Every finding on record at St. Francis Hospice Care, Inc

Based on interview and record review, the agency failed to develop an individualized plan of care (a nursing care plan is a written document that outlines the individualized care a patient will receive, which includes: a patients needs, the problem, the goal and interventions to meet the goal) for two of five sampled patients (Patients 2 and 3) when the patients' care plans did not include discharge planning. This failure had the potential to cause Patients 2 and 3, as well as the patients family members, to have a poor understanding of the patients medical conditions and treatment plans, difficulties accessing necessary post-discharge care, complications due to the lack of proper follow-up, and decreased patient and family satisfaction. --- Findings: 1. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of November 21, 2024, with a benefit period of January 20, 2025, to March 20, 2025, (Benefit Period Nine). Patient 2 had diagnoses that included other specified degenerative (worsening) diseases of nervous system and autoimmune disease (the body's immune system mistakenly attacks healthy cells, tissues, or organs). A review of Patient 2s ";Face-to-Face Visit Note" (F2F: an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient), by a New Medical Director (N/MD), dated January 11, 2025, indicated, ";The patient is a 66 [year old] female who has cataracts [clouding of the lens of the eye] bilaterally [both eyes] and is nearly blind. She uses a walker and notes no pain, weight loss, and has been stable with strength. She wears pullups and gets assistance with bathing and dressing. She notes that she cleans herself when she has an accident in her pullups. She is very appropriate with her conversation and noted no [difficulty with breathing] or chest pain." A review of Patient 2s Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) meeting notes, dated January 17, 2025, indicated, ";IDG Discussion / Updated Comprehensive Assessment Review ... NURSING: ... [Patient 2s] symptoms and pain is well controlled with medication and her condition has improved. [Skilled Nurse-SN] informed patient on discharge plan and will refer [Medical Social Worker-MSW] to visit patient for safe discharge to the care of a primary physician. ... [Patient 2 and caregiver] verbalized understanding of all SN instructions and progressing towards understanding discharge planning ... SPIRITUAL: No new spiritual issues noted and/reported since last [IDG]. Will continue to provide assistance accordingly, to adhere with patient`s present [plan of care]. PSYCHOSOCIAL: [There was no documentation from the MSW]. PHYSICIAN: [New Medical Director-N/MD] to evaluate patient for possible discharge." A review of Patient 2s plans of care from January 11, 2025, to January 23, 2025, was conducted. There was no documented evidence to show discharge planning had been included in Patient 2s plans of care. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on January 21, 2025, at 12:35 PM, the Admin/DPCS verified the N/MD had conducted a F2F visit on January 11, 2025, and determined Patient 2 was not terminally ill and the agency should proceed with discharging Patient 2. The Admin/DPCS stated it was her responsibility to update Patient 2s plan of care to include discharge planning and had not. The Admin/DPCS stated she had initiated Patient 2s discharge at the January 17, 2025, IDG meeting and directed the Medical Social Worker (MSW) and the Spiritual Counselor (SC) to contact Patient 2 and Patient 2s family to discuss the discharge, provide family counseling, patient education and offer community services as needed, prior to the discharge. The Admin/DPCS stated there was no documented evidence to show the MSW or the SC had conducted and completed these duties. A review of Patient 2s MSW and SC visit notes, dated from January 11, 2025, to January 23, 2025, was conducted. There was no documented evidence to show the MSW or the SC had spoken to Patient 2 or Patient 2s family about the pending discharge from hospice services. During a home visit interview with Patient 2 and the Admin/DPCS on January 22, 2025, at 10:37 AM, Patient 2 stated the MSW had visited her yesterday (January 21, 2025) and told her she was being discharged from hospice services. Patient 2 stated she did not know why, when or where she was being discharged. During an interview with Patient 2s son on January 22, 2025, at 11:58 AM, Patient 2s son stated he did not know his mother was on hospice and did not know what hospice was. Patient 2s son stated no one had contacted him to discuss discharging his mother from hospice services. During an interview with the N/MD on January 23, 2025, from 10:34 AM to 12:30 PM, the N/MD stated he had conducted a F2F visit on January 11, 2025, with Patient 2 and determined she was no longer terminally ill and meant for Patient 2 to be discharged. The N/MD stated he had attended Patient 2s IDG meeting dated January 17, 2025, and discussed Patient 2s discharge due to not being terminally ill but had not provided documentation of the discussion or signed the IDG meeting notes to confirm his attendance. During an interview with the MSW on January 23, 2025, at 12:41 PM, the MSW stated he had spoken to Patient 2 on January 21, 2025, about being discharged from hospice services but had not documented his conversation. The MSW stated he had not reached out to Patient 2s son to discuss Patient 2s pending discharge. During an interview with the SC on January 23, 2025, at 1:38 PM, the SC stated he had been verbally told of Patient 2s pending discharge at the January 17, 2025, IDG meeting. The SC stated he had not reached out to Patient 2 or Patient 2s family to discuss the pending discharge because he did not know he was supposed to. 2. A review of Patient 3s face sheet, undated, indicated a start of care date of October 1, 2024, with a benefit period of December 30, 2024, to March 29, 2025, (Benefit Period Two). Patient 3 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). A review of Patient 3s IDG meeting notes, dated January 3, 2025, indicated, ";IDG Discussion / Updated Comprehensive Assessment Review ... NURSING: ... [Patient 3] is stable and have no signs of declining or worsening disease. Notified [Patient 3] [New Medical Director--N/MD] will be making a visit and will be notified when. ... PHYSICIAN: [N/MD] will schedule to evaluate patient for hospice services." A review of Patient 3s F2F, by the N/MD, dated January 11, 2025, indicated, ";[Patient 3] is a 59 [year old] female with a diagnosis of heart disease with heart failure. The patient is not on any medications that suggest heart failure and the hospital records do not document any signs of heart disease. The patient was walking around outside with no symptoms of [difficulty with breathing] or chest pain. She was [pleasant] and walks without a walker. She eats well and feeds herself. She has some right knee pain and notes can use assistance with bathing, however, does not need help with transfer, dressing, and cleaning herself. She can go to restroom on her own. She uses pullups but can change herself. ... At this time patient doesn`t have terminal illness. The patient does not meet hospice criteria at this time, please discharge safely to primary physician." A review of Patient 3s IDG meeting notes, dated January 17, 2025, indicated, ";IDG Discussion / Updated Comprehensive Assessment Review ... NURSING: ... [Patient 3] remains stable and no changes in her status after [N/MD] evaluation for terminal illness. [Patient 3] is aware she has improved significantly. [N/MD] recommend safe discharge to her primary physician, will discharge [Patient 3] as soon as her primary physician is located, or hospice will help recommend one. IDG agreed will notify [Patient 3] after safe discharge is established by next IDG. MSW [Medical Social Worker] to visit [Patient 3]. ... SPIRITUAL: SC will try to contact [Patient 3] for visit for spiritual support. PSYCHOSOCIAL: MSW will schedule visit with [Patient 3] as soon as possible to discuss safe discharge. I will also provide resources for [Patient 3] and obtain from [Patient 3] the name of her physician. PHYSICIAN: Evaluated [Patient 3] [January 11, 2025] and ordered safe discharge to [Patient 3s] primary physician as soon as located or refer [Patient 3] to a primary care physician. MSW to schedule visit with [Patient 3] for resources to help [Patient 3] with safe discharge from hospice services." A review of Patient 3s plans of care, dated from January 11, 2025, to January 23, 2025, was conducted. There was no documented evidence to show discharge planning had been included in Patient 3s plans of care. During an interview with the Admin/DPCS on January 22, 2025, at 1 PM, the Admin/DPCS stated the N/MD had conducted a F2F visit on January 11, 2025, and determined Patient 3 was not terminally ill and provided an order to discharge Patient 3. The Admin/DPCS stated it was her responsibility to update Patient 3s plan of care to include discharge planning and had not. The Admin/DPCS stated she had initiated Patient 3s discharge at the January 17, 2025, IDG meeting and directed the Medical Social Worker (MSW) and the Spiritual Counselor (SC) to contact Patient 3 and Patient 3s family to discuss the discharge, provide family counseling, patient education and offer community services as needed, prior to the discharge. The Admin/DPCS stated there was no documented evidence to show the MSW or the SC had conducted and completed these duties. A review of Patient 3s MSW and SC visit notes, dated from January 11, 2025, to January 23, 2025, was conducted. There was no documented evidence to show the MSW or the SC had spoken to Patient 3 or Patient 3s family about the pending discharge from hospice services. During a home visit interview with Patient 3 and the Admin/DPCS on January 22, 2025, at 10:30 AM, Patient 3 stated the MSW had visited her yesterday (January 21, 2025) and told her she needed hospice services and she was not dying. Patient 3 stated a nurse came by yesterday too and said she was being discharged but she did not know why, when or where she was being discharged. During an interview with Patient 3s Sister One on January 22, 2025, at 12:06 PM, Sister One stated the MSW had called her January 21, 2025, and had discussed how Patient 3 was doing but never mentioned anything about discharging Patient 3. Sister One stated, ";I don't want them to discharge her because she needs someone to take care of her!" During an interview with the N/MD on January 23, 2025, from 10:34 AM to 12:30 PM, the N/MD stated he had conducted a F2F visit on January 11, 2025, with Patient 3 and determined she was no longer terminally ill and had written a discharge order on the F2F visit document. The N/MD stated he had attended Patient 3s IDG meeting dated January 17, 2025, and discussed Patient 3s discharge due to not being terminally ill but had not provided documentation of the discussion or signed the IDG meeting notes to confirm his attendance. The N/MD stated it was his expectation that Patient 3's discharge plan would be activated, and Patient 3 would be discharged from the agency. During an interview with the MSW on January 23, 2025, at 12:57 PM, the MSW stated he had not spoken to Patient 3 or Patient 3s family about the pending discharge and should have. The MSW stated it was his responsibility to provide education and community services to the patients and their families prior to discharge. During an interview with the SC on January 23, 2025, at 1:53 PM, the SC stated he did not know Patient 3 was going to be discharged and had not talked to Patient 3 or Patient 3s family about a pending discharge. A review of the agencys policy and procedure titled ";The Plan of Care," dated November 2013, indicated, ";PURPOSE: To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. Each patient must have a written plan of care that specifies the care and services necessary to meet the patient's specific needs as identified in the comprehensive assessment. POLICY: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. This plan of care must be initiated at start of care. ... Content of the Plan: ... B. The plan of care includes but is not limited to: ... 7. Anticipated discharge. ..." A review of the agencys policy and procedure titled ";Discharge from Hospice Program," dated November 2013, indicated, ";PURPOSE: To establish standards and a process by which patients are discharged from the hospice program. POLICY: [Name of the agency] will provide service to a patient and family/caregiver as long as the patient is certified as terminally ill with a prognosis of six months or less, lives in the designated service area, and care can be provided safely and appropriately. Discharge Criteria 1. The Medical Director and/or attending physician determine the patient is not hospice appropriate, according to standard clinical criteria for determining disease prognosis of six (6) months or less. ... PROCEDURE: 1. The hospice interdisciplinary group will develop a discharge plan which includes the possibility that a patient's condition might stabilize or change such that the patient cannot be certified as terminally ill. The discharge planning process will include any necessary family counseling, patient education or other services needed prior to discharge. ..."

The agency failed to ensure that the Condition of Participation: L 520 §418.54 Initial and Comprehensive assessment of the patient was in compliance as follows: 1. Based on interview and record review, the agency failed to ensure the patients' comprehensive assessments (a detailed evaluation of a patient's complete health status that includes physical status, mental status, spiritual status and psychosocial status) were completed within five days after the start of care for six of six sampled patients (Patient 1, 2, 3, 4, 5, 6) when: a. For Patient 1 no psychosocial assessment (an evaluation of a person's mental health, social status, and functional capacity) was conducted. (Refer to L 523) b. For Patients 1, 2, 3, 4, 5, 6 the psychosocial and spiritual assessments did not identify, contact or provide an assessment of family members' spiritual and psychosocial needs. (Refer to L 523) 2. Based on interview and record review, the agency failed to ensure the comprehensive assessment identified the physical needs of one of six sampled patients (Patient 1) when Patient 1s lower left leg wound was not identified, assessed or treated. (Refer to L 524) The cumulative effect of these systemic practices resulted in the potential to cause Patients 1, 2, 3, 4, 5, and 6s family members to feel unsupported and unable to cope with the emotional and realistic challenges associated with a loved one's impending death, leading to increased stress, grief, and a lack of meaning during a difficult time. In addition, this failure caused Patient 1s wound to worsen as evidenced by exposed muscle within the wound, 2+ swelling [used to describe pitting edema, where a doctor presses on the swollen area and observes the depth of the indentation left behind] extending from the middle shin, up to the kneecap and pain.

Based on interview and record review, the agency failed to ensure the patients' comprehensive assessments (a detailed evaluation of a patient's complete health status that includes physical status, mental status, spiritual status and psychosocial status) were completed within five days after the start of care for six of six sampled patients (Patient 1, 2, 3, 4, 5, 6) when: 1. For Patient 1 no psychosocial assessment (an evaluation of a person's mental health, social status, and functional capacity) was conducted. 2. For Patients 1, 2, 3, 4, 5, 6 the psychosocial and spiritual assessments did not identify, contact or provide an assessment of family members' spiritual and psychosocial needs. These failures had the potential to cause Patients 1, 2, 3, 4, 5, and 6s family members to feel unsupported and unable to cope with the emotional and realistic challenges associated with a loved one's impending death, leading to increased stress, grief, and a lack of meaning during a difficult time. --- Findings: 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). Patient 1 was discharged on October 21, 2024. A review of Patient 1s Medical Social Workers (MSW) visit notes from September 30, 2024, to October 21, 2024, was conducted. There was no documented evidence to show the MSW had reached out to Patient 1 or conducted an initial psychosocial assessment. During an interview with the MSW on December 4, 2024, from 4:07 PM to 4:20 PM, the MSW stated he had not conducted a psychosocial assessment of Patient 1 or Patient 1s family and should have. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on December 5, 2024, at 2:37 PM, the Admin/DPCS stated Patient 1 and Patient 1s family should have received a psychosocial assessment and did not. A review of the agencys policy and procedure (P&P) titled ";Comprehensive Assessment," dated April 2020, the P&P indicated, ";PURPOSE: To provide guidelines for the comprehensive assessment. POLICY: A comprehensive patient assessment will be performed by the interdisciplinary group [a team of health care professional responsible for patient's health] no later than 5 [five] calendar days after the election of hospice [a specialized care for people nearing the end of life] care in consultation with attending physician. PROCEDURE: 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient's clinical record, including at least the following information, as relevant: ... R. Patient and family/caregiver support systems and the care the family/caregiver is available, capable, and willing to provide, including applicable strengths of patient, physical, psychosocial, and/or spiritual resources available. S. The patient's psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanisms, and the patient's and family/caregiver's reaction to illness. ... U. Involvement of family/caregiver, neighbors, and/or other individuals/organizations, including involvement in any support groups. ... F. Survival risk factors, such as the nature of the relationship with the patient, circumstances surrounding the death, behaviors before and after the death, and availability of coping mechanisms and potential for pathological grief reactions. ..." 2a. A review of Patient 1s face sheet, undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure. Patient 1 was discharged on October 21, 2024. A review of Patient 1s face sheet, section ";Authorized Rep [representative] (AR)/Emergency Contact (EC)," undated, was conducted. There was no documented evidence to show an AR or EC had been identified. A review of Patient 1s ";Spiritual Assessment," dated September 30, 2024, by a Spiritual Counselor (SC 1), was conducted. There was no documented evidence to show SC 1 had identified, contacted, or provided a spiritual assessment of family members or significant others. During an interview with SC 1 on December 4, 2024, from 3:50 PM, to 4:02 PM, SC 1 stated he had not identified, contacted, or provided a spiritual assessment of family members or significant others and should have. During an interview with the Admin/DPCS on December 5, 2024, at 2:37 PM, the Admin/DPCS stated SC 1 should have identified, contacted, and provided a spiritual assessment of family members or significant others and did not. 2b. A review of Patient 2s face sheet, undated, indicated a start of care date of November 21, 2024, with a benefit period of November 21, 2024, to January 19, 2025, (Benefit Period Eight). Patient 2 had diagnoses that included other specified degenerative (worsening) diseases of nervous system and autoimmune disease (the body's immune system mistakenly attacks healthy cells, tissues, or organs). A review of Patient 2s face sheet, section ";Authorized Rep (AR)/Emergency Contact (EC)," undated, indicated two names of staff at the facility where Patient 2 lived. A review of Patient 2s ";Spiritual Assessment," dated November 22, 2024, by SC 1, was conducted. There was no documented evidence to show SC 1 had identified, contacted, or provided a spiritual assessment of family members or significant others. A review of Patient 2s ";Psychosocial Assessment," dated November 23, 2024, by the MSW, was conducted. There was no documented evidence to show the MSW had identified, contacted, or provided a psychosocial assessment of family members or significant others. During an interview with a Licensed Vocational Nurse (LVN 2) and Patient 2 on December 3, 2024, from 9:55 AM to 11:14 AM, at the home visit, LVN 2 stated she did not know anything about Patient 2s family. Patient 2 stated her son called from time to time to check up on her and she called her son sometimes too but could not remember his phone number, she stated the facility helped her place the calls. Patient 2 stated she knew she was on hospice, and they helped her get diapers, wipes and medications. Patient 2 stated she did not know hospice was for people who had six months or less to live, "I'm not going to die in six months." Patient 2 stated she did not ask for hospice services and did not remember who had offered them to her. During an interview with SC 1 on December 4, 2024, from 3:50 PM, to 4:02 PM, SC 1 stated he had not identified, contacted, or provided a spiritual assessment of family members or significant others and should have. During an interview with the MSW on December 4, 2024, from 4:07 PM to 4:20 PM, the MSW stated he had not identified, contacted, or provided a psychosocial assessment of family members or significant others and should have. During an interview with the Admin/DPCS on December 5, 2024, at 2:51 PM, the Admin/DPCS stated the MSW and SC 1 should have identified, contacted, and provided psychosocial and spiritual assessment of family members or significant others and did not. 2c. A review of Patient 3s face sheet, undated, indicated a start of care date of October 1, 2024, with a benefit period of October 1, 2024, to December 29, 2024, (Benefit Period One). Patient 3 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 3s face sheet, section ";Authorized Rep (AR)/Emergency Contact (EC)," undated, was conducted. There was no documented evidence to show an AR or EC had been identified. A review of Patient 3s ";Spiritual Assessment," dated October 1, 2024, by SC 1, was conducted. There was no documented evidence to show SC 1 had identified, contacted, or provided a spiritual assessment of family members or significant others. A review of Patient 3s ";Psychosocial Assessment," dated October 3, 2024, by the MSW, was conducted. There was no documented evidence to show the MSW had identified, contacted, or provided a psychosocial assessment of family members or significant others. During an interview with LVN 2 and Patient 3 on December 3, 2024, from 9:58 AM to 10:43 AM, at the home visit, LVN 2 stated Patient 3 had no family that she knew of. Patient 3 stated her dad, sister one, sister two and her brother helped her with her care and life. Patient 3 stated it was best to call sister one because she knew all about her care. Patient 3 stated she did not know she was on hospice, had not asked for hospice, and did not know what hospice was. During an interview with SC 1 on December 4, 2024, from 3:50 PM, to 4:02 PM, SC 1 stated he had not identified, contacted, or provided a spiritual assessment of family members or significant others and should have. During an interview with the MSW on December 4, 2024, from 4:07 PM to 4:20 PM, the MSW stated he had not identified, contacted, or provided a psychosocial assessment of family members or significant others and should have. During an interview with the Admin/DPCS on December 5, 2024, at 3 PM, the Admin/DPCS stated the MSW and SC 1 should have identified, contacted, and provided psychosocial and spiritual assessment of family members or significant others and did not. During an interview with Patient 3s Sister One on December 6, 2024, at 12:43 PM, Sister One stated she knew her sister was getting some kind of aide but did not know from where and did not know Patient 3 was receiving hospice services. Patient 3s Sister One stated she knew what hospice was because her mother had hospice when she was diagnosed with cancer, and she was unaware of any terminal diagnoses for her sister. Sister One stated she had not been contacted by the hospice, or a Spiritual Counselor (SC) or a Medical Social Worker (MSW) to offer support or services to her or any of her other family members. The Sister One stated the hospice services her mother had received provided her whole family with support and guidance. 2d. A review of Patient 4s face sheet, undated, indicated a start of care date of September 9, 2024, with a benefit period of September 9, 2024, to December 7, 2024, (Benefit Period Two). Patient 4 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 4s face sheet, section ";Authorized Rep (AR)/Emergency Contact (EC)," undated, was conducted. There was no documented evidence to show an AR or EC had been identified. A review of Patient 4s ";Spiritual Assessment," dated September 11, 2024, by SC 1, was conducted. There was no documented evidence to show SC 1 had identified, contacted, or provided a spiritual assessment of family members or significant others. A review of Patient 4s ";Psychosocial Assessment," dated September 10, 2024, by the MSW, was conducted. There was no documented evidence to show the MSW had identified, contacted, or provided a psychosocial assessment of family members or significant others. During an interview with LVN 2 and Patient 4 on December 3, 2024, from 10:01 AM to 10:50 AM, at the home visit, LVN 2 stated she had not heard about any family for Patient 4, however she had heard Patient 4 talking on the phone to someone, but she had not asked who it was. Patient 4 stated her daughter lived in Missouri with her ex-husband and her son lived in Nevada, but she did not remember their phone numbers. Patient 4 stated she knew hospice was for dying people, "but I'm not dying in 6 months. I'm in good shape." Patient 4 stated she needed the hospice services so she could get her medications, however, she had not asked for hospice services and had not spoken to a physician about hospice services or a terminal diagnosis. During an interview with SC 1 on December 4, 2024, from 3:50 PM, to 4:02 PM, SC 1 stated he had not identified, contacted, or provided a spiritual assessment of family members or significant others and should have. During an interview with the MSW on December 4, 2024, from 4:07 PM to 4:20 PM, the MSW stated he had not identified, contacted, or provided a psychosocial assessment of family members or significant others and should have. During an interview with the Admin/DPCS on December 5, 2024, at 3:07 PM, the Admin/DPCS stated the MSW and SC 1 should have identified, contacted, and provided psychosocial and spiritual assessment of family members or significant others and did not. 2e. A review of Patient 5s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 5 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 5s face sheet, section ";Authorized Rep (AR)/Emergency Contact (EC)," undated, was conducted. There was no documented evidence to show an AR or EC had been identified. A review of Patient 5s ";Spiritual Assessment," dated July 29, 2024, by SC 1, was conducted. There was no documented evidence to show SC 1 had identified, contacted, or provided a spiritual assessment of family members or significant others. A review of Patient 5s ";Psychosocial Assessment," dated July 31, 2024, by the MSW, was conducted. There was no documented evidence to show the MSW had identified, contacted, or provided a psychosocial assessment of family members or significant others. During an interview with LVN 2 and Patient 5 on December 3, 2024, from 10:04 AM to 10:23 AM, at the home visit, LVN 2 stated Patient 5 had a sister in California and some family outside of California, but she did not know their names or contact numbers. Patient 5 stated she had a sister in California but did not remember a phone number. Patient 5 stated she understood hospice to be someone who comes in and takes care of you, gives you showers, cleans up, makes sure your medications are correct and makes you take your medications. Patient 5 stated, "I don't know how I ended up on hospice. I didn't ask for hospice. I don't know if the facility's owners asked for the hospice services for me. I don't think I would die in 6 months, I'm pretty healthy. I didn't talk to a doctor about hospice or a terminal diagnosis." During an interview with SC 1 on December 4, 2024, from 3:50 PM, to 4:02 PM, SC 1 stated he had not identified, contacted, or provided a spiritual assessment of family members or significant others and should have. During an interview with the MSW on December 4, 2024, from 4:07 PM to 4:20 PM, the MSW stated he had not identified, contacted, or provided a psychosocial assessment of family members or significant others and should have. During an interview with the Admin/DPCS on December 5, 2024, at 3:18 PM, the Admin/DPCS stated the MSW and SC 1 should have identified, contacted, and provided psychosocial and spiritual assessment of family members or significant others and did not. 2f. A review of Patient 6s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 6 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 6s face sheet, section ";Authorized Rep (AR)/Emergency Contact (EC)," undated, was conducted. There was no documented evidence to show an AR or EC had been identified. A review of Patient 6s ";Spiritual Assessment," dated July 29, 2024, by SC 1, was conducted. There was no documented evidence to show SC 1 had identified, contacted, or provided a spiritual assessment of family members or significant others. A review of Patient 6s ";Psychosocial Assessment," dated July 28, 2024, by the MSW, indicated a sister in Texas. There was no documented evidence to show the MSW had contacted or provided a psychosocial assessment of the sister in Texas. During an interview with LVN 2 and Patient 6 on December 3, 2024, from 10:08 AM to 11:22 AM, at the home visit, LVN 2 stated Patient 6 had a lot of family and they all lived in California, but she did not know the names or contact numbers. Patient 6 stated she had a sister and a daughter and provided their contact numbers. Patient 6 stated she did not know she was on hospice, and she did not know what hospice was. During an interview with SC 1 on December 4, 2024, from 3:50 PM, to 4:02 PM, SC 1 stated he had not identified, contacted, or provided a spiritual assessment of family members or significant others and should have. During an interview with the MSW on December 4, 2024, from 4:07 PM to 4:20 PM, the MSW stated he had not contacted, or provided a psychosocial assessment of the sister in Texas and should have. During an interview with the Admin/DPCS on December 5, 2024, at 3:29 PM, the Admin/DPCS stated the MSW should have contacted, and provided a psychosocial assessment of the sister in Texas and did not. SC 1 should have identified, contacted, and provided psychosocial and spiritual assessment of family members or significant others and did not. During an interview with Patient 6s sister on December 6, 2024, at 4:12 PM, Patient 6s sister stated she helped take care of her sister and was not notified she was admitted to hospice care, ";My sister isn't dying and she should not be on hospice!" Patient 6's sister stated her sister did not have a terminal diagnosis of any kind and she had not been contacted by a SC or a MSW from the hospice to offer support or guidance. Patient 6's sister stated she was worried her sister being on hospice would cause a problem with the other services they had been working on getting her, ";like housing." A review of the agencys policy and procedure (P&P) titled ";Spiritual Care Counseling Services," dated November 2013, the P&P indicated, ";PURPOSE: To provide guidelines for the appropriate assessment and provision of service to meet the spiritual needs of patients and family/caregivers. POLICY: Hospice will provide spiritual care counseling in keeping with the patient's and family/caregiver's belief system and practice, and in accordance with the plan of care. ... An initial spiritual assessment for all consenting patients and/or documentation supporting attempts to make such an assessment shall be completed within a reasonable period of time. ... The designated person providing spiritual services shall have the following qualifications: 1. Demonstrated experience and training to support the spiritual needs of the patient and family. ... PROCEDURE: ... 2. The Hospice Chaplain will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient and family. 3. If the patient and family/caregiver requests spiritual support from hospice, the Hospice Chaplain will provide services directly or coordinate a referral to appropriate resources. 4. The Hospice Chaplain will develop an individualized spiritual/pastoral plan of care, which will demonstrate an effort to work closely with local clergy as desired by the patient, and provide spiritual support, as defined and requested by the patient and family/caregiver. 5. The Hospice Chaplain will conduct religious services of prayer, worship, and rituals for patients/families, as requested. 6. The Hospice Chaplain will offer patients and family/caregivers of different philosophies and religious beliefs opportunities to discuss and share their thoughts, feelings, beliefs, and values. 7. If the patient and family/caregiver identify involvement with a local church, synagogue, mosque, etc., and permission is given to contact them, the Hospice Chaplain will call to coordinate care. The identified spiritual support person will be encouraged to participate as an interdisciplinary group member in developing the plan of care and to document his/her interventions. 8. Spiritual care assessments and counseling will be documented in the patient's clinical records as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care. ... 10. Ongoing comprehensive assessments will be made by the interdisciplinary group members to identify any developing spiritual needs of the patient and family/caregiver and to update the plan of care to meet those needs. ..." A review of the agencys policy and procedure (P&P) titled ";Psychosocial Services," dated November 2013, the P&P indicated, ";PURPOSE: To ensure that appropriate psychosocial services are provided to hospice patients and family/caregivers. POLICY: ... Psychosocial services will include: ... 2. Providing psychosocial and emotional support to the patient/family. ... 5. Patient and family/caregiver counseling regarding of death, dying, and grief. ... A social worker will be assigned to each patient and family/caregiver based on the patient's and family's needs and acceptance of these services. The social worker will be a member of the interdisciplinary group and will participate in the development, implementation, and revision of the plan of care. PROCEDURE: 1. The social worker will contribute to the comprehensive assessment and ongoing update to the comprehensive assessment based on the needs of the patient. Assessment activities of the medical social worker will include, but not be limited to: ... B. The patient and family/caregiver psychosocial status, potential for risk of suicide and/or abuse or neglect. ... D. Family dynamics and communication patterns, obstacles to learning or ability to participate in provision of care, obstacles to compliance with the plan of care. E. Patient and family/caregiver response to psychosocial interventions. ... G. Need for counseling related to risk assessment for pathological grief. H. Special needs related to cultural diversity, including communication, space, role of family members, and special traditions. ... L. Patient and family/caregiver response to interventions when referred to available community resources and their satisfaction with services provided. M. Bereavement needs. 2. All psychosocial services will be performed at the patient's place of residence, as appropriate. A. Psychosocial assessments will be performed on each new hospice admission. B. Patient and family/caregiver counseling will be offered to every patient and family/caregiver and, as appropriate, will be provided to the patient and family/caregiver by a licensed social worker or other interdisciplinary group member. C. Crisis intervention services will be provided to patients and family/caregivers when required, 24 hours a day, seven (7) day a week. D. Information about and referrals to additional community support services will be made available to the patient and family/caregiver. The patient and family/caregiver's interest in and ability to access these resources will be assessed. ... G. Assistance with funeral planning will be provided, including transfer of responsibilities regarding fiscal, legal, and health care decisions. H. Patient and family/caregiver questions and concerns will be promptly addressed and answered. 3. Psychosocial assessments and interventions will be documented in the patient's clinical record as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care. Documentation will include A. Goals of care. B. Observations of the psychosocial needs or problems of the patient and family/caregiver, including counseling needs, assistance with planning for wills, funeral arrangements, financial planning, etc. C. Interventions provided to address the psychosocial needs or problems of the patient and family/caregiver and the patient's response and progress towards goals. D. Plans and/or referrals made to address the psychosocial needs or problems of the patient and family/caregiver, in accordance with the interdisciplinary group plan of care. ..."

Based on interview and record review, the agency failed to ensure the comprehensive assessment (a detailed evaluation of a patient's complete health status that includes physical status, mental status, spiritual status and psychosocial status) identified the physical needs of one of six sampled patients (Patient 1) when Patient 1s lower left leg wound was not identified, assessed or treated. This failure caused Patient 1s wound to worsen as evidenced by exposed muscle within the wound, 2+ swelling [used to describe pitting edema, where a doctor presses on the swollen area and observes the depth of the indentation left behind] extending from the middle shin, up to the kneecap and pain. --- Findings: A review of Patient 1s acute care hospitals nursing note, dated September 16, 2024, indicated, ";[Wound assessment left lower leg] Current Measurements: Length: 4.6 cm [centimeters-a unit of measurement], Width: 4.2 cm, Depth: 0.8 cm. Wound Bed Presentation: Tissue Color: red and yellow. Tissue Appearance: clean, moist, soft, granulation [new connective tissue that forms in the body's response to injury during the wound healing process], and non-granular [indicates a wound that is not properly forming new blood vessels and connective tissue necessary for healing, signifying a stalled or unhealthy wound], Granular: 80% [percent], Slough [dead tissue cells and debris]: 10%, Eschar [hard dead tissue covering wound bed]: 0%, Epithelization [wound tissue repair process]: 0%, Non-granular: 10%, Exposed Anatomy [part of the body]: adipose [fat tissue]. Procedure Note: [Patient 1s] wound vac [Vacuum Assisted Closure (VAC), a medical device that uses suction to help wounds heal faster by removing excess fluid, promoting blood flow, and drawing the edges of the wound together] dressing change performed today. Wound bed presents with clean, moist, and soft tissue and appears to be healing, shows no evidence of infection, is showing improvement of approximated wound edges, is granulating, is presented with slough, is nongranulated, has serosanguineous [liquid part of the blood] drainage, with no odor. ... [Patient 1] would benefit from wound vac care upon discharge. ..." A review of Patient 1s acute care hospitals ";Inpatient Discharge Summary," dated September 9, 2024, to September 16, 2024, indicated, to discharge home with wound vac and home health services (a group of medical services that are provided care in patient's home to treat or manage an illness or injury). A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). Patient 1 was discharged on October 21, 2024. A review of Patient 1s acute care hospitals physicians progress note, dated October 9, 2024, indicated, ";Patient presents today for hospital follow up for left [front] shin wound. She was recently hospitalized for this wound (9/9/24-9/16/24) and diagnosed with cellulitis [bacterial infection in the skin]. ... Due to improvement to wound, she was discharged home with recommendations to continue wound VAC, [and antibiotic] However, patient did not follow these recommendations and never utilized wound vac. Additionally, she did not take her antibiotic, ... as prescribed. She reports finishing these pills" a couple days ago." She also reports that her referred home health nurse only comes [two] days per week. Home health is supposed to be coming three times per week. She utilizes home health for assistance with showering. Due to their infrequent visits, patient has not been cleaning wound regularly. She reports placing bandage to wound, and covering wound, "24/7 [24 hours 7 days a week]." She does not clean the wound with any other topical or soap. She reports increased pain to left leg, describing it as significant "stinging." She also has swelling and pain that extends from wound to knee. Reports fever approximately one week ago with home health nurse reporting a temperature of 102F [degrees Fahrenheit--normal range from 97F to 99F] for one day. She is requesting referrals for home health to increase her nurse visits for assistance with showering/cleaning wound. She is also requesting [pain medication] for discomfort to leg. ...Physical Exam ... Skin: Comments: See left leg wound image under media. LLE [left lower extremity]: wound measures [approximately one inch by one inch] with discoloration and slight erythema [redness of the skin] noted to wound edges, there is exposed muscle showing with discharge noted. No active bleeding. 2+ swelling, also noted and extending to [kneecap] region. Assessment and Plan: ... Due to home health nurse only coming [two] out of requested [three] days, placed STAT [immediate] referral for home health to increase nursing aid assistance from [two] to [three] days for assistance with [activities of daily living], such as bathing, requested [Registered Nurse] for medical management, and nursing for wound vac assistance [Monday/Wednesday/Friday], STAT wound clinic, [pain medication for] breakthrough pain [a sudden increase in pain] [for seven days], Recommended [pain medication] for pain control, Left message at... Home Health Service that assists [Patient 1] to recommend they visit the patient three times per week (instead of current [two]), Recommended that patient return in [two to three] weeks to ensure follow up with home health, wound vac, and wound clinic. Discussed the severity of this persistent open wound. ..." During an interview with Patient 1s Attending Physician (AP 1) from the acute care hospital on December 3, 2024, at 2:33 PM, AP 1 stated Patient 1 was seen on September 16, 2024, and discharged with an order for home health services, not hospice services [a specialized care for patients who are nearing the end of their life], for her lower left leg wound, with Physical Therapy Services and Occupational Therapy [a form of therapy for people with physical or mental illness through activities of daily living] Services. AP 1 stated Patient 1 had returned on October 9, 2024, and they found the wound had worsened because it had not been properly cared for. AP 1 stated this was when they found out Patient 1 had been on hospice services so the hospice was contacted and directed to discharge Patient 1, so they could get her home health services. A review of Patient 1s ";Face-to-Face Encounter" (F2F-an in-person clinical assessment of a patient), dated September 30, 2024, by the hospice facility's Nurse Practitioner (NP), was conducted. There was no documented evidence Patient 1s left lower leg wound had been identified, assessed, or treated. During an interview with the NP on December 5, 2024, at 1:32 PM, the NP stated he had conducted a F2F for Patient 1 on September 30, 2024, in order to qualify her for hospice services. The NP stated he was assigned patients by the hospice agency to conduct F2F assessments, and he reviewed History and Physical (H&P--a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing) only if it was provided by the agency. The NP stated he did not assess patients skin and he would not know there was a wound unless the patient told him. The NP stated, ";The admitting nurse would take care this and if I had been made aware I would have documented, it." A review of Patient 1s admission assessment to the hospice facility, dated September 30, 2024, by the Administrator/Director of Patient Care Services (Admin/DPCS), was conducted. There was no documented evidence Patient 1s left lower leg wound had been identified, assessed, or treated. During an interview with the Admin/DPCS on December 5, 2024, at 2:21 PM, the Admin/DPCS stated she saw a dressing on Patient 1s left lower leg but did not remove the dressing, assess or treat the wound. The Admin/DPCS stated she did not ask Patient 1 about the wound or document its presence in her notes. A review of Patient 1s skilled nursing visit note, dated October 9, 2024, by the hospice facility Registered Nurse (RN 1), was conducted. There was no documented evidence Patient 1s left lower leg wound had been identified, assessed, or treated. (This was the same day [October 9, 2024] Patient 1 returned to the acute care hospital and AP 1 found the wound had worsened) During an interview with RN 1 on December 2, 2024, at 3:22 PM, RN 1 stated he had conducted a head-to-toe assessment (a comprehensive physical exam that involves systematically checking the patient's entire body, from head to toe, to identify any potential health issues) of Patient 1 but did not see any wounds. RN 1 stated Patient 1 did not mention the wound to him. A review of Patient 1s skilled nursing note, dated October 17, 2024, by the hospice facility Licensed Vocational Nurse (LVN 1) indicated, ";... Patient noted with wound to [left lower extremity], MD [Medical Director] notified and wound care treatment as follows: cleansed with [normal saline--salt water] patted dry, applied [wound medication], covered with dry dressing then with [a binding dressing], [Patient 1] asking for something that will help alleviate pain since nothing else is working, MD notified. ..." There was no documented evidence to show LVN 1 had documented the wounds characteristics (wound characteristics are: appearance, signs of infection, location, size, and base material: wounds can be made up of different base materials, such as muscle, bone, tendon, subcutaneous tissue [under the layers of the skin], eschar [dead tissue], or granulation tissue [new tissue that develop at the wound site]). During an interview with LVN 1 on December 5, 2024, at 12:41 PM, LVN 1 stated she discovered the wound at her visit because Patient 1 said her leg was hurting. LVN 1 stated no one at the hospice agency had mentioned the wound to her and she forgot to document the size and characteristics of the wound. LVN 1 stated ";I know I took a picture of the wound but forgot to send it to the office. The wound was big, and it was oozing." During an interview with the Admin/DPCS on December 5, 2024, at 2:37 PM, the Admin/DPCS stated Patient 1s wound should have been identified, assessed and treated by the NP, Admin/DPCS, and RN 1. The Admin/DPCS further stated LVN 1 should have documented the wounds characteristics and provided the information to the Admin/DPCS. The Admin/DPCS confirmed the hospice facility did not provide Patient 1 with wound care for 17 days from September 30, 2024, through October 17, 2024, which contributed to the worsening of Patient 1s wound. A review of the agencys policy and procedure (P&P) titled ";Comprehensive Assessment," dated April 2020, the P&P indicated, ";PURPOSE: To provide guidelines for the comprehensive assessment. POLICY: A comprehensive patient assessment will be performed by the interdisciplinary group [ a group of health care professionals who work in a coordinated fashion toward a common goal for a patient] no later than 5 [five] calendar days after the election of hospice care in consultation with attending physician. PROCEDURE: 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient's clinical record, including at least the following information, as relevant: ... E. Current treatment and patient response to that treatment. ... G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient's terminal illness. ... K. Patient's past and present medical and psychosocial history including pertinent diagnosis and any co-morbid conditions. L. Name and address of the patient's attending physician. M. Name of the hospital and other agencies or persons involved in the past and present care of the patient. ... AA. Specific, individualized patient needs/problems pertinent to the hospice care being provided. BB. Past medical and surgical care, including dates of onset/exacerbation [worsening]. ..."

The agency failed to ensure that the Condition of Participation: L 536 §418.56 Interdisciplinary group, care planning, and coordination of services was in compliance as follows: 1. Based on interview and record review, the agency failed to ensure the hospice interdisciplinary group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) included a doctor of medicine or osteopathy (a branch of medical practice that emphasizes the treatment of medical disorders through the manipulation and massage of the bones, joints, and muscles) for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6) when there was no documented evidence to show a physician was in attendance at IDG meetings. (Refer to L 541) 2. Based on interview and record review, the agency failed to develop an individualized plan of care (a nursing care plan is a written document that outlines the individualized care a patient will receive, which includes: a patients needs, the problem, the goal and interventions to meet the goal) for one of six sampled patients (Patient 1) when Patient 1s lower left leg wound was not care planned. (Refer to L 545) 3. Based on interview and record review, the agency failed to ensure the hospices IDG reviewed, revised, and documented the individualized care plan as frequently as the patients condition required, but no less frequently than every 15 calendar days, for one of six sampled patients (Patient 1) when there was no discussion or documentation of Patient 1's left lower leg wound and there was no documented evidence to show a physician or Registered Nurse (RN) was in attendance to provide wound consultation. (Refer to L 552) The cumulative effect of these systemic practices resulted in the potential to cause Patients 1, 2, 3, 4, 5, and 6 to suffer a decreased quality of care, an increased risk of medical errors, poor outcomes, misdiagnoses, and limited access to specialized expertise. In addition, these failures caused Patient 1s wound to worsen as evidenced by exposed muscle within the wound, 2+ swelling [used to describe pitting edema, where a doctor presses on the swollen area and observes the depth of the indentation left behind] extending from the middle shin, up to the kneecap and pain.

Based on interview and record review, the agency failed to ensure the hospice interdisciplinary group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) included a doctor of medicine or osteopathy (a branch of medical practice that emphasizes the treatment of medical disorders through the manipulation and massage of the bones, joints, and muscles) for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6) when there was no documented evidence to show a physician was in attendance at IDG meetings. This failure had the potential to cause Patients 1, 2, 3, 4, 5, and 6 to suffer a decreased quality of care, an increased risk of medical errors, poor outcomes, misdiagnoses, and limited access to specialized expertise. --- Findings: 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). Patient 1 was discharged on October 21, 2024. A review of Patient 1s IDG meetings indicated meetings had been held on September 30, 2024 and October 11, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:05 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 1s IDG meetings, ";I cant remember if I did or not." During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on December 5, 2024, at 2:44 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 1s IDG meetings. 2. A review of Patient 2s face sheet, undated, indicated a start of care date of November 21, 2024, with a benefit period of November 21, 2024, to January 19, 2025, (Benefit Period Eight). Patient 2 had diagnoses that included other specified degenerative (worsening) diseases of nervous system and autoimmune disease (the body's immune system mistakenly attacks healthy cells, tissues, or organs). A review of Patient 2s IDG meetings indicated meetings had been held on November 21, 2024 and November 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the MD or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:08 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 2s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 2:59 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 2s IDG meetings. 3. A review of Patient 3s face sheet, undated, indicated a start of care date of October 1, 2024, with a benefit period of October 1, 2024, to December 29, 2024, (Benefit Period One). Patient 3 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 3s IDG meetings indicated meetings had been held on October 1, 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the MD or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:14 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 3s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:02 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 3s IDG meetings. 4. A review of Patient 4s face sheet, undated, indicated a start of care date of September 9, 2024, with a benefit period of September 9, 2024, to December 7, 2024, (Benefit Period Two). Patient 4 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 4s IDG meetings indicated meetings had been held on September 9, 13, and 27, 2024, October 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the MD or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:18 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 4s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:07 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 4s IDG meetings. 5. A review of Patient 5s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 5 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 5s IDG meetings indicated meetings had been held on July 27, 2024, and August 2, 16, and 30, 2024, September 13, and 27, 2024, October 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the MD or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:21 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 5s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:18 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 5s IDG meetings. 6. A review of Patient 6s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 6 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 6s IDG meetings indicated meetings had been held on July 27, 2024, and August 2, 16, and 30, 2024, September 13, and 27, 2024, October 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the MD or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:22 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 6s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:29 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 6s IDG meetings. A review of the agencys policy and procedure (P&P) titled, ";Interdisciplinary Group Membership and Responsibilities," dated November 2013, the P&P indicated, ";PURPOSE: To define the membership and responsibilities of the interdisciplinary team/group. ... PROCEDURE: 1. The hospice interdisciplinary team/group members will include, at a minimum: A Physician ..."

Based on interview and record review, the agency failed to develop an individualized plan of care (a nursing care plan is a written document that outlines the individualized care a patient will receive, which includes: a patients needs, the problem, the goal and interventions to meet the goal) for one of six sampled patients (Patient 1) when Patient 1s lower left leg wound was not care planned. This failure caused Patient 1s wound to worsen as evidenced by exposed muscle within the wound, 2+ swelling [used to describe pitting edema, where a doctor presses on the swollen area and observes the depth of the indentation left behind] extending from the middle shin, up to the kneecap and pain. --- Findings: A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). Patient 1 was discharged on October 21, 2024. A review of Patient 1s acute care hospitals nursing note, dated September 16, 2024, indicated, ";[Wound assessment left lower leg] Current Measurements: Length: 4.6 cm [centimeters-a unit of measurement], Width: 4.2 cm, Depth: 0.8 cm. Wound Bed Presentation: Tissue Color: red and yellow. Tissue Appearance: clean, moist, soft, granulation [new connective tissue that forms in the body's response to injury during the wound healing process], and non-granular [indicates a wound that is not properly forming new blood vessels and connective tissue necessary for healing, signifying a stalled or unhealthy wound], Granular: 80% [percent], Slough [dead tissue cells and debris]: 10%, Eschar [hard dead tissue covering wound bed]: 0%, Epithelization [wound tissue repair process]: 0%, Non-granular: 10%, Exposed Anatomy [part of the body]: adipose [fat tissue]. Procedure Note: [Patient 1s] wound vac [Vacuum Assisted Closure (VAC), a medical device that uses suction to help wounds heal faster by removing excess fluid, promoting blood flow, and drawing the edges of the wound together] dressing change performed today. Wound bed presents with clean, moist, and soft tissue and appears to be healing, shows no evidence of infection, is showing improvement of approximated wound edges, is granulating, is presented with slough, is nongranulated, has serosanguineous [liquid part of the blood] drainage, with no odor. ... [Patient 1] would benefit from wound vac care upon discharge. ..." A review of Patient 1s acute care hospitals ";Inpatient Discharge Summary," dated September 9, 2024, to September 16, 2024, indicated, to discharge home with wound vac and home health services. A review of Patient 1s acute care hospitals physicians progress note, dated October 9, 2024, indicated, ";Patient presents today for hospital follow up for left [front] shin wound. She was recently hospitalized for this wound (9/9/24-9/16/24) and diagnosed with cellulitis [bacterial infection in the skin]. ... Due to improvement to wound, she was discharged home with recommendations to continue wound VAC, [and antibiotic] However, patient did not follow these recommendations and never utilized wound vac. Additionally, she did not take her antibiotic, ... as prescribed. She reports finishing these pills" a couple days ago." She also reports that her referred home health nurse only comes [two] days per week. Home health is supposed to be coming three times per week. She utilizes home health for assistance with showering. Due to their infrequent visits, patient has not been cleaning wound regularly. She reports placing bandage to wound, and covering wound, "24/7." She does not clean the wound with any other topical or soap. She reports increased pain to left leg, describing it as significant "stinging." She also has swelling and pain that extends from wound to knee. Reports fever approximately one week ago with home health nurse reporting a temperature of 102F [degrees Fahrenheit] for one day. She is requesting referrals for home health to increase her nurse visits for assistance with showering/cleaning wound. She is also requesting [pain medication] for discomfort to leg. ...Physical Exam ... Skin: Comments: See left leg wound image under media. LLE [left lower extremity]: wound measures [approximately one inch by one inch] with discoloration and slight erythema noted to wound edges, there is exposed muscle showing with discharge noted. No active bleeding. 2+ swelling, also noted and extending to [kneecap] region. Assessment and Plan: ... Due to home health nurse only coming [two] out of requested [three] days, placed STAT [immediate] referral for home health to increase nursing aid assistance from [two] to [three] days for assistance with [activities of daily living], such as bathing, requested [Registered Nurse] for medical management, and nursing for wound vac assistance [Monday/Wednesday/Friday], STAT wound clinic, [pain medication for] breakthrough pain [for seven days], Recommended [pain medication] for pain control, Left message at... Home Health Service that assists [Patient 1] to recommend they visit the patient three times per week (instead of current [two]), Recommended that patient return in [two to three] weeks to ensure follow up with home health, wound vac, and wound clinic. Discussed the severity of this persistent open wound. ..." During an interview with Patient 1s Attending Physician (AP 1) from the acute care hospital on December 3, 2024, at 2:33 PM, AP 1 stated Patient 1 was seen on September 16, 2024, and discharged with an order for home health services, not hospice services, for her lower left leg wound, with Physical Therapy Services and Occupational Therapy Services. AP 1 stated Patient 1 had returned on October 9, 2024, and they found the wound had worsened because it had not been properly cared for. AP 1 stated this was when they found out Patient 1 had been on hospice services so the hospice was contacted and directed to discharge Patient 1, so they could get her home health services. A review of Patient 1s admission assessment, dated September 30, 2024, by the Administrator/Director of Patient Care Services (Admin/DPCS), was conducted. There was no documented evidence Patient 1s left lower leg wound had been identified, assessed, or treated. A review of Patient 1s care plans from September 30, 2024, to October 21, 2024 (discharge), was conducted. There was no documented evidence to show a care plan for Patient 1s lower left leg wound. A review of Patient 1s physicians orders from September 30, 2024, to October 21, 2024, was conducted. There was no documented evidence to show a physicians treatment order for Patient 1s lower left leg wound. During an interview with the Medical Director (MD) on December 5, 2024, at 10:05 AM, the MD stated he did not remember Patient 1 or the presence of a wound. During an interview with the Admin/DPCS on December 5, 2024, from 2:21 PM, to 2:37 PM, the Admin/DPCS stated she saw a dressing on Patient 1s left lower leg but did not remove the dressing, assess or treat the wound. The Admin/DPCS stated she did not ask Patient 1 about the wound or document its presence in her notes and she did not care plan or obtain a wound treatment order from the physician and should have. The Admin/DPCS confirmed the agency did not provide Patient 1 with wound care for 17 days which contributed to the worsening of Patient 1s wound. A review of the agencys policy and procedure (P&P) titled ";The Plan of Care," dated November 2013, the P&P indicated, ";PURPOSE: To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. Each patient must have a written plan of care that specifies the care and services necessary to meet the patient's specific needs as identified in the comprehensive assessment. POLICY: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. This plan of care must be initiated at start of care. ..."

Based on interview and record review, the agency failed to ensure the hospices interdisciplinary group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) reviewed, revised, and documented the individualized care plan (a nursing care plan is a written document that outlines the individualized care a patient will receive, which includes: a patients needs, the problem, the goal and interventions to meet the goal) as frequently as the patients condition required, but no less frequently than every 15 calendar days, for one of six sampled patients (Patient 1) when there was no discussion or documentation of Patient 1's left lower leg wound and there was no documented evidence to show a physician or Registered Nurse (RN) was in attendance to provide wound consultation. This failure caused Patient 1s wound to worsen as evidenced by exposed muscle within the wound, 2+ swelling [used to describe pitting edema, where a doctor presses on the swollen area and observes the depth of the indentation left behind] extending from the middle shin, up to the kneecap and pain. --- Findings: A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). Patient 1 was discharged on October 21, 2024. A review of Patient 1s acute care hospitals nursing note, dated September 16, 2024, indicated, ";[Wound assessment left lower leg] Current Measurements: Length: 4.6 cm [centimeters-a unit of measurement], Width: 4.2 cm, Depth: 0.8 cm. Wound Bed Presentation: Tissue Color: red and yellow. Tissue Appearance: clean, moist, soft, granulation [new connective tissue that forms in the body's response to injury during the wound healing process], and non-granular [indicates a wound that is not properly forming new blood vessels and connective tissue necessary for healing, signifying a stalled or unhealthy wound], Granular: 80% [percent], Slough [dead tissue cells and debris]: 10%, Eschar [hard dead tissue covering wound bed]: 0%, Epithelization [wound tissue repair process]: 0%, Non-granular: 10%, Exposed Anatomy [part of the body]: adipose [fat tissue]. Procedure Note: [Patient 1s] wound vac [Vacuum Assisted Closure (VAC), a medical device that uses suction to help wounds heal faster by removing excess fluid, promoting blood flow, and drawing the edges of the wound together] dressing change performed today. Wound bed presents with clean, moist, and soft tissue and appears to be healing, shows no evidence of infection, is showing improvement of approximated wound edges, is granulating, is presented with slough, is nongranulated, has serosanguineous [liquid part of the blood] drainage, with no odor. ... [Patient 1] would benefit from wound vac care upon discharge. ..." A review of Patient 1s acute care hospitals ";Inpatient Discharge Summary," dated September 9, 2024, to September 16, 2024, indicated, to discharge home with wound vac and home health services. A review of Patient 1s acute care hospitals physicians progress note, dated October 9, 2024, indicated, ";Patient presents today for hospital follow up for left [front] shin wound. She was recently hospitalized for this wound (9/9/24-9/16/24) and diagnosed with cellulitis [bacterial infection in the skin]. ... Due to improvement to wound, she was discharged home with recommendations to continue wound VAC, [and antibiotic] However, patient did not follow these recommendations and never utilized wound vac. Additionally, she did not take her antibiotic, ... as prescribed. She reports finishing these pills" a couple days ago." She also reports that her referred home health nurse only comes [two] days per week. Home health is supposed to be coming three times per week. She utilizes home health for assistance with showering. Due to their infrequent visits, patient has not been cleaning wound regularly. She reports placing bandage to wound, and covering wound, "24/7." She does not clean the wound with any other topical or soap. She reports increased pain to left leg, describing it as significant "stinging." She also has swelling and pain that extends from wound to knee. Reports fever approximately one week ago with home health nurse reporting a temperature of 102F [degrees Fahrenheit] for one day. She is requesting referrals for home health to increase her nurse visits for assistance with showering/cleaning wound. She is also requesting [pain medication] for discomfort to leg. ...Physical Exam ... Skin: Comments: See left leg wound image under media. LLE [left lower extremity]: wound measures [approximately one inch by one inch] with discoloration and slight erythema noted to wound edges, there is exposed muscle showing with discharge noted. No active bleeding. 2+ swelling, also noted and extending to [kneecap] region. Assessment and Plan: ... Due to home health nurse only coming [two] out of requested [three] days, placed STAT [immediate] referral for home health to increase nursing aid assistance from [two] to [three] days for assistance with [activities of daily living], such as bathing, requested [Registered Nurse] for medical management, and nursing for wound vac assistance [Monday/Wednesday/Friday], STAT wound clinic, [pain medication for] breakthrough pain [for seven days], Recommended [pain medication] for pain control, Left message at... Home Health Service that assists [Patient 1] to recommend they visit the patient three times per week (instead of current [two]), Recommended that patient return in [two to three] weeks to ensure follow up with home health, wound vac, and wound clinic. Discussed the severity of this persistent open wound. ..." During an interview with Patient 1s Attending Physician (AP 1) from the acute care hospital on December 3, 2024, at 2:33 PM, AP 1 stated Patient 1 was seen on September 16, 2024, and discharged with an order for home health services, not hospice services, for her lower left leg wound, with Physical Therapy Services and Occupational Therapy Services. AP 1 stated Patient 1 had returned on October 9, 2024, and they found the wound had worsened because it had not been properly cared for. AP 1 stated this was when they found out Patient 1 had been on hospice services so the hospice was contacted and directed to discharge Patient 1, so they could get her home health services. A review of Patient 1s admission assessment, dated September 30, 2024, by the Administrator/Director of Patient Care Services (Admin/DPCS), was conducted. There was no documented evidence Patient 1s left lower leg wound had been identified, assessed, or treated. A review of Patient 1s care plans from September 30, 2024, to October 21, 2024 (discharge), was conducted. There was no documented evidence to show a care plan for Patient 1s lower left leg wound. During an interview with the Admin/DPCS on December 5, 2024, from 2:21 PM, to 2:37 PM, the Admin/DPCS stated she saw a dressing on Patient 1s left lower leg but did not remove the dressing, assess or treat the wound. The Admin/DPCS stated she did not ask Patient 1 about the wound or document its presence in her notes and she did not care plan or obtain a wound treatment order from the physician and should have. A review of Patient 1s skilled nursing note, dated October 17, 2024, by a Licensed Vocational Nurse (LVN 1) indicated, ";... Patient noted with wound to [left lower extremity], MD [Medical Director] notified and wound care treatment as follows: cleansed with [normal saline] patted dry, applied [wound medication], covered with dry dressing then with [a binding dressing], [Patient 1] asking for something that will help alleviate pain since nothing else is working, MD notified. ..." There was no documented evidence to show LVN 1 had documented the wounds characteristics (wound characteristics are: appearance, signs of infection, location, size, and base material: wounds can be made up of different base materials, such as muscle, bone, tendon, subcutaneous tissue, eschar, or granulation tissue). A review of Patient 1s physicians orders from September 30, 2024, to October 21, 2024, was conducted. There was no documented evidence to show a physicians treatment order for Patient 1s lower left leg wound. During an interview with LVN 1 on December 5, 2024, at 12:41 PM, LVN 1 stated she discovered the wound at her visit because Patient 1 said her leg was hurting. LVN 1 stated no one at the agency had mentioned the wound to her and she forgot to document the size and characteristics of the wound. LVN 1 stated ";I know I took a picture of the wound but forgot to send it to the office. The wound was big, and it was oozing." A review of Patient 1s IDG meetings indicated meetings had been held on September 30, 2024 and October 11, 2024. There was no documented evidence to show a discussion or medical direction for Patient 1s lower left leg wound. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD), a physician designee or a Registered Nurse (RN) had attended Patient 1s IDG meetings. During an interview with the MD on December 5, 2024, at 10:05 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 1s IDG meetings, ";I cant remember if I did or not." The MD stated he did not remember Patient 1 or the presence of a wound. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on December 5, 2024, at 2:44 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 1s IDG meetings. The Admin/DPCS stated she could not show documented evidence an RN had attended Patient 1s IDG meetings or a physicians order had been obtained for the wound treatment LVN 1 performed October 17, 2024, on Patient 1. The Admin/DPCS confirmed the agency did not review or revise Patient 1s care plan for the lower left leg wound for 17 days which contributed to the worsening of Patient 1s wound. A review of the agencys policy and procedure (P&P) titled, ";Interdisciplinary Group Membership and Responsibilities," dated November 2013, the P&P indicated, ";PURPOSE: To define the membership and responsibilities of the interdisciplinary team/group. ... PROCEDURE: 1. The hospice interdisciplinary team/group members will include, at a minimum: A Physician, B Registered nurse ..." A review of the agencys policy and procedure (P&P) titled, ";Interdisciplinary Group Meeting," dated November 2013, the P&P indicated, ";PURPOSE: To define the process for interdisciplinary group meetings and documenting patient status in the clinical record. ... POLICY: 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 meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The patient and family/caregiver will be informed of the schedule for this meeting, its purpose, and that the discussion is confidential. PROCEDURE: 1. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor. 2. Referrals and admissions will be reviewed to establish appropriateness for hospice care. Obstacles to access of care issues will be identified and resolved. Admissions will be reviewed to ensure compliance with hospice policies and procedures. ..."

The agency failed to ensure the Condition of Participation: L 648 §418.100 Organization and administration of services was in compliance when: Based on interview and record review, the Governing Body (GB) failed to operate and manage the agency from July 27, 2024, to December 10, 2024, for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6) when: 1. The agency failed to ensure the patients' comprehensive assessments (a detailed evaluation of a patient's complete health status that includes physical status, mental status, spiritual status and psychosocial status) were completed within five days after the start of care for six of six sampled patients (Patient 1, 2, 3, 4, 5, 6) when: a. For Patient 1 no psychosocial assessment (an evaluation of a person's mental health, social status, and functional capacity) was conducted. (Refer to L 651) b. For Patients 1, 2, 3, 4, 5, 6 the psychosocial and spiritual assessments did not identify, contact or provide an assessment of family members' spiritual and psychosocial needs. (Refer to L 651) 2. The agency failed to ensure the comprehensive assessment identified the physical needs of one of six sampled patients (Patient 1) when Patient 1s lower left leg wound was not identified, assessed or treated. (Refer to L 651) 3. The agency failed to ensure the hospice interdisciplinary group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) included a doctor of medicine or osteopathy (a branch of medical practice that emphasizes the treatment of medical disorders through the manipulation and massage of the bones, joints, and muscles) for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6) when there was no documented evidence to show a physician was in attendance at IDG meetings. (Refer to L 651) 4. The agency failed to develop an individualized plan of care (a nursing care plan is a written document that outlines the individualized care a patient will receive, which includes: a patients needs, the problem, the goal and interventions to meet the goal) for one of six sampled patients (Patient 1) when Patient 1s lower left leg wound was not care planned. (Refer to L 651) 5. The agency failed to ensure the hospices IDG reviewed, revised, and documented the individualized care plan as frequently as the patients condition required, but no less frequently than every 15 calendar days, for one of six sampled patients (Patient 1) when there was no discussion or documentation of Patient 1's left lower leg wound and there was no documented evidence to show a physician or Registered Nurse (RN) was in attendance to provide wound consultation. (Refer to L 651) 6. The agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6) when: a. For Patients 1, 2, 3, 4, 5, and 6, the MD copied and pasted the narrative from the ";Face-to-Face Encounter" (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) into the ";Certifying Physician Narrative" section and did not compose a physician's summary which reflected the patients' individual clinical circumstances and supported a prognosis of six months or less of life expectancy. (Refer to L 651) b. For Patients 1, 3, 4, 5, and 6, the CTI for the first and second 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. (Refer to L 651) c. For Patient 2 the MD failed to sign a written certification of the patients' terminal illness (A signed document from a physician that confirms a patient's terminal illness diagnosis. It must be on file in the patient's medical record before a claim is submitted for payment. The written certification includes a narrative explanation of the patient's clinical findings and a life expectancy of six months or less) before submitting a claim for payment. (Refer to L 651) 7. The MD failed his responsibility for the medical component of the hospice program for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6) when: a. An attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. The MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. (Refer to L 651) b. The MD failed to attend IDG meetings or appoint an associate physician to attend the meetings in his place, in order to act as a medical resource to the IDG, establish the plans of care or review and update the plans of care every 15 days, or more frequently as needed, in conjunction with the attending physician and the IDG. (Refer to L 651) The cumulative effect of these systemic practices resulted in the potential for Patients 1, 2, 3, 4, 5, and 6s family members to feel unsupported and unable to cope with the emotional and realistic challenges associated with a loved one's impending death, leading to increased stress, grief, and a lack of meaning during a difficult time. These failures caused Patient 1s wound to worsen as evidenced by exposed muscle within the wound, 2+ swelling [used to describe pitting edema, where a doctor presses on the swollen area and observes the depth of the indentation left behind] extending from the middle shin, up to the kneecap and pain. These failures had the potential to cause Patients 1, 2, 3, 4, 5, and 6 to suffer a decreased quality of care, an increased risk of medical errors, poor outcomes, misdiagnoses, and limited access to specialized expertise. And these failures had the potential to cause Patients 1, 2, 3, 4, 5, and 6, to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to not being properly evaluated as terminally ill.

Based on interview and record review, the Governing Body (GB) failed to operate and manage the agency from July 27, 2024, to December 10, 2024, for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6) when: 1. The agency failed to ensure the patients' comprehensive assessments (a detailed evaluation of a patient's complete health status that includes physical status, mental status, spiritual status and psychosocial status) were completed within five days after the start of care for six of six sampled patients (Patient 1, 2, 3, 4, 5, 6) when: a. For Patient 1 no psychosocial assessment (an evaluation of a person's mental health, social status, and functional capacity) was conducted. b. For Patients 1, 2, 3, 4, 5, 6 the psychosocial and spiritual assessments did not identify, contact or provide an assessment of family members' spiritual and psychosocial needs. These failures had the potential to cause Patients 1, 2, 3, 4, 5, and 6s family members to feel unsupported and unable to cope with the emotional and realistic challenges associated with a loved one's impending death, leading to increased stress, grief, and a lack of meaning during a difficult time. 2. The agency failed to ensure the comprehensive assessment identified the physical needs of one of six sampled patients (Patient 1) when Patient 1s lower left leg wound was not identified, assessed or treated. This failure caused Patient 1s wound to worsen as evidenced by exposed muscle within the wound, 2+ swelling [used to describe pitting edema, where a doctor presses on the swollen area and observes the depth of the indentation left behind] extending from the middle shin, up to the kneecap and pain. 3. The agency failed to ensure the hospice interdisciplinary group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) included a doctor of medicine or osteopathy (a branch of medical practice that emphasizes the treatment of medical disorders through the manipulation and massage of the bones, joints, and muscles) for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6) when there was no documented evidence to show a physician was in attendance at IDG meetings. This failure had the potential to cause Patients 1, 2, 3, 4, 5, and 6 to suffer a decreased quality of care, an increased risk of medical errors, poor outcomes, misdiagnoses, and limited access to specialized expertise. 4. The agency failed to develop an individualized plan of care (a nursing care plan is a written document that outlines the individualized care a patient will receive, which includes: a patients needs, the problem, the goal and interventions to meet the goal) for one of six sampled patients (Patient 1) when Patient 1s lower left leg wound was not care planned. This failure caused Patient 1s wound to worsen as evidenced by exposed muscle within the wound, 2+ swelling [used to describe pitting edema, where a doctor presses on the swollen area and observes the depth of the indentation left behind] extending from the middle shin, up to the kneecap and pain. 5. The agency failed to ensure the hospices IDG reviewed, revised, and documented the individualized care plan as frequently as the patients condition required, but no less frequently than every 15 calendar days, for one of six sampled patients (Patient 1) when there was no discussion or documentation of Patient 1's left lower leg wound and there was no documented evidence to show a physician or Registered Nurse (RN) was in attendance to provide wound consultation. This failure caused Patient 1s wound to worsen as evidenced by exposed muscle within the wound, 2+ swelling [used to describe pitting edema, where a doctor presses on the swollen area and observes the depth of the indentation left behind] extending from the middle shin, up to the kneecap and pain. 6. The agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6) when: a. For Patients 1, 2, 3, 4, 5, and 6, the MD copied and pasted the narrative from the ";Face-to-Face Encounter" (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) into the ";Certifying Physician Narrative" section and did not compose a physician's summary which reflected the patients' individual clinical circumstances and supported a prognosis of six months or less of life expectancy. b. For Patients 1, 3, 4, 5, and 6, the CTI for the first and second 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. c. For Patient 2 the MD failed to sign a written certification of the patients' terminal illness (A signed document from a physician that confirms a patient's terminal illness diagnosis. It must be on file in the patient's medical record before a claim is submitted for payment. The written certification includes a narrative explanation of the patient's clinical findings and a life expectancy of six months or less) before submitting a claim for payment. These failures had the potential to cause Patients 1, 2, 3, 4, 5, and 6, to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to not being properly evaluated as terminally ill. 7. The MD failed his responsibility for the medical component of the hospice program for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6) when: a. An attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. The MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. This failure had the potential to cause Patients 1, 2, 3, 4, 5, and 6, to give up curative treatments and opt for palliative care, too soon, due to not being properly evaluated as terminally ill. b. The MD failed to attend IDG meetings or appoint an associate physician to attend the meetings in his place, in order to act as a medical resource to the IDG, establish the plans of care or review and update the plans of care every 15 days, or more frequently as needed, in conjunction with the attending physician and the IDG. This failure had the potential to cause Patients 1, 2, 3, 4, 5, and 6 to suffer a decreased quality of care, an increased risk of medical errors, poor outcomes, misdiagnoses, and limited access to specialized expertise. --- Findings: 1a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). Patient 1 was discharged on October 21, 2024. A review of Patient 1s Medical Social Workers (MSW) visit notes from September 30, 2024, to October 21, 2024, was conducted. There was no documented evidence to show the MSW had reached out to Patient 1 or conducted an initial psychosocial assessment. During an interview with the MSW on December 4, 2024, from 4:07 PM to 4:20 PM, the MSW stated he had not conducted a psychosocial assessment of Patient 1 or Patient 1s family and should have. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on December 5, 2024, at 2:37 PM, the Admin/DPCS stated Patient 1 and Patient 1s family should have received a psychosocial assessment and did not. A review of the agencys policy and procedure (P&P) titled ";Comprehensive Assessment," dated April 2020, the P&P indicated, ";PURPOSE: To provide guidelines for the comprehensive assessment. POLICY: A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 [five] calendar days after the election of hospice care in consultation with attending physician. PROCEDURE: 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient's clinical record, including at least the following information, as relevant: ... R. Patient and family/caregiver support systems and the care the family/caregiver is available, capable, and willing to provide, including applicable strengths of patient, physical, psychosocial, and/or spiritual resources available. S. The patient's psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanisms, and the patient's and family/caregiver's reaction to illness. ... U. Involvement of family/caregiver, neighbors, and/or other individuals/organizations, including involvement in any support groups. ... F. Survival risk factors, such as the nature of the relationship with the patient, circumstances surrounding the death, behaviors before and after the death, and availability of coping mechanisms and potential for pathological grief reactions. ..." 1b. A review of Patient 1s face sheet, undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). Patient 1 was discharged on October 21, 2024. A review of Patient 1s face sheet, section ";Authorized Rep [representative] (AR)/Emergency Contact (EC)," undated, was conducted. There was no documented evidence to show an AR or EC had been identified. A review of Patient 1s ";Spiritual Assessment," dated September 30, 2024, by a Spiritual Counselor (SC 1), was conducted. There was no documented evidence to show SC 1 had identified, contacted, or provided a spiritual assessment of family members or significant others. During an interview with SC 1 on December 4, 2024, from 3:50 PM, to 4:02 PM, SC 1 stated he had not identified, contacted, or provided a spiritual assessment of family members or significant others and should have. During an interview with the Admin/DPCS on December 5, 2024, at 2:37 PM, the Admin/DPCS stated SC 1 should have identified, contacted, and provided a spiritual assessment of family members or significant others and did not. A review of Patient 2s face sheet, undated, indicated a start of care date of November 21, 2024, with a benefit period of November 21, 2024, to January 19, 2025, (Benefit Period Eight). Patient 2 had diagnoses that included other specified degenerative (worsening) diseases of nervous system and autoimmune disease (the body's immune system mistakenly attacks healthy cells, tissues, or organs). A review of Patient 2s face sheet, section ";Authorized Rep (AR)/Emergency Contact (EC)," undated, indicated two names of staff at the facility where Patient 2 lived. A review of Patient 2s ";Spiritual Assessment," dated November 22, 2024, by SC 1, was conducted. There was no documented evidence to show SC 1 had identified, contacted, or provided a spiritual assessment of family members or significant others. A review of Patient 2s ";Psychosocial Assessment," dated November 23, 2024, by the Medical Social Worker (MSW), was conducted. There was no documented evidence to show the MSW had identified, contacted, or provided a psychosocial assessment of family members or significant others. During a home visit with a Licensed Vocational Nurse (LVN 2) and Patient 2 on December 3, 2024, from 9:55 AM to 11:14 AM, LVN 2 stated she did not know anything about Patient 2s family. Patient 2 stated her son called from time to time to check up on her and she called her son sometimes too but could not remember his phone number, she stated the facility helped her place the calls. Patient 2 stated she knew she was on hospice, and they helped her get diapers, wipes and medications. Patient 2 stated she did not know hospice was for people who had six months or less to live, "I'm not going to die in six months." Patient 2 stated she did not ask for hospice services and did not remember who had offered them to her. During an interview with SC 1 on December 4, 2024, from 3:50 PM, to 4:02 PM, SC 1 stated he had not identified, contacted, or provided a spiritual assessment of family members or significant others and should have. During an interview with the MSW on December 4, 2024, from 4:07 PM to 4:20 PM, the MSW stated he had not identified, contacted, or provided a psychosocial assessment of family members or significant others and should have. During an interview with the Admin/DPCS on December 5, 2024, at 2:51 PM, the Admin/DPCS stated the MSW and SC 1 should have identified, contacted, and provided psychosocial and spiritual assessment of family members or significant others and did not. A review of Patient 3s face sheet, undated, indicated a start of care date of October 1, 2024, with a benefit period of October 1, 2024, to December 29, 2024, (Benefit Period One). Patient 3 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 3s face sheet, section ";Authorized Rep (AR)/Emergency Contact (EC)," undated, was conducted. There was no documented evidence to show an AR or EC had been identified. A review of Patient 3s ";Spiritual Assessment," dated October 1, 2024, by SC 1, was conducted. There was no documented evidence to show SC 1 had identified, contacted, or provided a spiritual assessment of family members or significant others. A review of Patient 3s ";Psychosocial Assessment," dated October 3, 2024, by the MSW, was conducted. There was no documented evidence to show the MSW had identified, contacted, or provided a psychosocial assessment of family members or significant others. During a home visit with LVN 2 and Patient 3 on December 3, 2024, from 9:58 AM to 10:43 AM, LVN 2 stated Patient 3 had no family that she knew of. Patient 3 stated her dad, sister one, sister two and her brother helped her with her care and life. Patient 3 stated it was best to call sister one because she knew all about her care. Patient 3 stated she did not know she was on hospice, had not asked for hospice, and did not know what hospice was. During an interview with SC 1 on December 4, 2024, from 3:50 PM, to 4:02 PM, SC 1 stated he had not identified, contacted, or provided a spiritual assessment of family members or significant others and should have. During an interview with the MSW on December 4, 2024, from 4:07 PM to 4:20 PM, the MSW stated he had not identified, contacted, or provided a psychosocial assessment of family members or significant others and should have. During an interview with the Admin/DPCS on December 5, 2024, at 3 PM, the Admin/DPCS stated the MSW and SC 1 should have identified, contacted, and provided psychosocial and spiritual assessment of family members or significant others and did not. During an interview with Patient 3s Sister One on December 6, 2024, at 12:43 PM, Sister One stated she knew her sister was getting some kind of aide but did not know from where and did not know Patient 3 was receiving hospice services. Patient 3s Sister One stated she knew what hospice was because her mother had hospice when she was diagnosed with cancer, and she was unaware of any terminal diagnoses for her sister. Sister One stated she had not been contacted by the hospice, or a Spiritual Counselor (SC) or a Medical Social Worker (MSW) to offer support or services to her or any of her other family members. The Sister One stated the hospice services her mother had received provided her whole family with support and guidance. A review of Patient 4s face sheet, undated, indicated a start of care date of September 9, 2024, with a benefit period of September 9, 2024, to December 7, 2024, (Benefit Period Two). Patient 4 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 4s face sheet, section ";Authorized Rep (AR)/Emergency Contact (EC)," undated, was conducted. There was no documented evidence to show an AR or EC had been identified. A review of Patient 4s ";Spiritual Assessment," dated September 11, 2024, by SC 1, was conducted. There was no documented evidence to show SC 1 had identified, contacted, or provided a spiritual assessment of family members or significant others. A review of Patient 4s ";Psychosocial Assessment," dated September 10, 2024, by the MSW, was conducted. There was no documented evidence to show the MSW had identified, contacted, or provided a psychosocial assessment of family members or significant others. During a home visit with LVN 2 and Patient 4 on December 3, 2024, from 10:01 AM to 10:50 AM, LVN 2 stated she had not heard about any family for Patient 4, however she had heard Patient 4 talking on the phone to someone, but she had not asked who it was. Patient 4 stated her daughter lived in Missouri with her ex-husband and her son lived in Nevada, but she did not remember their phone numbers. Patient 4 stated she knew hospice was for dying people, "but I'm not dying in 6 months. I'm in good shape." Patient 4 stated she needed the hospice services so she could get her medications, however, she had not asked for hospice services and had not spoken to a physician about hospice services or a terminal diagnosis. During an interview with SC 1 on December 4, 2024, from 3:50 PM, to 4:02 PM, SC 1 stated he had not identified, contacted, or provided a spiritual assessment of family members or significant others and should have. During an interview with the MSW on December 4, 2024, from 4:07 PM to 4:20 PM, the MSW stated he had not identified, contacted, or provided a psychosocial assessment of family members or significant others and should have. During an interview with the Admin/DPCS on December 5, 2024, at 3:07 PM, the Admin/DPCS stated the MSW and SC 1 should have identified, contacted, and provided psychosocial and spiritual assessment of family members or significant others and did not. A review of Patient 5s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 5 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 5s face sheet, section ";Authorized Rep (AR)/Emergency Contact (EC)," undated, was conducted. There was no documented evidence to show an AR or EC had been identified. A review of Patient 5s ";Spiritual Assessment," dated July 29, 2024, by SC 1, was conducted. There was no documented evidence to show SC 1 had identified, contacted, or provided a spiritual assessment of family members or significant others. A review of Patient 5s ";Psychosocial Assessment," dated July 31, 2024, by the MSW, was conducted. There was no documented evidence to show the MSW had identified, contacted, or provided a psychosocial assessment of family members or significant others. During a home visit with LVN 2 and Patient 5 on December 3, 2024, from 10:04 AM to 10:23 AM, LVN 2 stated Patient 5 had a sister in California and some family outside of California, but she did not know their names or contact numbers. Patient 5 stated she had a sister in California but did not remember a phone number. Patient 5 stated she understood hospice to be someone who comes in and takes care of you, gives you showers, cleans up, makes sure your medications are correct and makes you take your medications. Patient 5 stated, "I don't know how I ended up on hospice. I didn't ask for hospice. I don't know if the facility's owners asked for the hospice services for me. I don't think I would die in 6 months, I'm pretty healthy. I didn't talk to a doctor about hospice or a terminal diagnosis." During an interview with SC 1 on December 4, 2024, from 3:50 PM, to 4:02 PM, SC 1 stated he had not identified, contacted, or provided a spiritual assessment of family members or significant others and should have. During an interview with the MSW on December 4, 2024, from 4:07 PM to 4:20 PM, the MSW stated he had not identified, contacted, or provided a psychosocial assessment of family members or significant others and should have. During an interview with the Admin/DPCS on December 5, 2024, at 3:18 PM, the Admin/DPCS stated the MSW and SC 1 should have identified, contacted, and provided psychosocial and spiritual assessment of family members or significant others and did not. A review of Patient 6s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 6 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 6s face sheet, section ";Authorized Rep (AR)/Emergency Contact (EC)," undated, was conducted. There was no documented evidence to show an AR or EC had been identified. A review of Patient 6s ";Spiritual Assessment," dated July 29, 2024, by SC 1, was conducted. There was no documented evidence to show SC 1 had identified, contacted, or provided a spiritual assessment of family members or significant others. A review of Patient 6s ";Psychosocial Assessment," dated July 28, 2024, by the MSW, indicated a sister in Texas. There was no documented evidence to show the MSW had contacted or provided a psychosocial assessment of the sister in Texas. During a home visit with LVN 2 and Patient 6 on December 3, 2024, from 10:08 AM to 11:22 AM, LVN 2 stated Patient 6 had a lot of family and they all lived in California, but she did not know the names or contact numbers. Patient 6 stated she had a sister and a daughter and provided their contact numbers. Patient 6 stated she did not know she was on hospice, and she did not know what hospice was. During an interview with SC 1 on December 4, 2024, from 3:50 PM, to 4:02 PM, SC 1 stated he had not identified, contacted, or provided a spiritual assessment of family members or significant others and should have. During an interview with the MSW on December 4, 2024, from 4:07 PM to 4:20 PM, the MSW stated he had not contacted, or provided a psychosocial assessment of the sister in Texas and should have. During an interview with the Admin/DPCS on December 5, 2024, at 3:29 PM, the Admin/DPCS stated the MSW should have contacted, and provided a psychosocial assessment of the sister in Texas and did not. SC 1 should have identified, contacted, and provided psychosocial and spiritual assessment of family members or significant others and did not. During an interview with Patient 6s sister on December 6, 2024, at 4:12 PM, Patient 6s sister stated she helped take care of her sister and was not notified she was admitted to hospice care, ";My sister isn't dying and she should not be on hospice!" Patient 6's sister stated her sister did not have a terminal diagnosis of any kind and she had not been contacted by a SC or a MSW from the hospice to offer support or guidance. Patient 6's sister stated she was worried her sister being on hospice would cause a problem with the other services they had been working on getting her, ";like housing." A review of the agencys policy and procedure (P&P) titled ";Spiritual Care Counseling Services," dated November 2013, the P&P indicated, ";PURPOSE: To provide guidelines for the appropriate assessment and provision of service to meet the spiritual needs of patients and family/caregivers. POLICY: Hospice will provide spiritual care counseling in keeping with the patient's and family/caregiver's belief system and practice, and in accordance with the plan of care. ... An initial spiritual assessment for all consenting patients and/or documentation supporting attempts to make such an assessment shall be completed within a reasonable period of time. ... The designated person providing spiritual services shall have the following qualifications: 1. Demonstrated experience and training to support the spiritual needs of the patient and family. ... PROCEDURE: ... 2. The Hospice Chaplain will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient and family. 3. If the patient and family/caregiver requests spiritual support from hospice, the Hospice Chaplain will provide services directly or coordinate a referral to appropriate resources. 4. The Hospice Chaplain will develop an individualized spiritual/pastoral plan of care, which will demonstrate an effort to work closely with local clergy as desired by the patient, and provide spiritual support, as defined and requested by the patient and family/caregiver. 5. The Hospice Chaplain will conduct religious services of prayer, worship, and rituals for patients/families, as requested. 6. The Hospice Chaplain will offer patients and family/caregivers of different philosophies and religious beliefs opportunities to discuss and share their thoughts, feelings, beliefs, and values. 7. If the patient and family/caregiver identify involvement with a local church, synagogue, mosque, etc., and permission is given to contact them, the Hospice Chaplain will call to coordinate care. The identified spiritual support person will be encouraged to participate as an interdisciplinary group member in developing the plan of care and to document his/her interventions. 8. Spiritual care assessments and counseling will be documented in the patient's clinical records as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care. ... 10. Ongoing comprehensive assessments will be made by the interdisciplinary group members to identify any developing spiritual needs of the patient and family/caregiver and to update the plan of care to meet those needs. ..." A review of the agencys policy and procedure (P&P) titled ";Psychosocial Services," dated November 2013, the P&P indicated, ";PURPOSE: To ensure that appropriate psychosocial services are provided to hospice patients and family/caregivers. POLICY: ... Psychosocial services will include: ... 2. Providing psychosocial and emotional support to the patient/family. ... 5. Patient and family/caregiver counseling regarding of death, dying, and grief. ... A social worker will be assigned to each patient and family/caregiver based on the patient's and family's needs and acceptance of these services. The social worker will be a member of the interdisciplinary group and will participate in the development, implementation, and revision of the plan of care. PROCEDURE: 1. The social worker will contribute to the comprehensive assessment and ongoing update to the comprehensive assessment based on the needs of the patient. Assessment activities of the medical social worker will include, but not be limited to: ... B. The patient and family/caregiver psychosocial status, potential for risk of suicide and/or abuse or neglect. ... D. Family dynamics and communication patterns, obstacles to learning or ability to participate in provision of care, obstacles to compliance with the plan of care. E. Patient and family/caregiver response to psychosocial interventions. ... G. Need for counseling related to risk assessment for pathological grief. H. Special needs related to cultural diversity, including communication, space, role of family members, and special traditions. ... L. Patient and family/caregiver response to interventions when referred to available community resources and their satisfaction with services provided. M. Bereavement needs. 2. All psychosocial services will be performed at the patient's place of residence, as appropriate. A. Psychosocial assessments will be performed on each new hospice admission. B. Patient and family/caregiver counseling will be offered to every patient and family/caregiver and, as appropriate, will be provided to the patient and family/caregiver by a licensed social worker or other interdisciplinary group member. C. Crisis intervention services will be provided to patients and family/caregivers when required, 24 hours a day, seven (7) day a week. D. Information about and referrals to additional community support services will be made available to the patient and family/caregiver. The patient and family/caregiver's interest in and ability to access these resources will be assessed. ... G. Assistance with funeral planning will be provided, including transfer of responsibilities regarding fiscal, legal, and health care decisions. H. Patient and family/caregiver questions and concerns will be promptly addressed and answered. 3. Psychosocial assessments and interventions will be documented in the patient's clinical record as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care. Documentation will include A. Goals of care. B. Observations of the psychosocial needs or problems of the patient and family/caregiver, including counseling needs, assistance with planning for wills, funeral arrangements, financial planning, etc. C. Interventions provided to address the psychosocial needs or problems of the patient and family/caregiver and the patient's response and progress towards goals. D. Plans and/or referrals made to address the psychosocial needs or problems of the patient and family/caregiver, in accordance with the interdisciplinary group plan of care. ..." 2. A review of Patient 1s face sheet, undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure. Patient 1 was discharged on October 21, 2024. A review of Patient 1s acute care hospitals nursing note, dated September 16, 2024, indicated, ";[Wound assessment left lower leg] Current Measurements: Length: 4.6 cm [centimeters-a unit of measurement], Width: 4.2 cm, Depth: 0.8 cm. Wound Bed Presentation: Tissue Color: red and yellow. Tissue Appearance: clean, moist, soft, granulation [new connective tissue that forms in the body's response to injury during the wound healing process], and non-granular [indicates a wound that is not properly forming new blood vessels and connective tissue necessary for healing, signifying a stalled or unhealthy wound], Granular: 80% [percent], Slough [dead tissue cells and debris]: 10%, Eschar [hard dead tissue covering wound bed]: 0%, Epithelization [wound tissue repair process]: 0%, Non-granular: 10%, Exposed Anatomy [part of the body]: adipose [fat tissue]. Procedure Note: [Patient 1s] wound vac [Vacuum Assisted Closure (VAC), a medical device that uses suction to help wounds heal faster by removing excess fluid, promoting blood flow, and drawing the edges of the wound together] dressing change performed today. Wound bed presents with clean, moist, and soft tissue and appears to be healing, shows no evidence of infection, is showing improvement of approximated wound edges, is granulating, is presented with slough, is nongranulated, has serosanguineous [liquid part of the blood] drainage, with no odor. ... [Patient 1] would benefit from wound vac care upon discharge. ..." A review of Patient 1s acute care hospitals ";Inpatient Discharge Summary," dated September 9, 2024, to September 16, 2024, indicated, to discharge home with wound vac and home health services. A review of Patient 1s acute care hospitals physicians progress note, dated October 9, 2024, indicated, ";Patient presents today for hospital follow up for left [front] shin wound. She was recently hospitalized for this wound (9/9/24-9/16/24) and diagnosed with cellulitis [bacterial infection in the skin]. ... Due to improvement to wound, she was discharged home with recommendations to continue wound VAC, [and antibiotic] However, patient did not follow these recommendations and never utilized wound vac. Additionally, she did not take her antibiotic, ... as prescribed. She reports finishing these pills" a couple days ago." She also reports that her referred home health nurse only comes [two] days per week. Home health is supposed to be coming three times per week. She utilizes home health for assistance with showering. Due to their infrequent visits, patient has not been cleaning wound regularly. She reports placing bandage to wound, and covering wound, "24/7." She does not clean the wound with any other topical or soap. She reports increased pain to left leg, describing it as significant "stinging." She also has swelling and pain that extends from wound to knee. Reports fever approximately one week ago with home health nurse reporting a temperature of 102F [degrees Fahrenheit] for one day. She is requesting referrals for home health to increase her nurse visits for assistance with showering/cleaning wound. She is also requesting [pain medication] for discomfort to leg. ...Physical Exam ... Skin: Comments: See left leg wound image under media. LLE [left lower extremity]: wound measures [approximately one inch by one inch] with discoloration and slight erythema noted to wound edges, there is exposed muscle showing with discharge noted. No active bleeding. 2+ swelling, also noted and extending to [kneecap] region. Assessment and Plan: ... Due to home health nurse only coming [two] out of requested [three] days, placed STAT [immediate] referral for home health to increase nursing aid assistance from [two] to [three] days for assistance with [activities of daily living], such as bathing, requested [Registered Nurse] for medical management, and nursing for wound vac assistance [Monday/Wednesday/Friday], STAT wound clinic, [pain medication for] breakthrough pain [for seven days], Recommended [pain medication] for pain control, Left message at... Home Health Service that assists [Patient 1] to recommend they visit the patient three times per week (instead of current [two]), Recommended that patient return in [two to three] weeks to ensure follow up with home health, wound vac, and wound clinic. Discussed the severity of this persistent open wound. ..." During an interview with Patient 1s Attending Physician (AP 1) from the acute care hospital on December 3, 2024, at 2:33 PM, AP 1 stated Patient 1 was seen on September 16, 2024, and discharged with an order for home health services, not hospice services, for her lower left leg wound, with Physical Therapy Services and Occupational Therapy Services. AP 1 stated Patient 1 had returned on October 9, 2024, and they found the wound had worsened because it had not been properly cared for. AP 1 stated this was when they found out Patient 1 had been on hospice services so the hospice was contacted and directed to discharge Patient 1, so they could get her home health services. A review of Patient 1s ";Face-to-Face Encounter" (F2F-an in-person clinical assessment of a patient), dated September 30, 2024, by a Nurse Practitioner (NP), was conducted. There was no documented evidence Patient 1s left lower leg wound had been identified, assessed, or treated. During an interview with the NP on December 5, 2024, at 1:32 PM, the NP stated he had conducted a F2F for Patient 1 on September 30, 2024, in order to qualify her for hospice services. The NP stated he was assigned patients by the hospice agency to conduct F2F assessments, and he reviewed H&P only if it was provided by the agency. The NP stated he did not assess patients skin and he would not know there was a wound unless the patient told him. The NP stated, ";The admitting nurse would take care this and if I had been made aware I would have documented, it." A review of Patient 1s admission assessment, dated September 30, 2024, by the Administrator/Director of Patient Care Services (Admin/DPCS), was conducted. There was no documented evidence Patient 1s left lower leg wound had been identified, assessed, or treated. During an interview with the Admin/DPCS on December 5, 2024, at 2:21 PM, the Admin/DPCS stated she saw a dressing on Patient 1s left lower leg but did not remove the dressing, assess or treat the wound. The Admin/DPCS stated she did not ask Patient 1 about the wound or document its presence in her notes. A review of Patient 1s skilled nursing visit note, dated October 9, 2024, by a Registered Nurse (RN 1), was conducted. There was no documented evidence Patient 1s left lower leg wound had been identified, assessed, or treated. (This was the same day Patient 1 returned to the acute care hospital and AP 1 found the wound had worsened) During an interview with RN 1 on December 2, 2024, at 3:22 PM, RN 1 stated he had conducted a head-to-toe assessment (a comprehensive physical exam that involves systematically checking the patient's entire body, from head to toe, to identify any potential health issues) of Patient 1 but did not see any wounds. RN 1 stated Patient 1 did not mention the wound to him. A review of Patient 1s skilled nursing note, dated October 17, 2024, by a Licensed Vocational Nurse (LVN 1) indicated, ";... Patient noted with wound to [left lower extremity], MD [Medical Director] notified and wound care treatment as follows: cleansed with [normal saline] patted dry, applied [wound medication], covered with dry dressing then with [a binding dressing], [Patient 1] asking for something that will help alleviate pain since nothing else is working, MD notified. ..." There was no documented evidence to show LVN 1 had documented the wounds characteristics (wound characteristics are: appearance, signs of infection, location, size, and base material: wounds can be made up of different base materials, such as muscle, bone, tendon, subcutaneous tissue, eschar, or granulation tissue). During an interview with LVN 1 on December 5, 2024, at 12:41 PM, LVN 1 stated she discovered the wound at her visit because Patient 1 said her leg was hurting. LVN 1 stated no one at the agency had mentioned the wound to her and she forgot to document the size and characteristics of the wound. LVN 1 stated ";I know I took a picture of the wound but forgot to send it to the office. The wound was big, and it was oozing." During an interview with the Admin/DPCS on December 5, 2024, at 2:37 PM, the Admin/DPCS stated Patient 1s wound should have been identified, assessed and treated by the NP, Admin/DPCS, and RN 1. The Admin/DPCS further stated LVN 1 should have documented the wounds characteristics and provided the information to her. The Admin/DPCS confirmed the agency did not provide Patient 1 with wound care for 17 days which contributed to the worsening of Patient 1s wound. A review of the agencys policy and procedure (P&P) titled ";Comprehensive Assessment," dated April 2020, the P&P indicated, ";PURPOSE: To provide guidelines for the comprehensive assessment. POLICY: A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 [five] calendar days after the election of hospice care in consultation with attending physician. PROCEDURE: 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient's clinical record, including at least the following information, as relevant: ... E. Current treatment and patient response to that treatment. ... G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient's terminal illness. ... K. Patient's past and present medical and psychosocial history including pertinent diagnosis and any co-morbid conditions. L. Name and address of the patient's attending physician. M. Name of the hospital and other agencies or persons involved in the past and present care of the patient. ... AA. Specific, individualized patient needs/problems pertinent to the hospice care being provided. BB. Past medical and surgical care, including dates of onset/exacerbation [worsening]. ..." 3a. A review of Patient 1s face sheet, undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure. Patient 1 was discharged on October 21, 2024. A review of Patient 1s IDG meetings indicated meetings had been held on September 30, 2024 and October 11, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the MD or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:05 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 1s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 2:44 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 1s IDG meetings. 3b. A review of Patient 2s face sheet, undated, indicated a start of care date of November 21, 2024, with a benefit period of November 21, 2024, to January 19, 2025, (Benefit Period Eight). Patient 2 had diagnoses that included other specified degenerative diseases of nervous system and autoimmune disease. A review of Patient 2s IDG meetings indicated meetings had been held on November 21, 2024 and November 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:08 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 2s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 2:59 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 2s IDG meetings. 3c. A review of Patient 3s face sheet, undated, indicated a start of care date of October 1, 2024, with a benefit period of October 1, 2024, to December 29, 2024, (Benefit Period One). Patient 3 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 3s IDG meetings indicated meetings had been held on October 1, 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:14 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 3s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:02 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 3s IDG meetings. 3d. A review of Patient 4s face sheet, undated, indicated a start of care date of September 9, 2024, with a benefit period of September 9, 2024, to December 7, 2024, (Benefit Period Two). Patient 4 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 4s IDG meetings indicated meetings had been held on September 9, 13, and 27, 2024, October 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:18 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 4s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:07 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 4s IDG meetings. 3e. A review of Patient 5s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 5 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 5s IDG meetings indicated meetings had been held on July 27, 2024, and August 2, 16, and 30, 2024, September 13, and 27, 2024, October 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:21 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 5s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:18 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 5s IDG meetings. 3f. A review of Patient 6s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 6 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 6s IDG meetings indicated meetings had been held on July 27, 2024, and August 2, 16, and 30, 2024, September 13, and 27, 2024, October 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:22 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 6s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:29 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 6s IDG meetings. A review of the agencys policy and procedure (P&P) titled, ";Interdisciplinary Group Membership and Responsibilities," dated November 2013, the P&P indicated, ";PURPOSE: To define the membership and responsibilities of the interdisciplinary team/group. ... PROCEDURE: 1. The hospice interdisciplinary team/group members will include, at a minimum: A Physician ..." 4. A review of Patient 1s face sheet, undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure. Patient 1 was discharged on October 21, 2024. A review of Patient 1s acute care hospitals nursing note, dated September 16, 2024, indicated, ";[Wound assessment left lower leg] Current Measurements: Length: 4.6 cm [centimeters-a unit of measurement], Width: 4.2 cm, Depth: 0.8 cm. Wound Bed Presentation: Tissue Color: red and yellow. Tissue Appearance: clean, moist, soft, granulation [new connective tissue that forms in the body's response to injury during the wound healing process], and non-granular [indicates a wound that is not properly forming new blood vessels and connective tissue necessary for healing, signifying a stalled or unhealthy wound], Granular: 80% [percent], Slough [dead tissue cells and debris]: 10%, Eschar [hard dead tissue covering wound bed]: 0%, Epithelization [wound tissue repair process]: 0%, Non-granular: 10%, Exposed Anatomy [part of the body]: adipose [fat tissue]. Procedure Note: [Patient 1s] wound vac [Vacuum Assisted Closure (VAC), a medical device that uses suction to help wounds heal faster by removing excess fluid, promoting blood flow, and drawing the edges of the wound together] dressing change performed today. Wound bed presents with clean, moist, and soft tissue and appears to be healing, shows no evidence of infection, is showing improvement of approximated wound edges, is granulating, is presented with slough, is nongranulated, has serosanguineous [liquid part of the blood] drainage, with no odor. ... [Patient 1] would benefit from wound vac care upon discharge. ..." A review of Patient 1s acute care hospitals ";Inpatient Discharge Summary," dated September 9, 2024, to September 16, 2024, indicated, to discharge home with wound vac and home health services. A review of Patient 1s acute care hospitals physicians progress note, dated October 9, 2024, indicated, ";Patient presents today for hospital follow up for left [front] shin wound. She was recently hospitalized for this wound (9/9/24-9/16/24) and diagnosed with cellulitis [bacterial infection in the skin]. ... Due to improvement to wound, she was discharged home with recommendations to continue wound VAC, [and antibiotic] However, patient did not follow these recommendations and never utilized wound vac. Additionally, she did not take her antibiotic, ... as prescribed. She reports finishing these pills" a couple days ago." She also reports that her referred home health nurse only comes [two] days per week. Home health is supposed to be coming three times per week. She utilizes home health for assistance with showering. Due to their infrequent visits, patient has not been cleaning wound regularly. She reports placing bandage to wound, and covering wound, "24/7." She does not clean the wound with any other topical or soap. She reports increased pain to left leg, describing it as significant "stinging." She also has swelling and pain that extends from wound to knee. Reports fever approximately one week ago with home health nurse reporting a temperature of 102F [degrees Fahrenheit] for one day. She is requesting referrals for home health to increase her nurse visits for assistance with showering/cleaning wound. She is also requesting [pain medication] for discomfort to leg. ...Physical Exam ... Skin: Comments: See left leg wound image under media. LLE [left lower extremity]: wound measures [approximately one inch by one inch] with discoloration and slight erythema noted to wound edges, there is exposed muscle showing with discharge noted. No active bleeding. 2+ swelling, also noted and extending to [kneecap] region. Assessment and Plan: ... Due to home health nurse only coming [two] out of requested [three] days, placed STAT [immediate] referral for home health to increase nursing aid assistance from [two] to [three] days for assistance with [activities of daily living], such as bathing, requested [Registered Nurse] for medical management, and nursing for wound vac assistance [Monday/Wednesday/Friday], STAT wound clinic, [pain medication for] breakthrough pain [for seven days], Recommended [pain medication] for pain control, Left message at... Home Health Service that assists [Patient 1] to recommend they visit the patient three times per week (instead of current [two]), Recommended that patient return in [two to three] weeks to ensure follow up with home health, wound vac, and wound clinic. Discussed the severity of this persistent open wound. ..." During an interview with Patient 1s Attending Physician (AP 1) from the acute care hospital on December 3, 2024, at 2:33 PM, AP 1 stated Patient 1 was seen on September 16, 2024, and discharged with an order for home health services, not hospice services, for her lower left leg wound, with Physical Therapy Services and Occupational Therapy Services. AP 1 stated Patient 1 had returned on October 9, 2024, and they found the wound had worsened because it had not been properly cared for. AP 1 stated this was when they found out Patient 1 had been on hospice services so the hospice was contacted and directed to discharge Patient 1, so they could get her home health services. A review of Patient 1s admission assessment, dated September 30, 2024, by the Administrator/Director of Patient Care Services (Admin/DPCS), was conducted. There was no documented evidence Patient 1s left lower leg wound had been identified, assessed, or treated. A review of Patient 1s care plans from September 30, 2024, to October 21, 2024 (discharge), was conducted. There was no documented evidence to show a care plan for Patient 1s lower left leg wound. A review of Patient 1s physicians orders from September 30, 2024, to October 21, 2024, was conducted. There was no documented evidence to show a physicians treatment order for Patient 1s lower left leg wound. During an interview with the Medical Director (MD) on December 5, 2024, at 10:05 AM, the MD stated he did not remember Patient 1 or the presence of a wound. During an interview with the Admin/DPCS on December 5, 2024, from 2:21 PM, to 2:37 PM, the Admin/DPCS stated she saw a dressing on Patient 1s left lower leg but did not remove the dressing, assess or treat the wound. The Admin/DPCS stated she did not ask Patient 1 about the wound or document its presence in her notes and she did not care plan or obtain a wound treatment order from the physician and should have. The Admin/DPCS confirmed the agency did not provide Patient 1 with wound care for 17 days which contributed to the worsening of Patient 1s wound. A review of the agencys policy and procedure (P&P) titled ";The Plan of Care," dated November 2013, the P&P indicated, ";PURPOSE: To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. Each patient must have a written plan of care that specifies the care and services necessary to meet the patient's specific needs as identified in the comprehensive assessment. POLICY: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. This plan of care must be initiated at start of care. ..." 5. A review of Patient 1s face sheet, undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure. Patient 1 was discharged on October 21, 2024. A review of Patient 1s acute care hospitals nursing note, dated September 16, 2024, indicated, ";[Wound assessment left lower leg] Current Measurements: Length: 4.6 cm [centimeters-a unit of measurement], Width: 4.2 cm, Depth: 0.8 cm. Wound Bed Presentation: Tissue Color: red and yellow. Tissue Appearance: clean, moist, soft, granulation [new connective tissue that forms in the body's response to injury during the wound healing process], and non-granular [indicates a wound that is not properly forming new blood vessels and connective tissue necessary for healing, signifying a stalled or unhealthy wound], Granular: 80% [percent], Slough [dead tissue cells and debris]: 10%, Eschar [hard dead tissue covering wound bed]: 0%, Epithelization [wound tissue repair process]: 0%, Non-granular: 10%, Exposed Anatomy [part of the body]: adipose [fat tissue]. Procedure Note: [Patient 1s] wound vac [Vacuum Assisted Closure (VAC), a medical device that uses suction to help wounds heal faster by removing excess fluid, promoting blood flow, and drawing the edges of the wound together] dressing change performed today. Wound bed presents with clean, moist, and soft tissue and appears to be healing, shows no evidence of infection, is showing improvement of approximated wound edges, is granulating, is presented with slough, is nongranulated, has serosanguineous [liquid part of the blood] drainage, with no odor. ... [Patient 1] would benefit from wound vac care upon discharge. ..." A review of Patient 1s acute care hospitals ";Inpatient Discharge Summary," dated September 9, 2024, to September 16, 2024, indicated, to discharge home with wound vac and home health services. A review of Patient 1s acute care hospitals physicians progress note, dated October 9, 2024, indicated, ";Patient presents today for hospital follow up for left [front] shin wound. She was recently hospitalized for this wound (9/9/24-9/16/24) and diagnosed with cellulitis [bacterial infection in the skin]. ... Due to improvement to wound, she was discharged home with recommendations to continue wound VAC, [and antibiotic] However, patient did not follow these recommendations and never utilized wound vac. Additionally, she did not take her antibiotic, ... as prescribed. She reports finishing these pills" a couple days ago." She also reports that her referred home health nurse only comes [two] days per week. Home health is supposed to be coming three times per week. She utilizes home health for assistance with showering. Due to their infrequent visits, patient has not been cleaning wound regularly. She reports placing bandage to wound, and covering wound, "24/7." She does not clean the wound with any other topical or soap. She reports increased pain to left leg, describing it as significant "stinging." She also has swelling and pain that extends from wound to knee. Reports fever approximately one week ago with home health nurse reporting a temperature of 102F [degrees Fahrenheit] for one day. She is requesting referrals for home health to increase her nurse visits for assistance with showering/cleaning wound. She is also requesting [pain medication] for discomfort to leg. ...Physical Exam ... Skin: Comments: See left leg wound image under media. LLE [left lower extremity]: wound measures [approximately one inch by one inch] with discoloration and slight erythema noted to wound edges, there is exposed muscle showing with discharge noted. No active bleeding. 2+ swelling, also noted and extending to [kneecap] region. Assessment and Plan: ... Due to home health nurse only coming [two] out of requested [three] days, placed STAT [immediate] referral for home health to increase nursing aid assistance from [two] to [three] days for assistance with [activities of daily living], such as bathing, requested [Registered Nurse] for medical management, and nursing for wound vac assistance [Monday/Wednesday/Friday], STAT wound clinic, [pain medication for] breakthrough pain [for seven days], Recommended [pain medication] for pain control, Left message at... Home Health Service that assists [Patient 1] to recommend they visit the patient three times per week (instead of current [two]), Recommended that patient return in [two to three] weeks to ensure follow up with home health, wound vac, and wound clinic. Discussed the severity of this persistent open wound. ..." During an interview with Patient 1s Attending Physician (AP 1) from the acute care hospital on December 3, 2024, at 2:33 PM, AP 1 stated Patient 1 was seen on September 16, 2024, and discharged with an order for home health services, not hospice services, for her lower left leg wound, with Physical Therapy Services and Occupational Therapy Services. AP 1 stated Patient 1 had returned on October 9, 2024, and they found the wound had worsened because it had not been properly cared for. AP 1 stated this was when they found out Patient 1 had been on hospice services so the hospice was contacted and directed to discharge Patient 1, so they could get her home health services. A review of Patient 1s admission assessment, dated September 30, 2024, by the Administrator/Director of Patient Care Services (Admin/DPCS), was conducted. There was no documented evidence Patient 1s left lower leg wound had been identified, assessed, or treated. A review of Patient 1s care plans from September 30, 2024, to October 21, 2024 (discharge), was conducted. There was no documented evidence to show a care plan for Patient 1s lower left leg wound. During an interview with the Admin/DPCS on December 5, 2024, from 2:21 PM, to 2:37 PM, the Admin/DPCS stated she saw a dressing on Patient 1s left lower leg but did not remove the dressing, assess or treat the wound. The Admin/DPCS stated she did not ask Patient 1 about the wound or document its presence in her notes and she did not care plan or obtain a wound treatment order from the physician and should have. A review of Patient 1s skilled nursing note, dated October 17, 2024, by a Licensed Vocational Nurse (LVN 1) indicated, ";... Patient noted with wound to [left lower extremity], MD [Medical Director] notified and wound care treatment as follows: cleansed with [normal saline] patted dry, applied [wound medication], covered with dry dressing then with [a binding dressing], [Patient 1] asking for something that will help alleviate pain since nothing else is working, MD notified. ..." There was no documented evidence to show LVN 1 had documented the wounds characteristics (wound characteristics are: appearance, signs of infection, location, size, and base material: wounds can be made up of different base materials, such as muscle, bone, tendon, subcutaneous tissue, eschar, or granulation tissue). A review of Patient 1s physicians orders from September 30, 2024, to October 21, 2024, was conducted. There was no documented evidence to show a physicians treatment order for Patient 1s lower left leg wound. During an interview with LVN 1 on December 5, 2024, at 12:41 PM, LVN 1 stated she discovered the wound at her visit because Patient 1 said her leg was hurting. LVN 1 stated no one at the agency had mentioned the wound to her and she forgot to document the size and characteristics of the wound. LVN 1 stated ";I know I took a picture of the wound but forgot to send it to the office. The wound was big, and it was oozing." A review of Patient 1s IDG meetings indicated meetings had been held on September 30, 2024 and October 11, 2024. There was no documented evidence to show a discussion or medical direction for Patient 1s lower left leg wound. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD), a physician designee or a Registered Nurse (RN) had attended Patient 1s IDG meetings. During an interview with the MD on December 5, 2024, at 10:05 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 1s IDG meetings, ";I cant remember if I did or not." The MD stated he did not remember Patient 1 or the presence of a wound. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on December 5, 2024, at 2:44 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 1s IDG meetings. The Admin/DPCS stated she could not show documented evidence an RN had attended Patient 1s IDG meetings or a physicians order had been obtained for the wound treatment LVN 1 performed October 17, 2024, on Patient 1. The Admin/DPCS confirmed the agency did not review or revise Patient 1s care plan for the lower left leg wound for 17 days which contributed to the worsening of Patient 1s wound. A review of the agencys policy and procedure (P&P) titled, ";Interdisciplinary Group Membership and Responsibilities," dated November 2013, the P&P indicated, ";PURPOSE: To define the membership and responsibilities of the interdisciplinary team/group. ... PROCEDURE: 1. The hospice interdisciplinary team/group members will include, at a minimum: A Physician, B Registered nurse ..." A review of the agencys policy and procedure (P&P) titled, ";Interdisciplinary Group Meeting," dated November 2013, the P&P indicated, ";PURPOSE: To define the process for interdisciplinary group meetings and documenting patient status in the clinical record. ... POLICY: 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 meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The patient and family/caregiver will be informed of the schedule for this meeting, its purpose, and that the discussion is confidential. PROCEDURE: 1. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor. 2. Referrals and admissions will be reviewed to establish appropriateness for hospice care. Obstacles to access of care issues will be identified and resolved. Admissions will be reviewed to ensure compliance with hospice policies and procedures. ..." 6a. A review of Patient 1s face sheet, undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 1s Physicians History and Physical (H&P-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), dated August 29, 2024, to September 2, 2024, indicated the following: ";acute psychosis [a severe and sudden loss of contact with reality], aggressive behavior bipolar disorder [sudden, intense outbursts of anger or hostility, often characterized as "bipolar rage," which can manifest as verbal abuse, physical aggression, or impulsive actions], chest pain ... The patient's atypical [not normal] chest pain has been evaluated with a cardiac [relating to the heart] workup, which was negative for acute [sudden] ischemia [loss of blood flow], and her laboratory results were within normal limits, indicating a low risk for cardiac disease., Parkinson disease, symptomatic [a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination], psychosis [a clinical syndrome that involves hallucinations, delusions, disorganized thoughts or behaviors, or some combination of these], and schizoaffective disorder, depressive type [a mental health condition causing hallucinations and delusions along with a mood disorder in the form of depressive episodes]." A review of Patient 1s ";Physicians Certification for Hospice Benefit [Second Benefit Period]," dated September 30, 2024, to December 28, 2024, by a Medical Director (MD), indicated, ";Physician Face to Face [F2F] Narrative: This is a F2F of [Patient 1] a 56-year-old Hispanic, female alert and oriented 2X [a person knows who and where they are but not what time it is or what is happening to them]. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart failure ... co-morbidities [the concurrent presence of two or more diseases or medical conditions]: constipation [stools are hard, dry, lumpy, or difficult to pass], insomnia [difficulty sleeping], anxiety [an emotion that can feel like fear, dread, or uneasiness], generalized [all over] weakness, hypertension [high blood pressure], hyperlipidemia [high levels of fat in the blood], GERD [Gastroesophageal reflux disease-a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach], dizziness, CAD [Coronary artery disease-damage or disease in the heart's major blood vessels], and dyspnea [difficulty breathing], depression. The family noted that she is experiencing heightened fatigue [a feeling of extreme tiredness or lack of energy], overall weakness, feelings of depression, occasional seizures [a temporary episode of abnormal electrical activity in the brain that can cause changes in a person's movements, feelings, behaviors, and level of consciousness], schizophrenia [a chronic mental illness that affects a person's thoughts, feelings, and behaviors], confusion, anxiety, shortness of breath, and [Patient 1] is continent [able to control] of bowel and bladder, requires moderate assistance with ADL`s [Activities of Daily Living- a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility] and medication administration. We will continue pain and respiratory assessment and aggressive patient comfort and maintenance of human dignity. ... Certifying Physician Narrative: This is a F2F of [Patient 1] a 56-year-old Hispanic, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart failure ... co-morbidities: constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. The family noted that she is experiencing heightened fatigue, overall weakness, feelings of depression, occasional seizures, schizophrenia, confusion, anxiety, shortness of breath, and [Patient 1] is continent of bowel and bladder, requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive patient comfort and maintenance of human dignity. ..." A review of Patient 1s billing summary, undated, indicated a claim for payment was submitted in September and October 2024. A review of Patient 2s face sheet, undated, indicated a start of care date of November 21, 2024, with a benefit period of November 21, 2024, to January 19, 2025, (Benefit Period Eight). Patient 2 had diagnoses that included other specified degenerative diseases of nervous system and autoimmune disease. A review of Patient 2s ";Physicians Certification for Hospice Benefit [Eighth Benefit Period]," dated November 21, 2024, to January 19, 2025, by a Medical Director (MD), indicated, ";Physician Face to Face [F2F] Narrative: This is a F2F of [Patient 2] a 66-year-old Hispanic, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of other specified degenerative diseases of nervous system ..., co-morbidities: DM [diabetes mellitus- a condition where blood sugar is too high], cataract [a clouding of the eye's lens that can lead to vision loss], constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. The family shared that the patient feels weakness and pain in her legs when walking. They also observed that she experiences shortness of breath during physical activities. In addition, her food intake has decreased over the past month. She has episodes of incontinence [loss of bladder or bowel control], and requires moderate help with activities of daily living, taking her medications. Her skin is intact [unbroken]. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ... Certifying Physician Narrative: This is a F2F of [Patient 2] a 66-year-old Hispanic, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of other specified degenerative diseases of nervous system ..., co-morbidities: DM, cataract, constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. The family shared that the patient feels weakness and pain in her legs when walking. They also observed that she experiences shortness of breath during physical activities. In addition, her food intake has decreased over the past month. She has episodes of incontinence and requires moderate help with activities of daily living, taking her medications. Her skin is intact. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ..." A review of Patient 2s billing summary, undated, indicated a claim for payment was submitted in August, September and October 2024. A review of Patient 3s face sheet, undated, indicated a start of care date of October 1, 2024, with a benefit period of October 1, 2024, to December 29, 2024, (Benefit Period One). Patient 3 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 3s ";Physicians Certification for Hospice Benefit [First Benefit Period]," dated October 1, 2024, to December 29, 2024, by a Medical Director (MD), indicated, ";Physician Face to Face [F2F] Narrative: This is a F2F of [Patient 3] a 59-year-old Hispanic, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnose of Hypertensive heart disease with heart failure ..., co-morbidities: constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. The patient is at risk for falling due to a history of previous falls and an unsteady gait while walking. The patient reports experiencing shortness of breath, depression, confusion, anxiety, and a poor appetite. Patient is incontinent of bladder, requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ... Certifying Physician Narrative: This is a F2F of [Patient 3] a 59-year-old Hispanic, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnose of Hypertensive heart disease with heart failure ..., co-morbidities: constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. The patient is at risk for falling due to a history of previous falls and an unsteady gait while walking. The patient reports experiencing shortness of breath, depression, confusion, anxiety, and a poor appetite. Patient is incontinent of bladder, requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ..." A review of Patient 3s billing summary, undated, indicated a claim for payment was submitted in October 2024. A review of Patient 4s face sheet, undated, indicated a start of care date of September 9, 2024, with a benefit period of September 9, 2024, to December 7, 2024, (Benefit Period Two). Patient 4 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 4s ";Physicians Certification for Hospice Benefit [Second Benefit Period]," dated September 9, 2024, to December 7, 2024, by a Medical Director (MD), indicated, ";Physician Face to Face [F2F] Narrative: This is a F2F of [Patient 4] a 66 -year-old, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart disease with heart failure ..., co-morbidities: constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. Family reported increased fatigue, generalized weakness, depression, confusion, anxiety, dyspnea, and poor appetite. [Patient 4] is continent of bowel and bladder, requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ... Certifying Physician Narrative: This is a F2F of [Patient 4] a 66 -year-old, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart disease with heart failure ..., co-morbidities: constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. Family reported increased fatigue, generalized weakness, depression, confusion, anxiety, dyspnea, and poor appetite. [Patient 4] is continent of bowel and bladder, requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ..." A review of Patient 4s billing summary, undated, indicated a claim for payment was submitted in September and October 2024. A review of Patient 5s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 5 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 5s ";Physicians Certification for Hospice Benefit [First Benefit Period]," dated July 27, 2024, to October 24, 2024, by a Medical Director (MD), indicated, ";Physician Face to Face [F2F] Narrative: This is a F2F of [Patient 5] a 58 -year-old female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart disease heart failure ..., co-morbidities: constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. Family reported increased of fatigue, generalized weakness, depression, confusion, anxiety, dyspnea, and poor appetite. Patient is continent of bowel and bladder, requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ... Certifying Physician Narrative: This is a F2F of [Patient 5] a 58 -year-old female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart disease heart failure ..., co-morbidities: constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. Family reported increased of fatigue, generalized weakness, depression, confusion, anxiety, dyspnea, and poor appetite. Patient is continent of bowel and bladder, requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ..." A review of Patient 5s billing summary, undated, indicated a claim for payment was submitted in August, September and October 2024. A review of Patient 6s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 6 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 6s ";Physicians Certification for Hospice Benefit [First Benefit Period]," dated July 27, 2024, to October 24, 2024, by a Medical Director (MD), indicated, ";Physician Face to Face [F2F] Narrative: This is a F2F of [Patient 6] a 68-year-old Afro-American, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart disease with heart failure ..., co-morbidities: IDDM [Insulin-dependent diabetes mellitus--a chronic autoimmune disease that occurs when the pancreas-a body organ-stops producing insulin--a hormone that regulates blood sugar], Chest pain, [liver lesion is an abnormal growth of cells within the liver], primary osteoarthritis [a degenerative joint disease that causes the tissues in the joints to break down over time] of the left knee, anxiety, lower extremities weakness, hyperlipidemia, hypertension, depression, insomnia, constipation. The family noted a rise in fatigue, overall weakness, depression, confusion, anxiety, shortness of breath, unsteady walking, and a lack of appetite. [Patient 6] is continent of bowel and bladder requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ... Certifying Physician Narrative: This is a F2F of [Patient 6] a 68-year-old Afro-American, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart disease with heart failure ..., co-morbidities: IDDM, Chest pain, [liver lesion], primary osteoarthritis of the left knee, anxiety, lower extremities weakness, hyperlipidemia, hypertension, depression, insomnia, constipation. The family noted a rise in fatigue, overall weakness, depression, confusion, anxiety, shortness of breath, unsteady walking, and a lack of appetite. [Patient 6] is continent of bowel and bladder requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ..." A review of Patient 6s billing summary, undated, indicated a claim for payment was submitted in August, September and October 2024. During an interview with the Medical Director (MD) on December 5, 2024, from 9:59 AM to 10:22 AM, the MD stated he was aware of the requirement to reach out to patients' attending physicians for a confirmation of service needs, verification of the patients' medical prognosis and supporting documentation, however he relied on agency staff to do this for him. The MD stated he had not consulted with Patients 1, 2, 3, 4, 5, or 6s attending physicians, or reviewed H&P supporting a terminal diagnosis, or composed a physician's summary which reflected the patients' individual clinical circumstances supporting a prognosis of six months or less of life expectancy. A review of the agencys policy and procedure (P&P) titled, ";Certification of Terminal illness," dated April 2020, the P&P indicated, ";PROCEDURE: 1. At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on: his/her review of the patient's medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms.) The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election. ... 3. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. Initially, the clinical information may be provided verbally, and must be documented in the clinical record and included as part of the hospice's eligibility assessment. 4. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. ..." 6b. A review of Patient 1s face sheet, undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 1s ";Physicians Certification for Hospice Benefit," dated September 30, 2024, to December 28, 2024, indicated Patient 1 was in her second 90-day benefit period. Patient 1s ";Physicians Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP) should sign. Patient 1s ";Physicians Certification for Hospice Benefit," indicated a Medical Directors (MD)s signature on both lines There was no documented evidence to show an AP had signed Patient 1s ";Physicians Certification for Hospice Benefit." A review of Patient 1s billing summary, undated, indicated a claim for payment was submitted in September and October 2024. A review of Patient 3s face sheet, undated, indicated a start of care date of October 1, 2024, with a benefit period of October 1, 2024, to December 29, 2024, (Benefit Period One). Patient 3 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 3s ";Physicians Certification for Hospice Benefit," dated October 1, 2024, to December 29, 2024, indicated Patient 3 was in her first 90-day benefit period. Patient 3s ";Physicians Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP) should sign. Patient 3s ";Physicians Certification for Hospice Benefit," indicated a Medical Directors (MD)s signature where the MD should sign, and the attending physicians signature line indicated for a Nurse Practitioner (NP) to sign. The NP had not signed the ";Physicians Certification for Hospice Benefit." There was no documented evidence to show an AP had signed Patient 3s ";Physicians Certification for Hospice Benefit." During an interview with the NP on December 5, 2024, at 1:38 PM, the NP stated he knew an NP could not certify a patients terminal illness. The NP stated he would not have signed Patient 3s ";Physicians Certification for Hospice Benefit," dated October 1, 2024, to December 29, 2024. A review of Patient 3s billing summary, undated, indicated a claim for payment was submitted in October 2024. A review of Patient 4s face sheet, undated, indicated a start of care date of September 9, 2024, with a benefit period of September 9, 2024, to December 7, 2024, (Benefit Period Two). Patient 4 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 4s ";Physicians Certification for Hospice Benefit," dated September 9, 2024, to December 7, 2024, indicated Patient 4 was in her second 90-day benefit period. Patient 4s ";Physicians Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP) should sign. Patient 4s ";Physicians Certification for Hospice Benefit," indicated a Medical Directors (MD)s signature where the MD should sign, and the attending physicians signature line indicated for the MD to sign again. The MD had not signed the ";Physicians Certification for Hospice Benefit," a second time. There was no documented evidence to show an AP had signed Patient 4s ";Physicians Certification for Hospice Benefit." A review of Patient 4s billing summary, undated, indicated a claim for payment was submitted in September and October 2024. A review of Patient 5s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 5 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 5s ";Physicians Certification for Hospice Benefit," dated July 27, 2024, to October 24, 2024, indicated Patient 5 was in her first 90-day benefit period. Patient 5s ";Physicians Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP) should sign. Patient 5s ";Physicians Certification for Hospice Benefit," indicated a Medical Directors (MD)s signature where the MD should sign, and the attending physicians signature line indicated for a Nurse Practitioner (NP) to sign. The NP had not signed the ";Physicians Certification for Hospice Benefit." There was no documented evidence to show an AP had signed Patient 5s ";Physicians Certification for Hospice Benefit." During an interview with the NP on December 5, 2024, at 1:44 PM, the NP stated he knew an NP could not certify a patients terminal illness. The NP stated he would not have signed Patient 5s ";Physicians Certification for Hospice Benefit," dated July 27, 2024, to October 24, 2024. A review of Patient 5s billing summary, undated, indicated a claim for payment was submitted in August, September and October 2024. A review of Patient 6s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 6 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 6s ";Physicians Certification for Hospice Benefit," dated July 27, 2024, to October 24, 2024, indicated Patient 6 was in her first 90-day benefit period. Patient 6s ";Physicians Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP) should sign. Patient 6s ";Physicians Certification for Hospice Benefit," indicated a Medical Directors (MD)s signature where the MD should sign, and the attending physicians signature line indicated for the MD to sign again. The MD had not signed the ";Physicians Certification for Hospice Benefit," a second time. There was no documented evidence to show an AP had signed Patient 6s ";Physicians Certification for Hospice Benefit." A review of Patient 6s billing summary, undated, indicated a claim for payment was submitted in August, September and October 2024. During an interview with the Medical Director (MD) on December 5, 2024, from 9:59 AM to 10:22 AM, the MD stated he did not know the CTI for the first and second 90-day benefit periods needed to be signed by two physicians. The MD stated he did not know an NP could not sign a CTI and he relied on the staff at the agency to obtain the required signatures on the CTIs. A review of the agencys policy and procedure (P&P) titled, ";Certification of Terminal illness," dated April 2020, the P&P indicated, ";PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. ... 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. ... PROCEDURE: 1. ... (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms.) The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election. ... 4. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. ..." 6c. A review of Patient 2s face sheet, undated, indicated a start of care date of November 21, 2024, with a benefit period of November 21, 2024, to January 19, 2025, (Benefit Period Eight). Patient 2 had diagnoses that included other specified degenerative diseases of nervous system and autoimmune disease. A review of Patient 2s ";Physicians Certification for Hospice Benefit [Eighth Benefit Period]," dated November 21, 2024, to January 19, 2025, was conducted. There was no documented evidence to show a signature from the MD. A review of Patient 2s billing summary, undated, indicated a claim for payment was submitted in August, September and October 2024. During an interview with the MD on December 5, 2024, at 10:08 AM, the MD stated if the agency staff did not send him the CTI to sign, he would not be aware Patient 2s CTI needed his signature. The MD stated Patient 2s CTI was not signed because he was unaware it existed. A review of the agencys policy and procedure (P&P) titled, ";Certification of Terminal illness," dated April 2020, the P&P indicated, ";PROCEDURE: ... 2. If written certification cannot be obtained within two (2) calendar days following the start of care, verbal certification must be obtained and documented in the clinical record within two (2) days following initiation of care and written certification must be obtained before the hospice submits a claim for payment. ... 4. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. ..." 7a. A review of Patient 1s face sheet, undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure. Patient 1 was discharged on October 21, 2024. A review of Patient 1s Physicians History and Physical (H&P-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), dated August 29, 2024, to September 2, 2024, indicated the following: ";acute psychosis [a severe and sudden loss of contact with reality], aggressive behavior bipolar disorder [sudden, intense outbursts of anger or hostility, often characterized as "bipolar rage," which can manifest as verbal abuse, physical aggression, or impulsive actions], chest pain ... The patient's atypical [not normal] chest pain has been evaluated with a cardiac [relating to the heart] workup, which was negative for acute [sudden] ischemia [loss of blood flow], and her laboratory results were within normal limits, indicating a low risk for cardiac disease, Parkinson disease, symptomatic [a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination], psychosis [a clinical syndrome that involves hallucinations, delusions, disorganized thoughts or behaviors, or some combination of these], and schizoaffective disorder, depressive type [a mental health condition causing hallucinations and delusions along with a mood disorder in the form of depressive episodes]." A review of Patient 1s physicians orders indicated a verbal hospice referral order (A "verbal order" is a medical instruction given verbally by a healthcare provider, like a doctor, to a licensed healthcare professional, such as a nurse, instead of being written down; essentially, a spoken order that needs to be documented and confirmed by the receiving individual) dated September 30, 2024, documented by the Administrator/Director of Patient Care Services (Admin/DPCS) and indicating the Medical Director (MD) as the signing physician. The verbal hospice referral order indicated, ";For Hospice Evaluation," and the verbal order was not signed by the MD. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with Patient 1s Attending Physician (AP 1) on December 3, 2024, at 2:33 PM, AP 1 stated she had not been contacted to discuss Patient 1s suitability for hospice services. Patient 1 did not have a terminal diagnosis and did not qualify for hospice services. Patient 1 was seen on September 16, 2024, and discharged with an order for home health services, not hospice services, for her lower left leg wound, Physical Therapy and Occupational Therapy. AP 1 stated Patient 1 had returned on October 9, 2024, and they found the wound had worsened because it had not been properly cared for. AP 1 stated this was when we found out Patient 1 had been on hospice services so the hospice was contacted and directed to discharge Patient 1 so we could get her home health services. During an interview with the Medical Director (MD) on December 5, 2024, at 9:59 AM, the MD stated he did not know the Admin/DPCS was writing verbal orders in his name referring hospice patients to the agency. The MD stated he did not sign Patient 1s verbal hospice referral order because he had not known it existed. The MD stated he was aware of the requirement to obtain the attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation, however, he relied on the hospice staff to get this information. The MD confirmed he had not reached out to Patient 1s attending physician, or verified Patient 1s medical prognosis or reviewed supporting documentation. During an interview with a Nurse Practitioner (NP) on December 5, 2024, at 1:32 PM, the NP stated he had performed a Face-to-Face Assessment (F2F-an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) for Patient 1 on September 30, 2024, in order to qualify her for hospice services. The NP stated he was assigned patients by the hospice agency to conduct F2F assessments, he was not involved in the referral process. The NP stated he did not ask patients about family members, emergency contacts or attending physicians. The NP stated he reviewed H&P only if it was provided by the agency. During an interview with the Admin/DPCS on December 5, 2024, at 2:12 PM, the Admin/DPCS stated she handled the intakes for the agency. The Admin/DPCS stated Patient 1 had referred herself for hospice services and had told her she did not have an attending physician. The Admin/DPCS stated she had not attempted to identify an attending physician and had written the verbal order for the MD to refer Patient 1 to the hospice. The Admin/DPCS stated she did not know the MD could not refer patients to his own hospice agency, ";I thought this was OK." The Admin/DPCS stated she did not know why the verbal order was not sent to the MD for signature. A review of Patient 2s face sheet, undated, indicated a start of care date of November 21, 2024, with a benefit period of November 21, 2024, to January 19, 2025, (Benefit Period Eight). Patient 2 had diagnoses that included other specified degenerative diseases of nervous system and autoimmune disease. A review of Patient 2s physicians orders indicated a verbal hospice referral order dated November 21, 2024, documented by the Admin/DPCS and indicating the Medical Director (MD) as the signing physician. The verbal hospice referral order indicated, ";For Hospice Evaluation," and the verbal order was not signed by the MD. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During a home visit with a Licensed Vocational Nurse (LVN 2) and Patient 2 on December 3, 2024, from 9:55 AM to 11:14 AM, LVN 2 stated she did not know anything about family, or doctors involved in Patient 2s care. Patient 2 stated her son called from time to time to check up on her. Patient 2 stated she called her son sometimes too but could not remember his phone number, she stated the facility helped her place the calls. Patient 2 stated she did not have a doctor to see her or take care of her and she had lost her insurance card. Patient 2 stated she knew she was on hospice, and they helped her get diapers, wipes and medications. Patient 2 stated she did not know hospice was for people who had six months or less to live, "I'm not going to die in six months." Patient 2 stated she did not ask for hospice services and did not remember who had offered them to her. Patient 2 stated a doctor had never discussed hospice services with her or explained what it was all about. Patient 2 stated "What I need is an attending physician to take care of me." During an interview with an Assisted Living Facility (ALF-a living arrangement in which people with special needs, especially seniors, live in a facility that provides help with everyday tasks such as bathing, dressing, and taking medication) /Owner (ALF/Owner 2) on December 5, 2024, at 9:45 AM, the ALF/Owner 2 stated the facility did not have a folder with information on the patients, they just kept the contract and an active medication list in case the patient went to the emergency room. The ALF/Owner 2 stated they did not inquire about family or doctors of their patients and did not keep contact numbers, ";that was the patients' responsibility." The ALF/Owner 2 stated staff may have written down a family phone number in order to help a patient make a call and she would inquire with her staff. ALF/Owner 2 stated she may have referred Patient 2 to hospice. ALF/Owner 2 did not provide contact information for Patient 2s son. During an interview with the Medical Director (MD) on December 5, 2024, at 10:08 AM, the MD stated he did not know the Admin/DPCS was writing verbal orders in his name referring hospice patients to the agency. The MD stated he did not sign Patient 2s verbal hospice referral order because he had not known it existed. The MD stated he was aware of the requirement to obtain the attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation, however, he relied on the hospice staff to get this information. The MD confirmed he had not reached out to Patient 2s attending physician, or verified Patient 2s medical prognosis or reviewed supporting documentation. During an interview with a Nurse Practitioner (NP) on December 5, 2024, at 1:36 PM, the NP stated he had performed a Face-to-Face Assessment (F2F) for Patient 2 on November 21, 2024, in order to qualify her for hospice services. The NP stated he was assigned patients by the hospice agency to conduct F2F assessments, he was not involved in the referral process. The NP stated he did not ask patients about family members, emergency contacts or attending physicians and he reviewed H&P only if it was provided by the agency. The NP stated he may have spoken on the phone with Patient 2s son at his visit but he could not remember. During an interview with the Admin/DPCS on December 5, 2024, at 2:51 PM, the Admin/DPCS stated she handled the intakes for the agency. The Admin/DPCS stated she did not remember who referred Patient 2 for hospice services and Patient 2 had told her she did not have an attending physician. The Admin/DPCS stated she had not attempted to identify an attending physician and had written the verbal order for the MD to refer Patient 2 to the hospice. The Admin/DPCS stated she did not know the MD could not refer patients to his own hospice agency, ";I thought this was OK." The Admin/DPCS stated she did not know why the verbal order was not sent to the MD for signature. A review of Patient 3s face sheet, undated, indicated a start of care date of October 1, 2024, with a benefit period of October 1, 2024, to December 29, 2024, (Benefit Period One). Patient 3 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 3s physicians orders indicated a verbal hospice referral order dated October 1, 2024, documented by the Admin/DPCS and indicating the Medical Director (MD) as the signing physician. The verbal hospice referral order indicated, ";For Hospice Evaluation," and the verbal order was not signed by the MD. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During a home visit with LVN 2 and Patient 3 on December 3, 2024, from 9:58 AM to 10:43 AM, LVN 2 stated Patient 3 had no family that she knew of. LVN 2 stated yesterday (December 2, 2024) Patient 3 had an x-ray to her chest and stomach, but LVN 2 did not know about any doctors, or the facility Patient 3 had gone to. LVN 2 stated Patient 3 did not tell her why she needed the x-ray. Patient 3 stated her dad, sister one, sister two and her brother helped her with her care and life. Patient 3 stated it was best to call sister one because she knew all about her care and her Attending Physician (AP 2) was at (name of an acute care hospital) but she did not have his phone number. Patient 3 stated AP 2 had ordered x-rays after she got sick, Patient 3 rubbed her upper chest with her hand, "I was coughing." Patient 3 stated she did not know she was on hospice and did not know what hospice was. Patient 3 stated she had not asked for hospice and AP 2 had not spoken with her about hospice. During an interview with an ALF/Owner 2 on December 5, 2024, at 9:45 AM, the ALF/Owner 2 stated the facility did not have a folder with information on the patients, they just kept the contract and an active medication list in case the patient went to the emergency room. The ALF/Owner 2 stated they did not inquire about family or doctors of their patients and did not keep contact numbers, ";that was the patients' responsibility." The ALF/Owner 2 stated she did not refer Patient 3 to hospice. During an interview with the Medical Director (MD) on December 5, 2024, at 10:14 AM, the MD stated he did not know the Admin/DPCS was writing verbal orders in his name referring hospice patients to the agency. The MD stated he did not sign Patient 3s verbal hospice referral order because he had not known it existed. The MD stated he was aware of the requirement to obtain the attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation, however, he relied on the hospice staff to get this information. The MD confirmed he had not reached out to Patient 3s attending physician, or verified Patient 3s medical prognosis or reviewed supporting documentation. During an interview with a Nurse Practitioner (NP) on December 5, 2024, at 1:38 PM, the NP stated he had performed a Face-to-Face Assessment (F2F) for Patient 3 on October 1, 2024, in order to qualify her for hospice services. The NP stated he was assigned patients by the hospice agency to conduct F2F assessments, he was not involved in the referral process. The NP stated he did not ask patients about family members, emergency contacts or attending physicians and he reviewed H&P only if it was provided by the agency. During an interview with the Admin/DPCS on December 5, 2024, at 3 PM, the Admin/DPCS stated she handled the intakes for the agency. The Admin/DPCS stated she did not remember who referred Patient 3 for hospice services and Patient 3 had told her she did not have an attending physician. The Admin/DPCS stated she had not attempted to identify an attending physician and had written the verbal order for the MD to refer Patient 3 to the hospice. The Admin/DPCS stated she did not know the MD could not refer patients to his own hospice agency, ";I thought this was OK." The Admin/DPCS stated she did not know why the verbal order was not sent to the MD for signature. During an interview with Patient 3s Sister One on December 6, 2024, at 12:43 PM, Sister One stated she knew her sister was getting some kind of aide but did not know from where and did not know Patient 3 was receiving hospice services. Patient 3s Sister One stated she knew what hospice was because her mother had hospice when she was diagnosed with cancer, and she was unaware of any terminal diagnoses for her sister. Sister One stated she had not been contacted by the hospice, or a Spiritual Counselor (SC) or a Medical Social Worker (MSW) to offer support or services to her or any of her other family members. The Sister One stated the hospice services her mother had received provided her whole family with support and guidance. During an interview with a Quality Services Director (QSD) at Patient 3s suggested acute care hospital on December 6, 2024, at 2:51 PM, the QSD stated she was unable to find the physician Patient 3 had indicated among the acute care hospitals staff. The QSD stated Patient 3 had visited the hospitals emergency room for back and flank pain on August 8, 2023, but had left the hospital against medical advice and a thorough assessment was not completed. A review of Patient 4s face sheet, undated, indicated a start of care date of September 9, 2024, with a benefit period of September 9, 2024, to December 7, 2024, (Benefit Period Two). Patient 4 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 4s physicians orders indicated a verbal hospice referral order dated September 9, 2024, documented by the Admin/DPCS and indicating the Medical Director (MD) as the signing physician. The verbal hospice referral order indicated, ";For Hospice Evaluation," and the verbal order was not signed by the MD. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During a home visit with LVN 2 and Patient 4 on December 3, 2024, from 10:01 AM to 10:50 AM, LVN 2 stated she had not heard about any family or doctors for Patient 4. LVN 2 stated she had heard Patient 4 talking on the phone to someone, but she had not asked who it was. LVN 2 stated, "She has good days and bad days. Can be confused and agitated." Patient 4 stated her daughter lived in Missouri with her ex-husband and her son lived in Nevada, but she did not remember their phone numbers. Patient 4 stated she saw a Nurse Practitioner (NP) who gave her medication but could not remember her phone number and she knew hospice was for dying people, "but I'm not dying in 6 months. I'm in good shape." Patient 4 stated she needed the hospice services so she could get her medications and showed her insurance card which indicated an acute care hospital. Patient 4 stated she had not asked for hospice services and had not spoken to a physician about hospice services or a terminal diagnosis. During an interview with an ALF/Owner 2 on December 5, 2024, at 9:45 AM, the ALF/Owner 2 stated the facility did not have a folder with information on the patients, they just kept the contract and an active medication list in case the patient went to the emergency room. The ALF/Owner 2 stated they did not inquire about family or doctors of their patients and did not keep contact numbers, ";that was the patients' responsibility." ALF/Owner 2 stated she may have referred Patient 4 to hospice. During an interview with the Medical Director (MD) on December 5, 2024, at 10:18 AM, the MD stated he did not know the Admin/DPCS was writing verbal orders in his name referring hospice patients to the agency. The MD stated he did not sign Patient 4s verbal hospice referral order because he had not known it existed. The MD stated he was aware of the requirement to obtain the attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation, however, he relied on the hospice staff to get this information. The MD confirmed he had not reached out to Patient 4s attending physician, or verified Patient 4s medical prognosis or reviewed supporting documentation. During an interview with a Nurse Practitioner (NP) on December 5, 2024, at 1:43 PM, the NP stated he had performed a Face-to-Face Assessment (F2F) for Patient 4 on September 9, 2024, in order to qualify her for hospice services. The NP stated he was assigned patients by the hospice agency to conduct F2F assessments, he was not involved in the referral process. The NP stated he did not ask patients about family members, emergency contacts or attending physicians and he reviewed H&P only if it was provided by the agency. The NP stated he remembered speaking with a female family member at Patient 4s F2F, ";Thats all I remember." During an interview with the Admin/DPCS on December 5, 2024, at 3:07 PM, the Admin/DPCS stated she handled the intakes for the agency. The Admin/DPCS stated the ALF had referred Patient 4 for hospice services and Patient 4 had told her she did not have an attending physician. The Admin/DPCS stated she had not attempted to identify an attending physician and had written the verbal order for the MD to refer Patient 4 to the hospice. The Admin/DPCS stated she did not know the MD could not refer patients to his own hospice agency, ";I thought this was OK." The Admin/DPCS stated she did not know why the verbal order was not sent to the MD for signature. During an interview with a Regulatory Compliance, Healthcare Program Administrator (RC/HPA) at Patient 4s suggested acute care hospital on December 9, 2024, at 1:09 PM, the RC/HPA stated she could not identify a physician for Patient 4. A review of Patient 5s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 5 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 5s physicians orders indicated a verbal hospice referral order dated July 27, 2024, documented by the Admin/DPCS and indicating the Medical Director (MD) as the signing physician. The verbal hospice referral order indicated, ";For Hospice Evaluation," and the verbal order was not signed by the MD. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During a home visit with LVN 2 and Patient 5 on December 3, 2024, from 10:04 AM to 10:23 AM, LVN 2 stated Patient 5 had a sister in California and some family outside of California, but she did not know their names or contact numbers. LVN 2 stated Patient 5 had primary care doctors she saw but LVN 2 did not know their names or contact numbers. LVN 2 stated Patient 5 was very independent and took care of her own needs. Patient 5 stated she had a sister in California but did not remember a phone number. Patient 5 stated she saw her neurologist (Attending Physician-AP 3) every three months and AP 4 used to take care of her diabetes, but she was not the acute care hospital anymore. Patient 5 showed her insurance card which indicated AP 5. Patient 5 stated she understood hospice to be someone who comes in and takes care of you, gives you showers, cleans up, makes sure your medications are correct and makes you take your medications. Patient 5 stated, "I don't know how I ended up on hospice. I didn't ask for hospice. I don't know if the facility's owners asked for the hospice services for me. I don't think I would die in 6 months, I'm pretty healthy. I didn't talk to a doctor about hospice or a terminal diagnosis." During an interview with an ALF/Owner 2 on December 5, 2024, at 9:45 AM, the ALF/Owner 2 stated the facility did not have a folder with information on the patients, they just kept the contract and an active medication list in case the patient went to the emergency room. The ALF/Owner 2 stated they did not inquire about family or doctors of their patients and did not keep contact numbers, ";that was the patients' responsibility." The ALF/Owner 2 stated she did not refer Patient 5 to hospice. During an interview with the Medical Director (MD) on December 5, 2024, at 10:21 AM, the MD stated he did not know the Admin/DPCS was writing verbal orders in his name referring hospice patients to the agency. The MD stated he did not sign Patient 5s verbal hospice referral order because he had not known it existed. The MD stated he was aware of the requirement to obtain the attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation, however, he relied on the hospice staff to get this information. The MD confirmed he had not reached out to Patient 5s attending physician, or verified Patient 5s medical prognosis or reviewed supporting documentation. During an interview with a Nurse Practitioner (NP) on December 5, 2024, at 1:44 PM, the NP stated he had performed a Face-to-Face Assessment (F2F) for Patient 5 on July 27, 2024, in order to qualify her for hospice services. The NP stated he was assigned patients by the hospice agency to conduct F2F assessments, he was not involved in the referral process. The NP stated he did not ask patients about family members, emergency contacts or attending physicians and he reviewed H&P only if it was provided by the agency. The NP stated he did not remember speaking with a family member. During an interview with the Admin/DPCS on December 5, 2024, at 3:18 PM, the Admin/DPCS stated she handled the intakes for the agency. The Admin/DPCS stated the ALF had referred Patient 5 for hospice services and Patient 5 had told her she did not have an attending physician. The Admin/DPCS stated she had not attempted to identify an attending physician and had written the verbal order for the MD to refer Patient 5 to the hospice. The Admin/DPCS stated she did not know the MD could not refer patients to his own hospice agency, ";I thought this was OK." The Admin/DPCS stated she did not know why the verbal order was not sent to the MD for signature. During an interview with Patient 5s AP 4 on December 10, 2024, at 10:28 AM, AP 4 stated she had provided care for Patient 5 up until the Spring of 2024, and she did not have any terminal diagnoses. AP 4 stated Patient 5s main issues were her seizures and homelessness as well as episodes of forgetfulness and confusion. AP 4 stated she did not know Patient 5 was on hospice services and the hospice had not spoken to her about Patient 5s prognosis. AP 4 stated Patient 5 did not have heart failure. During an interview with Patient 5s AP 6 on December 10, 2024, at 1 PM, AP 6 stated he was Patient 5s attending physician and had last seen Patient 5 on September 27, 2024, and she had made no mention of being on hospice care. AP 6 stated he reviewed Patient 5s clinical record and there was no mention of the need for hospice care and Patient 5 had no terminal diagnoses. AP 6 stated no one from a hospice had spoken to him about Patient 5s prognosis or proposed hospice care and Patient 5 did not qualify for hospice care. AP 6 stated Patient 5 had a echocardiogram (an ultrasound that uses sound waves to create images of the heart and nearby blood vessels) in May 2024 and there was no indication of heart failure. A review of Patient 6s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 6 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 6s physicians orders indicated a verbal hospice referral order dated July 27, 2024, documented by the Admin/DPCS and indicating the Medical Director (MD) as the signing physician. The verbal hospice referral order indicated, ";For Hospice Evaluation," and the verbal order was not signed by the MD. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During a home visit with LVN 2 and Patient 6 on December 3, 2024, from 10:08 AM to 11:22 AM, LVN 2 stated Patient 6 had a lot of family and they all lived in California, but she did not know the names or contact numbers. LVN 2 stated she did not know about any doctors Patient 6 saw. Patient 6 stated she had a sister and a daughter and provided their contact numbers. Patient 6 stated her Clinical Therapist (CT) knew everything about her medical care and provided a contact number. Patient 6 stated she did not know she was on hospice, and she did not know what hospice was. During an interview with an ALF/Owner 2 on December 5, 2024, at 9:45 AM, the ALF/Owner 2 stated the facility did not have a folder with information on the patients, they just kept the contract and an active medication list in case the patient went to the emergency room. The ALF/Owner 2 stated they did not inquire about family or doctors of their patients and did not keep contact numbers, ";that was the patients' responsibility." The ALF/Owner 2 stated she did not refer Patient 6 to hospice. During an interview with the Medical Director (MD) on December 5, 2024, at 10:22 AM, the MD stated he did not know the Admin/DPCS was writing verbal orders in his name referring hospice patients to the agency. The MD stated he did not sign Patient 6s verbal hospice referral order because he had not known it existed. The MD stated he was aware of the requirement to obtain the attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation, however, he relied on the hospice staff to get this information. The MD confirmed he had not reached out to Patient 6s attending physician, or verified Patient 6s medical prognosis or reviewed supporting documentation. During an interview with a Nurse Practitioner (NP) on December 5, 2024, at 1:45 PM, the NP stated he had performed a Face-to-Face Assessment (F2F) for Patient 6 on July 27, 2024, in order to qualify her for hospice services. The NP stated he was assigned patients by the hospice agency to conduct F2F assessments, he was not involved in the referral process. The NP stated he did not ask patients about family members, emergency contacts or attending physicians and he reviewed H&P only if it was provided by the agency. The NP stated he did not remember speaking with a family member. During an interview with the Admin/DPCS on December 5, 2024, at 3:29 PM, the Admin/DPCS stated she handled the intakes for the agency. The Admin/DPCS stated Patient 6 had referred herself for hospice services and Patient 6 had told her she did not have an attending physician. The Admin/DPCS stated she had not attempted to identify an attending physician and had written the verbal order for the MD to refer Patient 6 to the hospice. The Admin/DPCS stated she did not know the MD could not refer patients to his own hospice agency, ";I thought this was OK." The Admin/DPCS stated she did not know why the verbal order was not sent to the MD for signature. During an interview with Patient 6s Clinical Therapist (CT) on December 6, 2024, at 3:17 PM, The CT stated no one called him to discuss hospice services for Patient 6 and he did not think Patient 6 was appropriate for hospice. The CT stated he took Patient 6 to all her Primary Care Physician (PCP) visits and the PCP never spoke to him about a terminal diagnosis and a need for hospice care. During an interview with Patient 6s sister on December 6, 2024, at 4:12 PM, Patient 6s sister stated she helped take care of her sister and was not notified she was admitted to hospice care, ";My sister isn't dying and she should not be on hospice!" Patient 6's sister stated her sister did not have a terminal diagnosis of any kind and she had not been contacted by a SC or a MSW from the hospice to offer support or guidance. Patient 6's sister stated she was worried her sister being on hospice would cause a problem with the other services they had been working on getting her, ";like housing." A review of the agencys policy and procedure (P&P) titled, ";Intake Process," dated November 2013, the P&P indicated, ";PURPOSE: To establish the process for acceptance and entry of patients into hospice. ... PROCEDURE: 1. Hospice referrals will be documented on a referral and intake form. ... A. Intake personnel will document information regarding patient demographics, diagnoses, services needed, medications, attending physician, hospitalization, etc., in order to make the initial determination whether the patient's needs can be met by hospice and if he/she meets eligibility criteria. ... D. If the referral call is not from a physician, the physician (or other authorized licensed independent practitioner) will be contacted to confirm service needs, as well as the patient's medical prognosis and supporting documentation, and to obtain verbal orders. ..." A review of the agencys policy and procedure (P&P) titled, ";Physician Services – Medical Director," dated November 2013, the P&P indicated, ";PURPOSE: To ensure qualified medical direction and consultation for the delivery of hospice services and programs. To demonstrate that the Medical Director/hospice team physician (physician designee) has overall responsibility for patient care through documentation that demonstrates interaction/communication with the attending physician as necessary for appropriate medical care. POLICY: ... The duties and responsibilities of the Medical Director will include, but not be limited to, the following: 1. Overall responsibility for the medical component of hospice patient care program. Assuring the provision of quality care that meets the medical needs of the patient and family. 2. Consulting and coordinating care with attending physicians, if requested, regarding pain and symptoms management for hospice patients; when attending physician is not available, may function as the designee physician. 3. Reviewing patients' medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness. 4. Reviewing necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician. 5. Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services. 6. Assisting in developing and implementing the plan of care that is coordinated with the attending physician. 7. Ensuring the availability of physician services and providing a substitute in the absence of the attending physician. ..." 7b. A review of Patient 1s face sheet, undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure. Patient 1 was discharged on October 21, 2024. A review of Patient 1s IDG meetings indicated meetings had been held on September 30, 2024 and October 11, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:05 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 1s IDG meetings, ";I cant remember if I did or not." During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on December 5, 2024, at 2:44 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 1s IDG meetings. A review of Patient 2s face sheet, undated, indicated a start of care date of November 21, 2024, with a benefit period of November 21, 2024, to January 19, 2025, (Benefit Period Eight). Patient 2 had diagnos es that included other specified degenerative diseases of nervous system and autoimmune disease. A review of Patient 2s IDG meetings indicated meetings had been held on November 21, 2024 and November 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:08 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 2s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 2:59 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 2s IDG meetings. A review of Patient 3s face sheet, undated, indicated a start of care date of October 1, 2024, with a benefit period of October 1, 2024, to December 29, 2024, (Benefit Period One). Patient 3 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 3s IDG meetings indicated meetings had been held on October 1, 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:14 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 3s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:02 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 3s IDG meetings. A review of Patient 4s face sheet, undated, indicated a start of care date of September 9, 2024, with a benefit period of September 9, 2024, to December 7, 2024, (Benefit Period Two). Patient 4 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 4s IDG meetings indicated meetings had been held on September 9, 13, and 27, 2024, October 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:18 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 4s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:07 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 4s IDG meetings. A review of Patient 5s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 5 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 5s IDG meetings indicated meetings had been held on July 27, 2024, and August 2, 16, and 30, 2024, September 13, and 27, 2024, October 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:21 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 5s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:18 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 5s IDG meetings. A review of Patient 6s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 6 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 6s IDG meetings indicated meetings had been held on July 27, 2024, and August 2, 16, and 30, 2024, September 13, and 27, 2024, October 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:22 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 6s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:29 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 6s IDG meetings. A review of the agencys policy and procedure (P&P) titled, ";Interdisciplinary Group Membership and Responsibilities," dated November 2013, the P&P indicated, ";PURPOSE: To define the membership and responsibilities of the interdisciplinary team/group. ... PROCEDURE: 1. The hospice interdisciplinary team/group members will include, at a minimum: A Physician ..." A review of the agencys policy and procedure (P&P) titled, ";Interdisciplinary Group Meeting," dated November 2013, the P&P indicated, ";PURPOSE: To define the process for interdisciplinary group meetings and documenting patient status in the clinical record. ... POLICY: 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 meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The patient and family/caregiver will be informed of the schedule for this meeting, its purpose, and that the discussion is confidential. PROCEDURE: 1. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor. 2. Referrals and admissions will be reviewed to establish appropriateness for hospice care. Obstacles to access of care issues will be identified and resolved. Admissions will be reviewed to ensure compliance with hospice policies and procedures. ..." A review of the agencys policy and procedure (P&P) titled ";Physician Services – Medical Director," dated November 2013, the P&P indicated, ";PURPOSE: To ensure qualified medical direction and consultation for the delivery of hospice services and programs. To demonstrate that the Medical Director/hospice team physician (physician designee) has overall responsibility for patient care through documentation that demonstrates interaction/communication with the attending physician as necessary for appropriate medical care. ... POLICY: ... The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. ... The hospice team physician {physician designee) is available whenever the hospice Medical Director is unable to perform his/her duties due to illness, vacation or upon request. The duties and responsibilities of the Medical Director will include, but not be limited to, the following: 1. Overall responsibility for the medical component of hospice patient care program. Assuring the provision of quality care that meets the medical needs of the patient and family. ... 3. Reviewing patients' medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness. 4. Reviewing necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician. 5. Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services. ... 7. Ensuring the availability of physician services and providing a substitute in the absence of the attending physician. 8. Acting as medical resource to the hospice interdisciplinary group. Participating in the development and implementation of the policies related to the care provided by the interdisciplinary team. ... 13. Acting as primary physician for patients whose referring physicians desire to relinquish that care and/or if the referring physicians are not available for further contact. 14. Managing oversight of the patient's medications and treatments. 15. Attending interdisciplinary group meetings and working in a team approach with the group. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) and Administrator Designee (AD) on December 5, 2024, from 2:12 PM to 4:10 PM, The Admin/DPCS stated she and the AD were members of the Governing Body (GB) and assumed full legal authority and responsibility for the operation of the agency, and for the quality of care and services provided. The Admin/DPCS stated the GB had not identified that: 1. The patients' comprehensive assessments were not completed within five days after the start of care for Patients 1, 2, 3, 4, 5, 6 when: a. For Patient 1 no psychosocial assessment was conducted. b. For Patients 1, 2, 3, 4, 5, 6 the psychosocial and spiritual assessments did not identify, contact or provide an assessment of family members' spiritual and psychosocial needs. 2. The comprehensive assessment did not identify the physical needs of Patient 1 when Patient 1s lower left leg wound was not identified, assessed or treated. 3. The hospice interdisciplinary group did not include a doctor of medicine or osteopathy for Patients 1, 2, 3, 4, 5, and 6 when there was no documented evidence to show a physician was in attendance at IDG meetings. 4. An individualized plan of care was not developed for Patient 1 when Patient 1s lower left leg wound was not care planned. 5. The hospices interdisciplinary group had not reviewed, revised, and documented the individualized care plan as frequently as the patients condition required, but no less frequently than every 15 calendar days, for Patient 1 when there was no discussion or documentation of Patient 1's left lower leg wound and there was no documented evidence to show a physician or Registered Nurse (RN) was in attendance to provide wound consultation. 6. The Medical Director (MD) did not certify the patients' terminal illnesses before the agency submitted a claim for payment, Patients 1, 2, 3, 4, 5, and 6) when: a. For Patients 1, 2, 3, 4, 5, and 6, the Medical Director copied and pasted the narrative from the ";Face-to-Face Encounter" (F2F) into the ";Certifying Physician Narrative" section and did not compose a physician's summary which reflected the patients' individual clinical circumstances and supported a prognosis of six months or less of life expectancy. b. For Patients 1, 3, 4, 5, and 6, the CTI for the first and second 90-day benefit period was not signed by two physicians. c. For Patient 2 the Medical Director (MD) failed to sign a written certification of the patients' terminal illness before submitting a claim for payment. 7. The Medical Director (MD) was not providing the medical component of the hospice program Patients 1, 2, 3, 4, 5, and 6 when: a. An attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. The MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. b. The Medical Director (MD) failed to attend Interdisciplinary Group (IDG) meetings or appoint an associate physician to attend the meetings in his place, in order to act as a medical resource to the IDG, establish the plans of care or review and update the plans of care every 15 days, or more frequently as needed, in conjunction with the attending physician and the IDG. A review of the agencys policy and procedure (P&P) titled ";Governing Body," dated November 2013, the P&P indicated, ";PURPOSE: To outline the roles and responsibilities of the Governing Body. POLICY: The governing body shall: ... 2. Assume full legal authority and responsibility for the operation of the program. ... 5. At least annually, conduct an organized, effective and documented evaluation of overall agency functioning. ... PROCEDURE: ... 4. The Governing Body will routinely evaluate to what extent the hospice has met the needs of the community for hospice care, has provided adequate and appropriate care to patients, ..."

The agency failed to ensure that the Condition of Participation: L 664 §418.102 Medical director was in compliance as follows: 1. Based on interview and record review, the agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6) when: a. For Patients 1, 2, 3, 4, 5, and 6, the Medical Director copied and pasted the narrative from the ";Face-to-Face Encounter" (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) into the ";Certifying Physician Narrative" section and did not compose a physician's summary which reflected the patients' individual clinical circumstances and supported a prognosis of six months or less of life expectancy. (Refer to L 667) b. For Patients 1, 3, 4, 5, and 6, the CTI for the first and second 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. (Refer to L 667) c. For Patient 2 the Medical Director (MD) failed to sign a written certification of the patients' terminal illness (A signed document from a physician that confirms a patient's terminal illness diagnosis. It must be on file in the patient's medical record before a claim is submitted for payment. The written certification includes a narrative explanation of the patient's clinical findings and a life expectancy of six months or less) before submitting a claim for payment. (Refer to L 667) 2. Based on interview and record review, the Medical Director (MD) failed his responsibility for the medical component of the hospice program for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6) when: a. An attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. The MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. (Refer to L 669) b. The Medical Director (MD) failed to attend Interdisciplinary Group (IDG- a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) meetings or appoint an associate physician to attend the meetings in his place, in order to act as a medical resource to the IDG, establish the plans of care or review and update the plans of care every 15 days, or more frequently as needed, in conjunction with the attending physician and the IDG. (Refer to L 669) The cumulative effect of these systemic practices resulted in the potential to cause Patients 1, 2, 3, 4, 5, and 6 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon. In addition, the potential to cause Patients 1, 2, 3, 4, 5, and 6 to suffer a decreased quality of care, an increased risk of medical errors, poor outcomes, misdiagnoses, and limited access to specialized expertise.

Based on interview and record review, the agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6) when: 1. For Patients 1, 2, 3, 4, 5, and 6, the Medical Director copied and pasted the narrative from the ";Face-to-Face Encounter" (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) into the ";Certifying Physician Narrative" section and did not compose a physician's summary which reflected the patients' individual clinical circumstances and supported a prognosis of six months or less of life expectancy. 2. For Patients 1, 3, 4, 5, and 6, the CTI for the first and second 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. 3. For Patient 2 the Medical Director (MD) failed to sign a written certification of the patients' terminal illness (A signed document from a physician that confirms a patient's terminal illness diagnosis. It must be on file in the patient's medical record before a claim is submitted for payment. The written certification includes a narrative explanation of the patient's clinical findings and a life expectancy of six months or less) before submitting a claim for payment. These failures had the potential to cause Patients 1, 2, 3, 4, 5, and 6, to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to not being properly evaluated as terminally ill. --- Findings: 1a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). A review of Patient 1s Physicians History and Physical (H&P-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), dated August 29, 2024, to September 2, 2024, indicated the following: ";Acute psychosis [a severe and sudden loss of contact with reality]Aggressive behavior bipolar disorder [sudden, intense outbursts of anger or hostility, often characterized as "bipolar rage," which can manifest as verbal abuse, physical aggression, or impulsive actions], Chest pain ... The patient's atypical [not normal] chest pain has been evaluated with a cardiac [relating to the heart] workup, which was negative for acute [sudden] ischemia [loss of blood flow], and her laboratory results were within normal limits, indicating a low risk for cardiac disease, Parkinson disease, symptomatic [a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination]Psychosis [a clinical syndrome that involves hallucinations, delusions, disorganized thoughts or behaviors, or some combination of these], and Schizoaffective disorder, depressive type [a mental health condition causing hallucinations and delusions along with a mood disorder in the form of depressive episodes]." A review of Patient 1s ";Physicians Certification for Hospice Benefit [Second Benefit Period]," dated September 30, 2024, to December 28, 2024, by a Medical Director (MD), indicated, ";Physician Face to Face [F2F] Narrative: This is a F2F of [Patient 1] a 56-year-old Hispanic, female alert and oriented [a person knows who and where they are but not what time it is or what is happening to them]. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart failure ... co-morbidities [the concurrent presence of two or more diseases or medical conditions]: constipation [stools are hard, dry, lumpy, or difficult to pass], insomnia [difficulty sleeping], anxiety [an emotion that can feel like fear, dread, or uneasiness], generalized [all over] weakness, hypertension [high blood pressure], hyperlipidemia [high levels of fat in the blood], GERD [Gastroesophageal reflux disease-a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach], dizziness, CAD [Coronary artery disease-damage or disease in the heart's major blood vessels], and dyspnea [difficulty breathing], depression. The family noted that she is experiencing heightened fatigue [a feeling of extreme tiredness or lack of energy], overall weakness, feelings of depression, occasional seizures [a temporary episode of abnormal electrical activity in the brain that can cause changes in a person's movements, feelings, behaviors, and level of consciousness], schizophrenia [a chronic mental illness that affects a person's thoughts, feelings, and behaviors], confusion, anxiety, shortness of breath, and [Patient 1] is continent [able to control] of bowel and bladder, requires moderate assistance with ADL`s [Activities of Daily Living- a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility] and medication administration. We will continue pain and respiratory assessment and aggressive patient comfort and maintenance of human dignity. ... Certifying Physician Narrative: This is a F2F of [Patient 1] a 56-year-old Hispanic, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart failure ... co-morbidities: constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. The family noted that she is experiencing heightened fatigue, overall weakness, feelings of depression, occasional seizures, schizophrenia, confusion, anxiety, shortness of breath, and [Patient 1] is continent of bowel and bladder, requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive patient comfort and maintenance of human dignity. ..." A review of Patient 1s billing summary, undated, indicated a claim for payment was submitted in September and October 2024. 1b. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of November 21, 2024, with a benefit period of November 21, 2024, to January 19, 2025, (Benefit Period Eight). Patient 2 had diagnoses that included other specified degenerative (worsening) diseases of nervous system and autoimmune disease (the body's immune system mistakenly attacks healthy cells, tissues, or organs). A review of Patient 2s ";Physicians Certification for Hospice Benefit [Eighth Benefit Period]," dated November 21, 2024, to January 19, 2025, by a Medical Director (MD), indicated, ";Physician Face to Face [F2F] Narrative: This is a F2F of [Patient 2] a 66-year-old Hispanic, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of other specified degenerative diseases of nervous system ..., co-morbidities: DM [diabetes mellitus- a condition where blood sugar is too high], cataract [a clouding of the eye's lens that can lead to vision loss], constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. The family shared that the patient feels weakness and pain in her legs when walking. They also observed that she experiences shortness of breath during physical activities. In addition, her food intake has decreased over the past month. She has episodes of incontinence [loss of bladder or bowel control], and requires moderate help with activities of daily living, taking her medications. Her skin is intact [unbroken]. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ... Certifying Physician Narrative: This is a F2F of [Patient 2] a 66-year-old Hispanic, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of other specified degenerative diseases of nervous system ..., co-morbidities: DM, cataract, constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. The family shared that the patient feels weakness and pain in her legs when walking. They also observed that she experiences shortness of breath during physical activities. In addition, her food intake has decreased over the past month. She has episodes of incontinence and requires moderate help with activities of daily living, taking her medications. Her skin is intact. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ..." A review of Patient 2s billing summary, undated, indicated a claim for payment was submitted in August, September and October 2024. 1c. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of October 1, 2024, with a benefit period of October 1, 2024, to December 29, 2024, (Benefit Period One). Patient 3 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). A review of Patient 3s ";Physicians Certification for Hospice Benefit [First Benefit Period]," dated October 1, 2024, to December 29, 2024, by a Medical Director (MD), indicated, ";Physician Face to Face [F2F] Narrative: This is a F2F of [Patient 3] a 59-year-old Hispanic, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnose of Hypertensive heart disease with heart failure ..., co-morbidities: constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. The patient is at risk for falling due to a history of previous falls and an unsteady gait while walking. The patient reports experiencing shortness of breath, depression, confusion, anxiety, and a poor appetite. Patient is incontinent of bladder, requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ... Certifying Physician Narrative: This is a F2F of [Patient 3] a 59-year-old Hispanic, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnose of Hypertensive heart disease with heart failure ..., co-morbidities: constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. The patient is at risk for falling due to a history of previous falls and an unsteady gait while walking. The patient reports experiencing shortness of breath, depression, confusion, anxiety, and a poor appetite. Patient is incontinent of bladder, requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ..." A review of Patient 3s billing summary, undated, indicated a claim for payment was submitted in October 2024. 1d. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 9, 2024, with a benefit period of September 9, 2024, to December 7, 2024, (Benefit Period Two). Patient 4 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). A review of Patient 4s ";Physicians Certification for Hospice Benefit [Second Benefit Period]," dated September 9, 2024, to December 7, 2024, by a Medical Director (MD), indicated, ";Physician Face to Face [F2F] Narrative: This is a F2F of [Patient 4] a 66 -year-old, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart disease with heart failure ..., co-morbidities: constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. Family reported increased fatigue, generalized weakness, depression, confusion, anxiety, dyspnea, and poor appetite. [Patient 4] is continent of bowel and bladder, requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ... Certifying Physician Narrative: This is a F2F of [Patient 4] a 66 -year-old, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart disease with heart failure ..., co-morbidities: constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. Family reported increased fatigue, generalized weakness, depression, confusion, anxiety, dyspnea, and poor appetite. [Patient 4] is continent of bowel and bladder, requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ..." A review of Patient 4s billing summary, undated, indicated a claim for payment was submitted in September and October 2024. 1e. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 5 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). A review of Patient 5s ";Physicians Certification for Hospice Benefit [First Benefit Period]," dated July 27, 2024, to October 24, 2024, by a Medical Director (MD), indicated, ";Physician Face to Face [F2F] Narrative: This is a F2F of [Patient 5] a 58 -year-old female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart disease heart failure ..., co-morbidities: constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. Family reported increased of fatigue, generalized weakness, depression, confusion, anxiety, dyspnea, and poor appetite. Patient is continent of bowel and bladder, requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ... Certifying Physician Narrative: This is a F2F of [Patient 5] a 58 -year-old female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart disease heart failure ..., co-morbidities: constipation, insomnia, anxiety, generalized weakness, hypertension, hyperlipidemia, GERD, dizziness, CAD, and dyspnea, depression. Family reported increased of fatigue, generalized weakness, depression, confusion, anxiety, dyspnea, and poor appetite. Patient is continent of bowel and bladder, requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ..." A review of Patient 5s billing summary, undated, indicated a claim for payment was submitted in August, September and October 2024. 1f. A review of Patient 6s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 6 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). A review of Patient 6s ";Physicians Certification for Hospice Benefit [First Benefit Period]," dated July 27, 2024, to October 24, 2024, by a Medical Director (MD), indicated, ";Physician Face to Face [F2F] Narrative: This is a F2F of [Patient 6] a 68-year-old Afro-American, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart disease with heart failure ..., co-morbidities: IDDM [Insulin-dependent diabetes mellitus--a chronic autoimmune disease that occurs when the pancreas-a body organ-stops producing insulin--a hormone that regulates blood sugar], Chest pain, [liver lesion is an abnormal growth of cells within the liver], primary osteoarthritis [a degenerative joint disease that causes the tissues in the joints to break down over time] of the left knee, anxiety, lower extremities weakness, hyperlipidemia, hypertension, depression, insomnia, constipation. The family noted a rise in fatigue, overall weakness, depression, confusion, anxiety, shortness of breath, unsteady walking, and a lack of appetite. [Patient 6] is continent of bowel and bladder requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ... Certifying Physician Narrative: This is a F2F of [Patient 6] a 68-year-old Afro-American, female alert and oriented 2X. Admitted to Hospice under the routine level of care with the terminal diagnosis of Hypertensive heart disease with heart failure ..., co-morbidities: IDDM, Chest pain, [liver lesion], primary osteoarthritis of the left knee, anxiety, lower extremities weakness, hyperlipidemia, hypertension, depression, insomnia, constipation. The family noted a rise in fatigue, overall weakness, depression, confusion, anxiety, shortness of breath, unsteady walking, and a lack of appetite. [Patient 6] is continent of bowel and bladder requires moderate assistance with ADL`s and medication administration. We will continue pain and respiratory assessment and aggressive management to insure patient comfort and maintenance of human dignity. ..." A review of Patient 6s billing summary, undated, indicated a claim for payment was submitted in August, September and October 2024. During an interview with the Medical Director (MD) on December 5, 2024, from 9:59 AM to 10:22 AM, the MD stated he was aware of the requirement to reach out to patients' attending physicians for a confirmation of service needs, verification of the patients' medical prognosis and supporting documentation, however he relied on agency staff to do this for him. The MD stated he had not consulted with Patients 1, 2, 3, 4, 5, or 6s attending physicians, or reviewed H&P supporting a terminal diagnosis, or composed a physician's summary which reflected the patients' individual clinical circumstances supporting a prognosis of six months or less of life expectancy. A review of the agencys policy and procedure (P&P) titled, ";Certification of Terminal illness," dated April 2020, the P&P indicated, ";PROCEDURE: 1. At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on: his/her review of the patient's medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms.) The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election. ... 3. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. Initially, the clinical information may be provided verbally, and must be documented in the clinical record and included as part of the hospice's eligibility assessment. 4. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. ..." 2a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). A review of Patient 1s ";Physicians Certification for Hospice Benefit," dated September 30, 2024, to December 28, 2024, indicated Patient 1 was in her second 90-day benefit period. Patient 1s ";Physicians Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP) should sign. Patient 1s ";Physicians Certification for Hospice Benefit," indicated a Medical Directors (MD)s signature on both lines There was no documented evidence to show an AP had signed Patient 1s ";Physicians Certification for Hospice Benefit." A review of Patient 1s billing summary, undated, indicated a claim for payment was submitted in September and October 2024. 2b. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of October 1, 2024, with a benefit period of October 1, 2024, to December 29, 2024, (Benefit Period One). Patient 3 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). A review of Patient 3s ";Physicians Certification for Hospice Benefit," dated October 1, 2024, to December 29, 2024, indicated Patient 3 was in her first 90-day benefit period. Patient 3s ";Physicians Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP) should sign. Patient 3s ";Physicians Certification for Hospice Benefit," indicated a Medical Directors (MD)s signature where the MD should sign, and the attending physicians signature line indicated for a Nurse Practitioner (NP) to sign. The NP had not signed the ";Physicians Certification for Hospice Benefit." There was no documented evidence to show an AP had signed Patient 3s ";Physicians Certification for Hospice Benefit." During an interview with the NP on December 5, 2024, at 1:38 PM, the NP stated he knew an NP could not certify a patients terminal illness. The NP stated he would not have signed Patient 3s ";Physicians Certification for Hospice Benefit," dated October 1, 2024, to December 29, 2024. A review of Patient 3s billing summary, undated, indicated a claim for payment was submitted in October 2024. 2c. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 9, 2024, with a benefit period of September 9, 2024, to December 7, 2024, (Benefit Period Two). Patient 4 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). A review of Patient 4s ";Physicians Certification for Hospice Benefit," dated September 9, 2024, to December 7, 2024, indicated Patient 4 was in her second 90-day benefit period. Patient 4s ";Physicians Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP) should sign. Patient 4s ";Physicians Certification for Hospice Benefit," indicated a Medical Directors (MD)s signature where the MD should sign, and the attending physicians signature line indicated for the MD to sign again. The MD had not signed the ";Physicians Certification for Hospice Benefit," a second time. There was no documented evidence to show an AP had signed Patient 4s ";Physicians Certification for Hospice Benefit." A review of Patient 4s billing summary, undated, indicated a claim for payment was submitted in September and October 2024. 2d. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 5 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). A review of Patient 5s ";Physicians Certification for Hospice Benefit," dated July 27, 2024, to October 24, 2024, indicated Patient 5 was in her first 90-day benefit period. Patient 5s ";Physicians Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP) should sign. Patient 5s ";Physicians Certification for Hospice Benefit," indicated a Medical Directors (MD)s signature where the MD should sign, and the attending physicians signature line indicated for a Nurse Practitioner (NP) to sign. The NP had not signed the ";Physicians Certification for Hospice Benefit." There was no documented evidence to show an AP had signed Patient 5s ";Physicians Certification for Hospice Benefit." During an interview with the NP on December 5, 2024, at 1:44 PM, the NP stated he knew an NP could not certify a patients terminal illness. The NP stated he would not have signed Patient 5s ";Physicians Certification for Hospice Benefit," dated July 27, 2024, to October 24, 2024. A review of Patient 5s billing summary, undated, indicated a claim for payment was submitted in August, September and October 2024. 2e. A review of Patient 6s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 6 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). A review of Patient 6s ";Physicians Certification for Hospice Benefit," dated July 27, 2024, to October 24, 2024, indicated Patient 6 was in her first 90-day benefit period. Patient 6s ";Physicians Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP) should sign. Patient 6s ";Physicians Certification for Hospice Benefit," indicated a Medical Directors (MD)s signature where the MD should sign, and the attending physicians signature line indicated for the MD to sign again. The MD had not signed the ";Physicians Certification for Hospice Benefit," a second time. There was no documented evidence to show an AP had signed Patient 6s ";Physicians Certification for Hospice Benefit." A review of Patient 6s billing summary, undated, indicated a claim for payment was submitted in August, September and October 2024. During an interview with the Medical Director (MD) on December 5, 2024, from 9:59 AM to 10:22 AM, the MD stated he did not know the CTI for the first and second 90-day benefit periods needed to be signed by two physicians. The MD stated he did not know an NP could not sign a CTI and he relied on the staff at the agency to obtain the required signatures on the CTIs. A review of the agencys policy and procedure (P&P) titled, ";Certification of Terminal illness," dated April 2020, the P&P indicated, ";PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. ... 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. ... PROCEDURE: 1. ... (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms.) The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election. ... 4. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. ..." 3. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of November 21, 2024, with a benefit period of November 21, 2024, to January 19, 2025, (Benefit Period Eight). Patient 2 had diagnoses that included other specified degenerative (worsening) diseases of nervous system and autoimmune disease (the body's immune system mistakenly attacks healthy cells, tissues, or organs). A review of Patient 2s ";Physicians Certification for Hospice Benefit [Eighth Benefit Period]," dated November 21, 2024, to January 19, 2025, was conducted. There was no documented evidence to show a signature from the MD. A review of Patient 2s billing summary, undated, indicated a claim for payment was submitted in August, September and October 2024. During an interview with the MD on December 5, 2024, at 10:08 AM, the MD stated if the agency staff did not send him the CTI to sign, he would not be aware Patient 2s CTI needed his signature. The MD stated Patient 2s CTI was not signed because he was unaware it existed. A review of the agencys policy and procedure (P&P) titled, ";Certification of Terminal illness," dated April 2020, the P&P indicated, ";PROCEDURE: ... 2. If written certification cannot be obtained within two (2) calendar days following the start of care, verbal certification must be obtained and documented in the clinical record within two (2) days following initiation of care and written certification must be obtained before the hospice submits a claim for payment. ... 4. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. ..."

Based on interview and record review, the Medical Director (MD) failed his responsibility for the medical component of the hospice program for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6) when: 1. An attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. The MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. This failure had the potential to cause Patients 1, 2, 3, 4, 5, and 6, to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to not being properly evaluated as terminally ill. 2. The Medical Director (MD) failed to attend Interdisciplinary Group (IDG- a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) meetings or appoint an associate physician to attend the meetings in his place, in order to act as a medical resource to the IDG, establish the plans of care or review and update the plans of care every 15 days, or more frequently as needed, in conjunction with the attending physician and the IDG. This failure had the potential to cause Patients 1, 2, 3, 4, 5, and 6 to suffer a decreased quality of care, an increased risk of medical errors, poor outcomes, misdiagnoses, and limited access to specialized expertise. --- Findings: 1a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure (a condition where chronic high blood pressure damages the heart causing the heart's pumping power to be reduced, making it harder to deliver oxygen and nutrients to the body). Patient 1 was discharged on October 21, 2024. A review of Patient 1s Physicians History and Physical (H&P-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), dated August 29, 2024, to September 2, 2024, indicated the following: ";Acute psychosis [a severe and sudden loss of contact with reality]Aggressive behavior bipolar disorder [sudden, intense outbursts of anger or hostility, often characterized as "bipolar rage," which can manifest as verbal abuse, physical aggression, or impulsive actions], Chest pain ... The patient's atypical [not normal] chest pain has been evaluated with a cardiac [relating to the heart] workup, which was negative for acute [sudden] ischemia [loss of blood flow], and her laboratory results were within normal limits, indicating a low risk for cardiac disease, Parkinson disease, symptomatic [a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination], Psychosis [a clinical syndrome that involves hallucinations, delusions, disorganized thoughts or behaviors, or some combination of these], and Schizoaffective disorder, depressive type [a mental health condition causing hallucinations and delusions along with a mood disorder in the form of depressive episodes]." A review of Patient 1s physicians orders indicated a verbal hospice referral order (A "verbal order" is a medical instruction given verbally by a healthcare provider, like a doctor, to a licensed healthcare professional, such as a nurse, instead of being written down; essentially, a spoken order that needs to be documented and confirmed by the receiving individual) dated September 30, 2024, documented by the Administrator/Director of Patient Care Services (Admin/DPCS) and indicating the Medical Director (MD) as the signing physician. The verbal hospice referral order indicated, ";For Hospice Evaluation," and the verbal order was not signed by the MD. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with Patient 1s Attending Physician (AP 1) on December 3, 2024, at 2:33 PM, AP 1 stated she had not been contacted to discuss Patient 1s suitability for hospice services. Patient 1 did not have a terminal diagnosis and did not qualify for hospice services. Patient 1 was seen on September 16, 2024, and discharged with an order for home health services, not hospice services, for her lower left leg wound, Physical Therapy and Occupational Therapy. AP 1 stated Patient 1 had returned on October 9, 2024, and they found the wound had worsened because it had not been properly cared for. AP 1 stated this was when we found out Patient 1 had been on hospice services so the hospice was contacted and directed to discharge Patient 1 so we could get her home health services. During an interview with the Medical Director (MD) on December 5, 2024, at 9:59 AM, the MD stated he did not know the Admin/DPCS was writing verbal orders in his name referring hospice patients to the agency. The MD stated he did not sign Patient 1s verbal hospice referral order because he had not known it existed. The MD stated he was aware of the requirement to obtain the attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation, however, he relied on the hospice staff to get this information. The MD confirmed he had not reached out to Patient 1s attending physician, or verified Patient 1s medical prognosis or reviewed supporting documentation. During an interview with a Nurse Practitioner (NP) on December 5, 2024, at 1:32 PM, the NP stated he had performed a Face-to-Face Assessment (F2F-an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) for Patient 1 on September 30, 2024, in order to qualify her for hospice services. The NP stated he was assigned patients by the hospice agency to conduct F2F assessments, he was not involved in the referral process. The NP stated he did not ask patients about family members, emergency contacts or attending physicians. The NP stated he reviewed H&P only if it was provided by the agency. During an interview with the Admin/DPCS on December 5, 2024, at 2:12 PM, the Admin/DPCS stated she handled the intakes for the agency. The Admin/DPCS stated Patient 1 had referred herself for hospice services and had told her she did not have an attending physician. The Admin/DPCS stated she had not attempted to identify an attending physician and had written the verbal order for the MD to refer Patient 1 to the hospice. The Admin/DPCS stated she did not know the MD could not refer patients to his own hospice agency, ";I thought this was OK." The Admin/DPCS stated she did not know why the verbal order was not sent to the MD for signature. 1b. A review of Patient 2s face sheet, undated, indicated a start of care date of November 21, 2024, with a benefit period of November 21, 2024, to January 19, 2025, (Benefit Period Eight). Patient 2 had diagnoses that included other specified degenerative (worsening) diseases of nervous system and autoimmune disease (the body's immune system mistakenly attacks healthy cells, tissues, or organs). A review of Patient 2s physicians orders indicated a verbal hospice referral order dated November 21, 2024, documented by the Admin/DPCS and indicating the Medical Director (MD) as the signing physician. The verbal hospice referral order indicated, ";For Hospice Evaluation," and the verbal order was not signed by the MD. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with a Licensed Vocational Nurse (LVN 2) and Patient 2 on December 3, 2024, from 9:55 AM to 11:14 AM, at the home visit, LVN 2 stated she did not know anything about family, or doctors involved in Patient 2s care. Patient 2 stated her son called from time to time to check up on her. Patient 2 stated she called her son sometimes too but could not remember his phone number, she stated the facility helped her place the calls. Patient 2 stated she did not have a doctor to see her or take care of her and she had lost her insurance card. Patient 2 stated she knew she was on hospice, and they helped her get diapers, wipes and medications. Patient 2 stated she did not know hospice was for people who had six months or less to live, "I'm not going to die in six months." Patient 2 stated she did not ask for hospice services and did not remember who had offered them to her. Patient 2 stated a doctor had never discussed hospice services with her or explained what it was all about. Patient 2 stated "What I need is an attending physician to take care of me." During an interview with an Assisted Living Facility (ALF-a living arrangement in which people with special needs, especially seniors, live in a facility that provides help with everyday tasks such as bathing, dressing, and taking medication) /Owner (ALF/Owner 2) on December 5, 2024, at 9:45 AM, the ALF/Owner 2 stated the facility did not have a folder with information on the patients, they just kept the contract and an active medication list in case the patient went to the emergency room. The ALF/Owner 2 stated they did not inquire about family or doctors of their patients and did not keep contact numbers, ";that was the patients' responsibility." The ALF/Owner 2 stated staff may have written down a family phone number in order to help a patient make a call and she would inquire with her staff. ALF/Owner 2 stated she may have referred Patient 2 to hospice. ALF/Owner 2 did not provide contact information for Patient 2s son. During an interview with the Medical Director (MD) on December 5, 2024, at 10:08 AM, the MD stated he did not know the Admin/DPCS was writing verbal orders in his name referring hospice patients to the agency. The MD stated he did not sign Patient 2s verbal hospice referral order because he had not known it existed. The MD stated he was aware of the requirement to obtain the attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation, however, he relied on the hospice staff to get this information. The MD confirmed he had not reached out to Patient 2s attending physician, or verified Patient 2s medical prognosis or reviewed supporting documentation. During an interview with a Nurse Practitioner (NP) on December 5, 2024, at 1:36 PM, the NP stated he had performed a Face-to-Face Assessment (F2F) for Patient 2 on November 21, 2024, in order to qualify her for hospice services. The NP stated he was assigned patients by the hospice agency to conduct F2F assessments, he was not involved in the referral process. The NP stated he did not ask patients about family members, emergency contacts or attending physicians and he reviewed H&P only if it was provided by the agency. The NP stated he may have spoken on the phone with Patient 2s son at his visit but he could not remember. During an interview with the Admin/DPCS on December 5, 2024, at 2:51 PM, the Admin/DPCS stated she handled the intakes for the agency. The Admin/DPCS stated she did not remember who referred Patient 2 for hospice services and Patient 2 had told her she did not have an attending physician. The Admin/DPCS stated she had not attempted to identify an attending physician and had written the verbal order for the MD to refer Patient 2 to the hospice. The Admin/DPCS stated she did not know the MD could not refer patients to his own hospice agency, ";I thought this was OK." The Admin/DPCS stated she did not know why the verbal order was not sent to the MD for signature. 1c. A review of Patient 3s face sheet, undated, indicated a start of care date of October 1, 2024, with a benefit period of October 1, 2024, to December 29, 2024, (Benefit Period One). Patient 3 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 3s physicians orders indicated a verbal hospice referral order dated October 1, 2024, documented by the Admin/DPCS and indicating the Medical Director (MD) as the signing physician. The verbal hospice referral order indicated, ";For Hospice Evaluation," and the verbal order was not signed by the MD. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with LVN 2 and Patient 3 on December 3, 2024, from 9:58 AM to 10:43 AM, at the home visit, LVN 2 stated Patient 3 had no family that she knew of. LVN 2 stated yesterday (December 2, 2024) Patient 3 had an x-ray to her chest and stomach, but LVN 2 did not know about any doctors, or the facility Patient 3 had gone to. LVN 2 stated Patient 3 did not tell her why she needed the x-ray. Patient 3 stated her dad, sister one, sister two and her brother helped her with her care and life. Patient 3 stated it was best to call sister one because she knew all about her care and her Attending Physician (AP 2) was at (name of an acute care hospital) but she did not have his phone number. Patient 3 stated AP 2 had ordered x-rays after she got sick, Patient 3 rubbed her upper chest with her hand, "I was coughing." Patient 3 stated she did not know she was on hospice and did not know what hospice was. Patient 3 stated she had not asked for hospice and AP 2 had not spoken with her about hospice. During an interview with an ALF/Owner 2 on December 5, 2024, at 9:45 AM, the ALF/Owner 2 stated the facility did not have a folder with information on the patients, they just kept the contract and an active medication list in case the patient went to the emergency room. The ALF/Owner 2 stated they did not inquire about family or doctors of their patients and did not keep contact numbers, ";that was the patients' responsibility." The ALF/Owner 2 stated she did not refer Patient 3 to hospice. During an interview with the Medical Director (MD) on December 5, 2024, at 10:14 AM, the MD stated he did not know the Admin/DPCS was writing verbal orders in his name referring hospice patients to the agency. The MD stated he did not sign Patient 3s verbal hospice referral order because he had not known it existed. The MD stated he was aware of the requirement to obtain the attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation, however, he relied on the hospice staff to get this information. The MD confirmed he had not reached out to Patient 3s attending physician, or verified Patient 3s medical prognosis or reviewed supporting documentation. During an interview with a Nurse Practitioner (NP) on December 5, 2024, at 1:38 PM, the NP stated he had performed a Face-to-Face Assessment (F2F) for Patient 3 on October 1, 2024, in order to qualify her for hospice services. The NP stated he was assigned patients by the hospice agency to conduct F2F assessments, he was not involved in the referral process. The NP stated he did not ask patients about family members, emergency contacts or attending physicians and he reviewed H&P only if it was provided by the agency. During an interview with the Admin/DPCS on December 5, 2024, at 3 PM, the Admin/DPCS stated she handled the intakes for the agency. The Admin/DPCS stated she did not remember who referred Patient 3 for hospice services and Patient 3 had told her she did not have an attending physician. The Admin/DPCS stated she had not attempted to identify an attending physician and had written the verbal order for the MD to refer Patient 3 to the hospice. The Admin/DPCS stated she did not know the MD could not refer patients to his own hospice agency, ";I thought this was OK." The Admin/DPCS stated she did not know why the verbal order was not sent to the MD for signature. During an interview with Patient 3s Sister One on December 6, 2024, at 12:43 PM, Sister One stated she knew her sister was getting some kind of aide but did not know from where and did not know Patient 3 was receiving hospice services. Patient 3s Sister One stated she knew what hospice was because her mother had hospice when she was diagnosed with cancer, and she was unaware of any terminal diagnoses for her sister. Sister One stated she had not been contacted by the hospice, or a Spiritual Counselor (SC) or a Medical Social Worker (MSW) to offer support or services to her or any of her other family members. The Sister One stated the hospice services her mother had received provided her whole family with support and guidance. During an interview with a Quality Services Director (QSD) at Patient 3s suggested acute care hospital on December 6, 2024, at 2:51 PM, the QSD stated she was unable to find the physician Patient 3 had indicated among the acute care hospitals staff. The QSD stated Patient 3 had visited the hospitals emergency room for back and flank pain on August 8, 2023, but had left the hospital against medical advice and a thorough assessment was not completed. 1d. A review of Patient 4s face sheet, undated, indicated a start of care date of September 9, 2024, with a benefit period of September 9, 2024, to December 7, 2024, (Benefit Period Two). Patient 4 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 4s physicians orders indicated a verbal hospice referral order dated September 9, 2024, documented by the Admin/DPCS and indicating the Medical Director (MD) as the signing physician. The verbal hospice referral order indicated, ";For Hospice Evaluation," and the verbal order was not signed by the MD. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with LVN 2 and Patient 4 on December 3, 2024, from 10:01 AM to 10:50 AM, at the home visit, LVN 2 stated she had not heard about any family or doctors for Patient 4. LVN 2 stated she had heard Patient 4 talking on the phone to someone, but she had not asked who it was. LVN 2 stated, "She has good days and bad days. Can be confused and agitated." Patient 4 stated her daughter lived in Missouri with her ex-husband and her son lived in Nevada, but she did not remember their phone numbers. Patient 4 stated she saw a Nurse Practitioner (NP) who gave her medication but could not remember her phone number and she knew hospice was for dying people, "but I'm not dying in 6 months. I'm in good shape." Patient 4 stated she needed the hospice services so she could get her medications and showed her insurance card which indicated an acute care hospital. Patient 4 stated she had not asked for hospice services and had not spoken to a physician about hospice services or a terminal diagnosis. During an interview with an ALF/Owner 2 on December 5, 2024, at 9:45 AM, the ALF/Owner 2 stated the facility did not have a folder with information on the patients, they just kept the contract and an active medication list in case the patient went to the emergency room. The ALF/Owner 2 stated they did not inquire about family or doctors of their patients and did not keep contact numbers, ";that was the patients' responsibility." ALF/Owner 2 stated she may have referred Patient 4 to hospice. During an interview with the Medical Director (MD) on December 5, 2024, at 10:18 AM, the MD stated he did not know the Admin/DPCS was writing verbal orders in his name referring hospice patients to the agency. The MD stated he did not sign Patient 4s verbal hospice referral order because he had not known it existed. The MD stated he was aware of the requirement to obtain the attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation, however, he relied on the hospice staff to get this information. The MD confirmed he had not reached out to Patient 4s attending physician, or verified Patient 4s medical prognosis or reviewed supporting documentation. During an interview with a Nurse Practitioner (NP) on December 5, 2024, at 1:43 PM, the NP stated he had performed a Face-to-Face Assessment (F2F) for Patient 4 on September 9, 2024, in order to qualify her for hospice services. The NP stated he was assigned patients by the hospice agency to conduct F2F assessments, he was not involved in the referral process. The NP stated he did not ask patients about family members, emergency contacts or attending physicians and he reviewed H&P only if it was provided by the agency. The NP stated he remembered speaking with a female family member at Patient 4s F2F, ";Thats all I remember." During an interview with the Admin/DPCS on December 5, 2024, at 3:07 PM, the Admin/DPCS stated she handled the intakes for the agency. The Admin/DPCS stated the ALF had referred Patient 4 for hospice services and Patient 4 had told her she did not have an attending physician. The Admin/DPCS stated she had not attempted to identify an attending physician and had written the verbal order for the MD to refer Patient 4 to the hospice. The Admin/DPCS stated she did not know the MD could not refer patients to his own hospice agency, ";I thought this was OK." The Admin/DPCS stated she did not know why the verbal order was not sent to the MD for signature. During an interview with a Regulatory Compliance, Healthcare Program Administrator (RC/HPA) at Patient 4s suggested acute care hospital on December 9, 2024, at 1:09 PM, the RC/HPA stated she could not identify a physician for Patient 4. 1e. A review of Patient 5s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 5 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 5s physicians orders indicated a verbal hospice referral order dated July 27, 2024, documented by the Admin/DPCS and indicating the Medical Director (MD) as the signing physician. The verbal hospice referral order indicated, ";For Hospice Evaluation," and the verbal order was not signed by the MD. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with LVN 2 and Patient 5 on December 3, 2024, from 10:04 AM to 10:23 AM, at the home visit, LVN 2 stated Patient 5 had a sister in California and some family outside of California, but she did not know their names or contact numbers. LVN 2 stated Patient 5 had primary care doctors she saw but LVN 2 did not know their names or contact numbers. LVN 2 stated Patient 5 was very independent and took care of her own needs. Patient 5 stated she had a sister in California but did not remember a phone number. Patient 5 stated she saw her neurologist (Attending Physician-AP 3) every three months and AP 4 used to take care of her diabetes, but she was not the acute care hospital anymore. Patient 5 showed her insurance card which indicated AP 5. Patient 5 stated she understood hospice to be someone who comes in and takes care of you, gives you showers, cleans up, makes sure your medications are correct and makes you take your medications. Patient 5 stated, "I don't know how I ended up on hospice. I didn't ask for hospice. I don't know if the facility's owners asked for the hospice services for me. I don't think I would die in 6 months, I'm pretty healthy. I didn't talk to a doctor about hospice or a terminal diagnosis." During an interview with an ALF/Owner 2 on December 5, 2024, at 9:45 AM, the ALF/Owner 2 stated the facility did not have a folder with information on the patients, they just kept the contract and an active medication list in case the patient went to the emergency room. The ALF/Owner 2 stated they did not inquire about family or doctors of their patients and did not keep contact numbers, ";that was the patients' responsibility." The ALF/Owner 2 stated she did not refer Patient 5 to hospice. During an interview with the Medical Director (MD) on December 5, 2024, at 10:21 AM, the MD stated he did not know the Admin/DPCS was writing verbal orders in his name referring hospice patients to the agency. The MD stated he did not sign Patient 5s verbal hospice referral order because he had not known it existed. The MD stated he was aware of the requirement to obtain the attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation, however, he relied on the hospice staff to get this information. The MD confirmed he had not reached out to Patient 5s attending physician, or verified Patient 5s medical prognosis or reviewed supporting documentation. During an interview with a Nurse Practitioner (NP) on December 5, 2024, at 1:44 PM, the NP stated he had performed a Face-to-Face Assessment (F2F) for Patient 5 on July 27, 2024, in order to qualify her for hospice services. The NP stated he was assigned patients by the hospice agency to conduct F2F assessments, he was not involved in the referral process. The NP stated he did not ask patients about family members, emergency contacts or attending physicians and he reviewed H&P only if it was provided by the agency. The NP stated he did not remember speaking with a family member. During an interview with the Admin/DPCS on December 5, 2024, at 3:18 PM, the Admin/DPCS stated she handled the intakes for the agency. The Admin/DPCS stated the ALF/Owner 2 had referred Patient 5 for hospice services and Patient 5 had told her she did not have an attending physician. The Admin/DPCS stated she had not attempted to identify an attending physician and had written the verbal order for the MD to refer Patient 5 to the hospice. The Admin/DPCS stated she did not know the MD could not refer patients to his own hospice agency, ";I thought this was OK." The Admin/DPCS stated she did not know why the verbal order was not sent to the MD for signature. During an interview with Patient 5s AP 4 on December 10, 2024, at 10:28 AM, AP 4 stated she had provided care for Patient 5 up until the Spring of 2024, and she did not have any terminal diagnoses. AP 4 stated Patient 5s main issues were her seizures and homelessness as well as episodes of forgetfulness and confusion. AP 4 stated she did not know Patient 5 was on hospice services and the hospice had not spoken to her about Patient 5s prognosis. AP 4 stated Patient 5 did not have heart failure. During an interview with Patient 5s AP 6 on December 10, 2024, at 1 PM, AP 6 stated he was Patient 5s attending physician and had last seen Patient 5 on September 27, 2024, and she had made no mention of being on hospice care. AP 6 stated he reviewed Patient 5s clinical record and there was no mention of the need for hospice care and Patient 5 had no terminal diagnoses. AP 6 stated no one from a hospice had spoken to him about Patient 5s prognosis or proposed hospice care and Patient 5 did not qualify for hospice care. AP 6 stated Patient 5 had a echocardiogram (an ultrasound that uses sound waves to create images of the heart and nearby blood vessels) in May 2024 and there was no indication of heart failure. 1f. A review of Patient 6s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 6 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 6s physicians orders indicated a verbal hospice referral order dated July 27, 2024, documented by the Admin/DPCS and indicating the Medical Director (MD) as the signing physician. The verbal hospice referral order indicated, ";For Hospice Evaluation," and the verbal order was not signed by the MD. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with LVN 2 and Patient 6 on December 3, 2024, from 10:08 AM to 11:22 AM, at the home visit, LVN 2 stated Patient 6 had a lot of family and they all lived in California, but she did not know the names or contact numbers. LVN 2 stated she did not know about any doctors Patient 6 saw. Patient 6 stated she had a sister and a daughter and provided their contact numbers. Patient 6 stated her Clinical Therapist (CT) knew everything about her medical care and provided a contact number. Patient 6 stated she did not know she was on hospice, and she did not know what hospice was. During an interview with an ALF/Owner 2 on December 5, 2024, at 9:45 AM, the ALF/Owner 2 stated the facility did not have a folder with information on the patients, they just kept the contract and an active medication list in case the patient went to the emergency room. The ALF/Owner 2 stated they did not inquire about family or doctors of their patients and did not keep contact numbers, ";that was the patients' responsibility." The ALF/Owner 2 stated she did not refer Patient 6 to hospice. During an interview with the Medical Director (MD) on December 5, 2024, at 10:22 AM, the MD stated he did not know the Admin/DPCS was writing verbal orders in his name referring hospice patients to the agency. The MD stated he did not sign Patient 6s verbal hospice referral order because he had not known it existed. The MD stated he was aware of the requirement to obtain the attending physician's referral order for hospice services, confirmation of service needs, verification of the patients' medical prognosis and supporting documentation, however, he relied on the hospice staff to get this information. The MD confirmed he had not reached out to Patient 6s attending physician, or verified Patient 6s medical prognosis or reviewed supporting documentation. During an interview with a Nurse Practitioner (NP) on December 5, 2024, at 1:45 PM, the NP stated he had performed a Face-to-Face Assessment (F2F) for Patient 6 on July 27, 2024, in order to qualify her for hospice services. The NP stated he was assigned patients by the hospice agency to conduct F2F assessments, he was not involved in the referral process. The NP stated he did not ask patients about family members, emergency contacts or attending physicians and he reviewed H&P only if it was provided by the agency. The NP stated he did not remember speaking with a family member. During an interview with the Admin/DPCS on December 5, 2024, at 3:29 PM, the Admin/DPCS stated she handled the intakes for the agency. The Admin/DPCS stated Patient 6 had referred herself for hospice services and Patient 6 had told her she did not have an attending physician. The Admin/DPCS stated she had not attempted to identify an attending physician and had written the verbal order for the MD to refer Patient 6 to the hospice. The Admin/DPCS stated she did not know the MD could not refer patients to his own hospice agency, ";I thought this was OK." The Admin/DPCS stated she did not know why the verbal order was not sent to the MD for signature. During an interview with Patient 6s Clinical Therapist (CT) on December 6, 2024, at 3:17 PM, The CT stated no one called him to discuss hospice services for Patient 6 and he did not think Patient 6 was appropriate for hospice. The CT stated he took Patient 6 to all her Primary Care Physician (PCP) visits and the PCP never spoke to him about a terminal diagnosis and a need for hospice care. During an interview with Patient 6s sister on December 6, 2024, at 4:12 PM, Patient 6s sister stated she helped take care of her sister and was not notified she was admitted to hospice care, ";My sister isn't dying and she should not be on hospice!" Patient 6's sister stated her sister did not have a terminal diagnosis of any kind and she had not been contacted by a SC or a MSW from the hospice to offer support or guidance. Patient 6's sister stated she was worried her sister being on hospice would cause a problem with the other services they had been working on getting her, ";like housing." A review of the agencys policy and procedure (P&P) titled, ";Intake Process," dated November 2013, the P&P indicated, ";PURPOSE: To establish the pr ocess for acceptance and entry of patients into hospice. ... PROCEDURE: 1. Hospice referrals will be documented on a referral and intake form. ... A. Intake personnel will document information regarding patient demographics, diagnoses, services needed, medications, attending physician, hospitalization, etc., in order to make the initial determination whether the patient's needs can be met by hospice and if he/she meets eligibility criteria. ... D. If the referral call is not from a physician, the physician (or other authorized licensed independent practitioner) will be contacted to confirm service needs, as well as the patient's medical prognosis and supporting documentation, and to obtain verbal orders. ..." A review of the agencys policy and procedure (P&P) titled, ";Physician Services – Medical Director," dated November 2013, the P&P indicated, ";PURPOSE: To ensure qualified medical direction and consultation for the delivery of hospice services and programs. To demonstrate that the Medical Director/hospice team physician (physician designee) has overall responsibility for patient care through documentation that demonstrates interaction/communication with the attending physician as necessary for appropriate medical care. POLICY: ... The duties and responsibilities of the Medical Director will include, but not be limited to, the following: 1. Overall responsibility for the medical component of hospice patient care program. Assuring the provision of quality care that meets the medical needs of the patient and family. 2. Consulting and coordinating care with attending physicians, if requested, regarding pain and symptoms management for hospice patients; when attending physician is not available, may function as the designee physician. 3. Reviewing patients' medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness. 4. Reviewing necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician. 5. Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services. 6. Assisting in developing and implementing the plan of care that is coordinated with the attending physician. 7. Ensuring the availability of physician services and providing a substitute in the absence of the attending physician. ..." 2a. A review of Patient 1s face sheet, undated, indicated a start of care date of September 30, 2024, with a benefit period of September 30, 2024, to December 28, 2024, (Benefit Period Two). Patient 1 had diagnoses that included hypertensive heart disease with heart failure. Patient 1 was discharged on October 21, 2024. A review of Patient 1s IDG meetings indicated meetings had been held on September 30, 2024 and October 11, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:05 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 1s IDG meetings, ";I cant remember if I did or not." During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on December 5, 2024, at 2:44 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 1s IDG meetings. 2b. A review of Patient 2s face sheet, undated, indicated a start of care date of November 21, 2024, with a benefit period of November 21, 2024, to January 19, 2025, (Benefit Period Eight). Patient 2 had diagnoses that included other specified degenerative (worsening) diseases of nervous system and autoimmune disease (the body's immune system mistakenly attacks healthy cells, tissues, or organs). A review of Patient 2s IDG meetings indicated meetings had been held on November 21, 2024 and November 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:08 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 2s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 2:59 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 2s IDG meetings. 2c. A review of Patient 3s face sheet, undated, indicated a start of care date of October 1, 2024, with a benefit period of October 1, 2024, to December 29, 2024, (Benefit Period One). Patient 3 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 3s IDG meetings indicated meetings had been held on October 1, 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:14 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 3s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:02 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 3s IDG meetings. 2d. A review of Patient 4s face sheet, undated, indicated a start of care date of September 9, 2024, with a benefit period of September 9, 2024, to December 7, 2024, (Benefit Period Two). Patient 4 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 4s IDG meetings indicated meetings had been held on September 9, 13, and 27, 2024, October 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:18 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 4s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:07 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 4s IDG meetings. 2e. A review of Patient 5s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 5 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 5s IDG meetings indicated meetings had been held on July 27, 2024, and August 2, 16, and 30, 2024, September 13, and 27, 2024, October 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:21 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 5s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:18 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 5s IDG meetings. 2f. A review of Patient 6s face sheet, undated, indicated a start of care date of July 27, 2024, with a benefit period of July 27, 2024, to October 24, 2024, (Benefit Period One). Patient 6 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 6s IDG meetings indicated meetings had been held on July 27, 2024, and August 2, 16, and 30, 2024, September 13, and 27, 2024, October 11, and 25, 2024, and November 8, and 22, 2024. A review of the signatures for attendance was conducted. There was no documented evidence to show the Medical Director (MD) or a physician designee had attended the IDG meetings. During an interview with the MD on December 5, 2024, at 10:22 AM, the MD stated he attended some IDG meetings by phone but not all of them. The MD stated there was no physician designee to fill in for him when he could not attend and he could not show documented evidence he attended Patient 6s IDG meetings, ";I cant remember if I did or not." During an interview with the Admin/DPCS on December 5, 2024, at 3:29 PM, the Admin/DPCS stated the MD attended the IDG meetings by phone but not all of them. The Admin/DPCS stated there was no physician designee to fill in for the MD when he could not attend the IDG meetings, and she could not show documented evidence the MD had attended Patient 6s IDG meetings. A review of the agencys policy and procedure (P&P) titled, ";Interdisciplinary Group Membership and Responsibilities," dated November 2013, the P&P indicated, ";PURPOSE: To define the membership and responsibilities of the interdisciplinary team/group. ... PROCEDURE: 1. The hospice interdisciplinary team/group members will include, at a minimum: A Physician ..." A review of the agencys policy and procedure (P&P) titled, ";Interdisciplinary Group Meeting," dated November 2013, the P&P indicated, ";PURPOSE: To define the process for interdisciplinary group meetings and documenting patient status in the clinical record. ... POLICY: 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 meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The patient and family/caregiver will be informed of the schedule for this meeting, its purpose, and that the discussion is confidential. PROCEDURE: 1. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor. 2. Referrals and admissions will be reviewed to establish appropriateness for hospice care. Obstacles to access of care issues will be identified and resolved. Admissions will be reviewed to ensure compliance with hospice policies and procedures. ..." A review of the agencys policy and procedure (P&P) titled ";Physician Services – Medical Director," dated November 2013, the P&P indicated, ";PURPOSE: To ensure qualified medical direction and consultation for the delivery of hospice services and programs. To demonstrate that the Medical Director/hospice team physician (physician designee) has overall responsibility for patient care through documentation that demonstrates interaction/communication with the attending physician as necessary for appropriate medical care. ... POLICY: ... The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. ... The hospice team physician {physician designee) is available whenever the hospice Medical Director is unable to perform his/her duties due to illness, vacation or upon request. The duties and responsibilities of the Medical Director will include, but not be limited to, the following: 1. Overall responsibility for the medical component of hospice patient care program. Assuring the provision of quality care that meets the medical needs of the patient and family. ... 3. Reviewing patients' medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness. 4. Reviewing necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician. 5. Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services. ... 7. Ensuring the availability of physician services and providing a substitute in the absence of the attending physician. 8. Acting as medical resource to the hospice interdisciplinary group. Participating in the development and implementation of the policies related to the care provided by the interdisciplinary team. ... 13. Acting as primary physician for patients whose referring physicians desire to relinquish that care and/or if the referring physicians are not available for further contact. 14. Managing oversight of the patient's medications and treatments. 15. Attending interdisciplinary group meetings and working in a team approach with the group.

Observed in Record Review. In 1 of 7 patient records reviewed, the organization failed to ensure the interdisciplinary group complete the comprehensive assessment no later than 5 calendar days after the election of hospice care. For example: on review RRNHV#4 there was no initial psychosocial assessment documented. After discussion with the PDCS and reaching out to the MSW it was noted that the family had requested to move assessment to next month, yet there was no documentation of this in the patient record. A late entry was added per the MSW at time of survey. This observation was reviewed with the DPCS.

Observed in Record Review. In 4 of 7 patient records reviewed, for patients admitted since 7/1/23, the hospice failed to update the comprehensive assessment as frequently as the patient condition requires, but no less frequently than every 15 days. For example, on review of RRNHV#4 there was a gap in RN visits of 17 days. In RRNHV#5 there was a 23 day gap between RN visits. In review of RRNHV#6 there was a 17 day gap, and in RRNHV#7 there was a gap of 20 days between RN comprehensive assessments. This observation was reviewed with the DPCS.

Observed in Record Review. In 2 of 7 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness. For example: on review of RRNHV#3 the LVN documented education on the patient utilizing albuterol inhaler for shortness of breath, however there was no albuterol physicians order reflected on the plan of care. IN RRNHV#2 the patient was being seen by the MSW yet there was no psychosocial care plan. This observation was reviewed with the DPCS.

Observed in Record Review. In 1 of 1 patient records reviewed, where the patient had been discharged from HCO services, the Surveyor noted the patient had been 'discharged for non-compliance with treatment/poc'; however, there had been no documentation supporting non-compliance, no communication with the patient that the HCO had been considering discharge, nor interdisciplinary communication that the patient had been non-compliant. In RR #6, the patient had been seen by clinicians per the prescribed plan of care frequency. The most recent visit, 2 days prior to discharge, documented the patient as still needing the services of the hospice. 2 days later the patient had been discharged. The last documented IDG for the patient at the beginning of May did not provide any indication patient had been non-compliant, and the IDG for the end of May had been incomplete. There had been no ABN nor a NOMNC in the patient record. This was validated with the DON and the CEO.

Observed in Record Review. In 1 of 5 patient records reviewed, The Surveyor noted not all patient care needs had been addressed in the Plan of Care (POC) with goals and interventions. RR #1, the patient had renal failure and been on dialysis. This had not been included on the POC. The same patient had a recent fall with rib fractures. This had been documented in the narrative note of 1 clinical visit, but was not added as a diagnosis with interventions and goals nor had this been addressed in the IDG meeting. This was validated with the DON.

Observed in Record Review. In 2 of 3 patient records reviewed, of patients new to the HCO since the previous survey, the Surveyor noted the Spiritual Care (SC) Provider had not had contact with the patient post election of the Hospice Benefit. RR #4, the Spiritual Care Comprehensive Assessment had been documented by an RN, and in RR #5, the SC had not had documented any contact with the patient. This was validated with the DON.

Observed in Record Review. In 4 of 5 patient records reviewed, the hospice failed to update the comprehensive assessment as frequently as the condition of the patient requires, but no less frequently than every 15 days. For example, RR #1 the patient had 1 period with 32 days between a documented RN Comprehensive visit and another period with 17 days. RR #2, the patient had 20 days between documented RN comprehensive visits. RR #3 the patient had gone 18 days, and RR #5, the patient had been 24 days without an RN comprehensive visit. This was validated with the DON.

Observed in Record Review. In 3 of 5 patient records reviewed, the Surveyor noted multiple medications ordered as needed without specific clinical parameters for use. For example, in RR # 3 Ibuprofen 600mg 1 Tab Oral As needed every 6 hours Acute mild to moderate pain; Acetaminophen 500mg Extra Strength Tablet 2 Tabs As needed every 6 hours mild Pain; Tramadol Hydrochloride 50mg 1 Tab As needed every 8 hours, Acute pain management; Hydrocodone Bitartrate/Acetaminophen 10mg-325mg Tablet As needed every 6 hours Moderate to severe pain. In RR #4, the patient had Tylenol Extra Strength 500mg 1 Tab Every 6 Hours As Needed Mild Pain; Tramadol Hydrochloride 50mg 1 Tab 3 Times A Day Moderate To Severe Pain and in RR #5, the patient had Hydrocodone Bitartrate/Acetaminophen 10mg-325mg 1 Tab As needed every 6 hours Severe pain; Tylenol 325mg 2 Tab Every 8 hrs – PRN Pain - Mild- Severe. This was validated with the DON. Observed in Record Review. In 1 of 7 patient records reviewed, the Surveyor noted patient care orders to be incomplete. For example, RR #2, the patient had wound care orders that did not state who would complete the care and the frequency the wound care would be done. This was validated with the DON

Observed in Record Review. In 2 of 6 patient records reviewed, the Surveyor noted IDG meeting documentation missing from the patient record. RR #1, the patient had been missing IDG meeting notes from both meetings held in June. RR #6, had been missing IDG meeting notes from the end of May prior to the patient's discharge from the HCO. This was validated with the DON.

Observed in Record Review. In 2 of 6 patient records reviewed, The Surveyor noted collaboration between clinicians providing patient care had not been documented. In RR #1, The LVN documented the patient had a fall with rib fractures; however, there is no documented communication with the RN Case Manager, or other IDG members. In RR #6, Patient discharged for non-compliance; however, there is no documentation in the record of communication and collaboration between disciplines related to non-compliance. This was validated with the DON.

Observed in Tracer Activities. The governing body for the organization that assumes full legal authority and responsibility for the management of the hospice failed to sustain compliance with reports and recommendations from accreditation, certification, and regulatory bodies, as repeat Condition level findings from previous survey were noted again during survey process in COP's 418.52, 418.54, 418.56 and 418.116.

Observed in Record Review. In 2 of 2 patient records reviewed, where the patient had been discharged from the HCO, there had been no documentation that the patient had been included in the discharge process and signed the ABN/NOMNC. The Surveyor reviewed 2 available live discharge records. RR #6 had been missing a NOMNC and there had been no documentation the patient had been included in the discharge process nor informed about the discharge, and RR #7 the NOMNC had been signed on the same date of discharge. Validated with the DON.

Observed in Record Review. In 4 of 10 patient records reviewed, for active records, the hospice interdisciplinary group failed to complete the comprehensive assessment no later than 5 calendar days after the election of hospice. For example: in RR#4 the RN initial comprehensive assessment noted that spiritual distress was moderate and yes a spiritual care visit was needed, yet there has been no chaplain visit documented to date nearly 2 months past admission. Similar documentation for need for spiritual care services was noted for RR#7, RR#8, yet the spiritual comprehensive assessment has not been conducted. In RR#10 the spiritual care assessment was not conducted until 3 months after admission, with no documentation of explanation of delaying the assessment. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 4 of 14 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identified the patient need for hospice care and services. For example: on Review of HV#2 the patient was noted through documentation, staff and caregiver interview that the patient had end stage renal disease and on dialysis, however the comprehensive assessment failed fully assess the renal system as there was no mention of the dialysis or issues with renal function in the initial assessment, nor was there assessment of the dialysis access documented in the record. In RR#7 the patient was noted to be diabetic on admission yet after the first two visits the endocrine system was not noted to be assessed. Further the aide documented multiple falls, and a wound, yet there was no mention of these issues as being assessed in the comprehensive assessment by the SN during the head to toe assessment. In RR#10 the plan of care notes the use of O2, yet during the comprehensive assessment and review of the respiratory system the issues were not assess and need for O2 is marked as none. In review of RR#12 there was no evidence of a post death bereavement risk assessment noted to be conducted post death as required. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 7 of 10 patient records reviewed, for active patients, the hospice failed to update the comprehensive assessment as frequently as the condition of the patient requires, but no less frequently than every 15 days. For example: on review of RR#4 there was a 28 day gap in RN visits from 3/28 to 4/25 with no RN visit documented since. In Benefit period 3 of RR#5 there was a 23 day and a 22day gap in RN comprehensive assessments conducted. Similar gaps in RN comprehensive assessments greater than 15 days was noted in RR#6, RR#7, RR#8, RR#9, and RR#10. On discussion with the Administrator/DPCS she acknowledged that the RN was currently seeing patient's monthly. Observed in Record Review. In 9 of 10 patient records reviewed, for active patients, the update of the comprehensive assessment did not consider changes that took place since the initial assessment to include the patient's progress toward desired outcomes or reassessment of the patient's response to care. For example: Throughout the records reviewed the care plan lacked progress toward goals and outcomes as the goals and interventions were established on admission and remained unchanged from IDG to IDG throughout care. Further, the IDG summary each IDG meeting was noted to be copied from clinical notes and did not capture changes and progress to desired outcomes that occurred over the 2 week period. In review of RR#4 the IDG summary on 4/28/23 did not include a nursing update. In HV#2 the IDG documentation did not include a spiritual or psychosocial summary on 4/14/23 and no spiritual summary on 3/31 or 3/17. On RR#8 4/28/23 IDG did not include an update from the RN, and no spiritual update on 4/28 or 4/14. Similar IDG meeting that lacked summary update and progress can be seen in RR#9 and RR#10.

Observed in Record Review. In 10 of 10 patient records reviewed, for active patients, the organization failed to ensure the written plan of care was individualized and reflect patient and family goals based on problems identified in the comprehensive assessment that are specific, measurable, achievable, realistic, and time bound. On review of the clinical records there was a pattern noted of lacking being measurable, and for lack of individualized time frames for achieving goals, as most goals had a time frame to achieve in 6 weeks. Such as in HV#3 no fall episodes at all times with period of 6 weeks, prevent pain and discomfort due to injury in 6 weeks, and reduce discomfort with improved bowel elimination status in 6 weeks, and Pt/CG will verbalize/express understanding of medication/treatment orders and side effects in 6 weeks. Similar issues can be seen all care plans reviewed. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 10 of 10 patient records reviewed, for active patients, the organization failed to ensure the plan of care contained a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. For example: throughout all records reviewed the frequencies established were noted to include PRN visits such as SN 1 time a week and 3 PRN, and MSW 1 time a month and 1 PRN, however there were no details to indicate when a PRN visit was to be used. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 6 of 14 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: On review of HV#2 the nursing documentation and conversation with RN and patient caregiver revealed the patient was on dialysis two times a week, yet this was not reflected in the hospice plan of care. In review of HV#3 there was an order for wound care to the patient's toe, and an infection with antibiotics ordered, but no care plan to direct the care provided. In RR#5 documentation noted issues with nutrition, fall risk that increased from moderate to high, and oxygen use, but the issues identified were not reflected in the plan of care. In RR#7 the documentation noted issues with nausea, and a wound and falls, yet no care plan to reflect the identified issues. In RR#10 the patient was being seen by the chaplain yet there was no spiritual care plan established. In review of RR#12 discharged for death, there was an established care plan for bereavement, yet the plan did not specify specific interventions. the interventions read social worker will assist in the grieving process. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RR#4 the patient was ordered Clonidine Q 8 hours and PRN, yet there were no parameters to guide the patient to know when to use a PRN dose. There was a O2 order noted in the care plan interventions for 2-5 liters/min in RR#4 and RR#10, yet there were no parameter to indication when to use what liter flow. In RR#4, RR#7, and RR#9 there was a goal on the care plan for optimal blood glucose management yet there were no physicians orders for blood glucose management/monitoring. In review of RR#5, and HV#3 there was O2 listed in the DME section of the plan of care but there was no mention of the route of delivery as required by policy. In RR#8 there was documentation of O2 use in the nurses notes but no orders for O2 noted on the record. In review of HV#1, HV#2, HV#3, RR#9 and RR#10 there was a listing of nutritional supplement in the supplies section of the plan of care yet no details of the order of route, dose, frequency or indication as required by policy. These observations were reviewed with the Administrator/DPCS, RN and Owner.

Observed in Record Review. In 6 of 10 patient records reviewed, the organization failed to ensure the plan of care include all medical supplies and appliances necessary to meet the needs of the patient. For example: on review of RR#4 there were no supplies or DME listed on the patient's plan of care. In the home observation for HV#3 it was noted the there were multiple supplies, and a hospital bed, and nebulizer noted in the patient home yet they were not included in the plan of care. In RR#6 there were no supplies included on the plan of care. In RR#8 the documentation noted O2 in the home but the O2 concentrator or O2 tanks were not listed on the plan of care. In RR#9 the documentation noted a walker, bed, over bed table and shower chair were in the home, yet only the walker was listed on the care plan. In RR#10 there was documentation of O2 in the home, but there was no O2 equipment listed as DME on the plan. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 13 of 14 patient records reviewed, for active patient, the hospice interdisciplinary group failed to review, revise, and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. For all active records review the organization failed to conduct an IDG review that was scheduled for 5/11/23 causing all records reviewed, with the exception of a new admit of less that 15 days of service, to fall out of compliance with the requirement. On review of d/c records (RR#11, RR#12, RR#13, RR#14) there was no documentation of IDG meeting to discuss discharge after the patient was discharged. This observation was reviewed with the Administrator/DPCS, Owner and RN.

Observed in Record Review. In 2 of 2 patient records reviewed, where hospice aide services were provided, the organization failed to ensure that care and services were provided in accordance with the aide plan of care. For example: on the home observation for HV#3 with the hospice aide, it was noted that the aide plan of care assigned mouth care, file nails, ROM, and apply lotion each visit, however on observation these tasks were not provided on the home visit. On review of the record for HV#3 the aide was assigned to record the last BM yet failed to do so on most documented visits. For the visit on 4/25/23 there were no tasks documented as complete even though the comments box noted some tasks were performed. In review of RR#7, the aide assigned a shower yet the documentation states a bed bath was performed for the last three visits. There was no documentation that the RN approved the change in bath type. Further there was no recording of the last BM on multiple visits. These observations were reviewed with the Administrator/DPCS. Observed in Record Review. In 3 of 10 patient records reviewed, for active patients, the organization failed to ensure the patient record contain information that reflects the patient's care, treatment and services. For example: on review of RR#4 the initial bereavement risk assessment documentation was opened but remined incomplete and not submitted within submission policy. On HV#1 the RN initial comprehensive assessment documentation remained incomplete 6 day after admission. On RR#9 the initial bereavement risk assessment was noted tp be incomplete in the system. These observations were reviewed with the Administrator/DPCS. Observed in Record Review. In 7 of 10 patient records reviewed, for active records, the organization failed to ensure the care and services are provided in accordance with the plan of care. For example: on review of HV#2 the Chaplain was ordered 1 time and PRN, but documentation noted he was to see the patient monthly and visits only occurred at admit and then six months later but the visit was not noted to be a PRN visit. In HV#3 the aide was ordered 2 times a week but in Benefit period 2 there were no documented visits in week 2, one in week 3, none in week 4, and only 1 time a week in weeks 5,6, 8 and 9. Further the chaplain was ordered 1 time and PRN but the patient was seen on admission in December and not again until visits were made in April and May. Documentation by the chaplain noted frequency was 1 time a month. In RR#5 the nurse was scheduled 1 time a week - in benefit period 3 the patient was seen 2 x week in week 2, 3, 6 and 9, with weeks 2, 3, and 6 having visits by the LVN and RN on the same day. In RR#6, RR#8, and RR#10 the SN was also ordered 1 time a week, yet there were also incidences where the patient was seen 2 times a week as the RN and LVN documented visits the same week. In RR#9 the MSW was ordered 1 time and PRN but per documentation was seeing the patient monthly. In RR#10 the chaplain was ordered 1 time and PRN but per documentation was seeing the patient monthly. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 6 of 10 patient records reviewed, the organization failed to ensure the ongoing sharing of information between all disciplines providing care and services in all settings. For example: on review of RR#7 the hospice aide documented patient falls, and a wound yet there was no documentation that the information was reported to the supervising RN. In review of RR#5, RR#6, RR#8 and RR#10 there was no documentation to collaboration between the LVN and the supervising RN to coordinate the patient's care. There was multiple times when the RN and LVN saw patients even on the same day but no documentation of collaboration on the patient's care. In review of HV#2 the patient was noted to be receiving dialysis two times a week at a dialysis center yet there was no documentation of collaboration and/or sharing of information between the hospice and the dialysis center, even though during conversation with the caregiver on home observation it was noted that many medication changes were generated from the dialysis center. These observations were reviewed with the Administrator/DPCS.

Observed in HR File Review. In 1 of 1 HR files reviewed, for hospice aides, the organization failed to ensure the aide initial competency was completed and included all required elements. On review of the HR file for the Hospice Aide the file included a blank initial competency assessment skills checklist, that was not completed, nor signed. This observation was reviewed with the Administrator/DPCS. Observed in HR File Review. In the one CHHA HR file reviewed it was noted that the organization failed to ensure initial competency skills assessment was completed. On review of HR#5 (CHHA) the initial competency assessment skills checklist was included in the personnel file but was left blank, as no tasks were completed, thus failing to assess the aides performance of tasks with a patient or pseudo-patient. This observation was reviewed with the Administrator/DPCS.

Observed in Leadership Session. The governing body for the organization that assumes full legal authority and responsibility for the management of the hospice failed to sustain compliance with reports and recommendations from accreditation, certification, and regulatory bodies, as repeat Condition level findings from previous survey were noted again during survey process in COP's 418.54 and 418.56.

Observed in HR File Review. In 5 of 7 HR files reviewed, the organization failed to ensure each employee was provided with orientation relevant to its policies and procedures, to include, emergency management, infection prevention and control and assessing and managing pain. On review HR# 1, HR#4, HR#5, HR#6, and HR#7 there was no indication that orientation to the organization was provided as the orientation forms were included in the personnel files but were not completed or signed. These observations were reviewed with the Administrator/DPCS.

Observed in HR File Review. In 4 of 6 HR files reviewed, The organization failed to ensure all competence is initially assessed and documented as part of orientation for all individuals furnishing care. On review of HR#1 (RN), HR#4 (MD), HR#6(MSW/BC), and HR#7 (SC) there was no documentation of initial competency assessment noted in the HR file. Forms were included in the file but were incomplete and unsigned. These observations were reviewed with the Administrator/DPCS and Owner.

Observed in Record Review. In 1 of 2 patient records reviewed, where death occurred, the organization failed to ensure that the record contain all information to reflect the patient's, care, treatment, and services provided. On review of death record RR#11 there was no documentation in the record of who pronounced the death, as the death/disposal note was blank. Post mortem care was provided by the LVN. In discussion with the Administrator/DPCS she was able to articulate the process that all pronouncement was to done by RN, MD or authorities and is the reason the LVN did not complete the form, but there was no documentation of who was contacted to pronounce.

Observed in Patient Home. In 1 of 2 home visits conducted, where medication reconciliation was conducted, the organization failed to ensure the patient record contain all inform to reflect the patient's care, treatment, and services. For example: while observing the medication reconciliation during the home observation of HV#2, it was noted that the medications in the patient home did not match the meds listed on the patient's med profile. After a conversation with the patient's daughter during med reconciliation, she stated that they were no longer giving the patient amlodipine, and indomethacin and they had been discontinued as far back January. Further, she noted the Metoprolol that was ordered for daily had been changed to 2 times a day. On observation of the metoprolol bottle the instruction noted 2 times a day with an original order date in 2022. Discussion with the daughter also noted the patient was taking Carbidopa/Levadopa and had been throughout the hospice admission yet the medication was not listed on the medication profile. These observations were reviewed with the RN, and the Administrator/DPCS.

Observed in Record Review. In 9 of 10 patient records reviewed, the organization failed to ensure that entries into the clinical record are authenticated as required by policy. For example: On RR#4 the bereavement risk assessment was not signed in the system. In HV#1 the RN and MSW initial comprehensive assessment was not signed or dated in the system along with the bereavement risk assessment. In HV#2, HV#3, RR#5, RR#6, RR#7, RR#8, RR#9 and RR#10 the MSW documentation in the system was not signed or dated. In HV#3 the POLST was signed but not dated. In RR#7, RR#8, RR#9 and RR#10 the CTI's were signed on paper by the medical director yet they were not dated as required. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. For the record reviewed with live discharge for extended prognosis, the organization failed to document involving the patient in making decisions about their care, treatment, or services. On review of RR#14 the organization is unable to produce documentation of the Advance Beneficiary Notice (Notice of Medicare Noncoverage) for the patient d/c for extended prognosis. In the D/C summary it is documented that the patient was explained the form and verbalized understanding. Further discussion with the Leadership (Owner and Administrator) notes they are unfamiliar with the process of Medicare Notice of Noncoverage for discharge and did not present the form.