Every finding on record at Skyline Hospice Care, Inc

Upon patient record review, 1 of 14 (Patient #4) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. #4-Missing initial bereavement assessment.

Upon patient record review, 8 of 14 (Patient #2, 3, 5, 6, 7, 8, 9, 10) 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. #2-Dietary order indicated 1 can Ensure as a nutritional supplement, but did not indicate frequency or route. Corrected on-site #3-Supply order for Glucerna with no dietary order for amount, indication, frequency or route. Corrected on-site #5-Order dated 08/22 for for triamcinolone cream does not specify site for application. Corrected on-site. #6, 7, 8, 9, 10- No medication order for oxygen on the plan of care. Patient has oxygen treatment order on plan of care, but order is missing indication.

Upon client record review, 1 of 14 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. #5-SC visits ordered 1x month. No SC visit made in August.

Based on interview and record review the hospice agency failed to ensure the patient/family member received information regarding provision of volunteer services for one of 9 sampled patients (Patient 2). This deficient practice placed the patient/family member to lack knowledge and ability to understand fully the hospice services related to the provision of volunteer services for continuous care throughout patient's terminal illness. Findings: A review of Patient 2's clinical record indicated a start of care (SOC) of 2/16/22, with admitting terminal diagnosis of atherosclerotic heart disease (a buildup of fats and cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 2's plan of care (POC) /Interdisciplinary Group (IDG) review dated 4/18/22, indicated the skilled nurse (SN) to visit two times a week and as needed, hospice aide (HA) visit was two times a week, medical social worker (MSW) visit was one time and as needed, and spiritual counselor visit was one time and as needed. Volunteer service was declined. Further review of Patient 2's clinical record regarding the patient's decline to receive volunteer services indicated no documented evidence the patient/family member was provided or received information regarding the volunteer services. During a phone interview with Patient 2's family member (caregiver) on 7/21/22, at 4:00 p.m., stated, " I am not aware what the volunteer program is about. No one told me about it." During an interview and record review with the Director of Patient Care Services (DPCS) on 7/22/22, at 10:30 a.m., DPCS was not able to provide the documented evidence the hospice staff had provided the volunteer service information to the patient/family member. A review of the agency's policy and procedure titled "Volunteer Services," revised April 2020, indicated the Hospice Agency will provide volunteer services under the direction of a Volunteer Coordinator and with the assistance of trained hospice volunteers. Volunteer Coordinator will develop and implement a specialized volunteer orientation and training program that is sufficient to meet the needs of the patients and volunteers will document their activities/type of service and time worked on volunteer activity/clinical notes and submit this documentation for the patient's clinical records.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Initial and Comprehensive Assessment was met as follws: 1. The HA failed to accurately assessed the patient's eligibility for hospice services related to the palliation and management of the terminal illness and related conditions for eleven of 13 sampled patients (Patient 2, 3, 4, 5, 6, 7, 8,10, 11, 12 and 13). (Refer to L521) 2. The HA failed to ensure comprehensive assessment including vital signs, height, weight, and oxygen saturation (the fraction of oxygen-saturated hemoglobin relative to total hemoglobin in the blood- normal pulse oximeter readings usually range from 95 to 100 percent) was conducted to the patients for 8 of 13 sampled patients (Patient 4, 5, 6, 7, 8, 10, 11 and 12). (Refer to L524) 3. The HA staff failed to ensure one of 13 sampled patients (Patient 3) had home medications listed in the medication profile. (Refer to L530) 4. The HA failed to provide initial bereavement assessments for eight of 13 sampled patients (Patients 1, 4, 6, 7, 10, 11, 12 and 13). (Refer to L531) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with the Initial and Comprehensive Assessment of Patient to ensure highest quality of care are provided to the patients assessed for eligibility to receive hospice care and services. Based on observation, interview and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Initial and Comprehensive Assessment was met as evidenced by: 1. The HA failed to develop a comprehensive (a four-section written plan developed by the client's medical provider, the care coordination team and the client to help the client achieve his or her treatment goals) and resident-centered (seeing the person as an individual, and developing appropriate care for the specific patient) wound care plan regarding Patient 7's left forearm skin tear. The HA failed to document the ongoing assessment every visit for Patient 4. (Refer to L521) 2. The hospice staff failed to review all medications the patients were taking and update the medication profile with the currently used medications for two of 8 sampled (Patients 1, and 7). (Refer to L530) 4. The HA 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 two of 9 sampled patients (Patients 3 and 9). (Refer to L531) The cumulative effect of these deficient practices resulted in the failure of the hospice to deliver statutorily mandated compliance with the Federal regulations for Initial and Comprehensive Assessment of Patient to ensure the highest quality of care are being provided to the patients.

Based on observation, interview and record review, the hospice agency failed to conduct an ongoing comprehensive assessment (an assessment that helps healthcare professionals to identify care needs and actual and potential risks, to inform care planning, decision making, treatment and care options) that reflects the patient's health current status for two out of 9 sampled patients (Patient 7 and Patient 4). This deficient practice resulted in the patients not receiving the appropriate care services that could delay treatment and further intervention. Findings: a. A review of Patient 7's admission record indicated the patient was admitted to the hospice agency on 6/4/22, with a primary diagnosis of chronic obstructive pulmonary disease with acute exacerbation (COPD, symptoms with exacerbation (flare-up) including tiredness or fatigue, more shortness of breath than usual, more coughing, more wheezing than usual, feeling unwell, feeling as if you have a cold, mucus changes, swollen legs or ankles, trouble sleeping, and other). A review of Patient 7's "Updated Assessment" dated 7/16/22, indicated the patient was seen by visiting nurse between 11 a.m., to 12 p.m.. The visiting nurse's documentation included: Body system (Head to toe) Integumentary -Skin status was normal, warm and dry, skin turgor is fair. Wound/skin impairment "No", other observations, visiting nurse indicated "skin remains intact". On narrative and disease trajectory (the course or progression), visiting nurse wrote "Patient's skin assessed and remains intact." On the "updated assessment" dated 7/2/22 indicated patient was seen between 12 p.m., and 12:50 p.m., the visiting nurse wrote on Body system (Head to toe) Integumentary -Skin status was normal, warm and dry, skin turgor is fair. Wound/skin impairment "No", other observations, visiting nurse indicated "skin remains intact". On narrative and disease trajectory, visiting nurse wrote "Patient's skin assessed and remains intact." A review of the Plan of Care dated 7/20/22, indicated Patient 7 had issues to be addressed as follows: -Bereavement (grief is the response to loss, particularly to the loss of someone or some living thing that has died, to which a bond or affection was formed), -Cardiovascular (heart and blood vessels), -Covid-19 Emergency (is the disease caused by SARS-CoV-2 which can be severe when exposed to), -Endocrine (comprises the internal glands of the body), -gastro-intestinal (pertaining to the stomach), pain -Respiratory ( pertaining to the lungs and breathing) -Integumentary (skin assessment) no evidence an assessment was conducted. On 7/21/22 at 2:27 p.m., a home visit was conducted with Licensed Vocational Nurse (LVN) 1 at Patient 7's residence. Patient 7 was observed to be alert and oriented to name, person and time with periods of forgetfulness. Patient 7 was receiving oxygen via nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels), sitting on the recliner. LVN 2 performed wound dressing on Patient 7's left forearm. LVN 2 stated the skin tear was treated by the nurse who discovered it three weeks ago and LVN 2 saw it 4 days prior to this home visit. LVN 2 cleansed it with the wound cleansing foam and covered it the dry dressing and secured with tape. LVN 2 further stated that he conducted a head to toe and skin assessment every visit. A review of Patient 7's "Current treatment/Medication/DME (durable medical equipment) list indicated no documented evidence an order was obtained for treatment for left forearm skin tear. A review of the hospice agency's policy titled "Interdisciplinary Group Meeting", revised April 2020, indicated that an interdisciplinary group meeting plan of care update form will be used for updates of the patient and family/caregiver and the attending physician. It will note changes , response to treatment and progress towards targeted outcomes, which may include: an increase or decrease in symptoms or acuity, nutritional status, pain management, condition of skin/presence /status of pressure ulcers and plan for changes in treatments and procedures. b. On 7/22/2022, a review of Patient 4's history of nursing assessment was conducted and indicated the recent documented nursing assessment was on 6/30/2022. There was no ongoing assessment done after 6/30/2022. Patient 4 was provided skilled nurse services weekly. During interview with Director of Patient Care Services (DPCS) on 7/22/2022, at 11:27 a.m., DPCS stated that Patient 4 had been visited and assessed every week. DPCS acknowledged Patient 4 had no nursing assessment documented after 6/30/22. DPCS stated he was going to follow up with the (Registered Nurse) RN who conducted the assessments. DPCS further stated per hospice agency's policy, all assessments must be documented within 48 hours.

Upon patient record review 2 of 5 (Patients #2 and 4) did not have evidence in the patient record that the comprehensive assessment identifies 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. Patient 2: There was no evidence of a spiritual care assessment. Patient 4: There was no evidence of a psychosocial assessment.

Based on observation, interview and record review, the hospice agency failed to review all medications the patients were taking and failed to update the medication profile with the currently used medications for two of 9 sampled patients (Patients 1, and 7). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. Findings: a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 2/11/22, with diagnosis which included atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your artery causing obstruction of blood flow). A review of Patient 1's plan of care (POC) /Interdisciplinary group (IDG,team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) review dated 5/19/22, included orders for the skilled nurse (SN) to visit once a week, and hospice aide (HA) to visit three times a week. The skilled nurse was to educate the patient, family, and/or caregiver to notify hospice regarding changes and to assess and monitor effectiveness of medications. On 7/21/2022, at 11:00 a.m., during a joint home visit with the Director of Patient Care Services (DPCS), Patient 1 was observed lying on a hospital bed, awake, alert and with periods of forgetfulness. On 7/21/2022 at 11:30 a.m., during a review of Patient 1's current medications, indicated, multivitamins with minerals 1 tablet by mouth daily, and Amitriptyline Hydrochloride (anti depressant) 10 milligram (mg) 2 tablet by mouth at bedtime were not found. However, the hospice's medication profile indicated the Patient 1 was taking these medications. On 7/21/2022 at 11:45 a.m., during an interview, DPCS stated the visiting nurse should always check patient's medications every visit and update the medication profile in the patient clinical records. b. A review of Patient 7's admission record indicated the patient was admitted to the hospice agency on 6/4/22, with a primary diagnosis of chronic obstructive pulmonary disease with acute exacerbation (COPD, with symptoms of exacerbation (flare-up) including tiredness or fatigue, more shortness of breath than usual, more coughing, more wheezing than usual, feeling unwell, feeling as if you have a cold, mucus changes, swollen legs or ankles, trouble sleeping, and other). On 7/21/2022 at 2:27 p.m., a home visit was conducted with LVN 1. Patient 7 was observed to be alert and oriented to name, person and time with periods of forgetfulness. Patient 7 was observed to be using oxygen via nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels), sat on the recliner and LVN 1 proceeded with his visit. On 7/21/2022, during the observation and medication review with LVN 1, revealed the following medications were not found at Patient 7's home. 1. Acephen Suppository 650 milligrams (mg-a unit of solid measurement) 1 suppository rectally every 4 hours as needed for mild pain or fever 2. Albuterol sulfate 0.083% 1-unit dose via Handheld nebulizer every 4 hours as needed for difficulty breathing or congestion 3. Ativan 2 milligram per milliliter (ml-liquid measurement) liquid give 1 milligram equals to 1 ml every 4 hours as needed for anxiety or agitation 4. Bisacodyl suppository give one suppository daily as needed for constipation. 5. Hyoscyamine 0.125 mg 1 tablet every 6 hours as needed for excessive secretions 6. Morphine sulfate 20 mg per ml give 5 mg equals to 0.25 mg every 2 hours as needed for mild pain and shortness of breath 7. Zofran oral disintegrating tablet (ODT) 4 mg give 1 tab every 6 hours as needed for nausea or vomiting. 8. Atorvastatin 20 mg 1 tablet daily for high cholesterol 9. Entresto 24 mg-26 mg take 0.5 mg tablet twice daily for atrial fibrillation (is an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart) On 7/21/2022 at 4:05 p.m., during an interview with LVN 1, he stated he checked the medication every visit. On 7/22/2022 at 9:17 a.m., during an interview with the DPCS stated the visiting nurse should always check patients medications every visit. A review of the policy titled, "Medication Profile", revised April 2020, indicated that patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profile will be updated for each change to reflect current medications and new and /or discontinued medications. A drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed , when care is resumed after a patient has been placed on hold, and with the addition of a new medication. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. Based on review of the medication profile as well as the written material, changes in the plan of care may be required. Deviations from taking medications as ordered will be documented in clinical notes, and the physician will be notified.

Based on interview, and record review, the hospice agency (HA) failed to provide the initial bereavement assessments (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 two of nine sampled patients (Patients 3 and 9). This deficient practice had the potential to impact a family members' abilities to cope with the patients' death. Findings: a. A review of Patient 3's clinical record indicated a start of care date (SOC) of 2/18/22, with diagnosis which included atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your artery causing obstruction of blood flow). A review of Patient 3's Plan of Care summary for the certification period of 2/18/22 to 4/18/22, indicated the skilled nurse (SN) was scheduled to visit patient two times a week and was receiving routine level of care. Patient 3 declined social worker and volunteer services. A review of Patient 3's clinical record indicated that there was no initial bereavement assessment conducted. b. A review of Patient 9's Face sheet indicated Patient 9's start of care date was on 4/27/22 with the diagnosis of malignant neoplasm of the pancreas (a form of cancer that begins in the organ lying behind the lower part of the stomach. The pancreas secretes enzymes that aid digestion and hormones that help regulate the metabolism of sugars. This type of cancer is often detected late, spreads rapidly, and has a poor prognosis). The frequency of visits indicated MSW (medical social worker) once per month plus one as needed, RN (Registered Nurse) once for evaluation and every 14 days for supervisory visit, SC (Spiritual counselor) once per month and one as needed, SN (Skilled Nurse) for continuous care for pain, comfort, and symptom management with RN assessment every 72 hours. Volunteer services was declined. A review of the HA's document titled IDG (interdisciplinary group, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Discussion/Updated Comprehensive Assessment Review dated 4/27/22 indicated Patient 7 was admitted on continuous level of care on first benefit period 4/27/22 to 7/25/22. Patient 7 had multiple comorbidities, has progressive physical impairment and increasing generalized weakness. Patient resides at residence with family and was received after a short hospital stay due to increased abdominal pain, nausea, and vomiting. Due to patient's progressive decline and worsening prognosis, daughter opted for hospice care for comfort, pain, and symptom management. Patient is on Do not resuscitate status (DNR, a legal order signed by a physician that specifies you do not want to be resuscitated in an emergency), comfort focused treatment only, no artificial means of nutrition. Patient has a KPS (Karnofsky Palliative Scale, an assessment tool for predicting of length of survival in terminally ill patients) of 40 percent which means unable to care for self, disabled, requires special care and assistance, a PPS (Palliative performance Scale, (a useful tool for measuring the progressive decline of a palliative resident) of 40 percent which means mainly in bed and unable to do activity. IDG team updated on patient's current condition. Start of continuous care as conferred with MD (medical doctor) with RN reassessment every 72 hours. On 7/20/2022, during a review of Patient 9's POC dated 4/27/22 indicated the goal of bereavement was for the grieving family to cope with changes. Bereaved will have access to grief counseling for 13 months. Bereaved will have knowledge of how to utilize bereavement services. Interventions indicated HA's to offer encouraging tips and resources to get through grief. Assist family with the grieving process. Assist primary bereaved in coping with the dying process and death and reassess post-death. Attentive listening, understanding their loss. Offer encouraging tips to get through grief. On 7/2220/22 during a review of the Patient 9's electronic medical chart indicated that there was no initial bereavement assessment conducted. During an interview with the Director of Patient Care Services (DPCS) on 7/22/2022, at 10:30 a.m., the DPCS stated that the bereavement assessment should be conducted on admission. The DPCS further stated that Patients 3 and 9 did not have an initial bereavement assessment conducted on admission. A review of the agency's policy and procedure titled, "Bereavement Services," revised April 2020, indicated a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented as needed.

Upon patient record review, 2 of 5 (Patients 2 and 5) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 2: There was no evidence of RN visit the weeks of 7/3/2022 or 7/10/2022 and no update to the comprehensive assessment for this timeframe. Patient 5: There was no evidence of an RN full assessment from 6/17/2022 through todays date 7/22/2022 and no update to the comprehensive assessment for this timeframe.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Condition of Participation for IDG, Care Planning and Coordination of Services were met as evidenced by: 1. The HA failure to ensure the interdisciplinary (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) group meetings were held by all the members of interdisciplinary group for 7 of 9 patients reviewed (Patients 1, 2, 3, 4, 5, 7 and 8) (Refer L541) 2. The HA's failure to ensure that each patient and primary caregivers receive education and training regarding the use of a comfort pack (hospice emergency medications) for 2 out of 9 sampled patients (Patient 4 and Patient 7) (Refer to L544) 3. The HA's failure to provide comfort packs readily available in the patient's home for symptom management of their terminal illnesses for 2 out of 9 sampled patients (Patient 4 and Patient 7) (Refer to L549) The cumulative systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Care Planning, and Coordination of services to ensure highest quality of care are provided to the patients accurately assessed to receive hospice care and services.

Based on interview and record review, the hospice agency (HA) failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings were held by all the members of interdisciplinary group to discuss the patient's comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process, ongoing assessments and care planning process for four of 13 sampled patients, (Patients 3, 5, 12 and 13). This deficient practice has a potential for the patient's 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. A review of Patient 3's clinical record indicated a start of care (SOC) date of 12/22/2020, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 8/1/2022, indicated skilled nurse (SN) frequency of visits of once per week and one as needed, Hospice Aide once per week, Social Worker (MSW) and Spiritual Counsellor (SC) on initial comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), recertification, and as needed. Volunteer service was declined. A review of Patient 3's "POC/IDG Review" dated 7/5/2022, 7/18/2022, and 8/1/2022, indicated the spaces for MSW signature were left blank. A review of the "IDG Log" dated 7/5/2022, 7/18/22, and 8/1/2022 indicated there was no MSW signature. During an interview with the Director of Patient Care Services (DPCS), on 9/12/2022, at 2:35 p.m., she stated that the IDG team meeting should be held every two weeks with participation of all the IDG members (Medical doctor, DPCS, SN, MSW and spiritual counselor) even though the patient had refused any of above service. She stated when the IDG members participated in the IDG meeting, they should have signed right away. The DPCS was not able to provide the documented evidence all the IDG members had participated in the IDG meeting for 7/5/2022, 7/18/2022, and 8/1/2022. c. A review of Patient 5's clinical record indicated Patient 5 started hospice care on 12/28/21, with a terminal diagnosis of COPD. It indicated the Medical Director was the referring/attending/patient choice doctor. A review of the POC/IDG Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The SN visit was once a week and as needed. The MSW visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. A review of the "POC/IDG Review" dated 7/5/2022, 7/18/22, 8/1/2022, 8/15/2022, 8/29/2022 indicated the spaces of signature for the social worker, were blank. A review of the "IDG Log" dated 7/5/2022, 7/18/22, 8/1/2022, 8/15/2022, 8/29/2022 did not indicate signatures of the social worker. During an interview with the DPCS on 9/12/2022, at 3 p.m., she was not able to provide the documented evidence that the social worker had participated in the POC/IDG meetings. d. A review of Patient 12's clinical record indicated the patient was admitted to the HA on 6/27/2022, with diagnosis of unspecified COPD. A review of Patient 12's POC/IDG, dated 7/05/2022, SN frequency of visits of once per week and one as needed. The HA, MSW, SC, and volunteer service were declined. A review of Patient 12's POC/IDG meeting record indicated blank spaces, no signatures to indicate the Medical MSW had participated the meetings on 7/05/2022, 7/18/2022/, 8/01/2022 and 8/15/2022. e. A review of Patient 13's clinical record indicated the patient was admitted to the HA on 6/28/2022, with diagnosis of unspecified COPD. A review of Patient 13's POC/IDG, dated 7/05/2022, indicated RN frequency of visits to once every two weeks plus one visit as needed, and LVN visit to once a week plus one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of Patient 13's POC/IDG meeting record indicated blank spaces, no signatures to indicate the MSW had participated the meetings on 7/05/2022, 7/18/2022/, 8/01/2022, 8/15/2022 and 8/29/2022. During an interview with the DPCS, on 9/12/2022, at 2:35 p.m., she stated that the IDG team meeting should be held every two weeks with participation of all the IDG members (Medical doctor, DPCS, SN, MSW and spiritual counselor) even though the patient had refused any of above service. She stated when the IDG members participated in the IDG meeting, they should have signed right away. The DPCS was not able to provide the documented evidence that all the IDG members had participated in the IDG meeting for Patient 12 and 13 on the above days. A review of the agency's policy and procedure titled "Interdisciplinary Group Meeting," revised April 2017, 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 patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. Members of the interdisciplinary group meeting will sign an attendance from that will be kept by the hospice Clinical Supervisor/Nursing Supervisor. A review of the agency's policy titled, "Interdisciplinary Group Coordination of Care" revised in April 2017, indicated the care will be provided by an interdisciplinary group made up of physicians, nurses, social workers, certified hospice aides, homemakers, clergy, counselors, volunteers, and therapists. The interdisciplinary group (in collaboration with the attending physician, if, any) will conduct assessment, develop and update the plan of care, and review the effectiveness of care at minimum of every two (2) weeks. Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the interdisciplinary (IDG) group members have attended the meetings held for 4 of 11 patients, (Patients 4, 5, 6 and 7). This deficient practice violated the HA's policies and had the potential for the patients' needed care and services to not be provided timely and/or supervised and had the potential for patient's not to receive the appropriate comfort nursing care and symptom management for their terminal illnesses. Findings: 1. A review of Patient 4's admission record indicated the patient was admitted to the hospice agency on 3/8/22, with a primary diagnosis of heart disease unspecified (a common heart condition that affects the major blood vessels that supply the heart muscle) and diabetes (abnormal blood sugar levels) due to underlying condition with diabetic polyneuropathy (a condition that affects the multiple peripheral sensory and motor nerves that branch out from the spinal cord into the arms, hands, legs and feet). A review of Patient 4's medical record titled, "POC/IDG Review", did not indicate the Spiritual Counselor (SC) attended IDG on 3/15/22, 4/13/22, 4/27/22, 5/24/22, 6/8/22, 6/29/22, 7/9/22, 7/17/22, 8/10/22, 8/24/22, 9/7/22. The Registered nurse (RN) did not attend on 4/27/22 and 7/17/22 and Social worker (SW) did not attend on 3/15/22,4/13/22, 4/27/22, 7/17/22 and 9/7/22. 2. A review of Patient 5's admission record indicated the patient was admitted to the HA on 5/28/22, with a primary diagnosis of acute systolic and diastolic congestive heart failure (the inability of the heart muscles to pump enough blood to meet your body's demands). A review of Patient 5's medical record titled "POC/IDG Review", did not indicate the Hospice RN attended IDG on 6/8/22, 7/13/22, 8/24/22, 9/7/22, SC did not attend on 6/8/22, 7/13/22, 7/27/22, 8/10/22, 8/24/22, SW did not attend on 9/7/22. 3. A review of Patient 6's admission record indicated the patient was admitted to the HA on 4/26/22, with a primary diagnosis of left ventricular failure (left heart failure occurs when there is dysfunction of the left ventricle, resulting insufficient delivery of blood to vital organs). A review of Patient 6's medical record titled "POC/IDG Review", did not indicate the Hospice SW attended the IDG on 6/8/22, SW did not attend the IDG meeting on 6/8/22 and SC on 5/17/22 and 6/8/22. 4. A review of Patient 7's admission record indicated the patient was admitted to the HA on 9/3/21, with a primary diagnosis of Alzheimer's disease (a general term for memory loss and other cognitive abilities serious enough to interfere with daily life). A review of Patient 7's medical record titled "POC/IDG Review", did not indicate the Hospice SC did not attend the IDG meetings on 9/4/21, 9/29/21, 10/3/21, 10/26/21, 11/10/21, 11/23/21, 2/1/22, 2/15/22, 3/2/22, 3/15/22, 3/30/22, 4/27/22, 5/25/22, 6/8/22, 6/29/22, 7/13/22, 7/27/22. RN did not attend on 11/23/21, 6/8/22, 7/27/22. SW did not attend the IDG meetings on 9/4/21 and 9/29/21. During an interview on 9/7/2022 at 12:30 p.m., with the RN2, RN2 admitted that the members of the IDG should sign at the end of each patient review. RN 2 further added that if it is not signed, the member did not show attendance for the meeting. A review of the HA's policy titled, "Interdisciplinary Group Meeting", revised April 2018 indicated that the interdisciplinary group (IDG) will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care (POC), deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certifications and recertifications of patients on the hospice program. Each patient's POC will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. The meeting will be facilitated by the hospice clinical supervisor/nursing supervisor or designee. The hospice medical director and all hospice interdisciplinary group members (IDG members) will be present including volunteers and attending physicians, as available. The patient/family caregiver will be informed of the schedule for this meeting, its purpose and that the discussion is confidential. Members of the IDG meeting will sign an attendance form that will be kept by the hospice clinical supervisor/nursing supervisor. A review of the HA's policy titled, "Interdisciplinary Group Membership and Responsibilities", revised April 2018, indicated the hospice interdisciplinary team/group (IDT/IDG) members will include Physician, Registered Nurse, Social worker and Pastoral or other counselor. Additional members may include Physical therapist, speech therapist, Occupational therapist, Registered Dietitian, Pharmacist, Home care aide/home maker and volunteer. f. A review of Patient 4's admission record indicated the patient was admitted on 2/16/22, with a primary diagnosis of Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment; can seriously affect a person's ability to carry out daily activities). Patient 4's document titled, "POC/IDG Review," dated 2/16/22, indicated the SOC started on 2/16/22, on routine care. There was no documented evidence the MD, MSW, and chaplain participated in the POC/IDG review on 2/16/22 and 7/14/22. There was no documented evidence the chaplain participated in the POC/IDG review on 5/19/2022. There was no documented evidence the MD participated in the POC/IDG review on 6/16/22 and 6/30/22. g. A review of Patient 5's admission record indicated the patient was admitted on 5/17/22, with a primary diagnosis of alcoholic cirrhosis of liver (a late stage of scarring of the liver caused by years of excessive drinking) with ascites (fluid build up in the abdomen, usually as a result of cirrhosis). Patient 5's document titled, "POC/IDG Review," dated 5/19/22, indicated the SOC started on 5/17/22 on routine care. There was no documented evidence the MD participated in the POC/IDG review on 5/19/22, 6/2/22, 6/16/22, 6/30/22, and 7/14/22. During interview with DPCS on 7/22/22, at 10:50 a.m., DPCS stated that all members of IDG attended the meeting and all members should have signed the IDG. DPCS stated that IDG was a team effort and required coordination from all team members, which was reflected by the signatures of all members in the POC/IDG review. DPCS acknowledged that if it was not documented/signed, it was not done. A review of the HA's policy no. 4.001.1 titled "Interdisciplinary Group Membership and Responsibilities" revised April 2020 indicated that the interdisciplinary group (IDG) will collaborate with the patients attending physician to develop an individualized written plan of care. The hospice IDG group membership includes at a minimum a physician, registered nurse, social worker, pastoral or other counselor. Additional members may include a physician assistant and or nurse practitioner, physical therapist, speech therapist, registered dietitian, pharmacist, homecare aide, volunteer, bereavement coordinator. The IDG responsibilities include but are not limited to participation in the periodic review and updating of the plan of care of each patient receiving hospice services. A review of the HA's policy no. 4-031.1 titled "Interdisciplinary Group Plan of Care" revised April 2020 indicated the IDG (in collaboration with the attending physician) will conduct assessments, develop, and update the plan of care, and review the effectiveness of care a minimum of every 15 calendar days. The attending physician will receive a copy of the care plan updates.

Based on observation, interview, and record review, the hospice agency failed to educate patients and their families on the use of a comfort pack (a small supply of medications kept at the home available to rapidly treat symptoms that occur to patients with terminal illness) for two of nine patients (Patients 7 and 2). This failure had the potential for the patient's symptoms of pain and bodily discomfort due to terminal illness will not be mitigated promptly and effectively. Findings: a. A review of Patient 7's admission record indicated the patient was admitted on 6/4/22, with a primary diagnosis of chronic obstructive pulmonary disease with acute exacerbation (symptoms of a COPD exacerbation (flare-up) include tiredness or fatigue, more shortness of breath than usual, more coughing, more wheezing than usual, feeling unwell, feeling as if you have a cold, mucus changes, swollen legs or ankles, trouble sleeping, and other). On 7/21/22, during the home visit observation and medication review with LVN (Licensed Vocational Nurse) 1, it was revealed Patient 7 did not have a comfort pack available for symptom management. During a concurrent interview with LVN 1, stated SN (Skilled Nurse) reviewed medication every visit and the daughter take care of the patients' medications. LVN 1 called the daughter via phone call and daughter stated that the comfort pack was not delivered. Patient 7's wife at bedside also confirmed that she did not receive any comfort pack. On 7/21/22, at 4:31 p.m., during a phone interview with Patient 7's daughter, stated she did not know what a comfort pack was and the use of its contents and had not seen it in the patient's home. The daughter further stated that she was not there during Patient 7's admission to hospice. A review of Patient 7's document titled "Current Treatment/Medication/DME (Durable medical equipment) List indicated that a comfort pack contains the following medications: 1. Acephen Suppository 650 milligrams (mg-a unit of solid measurement) 1 suppository rectally every 4 hours as needed for mild pain or fever 2. Albuterol sulfate 0.083% 1-unit dose via Handheld nebulizer every 4 hours as needed for difficulty breathing or congestion 3. Ativan 2 milligram per milliliter (ml-liquid measurement) liquid give 1 milligram equals to 1 ml every 4 hours as needed for anxiety or agitation 4. Bisacodyl suppository give one suppository daily as needed for constipation. 5. Hyoscyamine 0.125 mg 1 tablet every 6 hours as needed for excessive secretions 6. Morphine sulfate 20 mg per ml give 5 mg equals to 0.25 mg every 2 hours as needed for mild pain and shortness of breath 7. Zofran oral disintegrating tablet (ODT) 4 mg give 1 tab every 6 hours as needed for nausea or vomiting. All listed medications were not found at Patient 7's home. On 7/22/22 at 9:17 a.m., during an interview with the Director of patient Care services (DPCS) stated the visiting nurse should always review patient's medications every visit. DPCS also stated that they do not have a specific policy for comfort packs and follows only the pharmacy contract. b. A review of Patient 4's admission record indicated Patient 4 was admitted on 2/16/22, with a primary diagnosis of Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment; can seriously affect a person's ability to carry out daily activities). A home visit with LVN 1 was conducted on 7/21/22 at 12:55 p.m. Patient 4 was observed to be alert and oriented to name. Patient 4 was sitting on her bed with side rails down. A rollator (a frame that has four wheels, brakes, handlebars, and a seat that gives you support when walking) was observed in Patient 4's room. LVN 1 proceeded with his assessment. During a phone interview with on 7/22/22 at 9:38 a.m., Patient 4's caregiver (FM 2) stated that the hospice staff never provided the patient a comfort pack. FM 2 stated that she had requested a comfort pack when Patient 4 was first admitted to the hospice. FM 2 also stated that she had asked for a comfort pack multiple times, but still had not provide Patient 4 with one. When asked if the hospice staff had discussed about comfort pack, FM 2 stated that none of the staff had spoken about comfort pack. FM 2 stated that she knew about comfort pack from her experience taking care of her own mom, who used to be a patient from of a different hospice agency. A review of Patient 4's "Current Treatment/Medication/DME List" indicated that a comfort pack was never ordered. A review of Patient 4's comprehensive nursing assessment dated 2/16/2022 indicated that the admitting nurse did not order a comfort pack or spoke about it with Patient 4's caregiver. A review of Patient 4's updated assessments dated 3/21/22, 5/24/22, and 6/30/22 indicated the visiting nurse did not place an order for a comfort pack or discuss it with FM 2. During an interview with LVN 1 on 7/22/22, at 10:21 a.m., LVN 1 stated when the hospice agency admitted a patient, they would assess the needs of the patient, including whether they needed a comfort pack or not. He stated that "Probably the nurse who admitted the patient didn't see the need for a comfort pack." During an interview with Director of Patient Care Services (DPCS) on 7/22/22, at 10:38 a.m., DPCS stated that when he admitted Patient 4 to the hospice agency, Patient 4 did not have any pain that required pain medications or a comfort pack. DPCS said that they had a contract with a pharmacy to deliver medications between 2-3 hours for a standard order, 2 hours for a stat order and 1-2 hours for a super stat order. DPCS said that it might take longer for the pharmacy to fill an order. DPCS stated that he had talked and educated FM 2 on comfort pack. A review of the narrative in Patient 4's comprehensive assessment dated 2/16/2022 and updated assessments dated 3/21/22, 5/24/22, and 6/30/22, DPCS acknowledged that the records indicated education and/or discussion on comfort pack never took place. DPCS stated, "If it wasn't documented, it wasn't done." A review of the policy no. 4-027.1 and policy no. 4-027.3 titled "The Plan of Care" A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The written plan of care will contain but will not be limited to patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching and their ability to safely self-administer drugs and biologicals.

Based on observation, interviews and record reviews, the hospice agency failed to ensure comfort packs (a small supply of medications kept at the home available to rapidly treat symptoms that occur to patients with terminal illness) for terminal illness symptom management were provided to two of nine patients, (Patient 4 and Patient 7). This deficient practice had the potential to delay interventions to provide comfort and symptoms relief related to the terminal illness and related conditions. Findings: a. A review of Patient 4's admission record indicated the Patient 4 was admitted on 2/16/22, with a primary diagnosis of Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment; can seriously affect a person's ability to carry out daily activities). A home visit with Licensed Vocational Nurse (LVN) 1 was conducted on 7/21/22, at 12:55 p.m., at Patient 4's residence. Patient 4 was observed to be alert and oriented to name. Patient 4 was sitting on her bed with side rails down. A rollator (a frame that has four wheels, brakes, handlebars, and a seat that gives you support when walking) was observed in Patient 4's room. LVN 1 proceeded to conduct Patient 4's assessment. During a phone interview with on 7/22/22 at 9:38 a.m., Patient 4's caregiver (FM 2) stated the hospice staff never provided comfort pack. FM 2 stated she had requested a comfort pack when Patient 4 was first admitted to the hospice agency. FM 2 stated she had asked for a comfort pack several times after Patient 4's admission, but had not received the kit. FM 2 further stated the hospice staff did not provide any information of the availability and emergency use of the comfort kit. A review of Patient 4's comprehensive nursing assessment dated 2/16/2022, indicated that the admitting nurse did not order a comfort pack or spoke about it with Patient 4's caregiver. A review of Patient 4's updated assessments dated 3/21/22, 5/24/22, and 6/30/22, indicated the visiting nurse did not place an order for a comfort pack or discussed it with FM 2. A review of Patient 4's "Current Treatment/Medication/DME List" indicated no evidence the comfort pack was ordered by the physician. During an interview with LVN 1 on 7/22/22, at 10:21 a.m., LVN 1 stated, whenever the hospice staff admit a patient for hospice services, they would assess the needs of the patient, including the need to be provided with a comfort pack. LVN 1 stated, "Probably the nurse who admitted the patient didn't see the need for a comfort pack." During an interview with Director of Patient Care Services (DPCS) on 7/22/22 at 10:38 a.m., DPCS stated when he admitted Patient 4 for hospice services the patient did not have any pain that required pain medications or a comfort pack. DPCS stated they had a contract with a pharmacy to deliver medications between 2-3 hours for a standard order, 2 hours for a STAT (most urgent or rush) order and 1-2 hours for a super STAT order. Further interview with DPCS stated he had talked and educated FM 2 regarding the emergency use of the comfort pack. However during a review of Patient 4's comprehensive assessment dated 2/16/2022 and updated assessments dated 3/21/22, 5/24/22, and 6/30/22, revealed no evidence education and/or discussion on the need of comfort pack was conducted. DPCS acknowledged it was not documented, "If it wasn't documented, it wasn't done." A review of the Pharmacy contract "Article 4: Responsibilities of the Pharmacy" signed and dated on 2/9/22, indicated that in an effort to meet the pharmaceutical and biological needs of the patient, services will include but not limited to: Pharmacy will be available during the Pharmacy's normal business hours to meet the needs of the hospice patients. Encino Care Pharmacy II and Skyline Hospice, Inc will arrange delivery of drugs in a timely manner to meet each patient's needs; overnight shipping, direct delivery and nursing pick up. Pharmacy will have needed-medications orders ready within 6-8 hours of order and STAT orders within 4 hours. Pharmacy and hospice will arrange delivery of drugs in a timely manner to meet each patient's needs, overnight mail, UPS, direct delivery. b. A review of Patient 7's admission record indicated the Patient 4 was admitted to the hospice agency on 6/4/22, with a primary diagnosis of chronic obstructive pulmonary disease with acute exacerbation (symptoms of a COPD exacerbation (flare-up) include tiredness or fatigue, more shortness of breath than usual, more coughing, more wheezing than usual). On 7/21/22, at 2:27 p.m., a home visit was conducted with LVN 1 at Patient 7's residence. Patient 7 was observed sitting on a recliner, alert and oriented to name, person and time with periods of forgetfulness. Patient 7 was observed to be using his oxygen via nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels). LVN 1 proceeded to perform Patient 7's health assessment. On 7/21/22, during a review of Patient 7's medication with LVN 1, it was noted Patient 7 did not have a comfort pack available for symptom management. During a concurrent interview with LVN 1 stated that he reviews medication every visit and the daughter takes care of the patients' medications. LVN 1 called the daughter via telephone and she stated the comfort pack was not delivered. Patient 7's wife at bedside also confirmed that she did not receive any comfort pack. A review of Patient 7's document titled "Current Treatment/Medication/DME (Durable medical equipment) List indicated a comfort pack contains the following medications: 1. Acephen Suppository 650 milligrams (mg-a unit of solid measurement) 1 suppository rectally every 4 hours as needed for mild pain or fever 2. Albuterol sulfate 0.083% 1-unit dose via Handheld nebulizer every 4 hours as needed for difficulty breathing or congestion 3. Ativan 2 milligram per milliliter (ml-liquid measurement) liquid give 1 milligram equals to 1 ml every 4 hours as needed for anxiety or agitation 4. Bisacodyl suppository give one suppository daily as needed for constipation. 5. Hyoscyamine 0.125 mg 1 tablet every 6 hours as needed for excessive secretions 6. Morphine sulfate 20 mg per ml give 5 mg equals to 0.25 mg every 2 hours as needed for mild pain and shortness of breath 7. Zofran oral disintegrating tablet (ODT) 4 mg give 1 tab every 6 hours as needed for nausea or vomiting. On 7/21/22, at 4:31 p.m., during a phone interview with Patient 7's daughter, stated she did not know what a comfort pack was and had not seen it in the patient's home. On 7/21/22 at 4:50 p.m., during a phone interview with pharmacist on call stated that on their receipt indicated that the comfort pack was delivered in 5/19/22 at 5:56 p.m.. On 7/22/22 at 9:17 a.m., during an interview with the Director of patient Care services (DPCS) stated that after the evaluation depending in how the pharmacy deliver between 2-3 hours for a standard order, 2 hours for a stat order and 1-2 hours for a super stat order. DPCS also stated "It depends sometimes it may take longer". Per DPCS, the visiting nurse should always review patient's medications every visit. DPCS also stated that they do not have a specific policy for sending out medications and follows the pharmacy contract. A review of the Pharmacy contract "Article 4: Responsibilities of the Pharmacy" signed and dated on 2/9/22, indicated in an effort to meet the pharmaceutical and biological needs of the patient, services will include but not limited to: Pharmacy will be available during the Pharmacy's normal business hours to meet the needs of the hospice patients. Encino Care Pharmacy II and Skyline Hospice, Inc will arrange delivery of drugs in a timely manner to meet each patient's needs; overnight shipping, direct delivery and nursing pick up. Pharmacy will have needed-medications orders ready within 6-8 hours of order and STAT orders within 4 hours. Pharmacy and hospice will arrange delivery of drugs in a timely manner to meet each patients needs, overnight mail, UPS, direct delivery. A review of the Pharmacy contract "Article 5: Responsibilities of Hospice" signed and dated on 2/9/22, indicated that Hospice is responsible for communication of all authorized prescriptions to pharmacy via telephone contact from Hospice's authorized representative or via Pharmacy's form; Hospice will assess and evaluate the drug and supply needs of each patient consulting with the interdisciplinary team, pharmacist as necessary, and obtaining physician's orders as needed. Hospice will keep records as appropriate of pharmacy consultation to be kept in patient's chart.

Upon client record review, 3 of 5 (Patients #2, #3, #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: RN visits ordered at SOC for 1 x week. There was no evidence of an RN visit or missed visit the weeks of 3/20/2022, 7/3/2022, or 7/10/2022. Patient 3: SN ordered 2x week at SOC. There was no evidence of a SN visit or missed visit week of 7/10/2022. Patient 5: RN visits ordered Q14 days at SOC, last RN visit documented 6/17/2022, missing visit for 7/1/2022, and 7/15/2022.

Based on interview and record review, the hospice agency failed to perform COVID 19 virus (respiratory disease caused by the SARS-CoV-2 virus) screening for 1 out of 9 sampled patients (Patient 1) before providing care in the patients' homes. This failure placed the patient and others at risk for contracting the COVID 19 virus and spread of infection. Findings: A review of Patient 1's clinical record indicated a start of care date (SOC) of 2/11/22, with diagnosis which included atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your artery causing obstruction of blood flow). A review of Patient 1's "Recertification Assessment" for the benefit period from 5/12/22 to 8/09/22, indicated Patient 1 was alert, oriented x 3 to person, place and time with episodes of forgetfulness, and dependent on walker or cane for ambulation with moderate assistance. It also indicated hospice staff should follow COVID-19 infection precaution guidelines for all health care professionals and will utilize personal protective equipment (PPE, like gowns, gloves, and mask) every visit. A review of Patient 1's "Visit Note LVN (Licensed Vocational Nurse)" dated 7/07/22 and 7/13/22, indicated the space for "COVID-19 Screening" was left blank (there was no documentation). On 7/22/22, at 10:30 a.m., during a concurrent interview and record review regarding Patient 1's electronic medical record, the Director of Patient Care Services (DPCS) stated that agency staff should do COVID-19 screening before all scheduled visits. The DPCS stated that nurses would call patients and/or patient's caregiver before their visit to prescreen them for COVID-19 and then it is logged into the patient's electronic medical record. The DPCS was unable to provide documentation that Patient 1 had COVID-19 screening on 7/07/22 and 7/13/22 before the scheduled skilled nurse home visit.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Core Services was met as follows: 1. The hospice agency failed to ensure bereavement services (emotional, psychosocial, and spiritual support services provided to the family before and after the death of the patient to assist the family in coping with issues related to grief, loss, and adjustment) were offered and provided for Patient 9 who passed away while on continuous care. Refer to L 596. 2. The hospice agency failed to ensure 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) was updated and the family/caregiver's needs were discussed and documented after the patients' death for 2 of 2 patients that passed, in a sample of 9 (Patient 3 and 9). Refer to L 596. The cumulative systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Core Services to ensure and anticipate grief reaction of the bereaved and providing an ongoing support to the family members after the hospice patient dies.

Based on interview and record review, the hospice agency failed to ensure 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) was updated and the family/caregiver's needs were discussed and documented after the patients' death for two of two patients, in a sample of 9, (Patients 9 and 3). This deficient practice placed the family at a potential risk for not receiving support and preparation after the patients' death. Findings: a. A review of Patient 9's Face sheet (admission record) indicated Patient 9's start of care date was on 4/27/22 with the diagnosis of malignant neoplasm of the pancreas (a form of cancer that begins in the organ lying behind the lower part of the stomach. The pancreas secretes enzymes that aid digestion and hormones that help regulate the metabolism of sugars. This type of cancer is often detected late, spreads rapidly, and has a poor prognosis). A review of the hospice document titled, IDG (interdisciplinary group, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Discussion/Updated Comprehensive Assessment Review dated 4/27/22 indicated Patient 7 was admitted on continuous level of care on first benefit period 4/27/22 to 7/25/22. Patient 7 has multiple comorbidities, has progressive physical impairment and increasing generalized weakness. Patient resides at residence with family and was received after a short hospital stay due to increased abdominal pain, nausea and vomiting. Due to patient's progressive decline and worsening prognosis, daughter opted for hospice care for comfort, pain and symptom management. Patient is on Do not resuscitate (DNR, a legal order signed by a physician that specifies you do not want to be resuscitated in an emergency) status, comfort focused treatment only, no artificial means of nutrition. Patient has a KPS (Karnofsky Palliative Scale, an assessment tool for predicting of length of survival in terminally ill patientsof 40 percent which means unable to care for self, disabled, requires special care and assistance) a PPS (Palliative performance Scale, a useful tool for measuring the progressive decline of a palliative resident) of 40 percent which means mainly in bed and unable to do activity. IDG team updated on patient's current condition. Start continuous care as conferred with MD (medical doctor) with RN (Registered Nurse) reassessment every 72 hours. On 7/20/2022, during a review of Patient 9's POC dated 4/27/22, indicated the goal of bereavement included for the grieving family to cope with changes. Bereaved will have access to grief counseling for 13 months. Bereaved will have knowledge of how to utilize bereavement services. Interventions indicated the hospice agency to offer encouraging tips and resources to get through grief. Assist family with the grieving process. Assist primary bereaved in coping with the dying process and death and reassess post-death. Attentive listening, understanding their loss. Offer encouraging tips to get through grief. The plan of care (POC) included MSW (medical social worker) once per month plus one as needed, RN (Registered Nurse) once for evaluation and every 14 days for supervisory visit, SC (Spiritual counselor) once per month and one as needed, SN (Skilled Nurse) for continuous care for pain, comfort and symptom management with RN assessment every 72 hours. Volunteer services was declined. A review of the communication log dated 5/5/22 at 3:17 a.m., hospice staff received a call from CC (continuous care, during a period of crisis, in which a patient requires continuous care that is predominantly nursing care to achieve palliation or management of acute medical symptoms necessary to maintain an individual at home) nurse stating that Patient 7 fell from the bed, CC was asking help from the patients daughter to bring patient back to bed but daughter refused stated that "Do not touch" patient and will call the paramedics. Daughter requested CC nurse to leave. At 3:27 a.m., RN made an outbound call to PCG (patient caregiver) and asked about Patient 9's condition and confirmed that she did fell from the bed and patient is now dead and not breathing. Family stated they are calling the mortuary now, RN will send a nurse as soon as possible to assess the patient and help them process everything, PCG agreed with verbalized understanding via phone call. At 4:00 a.m., hospice staff reported to the medical director that Patient 9 had expired and obtained order for discharge. A review of the document titled "Incidence Occurrence", indicated Patient 9 was under the care of Licensed Vocational Nurse 2 (LVN) starting 7:00 p.m., (32 hours of care). LVN 2 and other nurses were instructed to use the dining room table for computer charting for family was not able to provide a TV tray for nurses to stay inside the Patient 9's room. Family instructed LVN 2 to use their sofa or recliner to sleep or rest (to feel like at home). On 5/4/22, LVN 2 learned that family does not want to help during repositioning or incontinence care. LVN 2 informed HA. At 3:00 a.m., the same date, LVN 2 noticed that Patient 9 apparently had a sliding fall and found her on a fetal position on the floor next to the hospital bed. LVN 2 touched Patient 9's arm, skin felt cool, not stiff and had vomited in the small pillow. LVN 2 indicated she took all safety precautions, side rails up checking the patient often. On 7/22/22, during a review of the Patient 9's electronic medical chart indicated there was no documented evidence that post death assessment was conducted and the family/caregiver's needs were discussed after Patient 9's death. During a concurrent record review of Patient 3 and 9's electronic medical record and interview with the Director of Patient Care Services (DPCS), on 7/22/2022 at 10:30 a.m., the DPCS stated, "I am unable to provide the updated bereavement assessment for both patients." b. a. A review of Patient 3's closed clinical record indicated a start of care date (SOC) of 2/18/2022, with diagnoses which included atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your artery causing obstruction of blood flow). A review of Patient 3's "Discharge Summary" indicated hospice services ended on 3/21/2022, due to death. A review of the closed clinical record indicated no documented evidence that bereavement assessment was updated and the family/caregiver's needs were discussed after Patient 3's death. A review of the agency's policy and procedure titled, "Bereavement Services," revised April 2020, indicated within three to five weeks after the patient's death, a bereavement assessment will be completed by the bereavement counselor following the family/caregiver. This assessment will note and observe the bereaved for symptoms related to grief. The bereavement counselor will render a professional judgement as to whether the bereaved is experiencing normal grief, moderate grief, or a severe grief reaction.

Upon personnel record review, 4 of 6 (Personnel #1, #2, #4, #6 ) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel 1, 2, 4, 6 : There was no evidence of orientation on hospice philosophy.

Upon personnel record review, 4 of 6 (Personnel #1, #2, #4, #6) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 1, 2, 4, 6: There was no evidence of orientation specific to job requirements.

Upon personnel record review, 2 of 4 applicable (Personnel #2, #6) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 2 and 6: There was no evidence that a skills competency assessment had been performed during orientation (no proof of orientation).

Upon contract review, 2 of 2 (Medical Director and Alternate Medical Director) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable. The agency was not able to produce a contract for the Medical Director or Alternate Medical Director and no evidence that they were employed by the agency either. The Medical Director and Alternate Medical Director were functioning in these roles and identified by the staff.

Upon patient record review, 2 of 5 (Patients #3 and 5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patients 3 and 5 the certification of terminal illness narrative stating according to nursing notes and previous medical records patient is eligible for hospice, no further details.

Upon patient client record review, 5 of 5 (Patients #1, #2, #3, #4, #5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patients 1, 2, 3, 4, 5: There was no evidence of appropriately authenticated entries in the electronic medical records. Dozens of clinical documents were not signed.

Upon personnel record review, 1 of 1 applicable (Personnel #6) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 6: There was no evidence of a criminal background check.

Upon personnel record review, 5 of 5 applicable (Personnel #1, #2, #3, #4, #5) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel 1, 2, 3, 4, 5: There was no evidence of a criminal background check.