Every finding on record at Tag Hospice, Inc.

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 Conditions of Participations regarding Patient Rights was met as followed: --- 1. The HA failed to ensure three of 14 sampled patients (Patient 3, Patient 4, and Patient 14) received and were informed of their patient rights and responsibilities in a language the patients understood. This failure had the potential to result in patient and their family/caregivers not aware of patient rights and responsibilities. (Refer to L502). 2. The HA failed to ensure three of 14 sampled patients (Patient 3, Patient 4, and Patient 14) were aware of all Medicare-covered hospice services (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease). This failure resulted in patients being unaware about hospice benefit services. (Refer to L518). The cumulative effect of these systemic practices resulted in patients not knowing their hospice services with their limitations and their rights as hospice patient.

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 three of 14 sampled patients (Patient 3, Patient 4, and Patient 14) received their patient rights and responsibilities in a language they could understand. This failure had the potential to result in patient and their family/caregivers not aware of patient rights and responsibilities. --- Findings: a. During review of Patient 3s record untitled admission record, the admission record indicated a start of care date on 4/10/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain) and indicated the Spanish as the primary language. During a review of Patient 3's Informed Consent and Treatment Authorization, the Informed Consent and Treatment Authorization indicated it was in English and Patient 3 signed the consent on 4/10/2024 During a home visit observation on 5/15/2024, at 11 a.m., at Patient 3s residence, Patient 3 was awake. During the concurrent observation and a review of Patient 3s agency folder, indicated the folder contained an educational hospice booklet in English and did not have copies of the Patients Bill of Rights (information about rights as a patient) in the folder. During an interview on 5/15/2024, at 11:35 a.m., Patient 3 stated he did not know what hospice was and the HA did not explain that he had signed up for hospice. Patient 3 stated his Primary Care Physicians office had to explain it to him. Patient 3 stated the HAs folder was in English and that he could only read Spanish. Patient 3 stated he did not receive copies of the paperwork he signed. b. During a review of Patient 4s untitled admission record, the admission record indicated a start of care date on 4/10/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris and indicated Spanish as the primary language. During a review of Patient 4's Informed Consent and Treatment Authorization, Informed Consent and Treatment Authorization indicated it was in English and Patient 4 signed on 4/10/2024. During a home visit observation and a review of Patient 4's HA's folder, on 5/15/2024, at 11 a.m., at Patient 4's residence, Patient 4 was awake. Patient 4s agency folder contained an educational hospice booklet in English and there were no copies of Patients Bills of Rights in the folder. During an interview on 5/15/2024, at 11:08 a.m., Patient 4 stated the paperwork work she signed from the HA was in English and she could only read in Spanish. Patient 4 stated she did not receive copies of the paperwork. c. During a review of Patient 14s untitled admission record, the admission record indicated a start of care date on 7/8/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart as a result of chronic blood pressure) with heart failure (heart not pumping enough blood for the body), and indicated Spanish as the primary language. During a review of Patient 14's Informed Consent and Treatment Authorization, the Informed Consent and Treatment Authorization indicated it was in English was signed on 7/8/2023. During an interview on 5/16/2024, at 10:35 a.m., the representative of Patient 14 (Representative 1) stated Patient 14 was confused, did not read Spanish or English, and was not provided a copy of the hospice consents. Representative 1 stated when Patient 14s primary care physician office notified them that Patient 14 was on hospice. Representative 1 stated she learned Patient 14 was enrolled in hospice by Patient 14's primary physician, During an interview on 5/14/2025, at 11:15 am, with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated the HA should have intake forms, including Patients Bill of Rights in Spanish for Spanish speaking patients so that the patients could understand what they were signing. During an interview and concurrent record review of the HA intake forms including Patients Bill of Rights on 5/14/2024, at 11:24 am, the HA's Owner and Licensed Vocational Nurse 1 (CEO/LVN) both stated the HA had intake forms, including the Patients Bill of Rights, in English and did not have the intake forms in any other languages. During a review of the HAs policy titled, ";Patient Bill of Rights/Responsibilities," dated April 2020, indicated that, ";upon admission, the admitting clinician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights/Responsibilities in advance of furnishing care." The policy also indicated that, ";The Patient Bill of Rights/Responsibilities will be explained and distributed to the patient the initiation of organization services. This explanation will be in a language and manner he/she can reasonable be expected to understand."

Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure three of fourteen sampled patients (Patient 3, Patient 4 and Patient 14) were aware of what Medicare hospice services were. This failure resulted in denial of medical services as a result of being under hospice services. --- a. During review of Patient 3s record untitled admission record, the admission record indicated a start of care date on 4/10/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain) and indicated the Spanish as the primary language. During a review of Patient 3's Informed Consent and Treatment Authorization, the Informed Consent and Treatment Authorization indicated it was in English and Patient 3 signed the consent on 4/10/2024 During a home visit observation on 5/15/2024, at 11 a.m., at Patient 3s residence, Patient 3 was awake. During the concurrent observation and a review of Patient 3s agency folder, indicated the folder contained an educational hospice booklet in English and did not have copies of the Patients Bill of Rights (information about rights as a patient) in the folder. During an interview on 5/15/2024, at 11:35 a.m., Patient 3 stated he did not know what hospice was and the HA did not explain that he had signed up for hospice. Patient 3 stated his Primary Care Physicians office had to explain it to him. Patient 3 stated the HAs folder was in English and that he could read Spanish. Patient 3 stated he did not receive copies of the paperwork he signed. b. During a review of Patient 4s untitled admission record, the admission record indicated a start of care date on 4/10/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, and indicated Spanish as the primary language. During a review of Patient 4's Informed Consent and Treatment Authorization, Informed Consent and Treatment Authorization indicated it was in English and Patient 4 signed on 4/10/2024. During a home visit observation on 5/15/2024, at 11 a.m., the contents of Patient 4s agency folder contained an educational hospice booklet in English. There were no copies of Patients consents in the folder. During an interview on 5/15/2024 at 11:08 a.m., Patient 4 stated that the paperwork work she signed from the HA was in English and she only read in Spanish. Patient 4 also stated that she did not receive copies of the paperwork. During a home visit observation and interview on 5/15/2024, at 11 a.m., Patient 4 was awake and stated she found out she was in hospice services when she went to her primary care doctor on 4/25/2024 and the doctors office informed her that there cannot bill her visit because she is enrolled in hospice. Patient 4 stated she was surprised and did not know that the HA was for hospice services that it was not explained to her when she signed up for services and that she thought she was just signing up for medical supplies like a shower chair. During an interview on 5/15/2024 at 11:00 a.m., c. During a review of Patient 14s untitled admission record, the admission record indicated a start of care date on 7/8/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart as a result of chronic blood pressure) with heart failure (heart not pumping enough blood for the body), and indicated Spanish as the primary language. During a review of Patient 14's Informed Consent and Treatment Authorization, Informed Consent and Treatment Authorization indicated it was in English and Patient 4 signed on 7/8/2023. During an interview on 5/16/2024 at 10:35 a.m., the representative of Patient 14 (Representative 1) stated that Patient 14 was confused, does not read Spanish or English, and was not provided a copy of the hospice consents. Representative 1 also stated when Patient 14s primary care physician office notified them that Patient 14 was on hospice that the learned that Patient 14 had been signed up for hospice services. During an interview and concurrent record review of the HA intake forms including Patients Bill of Rights on 5/14/2024 at 11:24 am, Owner and Licensed Vocational Nurse 1 (CEO/LVN) stated the HA had intake forms, including consents for hospice, in English and did not have the intake forms in any other language. The ADM/DPCS stated the HA should have intake forms, including the consents in Spanish for Spanish speaking patients so that the patients would understand what they were signing. The ADM/DPCS stated the purpose of the initial visit by the HA was to, "explain the philosophy of palliative (comfort measures) care with patient." During a review of the HAs policy titled, ";Patient Bill of Rights/Responsibilities," dated April 2020, indicated that it is the right of each patient to , "be informed in advance of the service about the care to be furnished, the organization's scope of services and services under the Medicare Hospice Benefit and any limitations of those services." During a review of the facility's policy titled, "Admission Criteria and Process," dated April 2020, indicated that, " patient must desire hospice services." A review of the facility's policy titled, "Admission Criteria and Process, " dated April 2020, indicated that, "the patient must desire hospice services."

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of the Patient was met as follows: 1. The HA staff 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 hospice eligibility and management of terminal illness for two of 14 sampled patients (Patient 3 and Patient 4). (Refer to L524) 2. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) conducted biweekly meetings to update comprehensive assessment of patients and reflected current health status, for fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L533). The cumulative effect of this systemic practice 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 quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on observation, interview, and record review, the Hospice Agency (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 hospice eligibility and management of terminal illness for two of 14 sampled patients (Patient 3 and Patient 4). The deficient practice had the potential for Patient 3 and Patient 4 not receiving care and services to meet the patients care goal needs. --- a. A review of Patient 3 admission sheet, indicated Patient 3's a Start of Care (SOC) date of 4/10/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). A review of Patient 3s ";Comprehensive Nursing Assessment," dated 4/10/2024, indicated that Patient 3 required a walker or wheelchair for movement, has shortness of breath and general body weakness. Patient 3s ";Comprehensive Nursing Assessment," did not have a signature of the clinician. b. A review of Patient 4s admission sheet, indicated Patient 4's SOC date of 4/10/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. A review of Patient 4s medical record titled, ";Comprehensive Nursing Assessment," dated 4/10/2024, indicated that Patient 3 required a walker or wheelchair for movement, has shortness of breath and general body weakness. Patient 3s ";Comprehensive Nursing Assessment," did not have a signature of the clinician. During a home visit and an interview on 5/15/2024 at 11:43 a.m., with Patient 3, Patient 3 stated he was offered a wheelchair by the HA but he did not use a walker or wheelchair. Patient 3 stated that he has no heart issues and that he goes to the gym 3-4 times a week. During a home visit and an interview on 5/15/2024 at 11:45 a.m., with Patient 4, Patient 4 stated that she did not use a walker and never experienced shortness of breath. During the home visit and an observation on 5/15/2024 at 12:15 p.m., at Patient 3's and Patient 4's residence, Patient 3 and Patient 4 were observed walking independently. Patient 3 and Patient 4 were observed ambulating 20-25 feet without shortness of breath or difficulty moving. A review of the facilitys policy titled, ";Contents of Clinical Record," dated April 2020, indicated that, ";the clinical record will be dated and signed, including title and credentials, by the person providing the care/service." A review of the facilitys policy titled, ";Clinical/Service Data Collection," dated April 2020, indicated that, ";documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided."

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse (RN), Medical Social Worker (MSW), Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure resulted in patients not being properly evaluated which resulted in not being provided individualized focused care. --- A . A review of Patient 1s record untitled admission sheet, indicated a start of care date on 4/20/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). b. A review of Patient 2s record untitled admission sheet, indicated a start of care date on 4/14/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. c. A review of Patient 5s record untitled admission sheet, indicated a start of care date on 3/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. d. A review of Patient 6s record untitled admission sheet, indicated a start of care date on 3/22/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. e. A review of Patient 8s record untitled admission sheet, indicated a start of care date on 2/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. f. A review of Patient 11s record untitled admission sheet, indicated a start of care date on 8/21/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) without heart failure (heart not pumping enough blood for the body). g. A review of Patient 12s record untitled admission sheet, indicated a start of care date on 8/14/2023 with a primary diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions) h. A review of Patient 13s record untitled admission sheet, indicated a start of care date on 2/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris During a concurrent interview and record review on 5/17/2024 at 11:50 a.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 1 IDG dates 4/20/2024-5/7/2024, there were no nursing and physician signatures. ADM/DCPS stated, ";yes there are no signatures on the IDG for nursing and doctor, if there are no signatures it wasnt done." During a concurrent interview and record review on 5/17/2024 at 11:56 a.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 2 IDG dates 4/14/2024-5/1/2024, there were no nursing and physician signatures. ADM/DCPS stated, ";yes there are no signatures on the IDG for nursing and doctor, if there are no signatures it wasnt done." During a concurrent interview and record review on 5/17/2024 at 12:00 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 5 the IDG entry page was blank. ADM/DCPS stated, ";there is no IDG entry period for Patient 5. Not recorded not done." During a concurrent interview and record review on 5/17/2024 at 12:10 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 6 the IDG entry page was blank. ADM/DCPS stated, ";there is no IDG entry period for Patient 6. Not recorded not done." During a concurrent interview and record review on 5/17/2024 at 12:15 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 8 the IDG entry page was blank. ADM/DCPS stated, ";there is no IDG entry period for Patient 8. Not recorded not done." During a concurrent interview and record review on 5/17/2024 at 12:20 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 11 the IDG entries stop on 2/17/2024. ADM/DCPS stated, ";there are no signatures for nursing and doctor on any of the IDGs before 2/17/2024 and the IDG entries stop on 2/17/2024 for Patient 11." During a concurrent interview and record review on 5/17/2024 at 12:23 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 12 none of the IDG entries have nursing or physician signature. ADM/DCPS stated, ";there are no signatures for nursing and doctor on any of the IDGs for Patient 12. Not recorded not done." During a concurrent interview and record review on 5/17/2024 at 12:25 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 13 the IDG entry page was blank. ADM/DCPS stated, ";there is no IDG entry period for Patient 13. Not recorded not done." During record review of HAs policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities", revised Aril 2020, the policy and procedure indicated, ";The interdisciplinary group will collaborate with the patient's attending physician to develop an individualized written plan of care. When there is more than one ( 1) interdisciplinary group, the hospice will designate in advance the group responsible for program oversight and the establishment of policies that govern the day-to-day provision of hospice care and services." The policy further indicated, ";1. The hospice interdisciplinary group membership includes at a minimum: A. Physician (A doctor of medicine or osteopathy) B. Registered nurse C. Social worker D. Pastoral or other counselor." During record review of HAs policy and procedure titled, ";Interdisciplinary Group Meeting", revised Aril 2020, the policy and procedure indicated, ";The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires." a. A review of Patient 3s medical record, untitled admission sheet, indicated a start od care date of 4/10/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). b. A review of Patient 4s medical record, untitled admission sheet, indicated a start of care date on 4/10/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. c. A review of Patient 7s medical record, untitled admission sheet, indicated a start of care date of 3/22/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). d. A review of Patient 9s medical record, untitled admission sheet, indicated a start of care date of 9/3/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) with heart failure (heart not pumping enough blood for the body). e. A review of Patient 10s medical record, untitled admission sheet, indicated a start of care date of 9/3/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) with heart failure (heart not pumping enough blood for the body). f. A review of Patient 14s medical record, untitled admission sheet, indicated a start of care date on 7/8/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) with heart failure (heart not pumping enough blood for the body). During an interview on 5/16/2024 at 11:46 a.m., Administrator/Director of Patient Care Services (ADM/DPCS) stated that the Interdisciplinary Group (IDG) meeting is to review the patient's' plans of care. ADM/DPCS stated that the Medical Director (MD), Nursing services, Medical Social Worker, Spiritual Counsellor should be present during the meeting. ADM/DCPS stated that all those who participated should sign indicating that they were participants in the patients care review. During an interview and concurrent medical record review of Patient 3's medical record, Interdisciplinary Group Meetings, on 5/17/2024 at 12:30 p.m., ADM/DCPS stated that none of Patient 3's IDG meetings were not signed by the Medical Director (MD) or Nursing services. During an interview and concurrent medical record review of Patient 4's medical record, history Interdisciplinary Group Meetings, on 5/17/2024 at 12:35 p.m., ADM/DPCS stated that none of Patient 4's IDG's were not signed by the MD or Nursing services. During an interview and concurrent medical record review of Patient 7's medical record, history Interdisciplinary Group Meetings, on 5/17/2024 at 12:40 p.m., ADM/DPCS stated that none of Patient 7's IDG's were not signed by the MD or Nursing services. During an interview and concurrent medical record review of Patient 14's medical record, history Interdisciplinary Group Meetings, on 5/17/2024 at 12:45 p.m., ADM/DPCS stated that none of Patient 14's IDG's were not signed by the MD or Nursing services. During an interview and concurrent medical record review of Patient 9's medical record, history Interdisciplinary Group Meetings, on 5/17/2024 at 12:50 p.m., ADM/DPCS stated that none of Patient 9's IDG's were signed not by the MD or Nursing services. During an interview and concurrent medical record review of Patient 10's medical record, history Interdisciplinary Group Meetings, on 5/17/2024 at 12:55 p.m., ADM/DPCS stated that none of Patient 10's IDG's were not signed by the MD or Nursing services. A review of the facility's policy titled, "Clinical Service Data Collection," dated April 2020, indicated that, "documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care of the services provided." A review of the facility's policy titled, "Interdisciplinary Group Membership and Responsibilities," dated April 2020, indicated that, " the hospice interdisciplinary group membership includes at a minimum: Physician, Registered Nurse, Social Worker and Pastoral or other counsellor." A review of the facility's policy titled, "Interdiscplinary Group Meeting," dated April 2020, indicated that the group will meet, "no less frequently than every 15 days."

Based on an interview, and record review, the Hospice agency (HA) failed to ensure the Condition of Participation for Interdisciplinary Group, Care Planning, and Coordination of Services was met as follows: --- 1). The HA failed to ensure the 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) for eight of fourteen sampled patients (Patient 1, Patient 2, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12 and Patient 13), were reviewed and updated by interdisciplinary group (IDG, group of healthcare professionals working together to provide patients with the care they need). (Refer to L551) 2). The HA failed to ensure Skilled Nursing Services were provided to one of one sampled patient (Patient 13). (Refer to L584) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the quality of care was provided to the patients who were assessed to receive hospice care and services.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the 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) for eight of fourteen sampled patients (Patient 1, Patient 2, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12 and Patient 13), were reviewed and updated by interdisciplinary group (IDG, group of healthcare professionals working together to provide patients with the care they need). This deficient practice had the potential to affect the quality of care and services needed by the affected patients --- Findings: a). A review of Patient 1s admission sheet, indicated a start of care date on 4/20/2024 with primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). b). A review of Patient 2s admission sheet, indicated a start of care date on 4/14/2024 with primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. c). A review of Patient 5s admission sheet, indicated a start of care date on 3/25/2024 with primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. d). A review of Patient 6s admission sheet, indicated a start of care date on 3/22/2024 with primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. e). A review of Patient 8s admission sheet, indicated a start of care date on 2/25/2024 with primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. f). A review of Patient 11s admission sheet, indicated a start of care date on 8/21/2023 with primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) without heart failure (heart not pumping enough blood for the body). g). A review of Patient 12s admission sheet, indicated a start of care date on 8/14/2023 with primary diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). h). A review of Patient 13s admission sheet, indicated a start of care date on 2/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. During a concurrent interview and record review on 5/17/2024 at 11:50 a.m. with Administrator (ADM)/Director of Patient Care Services (DPCS), Patient 1s Electronic Medical Record (EMR) for IDG notes dated 4/20/2024 to 5/7/2024 were reviewed. The IDG notes did not indicate nurses and physicians signatures. The ADM/DPCS confirmed that the IDG notes did not indicate nurses and physicians signatures. During a concurrent interview and record review on 5/17/2024 at 11:56 a.m. with ADM/DPCS, Patient 2s EMR for IDG notes dated 4/14/2024 to 5/1/2024 were reviewed. The IDG notes did not indicate nurses and physicians signatures. The ADM/DPCS confirmed that the IDG notes did not indicate nurses and physicians signatures. During a concurrent interview and record review on 5/17/2024 at 12:00 p.m. with ADM/DPCS, Patient 5s EMR for IDG notes were reviewed. The ADM/DCPS confirmed that the IDG page was blank. During a concurrent interview and record review on 5/17/2024 at 12:10 p.m. with ADM/DPCS, Patient 6s EMR for IDG notes were reviewed. The ADM/DCPS confirmed that the IDG page was blank. During a concurrent interview and record review on 5/17/2024 at 12:15 p.m. with ADM/DPCS, Patient 8s EMR for IDG notes were reviewed. The ADM/DCPS confirmed that the IDG page was blank. During a concurrent interview and record review on 5/17/2024 at 12:20 p.m. with ADM/DPCS, Patient 11s EMR for IDG notes were reviewed. The IDG notes indicated last entry of 2/17/2024. The ADM/DPCS confirmed that the IDG notes did not indicate nurses and physicians signatures before 2/17/2024. During a concurrent interview and record review on 5/17/2024 at 12:23 p.m. with ADM/DPCS, Patient 12s EMR for IDG notes were reviewed. The IDG notes did not indicate nurses and physicians signatures. The ADM/DPCS confirmed that the IDG notes did not indicate nurses and physicians signatures. During a concurrent interview and record review on 5/17/2024 at 12:25 p.m. with ADM/DPCS, Patient 13s EMR for IDG notes were reviewed. The ADM/DCPS confirmed that the IDG page was blank. A review of HAs policy and procedure (P&P) titled, ";Interdisciplinary Group Meeting", dated 4/2020, indicated, the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress, and updates the plan of care. A review of the HAs P&P titled, ";Interdisciplinary Group Membership and Responsibilities", dated 4/2020, indicated, the interdisciplinary group will collaborate with the patient's attending physician to develop an individualized written plan of care. The P&P indicated the hospice interdisciplinary group members included at a minimum, a physician (a Doctor of Medicine or Osteopathy), RN, Social Worker and a Pastor or Counselor).

Based on interview and record review, the HA failed to ensure skilled nursing services were provided to one of one sampled patient (Patient 13). This deficient practice had the potential to result in patient not receiving the necessary care and services and had the potential to affect the patients quality of life. --- Findings: A review of Patient 13s admission sheet, indicated a start of care date on 2/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). During a concurrent interview and record review on 5/17/2024 at 12:25 p.m. with the Administrator (ADM)/Director of Patient Care Services (DPCS), Patient 13s Electronic Medical Record (EMR) for Skilled Nursing entry visit was reviewed. The Skilled Nursing entry history page was blank. The ADM/DCPS confirmed Patient 13 had no skilled nursing visit notes. The ADM/ DPCS stated it had been missed and the missed visits were not documented. A review of HAs policy and procedure (P&P) titled, ";Missed Visits", dated 4/2020, indicated, missed visits will be documented in the clinical record and will be rescheduled the same week if possible. The P&P indicated to notify the IDG and clinical supervisor of the missed visit and reason for missed visit.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Core Services was met as follows: --- 1. The HA failed to ensure three of fourteen sampled patients (Patient 3, Patient 4, Patient 14) terminal illnesses (an irreversible or incurable disease condition from which death is expected) were coordinated with the primary care physician. (Refer to L590). 2. The HA failed to ensure Registered Nurse (RN) supervisory visits for Licensed Vocational 1 (LVN) were conducted for eight of fourteen sampled patients (Patient 1, Patient 2, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12 and Patient 13). (Refer to L591). The cumulative effect of these systemic practices resulted in the HA not providing the core services/care as required and had the potential for the patients not to receive healthcare services that could affect their quality of life.

Based on interview and record review, the Hospice Agency (HA) failed to ensure three of fourteen sampled patients (Patient 3, Patient 4, Patient 14) terminal illnesses (an irreversible or incurable disease condition from which death is expected) were coordinated with the primary care physician. This failure resulted in patients receiving hospice services without being certified for hospice care and without the primary care physician coordination which had the potential for patients to receive hospice services when they are not terminally ill. --- Findings: a). A review of Patient 3s admission sheet, indicated a start of care date of 4/10/2024 with diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). A review of Patient 3's clinical record titled, "Physician's Certification for Hospice Benefit," indicated Registered Nurse (RN) 1 received verbal authorization from Patient 3s primary care doctor (MD1) for Patient 3s start of care on 4/10/2024. The physicians certification was not signed by MD1 and did not indicate MD1 was the referring physician. During an interview on 5/15/2024 at 11:35 a.m., Patient 3 stated that he did not know MD1 and had not spoken to any s from the HA. Patient 3 stated that MD2 was his primary care physician. b). A review of Patient 4s admission sheet, indicated a start of care date of 4/10/2024 with diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. c). A review of Patient 4's clinical record titled, "Physician's Certification for Hospice Benefit," indicated that RN1 received verbal authorization from MD1 for Patient 4s start of care on 4/10/2024. The record physician certification was not signed by MD1 and did not indicate MD1 was the referring physician. During an interview on 5/15/2024 at 11:00 a.m., Patient 4 stated that they (Patient 3 and Patient 4) went to see MD2 on 4/25/2024 and were denied services because they were both under hospice care. Patient 4 stated that their primary care physician didnt know about them under hospice care until the primacy care physicians clinic billed insurance for their visit. During an interview on 5/15/2024 at 11:08 a.m., Patient 4 stated that it was her primary care physicians office who explained that hospice was for dying patients. Patient 4 stated they have not spoken to any other doctor but their primary care physician. Patient 4 stated she did not know or had not spoken with MD1. d). A review of Patient 14s admission sheet, indicated a start of care date of 7/8/2023 with diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure with heart failure (heart not pumping enough blood for the body). e). A review of Patient 14's record titled, "Physician's Certification for Hospice Benefit," indicated that RN1 received verbal authorization from MD1 for Patient 14s start of care on 7/8/2023. The clinical record was not signed by MD1 and did not indicate MD1 was the referring physician. During an interview on 5/16/2024 at 2:00 p.m., the representative for MD2s medical practice (REPMD2) stated that MD2 had been the primary care physician for Patient 3 and Patient 4 for a long time. REPMD2 stated that the medical practice did not find out that Patients 3 and 4 were under hospice services until there were billing issues. REPMD2 stated that HA had not contacted the office or MD2 about Patient 3 and Patient 4. REPMD2 stated neither patient had medical issues to qualify for hospice care and services. During an interview on 5/16/2024 at 10:00 a.m., REPMD3s medical practice stated the medical office was surprised to learn that Patient 14 was under hospice services. REPMD3 stated that MD3 had been the primary care physician for Patient 14 for years, and that their office or MD3 had never been contacted by the HA regarding Patient 14 enrolled in hospice services nor requested medical records. REPMD3 stated MD3 did not believe Patient 14 was eligible for hospice services and had not referred Patient 14 for hospice services. During an interview on 5/17/24 at 10:33 a.m., the owner/Licensed Vocational Nurse (CEO/LVN) stated they have not gotten medical records from the primary care physician for Patient 3, Patient 4 and Patient 14. During an interview on 5/17/2024 at 12:20 p.m., the Administrator/Director of Patient Care Services (ADM/DPCS) stated the signature for the referring physician was missing on the certifications for Patient 3, Patient 4 and Patient 14. A review of the facility's policy and procedure (P&P) titled, "Comprehensive Assessment," indicated that the election of hospice is done in consultation of the attending (primary) physician." A review of the facility's P&P titled, "Medicaid Hospice Benefit," dated April 2020, indicated that an eligibility requirement is to have the attending physician certify prognosis of terminal illness for the first election period. A review of the facility's P&P titled, "Admission Criteria and Process, " dated April 2020, indicated that the HA will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician.

Based on interview and record review, the hospice agency (HA) failed to ensure Registered Nurse (RN) supervisory visits for Licensed Vocational 1 (LVN) were conducted for eight of fourteen patients (Patient 1, Patient 2, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12 and Patient 13). The deficient practice had the potential to result in a poor-quality patient care which can affect the health and safety of the patients under the HAs care. --- Findings: a. A review of Patient 1s admission sheet, indicated a start of care date on 4/20/2024 with primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). b. A review of Patient 2s admission sheet, indicated a start of care date on 4/14/2024 with primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. c. A review of Patient 5s admission sheet, indicated a start of care date on 3/25/2024 with primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. d. A review of Patient 6s admission sheet, indicated a start of care date on 3/22/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. e. A review of Patient 8s admission sheet, indicated a start of care date on 2/25/2024 with primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. f. A review of Patient 11s admission sheet, indicated a start of care date on 8/21/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) without heart failure (heart not pumping enough blood for the body). g. A review of Patient 12s admission sheet, indicated a start of care date on 8/14/2023 with primary diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions) h. A review of Patient 13s admission sheet, indicated a start of care date on 2/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. During a concurrent interview and record review on 5/17/2024 at 11:50 a.m. with the Administrator (ADM)/Director of Patient Care Services (DPCS), Patient 1, Patient 2, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12 and Patient 13s electronic medical records (EMR) were reviewed. Patient 1, Patient 2, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12 and Patient 13s EMR did not indicate RN visit notes documentation. The ADM/DPCS confirmed that there were no RN visit notes in Patient 1, Patient 2, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12 and Patient 13s chart. The ADM/DPCS stated, the EMRs were supposed to have RN supervisory visits for Licensed Vocational Nurses (LVNs) and Aides." A review of HAs policy and procedure (P&P) titled, ";Responsibilities/Supervision of Clinical Services", dated 4/2020, indicated, the Clinical Director/Director of Patient Care Services will assure supervision were maintained within the organization. The P&P indicated, supervision of the LPN/LVN will be completed by a registered nurse, by a visit to the patient's home with or without the LPN present at least every 30 days. The P&P indicated; a monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Volunteer Services was met as evidenced by: --- 1. The HA failed to ensure fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) had access to Volunteer Services. (Refer to: 643) 2. The HA failed to have a Volunteer Program. (Refer to: 643). The cumulative effect of these systemic practices resulted in the HA not ensuring they were providing services/care as required and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life

Based on interview and record review, the Hospice Agency (HA) failed to ensure fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5,Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) had access to Volunteer Services. and also failed to provide evidence that had a Volunteer Coordinator (supervisor of volunteers) or program to train and utilize volunteer services. This failure had the potential to result in patient and their family/caregivers not being able to receive Volunteer Services when needed. --- . A review of Patient 1s record untitled admission sheet, indicated a start of care date on 4/20/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). b. A review of Patient 2s record untitled admission sheet, indicated a start of care date on 4/14/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). C. A review of Patient 3s medical record, untitled admission sheet, indicated a start of care date of 4/10/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). D. A review of Patient 4s medical record, untitled admission sheet, indicated a start of care date on 4/10/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). E. A review of Patient 5s record untitled admission sheet, indicated a start of care date on 3/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). F.. A review of Patient 6s record untitled admission sheet, indicated a start of care date on 3/22/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris ( (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain) G. A review of Patient 7s medical record, untitled admission sheet, indicated a start of care date of 3/22/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). H. A review of Patient 8s record untitled admission sheet, indicated a start of care date on 2/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). I. A review of Patient 9s medical record, untitled admission sheet, indicated a start of care date of 9/3/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) with heart failure (heart not pumping enough blood for the body). J. A review of Patient 10s medical record, untitled admission sheet, indicated a start of care date of 9/3/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) with heart failure (heart not pumping enough blood for the body). K. A review of Patient 11s record untitled admission sheet, indicated a start of care date on 8/21/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) without heart failure (heart not pumping enough blood for the body). L. A review of Patient 12s record untitled admission sheet, indicated a start of care date on 8/14/2023 with a primary diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions) M. A review of Patient 13s record untitled admission sheet, indicated a start of care date on 2/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). N. A review of Patient 14s medical record, untitled admission sheet, indicated a start of care date on 7/8/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) with heart failure (heart not pumping enough blood for the body). During an interview on 5/14/2024 at 11:37 a.m., the owner of the HA who is also a Licensed Vocational Nurse (CEO/LVN) stated that the HA did not have a volunteer coordinator or volunteer. During an interview on 5/14/2024 at 11:38 a.m., Director of Patient Care Services (ADM/DPCS) stated that the HA does not have a volunteer coordinator or volunteers. ADM/DPCS also stated that the HA has never had a volunteer coordinator. A review of the facilities policy titled, "Volunteer Services," dated 2018, indicated that, "the hospice will provide volunteer services under the direction of the Volunteer Coordinator and with the assistance of trained hospice volunteers."

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Organization and Administration of Services was met as follows: --- 1. The hospice agency failed to ensure that the Administrator was knowledgeable regarding hospice regulations and that the governing body or the Administrator assumed full legal responsibility for the management, the provision of all hospice services, continuous quality assessment and performance improvement, and appointed a qualified administrator to run the day to day operation of the hospice. (Refer to L651). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Organization and Administration of Services to protect and promote the rights, of the patient in the hospice agency.

Based on record review and interview, the hospice agency failed to ensure that the governing body or the Administrator assumed full legal responsibility for the management, the provision of all hospice services, continuous quality assessment and performance improvement, and appointed a qualified administrator to run the day to day operation of the hospice. --- On 5/14/2024, at 10:45 a.m., during an interview with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that she has very limited hospice experience and this HA was the first hospice agency she has worked for and that this was her first hospice agency as an administrator. The ADM/DPCS and the CEO/LVN, both stated that the hospice agency did not have a volunteer coordinator, volunteer, physical therapist, occupational therapist, speech therapist, and competency/training or education program or system in place for all the hospice agency staff. On 5/14/2024, at 10:45 a.m., during an interview with the CEO/LVN, the CEO/LVN stated that she was the hospice agencys governing body and that she had minimal experience with hospice and that she relies on her consultant for the employee files, in-services, and the day-to-day operation as needed. The consultant was not available during the complaint validation survey. A review of the hospice agency's undated "Administrator Job Description, indicated "The Administrator is responsible for the overall direction of Hospice services. He/she is responsible for the employment of qualified Hospice personnel; is responsible for the provision of Hospice services, directly, and the delegation to coordination of Hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The administrator establishes, implements, evaluates goals and objectives, and processes that promote the standard of quality and contribute to the total organization and philosophy.

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 Physical therapy (PT a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise), Occupational therapy (healthcare provider who helps you improve your ability to perform daily tasks), Speech therapy, and dietary services were available for the 27 active patients. This deficient practice had the potential for the patients' needs not to be met. --- During an interview on 5/14/2024, at 11:23am, with ADM/DPCS, ADM/DPCS stated, ";we currently done have any physical therapy, speech therapy, occupational therapy services and contracts. We also don't have dietary services and contracts." During record review of agencys brochure, the brochure indicated, ";Our Services include: Care is provided by an interdisciplinary team of hospice trained professional including Physicians, Registered nurses, clinical social workers, non-denominational chaplains, home health aids/homemakers, physical and occupational therapists, dietitians, and volunteers."

Based on record review and interview, the Hospice Agency failed to provide documented evidence that all disciplines providing care had competency assessments, in-services training needed to ensure they were competent in furnishing care. This deficient practice had the potential of the patients not receiving adequate care. --- During the Complaint Validation survey conducted at the hospice agency from 5/13/2024 to 5/17/2023, the Hospice agency staff was asked to provide the employee files for review on 5/14/2024. The CEO/LVN stated all employee files were electronic and she would have to print out. The CEO/LVN was only able to provide the survey team with the Administrator/Director of Patient Care Services (ADM/DPCS) file, the DPCS Designee's(DD) file, and Licensed Vocational Nurse (LVN1)'s files for review. Review of the ADM/DPCS, DD and LVN 1's files indicated no application for employment, no competency skills assessment or in-services in their employee file. During an interview in the HA with the ADM/DPCS on 5/14/2024, at 1:00 p.m., the ADM/DPCS stated that she did not do know if the staff had competency skill assessment. During a interview in the HA with the CEO/LVN on 5/14/2024 at 1:00 p.m., the CEO/LVN stated that she did not know about competency and that her consultant had done everything. On 5/17/2024, the ADM/DPCS and the CEO/LVN was asked again to review the assessment of competency skills and in-services for their hospice staff. The hospice agency could not provide documented evidence that their staff had competency skill assessments and in-services.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Medical Director was met as evidenced by: --- 1. The HA failed to ensure, the medical director conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial certifications for one of fourteen sampled patients (Patient 11) to support diagnosis of the patients' terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The agency failed to ensure there was a physicians signature and documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice care and services. (Refer to L667). 2. The HA failed to ensure medical director conducted a review and verified the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for three of fourteen sampled patients (Patient 10, Patient 11, and Patient 12). (Refer to L 668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on interview and record review the HA failed to ensure initial Certification of illness (CTI) was signed by hospice physician for one of fourteen sample patients (Patient 11). The deficient practice resulted in patient being enrolled in hospice and receiving care without a physician authorization. --- A review of Patient 11s record untitled admission sheet, indicated a start of care date on 8/21/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) without heart failure (heart not pumping enough blood for the body). During a concurrent interview and record review on 5/17/2024 at 12:20 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 11 there is no physician signature on the Physicians Certification for Hospice benefit Certification #1: Statement for First 90-day period in the record. ADM/DCPS stated, ";There is no signature on the initial certification period 1 CTI by the physician for Patient 11. If its not signed its not done." During record review of HAs policy and procedure titled, ";Certification of Terminal Illness", revised Aril 2020, the policy and procedure indicated, ";1. At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on: his/her review of the patient's medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms.) The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election."

Based on interview and record review the Home Health Agency (HA) failed to ensure initial Certification of illness (CTI) was signed by hospice physician for three of fourteen sample patients (Patient 10, Patient 11, Patient 12). The deficient practice resulted in patient being enrolled in hospice and receiving care without a physician authorization. --- A review of Patient 11s record untitled admission sheet, indicated a start of care date on 8/21/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) without heart failure (heart not pumping enough blood for the body). During a concurrent interview and record review on 5/17/2024 at 12:20 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 11 there is no physician signature on the Physicians Certification for Hospice benefit Certification #2: Statement for Second 90-day period in the record and physician face to face entry page is blank. ADM/DCPS stated, ";There is no signature on the second certification period CTI by the physician for Patient 11. If its not signed its not done. There is no physician face to face entries for Patient 11." During a concurrent interview and record review on 5/17/2024 at 12:23 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 12 there is no physician signature on the Physicians Certification for Hospice benefit Certification #2: Statement for Second 90-day period, certification #3: Re-certification Statement for Next 60-day period, certification #4: Re-certification Statement for Next 60-day period in the record and physician face to face entry page is blank. ADM/DCPS stated, ";There is no signature on the second, third and the fourth certification period CTI by the physician for Patient 12. If its not signed its not done. There is no physician face to face entries for Patient 12." During record review of HAs policy and procedure titled, ";Certification of Terminal Illness", revised Aril 2020, the policy and procedure indicated, ";5. A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient's medical record or, if applicable, examination of the patient. A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than fifteen {15) calendar days prior or two (2) calendar days after the first day of each period. The signed and dated certification must be present prior to billing for each recertification period. 6. The hospice physician or nurse practitioner must have a face-to-face encounter with the patient within the 30 days prior to the 3rd benefit period recertification and within 30 days prior to each subsequent benefit period recertification." a. A review of Patient 10s medical record, untitled admission sheet, indicated a start of care date of 9/3/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) with heart failure (heart not pumping enough blood for the body). During a concurrent interview and record review of Patient 10's Certificate of Terminal Illness, Recertification #2 for the period of 12/2/2023 to 2/29/2024, on 5/17/2024 at 12:55 p.m., ADM/DPCS stated that there was no signature from a physician certifying the terminal illness.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) ) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [is a 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) on Clinical Records was met as follows: --- 1. The HA failed to ensure the clinical records for nine of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 13) had signatures on initial comprehensive assessment by the Registered Nurse (RN). (Refer to L679) 2. The HA failed to ensure Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) meetings were signed by the physician and registered nurse for 14 of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L679) 3. The HA failed to ensure the clinical records for four of 14 sampled patients (Patient 11, Patient 12, Patient 13, and Patient 14) had a signature on discharge summary by the RN (Refer to L679). 4. The HA failed to ensure the clinical records for three of 14 sampled patients (Patient 10, Patient 11, and Patient 12) had a signature on the CTI (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less) by the Physician. (Refer to L679) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records are safeguarded from unauthorized access by any individuals or hospice staff.

Based on interview and record review, the Hospice Agency (HA) failed to have record entries that were dated and signed in accordance with currently accepted standards of practice and hospice agency policy: 1.The HA failed to ensure the clinical records for nine of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 13) had signatures on initial comprehensive assessment by the RN. 2. The HA failed to ensure IDG meetings were signed by the physician and registered nurse for 14 of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). 3. The HA failed to ensure the clinical records for four of 14 sampled patients (Patient 11, Patient 12, Patient 13, and Patient 14) had a signature on discharge summary by the RN. 4. The HA failed to ensure the clinical records for three of 14 sampled patients (Patient 10, Patient 11, and Patient 12) had a signature on the CTI by Physician. The deficient practice resulted in patients medical records not being accurate, complete, signed, and dated by the disciplines furnishing services. --- A . A review of Patient 1s record untitled admission sheet, indicated a start of care date on 4/20/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). b. A review of Patient 2s record untitled admission sheet, indicated a start of care date on 4/14/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. c. A review of Patient 5s record untitled admission sheet, indicated a start of care date on 3/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. d. A review of Patient 6s record untitled admission sheet, indicated a start of care date on 3/22/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. e. A review of Patient 8s record untitled admission sheet, indicated a start of care date on 2/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. f. A review of Patient 11s record untitled admission sheet, indicated a start of care date on 8/21/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) without heart failure (heart not pumping enough blood for the body). g. A review of Patient 12s record untitled admission sheet, indicated a start of care date on 8/14/2023 with a primary diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions) h. A review of Patient 13s record untitled admission sheet, indicated a start of care date on 2/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris During a concurrent interview and record review on 5/17/2024 at 11:50 a.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 1 IDG dates 4/20/2024-5/7/2024, there were no nursing and physician signatures. ADM/DCPS stated, ";yes there are no signatures on the IDG for nursing and doctor, if there are no signatures it wasnt done." During further review of Patient 1s clinical record initial comprehensive assessment, there was no signature indicating who completed the document. The ADM/DPCS stated, ";there is no signature on initial comprehensive assessment for Patient 1. Not sure which nurse did it." During a concurrent interview and record review on 5/17/2024 at 11:56 a.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 2 IDG dates 4/14/2024-5/1/2024, there were no nursing and physician signatures. ADM/DCPS stated, ";yes there are no signatures on the IDG for nursing and doctor, if there are no signatures it wasnt done." During further review of Patient 2s clinical record initial comprehensive assessment, there was no signature indicating who completed the document. The ADM/DPCS stated, ";there is no signature on initial comprehensive assessment for Patient 2. Not sure which nurse did it." During a concurrent interview and record review on 5/17/2024 at 12:00 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 5 IDG entry page was blank. ADM/DCPS stated, ";there is no IDG entry period for Patient 5. Not recorded not done." During further review of Patient 5s clinical record initial comprehensive assessment, there was no signature indicating who completed the document. The ADM/DPCS stated, "; there is no signature on initial comprehensive assessment for Patient 5. Not sure which nurse did it." During a concurrent interview and record review on 5/17/2024 at 12:10 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 6 the IDG entry page was blank. ADM/DCPS stated, ";there is no IDG entry period for Patient 6. Not recorded not done." During further review of Patient 6s clinical record initial comprehensive assessment, there was no signature indicating who completed the document. The ADM/DPCS stated, "; there is no signature on initial comprehensive assessment for Patient 6. Not sure which nurse did it." During a concurrent interview and record review on 5/17/2024 at 12:15 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 8 the IDG entry page was blank. ADM/DCPS stated, ";there is no IDG entry period for Patient 8. Not recorded not done." During further review of Patient 8s clinical record initial comprehensive assessment, there was no signature indicating who completed the document. The ADM/DPCS stated, "; there is no signature on initial comprehensive assessment for Patient 8. Not sure which nurse did it." During a concurrent interview and record review on 5/17/2024 at 12:20 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 11 there is no physician signature on the Physicians Certification for Hospice benefit Certification #1: Statement for First 90-day period in the record. ADM/DCPS stated, ";There is no signature on the initial certification period 1 CTI by the physician for Patient 11. If its not signed its not done." Further record review of Patient 11s clinical record indicated there is no physician signature on the Physicians Certification for Hospice benefit Certification #2: Statement for Second 90-day period in the record and physician face to face entry page is blank. ADM/DCPS stated, ";There is no signature on the second certification period CTI by the physician for Patient 11. If its not signed its not done. There is no physician face to face entries for Patient 11." Further record review of Patient 11s clinical record, the IDG entries stop on 2/17/2024. ADM/DCPS stated, ";there are no signatures for nursing and doctor on any of the IDGs before 2/17/2024 and the IDG entries stop on 2/17/2024 for Patient 11." During a further review of patient 11s clinical record discharge summary, there was no signature indicated who completed the document. ADM/DPCS stated, ";I dont see a signature on the discharge summary for Patient 11. It wasnt done." During a concurrent interview and record review on 5/17/2024 at 12:23 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 12 there is no physician signature on the Physicians Certification for Hospice benefit Certification #2: Statement for Second 90-day period, certification #3: Re-certification Statement for Next 60-day period, certification #4: Re-certification Statement for Next 60-day period in the record and physician face to face entry page is blank. ADM/DCPS stated, ";There is no signature on the second, third and the fourth certification period CTI by the physician for Patient 12. If its not signed its not done. There is no physician face to face entries for Patient 12." Further review of Patient 12s clinical record none of the IDG entries have nursing or physician signature. ADM/DCPS stated, ";there are no signatures for nursing and doctor on any of the IDGs for Patient 12. Not recorded not done." During a further record review of patient 12s clinical record discharge summary, there was no signature indicated who completed the document. ADM/DPCS stated, ";I dont see a signature on the discharge summary for Patient 12. It wasnt done." During a concurrent interview and record review on 5/17/2024 at 12:25 p.m. with ADM/DPCS of the Electronic Medical Record (EMR) for Patient 13 the IDG entry page was blank. ADM/DCPS stated, ";there is no IDG entry period for Patient 13. Not recorded not done." During a further review of patient 13s clinical record discharge summary, there was no signature indicated who completed the document. ADM/DPCS stated, ";I dont see a signature on the discharge summary for Patient 13. It wasnt done." During further review of Patient 13s clinical record initial comprehensive assessment, there was no signature indicating who completed the document. The ADM/DPCS stated, ";there is no signature on initial comprehensive assessment for Patient 13. Not sure which nurse did it." During record review of HAs policy and procedure titled, ";Content of Clinical Record", revised Aril 2020, the policy and procedure indicated, ";Each entry will be dated and signed, including title and credentials, by the person providing the care/service." a. A review of Patient 3s medical record, untitled admission sheet, indicated a start od care date of 4/10/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). b. A review of Patient 4s medical record, untitled admission sheet, indicated a start of care date on 4/10/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. c. A review of Patient 7s medical record, untitled admission sheet, indicated a start of care date of 3/22/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). d. A review of Patient 14s medical record, untitled admission sheet, indicated a start of care date on 7/8/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) with heart failure (heart not pumping enough blood for the body). A review of Patient 3s medical record titled, ";Comprehensive Nursing Assessment," dated 4/10/2024, indicated that Patient 3 required a walker or wheelchair for movement, has shortness of breath and general body weakness. The document was unsigned by a clinician. A review of Patient 4s medical record titled, ";Comprehensive Nursing Assessment," dated 4/10/2024, indicated that Patient 3 required a walker or wheelchair for movement, has shortness of breath and general body weakness. The document was unsigned by a clinician. A review of Patient 7s medical record titled, ";Comprehensive Nursing Assessment," dated 3/7/2024, indicated that Patient 3 required a walker or wheelchair for movement, has shortness of breath and general body weakness. The document was unsigned by a clinician. A review of Patient 14's undated medical record titled, "Discharge Plan," was not signed by a clinician. During an interview and concurrent record review on 5/17/2024 at 12:30 p.m. of Patient 4's medical record titled, "Comprehensive Nursing Assessment," dated 4/10/202 , ADM/DCPS stated that the document was unsigned. During an interview and concurrent record review on 5/17/2024 at 12:35 p.m. of Patient 3's medical record titled, "Comprehensive Nursing Assessment," dated 4/10/2024, ADM/DCPS stated that the document was unsigned. During an interview and concurrent record review on 5/17/2024 at 12:40 p.m. of Patient 7's medical record titled, "Comprehensive Nursing Assessment," dated 4/10/2024, ADM/DCPS stated that the document was unsigned. During an interview and concurrent record review on 5/17/2024 at 12:45 p.m. of Patient 14's undated medical record titled, "Discharge Plan," , ADM/DCPS stated that the document was unsigned. a. A review of Patient 1s medical record, untitled admission sheet, indicated a start of care (SOC) date of 4/20/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). During a concurrent interview and record review on 5/17/2024 at 11:50 a.m. with Administrator/Director of Patient Care Services (ADM/DPCS) of Patient 1s Electronic Medical Record (EMR), the record indicated there were no nursing and physician signatures for the IDG dates from 4/20/2024 to 5/7/2024. The ADM/DPCS stated, ";Yes, there are no signatures on the IDG for nursing and doctor, if there are no signatures, it wasnt done." Further review of Patient 1s clinical record, titled Initial Comprehensive Assessment and dated 4/20/2024, there was no signature indicating who completed the document. The ADM/DPCS stated, ";There is no signature on initial comprehensive assessment for Patient 1. Not sure which nurse did it." b. A review of Patient 2s medical record, untitled admission sheet, indicated an SOC date of 4/14/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. During a concurrent interview and record review on 5/17/2024 at 11:56 a.m. with ADM/DPCS of Patient 2s Electronic Medical Record (EMR), the record indicated there were no nursing and physician signatures for the IDG dates from 4/14/2024 to 5/1/2024. The ADM/DPCS stated, ";Yes, there are no signatures on the IDG for nursing and doctor, if there are no signatures, it wasnt done." Further review of Patient 2s clinical record, titled Initial Comprehensive Assessment and dated 04/14/2024, there was no signature indicating who completed the document. The ADM/DPCS stated, ";There is no signature on initial comprehensive assessment for Patient 2. Not sure which nurse did it." c. A review of Patient 3s medical record, untitled admission sheet, indicated an SOC date of 4/10/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. A review of Patient 3s medical record titled, ";Comprehensive Nursing Assessment," dated 4/10/2024, indicated that Patient 3 required a walker or wheelchair for movement, has shortness of breath and general body weakness. The document was unsigned by a clinician. During an interview and concurrent record review on 5/17/2024 at 12:35 p.m. of Patient 3's medical record titled, "Comprehensive Nursing Assessment," dated 4/10/2024, the ADM/DPCS stated that the document was unsigned. Further review of Patient 3s IDG history, the ADM/DPCS stated that none of the IDGs were signed by the physician or nursing services. d. A review of Patient 4s medical record, untitled admission sheet, indicated an SOC date of 4/10/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. A review of Patient 4s medical record titled, ";Comprehensive Nursing Assessment," dated 4/10/2024, indicated that Patient 4 required a walker or wheelchair for movement, has shortness of breath and general body weakness. The document was unsigned by a clinician. During an interview and concurrent record review on 5/17/2024 at 12:30 p.m. of Patient 4's medical record titled, "Comprehensive Nursing Assessment," dated 4/10/2024, the ADM/DPCS stated that the document was unsigned. During a further record review of Patient 4s IDG history, the ADM/DPCS stated that none of the IDGs were signed by the physician or nursing services. e. A review of Patient 5s medical record, untitled admission sheet, indicated an SOC date of 3/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. During a concurrent interview and record review on 5/17/2024 at 12:00 p.m. with ADM/DPCS of Patient 5s Electronic Medical Record (EMR), the IDG entry page was blank. The ADM/DPCS stated, ";There is no IDG entry period for Patient 5. Not recorded, not done." During further review of Patient 5s clinical record, titled Initial Comprehensive Assessment and dated xx/xx/xxxx, there was no signature indicating who completed the document. The ADM/DPCS stated, ";There is no signature on initial comprehensive assessment for Patient 5. Not sure which nurse did it." f. A review of Patient 6s medical record, untitled admission sheet, indicated an SOC date of 3/22/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. During a concurrent interview and record review on 5/17/2024 at 12:10 p.m. with ADM/DPCS of Patient 6s Electronic Medical Record (EMR), the IDG entry page was blank. The ADM/DPCS stated, ";There is no IDG entry period for Patient 6. Not recorded, not done." Further review of Patient 6s clinical record, titled Initial Comprehensive Assessment and dated 3/22/2024, there was no signature indicating who completed the document. The ADM/DPCS stated, ";There is no signature on initial comprehensive assessment for Patient 6. Not sure which nurse did it." g. A review of Patient 7s medical record, untitled admission sheet, indicated an SOC date of 3/22/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. A review of Patient 7s medical record titled, ";Comprehensive Nursing Assessment," dated 3/22/2024, indicated that Patient 7 required a walker or wheelchair for movement, has shortness of breath and general body weakness. The document was unsigned by a clinician. During an interview and concurrent record review on 5/17/2024 at 12:40 p.m. of Patient 7's medical record titled, "Comprehensive Nursing Assessment," dated 3/22/2024, the ADM/DPCS stated that the document was unsigned. During a further record review of Patient 7s IDG history, the ADM/DPCS stated that none of the IDGs were signed by the physician or nursing services. h. A review of Patient 8s medical record, untitled admission sheet, indicated an SOC date of 2/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. During a concurrent interview and record review on 5/17/2024 at 12:15 p.m. with ADM/DPCS of Patient 8s Electronic Medical Record (EMR), the IDG entry page was blank. The ADM/DPCS stated, ";There is no IDG entry period for Patient 8. Not recorded, not done." Further review of Patient 8s clinical record, titled Initial Comprehensive Assessment and dated 2/25/2024, there was no signature indicating who completed the document. The ADM/DPCS stated, ";There is no signature on initial comprehensive assessment for Patient 8. Not sure which nurse did it." i.A review of Patient 9s medical record, untitled admission sheet, indicated an SOC date of 9/3/2023 with a primary diagnosis of hypertensive heart disease with heart failure. During an interview and concurrent record review on 5/17/2024 at 12:50 p.m. of Patient 9s Electronic Medical Record (EMR), medical records titled "POC/IDG Review", the ADM/DPCS stated that there were no signatures from a physician or nursing services documented. j.A review of Patient 10s medical record, untitled admission sheet, indicated an SOC date of 9/3/2023 with a primary diagnosis of hypertensive heart disease with heart failure. During an interview and concurrent record review on 5/17/2024 at 12:55 p.m. of Patient 10s Electronic Medical Record (EMR), there was no physician signature on the Physicians Certification for Hospice benefit Certification #2: Re-certification Statement for Second 90-day period in the record. Further review of patient 11s medical records, titled "POC/IDG" Review, the ADM/DPCS stated that there were no signatures from a physician or nursing services documented. k. A review of Patient 11s medical record, untitled admission sheet, indicated an SOC date of 8/21/2023 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart as a result of chronic high blood pressure) without heart failure (heart not pumping enough blood for the body). During a concurrent interview and record review on 5/17/2024 at 12:20 p.m. with ADM/DPCS of Patient 11s Electronic Medical Record (EMR), there was no physician signature on the Physicians Certification for Hospice benefit Certification #1: Statement for First 90-day period in the record. The ADM/DPCS stated, ";There is no signature on the initial certification period 1 CTI by the physician for Patient 11. If it's not signed, its not done." Further record review of Patient 11s clinical record, indicated there is no physician signature on the Physicians Certification for Hospice benefit Certification #2: Statement for Second 90-day period in the record and physician face to face entry page was blank. The ADM/DPCS stated, ";There is no signature on the second certification period CTI by the physician for Patient 11. If its not signed, its not done. There is no physician face to face entries for Patient 11." Patient 11s clinical record further indicated the IDG entries stopped on 2/17/2024. The ADM/DPCS stated, ";There are no signatures for nursing and doctor on any of the IDGs before 2/17/2024 and the IDG entries stopped on 2/17/2024 for Patient 11." Further review of patient 11s clinical record Discharge Summary, there was no signature to indicate who completed the document. The ADM/DPCS stated, ";I dont see a signature on the discharge summary for Patient 11. It wasnt done." l. A review of Patient 12s medical record, untitled admission sheet, indicated an SOC date of 8/14/2023 with a primary diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During a concurrent interview and record review on 5/17/2024 at 12:23 p.m. with ADM/DPCS of Patient 12s Electronic Medical Record (EMR), there was no physician signature on the Physicians Certification for Hospice benefit Certification #2: Statement for Second 90-day period, certification #3: Re-certification Statement for Next 60-day period, certification #4: Re-certification Statement for Next 60-day period in the record and physician face to face entry page was blank. The ADM/DPCS stated, ";There is no signature on the second, third and the fourth certification period CTI by the physician for Patient 12. If its not signed, its not done. There is no physician face to face entries for Patient 12." Further review of Patient 12s clinical record indicated none of the IDG entries have nursing or physician signatures. The ADM/DPCS stated, ";There are no signatures for nursing and doctor on any of the IDGs for Patient 12. Not recorded, not done." A further record review of Patient 12s clinical record Discharge Summary, there was no signature to indicate who completed the document. The ADM/DPCS stated, ";I dont see a signature on the discharge summary for Patient 12. It wasnt done." m. A review of Patient 13s medical record, untitled admission sheet, indicated an SOC date of 2/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris. During a concurrent interview and record review on 5/17/2024 at 12:25 p.m. with ADM/DPCS of Patient 13s Electronic Medical Record (EMR), the IDG entry page was blank. The ADM/DPCS stated, ";There is no IDG entry period for Patient 13. Not recorded, not done." A further review of patient 13s clinical record Discharge Summary, there was no signature to indicate who completed the document. The ADM/DPCS stated, ";I dont see a signature on the discharge summary for Patient 13. It wasnt done." Further review of Patient 13s clinical record titled Initial Comprehensive Assessment and dated 02/25/2024, indicated there was no signature indicating who completed the document. The ADM/DPCS stated, ";There is no signature on initial comprehensive assessment for Patient 13. Not sure which nurse did it." n. A review of Patient 14s medical record, untitled admission sheet, indicated an SOC date of 7/8/2023 with a primary diagnosis of hypertensive heart disease with heart failure. A review of Patient 14's undated medical record titled, "Discharge Plan," was not signed by a clinician. During an interview and concurrent record review on 5/17/2024 at 12:45 p.m. of Patient 14's undated medical record titled, "Discharge Plan", the ADM/DPCS stated that the document was unsigned. During a further record review of Patient 14s IDG history, the ADM/DPCS stated that none of the IDGs were signed by the physician or nursing services. A review of HAs policy and procedure titled, ";Content of Clinical Record", revised Aril 2020, the policy and procedure indicated, ";Each entry will be dated and signed, including title and credentials, by the person providing the care/service."