier between his backpack and Patient 11's bedside table and should have removed gloves, washed his hands and re-gloved after caring/assessing patient 11. Review of the hospices agency's policy and procedure titled "Bag Technique" revised November 2021, stipulates, " Paper towels/newspapers used as protective barrier for bag placement fn the patients home will be discarded . when the visit is complete reusable equipment will be cleaned using alcohol and/or soap and water as appropriate, hands will be washed and equipment and supplies will be returned. Hands will be decontaminated prior to returning clean equipment to bag."