Every finding on record at Silver Palm Hospice, Inc.

Based on observation, 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 Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) regarding Patients Rights was met as follows: 1. The HA failed to provide two of 14 sampled patients (Patient 10, and Patient 11) information of their rights and responsibilities in a language preferred and understood by the patients provided hospice care services. (Refer to L502) 2. The HA failed to inform five of 14 sampled patients (Patient 1, Patient 2, Patient 9, Patient 10, and Patient 11) about the services the HA provided and its specific limitations of these services. (Refer to L519) The cumulative effect of these systemic practice resulted in the failure of the hospice to deliver statutorily mandated Federal compliance for Patients Rights to ensure their rights are not violated and receive the highest quality of hospice care.

Based on interview, and record review, the Hospice Agency (HA) failed to provide two of 14 sampled patients (Patient 10, and Patient 11) information of their rights and responsibilities in a language preferred and understood by the patients provided hospice care services. This deficient practice has the potential to result in patients' lack of understanding of the pertinent (appropriate) information regarding care and services provided by the hospice that could impact patients quality of care and wellbeing. --- Findings: a. A review of Patient 10s admission record indicated a start of care (SOC) date of 7/6/2023 with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 10/19/2023, indicated the frequency of visits of the licensed vocational nurse (LVN) and hospice aide to one visit per week, the registered nurse (RN) and spiritual counselor (SC) to one visit per month plus 1 prn (pro re nata, which means ";as needed") visits, and the social worker (MSW) to visit once every 2 weeks plus 1 prn visits. During a telephone interview on 11/8/2023, at 10:05 a.m., with Patient 10, stated he had a folder provided by the HA at home. Patient 10 stated inside the folder was a lot of forms that he signed but did not understand and could not read any of it because all the forms inside the hospice folder were written in English. Patient 10 stated his preferred language was Spanish. b. A review of Patient 11s admission record indicated a start of care date of 5/19/23 with a terminal diagnosis of chronic diastolic congestive heart failure (a condition in which your heart's main pumping chamber [left ventricle] becomes stiff and unable to fill properly). A review of Patient 11's POC/IDG form, dated 10/19/23, indicated the frequency of visits of licensed vocational nurse to one visit per week plus 1 prn visit, hospice aide to 1 visit per week, and the registered nurse, spiritual counselor and the social worker to one visit per month plus 1 prn visits. During a telephone interview on 11/8/2023, at 10:05 a.m., with Patient 11, stated she had a folder provided by the HA at home. Patient 11 stated inside the folder was a lot of forms that he signed but did not understand and could not read any of it because all the forms inside the hospice folder were written in English. Patient 11 stated her preferred language was Spanish. During a concurrent interview and record review on 11/9/2023, at 12:05 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the admission forms provided to Patient 10 and Patient 11 were in English language, which included the signed consent forms and patient rights and responsibilities. DPCS stated all forms in the folder provided to hospice patients should be in the language the patients understood. During a review of the agencys undated policy and procedure titled, ";Patient Bill of Rights/Responsibilities", indicated each patient will be an active, informed participant in his/her plan of care. The patient Bill of Rights/Responsibilities will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand.

Based on observation, 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 inform five of 14 sampled patients (Patient 1, Patient 2, Patient 9, Patient 10, and Patient 11) about the services the HA provided and the limitations of these services. This deficient practice resulted in the violation of the patients' rights to be fully informed about the purpose of the hospice care services and its specific limitations. --- c. A review of Patient 9s admission record indicated a start of care (SOC) date of 8/18/23 with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Patient 9's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 10/19/23, indicated the frequency of visits of licensed vocational nurse (LVN) and social worker (MSW) to 1 visit per week plus 3 prn (pro re nata, which means ";as needed") visits, hospice aide to one visit per week, and the spiritual counselor (SC) to one visit per month plus 1 prn visit. During a joint home visit on 11/8/23, at 11:35 a.m., with the Licensed Vocational Nurse 1 (LVN 1) at Patient 9s residence, Patient 9 was observed sitting on a sofa, awake, alert but confused. During an interview on 11/8/23, at 11:45 a.m., with Patient 9s family member (FM 1), FM 1 stated her understanding of what hospice service was ";palliative care" and that if Patient 9 needs emergency care, she would call paramedics to bring Patient 9 to acute care hospital. Patient 9 further stated no doctor or nurses told her that Patient 9 had six months or less to live and that it would be insensitive if someone would tell her that. d. A review of Patient 10s admission record indicated a start of care (SOC) date of 7/6/23 with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Patient 10's POC/IDG form, dated 10/19/23, indicated the frequency of visits of licensed vocational nurse and hospice aide to one visit per week, the registered nurse and spiritual counselor to one visit per month plus 1 prn (pro re nata, which means ";as needed") visits, and the social worker to visit once every 2 weeks plus 1 prn visits. During a telephone interview on 11/8/23 at 10:05 a.m., with Patient 10, Patient 10 stated no doctor or nurses told him that he had six months or less to live, that he walks around the neighborhood regularly and feels okay. Patient 10 stated he did not know that hospice care was for those patients with terminal illness. e. A review of Patient 11s admission record indicated a start of care date of 5/19/23 with a terminal diagnosis of chronic diastolic congestive heart failure (a condition in which your heart's main pumping chamber [left ventricle] becomes stiff and unable to fill properly). A review of Patient 11's POC/IDG form dated 10/19/23, indicated the frequency of visits of licensed vocational nurse to one visit per week plus 1 prn visit, hospice aide to 1 visit per week, and the registered nurse, spiritual counselor and the social worker to one visit per month plus 1 prn visits. During a telephone interview on 11/8/23 at 10:05 a.m., with Patient 11, Patient 11 stated no doctor or nurses told her that she has terminal illness or that she was dying. Patient 11 stated hospice care is for those that needs medication and being visited by a nurse every week. During a review of the hospice agencys undated policy and procedure titled, ";Patient Bill of Rights/Responsibilities", indicated each patient will be an active, informed participant in his/her plan of care. The Patient Bill of Rights/Responsibilities statement defines the right of the patient to be informed in advance of service about the care to be furnished, the organizations scope of services and services under the Medicate Hospice Benefit and any limitations on these services. Findings: A review of Patient 1s admission record indicated a start of care (SOC) date of 9/15/23, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 10/19/23, indicated the frequency of visits of licensed vocational nurse (LVN) and hospice aide to one visit per week, the registered nurse (RN), and the social worker (MSW) to visit once every 2 weeks plus 1 prn visits. On 11/8/23, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 2. Patient 1 was observed walking on a steady gait without the use of an assistive device. During an interview with Patient 1, Patient 1 stated she was never told that she had six months or less to live or never explained regarding the hospice services being rendered. Patient 1 stated she drives her husband to go to his MD appointment. Patient 1 further stated that she never had an attending physician and her friend referred her to this hospice agency. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 9/25/23, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 10/19/23, indicated the frequency of visits of licensed vocational nurse (LVN) and hospice aide to one visit per week, the registered nurse (RN), and the social worker (MSW) to visit once every 2 weeks plus 1 prn visits. On 11/8/23, at 11 a.m., a home visit was conducted at Patient 2's residence with LVN 2. Patient 2 was observed sitting on a couch at the living room with a walker parked next to him. During an interview with Patient 2, Patient 2 stated he was never told that he had six months or less to live or never explained regarding the hospice services being rendered. Patient 2 further stated that he never had an attending physician and his friend referred him to the hospice agency.

Based on observation, interview and record review, the Hospice Agency failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of the Patient was met as follows: --- 1. The hospice agency failed to provide initial bereavement assessment (assessing participants and grieving families to ensure that appropriate bereavement services are provided through the continuum of care from enrollment through the year following the death of the participant) for four of 14 sampled patients (Patient 8, Patient 9, Patient 10, and Patient 12). (Refer to L531) 2. The hospice agency staff failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status, and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness for five of 14 sampled patients (Patient 1, Patient 2, Patient 10, Patient 11, and Patient 12). (Refer to L532) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on interview and record review, the hospice agency failed to provide initial bereavement assessment (assessing participants and grieving families to ensure that appropriate bereavement services are provided through the continuum of care from enrollment through the year following the death of the participant) for four of 14 sampled patients (Patient 8, Patient 9, Patient 10, and Patient 12). This deficient practice had the potential to impact the family members' abilities to cope with the patients' death. --- a. During a review of Patient 8's admission record indicated a start of care (SOC) date of 8/18/2023, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). During a review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 8/24/23, indicated the frequency of visits of licensed vocational nurse (LVN) to 1 visit per week plus 1 prn (pro re nata, which means ";as needed") visit, hospice aide to one visit per week, and the spiritual counselor (SC) and the social worker (MSW) to one visit per month plus 1 prn visit. A review of Patient 8's clinical record indicated that there was no initial bereavement assessment (assessing participants and grieving families to ensure that appropriate bereavement services are provided through the continuum of care from enrollment through the year following the death of the participant) conducted since the SOC on 8/18/2023. b. During a review of Patient 9s admission record indicated a start of care date of 8/18/2023 with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). During a review of Patient 9's POC/IDG form, dated 10/19/2023, indicated the frequency of visits of licensed vocational nurse to 1 visit per week plus 3 prn (as needed) visits, hospice aide to one visit per week, and the spiritual counselor and the social worker to one visit per month plus 1 prn visit. A review of Patient 9's clinical record indicated that there was no initial bereavement assessment conducted since the SOC on 8/18/2023. c. During a review of Patient 10s admission record indicated a start of care date of 7/6/2023 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 10's POC/IDG form, dated 7/13/2023, indicated the frequency of visits of licensed vocational nurse to one visit per week plus 3 prn visit, hospice aide to one visit a week, and the registered nurse, spiritual counselor and social worker to one visit per month plus 1 prn visit. A review of Patient 10's clinical record indicated that there was no initial bereavement assessment conducted since the SOC on 7/6/2023. d. During a review of Patient 12s admission record indicated a start of care date of 8/1/2023 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 12's POC/IDG form dated 8/10/2023, indicated the frequency of visits of licensed vocational nurse to one visit per week plus 3 prn visits, hospice aide to 1 visit per week, and the spiritual counselor and the social worker to one visit per month plus 1 prn visit. A review of Patient 12's clinical record indicated that there was no initial bereavement assessment conducted since the SOC on 8/1/2023. During a concurrent interview and record review on 11/9/23 at 12:05 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that a bereavement assessment should be conducted on admission. The DPCS further stated that Patient 8, Patient 9, Patient 10, and Patient 12 did not have an initial bereavement assessment conducted on admission. During a review of the agency's undated policy and procedure titled "Bereavement Plan," indicated bereavement care and services are an integral part of the total hospice program. Hospice bereavement service, provided by qualified staff and volunteers, begin with the initial assessment and continue through the bereavement period to help the patient/family cope with death-related grief and loss issues.

Based on observation, interview, and record review, the Hospice Agency (HA) staff failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status, and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness for five of 14 sampled patients (Patient 1, Patient 2, Patient 10, Patient 11, and Patient 12). This deficient practice resulted in the hospice agency certifying patients who did not meet the criteria required to receive the hospice benefits and service management of terminal illness that could affect their quality of life. --- e. A review of Patient 10s admission record indicated a start of care (SOC) date of 7/6/2023 with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). Patient 10's face sheet indicated the hospice Medical Director (Physician 1) was also the patient's referring and attending physician. A review of Patient 10's Comprehensive Nursing 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), dated 7/6/2023, indicated Patient 10 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related (anything that's connected or related to the heart) pain, no edema (swelling in parts of your body because of fluid trapped in your tissues, most often in your feet, ankles and legs), had normal respirations (breathing), mild dyspnea (difficult or labored breathing) with mild exertion, and requires minimum assistance only with ambulation, toileting, transfer, dressing, and bathing. The Comprehensive Nursing Assessment further indicated Patient 10 was on NYHA Stage II of heart failure (New York Heart Association Class II –mild symptoms, with mild shortness of breath and/or angina [chest pain or discomfort] and slight limitation during ordinary activity). The LCD Guidelines (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits eligibility) for hospice eligibility for heart disease indicated patients should meet criteria for NYHA Class IV level (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) and not NYHA Class II to qualify for hospice service. A review of Patient 10's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) from 7/6/2023 to 10/3/2023, indicated Patient 10's terminal diagnosis was hypertensive heart disease with heart failure. The Medical Director indicated Patient 10 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 10 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 10s terminal illness diagnosis. A review of Patient 10s LCD Hospice Eligibility Determination form for Heart Disease, dated 7/6/23, indicated Patient 10 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 10 was optimally treated for heart disease with diuretics (medications that are useful in treating heart failure, a condition in which the body holds too much water) and vasodilators (medicines that useful in managing high blood pressure). Section 2 was marked "yes" that Patient 10s heart disease met the criteria for NYHA Class IV level. A review of Patient 10's clinical record indicated there was no documented evidence Patient 10 was optimally treated for heart disease with diuretics and vasodilator. There was no documentation Patient 10 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 11/8/2023, at 9:39 a.m., Patient 10 stated no doctor or nurses told him that he had six months or less to live and did not know that hospice care was for those patients with terminal illness. Patient 10 further stated he was not dying and has been walking around his neighborhood without any assistance. During a concurrent interview and record review on 11/9/2023 at 12:05 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 10 was optimally treated for heart disease with diuretics and vasodilator. The DPCS stated there was no documented evidence Patient 10 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. f. A review of Patient 11s admission record indicated a start of care date of 5/19/2023 with a terminal diagnosis of chronic diastolic congestive heart failure (a condition in which your heart's main pumping chamber [left ventricle] becomes stiff and unable to fill properly). Patient 11's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. A review of Patient 11's Comprehensive Nursing Assessment, dated 5/19/2023, indicated Patient 11 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related pain, no edema, had normal respirations, regular pulse rate (heart rate), mild dyspnea with mild exertion, and requires minimum assistance only with ambulation, toileting, transfer, dressing, and bathing. The Comprehensive Nursing Assessment further indicated Patient 11 was on NYHA Stage II of heart failure. The LCD Guidelines for hospice eligibility for heart disease indicated patients should meet criteria for NYHA Class IV level and not NYHA Class II to qualify for hospice service. A review of Patient 11's "Physician Certification for Hospice Benefit" from 5/19/2023 to 8/16/2023, indicated Patient 11's terminal diagnosis was chronic diastolic congestive heart failure. The Medical Director indicated Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 11s terminal illness diagnosis. A review of Patient 11s LCD Hospice Eligibility Determination form for heart disease, dated 5/19/23, indicated Patient 11 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 11 has declined surgical procedures and was optimally treated for heart disease with diuretics and vasodilators. Section 2 was marked "yes" that Patient 11s heart disease met the criteria for NYHA Class IV level. A review of Patient 11's clinical record indicated there was no documented evidence Patient 11 had declined any surgical procedures or was optimally treated for heart disease with diuretics and vasodilator. There was no documentation Patient 11 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 11/8/2023 at 9:42 a.m., with Patient 11, Patient 11 stated no doctor or nurses told her that she has terminal illness or that she was dying. Patient 11 stated hospice care is for those that needed medications and being visited by a nurse every week. During a concurrent interview and record review on 11/9/2023 at 12:05 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 11 had declined surgical procedure or was optimally treated for heart disease with diuretics and vasodilator. The DPCS stated there was no documented evidence Patient 11 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. g. During a review of Patient 12s admission record indicated a start of care date of 8/1/2023 with a terminal diagnosis of hypertensive heart disease without heart failure. Patient 12's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. During a review of Patient 12's Comprehensive Assessment, dated 8/1/2023, indicated Patient 12 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related pain, no edema, had normal respirations, regular pulse, and required moderate assistance with bathing, transferring and ambulation, and minimum assistance with dressing, feeding and toileting. The Comprehensive Nursing Assessment further indicated Patient 12 was on NYHA Stage II of heart failure. The LCD Guidelines for hospice eligibility for heart disease indicated patients should meet criteria for NYHA Class IV level and not NYHA Class II to qualify for hospice service. A review of Patient 12's "Physician Certification for Hospice Benefit" from 8/1/2023 to 10/29/2023, indicated Patient 12's terminal diagnoses was hypertensive heart disease without heart failure. The Medical Director indicated Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 12s terminal illness diagnosis. A review of Patient 12s LCD Hospice Eligibility Determination form for Heart Disease, dated 8/1/2023, indicated Patient 12 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 12 was optimally treated for heart disease with diuretics and vasodilators. Section 2 was marked "yes" that Patient 12s heart disease met the criteria for NYHA Class IV level. A review of Patient 12's clinical record indicated there was no documented evidence Patient 12 was optimally treated for heart disease with diuretics and vasodilator. There was no documentation Patient 12 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 11/8/2023, at 2:40 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Patient 12 was alert, oriented x 3 (to person, place, and time), lives alone and can manage herself at home. LVN 2 stated Patient 2s blood pressure has been controlled with medications, has no shortness of breath at rest, never complained of any chest pain and was ambulatory using a cane or a walker. During a concurrent interview and record review on 11/9/2023 at 12:05 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 12 was optimally treated for heart disease with diuretics and vasodilator. The DPCS stated there was no documented evidence Patient 12 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a review of the agencys undated policy and procedure titled "Admission Criteria and Process", indicated hospice agency will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of six months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). HA will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. During a review of the agencys policy and procedure titled ";Certification of Terminal Illness", revised November 2021, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. Findings: a. A review of Patient 1s admission record indicated a start of care (SOC) date of 9/15/2023, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). Patient 1's clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 1's Physicians Certification for Hospice Benefit, dated 9/15/2023 to 12/13/2023, benefit period, indicated Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 11/8/2023, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 2. Patient 1 was observed walking on a steady gait without a use of assistive device. During an interview with Patient 1, Patient 1 stated she was never told that she had six months or less to live or never explained regarding the hospice services being rendered. Patient 1 stated she drives her husband to go to his MD appointment. Patient 1 further stated that she never had an attending physician and her friend referred her to the hospice agency. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 9/25/2023, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). Patient 2's clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 2's Physicians Certification for Hospice Benefit, dated 9/25/2023 to 12/23/2023, benefit period, indicated Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 11/8/2023, at 11 a.m., a home visit was conducted at Patient 2's residence with LVN 2. Patient 2 was observed sitting on a couch at the living room with a walker parked next to him. During an interview with Patient 2, Patient 2 stated he was never told that he had six months or less to live or never explained regarding the hospice services being rendered. Patient 2 further stated that he never had an attending physician and his friend referred him to the hospice agency.

Based on observation, interview, and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary), Care Planning, and Coordination of Services was met as follows: 1. The hospice agency failed to ensure the IDG meetings were held by all the members of interdisciplinary group to discuss the patients comprehensive and ongoing assessments and care planning process for five out of 14 sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). (Refer to L541) 2. The hospice agency failed to develop and complete the plan of care (POC, a form where you can summarize patients health conditions, specific care needs, goals, and current treatments) with measurable objectives, timeframe, and interventions to meet the patients' needs for 14 out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L545) 3. The hospice agency nursing staff failed to coordinate care and ensure the IDG was notified and the notification was documented when ordered home visit service was missed for one out of 14 sampled patients (Patient 11). (Refer to L554) 4. The hospice agency failed to ensure home visit was conducted in accordance with the plan of care for one out of 14 sampled patients (Patient 11). (Refer to L555) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care 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 interdisciplinary group (IDG, a team responsible for the holistic care of the hospice beneficiary) meetings were held by all the members of interdisciplinary group to discuss the patients comprehensive and ongoing assessments and care planning process for five out of 14 sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This deficient practice has a potential for the patients progress or decline will not be identified by the IDG, interventions will not be implemented, and patient care goals will not be achieved. --- Findings: a. During a review of Patient 8's admission record indicated a start of care (SOC) date of 8/18/2023, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs). During a review of Patient 8's Plan of Care (POC)/Interdisciplinary Group form, dated 10/19/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week and one as needed ([prn] pro re nata, which means ";as needed") visits, hospice aide to one visit per week, and the spiritual counselor (SC) and the social worker (MSW) to one visit per month and one as needed (prn) visit. The POC/IDG form indicated MSW did not attend the meeting. b. During a review of Patient 9s admission record indicated an SOC date of 8/18/2023 with a terminal diagnosis of unspecified Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). During a review of Patient 9's POC/IDG form, dated 10/19/2023, indicated the frequency of visits of licensed vocational nurse (LVN) and social worker (MSW) to one visit per week and three as needed (prn) visits, hospice aide to one visit per week, and the spiritual counselor (SC) to one visit per month and one as needed (prn) visit. The POC/IDG form has no signature from MSW that indicated MSW attended the IDG meeting. c. During a review of Patient 10s admission record indicated an SOC date of 7/6/2023 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 10's POC/IDG form, dated 10/19/2023, indicated the frequency of visits of licensed vocational nurse and hospice aide to one visit per week, the registered nurse and spiritual counselor to one visit per month and one as needed (prn) visits, and the social worker to visit once every two weeks and one as needed (prn) visits. The POC/IDG form has no signature from MSW that indicated MSW attended the IDG meeting. A further review of Patient 10s POC/IDG form, dated 11/2/2023, had no signature from the Medical Director (MD), Chaplain, and MSW to indicate they attended the meeting. d. During a review of Patient 11s admission record indicated an SOC date of 5/19/2023 with a terminal diagnosis of chronic diastolic congestive heart failure (a condition in which heart's main pumping chamber [left ventricle] becomes stiff and unable to fill properly). During a review of Patient 11's POC/IDG form, dated 10/19/2023, indicated the frequency of visits of licensed vocational nurse to one visit per week and one as needed (prn) visit, hospice aide to one visit per week, and the registered nurse, spiritual counselor and the social worker to one visit per month and one as needed (prn) visits. The POC/IDG form has no signature from MSW that indicated MSW attended the IDG meeting. A further review of Patient 11s POC/IDG form, dated 11/2/2023, has no signature from the Medical Director (MD), Chaplain, and MSW that indicated that they attended the meeting. e. During a review of Patient 12s admission record indicated an SOC date of 8/1/2023 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 12's POC/IDG form, dated 10/19/2023, indicated the frequency of visits of licensed vocational nurse to one visit per week and three as needed (prn) visits, hospice aide to one visit per week, and the spiritual counselor and the social to one visit per month and one as needed (prn) visits. The POC/IDG form has no signature from MSW that indicated MSW attended the IDG meeting. During a concurrent interview and record review on 11/9/2023 at 12:05 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated the agency holds IDG meetings every two weeks. The DPCS stated the IDG members attending the meetings include the RN, MSW, MD, and SC. The DPCS stated the IDG members are expected to sign the IDG Plan of Care after the meeting because their signature means they attended the meeting. The DPCS was not able to provide documented evidence all the IDG members had participated in the IDG meetings for Patient 8, 9, 10, 11, and 12 on the above days. During a review of the agency's policy and procedure titled, "Interdisciplinary Group Meeting," revised November 2021, indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor.

Based on interview and record review, the hospice agency failed to develop and complete the plan of care (POC, a form where patients health conditions, specific care needs, goals, and current treatments can be summarized) with measurable objectives, timeframe, and interventions to meet the patients' needs for 14 out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This deficient practice resulted in the patients not having a completed plan of care which had the potential to affect the provision of necessary care and services to the patients. --- h. During a review of Patient 8's admission record indicated a start of care date of 8/18/2023, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). During a review of Patient 8's Comprehensive Assessment, dated 8/18/2023, indicated Patient 8 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 8 had bradycardia (slow heart rate), pitting edema (a type of swelling, often in the lower legs), mild dyspnea (shortness of breath) with mild exertion, and labored respiration (breathing). During a review of Patient 8s clinical record indicated there was no plan of care developed and completed that included specific goals and interventions regarding patient care needs. i. During a review of Patient 9s admission record indicated a start of care date of 8/18/2023 with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). During a review of Patient 9's Comprehensive Assessment, dated 8/18/2023, indicated Patient 9 was awake, disoriented, and confused. Patient 9 was dependent on walker or cane for ambulation, had tachycardia (fast heart rate), mild dyspnea with mild exertion, and pitting edema. Patient 9 had depression and was taking medication for mood stabilization. During a review of Patient 9s clinical record indicated there was no plan of care developed and completed that included specific goals and interventions regarding patient care needs. j. During a review of Patient 10s admission record indicated a start of care date of 7/6/23 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 10's Comprehensive Assessment, dated 7/6/2023, indicated Patient 10 was awake, alert, oriented x 3 (to person, place, and time), and was confined to bed or chair. Patient 10 had generalized body pains that radiate to lower back, had mild dyspnea with mild exertion, and was noncompliant with medication. During a review of Patient 10s clinical record indicated there was no plan of care developed and completed that included specific goals and interventions regarding patient care needs. k. During a review of Patient 11s admission record indicated a start of care date of 5/19/2023 with a terminal diagnosis of chronic diastolic congestive heart failure (a condition in which your heart's main pumping chamber [left ventricle] becomes stiff and unable to fill properly). During a review of Patient 11's Comprehensive Assessment, dated 5/19/2023, indicated Patient 11 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on cane or walker for ambulation. Patient 11 had mild dyspnea with mild exertion, was high risk for skin impairment, and her sleep cycle was disturbed due to waking up at night and not being able to go back to sleep. During a review of Patient 11s clinical record indicated there was no plan of care developed and completed that included specific goals and interventions regarding patient care needs. l. During a review of Patient 12s admission record indicated a start of care date of 8/1/2023 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 12's Comprehensive Assessment, dated 8/1/2023, indicated Patient 12 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on cane or walker for ambulation. Patient 12 had mild dyspnea with mild exertion and feeling heavy in the chest when ambulating, had joint pain which was mostly in legs and can be generalized pain most days, and has periods of depression. During a review of Patient 12s clinical record indicated there was no plan of care developed and completed that includes specific goals and interventions regarding patient care needs. m. During a close record review of Patient 13s admission record indicated a start of care date of 6/6/2023 with a terminal diagnosis of malignant neoplasm of endometrium (a type of cancer that begins in the lining of the womb [uterus]). During a review of Patient 13's Comprehensive Assessment, dated 6/6/23, indicated Patient 13 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on cane or walker for ambulation. Patient 13 showed signs of anxiety, had poor appetite, and had generalized pain but the most pain she felt was near her abdomen area. Patient 13 also had a nephrostomy (a tube that lets urine drain from the kidney through an opening in the skin on the back). During a review of Patient 13s clinical record indicated there was no plan of care developed and completed that included specific goals and interventions regarding patient care needs. n. During a close record review of Patient 14s admission record indicated a start of care date of 5/19/2023 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 14's Comprehensive Assessment, dated 5/19/2023, indicated Patient 14 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on cane or walker for ambulation. Patient 14 was dependent on cane or walker for ambulation, was high risk for skin impairment and had type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). During a review of Patient 14s clinical record indicated there was no plan of care developed and completed that includes specific goals and interventions regarding patient care needs. During a concurrent interview and record review on 11/9/23 at 12:05 p.m. with the Director of Patient Care Services (DPCS), the DPCS confirmed the plan of care with measurable objectives, timeframe, and interventions were not developed for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14. During a review of the agency's policy and procedure titled, "The Plan of Care", revised November 2021, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen days. This plan will focus on identified problems, goals and interventions. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions. A review of Patient 1s admission record indicated a start of care (SOC) date of 9/15/23, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). During a review of Patient 1's Comprehensive Assessment, dated 9/15/23, indicated Patient 1 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 1 had pitting edema (a type of swelling, often in the lower legs) and mild dyspnea (shortness of breath) with mild exertion. During a review of Patient 1s clinical record indicated there was no plan of care developed and completed that includes specific goals and interventions regarding patient care needs. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 9/25/23, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). During a review of Patient 2's Comprehensive Assessment, dated 9/25/23, indicated Patient 2 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 2 had pitting edema (a type of swelling, often in the lower legs) and mild dyspnea (shortness of breath) with mild exertion. During a review of Patient 2s clinical record indicated there was no plan of care developed and completed that includes specific goals and interventions regarding patient care needs. c. A review of Patient 3s admission record indicated a start of care (SOC) date of 7/20/23, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). During a review of Patient 3's Comprehensive Assessment, dated 7/20/23, indicated Patient 3 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 3 had pitting edema (a type of swelling, often in the lower legs) and mild dyspnea (shortness of breath) with mild exertion. During a review of Patient 3s clinical record indicated there was no plan of care developed and completed that includes specific goals and interventions regarding patient care needs. d. A review of Patient 4s admission record indicated a start of care (SOC) date of 7/26/23, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). During a review of Patient 4's Comprehensive Assessment, dated 7/26/23, indicated Patient 4 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 4 had pitting edema (a type of swelling, often in the lower legs) and mild dyspnea (shortness of breath) with mild exertion. During a review of Patient 4s clinical record indicated there was no plan of care developed and completed that includes specific goals and interventions regarding patient care needs. e. A review of Patient 5s admission record indicated a start of care (SOC) date of 7/26/23, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). During a review of Patient 5's Comprehensive Assessment, dated 7/26/23, indicated Patient 5 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 5 had pitting edema (a type of swelling, often in the lower legs) and mild dyspnea (shortness of breath) with mild exertion. During a review of Patient 5s clinical record indicated there was no plan of care developed and completed that includes specific goals and interventions regarding patient care needs. f. A review of Patient 6s admission record indicated a start of care (SOC) date of 6/16/23, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and the important mental functions). During a review of Patient 6s Comprehensive Assessment, dated 6/16/23, indicated Patient 6 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 6 had pitting edema (a type of swelling, often in the lower legs) and mild dyspnea (shortness of breath) with mild exertion. During a review of Patient 6s clinical record indicated there was no plan of care developed and completed that includes specific goals and interventions regarding patient care needs. g. A review of Patient 7s admission record indicated a start of care (SOC) date of 5/19/23, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). During a review of Patient 7's Comprehensive Assessment, dated 5/19/23, indicated Patient 7 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 7 had pitting edema (a type of swelling, often in the lower legs) and mild dyspnea (shortness of breath) with mild exertion. During a review of Patient 7s clinical record indicated there was no plan of care developed and completed that includes specific goals and interventions regarding patient care needs.

Based on interview and record review, the hospice agency nursing staff failed to coordinate care and ensure the IDG (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) was notified and the notification was documented when an ordered home visit was missed for one out of 14 sampled patients (Patient 11). This failure had the potential to result in the patients hospice care needs and services not provided as indicated in the plan of care. --- Findings: During a review of Patient 11s admission record indicated a start of care (SOC) date of 5/19/2023 with a terminal diagnosis of chronic diastolic congestive heart failure (a condition in which heart's main pumping chamber [left ventricle] becomes stiff and unable to fill properly). During a review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 9/7/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week and one as needed (prn) visit, hospice aide to one visit per week, and the registered nurse, spiritual counselor and the social worker to one visit per month and one as needed (prn) visits. During a review of Patient 11s history of skilled nursing visit notes for the month of September 2023, indicated for the week starting on 9/10/2023 (Sunday) and ending on 9/16/2023 (Saturday), there was no LVN visit conducted. A further review of Patient 11s clinical record indicated there was no documented evidence that the agencys nursing staff had notified or communicated with the IDG about the missed visit in accordance with the agencys policy and procedure. During a concurrent interview and record review on 11/9/2023, at 12:05 p.m., with the Director of Patient Care Services (DPCS), the DPCS acknowledged the finding and stated patient care visit should be provided to patients in accordance with the plan of care. The DPCS stated for any missed visits, IDG should be notified promptly by the field nurses and notification should be documented in the patients electronic records per the agencys policies and procedures. During a review of the agencys undated policy and procedure titled, ";Missed Visits", 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. If a visit is missed and not rescheduled, the clinician will notify the IDG and clinical supervisor of the missed visit and reason for missed visit and will document in the patients clinical record. During a review of the agencys undated policy and procedure titled, ";Interdisciplinary Group Plan of Care", indicated the hospice interdisciplinary group will retain professional management responsibilities for the provision of services, including inpatient care, and will ensure that services are furnished in a safe and effective manner. Written evidence of care coordination will be found in the plan of care and/or interdisciplinary team meeting forms in the patients clinical record and will involve the hospice patients attending physician.

Based on interview and record review, the hospice agency failed to ensure care and services were provided in accordance with the plan of care (POC) for one out of 14 sampled patients (Patient 11). This failure had the potential to negatively affect the patient's physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. --- Findings: During a review of Patient 11s admission record indicated a start of care date of 5/19/2023 with a terminal diagnosis of chronic diastolic congestive heart failure (a condition in which heart's main pumping chamber [left ventricle] becomes stiff and unable to fill properly). During a review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 9/7/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week and one as needed (prn) visit, hospice aide to one visit per week, and the registered nurse, spiritual counselor and the social worker to one visit per month and one as needed (prn) visits. During a review of Patient 11s history of skilled nursing visit notes for the month of September 2023, indicated for the week starting on 9/10/2023 (Sunday) and ending on 9/16/2023 (Saturday), there was no LVN visit conducted. During a concurrent interview and record review on 11/9/2023 at 12:05 p.m., with the Director of Patient Care Services (DPCS), the DPCS acknowledged the finding and stated patient care visit should be provided to patients in accordance with the plan of care. During a review of the agency's policy and procedure titled, "The Plan of Care", revised November 2021, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide Volunteer Services and documentation of Volunteer orientation and training of the specific tasks that volunteers perform. This deficient practice resulted in hospice patients not receiving Volunteer services as required. --- Findings: On 11/9/2023, at 11:30 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated that the hospice agency had no monthly orientation and training for their agency's volunteers. DPCS was unable to provide the volunteer personnel files that included evidence of the required training consistent with the specific tasks the volunteers perform. On 11/9/2023, at 12 p.m., during an interview with the DPCS, she stated the visiting nurse should always offer volunteer services to their patients as part of the hospice agency's core services. A review of the agency's policy of "Volunteer Services", indicated the hospice will provide volunteer services under the direction of a volunteer coordinator or staff member responsible for planning, organizing and directing a comprehensive volunteer services program and with the assistance of trained hospice volunteers.

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 offer volunteers (provide assistance in the hospices ancillary and office activities as well as in direct patient care services, and/or help patients and families with household chores, shopping, transportation, and companionship) in day-to-day direct patient care roles for two out of 14 sampled patients (Patient 1 and 2). This deficient practice resulted in patients and family members not being helped with household chores, shopping, and companionship when needed. --- Findings: a. A review of Patient 1s admission record indicated a start of care (SOC) date of 9/15/2023, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 10/19/23, indicated the frequency of visits of licensed vocational nurse (LVN) and hospice aide to one visit per week, the registered nurse (RN), and the social worker (MSW) to visit once every 2 weeks plus 1 prn visits. On 11/8/2023, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 2. Patient 1 was observed walking on a steady gait without the use of an assistive device. When Patient 1 was asked if the hospice agency offered volunteer services such as running errands for grocery shopping or doing household chores, Patient 1 stated the volunteer service was not offered to her. Patient 1 stated that she really wanted that help if offered. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 9/25/2023, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 10/19/2023, indicated the frequency of visits of licensed vocational nurse (LVN) and hospice aide to one visit per week, the registered nurse (RN), and the social worker (MSW) to visit once every 2 weeks plus 1 prn visits. On 11/8/2023, at 11 a.m., a home visit was conducted at Patient 2's residence with LVN 2. Patient 2 was observed sitting on a couch at the living room with a walker parked next to him. When Patient 2 was asked if the visiting nurse offered volunteer services such as running errands for grocery shopping or doing household chores, he stated no, but he wanted the services. On 11/9/2023, at 12 p.m., during an interview with the Director of Patient Care Services (DPCS ), she stated the visiting nurse should always offer volunteer services to their patients as part of the hospice's core services. A review of the agency's policy of "Volunteer Services", indicated the hospice will provide volunteer services under the direction of a volunteer coordinator or staff member responsible for planning, organizing and directing a comprehensive volunteer services program and with the assistance of trained hospice volunteers.

Based on observation, interview, and record review, the Hospice Agency failed to ensure the Conditions of Participation regarding Organizational Environment was met as follows: --- 1. The hospice agency failed to ensure there was documented evidence that the governing body assumed full legal authority and responsibility in the operation and management of the hospice agency. (Refer to L651) 2. The hospice agency failed to provide counselling services that included bereavement (grief in the loss of a loved one) services for two out of 14 sample patients (Patient 1 and 2). (Refer to L652) 3. The hospice agency failed to ensure in-service training during the previous 12 months that were necessary to assess the skills and competence of all individuals providing direct patient care were provided. (Refer to L663). The cumulative effect of these systemic practice resulted in the failure of the hospice to deliver statutorily mandated Federal compliance for Organizational Environment to ensure the highest quality of care was provided to patients certified to receive the hospice benefits.

Based on interview, and record review, the hospice agency failed to ensure there was documented evidence that the governing body assumed full legal authority and responsibility in the operation and management of the hospice agency. This deficient practice had the potential to result in poor quality of care provided to all the patients under the agencys care. --- On 11/7/2023, at 11 a.m., a complaint validation survey was conducted at this hospice agency. A record of the governing body minutes was requested from the Administrator to review, however, there was no documented evidence that the governing body met and assumed full authority in the operation and management of the hospice agency. On 11/9/23, at 1 p.m., during an interview with Administrator, she stated the agency's governing body consists of their all-core services (physician, nursing, medical social services, and counselling) and they conduct meetings once a month. Administrator also stated that she cannot find any documented evidence of a governing body minutes that was held a year ago.

Based on observation, interview and record review, the hospice agency failed to provide counselling services that included bereavement (grief in the loss of a loved one) services for two out of 14 sample patients (Patient 1 and 2). This deficient practice has the potential to result in the patient/family of not having spiritual, and emotional support from the time of hospice admission, during the course of the terminal illness, and after the patient's death. --- a. A review of Patient 1s admission record indicated a start of care (SOC) date of 9/15/2023, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 10/19/23, indicated the frequency of visits of licensed vocational nurse (LVN) and hospice aide to one visit per week, the registered nurse (RN), and the social worker (MSW) to visit once every 2 weeks plus 1 prn visits. On 11/8/23, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 2. Patient 1 was observed walking on a steady gait without a use of assistive device. When Patient 1 was asked if the visiting nurse offered bereavement services for spiritual guidance to help with grieving, she stated she was not aware of it, but she would want to see a chaplain to visit her. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 9/25/23, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 10/19/23, indicated the frequency of visits of licensed vocational nurse (LVN) and hospice aide to one visit per week, the registered nurse (RN), and the social worker (MSW) to visit once every 2 weeks plus 1 prn visits. On 11/8/23, at 11:30 a.m., a home visit was conducted at Patient 2's residence with LVN 2. Patient 2 was observed sitting on a couch at the living room with a walker parked next to him. When Patient 2 was asked if the visiting nurse offered bereavement services, he stated the visiting nurse did not offer it. On 11/9/23, at 12:20 p.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should always offer bereavement services for a dying patient and family members.

Based on interview and record review, the hospice agency failed to ensure in-service training during the previous 12 months that were necessary to assess the skills and competence of all individuals providing direct patient care were provided. This deficient practice had the potential that personnel providing direct patient care had lack of knowledge and skills to provide the quality of care necessary to maintain the highest practicable physical, mental, and psychosocial well-being of the patients under the hospice services care. --- A review of the hospice agency's staff in-service logbook did not indicate documented evidence of training and in-services were provided to all staff from the year 2022 to the present date. On 11/9/2023, at 2 p.m., during an interview with the Director of Patient Care Service (DPCS), the DPCS was asked if the agency had provided in- services for all the staff. The DPCS stated, she could not provide any documented evidence of training and in-services that took place during the past year.

Based on observation, interview, and record review, the Hospice Agency failed to ensure the Condition of Participation for Medical Director was met as evidenced by: --- 1. The hospice agency failed to ensure the Medical Director and/or physician designee conducted an assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), 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 and services for four out of 14 sampled patients (Patient 1, Patient 2, Patient 11, and Patient 12). (Refer to L667) 2. The hospice agency failed to ensure the Medical Director and/or physician designee conducted a review and verified the patients clinical information to determine the patient needs of recertification of terminal illness for continued hospice care and services for three of 14 sampled patients (Patient 10, Patient 11, and Patient 12). (Refer to L 668) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory mandated (state law) compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was provided to the patients certified to receive hospice services.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Medical Director and/or physician designee conducted an assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (a hospice physician narrative designed to explain the clinical findings that support a life expectancy of six months or less), to qualify for hospice care and services (health care that focuses on the palliation to ease the symptoms without curing the underlying disease of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) for four of 14 sampled patients (Patient 1, Patient 2, Patient 11, and Patient 12). This deficient practice had the potential not to meet the needs for Patient 1, Patient 2, Patient 11, and Patient 12. --- Findings: e. During a review of Patient 11s admission record indicated a start of care date of 5/19/23 with a terminal diagnosis of chronic diastolic congestive heart failure (a condition in which your heart's main pumping chamber [left ventricle] becomes stiff and unable to fill properly). Patient 11's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. During a review of Patient 11's Comprehensive Nursing 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), dated 5/19/23, indicated Patient 11 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related pain, no edema, had normal respirations, regular pulse rate (heart rate), mild dyspnea with mild exertion, and requires minimum assistance only with ambulation, toileting, transfer, dressing, and bathing. The Comprehensive Nursing Assessment further indicated Patient 11 was on NYHA Stage II of heart failure (New York Heart Association Class II –mild symptoms, with mild shortness of breath and/or angina [chest pain or discomfort] and slight limitation during ordinary activity). The LCD Guidelines for hospice eligibility for heart disease indicated patients should meet criteria for NYHA Class IV level (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) and not NYHA Class II to qualify for hospice service. During a review of Patient 11's "Physician Certification for Hospice Benefit" "(Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the 1st benefit period from 5/19/23 to 8/16/23, indicated Patient 11's terminal diagnoses was chronic diastolic congestive heart failure. The Medical Director indicated Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 11s terminal illness diagnosis. During a review of Patient 11s LCD Hospice Eligibility Determination form for Heart Disease, dated 5/19/23, indicated Patient 11 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 11 has declined surgical procedures and was optimally treated for heart disease with diuretics and vasodilators. Section 2 was marked "yes" that Patient 11s heart disease met the criteria for NYHA Class IV level. During a review of Patient 11's clinical record indicated there was no documented evidence Patient 11 had declined any surgical procedures or was optimally treated for heart disease with diuretics and vasodilator. There was no documentation Patient 11 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 11/8/23 at 9:42 a.m. with Patient 11, Patient 11 stated no doctor or nurses told her that she has terminal illness or that she was dying. Patient 11 stated hospice care is for those that needed medications and being visited by a nurse every week. During a concurrent interview and record review on 11/9/23 at 12:05 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 11 had declined surgical procedure or was optimally treated for heart disease with diuretics and vasodilator. The DPCS stated there was no documented evidence Patient 11 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. f. During a review of Patient 12s admission record indicated a start of care date of 8/1/23 with a terminal diagnosis of hypertensive heart disease without heart failure. Patient 12's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. During a review of Patient 12's Comprehensive Assessment, dated 8/1/23, indicated Patient 12 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related pain, no edema, had normal respirations, regular pulse, and required moderate assistance with bathing, transferring and ambulation, and minimum assistance with dressing, feeding and toileting. The Comprehensive Nursing Assessment further indicated Patient 12 was on NYHA Stage II of heart failure. The LCD Guidelines for hospice eligibility for heart disease indicated patients should meet criteria for NYHA Class IV level and not NYHA Class II to qualify for hospice service. A review of Patient 12's "Physician Certification for Hospice Benefit" for the 1st benefit period from 8/1/23 to 10/29/23, indicated Patient 12's terminal diagnoses was hypertensive heart disease without heart failure. The Medical Director indicated Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 12s terminal illness diagnosis. A review of Patient 12s LCD Hospice Eligibility Determination form for Heart Disease, dated 8/1/23, indicated Patient 12 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 12 was optimally treated for heart disease with diuretics and vasodilators. Section 2 was marked "yes" that Patient 12s heart disease met the criteria for NYHA Class IV level. A review of Patient 12's clinical record indicated there was no documented evidence Patient 12 was optimally treated for heart disease with diuretics and vasodilator. There was no documentation Patient 12 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 11/8/23 at 2:40 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Patient 12 was alert, oriented x 3 (to person, place, and time), lives alone and can manage herself at home. LVN 2 stated Patient 2s blood pressure has been controlled with medications, has no shortness of breath at rest, never complained of any chest pain and was ambulatory using a cane or a walker. During a concurrent interview and record review on 11/9/23 at 12:05 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 12 was optimally treated for heart disease with diuretics and vasodilator. The DPCS stated there was no documented evidence Patient 12 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 11/9/23 at 1:00 p.m. with the hospice Medical Director (MD), MD stated he was not the attending physician and did not know who the attending physician was for Patients 1, 2, 3, 4, 10 and 12. MD stated he would be the attending physician for the patients once admitted to their hospice service. When asked how he determine patients were eligible for hospice service, MD stated, ";I look at the overall picture. I go to patient homes, do my observations, and compare their diagnosis from their old records, and I determine their eligibility. I see the whole picture, and the patient can benefit from hospice care. Thats why I signed the CTI." During a review of the agencys policy and procedure titled ";Certification of Terminal Illness," revised November 2021, indicated that the purpose of the policy and procedure is to ensure physician certification of terminal illness and authorization of hospice services, in accordance with applicable state and federal regulations and payer requirements. The policy and procedure further indicated that at the time of admission to hospice, the hospice Medical Director or patients 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 patient. Additionally, the policy and procedure indicated that the hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms and the certification must be complete no more than 15 calendar days prior to effective date of the hospice election statement. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. During a review of the agencys undated policy and procedure titled ";Physician Services-Medical Director", indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care. a. A review of Patient 1s admission record indicated a start of care (SOC) date of 9/15/23, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). Patient 1's clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 1's Physicians Certification for Hospice Benefit, dated 9/15/2023 to 12/13/23, benefit period, indicated Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 11/8/23, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 2. Patient 1 was observed walking on a steady gait without a use of assistive device. During an interview with Patient 1, Patient 1 stated she was never told that she had six months or less to live or never explained regarding the hospice services being rendered. Patient 1 stated she drives her husband to go to his MD appointment. Patient 1 further stated that she never had an attending physician and her friend referred her to the hospice agency. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 9/25/23, with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). Patient 2's clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 2's Physicians Certification for Hospice Benefit, dated 9/25/2023 to 12/23/23, benefit period, indicated Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 11/8/23, at 11 a.m., a home visit was conducted at Patient 2's residence with LVN 2. Patient 2 was observed sitting on a couch at the living room with a walker parked next to him. During an interview with Patient 2, Patient 2 stated he was never told that he had six months or less to live or never explained regarding the hospice services being rendered. Patient 2 further stated that he never had an attending physician and his friend referred him to the hospice agency. f. A review of Patient 8's Patient Information indicated Patient 8 was admitted to the hospice agency on 7/5/2023, with admitting diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) without heart failure. On 10/19/2023, at 1:00 p.m., a home visit was conducted with the Director of Patient Care Services (DPCS) at Patient 8s residence. Patient 8 was observed sitting on her couch at the living room. Patient 8 was walking with a steady gait without using an assistive device. On 10/19/2023, at 1:15 p.m., g. A review of Patient 9s Patient Information indicated an SOC date of 1/24/2023, with admitting diagnosis of hypertensive heart disease without heart failure. Patient 9's clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 9's Physicians Certification for Hospice Benefit, dated 1/24/2023 to 4/23/2023, benefit period, indicated Physician 1 signed the attending physician referral section to indicate Patient 9 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a telephone interview on 10/19/2023, at 2:00 p.m., Patient 9 stated he was not dying, and there was no doctor or any nurses from the agency told him that he has six months or less to live. Patient 9 stated the agency offered him incontinence pads (absorbent pads that are worn inside the underwear to soak up urine) every month and hand sanitizers by the hospice nurse just to be their patient. h. A review of Patient 10s Patient Information indicated an SOC date of 9/13/2023, with admitting diagnosis of hypertensive heart disease without heart failure. Patient 10's clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 10's Physicians Certification for Hospice Benefit, dated 9/13/2023 to 12/11/2023, benefit period, indicated Physician 1 signed the attending physician referral section to indicate Patient 10 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence that a comprehensive assessment was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. i. A review of Patient 11s Patient Information indicated an SOC date of 9/13/2023, with admitting diagnosis of atherosclerotic heart disease (thickening or hardening of arteries caused by a build up of plaque in the inner lining of an artery). Patient 11's clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 11's Physicians Certification for Hospice Benefit, dated 9/13/2023 to 12/11/2023, benefit period, indicated Physician 1 signed the attending physician referral section to indicate Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence that a comprehensive assessment was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a telephone interview on 10/19/2023, at 3:00 p.m. with Patient 11, Patient 11 stated she was not dying, and there was no doctor or any nurses from the agency told her that she has six months or less to live. Patient 11 stated the agency offered her incontinence pads every month and medical supplies by the hospice nurse just to be their patient. During a phone interview on 10/20/2023 at 4:05 p.m., with the Medical Director (Physician 1), Physician 1 stated she was only the Medical Director Designee for the agency. Physician 1 stated she was not the attending physician, and became the attending physician for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, and Patient 11 only upon admission to the hospice agency. Physician 1 stated she determined that patients were eligible for hospice services by reviewing patient's past medical records/history, and the assessment report by the registered nurse upon their initial visit to the patients and certify patients for hospice care using LCD guidelines. Physician 1 stated there should be a primary physician referral before the agency admit a patient. A review of the agencys policy and procedure titled "Admission Criteria and Process", revised November 2021, indicated HA will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of six months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). HA will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. A review of the agencys undated policy and procedure titled ";Certification of Terminal Illness", indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. During a phone interview on 10/20/23 at 4:05 p.m. with the Medical Director (Physician 1), Physician 1 stated she was only the Medical Director Designee for the agency. She stated she was not the attending physician, and became the attending physician for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, and Patient 11 only upon admission to the hospice agency. Physician 1 stated she determined the patients were eligible for hospice services by reviewing patient's past medical records/history, and the assessment report by the registered nurse upon their initial visit to the patients and certify patients for hospice care using LCD guidelines. Physician 1 stated there should be a primary physician referral before the agency admit a patient.

Based on interview and record review, the Hospice Agency failed to ensure the Medical Director or physician designee had the hospice patients' clinical information reviewed and justification obtained to recertify for continued hospice care and services for three of 14 sampled patients (Patient 10, Patient 11, and Patient 12). This deficient practice resulted for Patient 10, Patient 11, and Patient 12, to be re-certified for hospice care despite lacking verification of the clinical information to continue provision of hospice care which can affect the patients quality of life and well-being. --- a. During a review of Patient 10s admission record indicated a start of care (SOC) date of 7/6/2023 with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). Patient 10's face sheet indicated the hospice Medical Director (Physician 1) was also the patient's referring and attending physician. 1. During a review of Patient 10's Nursing Recertification (Re-Cert) 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), dated 10/6/23, indicated Patient 10 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related (anything that's related to the heart) pain, no edema (swelling in parts of your body because of fluid trapped in your tissues, most often in your feet, ankles and legs), had normal respirations (breathing), mild dyspnea (difficulty breathing) with mild exertion, and requires minimum assistance only with ambulation, toileting, transfer, dressing, and bathing. The Re-Cert Assessment further indicated Patient 10 was on New York Heart Association (NYHA) Class II (a stage in heart failure that has mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity). The Local Coverage Determination (LCD, guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits eligibility) guidelines for hospice eligibility for heart disease indicated patients should meet criteria for NYHA Class IV level (Class IV - (a stage in heart failure that has severe limitations, experiences symptoms even while at rest) and not NYHA Class II (a stage in heart failure that has mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity) to qualify for hospice service. During a review of Patient 10's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the 3rd benefit period from 10/4/23 to 12/2/23, indicated Patient 10's terminal diagnoses was hypertensive heart disease with heart failure. The Medical Director indicated Patient 10 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 10 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 10s terminal illness diagnosis. A review of Patient 10s LCD Hospice Eligibility Determination form for Heart Disease, dated 10/6/2023, indicated Patient 10 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 10 was optimally treated for heart disease with diuretics (medications that are useful in treating heart failure, a condition in which the body holds too much water) and vasodilators (medicines that useful in managing high blood pressure). Section 2 was marked "yes" that Patient 10s heart disease met the criteria for NYHA Class IV level. A review of Patient 10's clinical record indicated there was no documented evidence Patient 10 was optimally treated for heart disease with diuretics and vasodilator. There was no documentation Patient 10 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 11/8/2023, at 9:39 a.m., Patient 10 stated no doctor or nurses told him that he had six months or less to live and did not know that hospice care was for those patients with terminal illness. Patient 10 further stated he was not dying and has been walking around his neighborhood without any assistance. During a concurrent interview and record review on 11/9/23, at 12:05 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 10 was optimally treated for heart disease with diuretics and vasodilator. The DPCS stated there was no documented evidence Patient 10 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. b. During a review of Patient 11s admission record indicated a start of care date of 5/19/23 with a terminal diagnosis of chronic diastolic congestive heart failure (a condition in which your heart's main pumping chamber [left ventricle] becomes stiff and unable to fill properly). Patient 11's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. During a review of Patient 11's Nursing Re-Cert Assessment, dated 8/19/23, indicated Patient 11 was awake, alert, oriented to person, place, and time (x 3), had no cardiac-related pain, no edema, had normal respirations, regular pulse rate (heart rate), mild dyspnea with mild exertion, and requires minimum assistance only with ambulation, toileting, transfer, dressing, and bathing. The Re-Cert Assessment further indicated Patient 11 was on NYHA Stage II of heart failure. The LCD Guidelines for hospice eligibility for heart disease indicated patients should meet criteria for NYHA Class IV level and not NYHA Class II to qualify for hospice service. During a review of Patient 11's "Physician Certification for Hospice Benefit" for the 2nd benefit period from 8/17/23 to 11/14/23, indicated Patient 11's terminal diagnoses was chronic diastolic congestive heart failure. The Medical Director indicated Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 11s terminal illness diagnosis. During a review of Patient 11s LCD Hospice Eligibility Determination form for Heart Disease, dated 8/19/2023, indicated Patient 11 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 11 has declined surgical procedures and was optimally treated for heart disease with diuretics and vasodilators. Section 2 was marked "yes" that Patient 11s heart disease met the criteria for NYHA Class IV level. During a review of Patient 11's clinical record indicated there was no documented evidence Patient 11 had declined any surgical procedures or was optimally treated for heart disease with diuretics and vasodilator. There was no documentation Patient 11 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 11/8/2023 at 9:42 a.m. with Patient 11, Patient 11 stated no doctor or nurses told her that she has terminal illness or that she was dying. Patient 11 stated hospice care is for those that needed medications and being visited by a nurse every week. During a concurrent interview and record review on 11/9/2023 at 12:05 p.m., with the DPCS, the DPCS stated she was not able to find documented evidence Patient 11 had declined surgical procedure or was optimally treated for heart disease with diuretics and vasodilator. The DPCS stated there was no documented evidence Patient 11 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. c. During a review of Patient 12s admission record indicated a start of care date of 8/1/2023 with a terminal diagnosis of hypertensive heart disease without heart failure. Patient 12's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. During a review of Patient 12's Nursing Re-Cert Assessment, dated 11/1/23, indicated Patient 12 was awake, alert, oriented x 3, had no cardiac-related pain, no edema, had regular pulse, and required moderate assistance with bathing, transferring, ambulation, dressing, and toileting. The Re-Cert Assessment further indicated Patient 12 was on NYHA Stage II of heart failure. The LCD Guidelines for hospice eligibility for heart disease indicated patients should meet criteria for NYHA Class IV level and not NYHA Class II to qualify for hospice service. A review of Patient 12's "Physician Certification for Hospice Benefit" for the 2nd benefit period from 10/30/23 to 1/27/24, indicated Patient 12's terminal diagnoses was hypertensive heart disease without heart failure. The Medical Director indicated Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 12s terminal illness diagnosis. A review of Patient 12s LCD Hospice Eligibility Determination form for Heart Disease, dated 11/1/23, indicated Patient 12 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 12 was optimally treated for heart disease with diuretics and vasodilators. Section 2 was marked "yes" that Patient 12s heart disease met the criteria for NYHA Class IV level. A review of Patient 12's clinical record indicated there was no documented evidence Patient 12 was optimally treated for heart disease with diuretics and vasodilator. There was no documentation Patient 12 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 11/8/2023, at 2:40 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Patient 12 was alert, oriented x 3, lives alone and can manage herself at home. LVN 2 stated Patient 2s blood pressure has been controlled with medications, has no shortness of breath at rest, never complained of any chest pain and was ambulatory using a cane or a walker. During a concurrent interview and record review on 11/9/23, at 12:05 p.m., with the DPCS, the DPCS stated she was not able to find documented evidence Patient 12 was optimally treated for heart disease with diuretics and vasodilator. The DPCS stated there was no documented evidence Patient 12 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 11/9/23, at 1 p.m. with the hospice Medical Director (MD), MD stated he was not the attending physician and did not know who the attending physician was for Patients 10, 11 and 12. MD stated he would be the attending physician for the patients once admitted to their hospice service. When asked how he determine patients were eligible for hospice service, MD stated, ";I look at the overall picture. I go to patient homes, do my observations, and compare their diagnosis from their old records, and I determine their eligibility. I see the whole picture, and the patient can benefit from hospice care. Thats why I signed the CTI." During a review of the agencys policy and procedure (P&P) titled ";Certification of Terminal Illness," revised November 2021, indicated that the purpose of the policy and procedure is to ensure physician certification of terminal illness and authorization of hospice services, in accordance with applicable state and federal regulations and payer requirements. The policy and procedure further indicated that at the time of admission to hospice, the hospice Medical Director or patients 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 patient. Additionally, the policy and procedure indicated that the hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms and the certification must be complete no more than 15 calendar days prior to effective date of the hospice election statement. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. During a review of the agencys undated P&P) titled, ";Physician Services-Medical Director", indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1 The medication profile includes; Carvedilol 12.5mg take 1 pill twice a day, patient is taking Carvedilol 25mg take 1 pill twice a day.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1 The medication orders for this patient are written as Carvedilol 12.5mg twice a day, the patient was taking Carvedilol 25mg twice a day.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #1 The psychosocial assessment does not identify the patients grief related to the recent unexpected and tragic loss of her sister and multiple deaths of other family members over the last 2 years.