Every finding on record at Swift Care Hospice

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live), failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Patient Rights was met as followed: --- The HA failed to ensure to inform three out of eight sampled patients (Patients 5, Patient 6, and Patient 12) about the services the HA provided and the limitations of those services. This deficient practice resulted in Patients 5, Patient 6, and Patient 12, to not be aware about the care and services the HA provided and had the potential to result in misinformation, misunderstanding and miscommunication of hospice care and services provided for the patients. ( Refer to L519). The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated Federal compliance for Patients Rights to ensure Patients 5's, Patient 6's,and Patient 12's rights were not violated and patients received quality hospice care.

Based on observation, interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure to inform three out of eight sampled patients (Patients 5, Patient 6, and Patient 12), about the services the HA provided and the limitations of those services. This deficient practice resulted in Patients 5, Patient 6, and Patient 12, to not be aware about the care and services the HA provided and had the potential to result in misinformation, misunderstanding and miscommunication about hospice care and services provided to the patients. --- a. During a review of Patient 5s Patient Information Sheet, the Patient Information sheet indicated Patient 5s start of care (SOC) date was 8/12/2023, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time).   During a review of the agencys Local Coverage Determination (LCD, the agencys patients eligibility for medical necessity and hospice eligibility assessment form) guidelines, the LCD indicated that Patient 5 has a terminal diagnosis of hypertensive heart disease. During a review of Patient 5's Physicians Certification for Hospice Benefit also known as Certification of Terminal Illness (CTI, is the narrative summary, a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician), dated 8/22/2024 to 11/19/2024, the Physicians Certification for Hospice Benefit period number one indicated the HAs Medical Director (MD) signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a telephone interview on 9/19/2024, at 2:30 p.m., with Patient 5, Patient 5 stated she was not sick, and the HA did not tell her that she had a terminal illness with six months or less to live. Patient 5 stated the HA called her to ask if she would enroll in their hospice services. Patient 5 stated the HA offered for a nurse to come visit weekly, and provide medications, shower chair, bed pads, and a machine to check her blood sugar. b. During a review of Patient 6s Patient Information Sheet, the Patient Information sheet indicated Patient 6s SOC date was 6/27/2024, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental function). During a review of the agencys LCD guidelines, the LCD indicated that Patient 6 has a terminal diagnosis of Alzheimers disease. During a review of Patient 6's Physicians Certification for Hospice Benefit, dated 6/27/2024 to 9/24/2024, the Physicians Certification for Hospice Benefit period number one indicated that HAs MD signed the attending physician referral section to indicate Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit for Patient 6 did not have a comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a joint home visit observation on 9/19/2024, at 1:30 p.m., with Registered Nurse 2 (RN 2) at Patient 6's residence, Patient 6 was lying in bed awake, alert, and oriented, and only spoke Spanish. During an interview on 9/19/2024, at 1:40 p.m., with Family Member 1 (FM 1), FM 1 stated she did not have an idea what hospice services was about. FM 1 stated that the HAs visiting nurses (unknown) could not speak Spanish and both FM 1 and Patient 6 could not understand what the hospice service was all about. FM 1 stated that Patient 6 was not sick, and only needed a home health aid to assist with bathing. FM 1 stated she was worried that Patient 6 would not receive cardiopulmonary resuscitation (CPR) care and services during emergency due to being enrolled to hospice services. FM 1 stated that she was afraid that Patient 6 would lose his hospice eligibility or hospice benefits, and not receive hospice care when needed and eligible in the future. c.  During a review of Patient 12s Patient Information Sheet, the Patient Information indicated an SOC date of 8/21/2024, with a terminal diagnosis of hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys). During a review of the agencys LCD guidelines, the LCD indicated that Patient 12 has a terminal diagnosis of hypertensive chronic kidney disease. During a review of Patient 12's Physicians Certification for Hospice Benefit, dated 8/21/2024 to 11/19/2024, the Physicians Certification for Hospice Benefit period number one (1) indicated the MD signed the attending physician referral section to indicate Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During an interview with Registered Nurse (RN) 3 on 9/18/2024, at 1 p.m., RN 3 stated that the admission process starts when the HA receives referrals from patients' friends, or community resources. RN 3 stated the HA explains the hospice benefits (to the referred patients), and checked their (the patients) prognosis, previous medical records, and laboratory test results if available. RN 3 stated the MD would be notified of the patients admission referral to the agency. RN 3 stated the MD would conduct FaceTime (a video and audio call) with the patient to evaluate the patients eligibility for hospice services. During a telephone interview on 9/19/2024, at 3:30 p.m., with Patient 12s caregiver (PCG 1), PCG 1 stated the HA staff (not identified) did not explain to the patient (Patient 12) regarding the hospice service, that the patient was not dying and did not need to receive hospice services. PCG 1 stated the HA called Patient 12 to ask if he wanted to enroll in their hospice services and the HA offered Patient 12 for a nurse to come visit (at the patients residence) and to check his health condition. A review of the agency's undated document tilted " Admission Information" the the document indicated: "To provide patients with accurate information to make informed decisions regarding care or services. The scope of services: nursing, hospice aide and homemaker services, physical therapy, occupational therapy, speech language pathology, social worker, physician services, volunteers, counselors, dietary counseling, home medical equipment related to terminal illness, drugs and biologicals related to terminal illness, short term inpatient care, respite care, continuous care, bereavement counseling and medical supplies. At the time of initial assessment, the hospice will provide each patient with a statement of the scope of services provided directly and/or through contractual/written agreement. Patients will also be provided the following information: Care/service limitations, eligibility criteria, charges or patient liability for care/services and information regarding the Medicare Hospice benefit."

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) regarding Initial and Comprehensive Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process of the Patient) was met as follows. --- The HA failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to the manage of terminal illness (a disease or condition due to which a patient's death is anticipated in six months) and hospice eligibility for five of five sampled patients (Patient 5, Patient 6, Patient 9, Patient 10, and Patient 12).    This deficient practice had the potential to result in Patient 5, Patient 6, Patient 9, Patient 10, and Patient 12 not to receive appropriate healthcare services that could affect the quality of life and not receive hospice care and services when needed in the future due to lose of eligibility to receive hospice benefits. For Patient 6 and Patient 12, this deficient practice had the potential to result in these patients (Patient 6 and Patient 12) not to receive cardiopulmonary resuscitation (CPR, a lifesaving procedure performed when the heart stops beating) measures during an emergency due to being enrolled to hospice services that could lead to potential hospitalization and death. (Refer to L524) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care were being provided to patients certified to receive the Medicare hospice benefits.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to the manage of terminal illness (a disease or condition due to which a patient's death is anticipated in six months) and hospice eligibility for five of five sampled patients (Patient 5, Patient 6, Patient 9, Patient 10, and Patient 12).    This deficient practice had the potential to result in Patient 5, Patient 6, Patient 9, Patient 10, and Patient 12 not to receive appropriate healthcare services that could affect the quality of life and not receive hospice care and services when needed in the future due to lose of eligibility to receive hospice benefits. For Patient 6 and Patient 12, this deficient practice had the potential to result in these patients (Patient 6 and Patient 12) not to receive cardiopulmonary resuscitation (CPR, a lifesaving procedure performed when the heart stops beating) measures during an emergency due to being enrolled to hospice services that could lead to potential hospitalization and death. On 9/20/2024 at 4:50 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the providers non-compliance with one or more requirements of participation caused or likely to cause serious injury, harm, impairment, or death to a patient) in the presence of the Administrator related to the failure to conduct and document an accurate comprehensive assessment that reflected the patients (Patient 5, Patient 6, Patient 9, Patient 10, and Patient 12) current health status and identify their need for hospice care and services related to the management of terminal illness and hospice eligibility. On 9/20/2024, at 5:15 p.m., the survey team completed the survey tasks and conducted an exit conference, with the Director of Patient Care Services (DPCS) and Administrator with the IJ situations not removed. --- 3. During a review of Patient 9s Clinical Record indicated an SOC date of 9/6/2024 with a certification period of 9/6/2024 to12/4/2024 with the diagnosis of alzheimers disease (a brain disorder that slowly destroys memory and thinking skills, eventually making it difficult to perform basic tasks) and type 2 diabetes (a chronic condition that occurs when the body is unable to use insulin properly, resulting in high blood sugar levels). Skilled nurse (SN) frequency of visits for once a week and as needed, Hospice aide (HA) one a week for ADL( activities of daily living such as bathing and toileting, dressing) assistance, MD( physician) as needed and recertification, MSW( medical social worker) as needed and recertification for psychological management, Spiritual counselor (SC) as needed and recertification for spiritual management, volunteer (declined). During a review of Patient 9s document titled ";Physicians Certification for Hospice benefit (CTI-is the narrative summary, a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician) indicated that patient is a 77-year-old female who lives in a residential care facility with 24/hour caregiver in charge of aiding her in completing ADLs as well as providing her with daily medication. During an interview of Patient 9s daughter on 9/19/24 at 3:00 p.m., Daughter stated that Patient 9 used to live alone and takes care of herself and one day she went outside her home and fell twice on the street and suffered a laceration on her head with stitches. Daughter stated that she only talked to a social worker at the hospital for placement (a temporary or permanent place of board and lodging). Daughter stated she knows that the patient is going to be transferred to a board and care. Daughter stated that she spoke to a person at the board and care about help with payment for her board and lodging and was going to be referred to an agency that would provide her with her supplies and medications. Daughter stated that she have no knowledge that her mother was going to be admitted to hospice service and her mother is not dying. Daughter claimed that she had not spoken to a nurse and did not consent to hospice services. 4. During a review of Patient 10s Clinical Record indicated an SOC date of 9/10/2024 with a certification period of 9/10/2024 to12/8/2024 with the diagnosis of chronic obstructive pulmonary disease (COPD- progressive disease of the lungs making it difficult to breathe) and Human immunodeficiency virus (HIV+ a virus that attacks cells in the body to fight infection). Skilled nurse (SN) frequency of visits for once a week and as needed, Hospice aide (HA) one a week for ADL (activities of daily living such as bathing and toileting, dressing) assistance, MD(physician) as needed and recertification, MSW( medical social worker) as needed and recertification for psychological management, Spiritual counselor (SC) as needed and recertification for spiritual management, volunteer (declined). During a review of Patient 10s document titled ";Physicians Certification for Hospice indicated that patient is a 74-year-old male who lives in a residential care facility with 24/hour caregiver in charge of aiding him in completing ADLs as well as providing him with daily medication. During a joint home visit with DON and RN 1 on 9/19/2024 at 1:20 p.m. Patient 10 was observed sitting in the dining area with a portable oxygen at 5 liters per minute (lpm- unit of measurement) and uses a four-wheel walker for assistance in walking. Patient 10 is alert and oriented to name, place and person. Patient 10 stated that he was hospitalized and was discharged to this residential care facility. Patient 10 stated that he still goes to his infectious disease doctor, primary physician, and his pulmonologist. Patient 10 stated that he started his car the other day and went to "dollar tree." Patient 10 also stated he was referred to the hospice agency by the board and care and was told he will be given supplies, medication and ";whatever I need". During an interview with the MD on 9/20/2024 at 2:30 p.m., MD stated that he doesn't recall this patient. MD stated he would want to be called by the nurse during new admissions and medication orders. A review of the Hospice Agency's document titled " Admission Criteria and Process" revised 4/2021 indicated will admit a patient only on recommendation of the medical director in consultation with, or input from, the patient's attending physician, if any. The information can be obtained from the hospice nurse or others sharing the attending physician's knowledge of the patient. The patient's physician (or other authorized licensed independent practitioner) must order and approve the provision of hospice care, be willing to sign or have a representative who is willing to sign the death certificate, and be willing to discuss the patient's resuscitation status with the patient and family/caregiver. Based on the assessments, the plan of care-including problems, needs, goals, and outcomes-will be reviewed and updated by the interdisciplinary group members responsible for the case. Based upon the findings of the assessment, additional orders will be generated and forwarded to the physician ( or other authorized licensed independent practitioner) for signature( s ). The physician will be notified to verify any changes in medications, including over-the-counter medications, and treatment/interventions that require physician approval. Referral information provided by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician offices will assist in the determination of eligibility for admission to the program. If the request for service is not made by the patient's physician, he/she will be consulted prior to the evaluation visit/initiation of services. a. During a review of Patient 5s Patient Information Sheet, the Patient Information indicated a start of care (SOC) date of 8/12/2023, with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). During a review of the agencys LCD (local coverage determination-agencys patients eligibility assessment form) guidelines, the LCD indicated that Patient 5 has a terminal diagnosis of hypertensive heart disease. During a review of Patient 5's Physicians Certification for Hospice Benefit, dated 8/22/2024 to 11/19/2024, the Physicians Certification for Hospice Benefit period number (#) one (1) indicated Physician 1 signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a telephone interview on 9/19/2024, at 2:30 p.m., with Patient 5, Patient 5 stated she was not sick and the HA did not tell her she had a terminal illness with six months or less to live. Patient 2 stated the HA called her to ask if she wants to enroll to their hospice services and offered for a nurse to come visit her weekly, provide her with medications, shower chair, bed pads, machine to check her blood sugar. b. During a review of Patient 6s Patient Information Sheet, the Patient Information indicated a start of care (SOC) date of 6/27/2024, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental function). During a review of the agencys LCD (local coverage determination-agencys patients eligibility assessment form) guidelines, the LCD indicated that Patient 6 has a terminal diagnosis of Alzheimers disease. During a review of Patient 6's Physicians Certification for Hospice Benefit, dated 6/27/2024 to 9/24/2024, the Physicians Certification for Hospice Benefit period number (#) one (1) indicated Physician 1 signed the attending physician referral section to indicate Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a home visit observation on 9/19/2024, at 1:30 p.m., at Patient 6's residence with Registered Nurse (RN) 2, Patient 6 was lying in bed awake, alert, and oriented and only speaks Spanish. During an interview on 9/19/2024, at 1:40 p.m., with Family Member 1 (FM 1), FM 1 stated she did not have an idea what hospice services was about. The visiting nurses could not speak Spanish and both the FM1 and Patient 6 could not understand what the hospice services was all about. FM 1 also stated the patient was not sick and the patient only needed a home health aid to assist with bathing. FM 1 further stated she was worried that Patient 6 would not receive cardiopulmonary resuscitation (CPR) care and services during emergency situation due to being enrolled to hospice services and she was afraid the patient would lose his hospice eligibility/hospice benefits and not receive hospice care when needed and eligible in the future. c. During a review of Patient 12s Patient Information Sheet, the Patient Information indicated a start of care (SOC) date of 8/21/2024, with a terminal diagnosis of hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys). During a review of the agencys LCD (local coverage determination-agencys patients eligibility assessment form) guidelines, the LCD indicated that Patient 12 has a terminal diagnosis of hypertensive chronic kidney disease. During a review of Patient 12's Physicians Certification for Hospice Benefit, dated 8/21/2024 to 11/19/2024, the Physicians Certification for Hospice Benefit period number (#) one (1) indicated Physician 1 signed the attending physician referral section to indicate Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. The Physicians Certification for Hospice Benefit indicated there was no comprehensive assessment conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a telephone interview on 9/19/2024, at 3:30 p.m., with patients caregiver (PCG 1), PCG 1 stated the HA staff did not explain to the patient regarding the hospice service, that the patient was not dying and did not need be in hospice services. PCG 1 also stated the HA called the Patient 12 to ask if he wants to enroll to their hospice services and offered for a nurse to come visit him to check his health condition. During an interview with Registered Nurse (RN 1) on 8/18/2024, at 1 p.m., RN 1 stated that the admission process starts when they get referrals from patients' friends, or community referrals. RN 1 stated then they explain the hospice benefits, look at their prognosis and decline and look into medical records if they have it. RN 1 stated they ask the medical director (MD) when the patients referred to the agency especially if these patients had not seen or visited their primary doctors and the MD will be the referring and the attending doctor for that patient During a telephone interview on 9/21/2024, at 1:40 p.m., with the HAs Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient 5, Patient 6, Patient 9, Patient 10, and Patient 12, and he did not discuss the patients medical history with them. Physician 1 stated he was acting as their attending physician now because Patient 5, Patient 6, Patient 9, Patient 10, and Patient 12 were admitted to the hospice agency. Physician 1 stated he determined the patients were eligible for hospice care because he does face time with the patients on the telephone to conduct an assessment, based on the Registered Nurses assessment/visit notes, reviewing patients past medical records, and following the Local Coverage Determination (LCD, provide guidance in determining medical necessity of services) guidelines. Physician 1 stated the HA did not obtain any past medical records of Patient 5, Patient 6, Patient 9, Patient10, and Patient 12 and as a hospice physician, he could determine eligibility to hospice by interviewing the patients regarding present health condition, checking patient's medications, and doing head to toe assessment. A review of the agency's undated document titled " Medical Director Job Description", the document indicated a Medical Director, or Clinical Medical Director, is responsible for overseeing daily operations of a healthcare facility. The document indicated their duties include reviewing healthcare laws and regulations to implement on daily practices, monitoring facility or department budgets, developing strategies to improve communication between medical professionals and patients, and ensuring that the medical staff and facility comply with the federal rules, regulations and codes. A review of the agency's undated document tilted " Admission Information", indicated: "To provide patients with accurate information to make informed decisions regarding care or services. The scope of services: nursing, hospice aide and homemaker services, physical therapy, occupational therapy, speech language pathology, social worker, physician services, volunteers, counselors, dietary counseling, home medical equipment related to terminal illness, drugs and biologicals related to terminal illness, short tern inpatient care, respite care, continuous care, bereavement counseling and medical supplies. At time of initial assessment, Hospice will provide each patient with a statement of the scope of services provided directly and/or through contractual/written agreement. Patients will also be provided the following information: Care/service limitations, eligibility criteria, charges or patient liability for care/services, information regarding the Medicare Hospice benefit. Patient referrals may be made by anyone including the family, physician, discharge planners, healthcare workers, friends, relatives or the patient. When a telephone or verbal referral is received by Hospice, a referral form is completed by a RN. Referrals may also be received by fax in person or in the mail. The referral form includes at least the following information from the attending physician; • Patient identification information, e.g., name, address, telephone number, date of birth, sex, Medicare or social security number, insurance information, emergency contact and telephone number.• Physician's name, address and telephone number and alternative physician to contact if attending is not available.• Referral source. • Primary admitting terminal diagnosis and other diagnosis.• Medications and treatments required, including orders for treatments and symptom management.• Date of hospital discharge, if applicable.• Care or treatments to be provided, including frequency and duration.• Dietary restrictions.• Any other information reported, e.g., medical management of conditions unrelated to the terminal illness and current medical findings.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for License Professional Services was met as evidence by: --- 1. The HA failed to provide evidence their licensed providers were qualified and trained to provide hospice services to eight of eight sample patients (Patient 5,6,7,8,9,10,11 and 12). (Refer to L584). 2. The HA failed to ensure their Medical Social Worker, Physicians, and Spiritual Counselors participated in the planning of patients hospice care by failing to ensure they attend IDT meetings and contributed to the development of the individualized plan of care for eight of eight sampled patients (Patient 1, Patient 2, Patient 4, Patient 9, Patient 10, Patient 11, and Patient 12) plan of care (POC- an individualized care plan). (Refer to L585). The cumulative effect of these systemic practices resulted in the HA not ensuring their licensed personnel were providing services/care as required and had the potential to result in the patients to not receive appropriate healthcare services that could affect their quality of life.

Based on interview and record review, the Hospice Agency (HA) failed to provide evidence their licensed providers were qualified and trained to provide hospice services to eight of eight sample patients (Patient 5, 6, 7, 8, 9, 10, 11 and 12). This failure had the potential to result in patients being taken care of unqualified staff. --- A request was made to the HAs Office Personnel 1 to review the hospice agencys employee files on 9/18/2024 at 1 p.m. During an interview on 9/18/2024 at 1 p.m., with Office Personnel 1, Office Personnel 1 stated they do not have the Administrators employee file. Office personnel 1 stated that the Administrators file is with the Administrator and he will bring it tomorrow when he comes back to the office. During an interview with the Office Personnel 1 at 9/18/2024 at 2:10 p.m., the office personnel stated that the new Administrator (Admin-overseeing the daily operations of our agency and ensuring the highest level of care for our patients) oversees the day-to-day operations and performs the hiring of staff in the agency and fired most of the staff in the agency for their non-compliance. During an interview on 9/18/2024 at 2:30 p.m. with Office Personnel 2, Office personnel 2 stated she started working with the agency since 4/2024. Office Personnel 2 stated she has a checklist that she follows to check the requirements for each personnel to complete upon hire. On concurrent record review, the following employee files reviewed revealed the following file discrepancies: RN 3 was hired on 7/15/2024. RN 3s application file indicated that she graduated from nursing on 6/2024. RN 3 indicated no prior experience in hospice. RN 1 was hired on 7/15/2024. RN 1s application file indicated no prior experience in hospice. DON was hired on 6/2024. DONs application file did not contain a current CPR (basic life support training) on file. Hospice Aide 1 (HA 1) was hired on 6/7/2024. HA 1s employee file did not have a current CPR on file. Hospice Aide 2 (HA 2) was hired with an undated application and no current CPR on file. There was no volunteer coordinator, no social worker and no chaplain During an interview on 9/20/2024 at 3p.m., with the Administrator (Admin), the Admin stated he fired all the previous staff for their non-compliance with the program and is currently in the process of re-hiring staff since he came in eight months ago. A review of the HAs document titled ";Selection/Hiring of Personnel" revised on 4/2021, indicated the organization defines the qualifications and competencies for staff positions based on its mission, population and care, treatment and services goals. Hospice will use a consistent process for the selection of all hospice staff. Staff providing patient care will possess a license certification or registration. Validation will be assessed as follows: Valid license, certification or registration on hire and upon expiration of credentials, which can be verified by the organization if the credentials are not required by law or regulation. When a current license, certification or registration are required by law to practice a profession, the organization verifies these credentials with the primary source on hire and upon expiration. The hospice agency will maintain a staffing pattern that permits implementation of hospice's plan, promoting quality of care and fiscal stability.

Based on interview and record review, the Hospice Agency (HA) failed to ensure their Medical Social Worker (MSW) and Spiritual Counselor (SC) participated in the planning of patients hospice care by failing to ensure they attended the IDT meetings and contributed to the development of the individualized plan of care for two of 8 sampled patients (Patient 9 and Patient 10) plan of care (POC- an individualized care planned). This failure resulted in patients not being properly evaluated which resulted in not being provided individualized focused care. --- a. During a review of Patient 9s ";Patient Information Sheet," the Patient information Sheet indicated a SOC date of 9/6/2024 with a certification period of 9/6/2024 to 12/4/2024 with the diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills, eventually making it difficult to perform basic tasks) and type 2 diabetes (a chronic condition that occurs when the body is unable to use insulin properly, resulting in high blood sugar levels). The Patient Information Sheet further indicated the Skilled nurse (SN) frequency of visits would be for once a week and as needed. The Hospice aide (HA) one visit a week for ADL (activities of daily living such as bathing and toileting, dressing) assistance. The MD (physician) as needed and recertification. The MSW (medical social worker) as needed and recertification for psychological management. The Spiritual counselor (SC) would visit as needed and declined. During a review of Patient 9s document titled ";Physicians Certification for Hospice benefit (CTI-is the narrative summary, a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician) indicated that Patient 9 lives in a residential care facility with a 24/hour caregiver in charge of aiding her in completing ADLs as well as providing her with daily medication. b. During a review of Patient 10s Clinical Record, the clinical record indicated a SOC date of 9/10/2024 with a certification period of 9/10/2024 to 12/8/2024 with the diagnosis of chronic obstructive pulmonary disease (COPD- progressive disease of the lungs making it difficult to breathe) and Human immunodeficiency virus (HIV+ a virus that attacks cells in the body to fight infection). The record indicated the Skilled nurse (SN) frequency of visits was scheduled for once a week and as needed. The Hospice aide (HA) visit one a week for ADL (activities of daily living such as bathing and toileting, dressing) assistance. The MD(physician) visits as needed and recertification. The MSW(medical social worker) as needed and recertification for psychological management and the Spiritual counselor (SC) as needed and recertification for spiritual management and volunteer services were declined. A record review of Patient 9s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment" dated 9/6/2024 and 9/12/2024, indicated there was no signatures for the medical social worker on the IDT meeting. During a review of Patient 10s document titled ";Physicians Certification for Hospice indicated that Patient 10 lives in a residential care facility with a 24/hour caregiver in charge of aiding him in completing ADLs as well as providing her with daily medication. A record review of Patient 10s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment," dated 9/12/2024, indicated that there was no social worker who attended the IDT, and the Administrator signed as the spiritual coordinator. On 9/10/2024 the social worker and chaplain had not attended the IDT meeting. During a joint interview on 9/20/2024, at 3 p.m., with the DON and Admin, both stated the IDG group documented the meeting in the electronic medical record (EMR) right away. Each discipline had their own computer access, and each discipline entered their own note in the medical record. Both stated the IDG group, composed of the RN, MSW, Chaplain, and doctor and met every two weeks. A review of the HAs document titled ";Interdisciplinary Group Meeting" revised 4/2021, indicated the interdisciplinary group meeting 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 admissions/certifications and recertification of patients on the hospice program. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. The meeting will be facilitated by the hospice Clinical 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. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor. A review of the HAs document titled ";Interdisciplinary Group Coordination of Care" revised 4/2021, indicated the hospice agency will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated hospice care to patients and family/caregivers. It will be the responsibility of the Clinical Supervisor to assign a Case Manager who is a registered nurse (RN). The Case Manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge. The type and scope of services provided by the interdisciplinary group will be based upon the comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The exact combination of services and the level of care will be unique to each patient and family/caregiver unit, and it will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice. The interdisciplinary group will maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to its patients. The RN Case Manager will be qualified through education, training, and/or experience and will: Understand the principles of care provided Know required qualifications for hospice personnel providing care and know which hospice personnel possess these qualifications. Know the scope of care which can be provided by various interdisciplinary group members. Understand the nature of the patient population served. It will be the responsibility of the RN Case Manager to facilitate communication about changes in the patient's status among interdisciplinary group members and the patient's attending physician.

Based on interview and record review, the hospice agency (HA- is a comprehensive, holistic program of care and support for terminally ill patients and their families. Hospice care changes the focus to comfort care (palliative care) for pain relief and symptom management instead of care to cure the patients illness) failed to ensure the Conditions of Participation regarding Volunteers was met as follows: --- 1. The hospice agency (HA) failed to ensure that a volunteer coordinator (responsible for managing a hospice organization's volunteer program) and volunteers (provides support to patients and their families who are dealing with serious illness or terminal illness) was hired and trained according to its need in the hospice program. (Refer to L643) 2. The hospice agency (HA) failed to ensure proper utilization of their volunteers in the volunteer program which had the potential to result in the patients to not to receive the other benefit services that could contribute to the improvement of patient care. (Refer to L646) The cumulative effect of these systematic practices had the potential to result in the failure of HA to ensure the provision of quality healthcare in a safe environment.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill [a disease or condition due to which a patient's death is anticipated] patients who have six months or less to live) failed to provide information in their own language to patient and family members about the hospice services and its limitations for one out of 14 sampled patients (Patient 9). This deficient practice had the potential to result in the violation of patient's right to be fully informed of his/her rights and responsibilities available in the language that is commonly spoken by the patient. --- Findings: A review of Patient 9s "Patient Information sheet" indicated a start of care date of 7/13/23 with diagnosis of Alzheimer's disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks). A review of the "Visit Document" from the "Supportive Group"(a group of medical doctors, physician's assistant, and nurse practitioner contracted by the hospice agency to visit their patients) dated 8/22/23 referred to be seen by the hospice agency, indicated Patient 9's primary diagnosis of Alzheimer's disease, unspecified and gross weakness. Given the natural decline of the patient's illness, this patient has less than a six-month prognosis of survival. For disease stabilization, symptom management and disease modification. A review of the document titled "Local Coverage Determination (LCD) Guidelines" (provide guidance in determining medical necessity of services) indicated the patient does not qualify for hospice services. KPS (Karnofsky Palliative Scale- used to measure the level of patient activity and medical care requirements equivalent to 40%- Disabled; requires special care and assistance. PPS (Performance Palliative Scale- used to measure hospice eligibility for functional decline equivalent to 40% - Mainly in bed, unable to do any work, extensive evidence of disease, considerable dependence for care, normal or reduced intake and fully conscious or confused or drowsy. FAST (a reliable measure commonly used to assess functional status in patients with dementia) equivalent to 7-B speech ability is limited to use of a single intelligible word in an average day or in the course of an intensive interview. During a joint home visit with the Administrator/Director of Nursing Designee (Admin/DD) on 10/26/23 at 10 a.m., Patient 9 was awake, alert to name and person, not in any respiratory distress, able to walk with the assistance of a front wheeled walker with his Wife, as the primary caregiver present in the living room. Admin/DD proceeded with the home visit. During the interview with Patient 9's Wife at the same date and time, Wife stated she poorly understand and read English. Wife stated she requested for an Armenian speaking visiting nurse, but the hospice agency was unable to provide for them. During a concurrent review of Patient 9's hospice admission handbook, the documents inside the handbook were in English language and had no Armenian translation. Wife further stated that she was comfortable with her Armenian speaking neighbors who comes and visit often. When asked if other family members were informed of the hospice services, Wife stated "No". When asked why she refused the hospice aid, chaplain, volunteers and social worker, Wife stated because "I don't speak and understand much English and just don't want to deal with them." During an interview with the Admin/DD during the home visit, Admin/DD stated that she was covering for the visiting nurse this week. When asked if the current visiting staff knew how to speak the patient's wife language, Admin/DD stated "No", but she told the patient's wife to call the agency for any questions about the hospice services. When asked if the hospice agency notified Patient 9's daughter, Admin/DD stated, " No, but we can call and inform them." During a joint interview with the Director of Nursing (DON) and the Administrator (Admin) on 10/27/23 at 5:31 p.m., both Admin and DON agreed that it was important to coordinate with the patient's family about hospice services for the patient's safety and care. A review of the Hospice Agency's policy titled " Admission Criteria and Process" revised April 2021, indicated that once a patient is admitted to service, the organization will be responsible in providing care and services within its financial service capabilities, mission, and applicable laws and regulations. The patient must identify a family member/caregiver or legal representative who agrees to be the primary support caregiver if and when needed. These individuals will require a specific plan to be developed at time of admission with the social worker to the plan for when they are no longer independent. A review of the Hospice Agency's policy titled "Comprehensive Assessment" dated 2018, indicated during the comprehensive assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least the following information, as relevant: 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. Involvementof family/caregiver, neighbors, and/or other individuals/organizations, including involvement in any support groups

Based on observation, interview, and record review, the Hospice agency staff failed to document and conduct comprehensive assessment identifying the patients need for hospice care and services for 3 of 14 patients (1, 3, and 7). This deficient practice resulted in the Hospice agency claiming reimbursement for patients who did not need Hospice care and services or management of terminal illness and related conditions. --- Findings: On 10/17/2023, at 10:30 AM, unannounced complaint validation survey was conducted to the Hospice agency. On 9/18 2023 Patient 1s clinical record was reviewed and indicated the start of care date of 7/11/2023 with the terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Patient 1 had been transferred from another hospice agency. A review of Patient 1's comprehensive assessment completed by the interdisciplinary group indicated no documented evidence of a comprehensive evaluation and gathered clinical information of Patient 1's status for the need to be certified and admitted to the Medicare hospice program. A review of Patient 1s certification for Hospice benefit indicated starting 10/26/2023 to 1/26/2024, indicated no documented evidence that a terminal diagnosis was established through clinical information and other documentation that supported the medical prognosis of terminal illness which included a life expectancy of six months or less. There was no documented evidence that Patient 1 needed hospice to provide physical, psychosocial, emotional, or spiritual care, which was needed to meet the admission criteria for the Medicare Hospice benefit. Review a Patient 3 clinical record indicated the start of care was 9/22/2023 with a terminal diagnosis of after atherosclerosis of aorta (( a material called plaque (fat and calcium) has built up in the inside wall of a large blood vessel called the aorta and usually occurs in the abdominal section of the aorta and is a common cause of abdominal aneurysms) and heart disease( several types of heart conditions , which affects the blood flow to the heart). A review of the comprehensive assessment completed by the interdisciplinary group indicated there was no documented evidence of a thorough evaluation of Patient 3 status, for the need to be admitted to the Medicare hospice program. A review of Patient 3s certification for Hospice benefited indicated there from 9/22/23 to 12/20/23, indicated no documented evidence that a terminal diagnosis was established through clinical information and other documentation that supported the medical prognosis of terminal diagnosis which included a life expectancy of six months or less. There was no documented evidence that Patient 3 needed Hospice care services and did not the meet the admission criteria to receive the Medicare Hospice benefit. A review of patient 7s clinical record indicated the start of Hospice care date of 7/17/23 with the diagnosis of Alzheimer's disease unspecified (a progressive disease that destroys memory and other important mental functions). A review of the comprehensive assessment completed by the interdisciplinary group indicated there was no documented evidence of a comprehensive evaluation of Patient 7s status, for the need to be admitted to the Medicare Hospice program. A review a patient 7s certification for hospice benefit, certification #11 indicated that from 8/30/23 through 10/28/23; 10/29/23 through 12/27/23, the interdisciplinary group comprehensive assessment indicated no documented evidence that a terminal diagnosis was established, through gathered clinical information and other documentation that supported the medical prognosis of terminal illness which includes a life expectancy of less than 6 months. Review of Patient 7s the LCD Hospice eligibility determination form date at 8/30/23, was not signed by the referring physician who was the alternate designee and the LCD dated 10/29/23 through 12/27/23, also lack the signature of the alternate medical director and was also blank. There was no documented evidence that Patient 7 needed Hospice care in order to meet the admission criteria to receive the Medicare Hospice benefit. During an interview with the director of patient care services (DPCS) designee and the administrator (ADM) on 10/27/2023, at 11:40 AM, both stated the medical director did not conduct the certifications for terminal illness and was not conducting the face-to-face visits . The face to face visit/ was done by a support group of visiting physicians or nurse practitioners. During an interview with the CEO of the supportive group on 10/27/2023, at 3 PM stated, "her physicians go and visit the patient when informed by hospice agency that they need a physician however, they are not the primary physician of these patients, their staff does not participate in the inter disciplinary group meetings , there was no contract for certifying patients, just a contract for educating the hospice agency and they do not certify the patient for terminal illness which is the responsibility of the hospices medical director ". There was no documentation that the medical director of the hospice agency was involved in the care of the patient. Review of the Hospice policy and procedure, revised April 2021, titled," Provision of Care, Treatment and Services, Admission Criteria and Process under procedure number one indicates, ";Referral information provided by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician offices will assist in the determination of eligibility for admission to the program. If the request for services is not made by the patients physician, he or she will be consulted prior to the evaluation visit/ initiation of the services."

Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG - various hospice professionals, Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) complete the comprehensive assessment no later than 5 calendar days after election for 2 of 14 sampled patients (Patient 1 and Patient 3). Patients 1 and 3 were ordered to conduct nursing, medical social worker (MSW), and spiritual initial assessment to identify the patient/familys physical, psychosocial, emotional and spiritual needs and contribute to the development of the plan of care to address those needs. This failure had the potential for the patients hospice care needs will not be identified that could affect their quality of life. --- Findings: A review of Patient 1 ";Personal Information" sheet indicated a start of care on 7/17/2023, with a diagnosis Alzheimers Disease (a progressive disease that destroys memory and other important functions) A record review of Patient 1s record titled, ";Comprehensive Nursing Assessment", dated 7/17/2023 indicated Patient1 needed to be referred for ";Social Work" and ";Spiritual Care". A review of the HA Current Treatment/Medication /DME List and Plan of Care Summary (POC), dated 7/17/23, included MSW (social worker) to conduct initial assessment to provide psychosocial support to patient and family. May conduct telehealth visits if it is feasible and appropriate to do so. There was no documented evidence the MSW, and spiritual initial assessments were completed within 5 calendar days after its election for hospice. A review of Patient 3 ";Personal Information" sheet indicated a start of care of 9/22/2023, with diagnoses Atherosclerosis of aorta ( a material called plaque (fat and calcium) has built up in the inside wall of a large blood vessel called the aorta and usually occurs in the abdominal section of the aorta and is a common cause of abdominal aneurysms) and Heart Disease( several types of heart conditions , which affects the blood flow to the heart). A review of Patient 3s clinical form titled, ";Comprehensive Nursing Assessment" dated 9/22/2023, indicated the form was not signed to indicate the assessment was completed. A review of Patient 3s clinical form titled, ";POC/IDG (interdisciplinary group - a group of health care professionals with various areas of expertise who work together toward the goals of their patients)" dated 9/22/2023, indicated sections ";MSW signature," were left blank to indicate the assessment was completed. There was no documented evidence the MSW and nursing initial assessments were completed within 5 calendar days after its election for hospice. During a concurrent interview and record review on 10/27/23, at 3:37 p.m., the Administrator Designee/ Director of Patient Care Services(ADM/DPCS) and the Administrator (ADM)/Director of Patient care Services Designee (DD) reviewed Patients 1 and 3 clinical records and stated the assessments were not completed.

Based on observation, interview, and record review, the hospice staff failed to review of all of the patient's current medications the patient was taking for 2 out of 14 sampled patients (Patients 8 and Patient 9). This deficient practice had the potential to result in medication errors and adverse drug reactions. --- Findings: a. A review of Patient 8s "Patient Information sheet" indicated Patient 8 was admitted on 8/8/23 with diagnosis of hypertensive heart disease without heart failure (consistent changes in the heart resulting to chronic blood pressure elevation). A review of the "Visit Document" from the "Supportive Group"(a group of medical doctors, physician assistant and nurse practitioners contracted by the hospice agency to visit their patients) dated 8/14/23 referred to be seen by the hospice agency, indicated that Patient 8 was alert and oriented to name, place and person. Patient was able to verbalize needs and concerns. Skilled Nurse rendered teaching regarding all medications, plan of care, disease process, fall precautions, safety measures, comfort measures, proper use of medical equipment, symptom control and pain management. Given the natural decline of the patient's illness, this patient has less than a six-month prognosis of survival. For disease stabilization, symptom management and disease modification. Continue current plan of care and medications. Patient/family opted for hospice services and declined further treatment and aggressive treatment. A review of the Hospice agency's document titled "Patient Treatment/Medication List" the following discrepancies were noted: Melatonin 1 mg tablet 1 tablet at bedtime and promethazine 6.25 mg/100 ml, 5mg/5 ml give 5 ml every 6 hours as needed for cough was listed upon admission. During a telephone interview with the Patient 8's wife on 10/26/23 at 4:36 p.m., wife confirmed that patient is currently taking these medications except melatonin 1 mg tablet for insomnia and Promethazine 6.25 mg give 5 ml every 6 hours as needed for cough. These medications were not updated in the patient's plan of care or medication profile. b. A review of Patient 9s "Patient Information sheet" indicated an admission date of 7/13/23 with diagnosis of Alzheimer's disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks). A review of the "Visit Document" from the "Supportive Group"(a group of medical doctors, physician assistant and nurse practitioners contracted by the hospice agency to visit their patients) dated 8/22/23 referred to be seen by the hospice agency with a primary diagnosis of Alzheimer's disease, unspecified and gross weakness. Given the natural decline of the patient's illness, this patient has less than a six-month prognosis of survival. For disease stabilization, symptom management and disease modification. During a joint home visit with the Administrator/Director of Nursing Designee (Admin/DD) on 10/26/23 at 10 a.m., Patient 9 was observed awake, alert to name and person, not in any respiratory distress, able to walk with the assistance of a front wheeled walker with his wife as the primary caregiver present in the living room. Admin/DD proceeded with the home visit. Dering a review of the patient's current medications revealed the following medication discrepancies were noted: Vitamin D3 1000 IU (international units- for measurement) (25 mcg) 1 tablet daily as supplement, caregiver stated she gives to the patient over the counter was not listed in the medication list. Stool softener 250 mg daily was on the bubble pack. On the medication list it was docusate sodium 250 mg daily. Aceta-Gesic Tablet: 325 mg 2 Tabs PO every 6 hours PRN for moderate pain and temperature of 100.4 degrees Fahrenheit (F) was not in the patient's home. During a joint interview with the Administrator (Admin) and Director of Nursing (DON) on 10/27/23 at 12:34 p.m., both Admin and DON stated that the "Supportive Group" was a third-party contractor that conducts the home visits for our patients and sends their history and physical notes to the agency. During a joint interview with the Admin and the DON on 10/27/23 at 5:31 p.m., DON stated there was lack of an up-to-date documentation on the electronic medical record (EMR). Both Admin and DON agreed to verify medications on the medication list in comparison with the medications present in the patient's home. Both Admin and DON confirmed that it was important to update the medication profile for coordination of care, to prevent medication errors and promote patient safety. A review of the hospice agency's policy titled "Medication Profile" dated 2018 indicated patients receiving medications will have a current, accurate medication profile in the clinical record. The medication profile will be updated for each change to reflect the current medications, and new and/or discontinued medications. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient/family/caregiver, as well as other clinicians, understand the medication regimen.

Based on interview and record review, the hospice agency failed to conduct the initial bereavement assessments for 4 of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 7). This deficient practice had the potential to result in the patient/family's identified needs and resources will not be met that could impact their ability to cope with the patient's death. --- Findings: A review of Patient 1 ";Personal Information ";sheet indicated a start of care on 7/17/2023 with a diagnosis of Alzheimers Disease (a progressive disease that destroys memory and other important functions). Review of the plan of care Summary (POC) dated 7/17/2023 indicated for the bereavement coordinator to assess and evaluate bereavement and grieving risk factors within 5 days of admission. May conduct telehealth visits if it is feasible and appropriate to do so. A review of Patient 2 ";Personal Information ";sheet indicated a SOC of 3/18/2023, with diagnosis of unspecified systolic congestive heart failure (a specific type of heart failure that occurs in the left bottom chambers of the heart that weaken the heart contraction when the heartbeat causing less blood circulating through the body. A review of Patient 3 ";Personal Information ";sheet indicated a SOC of 9/22/2023, with diagnosis of Atherosclerosis of aorta (the largest artery /pipeline in the body that sends out blood to your entire body), gradual buildup of plaque [a sticky substance made of fat, cholesterol and other components] in the aorta). A review of Patient 7 ";Personal Information ";sheet indicated a SOC of 4/26/2023, with diagnosis of with a diagnosis of Alzheimers Disease (a progressive disease that destroys memory and other important functions). During a concurrent interview and record review on 10/27/23, at 3:33 p.m., with the Director of Patient Care Services Designee (DD) and Administrator (ADM), the DD stated the Patients 1, 2, 3, and 7 did not have bereavement assessments conducted and completed. The DD stated an assessment was supposed to be completed by the fifth day from admission. The DD stated a bereavement assessment was important, so the hospice staff would know the religion of the patients and ensures the spiritual well-being of the patients during the time going into the dying process. A review of facilitys policy and procedure titled, ";Bereavement Services" revised 7/2023, indicated ";A bereavement assessment will be completed by the hospice social worker at the time of admission to hospice. Within two (2) weeks after the death of a patient, a sympathy card." A review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised 7/2023, indicated ";During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant: A bereavement assessment of the needs of the patient family and other individuals..."

Based on interview and record review, the hospice agency failed to complete and update the comprehensive assessment for two of 14 sample patients (Patient 11 and 13). This deficient practice has the potential to result in patients' progress or decline in health status will not be identified for further treatment and intervention. --- Findings: a. A review of Patient 11's clinical record indicated a start of care date (SOC) of 06/15/2023 and an end of care date (EOC) of 09/10/2023, with diagnosis of chronic diastolic congestive heart failure (condition in which the hearts main pumping chamber becomes stiff and unable to fill properly). A review of Patient 11s POC/IDG form dated 07/14/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week and registered nurse (RN) every 14 days and re-certification. A review of Patient 11s Updated Assessment dated 08/10/2023 and 08/24/2023, indicated that it was incomplete and the sections COVID-19 Screening, Pain Screening, Vitals and Measurements, Environment/Safety, DME Device, Nature and Condition of Terminal Illness/LCD Eligibility, Neurological/Mental/Sensory, Cardiovascular, Respiratory, Immunological/Infection, Gastro-Intestinal, Nutrition, Endocrine, Genitourinary Reproductive, Sleep Rest, Musculoskeletal, Imminently Dying, Environmental/Safety, Personal Care and Support Needs, Teaching Needs, Referrals, Supervisory Note, Care Provided and Narrative and Disease Trajectory were all blank. Further review of the Updated Assessment dated 08/10/2023 and 08/24/2023, indicated that there was no signature from the licensed nurse who conducted the assessments. b. A review of Patient 13's clinical record indicated a start of care date (SOC) of 03/13/2023 and an end of care date (EOC) of 05/12/2023, with diagnosis of chronic diastolic congestive heart failure (condition in which the hearts main pumping chamber becomes stiff and unable to fill properly). A review of Patient 13s POC/IDG form dated 05/08/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week and registered nurse (RN) every 14 days and re-certification. A review of Patient 13s Re-Certification Assessment dated 05/12/2023, indicated that it was incomplete and the sections COVID-19 Screening, Pain Screening, Vitals and Measurements, Environment/Safety, DME Device, Nature and Condition of Terminal Illness/LCD Eligibility, Neurological/Mental/Sensory, Cardiovascular, Respiratory, Immunological/Infection, Gastro-Intestinal, Nutrition, Endocrine, Genitourinary Reproductive, Sleep Rest, Musculoskeletal, Imminently Dying, Environmental/Safety, Personal Care and Support Needs, Teaching Needs, Referrals, Supervisory Note, Care Provided and Narrative and Disease Trajectory were all blank. During a concurrent record review and interview with the Director of Patient Care Services (DPCS), on 10/27/2023 at 11:54 a.m., stated that updated assessments should be completed with signature. DPCS stated Patient 11 and Patient 13s updated assessments were incomplete, and she did not complete her notes. A review of the agencys policy and procedure titled ";Ongoing Assessment," dated 2018, indicated that the comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum every 15 days.

Based on interview, and record review, the hospice agency failed to ensure the Condition of Participation for IDG, Care Planning, Coordination of Services was met as follows: The hospice agency failed to ensure the interdisciplinary group (IDG, team members, physicians, nurses, therapists, social workers, and other professionals working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings were attended by its members of the interdisciplinary team, for six of 14 patients (Patients 8, 9, 10, 12, 13 and 14). (Refer to L541) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for IDG, Care Planning, Coordination of Services. --- .

Based on interview, and record review, the hospice agency failed to ensure the interdisciplinary group (IDG, team members, physicians, nurses, therapists, social workers, and other professionals working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings were attended by its members of the interdisciplinary team, for six of 14 patients (Patients 8, 9, 10, 12, 13 and 14). This deficient practice had the potential that patient's comprehensive and ongoing assessments (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) and care planning process will not be thoroughly performed, and concerns are not timely addressed which can affect the quality of care provided to the affected patients under the agencys care. --- e. A review of Patient 8s (P8) "Patient Information sheet" indicated P8 was admitted last 8/8/23 with diagnosis of hypertensive heart disease without heart failure ( consistent changes in the heart resulting to chronic blood pressure elevation). A review of the "Visit Document" from the "Supportive Group"( a group of medical doctors, physician assistant and nurse practitioners contracted by the hospice agency to visit their patients) dated 8/14/23 referred to be seen by the hospice agency, indicated that P8 is a case of an 81 year old male. Patient /family opted for hospice services and declined further treatment and aggressive treatment. Patient is alert and oriented to name, place and person. Patient is able to verbalize needs and concerns. Skilled Nurse rendered teaching regarding all medications, plan of care, disease process, fall precautions, safety measures, comfort measures, proper use of medical equipment, symptom control and pain management. Given the natural decline of the patient's illness, this patient has less than a six-month prognosis of survival. For disease stabilization, symptom management and disease modification. Continue current plan of care and medications. A review of Patient 8s medical record titled, ";POC/IDG Review", did not indicate the MSW (Medical Social Worker) attended the IDG on 8/8/23, 8/22/23, 9/5/23, 9/19/23 and 10/3/23. f. A review of Patient 9s (P9) "Patient Information sheet" indicated P9 was admitted last 7/13/23 with diagnosis of Alzheimer's disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks). A review of the "Visit Document" from the "Supportive Group"( a group of medical doctors, physician assistant and nurse practitioners contracted by the hospice agency to visit their patients) dated 8/22/23 referred to be seen by the hospice agency, indicated that P9 is a case of a 78 year old male with a primary diagnosis of Alzheimer's disease, unspecified and gross weakness. Given the natural decline of the patient's illness, this patient has less than a six-month prognosis of survival. For disease stabilization, symptom management and disease modification. A review of Patient 9s medical record titled, ";POC/IDG Review", did not indicate the MSW (Medical Social Worker) and the Registered Nurse (RN) attended the IDG on 7/13/23, 7/27/23, 8/10/23, 8/24/23, 9/7/23, 9/21/23 and 10/5/23. During an interview with the Director of Nursing (DON) on 10/27/23 at 11:55 a.m., DON stated that the members of the IDG should be the MD, Admin, DON, Chaplain and MSW and other staff. DON stated that they are supposed to sign the IDG on the day of and it serves as their attendance. DON stated that the signature in the electronic medical record (EMR) represents their attendance in the meeting. DON stated that if the EMR was not signed then they were not present in the IDG. A review of the HA's policy titled "Interdisciplinary Group Meeting" revised April 2021 indicated the IDG 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 admissions/certification and recertification of patients in the hospice program. The meeting will be facilitated by the hospice clinical supervisor or designee. The hospice Medical Director and al 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. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor. Swift Care Hospice Personnel will communicate changes in a timely manner via telephone, one to one meetings, interdisciplinary group meetings and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed and the outcome of the communication. All interdisciplinary group members, including those providing contracted services, will have access to the plan of care to ensure coordination and continuity. a. A review of Patient 10's clinical record indicated a start of care date (SOC) of 07/18/2023 and an end of care date (EOC) of 08/26/2023, with diagnosis of Alzheimers disease (decline in memory, thinking and behavior). A review of Patient 10s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 08/25/2023 and 08/11/2025 indicated the frequency of visits of skilled nurse (SN) to one visit per week and registered nurse (RN) every 14 days and re-certification. Further review of the POC/IDG form indicated that the Registered Nurse (RN) and Master of Social Work (MSW) signature were blank. A review of Patient 10s POC/IDG form dated 07/28/2023, indicated the frequency of visits of skilled nurse (SN) to one visit per week and registered nurse (RN) every 14 days and re-certification. Further review of the POC/IDG form indicated that the Master of Social Work (MSW) signature was blank. b. A review of Patient 12's clinical record indicated a start of care date (SOC) of 09/11/2023 and an end of care date (EOC) of 10/03/2023, with diagnosis of chronic diastolic congestive heart failure (condition in which the hearts main pumping chamber becomes stiff and unable to fill properly). A review of Patient 12s POC/IDG form dated 09/25/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week and registered nurse (RN) every two per month for supervisory and every certification. Further review of the POC/IDG form indicated that the Registered Nurse (RN) and Master of Social Work (MSW) signature were blank. A review of Patient 12s POC/IDG form dated 09/11/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week and registered nurse (RN) every two per month for supervisory and every certification. Further review of the POC/IDG form indicated that the Master of Social Work (MSW) signature was blank. c. A review of Patient 13's clinical record indicated a start of care date (SOC) of 03/13/2023 and an end of care date (EOC) of 05/12/2023, with diagnosis of chronic diastolic congestive heart failure (condition in which the hearts main pumping chamber becomes stiff and unable to fill properly). A review of Patient 13s POC/IDG form dated 05/08/2023, 04/24/2023, 04/10/2023, 03/27/2023 and 03/13/2023 indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week and registered nurse (RN) every 14 days and re-certification. Further review of the POC/IDG forms indicated that the Medical Doctor (MD), Registered Nurse (RN), Master of Social Work (MSW) and Chaplain signature were blank. d. A review of Patient 14's clinical record indicated a start of care date (SOC) of 03/24/2023 and an end of care date (EOC) of 10/03/2023, with diagnosis of chronic obstructive pulmonary disease (lung disease that block airflow and makes it difficult to breathe). A review of Patient 14s POC/IDG form dated 09/22/2023, 09/08/2023, 08/25/2023 and 08/11/2023 indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week and registered nurse (RN) every 14 days and re-certification. Further review of the POC/IDG form indicated that the Registered Nurse (RN) and Master of Social Work (MSW) signature were blank. During a concurrent record review and interview with the Director of Patient Care Services (DPCS), on 10/27/2023 at 11:54 a.m., she stated that IDGs are done every two weeks and staff sign in on the day of the meeting. DPCS further stated that the staff signatures are important because it indicates who attended the meeting.

Based on interview and record review, the hospice agency (HA,agency providing care to terminally ill patients who have six months or less to live) failed to follow the plan of care (POC) for ordered visits, for three of 14 sampled patients (Patient 1, Patient 2, and Patient 6). This deficient practice resulted patients not receiving care and services per physician order. --- a. . A review of Patient 1's Personal Information record indicated, Patient 1 was admitted to the HA on 7/17/2023, with an admitting diagnosis of Alzheimers disease ( memory loss.) A review of Patient 1s POC dated 7/17/2023, indicated skilled nurse to visit once per week and two as needed visits. The medical social worker (MSW) to visit within 5 days of the start of care and once a month. There were no MSW visits conducted for Patient 1 after 7/1/2023. b. A review of Patient 2's Personal Information record indicated Patient 2 was admitted to the HA on 3/18/2023, with admitting diagnosis of unspecified systolic congestive heart failure. A review of Patient 2s POC /IDG dated 3/18/2023, indicated Licensed Vocational nurse (LVN) visits once per week and one as need visits, MD visit as needed and recert every two weeks and one as need visits MSW, initial visits once a month and one as needed visit, and spiritual counselor visits once a month and one as needed visits. A review of Patient 2's Electronic Medical Record (EMR) indicated the following missed visits for Patient 2: Missed RN 14-day nursing visit from 4/15/2023 to 8/19/2023 Missed Master of Social work (MSW) after 3/20/2023. c. A review of Patient 6's Personal Information record indicated Patient 6 was admitted to the HA on 4/26/2023 and, with an admitting diagnosis of Alzheimers disease with late onset ( memory loss). A review of Patient 6s POC, dated 4/26/2023, and 7/5/2023 indicated skilled nurse visits once per week and two as needed visits, RN Assessment visit every 14 days, MSW initial visits and once a month, and spiritual counselor visits once a month. A review of the agencys EMR indicated the following missed visits for patient 6: Missed RN 14-day Assessment visit from 5/1/2023 to 8/1/2023. Missed Skilled nurse (LVN) visits from 6/14/2023 t0 8/30/2023. The last SN visit notes in the EMR was dated 8/30/2024. During a concurrent interview and record review with the director of patient care services designee and Administrator in the HAs conference room on 10/27/2023, the DD stated they review the hospice EMR daily.

Based on interview and record review of the quality assessment and performance improvement (QAPI) program for 2022 and 2023, the hospice agency (HA) failed to ensure the Conditions of Participation regarding quality assessment and performance improvement (QAPI) was met as follows: 1. The hospice agency (HA) failed to develop, implement, and maintain a quality assessment and performance improvement program (QAPI) that evaluated the Hospice care services and developed quality improvement activities for the year of 2022 and 2023. (Refer to L573). The cumulative effect of these systematic practices had the potential to result in the failure of HA to ensure the provision of quality healthcare in a safe environment. --- .

Based on interview and record review, the Hospice Agency (HA) failed to develop, implement, and maintain a quality assessment and performance improvement (QAPI, a coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement ( PI), which are critical for improving the quality of life and the quality of care and services delivered in a healthcare facility) program for the year of 2022 and 2023. The Hospice Agency (HA) failed to provide evidence that the quality assessment and performance improvement system was developed to ensure its program objectives, patient care disciplines, descriptions of how the program will be administered and coordinated, methodology for monitoring and evaluating the quality of care, priorities for resolution of problems, monitoring to determine effectiveness of actions, oversight responsibility reports to governing body, and documentation of the review of its own QAPI program were implemented. This deficient practice had the potential to affect the care provided to the patients and result inability of the Hospice Agency (HA) to identify issues, improve health, outcomes, patient safety, and quality patient care. --- On 10/27/2023, a review of the Hospice Agency's (HA) QAPI program indicated there was no documented evidence of QAPI meeting minutes for the year of 2022 and 2023. During an interview with Administrator in the hospice agencys conference room on 10/27/2023, at 11:30 a.m., the Administrator stated the Director of Patient Care Services (DPCS) was responsible overseeing the Quality Assessment & Improvement Performance. During an interview with the DPCS and the Administrator on 10/27/2023, 1:30 p.m., the DPCS stated that the quality assurance personnel is the Office Staff 1 and that she is the one responsible for the QAPI. During an interview with the Office Staff 1 in the HAs conference room on 10/23/2023, at 3:30 p.m., the Office Staff 1 stated that she is the one that reviews the patients' charts to ensure that the staff is documented and that the HA are in compliance with QAPI. The Office Staff 1 stated that she has been reviewing QAPI at another agency for over six years and she was not trained at this HA. The Office Staff 1 stated that she is not a licensed nurse. During an interview with the Director of Patient Care Services (DPCS) and the Administrator on 10/27/2023 at 1:30 p.m., the DPCS and the Administrator stated that they were not responsible for the QAPI management and could not find or provide any evidence for the functioning QAPI or that a program had been maintained. The DPCS and the Administrator stated they could not find or provide QAPI meeting minutes, or any documentation with signatures of core staff who had attended. The DPCS stated the previous Medical Director is no longer working for the agency, however, could not provide knowledge/documentation when the previous Medical Director left. Review of the Hospice agencys undated policy "Purpose of Quality Assessment/Performance Improvement Program (QAPI)": -Under Program Scopes indicated: the program will show measurable improvement in indicators related to improved palliative outcome and hospice services. Hospice will measure, analyze, and track quality indicators that enable the agency to assess processes of care, hospice services and operations as well as safety issues ranging from no harm, frequently occurring "slips" to sentinel events with serious adverse reactions/outcomes. -Under Performance Improvement activities indicated: Performance improvement activities will: 1. Focus on high risk, high volume, or problem prone areas; 2. Consider incidences, prevalence, and severity of problems in those areas; 3. Affect palliative outcomes, patient safety, and quality of care. The policy indicated the performance improvement activities will track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout Hospice agency.

Based on interview and record review, the hospice agency (HA) failed to provide post-death bereavement assessment and counseling for the patients family for one of 14 sampled patients (Patient 10). This deficient practice resulted in the patients family not receiving post-death bereavement assessment and counseling. --- Findings: A review of Patient 10's clinical record indicated a start of care (SOC) date of 07/18/2023 and an end of care (EOC) date of 08/26/2023, with diagnosis of Alzheimers disease (decline in memory, thinking and behavior). A review of Patient 10s POC (Plan of Care)/IDG (Interdisciplinary group, a team responsible for the holistic care of the hospice beneficiary) form dated 8/25/2023, indicated the frequency of visits of skilled nurse (SN) to one visit per week and registered nurse (RN) visit every 14 days and re-certification. A review of Patient 10s clinical record indicated that there was no post-death bereavement assessment and counseling for the patients family. During a concurrent interview and record review with the Director of Patient Care Services (DPCS), on 10/27/2023 at 11:54 a.m., the DPCS stated that the post death assessment is done within five days of the patients death. The DPCS further stated that there was no post death assessment for Patient 10 in the clinical records. A review of the agencys policy and procedure, titled ";Bereavement Services," dated 2018, indicated that the purpose of the policy and procedure is to ensure that appropriate and coordinated bereavement services are provided to families/caregivers. The policy further indicated that the program will provide bereavement services to the families/caregivers of hospice patients both before and after patients death in accordance with the plan of care.

Based on interview and record review, the Hospice Agency failed to ensure one of two volunteers of the hospice agency had been trained according to its need and the hospice program. This deficient practice had the potential that volunteers utilized for the agency could not function effectively according to its role and could not provide the quality services the patients may need. --- A request was made to the hospice agency to review their hospice volunteer training program on 10/26/2023 at 2:00 p.m. A review of the Hospice Agency's employee files revealed that the agency utilizes two volunteers but one of the volunteer staff (VS) had no certification of any trainings the hospice agency provided. During an interview on 10/27/2023 at 5:15 p.m., with the VS, the VS stated he did not have volunteer training for this agency. A review of the hospice agencys document titled, "Volunteer Training Program: Role of the Volunteer", indicated there are four types of volunteers that provide service: patient/family services, office services, community services and bereavement volunteer. Volunteers provide direct patient care services to the terminally ill and their families. Duties may include various forms of assistance, comfort measure, supportive measures such as reading or writing for the patient, sitting at the bedside, especially during the dying process and respite for families. Volunteers assist in clerical work, filing, answering telephones etc. They may assist in preparing and mailing newsletters, invitations, announcements, writing thank you notes or sympathy cards and aide staff during various hospice functions. Volunteers offer emotional support, companionship, assistance and other supportive services to bereaved families, significant others and/or caregivers. Additional training as well as experience as a hospice volunteer is required.

Based on interview and record review, the Hospice Agency failed to document the hours of work spent and the function for each volunteer used. This deficient practice resulted in the agencys failure to ensure proper utilization of their volunteers in the volunteer program and for the patients not to receive the other benefit services that could contribute to the improvement of patient care. --- A request was made to this hospice agency to review their hospice volunteer training program on 10/26/2023 at 2:00 p.m. During a concurrent interview and record review on 10/27/2023 at 5:15 p.m., with the Volunteer Coordinator (VC), the VC stated that she utilizes volunteers to call patients when they have concerns or needs about something like suggestions, with any help or assistance, and we talk to them (patients) on the phone, if its necessary. During the concurrent record review of the volunteer training program details, there was no written specifications noted for the cost saving plan, volunteer duties utilized and specified number of hours and training for their volunteers. A review of the hospice agencys document titled, "Job Description: Volunteer Coordinator", revised 11/21, indicated the volunteer coordinator is responsible for planning, coordinating and managing all volunteer program activities in the organization. Develop and maintain volunteer training and orientation program. Maintains monthly statistics. Coordinate support/education meetings. Participates as needed in the budget preparation for program development.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources programs] for Medical Director was met as follows: --- - The HA failed to ensure the medical director or physician designee signed the certification of terminal illness (CTI, illness with a prognosis of having 6 months of life or less) for one of 14 sampled patients (Patient 10). (Refer to L667). - The HA failed to ensure the Medical Director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, reviewing, and verifying patient clinical information necessary for initial certification and recertification of terminal illness (illness with a prognosis of having 6 months of life or less) for three of 14 sampled patients, (Patients 11,12 and 14). (Refer to 669). The cumulative effect of this systemic practices resulted in the failure of the hospice to deliver statutory (a written law or regulation) mandated compliance with Federal (government) regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on observation, interview and record review, the hospice agency failed to ensure the medical director or physician designee signed the certification of terminal illness (CTI, illness with a prognosis of having 6 months of life or less) for one of 14 sampled patients (Patient 10). The deficient practice resulted in the hospice agency providing patient care without attesting and confirming that physician composed the narrative based on review of patient medical record, team assessment and/or examination of the patient. --- A review of Patient 10's clinical record indicated a start of care date (SOC) of 07/18/2023 and an end of care date (EOC) of 08/26/2023, with diagnosis of Alzheimers disease (decline in memory, thinking and behavior). A review of Patient 10s Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) / Interdisciplinary Group (IDG, team members, physicians, nurses, therapists, social workers, and other professionals working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) form dated 08/25/2023, indicated the frequency of visits of skilled nurse (SN) was one visit per week and registered nurse (RN) every 14 days and re-certification. A review of Patient 10s ";Physicians Certification for Hospice Benefit" Certification number one, dated 07/18/2023 indicated that the medical director did not sign the Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less) attesting/confirming that he composed the narrative based on review of patient medical record, team assessment and/or examination of the patient. Further review of ";Physicians Certification for Hospice Benefit", indicated that face to face summary and certifying physician summary indicated to refer to third party documentation but no documentation was provided from the agency. During a concurrent record review and interview with the Director of Patient Care Services (DPCS), on 10/27/2023 at 11:54 a.m., the DPCS stated that she could not find the third-party documentation. During a telephone interview with the Medical Director, on 10/27/2023 at 4:16 p.m., he stated that the CTI is completed and reviewed by the Medical Director. A review of the agencys policy and procedure titled, ";Certification of Terminal Illness," dated 2018, indicated that the purpose of the policy and procedure is to ensure physician certification of terminal illness and authorization of hospice services, in accordance with applicable state and federal regulations and payer requirements. The policy and procedure further indicated that at the time of admission to hospice, the hospice Medical Director or patients attending physician will complete a certification narrative that reflects the patients individual circumstances based on his/her review of the patients medical record or, if applicable, examination of patient. Additionally, the policy and procedure indicated that the hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms and the certification must be complete no more than 15 calendar days prior to effective date of the hospice election statement.

Based on observation, interview and record review, the hospice agency failed to ensure the Medical Director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, reviewing, and verifying patient clinical information necessary for initial certification and recertification of terminal illness (illness with a prognosis of having 6 months of life or less) for three of 14 sampled patients, (Patients 11,12 and 14). These deficient practices resulted in the hospice medical director and/or the hospice attending physicians certifying patients for hospice care, without reviewing and verifying patients clinical information. --- a. A review of Patient 11's clinical record indicated a start of care date (SOC) of 06/15/2023 and an end of care date (EOC) of 09/10/2023, with diagnosis of chronic diastolic congestive heart failure (condition in which the hearts main pumping chamber becomes stiff and unable to fill properly). A review of Patient 11s Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) / Interdisciplinary Group (IDG, team members, physicians, nurses, therapists, social workers, and other professionals working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) form dated 07/14/2023, indicated the frequency of visits of licensed vocational nurse (LVN) was one visit per week and registered nurse (RN) every 14 days and re-certification. A review of Patient 11s Local Coverage Determination (LCD, provides guidance in determining medical necessity of services) dated 08/24/2023, indicated that the LCD was blank and that patient does not qualify per LCD Guidelines. A review of Patient 11s ";Physicians Certification for Hospice Benefit" Certification number one, dated 6/15/2023 indicated that medical director electronically signed on 6/15/2023 attesting/confirming that he composed the narrative based on review of patient medical record, team assessment and/or examination of the patient. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) of Patient 11s LCD form, on 10/27/2023 at 11:54 a.m., the DPCS stated that the LCD was blank for Patient 11 and that it should have been filled out. The DPCS further stated that it is important for the LCD to be completed because it determines the patients hospice eligibility. Additionally, DPCS stated that patients eligibility was determined by patients face-to-face assessment only and no history and physical documents. b. A review of Patient 12's clinical record indicated a start of care date (SOC) of 09/11/2023 and an end of care date (EOC) of 10/03/2023, with diagnosis of chronic diastolic congestive heart failure (condition in which the hearts main pumping chamber becomes stiff and unable to fill properly). A review of Patient 12s POC/IDG form dated 9/25/2023, indicated the frequency of visits of licensed vocational nurse (LVN) was one visit per week and registered nurse (RN) every two per month for supervisory and every certification. A review of Patient 12s LCD dated 9/25/2023, indicated that the patient does not qualify per LCD Guidelines. During a concurrent record review and interview with the Director of Patient Care Services (DPCS), on 10/27/2023 at 11:54 a.m., she stated that Patient 12s LCD indicated that patient does not qualify per LCD Guidelines. c. A review of Patient 14's clinical record indicated a start of care date (SOC) of 03/24/2023 and an end of care date (EOC) of 10/03/2023, with diagnosis of chronic obstructive pulmonary disease (lung disease that block airflow and makes it difficult to breathe). A review of Patient 14s POC/IDG form dated 9/22/2023, indicated the frequency of visits of licensed vocational nurse (LVN) was one visit per week and registered nurse (RN) every 14 days and re-certification. A review of Patient 14s LCD dated 9/24/2023, indicated that the patient does not qualify per LCD Guidelines. A review of Patient 14s ";Physicians Certification for Hospice Benefit" Certification number one, dated 03/24/2023 indicated that medical director electronically signed on 3/24/2023 attesting/confirming that he composed the narrative based on review of patient medical record, team assessment and/or examination of the patient. During a concurrent record review and interview with the Director of Patient Care Services (DPCS), on 10/27/2023 at 11:54 a.m., she stated that Patient 14s LCD indicated that patient does not qualify per LCD Guidelines. The DPCS further stated that patient eligibility was determined by team assessment and history and physical. Additionally, when history and physical documentation was requested, DPCS was unable to provide records. During a telephone interview with the Medical Director, on 10/27/2023 at 4:16 p.m., the Medical Director stated that he determines hospice eligibility through the LCD as well as looking at history and physical, comorbidities and hospitalization/surgery. During a review of the agencys policy and procedure titled, "Admission Criteria and Process", dated 2018, indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria developed by LCD (Local Coverage Determination). During a review of the agencys policy and procedure titled, ";Physician Services – Medical Director," dated 2018, indicated that the purpose of the policy and procedure is to ensure qualified medical direction and consultation for the delivery of hospice services and programs. The policy and procedure further indicated that the purpose of the policy and procedure is to demonstrates that the medical director/hospice team physician has overall responsibility for patient care through documentation that demonstrates interaction/communication with attending physician as necessary for appropriate medical care.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure clinical records included assessments and clinical notes for three of 14 sampled patients (Patients 8, Patient 9, and Patient 13). This deficient practice had the potential for lack of coordination of Patient 8, Patient 9, and Patient 13 clinical information and continuity of care services provided to the patients certified to receive the hospice care benefits. --- A review of Patient 13's Personal Information sheet indicated a start of care date (SOC) of 03/13/2023 and an end of care date (EOC) of 05/12/2023, with diagnosis of chronic diastolic congestive heart failure (condition in which the hearts main pumping chamber becomes stiff and unable to fill properly). A review of Patient 13s Plan of Care (POC)/Interdisciplinary Group (IDG) form dated 05/08/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week and registered nurse (RN) every 14 days and re-certification. A review of Patient 13s Clinical Records (in general), indicated that there was no visit notes documented by the LVN. During a concurrent record review and interview with the Director of Patient Care Services (DPCS), on 10/27/2023 at 11:54 a.m., the DPCS stated that Patient 13 did not have any skilled nursing notes and that the patient was being seen once a week by the LVN. The DPCS further stated that skilled notes were important so that healthcare team would be aware of how patient was doing. A review of the agencys policy and procedure titled ";Clinical Data Collection Review," dated 2020, indicated that the hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services. c. A review of Patient 8s "Personal Information sheet" indicated Patient 8 was admitted on 8/8/2023 with diagnosis of hypertensive heart disease without heart failure ( consistent changes in the heart resulting to chronic blood pressure elevation). A record review of Patient 8s electronic medical record (EMR), indicated the registered nurse (RN) was to conduct the supervisory visit every 14 days. Patient 8's EMT indicated a supervisory visit for the RN was on 8/22/2023 and has no supervisory notes for the RN after the date of 8/22/2023. The EMR indicated the skilled nurse was to conduct the home visit twice a week and the EMR has no weekly nursing notes for the date of 9/5/23 and 9/19/23, there were no skilled nurse notes after the date of 9/5/2023 and 9/19/2023 on Patient 8's EMR. A review of the HA's electronic medical record " Audit Log" the licensed vocational nurse (LVN) assigned to Patient 8 made late skilled notes on the following date and time, 10/17/2023 at 12:46 p.m., and 10/19/2023 at 9:04 p.m. The "Audit Log" indicated, the Director of Nursing (DON) made late skilled notes on 10/19/2023 at 2:00 p.m., for the following visit dated, 8/8/2023, 8/22/2023, 9/5/2023, 9/19/2023,10/3/2023, 10/17/2023, and the Administrator (Admin) made late entries on 10/18/2023 at 10:23 a.m. for the following date of 8/8/2023 and 8/22/2023. d. A review of Patient 9s "Patient Information sheet" indicated Patient 9 was admitted last 7/13/2023 with diagnosis of Alzheimer's disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks). A record review of Patient 9s electronic medical record (EMR), indicated for the skilled nurse to conduct home visit once a week. Patient 9's EMR weekly nursing notes for the following date 7/17/2023, 7/24/2023, 8/31/2023, 9/8/2023, 9/15/2023, 9/22/2023 and 9/26/2023 and did not have skilled nurse notes after the date of 9/26/2023 on Patient 9's EMR. A review of the HA's electronic medical record " Audit Log" for Patient 9 showed that the assigned LVN made late entries on the EMR dated 10/17/2023 at 8:37 p.m., the DON made late entries on 10/18/2023 at 3:44 p.m. on the IDG notes for 7/13/2023, 7/27/2023, 8/10/2023, 8/24/2023, 9/7/2023, 9/7/2023, 9/21/2023, and 10/5/2023 on Patient 9's EMR. During a joint interview on 10/27/2023, at 11:55 a.m., with the Director of Nursing (DON) and the Administrator (Admin) stated that the nurses were supposed to submit their notes within 24 to 48 hours. If the nurses could not submit, the nursed could send the notes every Friday. Both Admin and DON stated they both check the electronic medical record (EMR) on a daily basis. DON stated that it is important to submit their notes in EMR the to know the status of the patient and better coordination of care. A review of the HA's Job Description titled " Clinical Records Manager" revised 11/2021 signed by the DON upon hire indicated essential job functions/responsibilities include : Manages all daily clinical records functions including establishing and implementing clinical records policies. Ensures clinical record systems are maintained in compliance with state, federal and ACHC regulations. Maintains comprehensive working knowledge of state, federal, and ACHC documentation regulations and serves as a resource for appropriate organization personnel. Protects all clinical records through the establishment and implementation of control procedures for all open and closed records. Protects the confidentiality of patient and organization information through effective controls and direct supervision of clinical records. Manages the members of the clinical record team to ensure accurate and prompt. filing and retrieval of clinical records. A review of the HA's policy titled "Clinical data Collection Review" revised 4/2021 indicated the purpose is to establish a mechanism to ascertain that data is reliable, valid and accurate on an ongoing basis. Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving service. Entries into the clinical record will be made on the day care is provided to the patient. All documentation will be turned in to the office at the end of the workday.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the clinical records were completed and authenticated (genuine or real) by the author/HA staff (in general), for two of fourteen sampled patients (Patient 8 and Patient 9). This deficient practice resulted in clinical information entered in the patients records withoutvalidation of the accuracy of information that could affect patients' quality of care and well-being --- a. A review of Patient 8s "Patient Information sheet" indicated Patient 8 was admitted on 8/8/2023 with diagnosis of hypertensive heart disease without heart failure ( consistent changes in the heart resulting to chronic blood pressure elevation). A record review of Patient 8s electronic medical record (EMR) on 10/17/2023 at 5:38 p.m., indicated the registered nurse (RN) for supervisory visit every 14 days. The supervisory visit for the RN was 8/22/2023. There were no supervisory notes for the RN indicated after the date 8/22/2023. The EMR, indicated skilled nurse was to conduct the home visit twice a week. The EMR has no weekly nursing notes for 9/5/2023, 9/19/2023. A review of the HA's electronic medical record " Audit Log" the licensed vocational nurse (LVN) assigned to Patient 8 made late entries for her notes on 10/17/2023 at 12:46 p.m., and 10/19/2023 at 9:04 p.m., the Director of Nursing (DON) made late entries on 10/19/2023 at 2:00 p.m., for the visit dates for 8/8/2023, 8/22/2023, 9/5/2023, 9/19/2023, 10/3/2023, 10/17/2023, and the Administrator (Admin) made late entries on 10/18/2023 at 10:23 a.m., for the dates of 8/8/2023 and 8/22/2023. b. A review of Patient 9s "Patient Information sheet" indicated Patient 9 was admitted 7/13/2023 with diagnosis of Alzheimer's disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks). A record review of Patient 9s electronic medical record (EMR) , on 10/17/2023 at 5:38 p.m., indicated the skilled nurse was to conduct the home visit once a week. The EMR indicated no weekly nursing notes on 7/17/2023, 7/24/2023, 8/31/2023, 9/8/2023, 9/15/2023, 9/22/2023 and 9/26/2023. There were no skilled notes on Patient 9's EMR after 9/26/2023. A review of the HA's electronic medical record " Audit Log" for Patient 9 indicated that the assigned LVN made late entries on the EMR on 10/17/2023 at 8:37 p.m., the DON made late entries on 10/18/2023 at 3:44 p.m. on the IDG notes for 7/13/2023, 7/27/2023, 8/10/2023, 8/24/2023, 9/7/2023, 9/7/2023, 9/21/2023, and 10/5/2023 on Patient 9's EMR. During an interview on 10/27/23, at 11:55 a.m., with the Director of Nursing (DON) and the Administrator (Admin) stated that the nurses were supposed to submit their notes within 24 to 48 hours. If they cannot submit, they could send their notes every Friday. Both Admin and DON stated they both check the electronic medical record (EMR) on a daily basis. DON stated that it is important to submit their notes in EMR the to know the status of the patient and better coordination of care. A review of the HA's policy titled "Clinical data Collection Review" revised 4/2021 indicated the purpose is to establish a mechanism to ascertain that data is reliable, valid and accurate on an ongoing basis. Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving service. Entries into the clinical record will be made on the day care is provided to the patient. All documentation will be turned in to the office at the end of the workday.The clinical note will include:A. Care that was providedB. Treatment and/or invasive procedures performedC. Patient response to treatment and/or proceduresD. The date the service was provided (month, day, year) E. Signature of clinician and his/her credentials8. Signature authorization of clinical documentation will include the staff member's name and credentials ( as specified on professional licenses and/or certification documents).9. Initials will be used on forms where authentication signature space is designated on the form.10. All entries into the clinical record will reflect the date care was provided, including the month, day, and year. 11. Hospice aides will only make entries on the hospice aide visit form and on the case conference form.12. Late entries will be documented, stating "late entry for visit of ( date and time of visit)" and include:A. The date the _entry is made (month, day, year)B. The date and documentation that was originally omittedC. The signature and title of the staff member making the late entry13. Errors in documentation will be corrected as follows: A. Draw a line through the entry, date, and initial. B. Do not erase, use correction fluid, or deface a document.14. The information management system will be designed to ensure that: A. Data is collected and entered into the record in a systematic manner. B. Organization personnel use consistent definition of data, as specified in organization policies.