Every finding on record at Solid Hospice Care, Inc.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years.

Upon patient record review, 1 of 14 (Patient #6) 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. Patient #6-Patient was admitted 03/15/23. Initial bereavement assessment completed late on 03/27/23.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #4-MSW visits ordered for initial, at recert and PRN without number of PRN visits or indication for PRN visits.

Upon patient record review, 3 of 14 (Patient #1, 2, 7) 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-Record indicated order for triamcinolone cream 1% apply to affected area Q8 hours. Order did not identify the location for application. Corrected on-site. Patient #2-Record indicated order for Diclofenac topical gel 1% apply to affected area 2xday. Order did not identify the location for application. Corrected on-site. Patient #7-Record indicated order for Diclofenac topical gel 1% apply to affected area 2xday. Order did not identify the location for application. Corrected on-site.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #11-Patient discharged on 05/01/2024. Record did not contain evidence of discharge planning.

Upon client record review, 1 of 14 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8-Visit frequencies for SN was indicated as 1x week and PRN. There was no evidence of RN for weeks of 8/04, 08/18, 08/25, 09/01. (Separate frequency order for LVN visits 1x week and PRN met by visiting LVN.)

Upon patient record review, 5 of 14 (Patient #3, 4, 6, 8, 9) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #3-The aide care plan contained two separate visit frequencies. One frequency stated 2x per week and one stated 1x per week. Corrected on-site. Patients #4, #6-The aide visit frequency to be 1xweek. Aide care plan frequency stated: aide declined. Corrected on-site. Patient #8-The records indicated aide frequency to be 1x week and PRN. Aide care plan frequency states 1x week. Corrected on-site. Patient #9-There was no visit frequency indicated on aide care plan. Corrected on-site.

Based on interview and record review, the hospice agency (HA) failed to ensure notice of informations for six of 14 patients, (Patients 1, 2, 6, 9, 10 and 11), were written, explained, and provided in a language the patient could understand. This deficient practice resulted in the patients not understanding what hospice services are and its purpose and had the potential to affect the patients quality of life and quality of care. --- c. A review of Patient 9s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 7/8/22, with a primary diagnosis of fibromyalgia (widespread muscle pain and tenderness. This same document indicated that Patient 9s primary language was Spanish. A review of Patient 9s ";Physician Certification for Hospice Benefit (CTI)", indicated that Patient 10 was on certification # 4: re-certification statement for next 60-day period for certification period 3/5/23 to 5/3/23. Patient 9s secondary diagnoses included gastroesophageal reflux disease (GERD-acid reflux, a digestive disease in which stomach acid irritates the food pipe lining) and age-related physical debility. During an interview on 2/23/23, at 10:57am, Patient 9 stated that she did not know what hospice was, but she is on a program where she gets diapers, ensure (nutritional drink) and medications. Patient 9 stated that she does not have a terminal illness and no medical doctor ever told her she had six months or less to live. A review of Patient 9s admission consent forms including ";Patient/Family Bill of Rights", were in English and signed and dated by Patient 9 on 7/8/22. d. A review of Patient 10s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 11/21/22, with a primary diagnosis of hypertensive heart disease with heart failure (condition of high blood pressure causing the heart not to pump and function properly). Patient 10s Primary language was documented as Spanish on their Personal Information Sheet. A review of Patient 10s ";Physician Certification for Hospice Benefit (CTI)", indicated that Patient 10 was on certification #2: re-certification statement for second 90-day period for certification period 2/19/23 to 5/19/23. Patient 10s CTI indicated secondary diagnoses of hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone which can disrupt heart rate, body temperature and metabolism), type 2 diabetes (chronic condition that affects the way the body processes blood sugar) and physical age debility ( age related decline including weakness, fatigue, poor appetite and weight loss). During a phone interview on 3/22/23, at 11am, Patient 10 stated that she is not on hospice, it is a different program, but does not know the name. Patient 10 stated that she did not have a terminal illness and was not dying. Patient 10 stated that she was told by the nurse that the program that for the she is on, a nurse would come and check on her, give her medicine and any supplies that he needs. A review of Patient 10s admission consent forms including ";Patient/Family Bill of Rights", were in English and signed and dated by Patient 10 on 11/21/22. e. A review of Patient 11s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 11/3/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a lung disease that blocks airflow and makes it difficult to breathe). A review of Patient 11s Physicians Certification for Hospice Benefit (CTI), indicated that Patient 10 was on certification #2: re-certification statement for second 90-day period, with certification date 2/1/23 to 5/1/23. Patient 9s secondary diagnoses included GERD, chronic pain, and muscle weakness and physical debility. During an interview on 3/22/23, at 10:50am, Patient 11 stated that he does not know the hospice agency and he does not know what hospice is and he did not have a terminal illness. During an interview on 3/23/23, at 11:08am, Licensed Vocational Nurse 3 (LVN 3) stated that during admission the admitting nurse explains what hospice is. Then if the patient have any further questions then LVNs can explain more during the home visits. During an interview on 3/23/23, at 5:20pm, the Administrator/Director of Patient Care Services (ADM/DPCS) stated that during admission the registered nurse explains hospice benefits and rights with the patient and the patient signs the consents. ADM/DPCS stated that the patients gets a copy of consent and should be placed in hospice binder. ADM/DPCS stated that they explain to them what hospice is, what services are offered and explain that it is end of life care for those who have been diagnosed with terminal illness. a. A review of Patient 2s Patient Information Sheet, indicated a start of care (SOC) date of 10/28/2022, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). Patient 2s primary language was listed as Spanish. There was no Authorized Representative (AR)/Emergency Contact (EC) indicated for Patient 2. A review of Patient 2s "Physician's Certification for Hospice Benefit," (CTI #2) for the second 90- day period from 1/26/2023 to 4/25/2023, indicated a terminal diagnosis of hypertensive heart disease with heart failure. A review of Patient 2s Informed Consent and Medicare/Medi-Cal Election of Hospice Benefit, dated 10/28/2022, indicated the form was written in English and was signed by Patient 2. A review of Patient 2s Telehealth Visit and Authorization for Hospice Services, date 10/28/2022, indicated the form was written in English and was signed by Patient 2. The space for the signature of interpreter and date on the form was blank. b. A review of Patient 6s Patient Information Sheet indicated a start of care (SOC) date of 9/26/2022, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). Patient 6s primary language was listed as Spanish. There was no Authorized Representative (AR)/Emergency Contact (EC) indicated for Patient 6. A review of Patient 6s "Physician's Certification for Hospice Benefit," (CTI #2) for the second 90- day period from 12/25/2025 to 3/24/2023, indicated a terminal diagnosis of hypertensive heart disease with heart failure. A review of Patient 6s Informed Consent and Medicare/Medi-Cal Election of Hospice Benefit, dated 9/26/2022, indicated the form was written in English and was signed by Patient 6. A review of the hospice agencys (undated) policy titled, ";Patient Bill of Rights/Responsibilities" indicated that 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 failed to ensure the Condition of Participation for Initial and Comprehensive Assessment of the Patient was met as evidenced by: 1. The Hospice Agency (HA) failed to conduct an accurate comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patients current health status and identified the patients needs for hospice care and services related to eligibility and management of the terminal illness, for six of 14sampled patients, (Patients 1, 4, 6, 9, 11, and 12). This deficient practice resulted in the provision of hospice services who were not clinically eligible to receive hospice care and services. (Refer to L524). 2. The hospice agency (HA) failed to review all medications and update the medication profiles with the currently used medications for two of 14 sampled patients, (Patients 3 and 9). The deficient practice resulted in patients not receiving medications as ordered by the physician and had a potential to result in adverse side effects if the medications were not administered timely. (Refer to L 530). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Patient's Rights to protect and promote the rights, of the patient in the hospice agency. --- .

Based on observation, interview, and record review, the hospice agency failed to conduct an accurate comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patients current health status and identified the patients needs for hospice care and services related to eligibility and management of the terminal illness, for six of seven sampled patients, (Patients 1, 4, 6, 9, 11, and 12). This deficient practice resulted in the provision of hospice services who were not clinically eligible to receive hospice care and services. --- d. A review of Patient 9s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 7/8/22, with a primary diagnosis of fibromyalgia (widespread muscle pain and tenderness. This same document indicated that Patient 9s primary language was Spanish. A review of Patient 9s ";Physician Certification for Hospice Benefit (CTI)", indicated that Patient 10 was on certification # 4: re-certification statement for next 60-day period for certification period 3/5/23 to 5/3/23. Patient 9s secondary diagnoses included gastroesophageal reflux disease (GERD-acid reflux, a digestive disease in which stomach acid irritates the food pipe lining) and age-related physical debility. The RN (registered nurse) progress summary indicated the following assessment of Patient 9.... ...Patient is alert and responsive but is confused and disoriented x3. Her speech is limited to approximately 6 words in the entire conversation/assessment. Speech is garbled, difficult to understand. No meaningful verbal communication. KPS (Karnofsky score-a simple and rapid method to assess patient performance in activities of daily living [ADLs]) score 40 (indicating that patient is disabled: requires special care and assistance) and PPS (Palliative Performance Scale-can inform decisions about a patients hospice eligibility by helping clinicians recognize a patients functional decline) score of 40 (indicating that patient is mainly in bed and drowsy with confusion). NYHA (The New York Heart Association classification tool to classify the extent of heart failure) score IV (indicating that the patient has severe limitation of functional status. Symptoms of fatigue, palpitations, chest pain, dyspnea and syncope can be present with minimal physical activity and even at rest). Can not ambulate without assistance of walker and one person assist. Cannot sit up without assistance. She is totally dependent on caregiver in all her ADL needs, bathing, dressing, personal hygiene, transfer, locomotion due to generalized weakness and confusion. Patient 9s CTI had a NYHA score of IV, but there is no indication that Patient 9 has been diagnosed with heart failure. On 3/23/2023 at 10:30 am, a joint home visit was conducted with Licensed Vocational Nurse 3 (LVN 3) at Patient 9s home residence. Patient 9 was observed as being alert and oriented to person, place, time and situation. Primary Spanish speaking, speech was not garbled nor was it limited. Patient was able to make herself understood. Patient 9 lived by herself, she did not have a caretaker, her daughter would come to visit, but she was independent for ADLs including bathing, dressing, personal hygiene and transferring. Patient 9 stated that she uses a walker when she goes out of the house, but in the home, she does not need it. During an interview on 2/23/23, at 10:57am, Patient 9 stated that she does not have a terminal illness and no medical doctor ever told her she had six months or less to live. During a telephone interview on 3/25/23, at 1:45pm, primary care physician 3 (PCP 3) stated that he still sees Patient 9 in the clinic. Last visit was on 2/22/23. PCP 3 stated that he did not refer Patient 9 to hospice and was unaware she was under hospice. PCP 3 stated that Patient 9 is not terminal, he follows her regularly. She has old diagnosis of stomach cancer, but is cured now. Patient 9 just has fibromyalgia, which is chronic but not terminal. A review of Patient 9s LCD Hospice Eligibility Determination sheet, indicated that patient does not qualify for hospice per LCD guidelines. During an interview on 3/235/23, at 5:20pm, the Administrator/Director of Patient Care Services (ADM/DPCS) stated that he was not the admitting nurse for Patient 9 and never visited her, but stated he was familiar with her case. ADM/DPCS reviewed Patient 9s chart and stated her terminal diagnosis was fibromyalgia. ADM/DPCS stated that fibromyalgia alone will not qualify for terminal illness, but a combination of conditions it can be terminal. When asked what other condition Patient 9 had that contributed to her terminal illness; ADM/DPCS stated heart disease. Patient 9s CTI was reviewed with ADM/DPCS, there is no heart disease listed. e. A review of Patient 11s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 11/3/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a lung disease that blocks airflow and makes it difficult to breathe). A review of Patient 11s Physicians Certification for Hospice Benefit (CTI), indicated that Patient 10 was on certification #2: re-certification statement for second 90-day period, with certification date 2/1/23 to 5/1/23. Patient 9s secondary diagnoses included GERD, chronic pain, and muscle weakness and physical debility. According to the certifying physician summary, it indicated that Patient 10 presented with chronic fatigue and requires ADL (activities of daily living) assistance for most of his needs. Continued poor prognosis and worsening physical decline. Patient continues to need supportive devices, special transportation, or assistance to leave residence due to illness. A review of Patient 11s LCD Hospice Eligibility Determination sheet, indicated under Pulmonary Disease-section b, that Patient 9 had increasing visits to the ER (emergency room), hospitalization for pulmonary and respiratory failure. There was no evidence in Patient 9s medical record of this being accurate. During a telephone interview on 3/22/23, at 10:50am, Patient 11 stated that he does not have a terminal illness, he does not use oxygen and he can still go out independently and can drive himself. During the conversation, Patient 11 did not appear to get short of breath (SOB). During a phone interview on 3/25/23, at 9:41pm, Licensed Vocational Nurse 2 (LVN 2), stated that Patient 11 is aware he has terminal illness and that he has become more SOB, and needs assistance with ADLs. f. A review of Patient 12s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 9/9/22, with a primary diagnosis of hypertensive heart disease without heart failure (high blood). A review of Patient 12s ";Physician Certification for Hospice Benefit (CTI)", indicated that Patient 12 was on certification # 4: re-certification statement for next 60-day period for certification period 3/8/23 to 5/6/23. Patient 12s secondary diagnoses included gastroesophageal reflux disease (GERD-acid reflux, a digestive disease in which stomach acid irritates the food pipe lining), hyperlipidemia (high cholesterol-high levels of fat in the blood) and age-related physical debility (age related decline including weakness, fatigue, poor appetite and weight loss). Patient 12s CTI did not have an RN Prognosis summary, physician narrative (face to face summary and certifying physician summary and was not signed by the physician. During a phone interview on 3/22/23, at 11:00am, Patient 12 stated that she is not on hospice, but on a different program, but cannot remember what it is called. Patient 12 stated that ";she is not on hospice and does not have a terminal illness, she is not dying, she is fine." Patient 12 stated that she still sees her primary care provider every three months. During an interview on 3/22/23, at 3:pm ,PCP 1 stated that he did not refer Patient 12 for hospice. He still sees the patient and the last visit was on 3/16/23. PCP 1 stated that Patient 12 is not dying, she is able to drive herself to clinic, she is not eligible for hospice. A review of Patient 12s LCD Hospice Eligibility Determination sheet indicated that Patient 12 did not qualify per LCD guidelines. a. A review of Patient 1s Patient Information Sheet, indicated a start of care (SOC) date of 9/28/2022, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). Patient 1s primary language was Spanish. A review of Patient 1s 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 Review (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) dated 12/19/2022 indicated for a Skilled Nurse (SN) to visit once per week plus three visits as needed and a home health aide (HA) once a week. A review of Patient 1s Initial Comprehensive Assessment, dated 9/28/2023 indicated that Patient 1 did not need an interpreter. The assessment indicated Patient 1s Karnofsky Performance Scale [(KPS), an assessment tool for predicting of length of survival in terminally ill patients] of 50% (mainly sit/lie, cannot do any work, considerable assistance needed in self-care) and a Palliative Performance Scale [(PPS), a useful tool for measuring the progressive decline of a palliative resident] of 50% (mainly sit/lie, cannot do any work, considerable assistance needed in self-care). The assessment indicated that Patient 1 was awake and alert, oriented to time, place and person had a weight loss of more than 10% in six months. A review of Patient 1s undated form titled, "LCD Hospice Eligibility Determination" (LCD, Local Coverage Determination, an assessment to determine Patient 1's eligibility for hospice services) for Heart Disease indicated Patient 1 met the criteria for New York Heart Association classification (NYHA, a simple way of classifying the extent of heart failure) as Class IV [severe symptoms such as fatigue, palpitations (tremors or shivers) chest pain, dyspnea (difficulty breathing), or syncope (fainting) with features of heart failure with minimal physical activity and even at rest] level and had a history of unexplained syncope (fainting). During an interview on 3/22/2023 at 8:58 am, Family Member 1 stated she was the authorized representative/emergency contact for Patient 1. FM 1 stated Patient 1 was independent and was able to drive, grocery shop, bathe, clean his apartment and do his own laundry by himself. FM 1 stated that Patient 1 did not understand English very well and would need a Spanish translator. FM 1 stated Patient 1 did not have a medical condition that did not allow him to leave the house. During an interview on 3/22/2023 at 12:17 pm, Primary Care Physician (PCP 1) stated Patient 1 has been under his care since 2020 and Patient 1 does not have heart failure or heart disease and does not have a history of syncope (fainting). During an interview on 3/24/2023 at 9:30 am, Patient 1 stated he never had a terminal illness and was able to leave his home and drive to grocery shop if the store was near his house. Patient 1 stated he was not able to read or speak English well and mainly understood Spanish. During an interview on 3/25/2023, the Administrator (ADM)/ Director of Patient Care Services (DPCS) stated he did not have evidence to support Patient 1s loss of more than 10% of their weight in the last six months or history of syncope (fainting). b. A review of Patient 4s Patient Information Sheet indicated a start of care (SOC) date of 6/11/2022, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). A review of Patient 4s POC/IDG Review, dated 2/27/2023, indicated a Skilled Nurse (SN) visit once per week plus three additional visits as needed, and a home health aide (HA) visit once a week. The POC/IDG indicated a nutrition care plan for unintentional progressive weight loss greater than 10% over the last 6 months and an intervention of on-going assessment of weight change. A review of Patient 4s undated form titled, "LCD Hospice Eligibility Determination" (LCD, Local Coverage Determination, an assessment to determine Patient 6's eligibility for hospice services) for Heart Disease, indicated that Patient 4 met the criteria for New York Heart Association (NYHA) classification, a simple way of classifying the extent of heart failure NYHA Class IV [severe symptoms such as fatigue, palpitations (tremors or shivers) chest pain, dyspnea (difficulty breathing), or syncope (fainting) with features of heart failure with minimal physical activity and even at rest] and had a history of unexplained syncope (fainting). A review of Patient 4s Initial Comprehensive Assessment, dated 6/11/2022, indicated that Patient 4 was awake and alert, oriented to time, place and person had a weight loss of more than 10% in six months. Patient 4 weighed 247 pounds. A review of Patient 4s Comprehensive Assessment, dated 2/6/2023, indicated that Patient 4 was awake and alert, oriented to time, place and person had a weight loss of more than 10% in six months. Patient 4 weighed 247 pounds, the same weight from admission. During an interview record review on 3/25/2023 at 3:26 pm, the Administrator (ADM)/ director of Patient Care Services (DPCS) stated he was not able to provide supporting documentation for Patient 4s diagnosis of hypertensive heart disease with heart failure, loss of more than 10% of their weight in the last six months or history of syncope (fainting). c. A review of Patient 6s Patient Information Sheet indicated a start of care (SOC) date of 9/26/2022, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). Patient 6s primary language was Spanish. A review of Patient 6s Initial Comprehensive Assessment, dated 9/26/2022, indicated that Patient 6 was awake and alert, oriented to time, place and person and had a weight loss of more than 10% in six months. The assessment indicated Patient 6s Karnofsky Performance Scale [(KPS), an assessment tool for predicting of length of survival in terminally ill patients] of 30% (unable to care for self, severely disabled; hospital admission is indicated although death not imminent) and a Palliative Performance Scale [(PPS), a useful tool for measuring the progressive decline of a palliative resident] of 30% (bed bound, cannot do any work, total care in self-care). The Comprehensive Assessment indicated that Patient 6 presented with chest pain and required the use of nitroglycerin (medication used to provide relief from chest pain). The Comprehensive Assessment did not indicate Patient 6 had sensory deficits such as hard of hearing (deaf) or sensory aids (hearing aids). A review of Patient 6s undated form titled, "LCD Hospice Eligibility Determination" (LCD, Local Coverage Determination, an assessment to determine Patient 6's eligibility for hospice services) for Heart Disease, indicated that Patient 6 met the criteria for New York Heart Association (NYHA) classification, a simple way of classifying the extent of heart failure NYHA Class IV [severe symptoms such as fatigue, palpitations (tremors or shivers) chest pain, dyspnea (difficulty breathing), or syncope (fainting) with features of heart failure with minimal physical activity and even at rest] and had a history of unexplained syncope (fainting). A further review of Patient 6s clinical record did not indicate Patient 6 had problems with hearing. During an interview record review on 3/25/2023 at 3:26 pm, the Administrator (ADM)/ director of Patient Care Services (DPCS) stated he was not able to provide supporting documentation for Patient 6s diagnosis for heart failure, loss of more than 10% of their weight in the last six months or history of syncope (fainting). During an interview on 3/22/2023 at 3:58 pm, Patient 6 stated that she did not have a terminal illness and that she just had problems hearing and needed new hearing devices. Patient 6 stated to call Family Member (FM 2) because she was not able to hear very well on the phone. During an interview with on 3/22/2023 at 4:10 pm, FM 2 stated Patient 6 did not have a terminal illness and was not aware that Patient 6 was in hospice. FM 2 stated she took care of Patient 6s medical appointments and that Patient 6 did not have shortness of breath, high blood pressure, or heart failure. FM 2 stated Patient 6 had very bad hearing and that is why I go with her to her appointments. During an interview on 3/23/2023 at 1:25 pm, FM 2 stated Patient 6 did not have a terminal illness, did not use a cane or walker, did not have a history of syncope or falling, and did not have problems being short of breath. FM 1 stated that Patient 6 did not have a heart issue which required Patient 6 to use nitroglycerin. During an interview on 3/24/2023 at 9:52 am, the Office Manager (OM 1) for Primary Care Physician (PCP 2) stated PCP 2 was the primary care physician for Patient 6 and last saw her yesterday, 3/23/2023. OM 1 stated PCP 2 had not provided a referral for hospice evaluation for Patient 6. OM 1 stated Patient 6 did not have any heart disease, heart failure, or high blood pressure. OM 1 stated that Patient 6 has arthritis in her knees and decreased hearing that requires the use of hearing aids. During an interview record review on 3/25/2023 at 3:26 pm, the Administrator (ADM)/ director of Patient Care Services (DPCS) stated he was not able to provide supporting documentation for Patient 4s heart failure, loss of more than 10% of their weight in the last six months or history of syncope (fainting). During an interview record review on 3/25/2023 at 3:38 pm, the Administrator (ADM)/ director of Patient Care Services (DPCS) stated that Patient 6 did not have problems hearing. A review of the Hospice Agencys (undated) policy, Admission Criteria and Process, indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCD). The policy further indicated that the HA would admit a patient only on recommendation of the medical director in consultation with, or input from, the patient's attending physician, if any. The policy indicated that the patient must desire hospice services, and be aware of the diagnosis and prognosis.

Based on observation, interview and record review, the Hospice Agency (HA) failed to review all medications and update the medication profiles with the currently used medications for two of 14 sampled patients (Patients 3 and 9). The deficient practice resulted in patients not receiving medications as ordered by the physician and had a potential to result in adverse side effects if the medications were not administered timely. --- b. A review of Patient 9s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 7/8/22, with a primary diagnosis of fibromyalgia (widespread muscle pain and tenderness. This same document indicated that Patient 9s primary language was Spanish. A review of Patient 9s ";Physician Certification for Hospice Benefit (CTI)", indicated that Patient 10 was on certification # 4: re-certification statement for next 60-day period for certification period 3/5/23 to 5/3/23. Patient 9s secondary diagnoses included gastroesophageal reflux disease (GERD-acid reflux, a digestive disease in which stomach acid irritates the food pipe lining) and age-related physical debility. On 3/23/2023 at 10:30 am, a joint home visit was conducted with Licensed Vocational Nurse 3 (LVN 3) at Patient 9s home residence. Patient 9s medications were reviewed, and a discrepancy was found. Patient 9s medication profile was reviewed and indicated that Patient 9 was taking tramadol (pain medication) 100 milligrams (mg-a unit of measurement) 1 tablet every 8 hours as needed. Patient 9 did not have this medication in the home. During an interview on 3/23/23 at 11:15am, Patient 9 stated that she stopped taking the medication six months ago, because it made her dizzy and nauseated. A review of the Hospice Agencys policy title ";Medication Profile", dated 4/2019, indicated that patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications. a. A review of Patient 3s Patient Information Sheet, indicated a start of care (SOC) date of 5/23/2022, with a primary diagnosis of heart disease (disease that affects the heart or blood vessels), unspecified. A review of Patient 3s 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 Review (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 2/27/2023, indicated for a Skilled Nurse to visit once per week plus three additional visits and home health aide (HA) visit once a week. The POC/IDG indicated that the Medication Profile reviewed for contraindications, side effects, interactions, duplicate drug therapy and patient/patient caregiver compliance with meds and treatments therapy reviewed by IDG team. A review of Patient 3s Medication List indicated the following: -Quetiapine Fumarate 200 (milligram) mg tablet, one tab by mouth four times daily for Schizophrenia -Ibuprofen 800 mg tablet, one tablet by mouth every six hours for pain management -Seroquel 200 mg tablet, one tablet by mouth four times daily -Tylenol 1000 mg, one tablet by mouth once daily There was active two orders of same antipsychotic (psychotropic medication primarily used to manage psychosis) medication, Quetiapine (generic name) and Seroquel (Trade name). On 3/23/2023 at 10:00 am, a joint home visit was conducted with License Vocational Nurse (LVN 1), at Patient 3s home residence. Patient 3 was observed alert and oriented and sitting in a recliner. LVN 1 performed vitals signs, a skilled assessment and medication review. During the medication review with LVN 1, the following was observed: -Patient 1 stated she takes Ibuprofen 800 mg tablet, every six hours as needed -Tylenol 500 mg tablet, take two tablets by mouth three times a day. -Lidocane, topical ointment, 5%, for pain During a concurrent interview and record review on 3/23/2023 at 5:03 pm, Patient 3s Medication Profile was reviewed. Administrator (ADM)/ Director of Patient Care Services (DPCS) stated that the medications should be reviewed by the nurse every 14 days. The ADM/DPCS stated that the medication profile should match the label on the bottle of medication in the patients home. The ADM/DPCS stated that the nurse should get the medication profile and double check if the bottle of drugs were delivered, are within expiration and verify the patient's name, drug, dose, frequency. The ADM/DPCS stated that medications no longer used should be discontinued. The ADM/DPCS stated that medications should be checked to avoid medication error.

Based on interview and record review, the hospice agency failed to ensure a bereavement assessment and bereavement plan was developed and implemented to discuss and document the family/caregiver's needs after the patients' death for two of two sampled patients (Patient 8 and 13), according to the agency's policy. This deficient practice placed the family at a potential risk for not receiving support and preparation for what to expect after the patients' death. --- b. A review of Patient 13s ";Personal Information Sheet", indicated a SOC date of 11/2/22 and a end of care date (EOC) of 11/11/22. Reason for EOC was death. Patient 13s primary diagnosis was respiratory failure (serious condition where lungs cannot get enough oxygen in the blood and making it difficult to breathe). Patient 13s initial bereavement and post bereavement assessment (a tool used to assess the needs of the patient and family, focused on the social, spiritual and cultural factors that may impact their ability to cope with the patients death) was requested, but the Hospice Agency was not able to provide the documents. a. A review of Patient 8s Patient Information Sheet, indicated a start of care (SOC) date of 2/17/2022 and End of Care (EOC) date of 2/17/2023, with a primary diagnosis of respiratory failure (a serious condition where difficulty breath results in the lungs not able to get enough oxygen into the blood), unspecified with hypoxia (low levels of oxygen in body tissues). A review of Patient 8s Discharge Summary, dated 2/17/2023 indicated the reason for discharge was death and end of care (EOC) was 2/17/2023. A review of Patient 8s clinical record indicated that there was no bereavement assessment or post bereavement assessment performed. During an interview on 3/25/2023 at 2:41 pm, the Administrator (ADM)/ Director of Patient Care Services (DPCS) stated that a bereavement assessment is performed at admission and monthly. The ADM/DPCS stated that a bereavement plan was not done for Patient 8 because he died the same day that he was admitted. The ADM/DPCS stated that the purpose of the assessment was to provide counseling for the patient and family and to prepare them for the end of life and when the patient passes, we call the chaplain to perform the bereavement post assessment. The ADM/DPCS stated that when a patient passes, a condolence phone call is made to the families to give our condolences, flowers and a letter and provided to the families within three to five days. The ADM/DPCS stated there was no documentation indicating a phone call or letter was sent to Patient 8's family. A review of the hospice agency's policy titled, "Bereavement Assessment," indicated that on admission, the social worker or registered nurse will complete a bereavement risk assessment that will be given to the Bereavement Coordinator. The policy indicated that after death occurs, the hospice social worker or Bereavement Coordinator will develop a plan for intervention, based on the findings of the bereavement follow-up assessment and input from interdisciplinary group members. The policy indicated that all bereavement documentation will be submitted for filing in the patient's permanent clinical record.

Based on observation, interview and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, Coordination of Services was met as follows: The hospice agency failed to provide services as indicated in the plan of care for one of 14 sampled patients (Patient 4). The skilled nurse (SN) failed to assess Patient 4's wound condition and provide wound care during every visit. This deficient practice placed the patient in a potential risk for delayed wound healing (refer to L 543). The hospice agency (HA) failed to ensure its interdisciplinary group (IDG) reviewed and revised the patient's care plans in consultation with the physician, social worker and chaplain and document in the HospiceMD program (an accessible and secure web-based application used to manage, access and update patient electronic health records) for seven of 14 sampled patients (Patients 2, Patient 3, Patient 4, Patient 9, Patient 10, Patient 11, and Patient 12). This deficient practice resulted in the IDG not reviewing the patients care plans which had the potential to result in failure to identify changes in the patients progress and not updating the plan of care.(Refer to L552). The hospice agency failed to provide nurse visits in accordance with the Plan of Care (POC) and did not notify the medical director of the missed visits for two of 14 sampled patients (Patient 4 and Patient 12). This failure had the potential to result in Patients 4 and Patient 12 not receiving adequate nursing care which can affect patient's medical needs and treatments (refer to L 554). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with the Federal regulations for the Interdisciplinary group, Care planning, and Coordination of services of patients to ensure hospice care and services were provided to meet the patient's care goals. --- .

Based on interview and record review, the hospice agency failed to provide services as indicated in the plan of care for one of 14 sampled patients (Patient 4). This hospice skilled nurse (SN) failed to assess Patient 4's wound condition and provide wound care during every visit. This deficient practice placed the patient in a potential risk for delayed wound healing. --- A review of Patient 4s Patient Information Sheet indicated a start of care (SOC) date of 6/11/2022, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). A review of Patient 4s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 2/27/2023, indicated a Skilled Nurse (SN) visit once per week and three additional visits as needed, and a home health aide (HA) visit once a week. The POC/IDG indicated an Integumentary (an external layer or covering of the body)/Skin problem, wound, which was referred to Wound Treatment Evaluation by Wound Physician and interventions included to assess alteration in skin integrity every visit, assess changes in wound status such as check size, integrity, location, type/stage, signs and symptoms of infection, drainage, and effectiveness of current treatment. A review of Patient 4s Initial Comprehensive Assessment, dated 6/11/2022, indicated that Patient 1 was awake and alert, oriented to time, place and person. The assessment indicated Patient 4 had bilateral lower extremities wound and was referred for a wound treatment evaluation by Wound Physician. A review of Patient 4s POC/IDG notes dated 1/30/2023, did not have any documented IDG discussion, updated comprehensive assessment review from spiritual, psychosocial or physician core services and there were no signatures from the spiritual, psychosocial or physician core services. There were no notes indicating the status of Patient 4s bilateral lower extremities wound. A review of Patient 4s POC/IDG notes dated 2/13/2022 and 2/27/2023, did not have any documented IDG discussion, updated comprehensive assessment review from spiritual, psychosocial or physician core services and there were no signatures from the spiritual or psychosocial core services. There were no notes indicating the status of Patient 4s bilateral lower extremities wound. A review of Patient 4s Registered Nurse visit notes dated 2/3/2023, 2/10/2023, 2/24/2023, did not indicate that Patient 4s wound was assessed. The skin impairment assessment was blank. During an interview on 3/25/2023 at 12:43 pm, the Administrator (ADM)/Director of Patient Care Services (DPCS) stated that there was Wound care assessment or Skilled Nurse skin assessment performed after Patient 4s admission on 6/11/2022. The ADM/DPCS stated that it was important to perform a skin assessment and wound treatment each visit to prevent further breakdown and infection of the wound. A review of the hospice policy titled, The Plan of Care and dated 4/2019, indicated that a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The policy indicated that the care provided to the patient must be in accordance with the plan of care. The policy indicated that each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress toward goals.

Based on interview and record review, the hospice agency (HA) failed to ensure its interdisciplinary group (IDG) reviewed and revised the patient's care plans in consultation with the physician, social worker and chaplain and document in the HospiceMD program (an accessible and secure web-based application used to manage, access and update patient electronic health records) for seven of 14 sampled patients (Patients 2, Patient 3, Patient 4, Patient 9, Patient 10, Patient 11, and Patient 12). This deficient practice resulted in the IDG not reviewing the patients care plans which had the potential to result in failure to identify changes in the patients progress and not updating the plan of care. --- d. A review of Patient 9s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 7/8/22, with a primary diagnosis of fibromyalgia (widespread muscle pain and tenderness. A review of Patient 9s ";Physician Certification for Hospice Benefit (CTI)", indicated that Patient 10 was on certification # 4: re-certification statement for next 60-day period for certification period 3/5/23 to 5/3/23. Patient 9s secondary diagnoses included gastroesophageal reflux disease (GERD-acid reflux, a digestive disease in which stomach acid irritates the food pipe lining) and age-related physical debility (age related decline including weakness, fatigue, poor appetite and weight loss). A review of Patient 9s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 2/27/23, indicated for routine level of care, a home health aide (HHA) was to visit once per week, Medical Director (MD) wound visit as needed and recert (recertification), Social Worker (MSW) would visit per week plus 3 PRN (as needed), Spiritual Care (SC) wound visit once then PRN, Skilled Nursing (SN) would visit once per week plus 3 PRN and volunteer services were declined. The POC/IDG did not have updates documented for SC, MSW, or MD. The POC/IDG review did not have any documented signatures from MSW or SC. e. A review of Patient 10s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 11/21/22, with a primary diagnosis of hypertensive heart disease with heart failure (condition of high blood pressure causing the heart not to pump and function properly). A review of Patient 10s ";Physician Certification for Hospice Benefit (CTI)", indicated that Patient 10 was on certification #2: re-certification statement for second 90-day period for certification period 2/19/23 to 5/19/23. Patient 10s CTI indicated secondary diagnoses of hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone which can disrupt heart rate, body temperature and metabolism), type 2 diabetes (chronic condition that affects the way the body processes blood sugar) and physical age debility. A review of Patient 10s POC/ IDG Review, dated 1/30/23, 2/13/23 and 2/27/23 indicated for routine level of care, HHA was to visit once per week, MD wound visit as needed and recert, MSW would visit per week plus 3 PRN, SC wound visit once then PRN, SN would visit once per week plus 3 PRN and volunteer services were declined. The POC/IDG did not have updates documented for SC, MSW, or MD. The POC/IDG review did not have any documented signatures from MD, MSW or SC. f. A review of Patient 11s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 11/3/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a lung disease that blocks airflow and makes it difficult to breathe). A review of Patient 11s Physicians Certification for Hospice Benefit (CTI), indicated that Patient 10 was on certification #2: re-certification statement for second 90-day period, with certification date 2/1/23 to 5/1/23. Patient 9s secondary diagnoses included GERD, chronic pain, and muscle weakness and physical debility. A review of Patient 11s POC/ IDG Review, dated 1/23/23, 2/6/23 and 2/20/23 indicated for routine level of care, HHA was to visit once per week, MD wound visit as needed and recert, MSW would visit per week plus 3 PRN, SC wound visit once then PRN, SN would visit once per week plus 3 PRN and volunteer services were declined. The POC/IDG did not have updates documented for SC, MSW, or MD. The POC/IDG review did not have any documented signatures from MD, MSW or SC. g. A review of Patient 12s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 9/9/22, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A review of Patient 12s ";Physician Certification for Hospice Benefit (CTI)", indicated that Patient 12 was on certification # 4: re-certification statement for next 60-day period for certification period 3/8/23 to 5/6/23. Patient 12s secondary diagnoses included gastroesophageal reflux disease (GERD-acid reflux, a digestive disease in which stomach acid irritates the food pipe lining), hyperlipidemia (high cholesterol-high levels of fat in the blood) and age-related physical debility (age related decline including weakness, fatigue, poor appetite, and weight loss). Patient 12s CTI did not have an RN Prognosis summary, physician narrative (face to face summary and certifying physician summary and was not signed by the physician. A review of Patient 12s POC/ IDG Review, dated 1/23/23, 2/6/23 and 2/20/23 indicated for routine level of care, HHA was to visit once per week, MD wound visit as needed and recert, MSW would visit per week plus 3 PRN, SC wound visit once then PRN, SN would visit once per week plus 3 PRN and volunteer services were declined. The POC/IDG did not have updates documented for SC, MSW, or MD. The POC/IDG review did not have any documented signatures from MD, MSW or SC. During an interview on 3/25/23, at 3:33pm, the Administrator/Director of Patient Care Services (ADM/DPCS) stated that IDG meeting were done every two weeks. members include DPCS, SW, SC, MD, and any clinicians. Meeting are held in person, if anyone cannot come they can join virtually. ADM/DPCS stated that they need to have updates from each discipline because its the only way to tell if patient is declining or still needs services from the hospice program. ADM/DPCS also stated that all disciplines should be signing the POC/IDG in HospiceMD. a. A review of Patient 2s Patient Information Sheet, indicated a start of care (SOC) date of 10/28/2022, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). A review of Patient 2s 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 Review (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 1/30/2023, indicated for a Skilled Nurse to visit once per week plus three additional visits and home health aide (HA) visit once a week. The POC/IDG notes did not have any documented signatures from spiritual, psychosocial or physician core services. A review of Patient 2s POC/IDG notes dated 1/2/2023 and 1/16/2023 did not have any documented IDG discussion, updated comprehensive assessment review or signatures from spiritual, psychosocial or physician core services. There were no POC/IDG notes for 2/2023. b. a. A review of Patient 3s Patient Information Sheet, indicated a start of care (SOC) date of 5/23/2022, with a primary diagnosis of heart disease (disease that affects the heart or blood vessels), unspecified. A review of Patient 3s 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 Review (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 2/27/2023, indicated for a Skilled Nurse to visit once per week plus three additional visits and home health aide (HA) visit once a week. The POC/IDG notes did not have any documented IDG discussion, updated comprehensive assessment review from spiritual, psychosocial or physician core services and there were no signatures from spiritual, psychosocial or physician core services. A review of POC/IDG notes dated 1/30/2022 and 2/13/2022 did not have any documented IDG discussion, updated comprehensive assessment review from spiritual, psychosocial or physician core services and there were no signatures from the spiritual or psychosocial core services. c. A review of Patient 4s Patient Information Sheet indicated a start of care (SOC) date of 6/11/2022, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). A review of Patient 4s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 2/27/2023, indicated a Skilled Nurse (SN) visit once per week plus three additional visits as needed, and a home health aide (HA) visit once a week. The POC/IDG notes did not have any documented IDG discussion, updated comprehensive assessment review from spiritual, psychosocial or physician core services and there were no signatures from spiritual or psychosocial core services. A review of Patient 4s POC/IDG notes date 2/13/2023 and 2/27/2023 did not have any documented IDG discussion, updated comprehensive assessment review from spiritual, psychosocial or physician core services and there were no signatures from the spiritual or psychosocial core services. A review of the HAs policy titled ";Interdisciplinary Group Meeting", dated 4/2019, indicated that the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. The policy indicated that 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 (HA) failed to provide nurse visits in accordance with the Plan of Care (POC) and did not notify the medical director of the missed visits for two of 14 sampled patients (Patient 4 and Patient 12). This failure had the potential to result in Patients 4 and Patient 12 not receiving adequate nursing care which can affect patient's medical needs and treatments. --- b. A review of Patient 12s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 9/9/22, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A review of Patient 12s ";Physician Certification for Hospice Benefit (CTI)", indicated that Patient 12 was on certification # 4: re-certification statement for next 60-day period for certification period 3/8/23 to 5/6/23. Patient 12s secondary diagnoses included gastroesophageal reflux disease (GERD-acid reflux, a digestive disease in which stomach acid irritates the food pipe lining), hyperlipidemia (high cholesterol-high levels of fat in the blood) and age-related physical debility (age related decline including weakness, fatigue, poor appetite, and weight loss). A review of Patient 12s POC/ IDG Review, dated 2/20/23 indicated for routine level of care, and Patient 12 was to have home health aide (HHA) visit once per week. A review of the Health Aide Visit Note dated 11/1/22 and 11/7/23, indicated the HHA called Patient 12 multiple times, went to address no response. Patient 12s electronic medical record was reviewed, there was no documentation indicating that the HHA notified the office or the medical director of the missed visit. A review of Patient 4s Patient Information Sheet indicated a start of care (SOC) date of 6/11/2022, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). A review of Patient 4s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 2/27/2023, indicated a Skilled Nurse (SN) visit once per week plus three additional visits as needed, and a home health aide (HA) visit once a week. A review of Patient 4s SN missed visit notes dated 2/16/2023, 2/23/2023, 3/3/2023, and 3/10/2023 indicated that patient did not answer the phone or did not answer the door. A review of Patient 4s POC/IDG notes dated 2/13/2022 and 2/27/2023 did not have any documented IDG discussion, updated comprehensive assessment review from spiritual, psychosocial or physician core services and there were no signatures from the spiritual or psychosocial core services. There were no notes indicating Patient 6s the missed visits on 2/16/2023 or 2/23/2023. During an interview on 3/25/2023 at 11:11 am, the Administrator (ADM/ Director of Patient Care Services (DPCS) stated that if a patient refuses a nurse visit the hospice agency needs to follow up the patient within three days. The ADM/DPCS stated that the clinician must notify the office staff and the medical director informed and this should be in a narrative note under the visit notes. During a concurrent interview and record review at 12:23 pm with the ADM/DPCS, Patient 4s electronic record was reviewed. There was no record indicating that the medical director was notified of Patient 4s missed visits. A review of the hospice agencys (undated) policy titled, Missed Visits, indicated that the missed visit will be communicated to the interdisciplinary group at the IDG meeting. A review of the hospice agencys policy, The Plan of Care, dated 4/2019 indicated that a written individualized patient and family/caregiver plan of car will be established and maintained for each individual admitted to the hospice program. The policy indicated that the care provided to the patient must be in accordance with the plan of care.

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows: 1. The hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications of two of 13 sample patients, (Patients 1 , 4 and 6) to support diagnosis of the patients terminal illnesses and to qualify for hospice (healthcare that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care.(Refer to L 667) 2. The hospice agency to ensure the medical director and/or physician designee conducted accurate recertification of terminal illness for continued hospice care and services for three of seven sample patients (Patients 4 and 9) by failing to: ensure Patients 4 and 9 recertification had the physician's documentation of clinical information (including current history and physician's, laboratory, and imaging data biopsy results, etc.), conducted a face-to-face assessment of patient and has the agency's physician's signature to support diagnoses of terminal illnesses in order to determine continuous hospice care and services. (Refer to L 668) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services. --- .

Based on interview, and record review, the hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications of three of 14 sample patients, (Patients 1, 4, and 6) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. These deficient practices resulted in the hospice medical director and/or the hospice attending physicians certifying the patients for hospice care, without documentation of clinical evidence to support the terminal illness diagnoses and could result in a lack of and inappropriate care provided to the patients. --- a. A review of Patient 1s Patient Information Sheet, indicated a start of care (SOC) date of 9/28/2022, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). A review of Patient 1s "Physician's Certification for Hospice Benefit," (CTI #1) for the first 90- day period from 9/28/2022 to 12/26/2022, indicated a terminal diagnosis of hypertensive heart disease with heart failure. The CTI #1 was signed by the Medical Director (MD 2) and did not indicate any communication between MD 2 and Patient 1s Primary Care Physician (PCP 1) to validate that Patient 1 had a life expectancy of six months or less, if the terminal illness ran its normal course. During an interview on 3/22/2023 at 12:17 pm, PCP 1 stated Patient 1 was his patient since 2020 and that Patient 1 did not have heart disease or heart failure. PCP 1 stated Patient 1 did not have a terminal diagnosis and was not hospice eligible. PCP 1 stated never spoke to the Medical Director (MD 1) from the hospice agency. During an interview on 3/24/2023 at 9:30 am, Patient 1 stated he has never had a terminal illness. b. A review of Patient 4s "Physician's Certification for Hospice Benefit," (CTI) #1 for the first 90- day period from 6/11/2022 to 9/8/2022, indicated a terminal diagnosis of hypertensive heart disease with heart failure. The CTI Certifying Physician Summary indicated that Patient was referred to third party Medical Doctor and to see attached file for the progress note (Referral to Hospice/ Face to Face Encounter). During an interview on 3/23/2023 at 3:57 pm, Nurse Practitioner (NP 1) stated she worked for a third party Medical Service and performed patient assessments which included certifications of medical necessity which included hospice. NP 1 stated she ordered a referral for hospice with a terminal diagnosis of dementia for Patient 4. During a concurrent interview and record review with the Administrator (ADM)/Director of Patient Care Services (DPCS) on interview on 3/23/2023 at 5:41 pm, Patient 4s Referral to Hospice/Face to Face Encounter dated 5/5/2022 was reviewed. The ADM/DPCS stated there was no diagnosis of hypertensive heart disease with heart failure on the referral. When asked what the diagnosis should have been, the ADM/DPCS stated it should have been dementia. The ADM/DPCS stated the referral was used to certify the patient for hospice services and the primary diagnosis is incorrect. c. A review of Patient 6s Patient Information Sheet indicated a start of care (SOC) date of 9/26/2022, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). A review of Patient 6s "Physician's Certification for Hospice Benefit," (CTI #1) for the first 90- day period from 9/6/2022 to 12/24/2022, indicated a terminal diagnosis of hypertensive heart disease with heart failure. The CTI #2 was signed by the Medical Director (MD 2) and did not indicate any communication between MD 2 and Patient 2s Primary Care Physician (PCP 2) to validate that Patient 2 had a life expectancy of six months or less, if the terminal illness ran its normal course. During an interview on 3/22/2023 at 3:58 pm, Patient 6 stated she was not a patient of Solid Hospice and that she did not have a terminal illness. During an interview on 3/24/2023 at 9:52 am, the Office Manager (OM 1) for PCP 2 stated Patient 2 has been PCP 2s patient since 2018. OM 1 stated that no referral for a hospice evaluation was ordered for Patient 2. OM 1 stated Patient 2s diagnosis included degenerative joint disease of the knee and decreased hearing. OM 1 stated that Patient 2 did not have diagnoses of high blood pressure, heart disease or heart failure. During an interview on 3/22/23 at 3:50 pm, the Medical Director (MD 3) stated he does not have to contact the patients primary physician when admitting a patient for hospice services because they are usually already on hospice or come from the hospital. MD 3 stated the patients history and physical should be used in the initial certification, but we usually do not get it. MD 3 stated he just goes by the nursing assessment. A review of the hospice agencys policy titled, Certification of Terminal Illness, dated 11/2020, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy, if the disease runs its normal course, by the attending physician and the hospice Medical Director. The policy indicated the time of admission to hospice, the hospice Medical Director or the patients attending physician will complete a certification narrative that reflects the patient's individual circumstances based on his/her review of the patients medical record or, if applicable, examination of the patient. The hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms.

Based on interview, and record review, the hospice agency failed to ensure the medical director and/or physician designee conducted accurate recertification of terminal illness for continued hospice care and services, for three of 14 sampled patients (Patients 4 and 9) by failing to: ensure that Patients 4 and 9s recertification had the physician's documentation of clinical information (including current history and physician's, laboratory and imaging data biopsy results, etc.), conducted a face-to-face assessment of patient and had the agency's physician's signature to support diagnoses of terminal illnesses in order to determine continuous hospice care and services. This deficient practice resulted in the hospice medical director and/or the hospice attending physician recertified the patients to continue the hospice services, with inaccurate terminal diagnoses and lack of documentation of clinical evidence to support the diagnoses, that could result in lack and inappropriate care and services. --- c. A review of Patient 9s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 7/8/22, with a primary diagnosis of fibromyalgia (widespread muscle pain and tenderness. A review of Patient 9s ";Physician Certification for Hospice Benefit (CTI)", indicated that Patient 9 was on certification # 4: re-certification statement for next 60-day period for certification period 3/5/23 to 5/3/23. Patient 9s secondary diagnoses included gastroesophageal reflux disease (GERD-acid reflux, a digestive disease in which stomach acid irritates the food pipe lining) and age-related physical debility. There was no Face-to-Face summary documented by the medical director. Patient 9s CTIs # 1, 2, and 3 were reviewed in the electronic medical record, there were no Face-to-Face summaries documented by the medical director for any of the CTIs. During an interview on 3/25/23, at 10:50am, the Administrator/Director of Patient Care Services (ADM/DPCS) stated that it is important to have face-to-face visits with the medical director for certification and recertification to verify the patient has a terminal illness. The medical director has to observe the clinical symptoms. A review of the hospice agency's (HA) policy titled ";Face-To-Face Encounter", (undated), indicated the following... 1. The hospice director (employed, volunteer, or under contract) or a hospice employed nurse practitioner (NP) will perform a face-to-face encounter within 30 days prior to the hospice recertification for the third and all subsequent benefit periods. 2. During the face-to-face encounter, the hospice medical director or NP must gather and document clinical findings to determine the patients continued hospice eligibility. 3. The physician/NP who performs the face-to-face encounter with attest in writing that he/she had the face-to-face encounter, including the date of visit. 4. The face-to-face attestation must be signed and dated by the individual who preformed the visit. a. A review of Patient 4s Patient Information Sheet indicated a start of care (SOC) date of 6/11/2022, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). A review of Patient 4s "Physician's Certification for Hospice Benefit," (CTI) #3 for the next 60- day period from 9/9/2022 to 12/7/2022, indicated a terminal diagnosis of hypertensive heart disease with heart failure. The Physician Narrative for the face-to-face summary was blank. The CTI did not indicate that a face-to-face with Patient 4 was performed. A review of Patient 4s "Physician's Certification for Hospice Benefit," (CTI) #4 for the next 60- day period from 2/6/2023 to 4/6/2023, indicated a terminal diagnosis of hypertensive heart disease with heart failure. The Physician Narrative for the face-to-face summary was blank. The CTI did not indicate that a face-to-face with Patient 4 was performed.

Based on interview and record review, the Hospice Agency (HA) failed to ensure clinical visit notes were documented and completed for one of 14 sampled patients (Patient 11). This deficient practice had the potential for not to reflect in the clinical record the accurate status of Patient 11's condition. --- A review of Patient 11s ";Personal Information Sheet", indicated that the patient had a start of care (SOC) date of 11/3/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a lung disease that blocks airflow and makes it difficult to breathe). A review of Patient 11s Physicians Certification for Hospice Benefit (CTI), indicated that Patient 11 was on certification #2: re-certification statement for second 90-day period, with certification date 2/1/23 to 5/1/23. Patient 11's secondary diagnoses included GERD, chronic pain, and muscle weakness and physical debility. A review of Patient 11s POC/ IDG Review, dated 2/20/23 indicated for routine level of care and skilled nursing (SN) was to visit once per week. A review of Patient 11s ";Visit Note LVN," dated 3/3/23, 3/10/23 and 3/17/23, were not completed. There was no assessment done, no LVN (Licensed Vocational Nurse) summary, or an LVN signature. During a phone interview on 3/25/23, at 9:41 a.m., Licensed Vocational Nurse 2 (LVN 2) stated that her last home visits she did for Patient 11 was on 3/10/23, 3/17/23 and 3/21/23. LVN 2 stated that she is delayed on documentation, and she stated she normally inputs her notes within 24 to 48 hours after visit. During an interview on 3/22/23, at 2:08 p.m., the director of patient care services designee stated that after a home visit the nurse has seven days to complete charting (documentation). A review of the HAs policy titled, ";Entries Into the Clinical Record", dated 11/2018, indicated that entries into the clinical record will be made on the day the care is provided to the patient. All documentation will be turned into to the office within 3-5 days of the patient care.

Based on record review and interview the Hospice Agency (HA) failed to ensure that one 14 sampled patients (Patient 11) had signed copies of Patient rights and election statement in their clinical records charts. This deficient practice caused Patient 11 not to be aware of what hospice is, and what benefits are provided through the service. --- A review of Patient 11s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 11/3/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a lung disease that blocks airflow and makes it difficult to breathe). A review of Patient 11s Physicians Certification for Hospice Benefit (CTI), indicated that Patient 10 was on certification #2: re-certification statement for second 90-day period, with certification date 2/1/23 to 5/1/23. Patient 11s secondary diagnoses included GERD, chronic pain, and muscle weakness and physical debility. During an interview on 3/22/23, at 10:50am, Patient 11 stated that he does not know the hospice agency and he does not know what hospice is and he did not have a terminal illness. During a concurrent record review and interview on 3/22/23, at 1:34 p.m., Patient 11s clinical record was reviewed and there were no consents in the patients file. There was no signed patient acknowledgement to hospice benefits, patient rights. The Human Resource/Quality Assurance (HR/QA) stated that Patient 11 did not have any consents. During an interview on 3/25/23, at 5:20 p.m., the Administrator/Director of Patient Care Services (ADM/DPCS) stated that during the initial assessment, explanations of benefits is given. The ADM/DPCS stated the nurse makes sure the patient understands their rights and signs consents. The patient gets copy of consent and they should be placed in the hospice binder. The ADM/DPCS stated that he did not know why Patient 11 did not have his consents, but they should have been in his chart. A review of the HA policy titled, ";Patient Bill of Rights/Responsibilities", (undated), included the following: 1. Upon admission, the admitting clinician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights/Responsibilities in advance of furnishing care. 2. The patient will be requested to sign the Patient Bill of Rights/Responsibilities form. The original form will be kept in the patient's clinical record. A copy will be maintained by the patient. The patient's refusal to sign will be documented in the clinical record, including the reason for refusal.

Based on record review and interview, the Hospice Agency (HA) failed to ensure the documentation for three of 14 sampled patients (Patient 3, 4, and 9) was accurate and authentic. This deficient practice resulted in the failure to document accurately and ensure authenticity of the patients clinical records. --- c. A review of Patient 9s ";Personal Information Sheet", indicated that they had a start of care (SOC) date of 7/8/22, with a primary diagnosis of fibromyalgia (widespread muscle pain and tenderness. Patient 9s date of birth 9/4/53 (currently 70 years old). A review of Patient 9s ";Physician Certification for Hospice Benefit (CTI)", indicated that Patient 10 was on certification # 4: re-certification statement for next 60-day period for certification period 3/5/23 to 5/3/23. The Certifying Physician Summary, signed by Medical Director 1 (MD 1) on 3/5/23, stated the following.... Admit 78 years old female admitted to Mount Zion Hospice Care under routine level of care for 4th benefit period from 3/5/23 to 5/3/23 with hospice diagnosis fibromyalgia. Comorbidities include GERD, generalized muscle weakness, age related physical debility, anxiety. Patient 9 is not 78 years old, but 70 years old, Mount Zion Hospice is not the Hospice agency that Patient 9 was admitted to. During an interview on 3/25/23, at 3:41pm, the Administrator/Director of Patient Care Services (ADM/DPCS) stated no one is currently reviewing charts to make sure they are complete and accurate. ADM/DPCS stated that QA (quality assurance) is responsible for reviewing, but they are not trained yet to do the chart audits. A review of the HAs policy titled ";Clinical Record Review, dated 11/2018, indicated that each clinical record will be reviewed on a regularly scheduled basis by the quality assessment performance improvement (QAPI) coordinator, clinical director, clinical supervisor/nursing supervisor, or designee for accuracy of clinical records. a. A review of Patient 3s Patient Information Sheet, indicated a start of care (SOC) date of 5/23/2022, with a primary diagnosis of heart disease (disease that affects the heart or blood vessels), unspecified. During a review of Patient 3s HospiceMD Audit Log dated 3/21/2023 indicated the following: -Medical Director (MD 1) signed for Patient 3s Interdisciplinary (IDG) dated 2/27/2023 on 3/21/2023. -MD 2 signed for Patient 3s IDG Review dated 1/2/2023 on 3/21/2023. -MD2 signed for Patient 3s IDG Review dated 1/30/2023 on 3/20/2023. b. A review of Patient 4s Patient Information Sheet indicated a start of care (SOC) date of 6/11/2022, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). During a review of Patient 4s HospiceMD Audit Log dated 3/21/2023 indicated the following: -MD 2 signed for Patient 4s Certification dated 2/6/2023 on 3/21/2023 -MD 2 signed for Patient 4s IDG Review dated 2/13/2023 on 3/21/2023 -MD 1 signed for Patient 4s IDG Review dated 2/27/2023 on 3/21/2023. During an interview on 3/22/2023 at 1:40 pm, the former Medical Director (MD 2) stated that she had not signed into HospiceMD (an accessible and secure web-based application used to manage, access and update patient electronic health records) since February 2023. MD 2 stated her last day with the hospice agency was 2/23/2023. MD 2 stated that if a new patient was admitted to the agency, the information is typed into the electronic chart by office staff. During an interview on 3/25/2023 at 4:31 pm, the Medical Director (MD 1) stated he had not signed into HospiceMD (an accessible and secure web-based application used to manage, access and update patient electronic health records) within the last three days. MD 1 stated he was not trained in HospiceMD and only looks through it but does not know how to use it. MD 1 stated he just started at the end of February 2023 and had not performed any certifications, recertifications or any face-to-face visits. MD 1 stated he had not attended an Interdisciplinary Team (IDT) Meeting with all the members present. A review of the hospice agencys policy titled Computer Access to Information, dated 4/2019 indicated that authorized personnel will be assigned passwords and/or access codes and will complete a signed statement that no one else will be allowed to use his/her computer key. Signed staff security statements and pass code identification files will be secured and maintained in the Executive Director/Administrators or designees office. Electronic signature, when utilized, will be in compliance with individual state law. Signatures should conform to the following criteria: A. Unique to the person using it. B. Capable of verification or authentication. C. Under the sole control of the person using it.

Based on interview and record review, the Hospice agency (HA) failed to ensure that unauthorized individuals gained access to their HospiceMD (an accessible and secure web-based application used to manage, access and update patient electronic health records) electronic charting system. An unknown source was logging into the electronic charting system with a log in that did not belong to them. This deficient practice placed the patients' personal health information at risk for unauthorized use. --- During an interview on 3/22/2023 at 1:40 pm, the former Medical Director (MD 2) stated that she had not signed into the HAs electronic medical record (EMAR) since February 2023. MD 2 stated her last day with the hospice agency was 2/23/2023 and no longer works for the agency. During an interview on 3/22/23, at 3:50 pm, MD 1 stated that he has not certified any patients while working with the agency. MD 1 stated that he has not done any documentation in the agencys EMAR and that he is not trained in the electronic charting system and has not signed into the system at all. During an interview on 3/22/23, at 2:08pm, the director of patient care services designee (DPCSd) stated that staff is to use their own log in user name and passwords to log into the electronic charting system and cannot use someone elses log-in. This is for HIPPA (Health Insurance Portability and Accountability Act-a federal law to protect patient sensitive health information from being disclosed without the patients consent or knowledge) compliance. DPCSd stated she was not aware the someone was logging into the EMAR under the MDs name. MD 1s and MD 2s activity history on the HAs electronic charting system was reviewed. The report showed every time MD 1 and MD 2 logged on to the system and indicated what patient charts were reviewed by MD 1 and MD 2. The report showed that MD 1 logged onto the system multiple times on 3/21/23 and 3/22/23. This report also listed the IP address (Internet Protocol address-a numerical label that is connected to a specific computer or other electronic device that identifies that devices network interface and location) that MD 1 and 2 logged onto. That specific IP address did not match the IP address of the HAs office computers, but it did match an IP address of a device that the Director of Patient Care Services designee (DPCSd) logged into. A review of the HAs policy titled ";Computer access to information", dated 4/2019, indicated the following... 1. Authorized personnel will be assigned password and/or access codes and will complete a signed statement that no one else will be allowed to use his/her computer key. 2. If available, physicians choosing to electronically sign their orders will be assigned a unique password and/or access codes and will complete a signed statement that no one else will be allowed to use his/her computer key. The policy indicated that signatures should conform to the following criteria: A. Unique to the person using it. B. Capable of verification or authentication. C. Under the sole control of the person using it