Every finding on record at Spiritual Touch Hospice, Inc

Based on interview and record review, the Hospice Agency (HA) failed to ensure the emergency preparedness (a training to provide necessary skills to properly react during emergencies) training for all staff was conducted throughout the year. This failure had the potential to result in the hospice staff's lack of knowledge to readily and effectively respond during an emergency crisis situation. --- During a review of the agency's emergency preparedness program, the agency had insufficient documented evidence that emergency preparedness training was being conducted for all staff. No in-services or sign in sheets were observed in the emergency preparedness binder. On 8/31/2023, at 11:30 a.m., during a concurrent interview and record review with the office manager (OM), requested OM to provide in-services for the emergency drills and for the emergency preparedness training. The OM was not able to provide any documentation. The OM stated emergency drills are conducted at least quarterly. No in-services or sign in sheets were observed in the emergency preparedness binder. When asked why is it important to have an up to date emergency plan, the OM stated, "Although our emergency plan is fairly comprehensive, it is lacking in a few areas, and should be updated because things are always changing, and the plan should be as up to date as possible to provide our patients safety." During a review of the agency's policy, titled "Emergency Management Plan" and revised on November 2020, the policy indicated the agency will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those requirements. The policy indicated the training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing services under arrangement, and volunteers if applicable. Organization leadership will provide for orientation and annually thereafter of all personnel regarding participation in the emergency plan.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (the requirements that healthcare organizations must meet to participate in Federal healthcare programs) regarding Patient's Rights was met as follows: The HA failed to take appropriate corrective actions regarding an active employee who was convicted (found guilty) of elder abuse on 7/28/2023 for one of 14 active employees (Employee 1) (Refer to L510). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated (State law) compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits. --- .

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to take appropriate corrective actions regarding an active employee who was convicted (found guilty) of elder abuse on 7/31/2023 according to the Los Angeles Times online newspaper article dated 8/2/2023, for one of 14 active employees (Employee 1). This deficient practice placed 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) at risk for being abused or mistreated by Employee 1. --- On 8/30/2023, at 3:45 p.m. a complaint validation a complaint validation survey was conducted at the HA regarding a complaint allegation concerning Employee 1, who was the current Administrator (ADM) and the Director of Patient Care Services (DPCS) for the HA. The complaint indicated the ADM/DPS was convicted of elderly abuse of six disabled patients living in a boarding care facility (assisted living facility that offers personal assistance with basic daily tasks) from a previous hospice agency employer. The article indicated ";The victims in this case suffered horrific neglect and lack of care at the hands of those who were trusted with their well-being." A review of Employee 1's California Board of Nursing Registered Nurse Licensing details indicated Employee 1 had several administrative disciplinary actions (a management action taken to correct improper or inappropriate behavior or conduct and intended to be corrective in nature) filed against her (ADM/DPCS) on 8/5/2009, 6/21/2010, 10/3/2013, and on 5/22/2014. A review of the HAs Personnel Files indicated the HA hired Employee 1 on 9/1/2015 as the DPCS of the HA. A review of the HA's updated version dated 1/17/2023, "Organizational Chart," indicated Employee 1 was the active ADM and DPCS of the HA. A review of Employee 1s Comprehensive Criminal (background check) record with a completion date of 5/26/2023, the Comprehensive Criminal record indicated there was no criminal record found for Employee 1. The Comprehensive Criminal record indicated the report did not guarantee the accuracy or truthfulness of the information as to the subject of the investigation. A review of Los Angeles Times online article, dated 8/2/2023, indicated Employee 1 was convicted of elder and dependent adult abuse at a boarding care facility on 7/31/2023. The article indicated Employee 1 was one of three people who left six residents emaciated (abnormally thin or weak) and dehydrated (a condition in which you lose so much body fluid that your body can not function normally) and did not provide the care the patients needed at the board and care facility. Retrieved from: https://www.latimes.com/california/story/2023-08-02/dehydration-emaciation-4-convicted-of-elder-dependent-abuse-at-riverside-facility During an interview on 9/3/2023, at 2 p.m., Employee 1 stated she (DPCS/Employee 1) conducted field work (would go inside patients homes), and she would perform the initial, recertification, and conduct supervisory visits for the HAs LVNs (license vocational nurses) and Hospice aides. Employee 1 stated she would take the patients (in general) vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure), that would indicate the state of a patient's essential body functions for the patients (in general) and would perform skilled nursing interventions as ordered for the patients during her visits. When Employee 1 was asked what the HA would do if the HA would find out one of their active skilled nurses was convicted of abuse and was seeing patients. Employee 1 stated the HA would do an investigation, remove the alleged nurse from visiting and taking care of all assigned patients and will allow to work in the HA as office or staffing clerks until the investigation was done. Employee 1 stated she would not suspend or terminate their employment for being convicted, but she would do so once they were sentenced. When Employee 1 was asked if she knew any of her active employees had a current verified abuse violation, she stated she was not aware of any employee who was convicted of abuse. Employee 1 stated the HA did not have a complete policy and procedure for abuse screening and prevention and the HA including herself did not provide abuse training yearly for her active employees for the last three years. When Employee 1 was asked if the HAs Standard of Conduct (includes policies and rules for employees and employers to follow in the workplace) for all employees were annually reviewed, she stated no, and stated she could not show any documented evidence it was reviewed annually. A review of the HAs undated policy and procedure titled, ";Assessment of Possible Abuse/Neglect," indicated the HA will report all suspected cases of abuses neglect, or exploitation (means taking advantage of a resident for personal gain using manipulation, intimidation, threats, in compliance with appropriate state statutes to appropriate protection organizations) in compliance with appropriate state statutes to appropriate protection organizations. A review of the HA's undated policy and procedure entitled, "Standards of Conduct/Ethical Behavior", indicated the organization and its employees must, at all times, comply with all applicable laws and regulations. The organization will not condone the activities of personnel who achieves results through violation of the law, unethical business or patient care practices. The Standards of Conduct will be reviewed at new employee orientation and annually thereafter. The Standard of Conduct will be a part of the Employee Handbook and the employee will sign an acknowledgement of receipt and understanding of its contents at hire.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) staff failed to review and update the medication profiles for two of 14 sampled patients (Patients 2 and 12). This deficient practice had the potential to place Patients 2 and 12 at risk for medication errors and adverse drug reactions (unwanted, uncomfortable, or dangerous effects medications). --- A review of Patient 12's clinical records indicated a SOC date of 6/30/2023, with a terminal diagnosis of Malignant neoplasm of the pelvis , (cancer of the female productive systems .) A review of Patient 12s POC Summary, indicated the frequency of visits for the registered nurse (RN) to one visit per week. The skilled nurse was to instruct the patient and/or caregiver regarding new medications or treatments, monitor for side effects, to monitor and assess effectiveness of the current and any new medications or treatments. On 9/2/2023, at 11:00 a.m., a joint home visit was conducted to Patient 12's residence, with the LVN 2 (license Vocational Nurse). Patient 12 was observed lying in a bed in her bedroom sleeping , when she was awakened by the PCG and LVN 2, patient appeared , alert and oriented to time and place. On 9/2/2023, at 12: 29 p.m.., during a joint review of Patient 12s current medications in her residence with LVN 2 with the medications on her medical profile the following discrepancies were identified. The medication profile indicated oxygen (O2), 2-5 ipm via nasal cannula as needed for shortness of breath. The O2 was observed in the corner of the living room. During an interview with patient 12 at her kitchen table, she stated she has never used the O2. Review of patient 12s medication profile listed Morphine Sulfate 10/mg/5 ml solution. The physician ordered 10 mg/0.25 ml every 2-4 hors for moderate to severe pain. Observed was a empty bottle of Morphine IR 15 mg, take half a tablet (7.5 mg), every hour as needed for mild dyspnea pain. During an interview with patient 12, stated she took the morphine tablet the night before. On 9/3/2023, at 3:30 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated the visiting nurse need to review patients current medication and ask the patient or caregiver when and how they administer the prescribed medications every visit and update the medication profile in the patients clinical record. a. A review of patient 2's clinical record indicated a start of care (SOC) date of 6-27-22, with a diagnoses of Chronic Obstructive Pulmonary Disease (COPD) constriction of the airways and difficulty or discomfort in breathing. A review of patient 2's Plan of Care (POC) dated 8-30-23, included an order for Skilled Nursing (SN) to visit once per week, MSW visits once per month, spiritual counselor (SC) visits once per month and volunteer visits of twice per week. The POC further indicated for SN to monitor vital signs, covid symptoms, and to manage symptoms of pain. On 9-1-23 at 11:10 am. a home visit with the Director of Patient Care Services (DPCS) was conducted at patient 2s residence. A review of patient 2s Medication Profile provided by the agency, indicated Patient 2 had a physician's order for the following medication: Issue1 Losartan 40mg 1 tab orally QD for hypertension (on med profile) What was observed at home visit on medication label: Losartan 50mg 1 tab orally QD for hypertension (on med label) Issue2 Dubra 100mcg/5mcg 1 puff daily as needed for SOB and dyspnea (still on med profile) Per patient 2, Dubra was switched over 1 month ago to Wixela 50mcg 1 inhalation every 12 hours as needed for SOB and dyspnea. During an interview on 9-1-23 at 11:50am, DPCS stated the medication profile was not updated for patient 2 and will have to be reconfirmed with the medical director and pharmacy to ensure accuracy. During a review of the agencys policy entitled ";Medication Profile" dated November 2020, it indicated patients receiving medications administered by organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new/or discontinued medications.

Based on observation, interview, and record review, the hospice agency failed to accurately assess the eligibility for hospice (medical care given to people with life threatening diseases) services related to the palliation (relief of symptoms and suffering cause by life threatening diseases) and management of the terminal illness and related conditions for two of 14 sampled patients (Patients 13 and 14). This deficient practice had the potential to result in misuse of the hospice services that could result in substandard (below) provision (supplying something for use) of patient care for Patients 13 and 14. --- a. A review of Patient 13s clinical record indicated a start of care (SOC) date of 8/9/2023, with a terminal diagnosis of hypertensive heart disease without heart failure (a variety of changes in the left side of the heart and the coronary arteries as a result of chronic high blood pressure). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1 (medical director designee). A review of Patient 13's Physicians Certification for Hospice Benefit, dated 8/2/2023 to 11/16/2023, benefit period number 1, indicated the Medical Director signed the attending physician referral section to indicate Patient 13 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. During a joint home visit with LVN 2, Patient 13, and Patient 14 in their residence on 9/2/2023, at 11:20 a.m., when asked what hospice was, Patients 13 and 14, stated it was for those who had six months are less to live. When asked if Patient 13 was hospice, Patient 13 stated, ";I am not dying. I am receiving home health care." At that time, Patient 13, and Patient 14's hospice binders were reviewed with them and they both stated "We do not belong on hospice. We see our primary care physician and were never informed we were on hospice by our primary nor the hospice agency staff." Patients 13 and 14 stated, they thought they were receiving home health services. b. A review of Patient 14s clinical record indicated a start of care date of 8/15/2023, with a terminal diagnosis of Moyamoya disease (a rare, progressive disease cerebrovascular disorder caused by blocked arteries at the base of the brain. The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1 (Medical Director Designee). A review of Patient 14s Physicians Certification for Hospice Benefit dated 8/15/2023 to 11/12/2023, Benefit Period number 1, indicated the Medical Director signed the attending physician referral section to indicate Patient 14 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. During a phone interview on 9/2/2023, at 4:30 p.m., with Physician 2 (Medical Director), he stated he was the Medical Director of the hospice agency, however, he and the Medical director designee had an arrangement which consist of the MD designee doing the face-to-face assessment, interdisciplinary Group, pretty much overseeing that hospice agencies day-to-day operation, he just signs the Certification of Terminal Illness (CTI). During a telephone interview with Physician 1 (Designee), on 9/2/2023, he stated when the agency needs to evaluate the patient for hospice, he gets the information from the DPCS and conducts the face-to-face via zoom and refers them to the agency and she signed the referral attending physician section because no one would sign it. Physician 1 further stated he determined the patients were eligible for hospice services by reviewing the patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. During an interview with the ADM/DPCS, in the conference room of the hospice agency, on 9/3/2023, at 1:30 p.m., the Director of Patient Care Services (DPCS), she was not sure if Patients 13 and 14 met the criteria, due to another family member signing them up and was planning on have an interdisciplinary Group meeting to re-evaluate the two patients.

Based on interview and record review, the agency failed to ensure that ordered visits were done for five of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, and Patient 7). This deficient practice resulted patients not receiving care and services per physician order. --- a. A review of Patient 1's Personal Information record indicated Patient 1 was admitted to the Hospice Agency (HA) on 6/30/2023, with admitting diagnosis of congestive heart failure (an impairment of the heart's blood pumping action). A review of Patient 1s POC (plan of care)/IDG (Interdisciplinary group) dated 8/17/2023, indicated skilled nurse visits once per week and two as need visits, MSW (social worker) visits once a month and one as needed visit, and spiritual counselor visits once a month and one as needed visits. A review of the agencys Electronic Medical Record (EMR) indicated no MSW visits were done for Patient 1 after 7/1/2023. b. A review of Patient 2's Personal Information record indicated, Patient 2 was admitted to the HA on 6/27/2022, with an admitting diagnosis of chronic obstructive pulmonary disease (a progressive lung disease characterized by long term respiratory symptoms and airflow limitations). A review of Patient 2s POC dated 8/30/2023, indicated skilled nurse to visit once per week and two as needed visits. The MSW to visit once a month. The spiritual counselor to visit once a month and volunteer visits twice a month. A review of the agencys EMR indicated the following missed visits for Patient 2: Missed skilled nursing visit from 5/8/2023 to 5/19/2023 and from 7/24/2023 to 8/7/2023. Missed spiritual counselor visit from 3/27/2023 to 7/26/2023. Missed volunteer visits for August 2023. c. A review of Patient 3's Personal Information record indicated Patient 3 was admitted to the HA on 3/24/2021, with an admitting diagnosis of heart failure (a chronic condition when the heart is unable to pump blood as it should be). A review of Patient 3s POC, dated 8/30/2023, indicated skilled nurse visits once per week and two as needed visits, MSW visits once a month, and spiritual counselor visits once a month. A review of the agencys EMR indicated missed spiritual counselor visits for Patient 3. Last documented spiritual visit was on 9/30/2022. d. A review of Patient 6's Personal Information record, indicated Patient 6 was admitted to the HA on 2/22/2023, with an admitting diagnosis of hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure). A review of Patient 6s POC/IDG review dated 8/30/2023, indicated skilled nurse visits once a week and two as needed visits, MSW visits once a month, and HA visits once a month. A review of the agencys EMR indicated missed MSW visit. Last documented visit was on 7/29/2023. e. A review of Patient 7's Personal Information record, indicated that Patient 7 was admitted to the HA on 1/24/2023, with an admitting diagnosis of Alzheimers disease (a progressive mental deterioration that can occur in old age). A review of Patient 7s POC/IDG dated 8/3/2023, indicated the skilled nurse to visit once a week and MSW to visit once a month. A review of the agencys EMR indicated missed skilled nurse visits from 5/5/2023 to 5/19/2023 for Patient 7. On 9/3/2023 at 2:45 p.m., an interview was conducted with the LVN 1 in the agency office. LVN 1 stated when a home visit is missed, the Director of Patient Care Services (DPCS) is immediately notified, and the agency will attempt to reschedule the missed visit to comply with the physicians order. LVN 1 stated the medical director would be notified of the missed visit, and it would be documented in a communication note or under the section of the discipline that visit was missed. There was no documentation that attempts were made to reschedule the missed MSW visit or for the notification to the medical director for the missed visits. A review of the agencys policy on 9/3/2023, titled ";Missed Visits" and revised 2020, indicated if a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained. Missed visits will be documented in the clinical record.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to follow the physicians orders in the plan of care for two of 14 sampled patients (Patient 1 and Patient 2). This deficient practice had the potential to result in a risk in the patient not receiving the respiratory treatment and management. --- a. A review of Patient 1s "Patient Information" indicated, Patient 1 was admitted to HA on 6/30/23, with an admitting diagnosis of congestive heart failure (an impairment of the hearts blood pumping action). A review of Patient 1s Plan of Care/ Interdisciplinary Group (IDG) review indicated a skilled nurse to visit once a week, the Medical Social Worker (MSW) to visit once a month, and the spiritual counselor to visit once a month. On 9/1/23 at 10 a.m. an interview with DPCS was conducted inside of Patient 1s home. DPCS stated the oxygen (O2) concentrator (medical device that assist people who have a low level of oxygen in their blood) was ordered for Patient 1 but was not available in the patient's home. DPCS stated the family declined the delivery of the O2 concentrator from the medical supply company, as the patient would not need it. DPCS stated, the patient's family refused of the O2 concentrator was not documented on the patient's medical record. DPCS stated the patient and family's refusal of the O2 concentrator was not reported to the medical director. During a review of the agencys policy entitled ";Clinical /Service Data collection" dated November 2020, it indicated a clinical/service record will be maintained for each patient receiving care or services according to the organization policies found in this manual and will include at a minimum physician orders and evidence of physician oversight, any changes to the plan of care and services ordered. b. A review of Patient 2's "Patient Information" indicated, the patient was admitted to the HA on 6/27/22, with an admitting diagnosis of chronic obstructive pulmonary disease (a progressive lung disease characterized by long term respiratory symptoms and airflow limitations). A review of Patient 2s plan of care/ IDG review indicated skilled nurse visits of once a week, the MSW to visit once a month and the spiritual counselor to visit twice per week. On 9/1/23 at 11:50 a.m. an interview was conducted with DPCS inside of Patient 2s residence. DPCS stated O2 concentrator and suction machine was ordered for Patient 2 but is not currently in here due to Patient 2s refusal of the equipment. The agency failed to document the refusal of the O2 concentrator and suction machine to the medical director. DPCS stated it was only reported verbally in IDG meetings and there is no written documentation of refusing ordered equipment. During a review of the agencys policy entitled ";Clinical /Service Data collection" dated November 2020, it indicated a clinical/service record will be maintained for each patient receiving care or services according to the organization policies found in this manual and will include at a minimum physician orders and evidence of physician oversight, any changes to the plan of care and services ordered.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Medical Director conducted an accurate assessment, review, and verify the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services, for two out of 14 sampled patients (Patients 12, and 14). The Medical Director certified the patients for hospice care without documentation to support diagnosis of terminal illness. This deficient practice had a potential for the patients receiving the hospice services not eligible for hospice benefits. --- a. A review of Patient 13's "Patient Information" indicated, the patient was admitted to the HA on 8/15//23, with a terminal diagnosis of hypertensive heart disease (long-term condition that develops over many years in people who have high blood pressure) without heart failure (a condition in which the heart doesn't pump blood as well as it should). A review of Patient 13s ";Physicians Certification for Hospice Benefit", for certification period 8/15/23 to 11/12/23, indicated this was Patient 13s second recertification. The record indicated the Medical Director (MD 1) attested/confirmed he had composed the narrative based on his review of the patients medical record, team assessment and/or examination of the patient. The physicians face-to face and narrative summary was signed by MD 2. b. A review of Patient 14s clinical record indicated a start of care date of 8/15/2023, with a terminal diagnosis of Moyamoya disease ( a rare, progressive disease cerebrovascular disorder caused by blocked arteries at the base of the brain. The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1 (Medical Director Designee). A review of patient 14s record titled "; Physicians Certification for Hospice Benefit "; for the certification period of 8/15/23 to 11/12/23, indicated this was patient 14s 1st benefit period. The record also indicated the Medical Director (MD 1) attested and confirmed he had composed the narrative based on his review of the patients medical record, team assessment and/or examination of the patient. The physicians face-to face and narrative summary was signed by MD 2. During a joint home visit, on 8/31/23 at 11 a.m. with the Licensed Vocational Nurse (LVN 1) at Patient 13s and Patient 14s residence, Patient 13, and 14 were observed sitting on the porch waiting for the Skilled Nurse. Patient 13 and 14 were observed walking into the house with no difficulty and sitting at the dining table. Patient 13 and 14 were alert and oriented x 3 (to person, place, and time), ambulatory with the use of an assisted device (walker), was not on oxygen, and has no shortness of breath or complained of chest pain. During an interview, Patient 14 stated, he walks to the park in his community with Patient 13. Patient 14 further stated, they have not been ruled out as a candidate nor declined any surgical procedures, and nobody told them that they have a life expectancy of six months or less. On 9/2/23 at 1:40 p.m., during a phone interview with the Medical Director Designee (MD 1), he stated he certified patients, had terminal illness by following LCD criteria and admitted to hospice care by reviewing patients medical history, prior medical record, and reviewed the registered nurse initial assessment. MD 1 stated, he was not attending physician of Patient 13 and Patient 14. MD 1 stated, he did not contacted or had conversation with Patient 13 and Patient 14. MD 1 stated, he did not assessed the patient's diagnosis and/or eligibility for hospice service. On 9/2/23, at 4:30 p.m., during a phone interview with Physician 2 (Medical Director), stated, him and the Medical director designee have an arrangement which consist of the MD designee doing the face-to-face assessment, interdisciplinary Group, pretty much overseeing that hospice agencies day-to-day operation, he just signs the Certification of Terminal Illness (CTI). On 9/3/23, at 2:20 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find the documentation of Patient 13 and Patient 14 had been ruled out as a candidate or has declined surgical procedures. The DPCS stated the agency was planning to discharge Patient 13 and Patient 14 for the current benefit period, but the patient's family member requested to continue with the service. A review of the hospice agencys policy and procedure titled, ";Certification of Terminal Illness", revised November 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 that subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient's medical record or, if applicable, examination of the patient. A review of the hospice agencys policy and procedure titled, ";Physician Services – Medical Director", revised November 2020, indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The duties and responsibilities of the Medical Director will include, but not be limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, providing written certification and narrative of the terminal illness for all subsequent benefit periods, and consulting with attending physicians regarding pain and symptoms management for hospice patients.

Based on observation, interview and record review, the medical director failed to oversee the implementation of the entire physician, nursing, social work, therapy, and counseling areas within the hospice to ensure that these areas consistently meet patient and family need, and failed to ensure the Medical Director conducted an accurate assessment, review, and verify the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their needs and failed to be involved with and overseeing the hospice agency. This deficient practice resulted in the patients not receiving necessary care and services to meet the highest quality of care. --- a. A review of Patient 13's "Patient Information" indicated the patient was admitted to the HA on 8/15//23, with a terminal diagnosis of hypertensive heart disease (long-term condition that develops over many years in people who have high blood pressure) without heart failure (a condition in which the heart doesn't pump blood as well as it should). A review of Patient 13s ";Physicians Certification for Hospice Benefit", for certification period from 8/15/23 to 11/12/23, indicated this was Patient 13s 2nd recertification. The record also indicated the Medical Director (MD 1) attested/confirmed he had composed the narrative based on his review of patients medical record, team assessment and/or examination of the patient. The physicians Face-to face and narrative summary was signed by MD 2. b. A review of Patient 14s "Patient Information" indicated, a start of care date of 8/15/2023, with a terminal diagnosis of Moyamoya disease ( a rare, progressive disease cerebrovascular disorder caused by blocked arteries at the base of the brain. The patient's record further indicated the ";referring/attending/patient choice" physician was physician 1 (Medical Director designee). A review of patient 14s record titled "; Physicians Certification for Hospice Benefit "; for the certification period of 8/15/2023 to 11/12/2023, indicated this was patient 14s 1st benefit period. The record also indicated the Medical Director (MD 1) attested and confirmed he had composed the narrative based on his review of patients medical record, team assessment and/or examination of the patient. The physicians Face-to face and narrative summary was signed by MD 2. During a joint home visit, on 8/31/23 at 11:00 a.m. with the Licensed Vocational Nurse (LVN 1) at Patient 13s and patient 14s residence, Patient 13, and 14 were observed sitting on the porch waiting for the Skilled nurse. Patient 13 and 14 were observed walking into the house with no difficulty and sitting at the dining table. Patient 13 and 14 were alert and oriented x 3 (to person, place, and time), ambulatory with the use of an assisted device (walker), was not on oxygen, and was not having any shortness of breath or complaining of any chest pain. During an interview, Patient 14 stated he walks to the park in his community with patient 13). Patient 14 further stated they have not been ruled out as a candidate nor declined any surgical procedures, and nobody told them that they have a life expectancy of six months or less. On 9/2/23 at 1:40 p.m., during a phone interview with the Medical Director Designee (MD 1), he stated he certified patients had terminal illness by following LCD criteria and admitted to hospice care by reviewing patients medical history, prior medical record, and reviewed registered nurse initial assessment. When asked if he was the attending physician of Patient 13 and Patient 14, MD 1 stated he was not. When asked if he contacted or had conversation with Patient 13 and Patient 14s attending physician regarding patients diagnosis and/or eligibility for hospice service, MD 1 stated he did not. On 9/2/23, at 4:30 p.m., during a phone interview with Physician 2 (Medical Director), he stated that he is the medical director of the hospice agency, however, he and the Medical director designee have an arraignment which consist of the MD designee doing the face-to-face assessment, interdisciplinary Group, pretty much overseeing that hospice agencies day-to-day operation, he just signs the Certification of Terminal Illness (CTI). On 9/3/23, at 2:20 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find the documented evidence Patient 13 and Patient 14 had been ruled out as a candidate or has declined surgical procedures. The DPCS stated the agency was planning to discharge Patient 13 and Patient 14 for the current benefit period, but the patient's family member requested to continue with the service. A review of the hospice agencys policy and procedure titled, ";Certification of Terminal Illness", revised November 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 that subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient's medical record or, if applicable, examination of the patient. A review of the hospice agencys policy and procedure titled, ";Physician Services – Medical Director", revised November 2020, indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The duties and responsibilities of the Medical Director will include, but not be limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, providing written certification and narrative of the terminal illness for all subsequent benefit periods, and consulting with attending physicians regarding pain and symptoms management for hospice patients.

Based on interview and record review, the hospice agency failed to ensure the documentation for volunteer services were signed and authenticated by the person creating the volunteer visit note for one of 14 sampled patients (Patient 2). This deficient practice resulted in multiple entries of documented home visits for Patient 2 which was written and created by the volunteer coordinator and electronically signed by the volunteer. --- A review of Patient 2's "Patient Information" indicated the patient was admitted to the hospice agency (HA) on 6/27/22, with an admitting diagnosis of chronic obstructive pulmonary disease (a progressive lung disease characterized by long term respiratory symptoms and airflow limitations). A review of Patient 2s plan of care/ IDG review indicated skilled nurse to visit once a week. The MSW to visit once a month and the spiritual counselor to visit once a month and the volunteer to visit twice a week. A review of the agencys documentation titled ";Volunteer Note" dated 4/19/23, no signature by the author of the note was observed. On 9/3/23 at 10:30 a.m. an interview was conducted in the agency with the volunteer. Volunteer stated he mainly helps out around the office but has been on a few home visits for Patient 2. He further stated he has never written one visit note for Patient 2, but his electronic signature is documented on the volunteer notes for the following dates :4/12/23, 5/10/23, 5/17/23, 6/13/23, 6/20/23, 7/14/23, and 7/26/23. He stated he does remember the volunteer coordinator having him sign some documents electronically, but states he does not remember exactly what it was. During a review of the agencys undated, policy entitled ";Volunteer Services" it indicted that qualified volunteers will provide appropriate services in accordance with the plan of care and hospice program needs. Volunteers will report patient/family/caregiver response to volunteer services. Volunteers will document their activities/type of service and time worked on volunteer activity/clinical notes and submit this documentation for the patients clinical note.

Upon patient record review, 4 of 11 (Patient #4,7,9,10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #4,7,9 and 10 Oxygen missing from the med profile.

Upon patient record review, 1 of 11 (Patient #11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component completed timely. Patient #11 Start of care was 1/6/22. Initial bereavement assessment was completed on 1/15/22.

Upon patient record review, 7 of 11(Patient #1,2,3,4,5,6,7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. Patient #1,6 Plan of care did not contain interventions or goals for MSW. Patient #1,2,3,4,5,6,7 Plan of care did not contain interventions or goals for spiritual counselor Patient #1,3,6,7 Patient is taking pain medications but there is not a care plan for pain which includes interventions and goals. Patient #6 Plan of care did not contain interventions or goals for aide services.

Upon patient record review, 4 of 11 (Patient #5,6,8,9) 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 a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient #5 MSW order on 12/14/19 as needed. SC order on 12/14/19 as needed. No frequency was ordered with either discipline Patient #6 SC order on 11/11/20 as needed. No frequency was included in order. Patient #8 MSW ordered frequency as needed. SC order frequency as needed. Patient #9 SC frequency order on 12/11/21 was as needed without a frequency.

Upon client record review, 7 of 11 (Patient #1,2,3,4,8,10,11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 On 8/18/21, frequency order states RN 1x/month and LVN 1x/weekly. Three RN visits made in Aug (8/20/21, 8/22/21, 8/29/21) and two RN visits in Sept (9/5/21, 9/10/21). Patient #2 On 8/27/21, frequency order for SC 1x/month. No SC visit for the month of October. Patient #3 On 11/5/21, frequency order for SC 1x/month. No SC visit for the month of December. Patient #4 On 2/7/22, frequency order for SN 1x/week. Two SN visits completed week of 2/13/22 (2/15/22, 2/18/22). Patient #8 On 7/6/21, SN frequency stated RN 1x/week. On 7/14/21 LVN visited patient. There was not an order for the LVN visit. Patient #10 On 11/30/21, SN frequency states RN every 14 days and LVN weekly. RN visits on 12/2/21, 12/7/21, 12/17/21 and 12/31/21. Patient #11 On 1/6/22, SN frequency RN every 2 weeks and LVN 1x/week. RN visits 1/8/22, 1/12/22, 1/13/22, 1/14/22, 1/15/22. No evidence of an LVN visit the first week of care. LVN visits did not start until 1/11/22.

Upon patient record review 2 of 3 applicable (Patient #6,11) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #6 On 1/2/22, HHA visits ordered 2x/week. HHA visits on 2/15/22, 2/17/22, 2/19/22 without order for the 3rd visit. Patient #11 On 1/6/22, HHA visits ordered 2x/week. No visits completed the first week of care. Visits were completed as ordered the following week (1/12, 1/15).