Every finding on record at Tlc Palliative LLC

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 the Condition of Participation regarding Personnel Qualification was met as follows: --- The HA failed to provide evidence that their licensed professional staff (the nurse practitioner) were hired under an individual contract or under an arrangement with the HA, and qualified to provide patient care for three out of three sampled patients (Patient 1, Patient 2, and Patient 3). As a result, the non-compliance resulted in Patient 1, Patient 2, and Patient 3, not receiving hospice care and services and had the potential to result in assessing the patients incorrectly leading to misdiagnosis, improper treatment, worsening conditions, hospitalization, or death. (Refer to L784). 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 Personnel Qualifications to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on interview and record review, The Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide evidence that their licensed professional staff, the Nurse Practitioner (NP, a registered nurse with advanced training who provides patient care, similar to a doctor) were hired under an individual contract or under an arrangement with the HA, and qualified to provide patient care for three out of three sampled patients (Patient 1, Patient 2, and Patient 3). This deficient practice resulted in Patient 1, Patient 2, and Patient 3, not receiving hospice care and services and had the potential to result in assessing the patients incorrectly leading to misdiagnosis, improper treatment, worsening conditions, hospitalization, or death. On 10/10/2024 at 3:40 p.m., the Department called an Immediate Jeopardy Situation (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the HAs Director of Patient Care Services (DPCS)/Administrator related to failure to ensure that the licensed professional staff were hired under an individual contract or under an arrangement with the HA, and qualified to provide patient care for Patient 1, Patient 2, and Patient 3, which resulted in the patients not receiving hospice care and services and had the potential to result in assessing the patients incorrectly leading to misdiagnosis, improper treatment, worsening conditions, hospitalization, or death. . On 10/10/2024, at 4:20 p.m., the HA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 10/10/2024, at 4:30 p.m., the survey team completed the survey tasks and conducted an exit conference, with the DPCS/Administrator with the IJ situation not removed. --- During an interview with the DPCS on 10/10/2024 at 2:55 p.m., the DPCS stated he attempted to call the MD designee and MD designee stated she is currently out on a cruise. DPCS also stated that he also called the agencys MD and was told to give the survey team the HAs office phone number to call him back. DPCS also stated he called the NP and the NP told the DPCS that he is not available for an interview. a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 6/26/2024, with a terminal diagnosis of hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). A review of Patient 1's History and Physical (H&P) Home visit dated 9/2/2024, indicated Nurse Practitioner (NP) provided a head to toe assessment for Patient 1. b. During a review of Patient 2s admission record indicated a start of care (SOC) date of 5/21/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (a lung disease that blocks airflow and make it difficult to breathe). A review of Patient 2's H&P Home visit dated 9/2/2024, indicated NP provided a head to toe assessment for Patient 2. During an interview with Patient 2 on 10/10/2024, at 1 p.m., he stated the HHA did not explain to him regarding the hospice services, that he was not sick or dying in six months and he was upset knowing knowing he could not use his hospice benefits when he really needs it. He further stated that NP visited him on 10/9/2024, to do a head to toe assessment on him. c. During a review of Patient 3s admission record indicated a start of care (SOC) date of 5/21/2024, with a terminal diagnosis of atherosclerotic heart disease (damage in the heart's blood vessels). A review of Patient 3's H&P visit dated 9/2/2024, indicated NP provided a head to toe assessment for Patient 3. A review of the HA's NP employee personnel files indicated that there was no application nor signed contract found on file. During an interview with the Director Of patient Care Services (DPCS) on 10/9/2024, at 2 p.m., he stated he sent NP to do a face to face encounter with Patient 1, 2, and 3 on 9/2/2024, in order to formulate a H&P for these patients to evaluate hospice eligibility. When the DPCS was asked if the NP was a regular employee at the agency, He stated no, that the NP haven't sign a hiring contract or complete an application and go through the hiring process with the HHA at this time. An attempt to call for an interview with the NP on 10/10/28, at 1 p.m., and 1:30 p.m., but the NP did not return back call. An attempt to call for an interview with the HHAs Medical Director (MD) on 10/10/2024, on 10/10/2024, at 1 p.m., but MD did not return back call. A review of the HHAs undated policy and procedure ";Selection/Hiring Process", indicated an individual seeking an employment will complete an application, including information and verification about education, work experience, job history and references, and have a personnel interview.

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 follows: --- The Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure three of 14 patients (Patients 3, Patient 4 and Patient 5) were informed of their rights to receive information of the services provided by the hospice and the limitations of these services. (Refer to L519). The cumulative effect of this systemic practice resulted in the failure of the Hospice to deliver statutorily (written law) mandated compliance with Federal regulations for Patients' Rights to ensure their rights were not violated and provided the highest quality of 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 three out of 14 sampled patients (Patient 3, Patient 4, and Patient 5) were informed of their rights to receive information of the services provided by the hospice and the limitations of these services.    This deficient practice resulted in the rights of Patient 3, Patient 4, and Patient 5 being violated related to lack of credible information, lack of understanding, and miscommunication to these patients assessed and certified to receive the hospice benefits. --- a. During a review of Patient 3s admission record, the admission record indicated a start of care (SOC) date of 5/21/2024, with a terminal diagnosis of atherosclerotic heart disease (damage in the heart's blood vessels).  During a review of Patient 3's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 7/25/2024, the POC/IDG indicated the frequency of visits of skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification.   On 8/8/2024, at 12:50 p.m., a home visit was conducted at Patient 3's residence with registered nurse (RN 1). During an observation, Patient 3 was ambulating using a walker, alert and oriented, spoke Tagalog (language spoken by Filipinos in the Philippines) and signed her own visit consent. During a concurrent interview, Patient 3 was asked if hospice service was explained to her and stated she did not have an idea what hospice was about. Patient 3 also stated the HA would send a nurse (unidentified, no name badge or identification) to come visit her every week to take her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). Patient 3 stated she was not sick and that she was not dying in the next six months.   b. During a review of Patient 4s admission record, the admission record indicated a start of care (SOC) date of 5/20/2024, with a terminal diagnosis of atherosclerotic heart disease. During a review of Patient 4's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 7/25/2024, the POC/IDG indicated the frequency of visits of skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification.    On 8/8/2024, at 12 p.m., a home visit was conducted at Patient 4's residence with registered nurse (RN 1). During an observation, Patient 4 was ambulating with minimal exertion without an assistive device, alert and oriented with complaint of moderate bilateral knee pain. Patient 4 was asked if hospice service was explained to her and stated, "No". Patient 4 stated she thought she was enrolled in some kind of program.  Patient 4 stated she was not sick and was not dying in the next six months.   c. During a review of Patient 5s admission record, the admission record indicated a start of care (SOC) date of 4/8/2024, with a terminal diagnosis of hypertensive heart disease (a heart problem that occur because of high blood pressure that is present over a long time). During a review of Patient 5's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 7/25/2024, the POC/IDG indicated the frequency of visits of skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification.   During a phone interview, on 8/8/2024, at 1 p.m., with Patient 5's family member (FM 1), she stated the HA did not explaine to the family the purpose of hospice, and that Patient 5 was not dying in 6 months. FM 1 stated she only needed a nurse to visit her to monitor her health condition and take her vital signs.    During an interview, on 8/9/2024, at 12 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the visiting nurses should have explained to the patient and to the patients family the kind of service they provide and the limitations of these services.   During a review of the agencys undated policy and procedure titled, ";Rights/Responsibilities", the policy and procedure indicated each patient will be an active, informed participant in his/her plan of care. The patient will be informed during the initial assessment visit, in advance of furnishing care, of the hospice philosophy and program of care, the organizations mission and care and services provided directly or through contractual arrangements, and the goals of hospice, the interventions that support those goals and the identification of the staff providing service.     A review of the agency's undated policy and procedure, titled, "Admission Information", the policy and procedure 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 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.

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 Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live)) failed to conduct and document a 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 nine of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8 and Patient 9). (Refer to L524). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits. 1. The Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live)) failed to conduct and document a 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 nine of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8 and Patient 9). (Refer to L524). 2. The HA staff failed to do a skin assessment for an existing rash at lower bilateral extremities for one of 14 sample patients (Patient 5). (Refer to L533). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on 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 a comprehensive assessment that reflected the patients' current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for nine of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8 and Patient 9). This deficient practice resulted for these patients being certified for hospice care lacking documented evidence of patients' comprehensive assessments to determine their eligibility to receive the hospice benefits. --- f. During a review of Patient 6s admission record indicated a start of care (SOC) date of 4/8/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- a lung disease that blocks airflow and make it difficult to breathe). A review of Patient 6's Physicians Certification for Hospice Benefit, dated 4/8/2024 to 7/6/2024, indicated the 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. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical showing evidence to support the terminal illness diagnosis. During an interview on 8/7/2024 at 11:05 am, Patient 6 stated that she has a primary physician, and that the primary physician is not Physician 1. She stated that she has had the same primary physician, Physician 3, for more than four years. During an interview and concurrent record review of Patient 6s medical record on 8/9/2024 at 1:15pm, DPCS stated that If a patient has an attending physician that the Hospice Agency should contact that physician, but that it is not required for primary physicians to coordinate or sign the hospice certification of terminal illness. DPCS stated that no medical records were requested from the primary physician. g. During a review of Patient 7s admission record indicated a start of care (SOC) date of 3/18/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- a lung disease that blocks airflow and make it difficult to breathe). A review of Patient 7's Physicians Certification for Hospice Benefit, dated 3/18/2024 to 6/15/2024, indicated the Physician 1 signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical showing evidence to support the terminal illness diagnosis. During an interview and concurrent record review of Patient 7s medical record on 8/9/2024 at 1:15pm, DPCS stated that the hospice agency did not attempt or obtain any history and physical, history of laboratory testing, or any previous medical records. h. During a review of Patient 8s admission record indicated a start of care (SOC) date of 3/17/2024, with a terminal diagnosis of heart disease. A review of Patient 8's Physicians Certification for Hospice Benefit, dated 3/17/2024 to 6/14/2024, indicated the Physician 1 signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical showing evidence to support the terminal illness diagnosis. During an interview and concurrent record review of Patient 8s medical record on 8/9/2024 at 1:15pm, DPCS stated that the hospice agency did not attempt or obtain any history and physical, history of laboratory testing, or any previous medical records. i. During a review of Patient 9s admission record indicated a start of care (SOC) date of 3/8/2024, with a terminal diagnosis of atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your arteries). A review of Patient 9's Physicians Certification for Hospice Benefit, dated 3/8/2024 to 6/5/2024, indicated the Physician 1 signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical showing evidence to support the terminal illness diagnosis. During an interview and concurrent record review of Patient 9s medical record on 8/9/2024 at 1:15pm, DPCS stated that the hospice agency did not attempt or obtain any history and physical, history of laboratory testing, or any previous medical records. During an interview on 8/9/2024 at 12:55pm, Medical Director stated that if the patient has an attending physician that the attending physician should also sign on the hospice certificate of terminal illness. Medical Director also stated that evaluation of a patient for hospice eligibility should include review of the patients previous medical records. a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 6/26/2024, with a terminal diagnosis of hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 6/26/2024 to 9/23/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was 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. On 8/8/2024, at 10 a.m., a home visit was conducted at Patient 1's residence with RN 1 (registered nurse). Patient 1 was observed as alert and oriented, He was walking in steady gait (walking with balance) without using an assistive device (any kind of tool or device that can help simplify caregiving or make the environment safer). b. During a review of Patient 2s admission record indicated a start of care (SOC) date of 5/21/2024, with a terminal diagnosis of chronic obstructive pulmonary disease ( a lung disease that blocks airflow and make it difficult to breathe). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 5/21/2024 to 8/18/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was 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. c. During a review of Patient 3s admission record indicated a start of care (SOC) date of 5/21/2024, with a terminal diagnosis of atherosclerotic heart disease (damage in the heart's blood vessels). During a review of Patient 3's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 7/25/2024, indicated the frequency of visits of skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. On 8/8/2024, at 12:50 p.m., a home visit was conducted at Patient 3's residence with registered nurse (RN 1). Patient 3 was observed ambulating using a walker, alert and oriented , speaks Tagalog and signed her own visit consent. When Patient 3 was asked if hospice service was explained to her, Patient 3 stated she did not have an idea what hospice was about. Patient 3 also stated the HA would send a nurse (unidentified) to come visit her every week to take her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). Patient 3 further stated she was not sick and that she was not dying in the next six months. d. During a review of Patient 4s admission record indicated a start of care (SOC) date of 5/20/2024, with a terminal diagnosis of atherosclerotic heart disease. During a review of Patient 4's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 7/25/2024, indicated the frequency of visits of skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. On 8/8/2024, at 12 p.m., a home visit was conducted at Patient 4's residence with registered nurse (RN 1). Patient 4 was observed ambulating at 25 steps with minimal exertion and without using an assistive device, alert and oriented with complaint of moderate bilateral knee pain. When asked if hospice service was explained to her, she stated no, she thought she was enrolled into a program. Patient 4 further stated she was not sick and that she was not dying in the next six months. e. During a review of Patient 5s admission record indicated a start of care (SOC) date of 4/8/2024, with a terminal diagnosis of hypertensive heart disease (a heart problem that occur because of high blood pressure that is present over a long time). During a review of Patient 5's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 7/25/2024, indicated the frequency of visits of skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. On 8/8/2024, at 1 p.m., during a phone interview with family member (FM 1), she stated the HA did not explained to the family the purpose of hospice, that Patient 5 was not dying in 6 months and she only needed a nurse to visit her to monitor her health condition and takes her vital signs. During an interview on 8/8/2024, at 1 p.m., with the hospice Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8 and Patient 9, and have not spoken and/or discussed patients medical history with them. Physician 1 stated he was now the acting attending physician after these patients were admitted to hospice service since they all have no attending physician to refer them. Physician 1 also stated the HA gets word of mouth referral from family and friends and the HA have not obtained any past medical records to justify patient's eligibility. When asked how he determine patients were eligible for hospice care, Physician 1 stated these patients were eligible because of his face to face encounter/assessment of the patient, the registered nurse assessment/visit notes, reviewing patients past medical records, and following the LCD guidelines. On 8/8/2024, at 1:30 p.m., during an interview with the DPCS (director of patient care services),when asked about the agency's admission process, he stated the HA gets referral from hospital and word of mouth from patient's family and friends. Once referral was called to the agency, a nurse will be sent to the patient's residence to determine eligibility by doing a head to toe assessment and using the LCD guidelines. During a review of the agencys undated policy and procedure titled, ";Physician Services-Medical Director", indicated the hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care. During a review of the agencys undated policy and procedure titled "Admission Criteria and Process", indicated AH Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). AH Hospice Inc will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. During a review of the agencys undated policy and procedure titled ";Certification of Terminal Illness", indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification.

Based on interview, and record review, the Hospice Agency (HA) staff failed to document an update of the skin assessment for an existing rash at the lower bilateral extremities for one of 14 sample patients (Patient 5). This deficient practice has the potential in the delay to identify the progress or decline, and changes of the existing rash for further treatment and intervention. --- During a review of Patient 5s admission record indicated a start of care (SOC) date of 4/8/2024, with a terminal diagnosis of hypertensive heart disease (a heart problem that occur because of high blood pressure that is present over a long time). During a review of Patient 5's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) dated 7/25/2024, indicated the frequency of visits of skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. A review of Patient 5's Initial Comprehensive Nursing Assessment dated 4/8/2024, indicated the patient was identified with an existing bilateral lower extremities skin rashes and was prescribed Vani (treat eczema, dermatitis, allergies, rash) cream applied to affected areas. There was no comprehensive assessment identifying the location and distribution, size, shape, color, type, pattern of the skin rashes, and/or any description of any drainage. A review of Patient 5's SN (skilled nurse) Visit Notes dated 4/22/2024 and 5/6/2024, indicated no documented evidence of a skin assessment was done for the existing skin rashes at patient's bilateral lower extremities. During an interview with the director of patient care services (DPCS) on 8/9/2024, at 11 a.m., he stated the visiting nurse forgot to do an assessment on patient's skin rash at the lower extremities during the visit. A review of the HA's undated policy " "Wound Assessment ", indicated during initial and follow-up nursing visits, any non-intact skin areas shall be assessed and document, to complete measurement of the wound (length, width, depth) shall be documented at least weekly.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group, Care Planning, and Coordination of Services was met as follows: --- 1. The HA (hospice agency) failed to develop a plan of care for an existing skin rash for one out of 14 sampled patients (Patient 5). (Refer to L543). 2. The HA failed to provide prescribed Vanicream to an existing skin rashes for one out of 14 sampled patients (Patient 5). (Refer to L549). 3. The HA failed to notify the physician regarding a patient, who was assessed as a high risk for fall had a fall episode for one out 14 sampled patients (Patient 4). (Refer to L555). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care was provided to the patients who were assessed to receive hospice care and services. 4. The HA failed to develop a care plan for fall/safety for two patients (patient x and patient y) that were identified as a risk for fall/injury.

Based on interview and record review, the HA (hospice agency) failed to develop plans of care for three out of 14 sampled patients (Patient 5, Patient 6 and Patient 7). For Patient 5, the visiting nurse failed to develop a care plan for an existing skin rash. This deficient practice placed the patient's existing skin rashes at risk for ineffective skin treatment management. For Patient 6 and Patient 7, the HA failed to develop plans of care for patients identified as a fall risk. The deficient practice placed the patients at risk for falls that could lead to bodily injuries. --- During a review of Patient 5s admission record indicated a start of care (SOC) date of 4/8/2024, with a terminal diagnosis of hypertensive heart disease (a heart problem that occur because of high blood pressure that is present over a long time). During a review of Patient 5's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 7/25/2024, indicated the frequency of visits of skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. A review of Patient 5's Initial Comprehensive Nursing Assessment dated 4/8/2024, indicated the patient was identified with an existing bilateral lower extremities skin rashes and prescribed Vani cream was applied to affected areas. A review of Patient 5's POC summary dated 4/16/2024, indicated a physician's order to apply Vani cream to affected skin area once to twice a day for skin rashes. A further review of Patient 5's clinical record indicated no care plan was developed for the patient's existing skin rashes at her bilateral lower extremities. During an interview with the DPCS on 8/9/2024, at 11:30 a.m., he stated he could not find any documented evidence of a care plan for patient's skin rashes. During a review of Patient 6s admission record indicated a start of care (SOC) date of 4/8/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- a lung disease that blocks airflow and make it difficult to breathe). During a review of Patient 6's Fall Risk Assessment dated 7/1/2024, Patient 6 was identified as a moderate risk for falls, with a history of falling in the past two months, and under "fall precautions." During a review of Patient 6's Plan of Care dated 7/11/2024, there was no care plan to address the fall risk and prevention of falls. During a review of Patient 7s admission record indicated a start of care (SOC) date of 3/18/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- a lung disease that blocks airflow and make it difficult to breathe). During a review of Patient 7's Fall Risk Assessment dated 3/18/2024, Patient 7 was identified as a high risk for falls, a recent incident of falls, and required fall precautions. During a review of Patient 7's Plan of Care dated 7/25/2024, there was no care plan to address the fall risk and prevention of falls. During an interview on 8/9/2024 at 2:45pm DPCS stated that if a patient is identified as a fall risk there should be a care plan for it.

Based on interview and record review, the hospice agency (HA) failed to provide the prescribed Vani cream treatment as ordered to an existing skin rash for one out of 14 sampled patients (Patient 5). This deficient practice has the potential in the delay of the healing process of the patient's existing skin rash to the lower extremities. --- During a review of Patient 5s admission record indicated a start of care (SOC) date of 4/8/2024, with a terminal diagnosis of hypertensive heart disease (a heart problem that occur because of high blood pressure that is present over a long time). During a review of Patient 5's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 7/25/2024, indicated the frequency of visits of skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. A review of Patient 5's Initial Comprehensive Nursing Assessment dated 4/8/2024, indicated the patient was identified with an existing bilateral lower extremities skin rashes and prescribed Vani cream was applied to affected areas. A review of Patient 5's POC summary dated 4/16/2024, indicated a physician's order to apply Vani cream to affected skin area once to twice a day for skin rashes. A review of Patient 5's SN (skilled nurse) Visit Notes dated 4/22/2024 and 5/6/2024, indicated no documented evidence the visiting nurse applied the Vani cream to patient's skin rashes at bilateral lower extremities. During an interview with the DPCS (director of patient care services), he stated the visiting nurse should have provided the Vani cream skin care as ordered to Patient 5.

Based on interview, and record review, the hospice agency failed to notify the physician of the patient's fall incident for one out 14 sampled patients (Patient 4). This failure had the potential to delay provision of treatment or intervention that could lead to physical discomfort and recurrence of fall incidents. --- During a review of Patient 4s admission record indicated a start of care (SOC) date of 5/20/2024, with a terminal diagnosis of atherosclerotic heart disease. During a review of Patient 4's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 7/25/2024, indicated the frequency of visits of skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. A review of Patient 4's Fall Risk Assessment dated 6/17/2024, indicated a fall risk point of 9, identifying Patient 4 was high risk for fall. A review of Patient 4's Communication Note dated 7/1/2024, indicated the visiting nurse witnessed during her visit that the patient got up from the couch, lost her balance, fell to the ground and the back of the head hit the stationary bike. A review of Patient 4's SN (skilled nurse) visit note dated 7/1/2024, indicated no documented evidence the visiting nurse assessed the patient after the fall and notify the physician for further intervention. During an interview with the director of patient care services (DPCS) stated the visiting nurse should have notified the physician about patient's fall incident. A review of Agency's undated policy "Change of Condition", indicated the clinician is responsible for any specific treatment would notify the attending physician of significant changes in the patient's condition

Based on interview and record review the Hospice Agency (HA) failed to ensure the registered nurse hired had one year experience as a hospice nurse as indicated in their policy and procedure. This failure had the potential to result in not meeting the care and services for the patients. --- During a concurrent interview and record review of the Hospice Agency's personnel files on 8/9/2024 at 2:41pm, Director of Patient Care Services (DCPS) stated Registered Nurse 3 (RN3) was hired 12/21/23. DPCS stated RN3 got her license on 3/27/2023, 9 months prior to the hire date. DPCS stated that the requirement to hire a registered nurse must have a minimum of one year experience. A review of the Hospice Agency's undated policy titled, "Job Title/Position: Registered Nurse," indicated that, "Registered nurses shall have a minimum of one year of experience as a professional nurse."

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 for Medical Director was met as evidenced by: --- The hospice agency (HA) failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for nine out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8 and Patient 9). (Refer to L667). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Medical Director to ensure patients admitted for hospice care are comprehensively assessed by the Medical Director and/or physician designee to determine eligibility for hospice care.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for nine out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8 and Patient 9). This deficient practice resulted in Patients 1, 2, 3, 4, 5, 6, 7, 8 and 9, being certified and admitted for hospice care with no documented evidence of patients written clinical information was being reviewed and evaluated by the Medical Director and/or physician designee to support their diagnoses of terminal illness. --- a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 6/26/2024, with a terminal diagnosis of hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 6/26/2024 to 9/23/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was 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. On 8/8/2024, at 10 a.m., a home visit was conducted at Patient 1's residence with RN 1 (registered nurse). Patient 1 was observed as alert and oriented, He was walking in steady gait (walking with balance) without using an assistive device (any kind of tool or device that can help simplify caregiving or make the environment safer). b. During a review of Patient 2s admission record indicated a start of care (SOC) date of 5/21/2024, with a terminal diagnosis of chronic obstructive pulmonary disease ( a lung disease that blocks airflow and make it difficult to breathe). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 5/21/2024 to 8/18/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was 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. c. During a review of Patient 3s admission record indicated a start of care (SOC) date of 5/21/2024, with a terminal diagnosis of atherosclerotic heart disease (damage in the heart's blood vessels). A review of Patient 3's Physicians Certification for Hospice Benefit, dated 5/21/2024 to 8/18/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was 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 review of Patient 3's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 7/25/2024, indicated the frequency of visits of skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. On 8/8/2024, at 12:50 p.m., a home visit was conducted at Patient 3's residence with registered nurse (RN 1). Patient 3 was observed ambulating using a walker, alert and oriented , speaks Tagalog and signed her own visit consent. When Patient 3 was asked if hospice service was explained to her, Patient 3 stated she did not have an idea what hospice was about. Patient 3 also stated the HA would send a nurse (unidentified) to come visit her every week to take her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). Patient 3 further stated she was not sick and that she was not dying in the next six months. d. During a review of Patient 4s admission record indicated a start of care (SOC) date of 5/20/2024, with a terminal diagnosis of atherosclerotic heart disease. A review of Patient 4's Physicians Certification for Hospice Benefit, dated 5/20/2024 to 7/18/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was 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 review of Patient 4's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 7/25/2024, indicated the frequency of visits of skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. On 8/8/2024, at 12 p.m., a home visit was conducted at Patient 4's residence with registered nurse (RN 1). Patient 4 was observed ambulating at 25 steps with minimal exertion and without using an assistive device, alert and oriented with complaint of moderate bilateral knee pain. When asked if hospice service was explained to her, she stated no, she thought she was enrolled into a program. Patient 4 further stated she was not sick and that she was not dying in the next six months. e. During a review of Patient 5s admission record indicated a start of care (SOC) date of 4/8/2024, with a terminal diagnosis of hypertensive heart disease (a heart problem that occur because of high blood pressure that is present over a long time). A review of Patient 5's Physicians Certification for Hospice Benefit, dated 4/8/2024 to 7/6/2024, benefit period #1, indicated the 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. There was no documented evidence of a comprehensive assessment that was 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 review of Patient 5's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 7/25/2024, indicated the frequency of visits of skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification. On 8/8/2024, at 1 p.m., during a phone interview with family member (FM 1), she stated the HA did not explained to the family the purpose of hospice, that Patient 5 was not dying in 6 months and she only needed a nurse to visit her to monitor her health condition and takes her vital signs. During an interview on 8/8/2024, at 1 p.m., with the hospice Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8 and Patient 9, and have not spoken and/or discussed patients medical history with them. Physician 1 stated he was now the acting attending physician after these patients were admitted to hospice service since they all have no attending physician to refer them. Physician 1 also stated the HA gets word of mouth referral from family and friends and the HA have not obtained any past medical records to justify patient's eligibility. When asked how he determine patients were eligible for hospice care, Physician 1 stated these patients were eligible because of his face to face encounter/assessment of the patient, the registered nurse assessment/visit notes, reviewing patients past medical records, and following the LCD guidelines. On 8/8/2024, at 1:30 p.m., during an interview with the DPCS (director of patient care services),when asked about the agency's admission process, he stated the HA gets referral from hospital and word of mouth from patient's family and friends. Once referral was called to the agency, a nurse will be sent to the patient's residence to determine eligibility by doing a head to toe assessment and using the LCD guidelines. During a review of the agencys undated policy and procedure titled, ";Physician Services-Medical Director", indicated the hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care. During a review of the agencys undated policy and procedure titled "Admission Criteria and Process", indicated AH Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). AH Hospice Inc will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. During a review of the agencys undated policy and procedure titled ";Certification of Terminal Illness", indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. . f. During a review of Patient 6s admission record indicated a start of care (SOC) date of 4/8/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- a lung disease that blocks airflow and make it difficult to breathe). A review of Patient 6's Physicians Certification for Hospice Benefit, dated 4/8/2024 to 7/6/2024, indicated the 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. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical showing evidence to support the terminal illness diagnosis. During an interview on 8/7/2024 at 11:05 am, Patient 6 stated that she has a primary physician, and that the primary physician is not Physician 1. She stated that she has had the same primary physician, Physician 3, for more than four years. During an interview and concurrent record review of Patient 6s medical record on 8/9/2024 at 1:15pm, DPCS stated that If a patient has an attending physician that the Hospice Agency should contact that physician, but that it is not required for primary physicians to coordinate or sign the hospice certification of terminal illness. DPCS stated that no medical records were requested from the primary physician. g. During a review of Patient 7s admission record indicated a start of care (SOC) date of 3/18/2024, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- a lung disease that blocks airflow and make it difficult to breathe). A review of Patient 7's Physicians Certification for Hospice Benefit, dated 3/18/2024 to 6/15/2024, indicated the Physician 1 signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical showing evidence to support the terminal illness diagnosis. During an interview and concurrent record review of Patient 7s medical record on 8/9/2024 at 1:15pm, DPCS stated that the hospice agency did not attempt or obtain any history and physical, history of laboratory testing, or any previous medical records. h. During a review of Patient 8s admission record indicated a start of care (SOC) date of 3/17/2024, with a terminal diagnosis of heart disease. A review of Patient 8's Physicians Certification for Hospice Benefit, dated 3/17/2024 to 6/14/2024, indicated the Physician 1 signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical showing evidence to support the terminal illness diagnosis. During an interview and concurrent record review of Patient 8s medical record on 8/9/2024 at 1:15pm, DPCS stated that the hospice agency did not attempt or obtain any history and physical, history of laboratory testing, or any previous medical records. i. During a review of Patient 9s admission record indicated a start of care (SOC) date of 3/8/2024, with a terminal diagnosis of atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your arteries). A review of Patient 9's Physicians Certification for Hospice Benefit, dated 3/8/2024 to 6/5/2024, indicated the Physician 1 signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical showing evidence to support the terminal illness diagnosis. During an interview and concurrent record review of Patient 9s medical record on 8/9/2024 at 1:15pm, DPCS stated that the hospice agency did not attempt or obtain any history and physical, history of laboratory testing, or any previous medical records. During an interview on 8/9/2024 at 12:55pm, Medical Director stated that if the patient has an attending physician that the attending physician should also sign on the hospice certificate of terminal illness. Medical Director also stated that evaluation of a patient for hospice eligibility should include review of the patients previous medical records.

Upon patient record review, 1 of 5 records (Patient #3) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #3: There was no evidence in the patient record that the patient/representative received a copy of the patient's rights and responsibilities.