Every finding on record at Tranquility Hospice, Inc

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill [a disease or condition due to which a patient's death is anticipated] patients who have six months or less to live) failed to provide written information about the hospice services and limitation of services to one out of 14 sampled patients (Patient 11). This deficient practice had the potential for misinformation, misunderstanding, and miscommunication of hospice care and services provided to the patients. --- Findings: A review of Patient 11s face sheet indicated an admission date of 6/30/2023 with the diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart weakens over time and is unable to pump blood as it should be). A review of Patient 11's record titled ";Comprehensive Nursing Assessment", dated 6/30/2023, indicated Patient 11 was a 77 year old female who was unable to tolerate prolonged standing and required walker with ambulation/transfers. The record indicated Patient 11 had a fair to poor appetite and consumed less than 50 percent (%, a ratio) of her meals and needed maximum assistance or support with activities of daily living (ADLs, a term used to describe fundamental skills required to independently care for oneself). A joint home visit was conducted on 11/22/2023 at 3:30 p.m. with the Director of Nursing (DON) at Patient 11's home. During observation on 11/22/2023 at 3:30 p.m. with the DON, observed Patient 11 and her caregiver (CG1) spoke fluent Arabic. During a concurrent interview with the CG1, CG1 stated that the DON just delivered the hospice patient handbook a day prior the home visit. Caregiver stated she had not read the handbook. During an interview with the DON on 11/22/2023 at 5:30 p.m. asked the DON regarding the process of notification of notice of patient's rights and responsibilities and information about services, the DON stated that she had minimal training as a hospice nurse and that she had not read the job description upon hire. DON stated she does not know what the job entailed. A review of the HA's policy titled " Initial Assessment", revised May 2022, indicated admitting registered nurse will provide the patient or patient representative a verbal and written notice of the patient's bill of rights and it will be provided in a language and manner the patient can understand. A review of the HAs policy titled ";Rights and Responsibilities", revised May 2022, indicated to assist with fully understanding patients rights and responsibilities, all policies are available to organization personnel, the patient, and his/her representatives as well as other organizations and the interested public. Patient and family/caregiver responsibilities will be explained upon admission and as needed. The patient and family/caregiver are responsible for: providing accurate and complete information about the present complaints, past illnesses, hospitalizations, medications, changes in advanced directives, and other matters relating to the patients health. The policy further indicated the following: remaining under a doctors care while receiving hospice services, being fully informed by a physician of his or her medical condition, reporting unexpected changes in the patients conditions. The policy indicated the patients rights and responsibilities will be explained and distributed to the patient prior to the initiation of organization services. This explanation will be in a language that the patient and manager understand. When a patients representative signs the patients rights and responsibilities form, an explanation of that relationship must be documented and kept on file in the clinical record, including a copy of signed Durable Power of Attorney or legal guardianship.

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 failed to provide initial bereavement assessment for five of 14 sampled patients (Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). (Refer to L531) 2. The hospice agency staff failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status, and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness for eight of 14 sampled patients (Patient 1, Patient 2, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). (Refer to L532) 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 interview and record review, the hospice agency (HA) failed to provide initial bereavement assessment for five of 14 sampled patients (Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). This deficient practice had the potential to impact a family members' abilities to cope with the patients' death. --- Findings: a. During a review of Patient 6's admission record indicated a start of care date (SOC) of 9/8/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. During a review of Patient 6's POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 9/8/2023, indicated the frequency of visits for skilled nurse (SN) to 1 per week plus 3 prn (pro re nata, which means ";as needed") visits for clinical care and support and for any change of patients condition. Hospice aide, social worker (MSW), chaplain (SC), and volunteer services were declined. During a review of Patient 6's clinical record indicated that there was no initial bereavement assessment conducted. b. During a review of Patient 7's admission record indicated a start of care date of 9/6/2023, with a terminal diagnosis of COPD, unspecified. During a review of Patient 7's POC/IDG form dated 9/20/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 2-3 prn visit, the spiritual counselor to assess one time for spiritual needs, and MSW to assess one time for psychosocial needs. Hospice aide and volunteer services were declined. During a review of Patient 7's clinical record indicated that there was no initial bereavement assessment conducted. c. During a review of Patient 8's admission record indicated a start of care date of 9/6/2023, with a terminal diagnosis of heart disease (heart condition), unspecified. During a review of Patient 8's POC/IDG form dated 9/20/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 2-3 prn visit, the spiritual counselor to assess one time for spiritual needs, and MSW to assess one time for psychosocial needs. Hospice aide and volunteer services were declined. During a review of Patient 8's clinical record indicated that there was no initial bereavement assessment conducted. d. During a review of Patient 9's admission record indicated a start of care date of 9/5/2023, with a terminal diagnosis of heart disease, unspecified. During a review of Patient 9's POC/IDG form dated 9/5/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 2-3 prn visit, the spiritual counselor to assess one time for spiritual needs, and MSW to assess one time for psychosocial needs. Hospice aide and volunteer services were declined. During a review of Patient 9's clinical record indicated that there was no initial bereavement assessment conducted. e. During a closed record review of Patient 10's admission record indicated a start of care date of 3/6/2023, with a terminal diagnosis of heart disease, unspecified. During a review of Patient 10's POC/IDG form dated 3/15/2023, did not indicate the frequency of visits for skilled nurse. The spiritual counselor, social worker and hospice aide services were offered but declined. During a review of Patient 10's clinical record indicated that there was no initial bereavement assessment conducted. During an interview on 11/23/23 at 12:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that a bereavement assessment should be conducted on admission. The DPCS further stated that Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10 did not have an initial bereavement assessment conducted on admission. A review of the agency's policy and procedure titled "Bereavement Assessment," revised May 2022, indicated on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator. At a minimum, it will include: a. Patient and family/caregiver loss issues b. Survivor needs c. Social, spiritual, and cultural factors d. Services to be provided including individual counseling, support groups, and letters and cards. e. Referrals to be made f. Grief risk factors and potential for pathological grief reactions.

Based on observation, interview, and record review, the hospice agency failed to ensure the patient's eligibility for hospice services related to the palliation (relief of symptoms and suffering cause by life threatening diseases) and management of the terminal illness and related conditions were accurately assessed, for eight of 17 sampled patients, (Patient 1, Patient 2, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). This deficient practice resulted in patients admitted for hospice care not appropriately evaluated by the health care professionals to receive hospice care that are only awarded to patients certified to receive the benefits. --- a. A review of Patient 1's clinical record indicated Patient 1 was admitted to the hospice agency on 4/5/23, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-group of lung disease that block airflow and make it difficult to breathe). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 4/5/23 to 7/3/23, 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 results showing evidence to support the terminal illness diagnosis. On 11/23/23, at 11:30 a.m., a joint home visit was conducted to Patient 1's residence, with the License Vocational Nurse (LVN 1). Patient 1 was observed awake, alert, oriented, and ambulatory using a cane without any assistance from family members. On 11/23/2023 at 12 p.m., during an interview, when Patient 1 was asked if her attending physician referred her to hospice services, she stated she did not have an attending physician at this time and her friend referred her to the hospice agency. b. A review of Patient 2's clinical record indicated a start of care (SOC) date of 8/21/23, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and important mental function). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 8/21/23 to 11/18/23, 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 results showing evidence to support the terminal illness diagnosis. On 11/22/23, at 4 p.m., during a phone interview with Family Member 1, she stated, Patient 2's attending physician did not refer him to the hospice agency but by a friend that worked in their hospice agency. c. A review of Patient 5's clinical record indicated a start of care (SOC) date of 9/3/23, with a terminal diagnosis of chronic obstructive pulmonary disease ( COPD-group of lung disease that block airflow and make it difficult to breathe). A review of Patient 5's Physicians Certification for Hospice Benefit, dated 9/3/23 to 12/1/23, benefit period #1, indicated the Medical Director 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 was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 11/23/23, at 1 p.m., during an interview with the Director of Patient Services (DPCS), she stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital where the patient gets discharged from. On 11/23/23, at 12:30 p.m., during a phone interview with Physician 1, she stated that she was not the attending physician, and she does not know who the attending physicians for Patients 1,2, and 5. Physician 1 stated since Patients 1, 2 and 5 were admitted for hospice service, she now becomes the patient's attending physician, signed the referral attending physician section because no one would sign it. Physician 1 further stated that she determined the patients were eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated PRN 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). PRN Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. d. During a review of Patient 6s admission record indicated a start of care (SOC) date of 9/8/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation (refer to an increase in the severity of a disease or its signs and symptoms). Patient 6's face sheet (a documents that typically include the patient's name, address, date of birth, insurance information, and emergency contact information) indicated the patients referring/attending physician was the agencys previous Medical Director (Physician 2). Patient 6 telephone number on the face sheet indicated it was not a working number. During a review of Patient 6's Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), dated 9/8/2023, indicated Patient 6 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related (anything that's connected or related to the heart) pain, no edema (swelling in parts of your body because of fluid trapped in your tissues, most often in your feet, ankles and legs), had clear lung sounds, had mild dyspnea (difficult or labored breathing) with mild exertion, vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate) are within normal range, and ambulatory using a walker. During a review of Patient 6's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the first hospice benefit period from 9/8/2023 to 12/6/2023, indicated Patient 6's terminal diagnoses was COPD with acute exacerbation. The Medical Director (Physician 1) indicated Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 6s terminal illness diagnosis. During a review of Patient 6s LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) Hospice Eligibility Determination form for Pulmonary Disease (issues pertaining to the lungs), dated 9/8/2023, indicated Patient 6 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 6 had a disabling dyspnea(difficulty breathing) at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier) resulting in decreased functional capacity and had an increasing physician home visits prior to hospice admission. Section 2 was marked "yes" that Patient 6s had O2 sat (Oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 92–100%) less than or equal to 88% determined either by arterial blood gases (measures the balance of oxygen and carbon dioxide in your blood to see how well your lungs are working) or O2 saturation monitors. During a review of Patient 6's clinical record indicated there was no documented evidence Patient 6 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators resulting in decreased functional capacity, had an increasing physician home visits prior to hospice admission, or had O2 sat less than or equal to 88% determined either by arterial blood gases or O2 saturation monitors. During a concurrent interview and record review on 11/23/2023 at 12:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 6 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, had an increasing physician home visits prior to hospice admission, or had an O2sat less than or equal to 88%. e. During a review of Patient 7s admission record indicated a start of care date of 9/6/2023 with a terminal diagnosis of chronic obstructive pulmonary disease, unspecified. Patient 7's face sheet indicated the patients referring/attending physician was the agencys previous Medical Director (Physician 2). During a review of Patient 7's Comprehensive Nursing Assessment, dated 9/6/2023, indicated Patient 7 was awake, alert, oriented to person, place, and time, had no cardiac-related pain, no edema, had regular pulse rate (heart rate), had mild dyspnea with mild exertion, and was ambulatory using a walker. The Comprehensive Nursing Assessment further indicated Patient 7 meets and qualifies for hospice admission based on LCD guidelines. During a review of Patient 7's "Physician Certification for Hospice Benefit" for the first hospice benefit period from 9/6/2023 to 12/4/2023, indicated Patient 7's terminal diagnoses was COPD. The Medical Director indicated Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 7s terminal illness diagnosis. During a review of Patient 7s LCD Hospice Eligibility Determination form for Pulmonary Disease, dated 9/6/2023, indicated Patient 7 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 7 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators resulting in decreased functional capacity and had an increasing physician home visits prior to hospice admission. Section 2 was marked "yes" that Patient 7s had hypoxemia (a low level of oxygen in the blood) at rest on room air, as evidenced by pO2 (Partial pressure of oxygen, it reflects the amount of oxygen gas dissolved in the blood. Normal reading is 75 to 100 millimeters of mercury [mmHg]) less than or equal to 55 mmHg. During a review of Patient 7's clinical record indicated there was no documented evidence Patient 7 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators resulting in decreased functional capacity and had an increasing physician home visits prior to hospice admission. There was also no documentation Patient 7 had hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mmHg. During a telephone interview on 11/22/2023 at 12:23 p.m. with Patient 7s family member (FM 2), FM 2 stated she does not know if Patient 7s attending physician referred him to hospice care. FM 2 further stated Patient 7 was doing well, walking around using a walker, and does not have shortness of breath when at rest. During a concurrent interview and record review on 11/23/23 at 12:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 7 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators resulting in decreased functional capacity and had an increasing physician home visits prior to hospice admission. DPCS further stated that there was also no documentation Patient 7 had hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mmHg. f. During a review of Patient 8s admission record indicated a start of care date of 9/6/2023 with a terminal diagnosis of heart disease, unspecified. Patient 8's face sheet indicated the patients referring/attending physician was the agencys previous Medical Director. During a review of Patient 8's Comprehensive Assessment, dated 9/6/2023, indicated Patient 8 was awake, alert, oriented to person, place, and time, had no cardiac-related pain, no edema, had normal respirations, regular pulse, and ambulatory using a walker. The Comprehensive Nursing Assessment further indicated Patient 8 was on NYHA Stage IV of heart failure (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). During a review of Patient 8's "Physician Certification for Hospice Benefit" for the first benefit period from 9/6/2023 to 12/4/2023, indicated Patient 8's terminal diagnoses was heart disease, unspecified. The Medical Director indicated Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 8s terminal illness diagnosis. During a review of Patient 8s LCD Hospice Eligibility Determination form for Heart Disease, dated 9/6/2023, indicated Patient 8 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 8 had been ruled out as a candidate for surgical procedures. Section 2 was marked "yes" that Patient 12s heart disease met the criteria for NYHA Class IV level. During a review of Patient 8's clinical record indicated there was no documented evidence Patient 8 had been ruled out as a candidate for surgical procedures. There was also no documentation Patient 8 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a home visit at Patient 8s residence, on 11/22/2023 at 11:15 a.m., Patient 8 was observed laying on a couch, awake, alert, oriented, was on oxygen via a nasal canula (a device that delivers extra oxygen through a tube and into your nose), having no shortness of breath and not complaining of any chest pain. Upon close observation of the Patient 8s oxygen tank (metal cylinders that store oxygen under pressure), the oxygen was not on. During a concurrent interview, Patient 8 stated he had no surgery scheduled in the past, nor had been ruled out as a candidate for any surgical procedures. During a concurrent interview and record review on 11/23/2023 at 12:15 p.m. with the DPCS, the DPCS stated she was not able to find documented evidence Patient 8 had been ruled out as a candidate for surgical procedures. The DPCS further stated there was no documented evidence Patient 8 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. g. During a review of Patient 9s admission record indicated a start of care date of 9/5/2023 with a terminal diagnosis of heart disease, unspecified. Patient 9's face sheet indicated the patients referring/attending physician was the agencys previous Medical Director. During a review of Patient 9's Comprehensive Assessment, dated 9/5/2023, indicated Patient 9 was awake, alert, oriented to person, place, and time, had no cardiac-related pain, no edema, had normal respirations, regular pulse, and ambulatory using a walker. The Comprehensive Nursing Assessment further indicated Patient 9 was on NYHA Stage IV of heart failure. During a review of Patient 9's "Physician Certification for Hospice Benefit" for the first benefit period from 9/5/2023 to 12/3/2023, indicated Patient 9's terminal diagnoses was heart disease, unspecified. The Medical Director indicated Patient 9 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 9 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 8s terminal illness diagnosis. During a review of Patient 9s LCD Hospice Eligibility Determination form for Heart Disease, dated 9/5/2023, indicated Patient 9 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 9 had been ruled out as a candidate for surgical procedures. Section 2 was marked "yes" that Patient 12s heart disease met the criteria for NYHA Class IV level. During a review of Patient 9's clinical record indicated there was no documented evidence Patient 9 had been ruled out as a candidate for surgical procedures. There was also no documentation Patient 9 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 11/22/2023 at 12:31 p.m. with Patient 9, Patient 9 stated he can walk around his neighborhood, had no chest pain, had no surgery scheduled or had been ruled out as a candidate for any surgical procedures, and was not referred by his primary physician to hospice. During a concurrent interview and record review on 11/23/2023 at 12:15 p.m. with the DPCS, the DPCS stated she was not able to find documented evidence Patient 9 had been ruled out as a candidate for surgical procedures. The DPCS further stated there was no documented evidence Patient 9 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. h. During a closed record review of Patient 10s admission record indicated a start of care date of 3/6/2023 with a terminal diagnosis of heart disease, unspecified. Patient 10's face sheet indicated the patients referring/attending physician was the agencys previous Medical Director. During a review of Patient 10's Comprehensive Assessment, dated 3/6/2023, indicated Patient 10 was awake, alert, oriented to person, place, and time, had no cardiac-related pain, had normal respirations, regular pulse, and ambulatory using a cane or walker. The Comprehensive Nursing Assessment further indicated Patient 10 was on NYHA Stage IV of heart failure. During a review of Patient 10's "Physician Certification for Hospice Benefit" for the first benefit period from 3/6/2023 to 6/3/2023 signed by the agencys previous Medical Director (Physician 3), indicated ";Patient does not meet criteria for admission to hospice with unspecified heart disease and does not have a specified qualifying heart condition or any other hospice qualifying condition. Life expectancy exceeds six months." During a review of the agencys policy and procedure titled "Admission Criteria and Process", revised May 2022, indicated Tranquility Hospice Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of six months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). During a review of the agencys policy and procedure titled ";Certification of Terminal Illness", revised May 2022, 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 observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill [a disease or condition due to which a patient's death is anticipated] patients who have six months or less to live) failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met as follows: --- 1. The HA failed to ensure the Interdisciplinary Group (IDG, a group of health care professionals with various areas of expertise responsible for the holistic care of the hospice beneficiary) meetings were held by all the members of interdisciplinary group to discuss the patients comprehensive and ongoing assessments and care planning process for four out of 14 sampled patients (Patient 6, Patient 7, Patient 8, and Patient 9). (Refer to L541) 2. The HA failed to develop and complete the plan of care (POC, a form where you can summarize patients health conditions, specific care needs, goals, and current treatments) with measurable objectives, timeframe, and interventions to meet the patients' needs for two of fourteen sampled patients (Patient 9 and Patient 10). (Refer to L545) 3. The HA failed to ensure and maintain accurate labeling and documentation of medication profile (a written summary of all the medicines patient is taking regularly, including over-the-counter and complementary medicines) which included all the drugs and biologicals that patient was currently taking to meet the patient's needs for one out of 14 sampled patients (Patient 11). (Refer to L549) 4. The HA failed to ensure the patients' written plan of care was reviewed and revised by the Interdisciplinary Group no less frequently than every 15 days for five out of 14 sampled patients (Patient 6, Patient 7, Patient 8, Patient 9, and Patient 11). (Refer to L552) 5. The HA nursing staff failed to coordinate care and ensure the IDGs were notified, and the notifications were documented when ordered home visit service was missed for four out of 14 sampled patients (Patient 6, Patient 7, Patient 8, and Patient 9). (Refer to L554) 6. The HA failed to ensure home visits were conducted in accordance with the plan of care for four out of 14 sampled patients (Patient 6, Patient 7, Patient 8, and Patient 9). (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.

Based on interview and record review, the hospice agency (HA) failed to ensure the interdisciplinary group (IDG) meetings were held by all the members of interdisciplinary group to discuss the patients comprehensive and ongoing assessments and care planning process for four out of 14 sampled patients (Patient 6, Patient 7, Patient 8, and Patient 9). This deficient practice could potentially prevent the patients from reaching their care planning goals. --- Findings: a. During a review of Patient 6's admission record indicated a start of care (SOC) date of 9/8/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation (flare-up). During a review of Patient 6's POC (Plan of Care)/IDG (Interdisciplinary Group, a group of health care professionals with various areas of expertise responsible for the holistic care of the hospice beneficiary) forms dated 9/8/2023, 9/20/2023, 10/4/2023, and 10/18/2023, did not indicate the Medical Director (MD), the social worker (MSW), and the chaplain met to update the plan of care. There were no signatures in the record. b. During a review of Patient 7's admission record indicated an SOC date of 9/6/2023, with a terminal diagnosis of unspecified COPD. During a review of Patient 7's POC/IDG form dated 9/6/2023, did not indicate the MD, MSW, and the chaplain met to update the plan of care. There were no signatures in the record. During a review of Patient 7's POC/IDG forms dated 9/20/2023, 10/4/2023, and 10/18/2023, did not indicate the MD, the registered nurse (RN), MSW, and the chaplain met to update the plan of care. There were no signatures in the record. c. During a review of Patient 8's admission record indicated an SOC date of 9/6/2023, with a terminal diagnosis of unspecified heart disease (a general term that includes many types of heart problems). During a review of Patient 8's POC/IDG forms dated 9/20/2023 and 10/4/2023, did not indicate the MD, RN, MSW, and the chaplain met to update the plan of care. There were no signatures in the record. During a review of Patient 8's POC/IDG forms dated 10/18/2023 and 11/1/2023, did not indicate the MD, MSW, and the chaplain met to update the plan of care. There were no signatures in the record. d. During a review of Patient 9's admission record indicated an SOC date of 9/5/2023, with a terminal diagnosis of unspecified heart disease. During a review of Patient 9's POC/IDG form dated 9/5/2023, did not indicate the MD, MSW, and the chaplain met to update the plan of care. There were no signatures in the record. There were no other IDG meetings conducted for Patient 9 after the meeting on 9/5/2023. During an interview on 11/23/2023 at 12:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that IDG meetings were held every two weeks and that the group members (Medical Doctor, Registered Nurse, Social Worker, and Chaplain) needed to sign the POC/IDG form after each meeting because their signatures are their validation of attendance. During a review of the agencys policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities", revised May 2022, indicated the interdisciplinary group will collaborate with the patients attending physician to develop an individualized written plan of care. The hospice interdisciplinary group membership includes at a minimum: Physician, Registered Nurse, Social Worker, and Pastoral or other counselor(s). During a review of the agencys policy and procedure titled, ";Interdisciplinary Group Meeting", revised May 2022, 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, death and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor.

Based on interview and record review, the hospice agency (HA) failed to develop and complete the plan of care (POC, a form where you can summarize patients health conditions, specific care needs, goals, and current treatments) with measurable objectives, timeframe, and interventions to meet the patients' needs for two out of 14 sampled patients (Patient 9 and Patient 10). This deficient practice resulted in the patients not having a plan of care and had the potential to affect the provision of necessary care and services to the patients. --- Findings: a. During a review of Patient 9's admission record indicated a start of care date of 9/5/2023, with a terminal diagnosis of unspecified heart disease (a general term that includes many types of heart problems). During a review of Patient 9's Comprehensive Assessment, dated 9/5/2023, indicated Patient 9 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 9 had mild dyspnea (shortness of breath) with mild exertion, needs moderate assistance with toileting and transfer, and maximum assistance with bathing and ambulation. During a review of Patient 9s clinical record, the clinical record indicated there was no plan of care developed and completed that included specific goals and interventions regarding patient care needs. b. During a closed record review of Patient 10's admission record indicated a start of care date of 3/6/2023, with a terminal diagnosis of unspecified heart disease. During a review of Patient 10's Comprehensive Assessment, dated 3/6/2023, indicated Patient 10 was awake, alert, oriented x 3 (to person, place, and time), and was dependent on walker or cane for ambulation. Patient 10 had periods of shortness of breath with moderate exertion, needed moderate assistance with ADLs (activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating), at moderate risk for falls, had tachycardia (fast heart rate), and had increased respirations (breathing) due to severe pain. During a review of Patient 10s clinical record, the clinical record indicated there was no plan of care developed and completed that included specific goals and interventions regarding patient care needs. During an interview and concurrent record review on 11/23/2023 at 12:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS confirmed and acknowledged the plan of care with measurable objectives, timeframe, and interventions were not developed for Patient 9 and Patient 10. During a review of the agency's policy and procedure titled, "Interdisciplinary Group Membership and Responsibilities", revised May 2022, indicated the interdisciplinary group will collaborate with the patients attending physician to develop an individualized written plan of care. The interdisciplinary group responsibilities include but are not limited to participation in the establishment of the plan of care for each patient admitted to the hospice services, and participation in the periodic review and updating of the plan of care for each patient receiving hospice services.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure and maintain accurate labeling and documentation of medication profile (a written summary of all the medicines patient is taking regularly, including over-the-counter and complementary medicines) which included all the drugs and biologicals that patient was currently taking for one out of 14 sampled patients (Patient 11). This deficient practice had the potential to result in adverse effects and/or drug reactions and medication errors. --- Findings: During a review of Patient 11s face sheet indicated an admission date of 6/30/2023 with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a chronic condition when heart weakens and does not pump blood as it should be). A review of Patient 11's "Current Treatment/Medication/DME List" for the period of 9/28/2023 to 12/27/2023, indicated skilled nursing to assess all body systems with emphasis on signs and symptoms of pain, nausea, vomiting, anxiety (an intense and persistent worry) and agitation (a state of anxiety), constipation (a problem with passing stool), diarrhea (loose stool) once a week for clinical care and support and two to three times a week as needed for any change in patient's condition, pain and symptom management, and safety every visit. The record indicated skilled nursing to educate patient/caregiver regarding medication regimen, care and treatment, safe use of medical equipment, safety measures, reportable signs and symptoms to hospice doctor, use of universal/standard precautions, fall precautions, and oxygen (a gas essential to living organisms) precautions. During a joint home visit with the current Director of Nursing (DON) on 11/22/2023 at 3:00 p.m., at Patient 11's residence, observed Patient 11 was walking with the walker and was denied respiratory distress and pain. Patient 11's caregiver (CG1) was present. DON initiated her home visit. During an interview and concurrent review of Patient 11's medications with the DON and CG1 on 11/22/2023 at 3:00 p.m., the following discrepancies were noted in between Patient 11's current medications at home and medication profile on record: 1. A bottle labelled Famotidine (a medication used to prevent and treat heartburn) had diabetes (a group of disease that result in too much sugar in the blood) medication inside the bottle. Per CG1, the patient changes the bottles of her medications every time. 2. Restasis 0.05% eye emulsion (a medication used to treat chronic eye dryness) one drop, in both eyes, three times daily for dry eyes was not listed in the medication profile. 3. Chlordiazepoxide (a medication used to treat anxiety) 25 milligram (mg, a unit of measurement), one capsule, as needed, before meals for anxiety and agitation was changed to one tablet three times a day. 4. Atorvastatin (a medication used to decrease blood fat level) 20 mg, one tablet daily for cholesterol was not listed in Patient 11's medication profile. 5. Sertraline (an antidepressant ) 100 mg, daily, for agitation was not listed in Patient 11's medication profile. 6. Benazepril (a medication used to treat high blood pressure) 5 mg, one tablet, daily for high blood pressure was not listed in Patient 11's medication profile. 7. Farxiga (a medication that can be given to certain people with diabetes [a condition when blood sugar is high], heart disease, and kidney disease) 10 mg, one tablet, daily was not listed in Patient 11's medication profile. 8. Bactrim DS (a combination of two antibiotics to treat bacterial infection) one tablet, daily, for seven days for urinary tract infection (an infection in any part of the urinary system) not listed in Patient 11's medication profile. 9. Vitamin D3 (a dietary supplement) 26 micrograms (mcg, a unit of measurement), one tablet, daily, was not in Patient 11's medication profile. During an interview with CG1 on 11/22/2023 at 3:00 p.m. after the medication review, CG1 stated that Patient 11 continues to see her primary doctor at least every two to three months. CG1 stated that Patient 11 went to this doctor for complaint of low back pain. CG1 stated that Patient 11 was prescribed these medications per the primary doctor. When asked CG1 if Patient 11 was seen by the hospice doctor, CG1 stated, "The doctor called one time but did not come to see the patient." CG1 also stated that Patient 11 wants to continue seeing her primary doctor when she can. During an interview with the DON on 11/22/2023 at 5:30 p.m., the DON stated that she conducts medication review with the patient every home visit. The DON stated that it is important to maintain a current and updated medication profile for the patient. A review of the HA's policy titled " Medication Profile", dated May 2022, indicated that patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications. Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, strength, route, frequency, date, and time of administration. A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy. The interdisciplinary group will confer with an individual with education in drug management to ensure the drugs and biologicals meet the patient's needs.

Based on interview and record review, the hospice agency (HA) failed to ensure patients' written plan of care (POC) was reviewed and revised by the interdisciplinary group (IDG, a group of health care professionals with various areas of expertise responsible for the holistic care of the hospice beneficiary) no less frequently than every 15 days for five out of 14 sampled patients (Patient 6, Patient 7, Patient 8, Patient 9, and Patient 11). This deficient practice had a potential to result in lacking continuous assessment and care planning that meet patients' needs. --- A review of Patient 11s face sheet indicated an admission date of 6/30/2023 with the diagnosis of hypertensive heart disease with heart failure (the heart can weaken over time and heart failure may develop. High blood pressure also leads to thickening of the blood vessel walls. When combined with cholesterol deposits in the blood vessels, the risk of heart attack and stroke increases) A review of the HAs document titled ";Comprehensive Nursing Assessment" dated 6/30/2023 indicated that Patient 11 is a 77 year old female that is unable to tolerate prolonged standing and mainly sits and uses a walker for an assistive device. Appetite has been fair to poor, consumes less than 50% of her meals served and needs maximum assistance or support in doing ADLs. A review of the HA's document titled "Current Treatment/Medication/DME List" for the period of 9/28/2023 to 12/27/2023 indicated skilled nursing to assess all body systems with emphasis on signs and symptoms of pain, nausea, vomiting, anxiety and agitation, constipation, diarrhea, once a week for clinical care and support and 2-3 times a week as needed for any change in patient's condition, pain and symptom management and safety every visit. Skilled nursing to educate patient/caregiver regarding medication regimen, care and treatment, safe use of medical equipment, safety measures, reportable signs and symptoms to hospice doctor. Use of universal/standard precautions, fall precautions and oxygen precautions. A review of the Electronic medical record (EMR) on 11/22/23 at 1:00 p.m. revealed that only the current Director of Nursing signed the IDG meeting on the following dates: 6/30/23, 7/12/23, 7/26/23, 8/9/23, 8/23/23, 9/6/23, 9/20/23, 10/4/23, 10/18/23, 11/1/23 and 11/15/23. During a concurrent review and interview with the DON and office manager of the EMR revealed that signatures were present for the Medical Director (MD), and Spiritual Counselor (SC) were signed. When the office manager was asked when the EMR was signed, office manager denied signing the EMR. During a telephone interview with the MD on 11/23/23 at 11:59 p.m., MD stated that he has his own log in and password for the patients medical record. MD also admitted during the phone interview that he had not signed any IDG meetings in the EMR at this time. A review of the HA's policy titled "Interdisciplinary Group Membership Responsibilities" revised May 2022, 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 hospice interdisciplinary group membership includes at a minimum: Physician, Registered Nurse, Social Worker and Pastoral or other counselor. A review of the HA's policy titled " Interdisciplinary Coordination of Care" revised May 2022, indicated Tranquility Hospice Inc personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. When the patient requires services from the interdisciplinary group, the Case Manager will be responsible for cooperative care planning to assure goals, interventions, and outcomes are palliative in nature. Written evidence of care coordination will be found in the plan of care and/or inter­disciplinary team meeting forms in the patient's clinical record, and will involve the hospice patient's attending physician. Findings: a. During a review of Patient 6's admission record indicated a start of care date (SOC) of 9/8/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. During a review of Patient 6's clinical record indicated the POC/IDG meetings were conducted on 9/8/2023, 9/20/2023, 10/4/2023, and 10/18/2023. There was no documented evidence the POC/IDG meeting was conducted after 10/18/2023. b. During a review of Patient 7's admission record indicated a start of care date of 9/6/2023, with a terminal diagnosis of COPD, unspecified. During a review of Patient 7's clinical record indicated the POC/IDG meeting was conducted on 9/6/2023. There was no documented evidence the POC/IDG meeting was conducted after 9/6/2023. c. During a review of Patient 8's admission record indicated a start of care date of 9/6/2023, with a terminal diagnosis of heart disease, unspecified. During a review of Patient 8's clinical record indicated there was no documented evidence the POC/IDG meeting was conducted between 9/20/2023 to 10/17/2023. d. During a review of Patient 9's admission record indicated a start of care date of 9/5/2023, with a terminal diagnosis of heart disease, unspecified. During a review of Patient 9's clinical record indicated the POC/IDG meeting was conducted on 9/5/2023. There was no documented evidence the POC/IDG meeting was conducted after 9/5/2023. During an interview on 11/23/2023 at 12:15 p.m. with the Director of Patient Care Services (DPCS) with the Office manager (OM), the agency staff was not able to provide documented evidence the POC/IDG meetings were held every 15 days for Patient 6, Patient 7, Patient 8, and Patient 9 during the above period. During a review of the agencys policy and procedure titled, ";Interdisciplinary Group Meeting" revised May 2022, 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, death and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires.

Based on interview and record review, the hospice agency (HA) nursing staff failed to coordinate care and ensure the IDGs (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) where notified, and notifications were documented when ordered home visit service was missed for four out of 14 sampled patients (Patient 6, Patient 7, Patient 8, and Patient 9). This failure had the potential to result in patients end of life care needs not being met. --- Findings: a. During a review of Patient 6's admission record indicated a start of care date (SOC) of 9/8/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation (flare-up). During a review of Patient 6's POC (Plan of Care)/IDG (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) form dated 9/8/2023, indicated the frequency of visits for skilled nurse (SN) to one per week and three prn (as needed) visits for clinical care and support and for any change of patients condition. Hospice aide, social worker (MSW), chaplain (SC), and volunteer services were declined. During a review of Patient 6s history of skilled nursing visit notes indicated SN visited the Patient 6 only one time for the month of October 2023. There was also no SN visit conducted for the month of November 2023. A further review of Patient 6s clinical record indicated there was no documented evidence that the agencys nursing staff had notified or communicated with the IDG about the missed visit in accordance with the agencys policy and procedure. b. During a review of Patient 7's admission record indicated an SOC date of 9/6/2023, with a terminal diagnosis of unspecified COPD. During a review of Patient 7's POC/IDG form dated 9/20/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week and two to three prn (as needed) visit, the spiritual counselor to assess one time for spiritual needs, and MSW to assess one time for psychosocial needs. Hospice aide and volunteer services were declined. During a review of Patient 7s clinical record indicated there was no documented evidence MSW and the SC visited Patient 7 since the start of care. A further review of Patient 7s clinical record indicated there was no documented evidence that the agencys staff had notified or communicated with the IDG about the missed visit in accordance with the agencys policy and procedure. c. During a review of Patient 8's admission record indicated an SOC date of 9/6/2023, with a terminal diagnosis of unspecified heart disease. During a review of Patient 8's POC/IDG form dated 9/20/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week and two to three prn (as needed) visit, the spiritual counselor to assess one time for spiritual needs, and MSW to assess one time for psychosocial needs. Hospice aide and volunteer services were declined. During a review of Patient 8s clinical record indicated there was no documented evidence MSW and the SC visited Patient 8 since the start of care. A further review of Patient 8s clinical record indicated there was no documented evidence that the agencys staff had notified or communicated with the IDG about the missed visit in accordance with the agencys policy and procedure. d. During a review of Patient 9's admission record indicated an SOC date of 9/5/2023, with a terminal diagnosis of unspecified heart disease. During a review of Patient 9's POC/IDG form dated 9/5/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week and two to three prn (as needed) visit, the spiritual counselor to assess one time for spiritual needs, and MSW to assess one time for psychosocial needs. Hospice aide and volunteer services were declined. During a review of Patient 9s history of skilled nursing visit notes, indicated for the week starting on 10/15/2023 (Sunday) and ending on 10/21/2023 (Saturday), there was no SN visit conducted. For the week starting on 10/29/2023 (Sunday) and ending on 11/4/2023 (Saturday), there was no SN visit conducted. During a review of Patient 9s clinical record indicated there was no documented evidence MSW and the SC visited the patient since the start of care. A further review of Patient 9s clinical record indicated there was no documented evidence that the agencys staff had notified or communicated with the IDG about the missed visit in accordance with the agencys policy and procedure. During an interview and concurrent record review on 11/23/2023 at 12:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS acknowledged the finding and stated patient care visit should be provided to patients in accordance with the plan of care. The DPCS stated for any missed visits, IDG should be notified promptly by the field nurses and notification should be documented in the patients electronic records per the agencys policies and procedures. During a review of the agencys policy and procedure titled, ";Missed Visits", revised May 2022, indicated missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If a visit is missed and not rescheduled, the clinician will notify the IDG and clinical supervisor of the missed visit and reason for missed visit and will document in the patients clinical record.

Based on interview and record review, the hospice agency (HA) failed to ensure home visits were conducted in accordance with the plan of care (POC) for four out of 14 sampled patients (Patient 6, Patient 7, Patient 8, and Patient 9). This failure had the potential to negatively affect the patients' physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. --- Findings: a. During a review of Patient 6's admission record indicated a start of care date (SOC) of 9/8/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation (flare-up). During a review of Patient 6's POC (Plan of Care)/IDG (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) form dated 9/8/2023, indicated the frequency of visits for skilled nurse (SN) to one per week and three prn (pro re nata, which means ";as needed") visits for clinical care and support and for any change of patients condition. Hospice aide, social worker (MSW), chaplain (SC), and volunteer services were declined. During a review of Patient 6s history of skilled nursing visit notes indicated SN visited the Patient 6 only one time for the month of October 2023. There was also no SN visit conducted for the month of November 2023. b. During a review of Patient 7's admission record indicated an SOC date of 9/6/2023, with a terminal diagnosis of unspecified COPD. During a review of Patient 7's POC/IDG form dated 9/20/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week and two to three prn (as needed) visit, the spiritual counselor to assess one time for spiritual needs, and MSW to assess one time for psychosocial needs. Hospice aide and volunteer services were declined. During a review of Patient 7s clinical record indicated there was no documented evidence MSW and the SC visited Patient 7 since the start of care. c. During a review of Patient 8's admission record indicated an SOC date of 9/6/2023, with a terminal diagnosis of unspecified heart disease. During a review of Patient 8's POC/IDG form dated 9/20/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus two to three prn (as needed) visit, the spiritual counselor to assess one time for spiritual needs, and MSW to assess one time for psychosocial needs. Hospice aide and volunteer services were declined. During a review of Patient 8s clinical record indicated there was no documented evidence MSW and the SC visited Patient 8 since the start of care. d. During a review of Patient 9's admission record indicated an SOC date of 9/5/2023, with a terminal diagnosis of unspecified heart disease. During a review of Patient 9's POC/IDG form dated 9/5/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week and two to three prn (as needed) visit, the spiritual counselor to assess one time for spiritual needs, and MSW to assess one time for psychosocial needs. Hospice aide and volunteer services were declined. During a review of Patient 9s history of skilled nursing visit notes, indicated for the week starting on 10/15/2023 (Sunday) and ending on 10/21/2023 (Saturday), there was no SN visit conducted. For the week starting on 10/29/2023 (Sunday) and ending on 11/4/2023 (Saturday), there was no SN visit conducted. During a review of Patient 9s clinical record indicated there was no documented evidence MSW and the SC visited the patient since the start of care. During an interview and concurrent record review on 11/23/2023 at 12:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS acknowledged the finding and stated patient care visit should be provided to patients in accordance with the plan of care. During a review of the agency's policy and procedure titled, "The Plan of Care", revised May 2022, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Quality Assessment/Performance Improvement (QAPI, a resource that assists a hospice provider with implementation and maintenance of their quality improvement program and activities) were met as follows: 1. HA failed to collect quarterly data to ensure a functioning QAPI program. 2. HA failed to ensure the agency had ongoing performance improvement projects. The cumulative effect of these systemic practices resulted in the agency's failure to ensure the QAPI program improved patient care. --- Findings: During an interview with the Director of Nursing (DON)/Administrator on 11/22/2023 at 5:30 p.m., DON/Administrator stated that she is new and did not know what the job entailed. During an interview and concurrent record review of the HAs QAPI plan on 11/23/2023 at 1:00 p.m., the office manager (OM) was unable to provide written evidence of a quarterly QAPI review. OM stated that the current staff in the agency were all newly hired including the DON. A review of the hospice agency's policy titled " Orientation of Hospice Personnel to Assigned Responsibilities", revised May 2022, indicated Individuals possessing appropriate clinical training, experience, and evaluation in a clinical specialty area (e.g., oncology, neurology, etc.), in identified clinical settings (e.g., university medical centers, teaching institutions, etc.), will be consulted when a question concerning clinical specialty and/or practice arises. If appropriate, these individuals will provide an orientation, in the home, to the professional hospice personnel. Orientation in the patient's home may be necessary when the newly assigned hospice personnel has not had previous hospice experience or experience with a particular procedure, treatment, or equipment. A review of the hospice agency's policy titled " Governing Body", revised 2020, indicated the Governing Body will assume full legal authority, responsibility, and accountability for the quality assessment and performance improvement (QAPI) program. Relevant findings of performance improvement activities are consistently provided to the Governing Body to allow for oversight of the quality assessment and performance improvement (QAPI) program. The governing body will ensure the following: 1. That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained;2. That the program reflects the complexity of its organization and services and that it addresses all services including services provided under contract or arrangement;3. That the organization-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness;4. That focuses on indicators related to improved outcomes;5. That clear expectations for patient safety are established, implemented, and maintained;

Based on observation, interview, and record review, the hospice agency (HA) failed to the Condition of Participation for Infection Control was not met as evidenced by: The HA failed to follow accepted professional standards of practice for infection control when: The HA failed to follow nursing standards of practice for proper bag technique and handwashing during the home visit for Patient 11 ( Refer to L579) The HA failed to maintain a supply log and monitor expiry dates of their medical supplies in the office. (Refer to L580) These cumulative deficient practices had the potential to spread infection and cause serious harm, injury or death when expired medical supplies are sent for patient use. --- .

Based on observation, interview and record review, the hospice agency (HA) failed to observe proper infection control measures such as proper handwashing and proper bag technique during the home visit for 1 of 14 sampled patients (Patient 11). This deficient practice had the potential in contamination of the Patient 11's care equipment and placed Patient 11 at risk for infection. --- A review of Patient 11s face sheet indicated an admission date of 6/30/2023 with the diagnosis of hypertensive heart disease with heart failure (the heart can weaken over time and heart failure may develop. High blood pressure also leads to thickening of the blood vessel walls. When combined with cholesterol deposits in the blood vessels, the risk of heart attack and stroke increases) A review of the HAs document titled ";Comprehensive Nursing Assessment" dated 6/30/2023 indicated that Patient 11 is a 77 year old female that is unable to tolerate prolonged standing and mainly sits and uses a walker for an assistive device. Appetite has been fair to poor, consumes less than 50% of her meals served and needs maximum assistance or support in doing ADLs. A review of the HA's document titled "Current Treatment/Medication/DME List" for the period of 9/28/2023 to 12/27/2023 indicated skilled nursing to assess all body systems with emphasis on signs and symptoms of pain, nausea, vomiting, anxiety and agitation, constipation, diarrhea, once a week for clinical care and support and 2-3 times a week as needed for any change in patient's condition, pain and symptom management and safety every visit. Skilled nursing to educate patient/caregiver regarding medication regimen, care and treatment, safe use of medical equipment, safety measures, reportable signs and symptoms to hospice doctor. Use of universal/standard precautions, fall precautions and oxygen precautions. During a joint home visit with the current Director of Nursing (DON) on 11/22/2023 at 3:00 p.m., at Patient 11's residence. Observed that Patient 11 walks with the assistance of a walker, denied respiratory distress and denied pain. Patient 11's caregiver(daughter) was present. DON initiated her home visit. On 11/22/2023 at 3:05p.m., during home visit at Patient 11's home, the DON was observed , did not have her nursing bag. DON had her phone, a pulse oximeter and a wrist type blood pressure automated cuff with her. DON was observed not doing proper handwashing prior to her assessment. On 11/22/2023 at 3: 08p.m., during an interview with DON , DON stated " I already know her (Patient 11) and I visit her every week. When asked what are the other things she needs to check, DON stated, I check her vitals signs like the blood pressure, her pulse rate and lung sounds and temperature. DON also stated , I usually have my nursing bag with me but I don't have it today" DON also stated " I had training doing hospice for a short time, I am a retired acute nurse." DON also stated that she did not know what hospice philosophy and did not know what the job description entails. A review of the HA's policy titled " Clinical Director/Director of Patient Care Services" dated May 2022 indicated that The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. A review of the HA's policy titled " Standard Precautions" revised May 2022, indicated that General Precautions: Hand hygiene will be performed to prevent cross-contamination between the patient and personnel. An alternative to use of an alcohol based hand rub is to wash hands with an antimicrobial soap and water. A review of the HA's policy titled " Ongoing Comprehensive Assessment" revised May 2022 indicated 1. During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment.2. The nurse will assess each patient on each visit, for:A. Pain, including the origin, location, duration, severity, and relief measures B. Secondary symptoms related to the terminal illness such as, nausea, vomiting, and respiratory distress, and patient's response to medications and other interventionsC. Factors that alleviate or exacerbate physical symptomsD. Current treatment related to the identified symptoms and the patient's responseE. Vital signs appropriate to the patient's conditionF. Breath soundsG. Skin integrityH. Bowel sounds, elimination (urinary and bowel)I. Mental statusJ. Appetite/diet, nutritional statusK. Functional statusL. Safety/home environmentM. Patient and family/caregiver support A review of the HA's policy titled " Comprehensive Assessment" revised May 2022 indicated A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient's terminal illness.

Based on observation, interview, and record review, the hospice agency (HA) failed to follow professional standards of practice for infection control when the HA failed to maintain a supply log sheet and monitor expiry dates of their medical supplies in the office. This failure had the potential to spread infection and cause serious harm, injury or death when expired medical supplies are sent for patient use. --- During an agency tour at 11/21/2023 at 3:00 p.m., with the agency's supply clerk (SC), during observation of their storage/supply cabinet, observed the following: 1. Multiple bottles of Periwash, shampoo, calmoseptine cream, lotion, alcohol based hand sanitizers with no expiry information or manufacturer's date in stock. 2. 16Fr and 18 Fr Foley catheters (a medical device that helps drain urine from your bladder) used for patients were expired since 2021 3. Colostomy bags expired since 9/5/2023 On 11/21/2023 at 3:0 8p.m., during an interview with the SC, SC stated that she was not able to clarify with the suppliers when for the expiry dates of the supplies. SC stated that she also collects the receipts of the supplies delivered and does not maintain a supply log book. SC stated it will cause more infection if patients will use expired supplies and treatment will not be effective. During an interview with the current Director of Nursing/Administrator (DON/Admin) on 11/23/2023 at 2:00 p.m., DON/Admin stated that her training was just very basic in hospice. DON/Admin stated , "When I applied I have not read what the job description entails. A review of the HA's policy titled "Infection Control Plan" dated May 2022 indicated Establish the mechanism by which the organization will address surveillance, prevention, identification, control and reporting of infections, utilizing current scientific methods and epidemiologic principles. Guide organization personnel in the care and services they provide in relation to infection control practices. Provide for surveillance systems to track the occurrence and transmission of infections. Comply with all applicable local, state, and federal regulations, including, but not limited to: State and federal OSHA mandates. CDC recommendations and guidelines A review of the HA's policy titled " Safe/Effective use of equipment and supplies " dated May 2022, indicated specific operational information related to these items will be obtained from the company providing the equipment. This will include such information as: safety precautions and warnings.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Core Services was met as follows: 1. The HA failed to provide medical social services (services addressing social and emotional concerns related to the patient's illness and care and helping the patient access community) to eleven of 14 sampled patients, (Patient 1, Patient 2 Patient 3, Patient 4, Patient 5, Patient 7, Patient 8, Patient 9, Patient 10, Patient 12, and Patient 14). (Refer to L594) 2. The HA failed to ensure spiritual counselling (designed to address the unique spiritual or religious needs of each patient and their family at the end of life) services was provided to three of 14 sampled patients (Patient 7, Patient 8, and Patient 9). (Refer to L598). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily (written law) mandated compliance with the Federal Regulations to ensure Core Services were provided to all the patients receiving hospice benefits . --- .

Based on interview and record review, the hospice agency failed to provide medical social services (services addressing social and emotional concerns related to the patient's illness and care and helping the patient access community) to twelve of 14 sampled patients, (Patient 1, Patient 2 Patient 3, Patient 4, Patient 5, Patient 7, Patient 8, Patient 9, Patient 10, Patient 12 and Patient 14). This failure had the potential that the available services to support the psychosocial needs were not made available and accessible to the patients and family members under the agency's care. --- j. During a review of Patient 12's admission record indicated a start of care date (SOC) of 9/6/2023, with a terminal diagnosis of heart disease unspecified (problems with blood flow to the heart). During a review of Patient 12s Plan of Care (POC) Summary form, indicated there was an order dated 7/27/2023 for the social worker (MSW) to conduct an initial visit within 5 days from admission plus prn (pro re nata, which means ";as needed") visits to identify psychosocial issues/support needed by patient/family/patients caregiver. During a review of Patient 12's clinical record indicated there was no documented evidence a psychosocial assessment. k. During a review of Patient 14's admission record indicated a start of care date (SOC) of 4/1/2022, with a terminal diagnosis of senile degeneration of the brain ( also termed as memory loss). During a review of Patient 14's Plan of Care (POC) Summary form, indicated there was an order dated 4/1/2022 for the social worker (MSW) to conduct an initial visit within 5 days from admission plus prn (pro re nata, which means ";as needed") visits to identify psychosocial issues/support needed by patient/family/patients caregiver. During a review of Patient 14's clinical record indicated there was no documented evidence a psychosocial assessment. During an interview with the office manager (OM) on 11/23/2023 at 11:05 a.m., OM stated the agency does not have a Social Worker currently employed. A review of the HA's policy titled " Initial Assessment" revised May 2022 indicated that the Admitting registered nurse will determine the other disciplines to complete the appropriate sections of the comprehensive assessment based on identified problems and needs during this initial assessment. Nursing and bereavement sections will always be identified. A bereavement assessment of the needs of the patient's family and other individuals focusing on:1. The nature of the relationship to the patient2. Circumstances surrounding the illness/prognosis3. Behaviors prior to and after the illness/prognosis4. Survivor needs (social, spiritual and cultural) that may impact coping skills5. Potential for pathological grief reactions Findings: f. A review of Patient 7's "Personal Information indicated a start of care date (SOC) of 9/6/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), unspecified. During a review of Patient 7s Plan of Care (POC) Summary form, indicated there was an order dated 9/6/2023 for the social worker (MSW) to conduct an initial visit within 5 days from admission plus prn (pro re nata, which means ";as needed") visits to identify psychosocial issues/support needed by patient/family/patients caregiver. During a review of Patient 7's clinical record indicated there was no documented evidence a psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family) was completed since the SOC. g. During a review of Patient 8's admission record indicated a start of care date of 9/6/2023, with a terminal diagnosis of heart disease (heart condition), unspecified. During a review of Patient 8s POC Summary form, indicated there was an order dated 9/6/2023 for the social worker to conduct an initial visit within 5 days from admission plus prn visits to identify psychosocial issues/support needed by patient/family/patients caregiver. During a review of Patient 8's clinical record indicated there was no documented evidence a psychosocial assessment was completed since the SOC. h. During a review of Patient 9's admission record indicated a start of care date of 9/5/2023, with a terminal diagnosis of heart disease, unspecified. During a review of Patient 9s POC Summary form, indicated there was an order dated 9/5/2023 for the social worker to conduct an initial visit within 5 days from admission plus prn visits to identify psychosocial issues/support needed by patient/family/patients caregiver. During a review of Patient 9's clinical record indicated there was no documented evidence a psychosocial assessment was completed since the SOC. i. During a closed record review of Patient 10's admission record indicated a start of care date of 3/6/2023, with a terminal diagnosis of heart disease, unspecified. A review of Patient 10's Comprehensive Nursing Assessment, dated 3/6/2023, indicated Patient 10 was awake, alert, oriented to time, place, and person. The Comprehensive Nursing Assessment indicated MSW, chaplain, and volunteer services were offered. There was no documented evidence MSW had completed a psychosocial assessment on Patient 10 since the SOC. During an interview with the office manager (OM) on 11/23/2023 at 11:05 a.m., OM stated the agency does not have a Social Worker currently employed. During a review of the agency's policy and procedure titled "Psychosocial Assessment", revised May 2022, indicated a thorough psychosocial assessment will be initiated at the time of admission and continued throughout the course of care. The assessment will be completed and placed in the patients clinical record. a. A review of Patient 1's "Personal Information" indicated Patient 1 was admitted to the HA on 4/5/2023, with a terminal diagnosis of chronic obstructive pulmonary disorder (group of lung disease that block airflow and make it difficult to breathe). During a review of Patient 1s Plan of Care (POC) Summary form, indicated there was an order dated 4/5/23 for the social worker (MSW) to conduct an initial visit within 5 days from admission plus prn (pro re nata, which means ";as needed") visits to identify psychosocial issues/support needed by patient/family/patients caregiver. On 11/23/2023, at 11:30 a.m., a joint home visit was conducted to Patient 1's residence, with the Licensed Vocational Nurse (LVN 1). Patient 1 was observed awake, alert, oriented, and ambulatory using a cane without any assistance from family members. At 12 p.m., during an interview, when Patient 1 was asked if the visiting nurse offered medical social services to her, she stated no, that she was not aware of such services. During a review of Patient 1's clinical record indicated there was no documentation of a psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family) was completed since the start of care (SOC). b. A review of Patient 2's "Personal Information" indicated start of care (SOC) date of 8/21/2023, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and important mental function). During a review of Patient 2s Plan of Care (POC) Summary form, indicated there was an order dated 8/21/2023 for the social worker (MSW) to conduct an initial visit within 5 days from admission plus prn (pro re nata, which means ";as needed") visits to identify psychosocial issues/support needed by patient/family/patients caregiver. During a review of Patient 2's clinical record indicated there was no documented evidence a psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family) was completed since the SOC. c. A review of Patient 3's "Personal Information" indicated a start of care (SOC) date of 3/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disorder (group of lung disease that block airflow and make it difficult to breathe). During a review of Patient 3s Plan of Care (POC) Summary form, indicated there was an order dated 3/22/2023 for the social worker (MSW) to conduct an initial visit within 5 days from admission plus prn (pro re nata, which means ";as needed") visits to identify psychosocial issues/support needed by patient/family/patients caregiver. During a review of Patient 3's clinical record indicated there was no documented evidence a psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family) was completed since the SOC. d. A review of Patient 4's "Personal Information" indicated a start of care (SOC) date of 7/18/2023, with a terminal diagnosis of unspecified heart disease (heart damage caused by poor blood flow to the heart). During a review of Patient 4s Plan of Care (POC) Summary form, indicated there was an order dated 7/18/2023 for the social worker (MSW) to conduct an initial visit within 5 days from admission plus prn (pro re nata, which means ";as needed") visits to identify psychosocial issues/support needed by patient/family/patients caregiver. During a review of Patient 4's clinical record indicated there was no documented evidence a psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family) was completed since the SOC. e. A review of Patient 5's "Personal Information" indicated a start of care (SOC) date of 9/3/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (group of lung disease that block airflow and make it difficult to breathe). During a review of Patient 5s Plan of Care (POC) Summary form, indicated there was an order dated 9/3/2023 for the social worker (MSW) to conduct an initial visit within 5 days from admission plus prn (pro re nata, which means ";as needed") visits to identify psychosocial issues/support needed by patient/family/patients caregiver. During a review of Patient 5's clinical record indicated there was no documented evidence a psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family) was completed since the SOC.

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 Spiritual Counseling (designed to address the unique spiritual or religious needs of each patient and their family at the end of life) services was provided to three of 14 sampled patients (Patient 7, Patient 8, and Patient 9). This deficient practice had the potential to result in Patient 7, Patient 8, and Patient 9 and missed the opportunity to received spiritual services for terminal illness and during the dying process. --- Findings a. During a review of Patient 7's admission record indicated a start of care date (SOC) of 9/6/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), unspecified. During a review of Patient 7s Plan of Care (POC) Summary form, indicated there was an order dated 9/6/2023 for the spiritual counselor to conduct an initial visit within 5 days from admission plus prn (pro re nata, which means ";as needed") visits to identify spiritual issues/support needed by patient/family/patients caregiver. During a review of Patient 7's clinical record indicated there was no documented evidence a spiritual assessment was conducted or any notes from the agencys Chaplain explaining the services being offered by the agency was completed since SOC. b. During a review of Patient 8's admission record indicated a start of care date of 9/6/2023, with a terminal diagnosis of heart disease, unspecified. During a review of Patient 8s POC Summary form, indicated there was an order dated 9/6/2023 for the spiritual counselor to conduct an initial visit within 5 days from admission plus prn visits to identify spiritual issues/support needed by patient/family/patients caregiver. During a review of Patient 8's clinical record indicated there was no documented evidence a spiritual assessment was conducted or any notes from the agencys Chaplain explaining the services being offered by the agency was completed since SOC. c. During a review of Patient 9's admission record indicated a start of care date of 9/5/2023, with a terminal diagnosis of heart disease, unspecified. During a review of Patient 9s POC Summary form, indicated there was an order dated 9/5/2023 for the spiritual counselor to conduct an initial visit within 5 days from admission plus prn visits to identify spiritual issues/support needed by patient/family/patients caregiver. During a review of Patient 9's clinical record indicated there was no documented evidence a spiritual assessment was conducted or any notes from the agencys Chaplain explaining the services being offered by the agency was completed since SOC. During a telephone interview with the agency's Spiritual counselor (SC 1) on 11/23/2023 at 10:23 a.m., SC 1 stated that even if the patient or the patients family decline spiritual counseling service during the initial visit and assessment by the registered nurse, he will still try to contact them and explain the kind of service he offers. SC 1 stated this initial interaction with the patient and/or patients family will be documented in the patients clinical record. During a review of the agency's policy and procedure titled "Spiritual Assessment", revised May 2022, indicated a spiritual assessment will be completed for each patient/family by the Chaplain. The assessment will include, but not be limited to, evaluation of the following: 1. Coping with and adjusting to the patients terminal illness 2. Assessing bereavement needs 3. Religious and/or spiritual reactions to terminal illness

Based on record review and interview, the hospice agency failed to ensure to appoint designated persons in the governing body to assume full legal authority, responsibility and management of the hospice agency and failed to ensure an appointed, qualified administrator to run the day to day operation of the hospice. This deficient practice had the potential for hospice staff to provide quality of care and services that is required to meet the patients needs. --- On 11/23/2023, at 12:55 p.m., during a telephone interview with the owner/Chief executive officer (Owner/CEO), he stated he hired a new Director of Nursing/Administrator (DON/Admin) to manage the agency on his behalf. Owner/CEO stated that he has a lot of new staff in the agency as mot of his staff left. Owner/CEO stated that he does everything he could do when they conduct governing body meetings in the office. Per Owner/CEO stated that the staff, Director of Nursing (DON), Social Worker (SW), Medical Director (MD) attends the governing body meetings. Owner /CEO further stated he should have overseen the new staff in managing the hospice agency. During an interview with the Director of Nursing/Administrator (DON/Admin) on 11/22/23 at 5:30 p.m., stated that she has experience as an acute nurse and is now a retired nurse she accepted the job as the DON/Admin for this hospice agency. DON/Admin stated that she had minimal training to do hospice and is still learning about the hospice philosophy. DON/Admin stated that she had not read the job description and does not know what the job entailed when she came on board. A review of the hospice agency's job description of Executive Director/Administrator revised May 2022, indicated, "The Executive Director/Administrator is responsible for the overall direction of the day to day operations of the 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 and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy." A review of the Hospice Agency's policy titled " Governing Body" revised November 2020 indicated that the Governing Body will assume full legal authority, responsibility and accountability for the overall management and operations, the provision of services, fiscal operations, review of the organization's budget and its operational plans, and its quality assessment and performance improvement (QAPI-a resource that assists a hospice provider with implementation and maintenance of their quality improvement program and activities.) program. The Governing Body of TRANQUILITY HOSPICE INC will serve as the governing authority for the home care program, which will function according to TRANQUILITY HOSPICE INC's bylaws. Governing Body members will be selected based upon their industry experience, expertise, and professional relationships. How these selection factors support and strengthen the mission of the organization will be determining factors for placement as a Governing Body member. The Governing Body will appoint a qualified Executive Director/Administrator and establish procedures of systematic communication between the two (2). Performance of the Executive Director/Administrator will be monitored regularly through a procedure established by the Governing Body. A review of the Hospice Agency's policy titled " Orientation of Hospice Personnel to Assigned Responsibilities" revised May 2022, indicated that All hospice personnel will be oriented to the physical, psychosocial, and environmental aspects of care, including patient needs, Tranquility Hospice Inc personnel's specific responsibilities, and specific care they are to provide. This orientation may include verbal or written instruction and/or demonstration. The orientation to assigned responsibilities will occur on site, when appropriate, but minimally, on the telephone prior to caring for the patient.

Based on interview and record review, the Hospice Agency (HA) failed to employ a qualified Social Worker (MSW) and under the direction of the agency physician for one of one MSW. This deficient practice may impede to identify issues with patient treatment in reaching the maximum benefit from the hospice care and services. --- Findings: During a review of the agencys ";Organizational Chart" (shows the internal structure of an organization or company) provided by the agencys Office Manager (OM), on 11/21/2023 at 4:20 p.m., the Organizational chart indicated social worker 1 (MSW 1) was the current social worker of the hospice agency. During a telephone interview with MSW 1 on 11/22/2023 at 1:22 p.m., MSW 1 stated she has not started working with the hospice agency yet and conducted an assessment of any of the agencys active patients. During an interview with the OM on 11/23/2023 at 11:05 a.m., OM stated the agency does not have a Social worker currently employed. During a review of the agencys policy and procedure titled, ";Interdisciplinary Group Coordination of Care" revised May 2022, indicated core hospice services (nursing, social work, physician, and counselors) will be available 24 hours a day, seven (7) days a week, as will be drugs, biologicals, and medical supplies. During a review of agencys policy and procedure titled, ";Psychosocial Assessment" revised May 2022, indicated a thorough psychosocial assessment will be initiated at the time of admission and continued throughout the course of care.

2. the Hospice Agency failed to ensure the Medical Director assume overall responsibility for the medical component of the hospices patient care program for all patients admitted in the hospice program. (Refer to L669) Based on observation, interview, and record review, the Hospice Agency failed to ensure the Condition of Participation for Medical Director was met as evidenced by: 1. The hospice agency failed to ensure the Medical Director and/or physician designee conducted an 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 three out of 17 sampled patients (Patient 1, Patient 2, and Patient 5). (Refer to L667) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory mandated (state law) compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was provided to the patients certified to receive hospice services.

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 Medical Director and/or physician designee conducted an assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (a hospice physician narrative designed to explain the clinical findings that support a life expectancy of six months or less), to qualify for hospice care and services (health care that focuses on the palliation to ease the symptoms without curing the underlying disease of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) for eight of 17 sampled patients (Patient 1, Patient 2, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). This deficient practice resulted in the provision of hospice services with anticipation of life expectancy of six months or less to patients who were not clinically eligible to receive hospice services. --- d. During a review of Patient 6s admission record indicated a start of care (SOC) date of 9/8/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation (refer to an increase in the severity of a disease or its signs and symptoms). Patient 6's face sheet (a documents that typically include the patient's name, address, date of birth, insurance information, and emergency contact information) indicated the patients referring/attending physician was the agencys previous Medical Director (Physician 2). Patient 6 telephone number on the face sheet indicated it was not a working number. During a review of Patient 6's Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), dated 9/8/2023, indicated Patient 6 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related (anything that's connected or related to the heart) pain, no edema (swelling in parts of your body because of fluid trapped in your tissues, most often in your feet, ankles and legs), had clear lung sounds, had mild dyspnea (difficult or labored breathing) with mild exertion, vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate) are within normal range, and ambulatory using a walker. During a review of Patient 6's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the first hospice benefit period from 9/8/2023 to 12/6/2023, indicated Patient 6's terminal diagnoses was COPD with acute exacerbation. The Medical Director (Physician 1) indicated Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 6s terminal illness diagnosis. During a review of Patient 6s LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) Hospice Eligibility Determination form for Pulmonary Disease (issues pertaining to the lungs), dated 9/8/2023, indicated Patient 6 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 6 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier) resulting in decreased functional capacity and had an increasing physician home visits prior to hospice admission. Section 2 was marked "yes" that Patient 6s had O2 sat (Oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 92–100%) less than or equal to 88% determined either by arterial blood gases (measures the balance of oxygen and carbon dioxide in your blood to see how well your lungs are working) or O2 saturation monitors. During a review of Patient 6's clinical record indicated there was no documented evidence Patient 6 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators resulting in decreased functional capacity, had an increasing physician home visits prior to hospice admission, or had O2 sat less than or equal to 88% determined either by arterial blood gases or O2 saturation monitors. During a concurrent interview and record review on 11/23/2023 at 12:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 6 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, had an increasing physician home visits prior to hospice admission, or had an O2sat less than or equal to 88%. e. During a review of Patient 7s admission record indicated a start of care date of 9/6/2023 with a terminal diagnosis of chronic obstructive pulmonary disease, unspecified. Patient 7's face sheet indicated the patients referring/attending physician was the agencys previous Medical Director (Physician 2). During a review of Patient 7's Comprehensive Nursing Assessment, dated 9/6/2023, indicated Patient 7 was awake, alert, oriented to person, place, and time, had no cardiac-related pain, no edema, had regular pulse rate (heart rate), had mild dyspnea with mild exertion, and was ambulatory using a walker. The Comprehensive Nursing Assessment further indicated Patient 7 meets and qualifies for hospice admission based on LCD guidelines. During a review of Patient 7's "Physician Certification for Hospice Benefit" for the first hospice benefit period from 9/6/2023 to 12/4/2023, indicated Patient 7's terminal diagnoses was COPD. The Medical Director indicated Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 7s terminal illness diagnosis. During a review of Patient 7s LCD Hospice Eligibility Determination form for Pulmonary Disease, dated 9/6/2023, indicated Patient 7 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 7 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators resulting in decreased functional capacity and had an increasing physician home visits prior to hospice admission. Section 2 was marked "yes" that Patient 7s had hypoxemia (a low level of oxygen in the blood) at rest on room air, as evidenced by pO2 (Partial pressure of oxygen, it reflects the amount of oxygen gas dissolved in the blood. Normal reading is 75 to 100 millimeters of mercury [mmHg]) less than or equal to 55 mmHg. During a review of Patient 7's clinical record indicated there was no documented evidence Patient 7 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators resulting in decreased functional capacity and had an increasing physician home visits prior to hospice admission. There was also no documentation Patient 7 had hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mmHg. During a telephone interview on 11/22/2023 at 12:23 p.m. with Patient 7s family member (FM 2), FM 2 stated she does not know if Patient 7s attending physician referred him to hospice care. FM 2 further stated Patient 7 was doing well, walking around using a walker, and does not have shortness of breath when at rest. During a concurrent interview and record review on 11/23/23 at 12:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 7 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators resulting in decreased functional capacity and had an increasing physician home visits prior to hospice admission. DPCS further stated that there was also no documentation Patient 7 had hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mmHg. f. During a review of Patient 8s admission record indicated a start of care date of 9/6/2023 with a terminal diagnosis of heart disease, unspecified. Patient 8's face sheet indicated the patients referring/attending physician was the agencys previous Medical Director. During a review of Patient 8's Comprehensive Assessment, dated 9/6/2023, indicated Patient 8 was awake, alert, oriented to person, place, and time, had no cardiac-related pain, no edema, had normal respirations, regular pulse, and ambulatory using a walker. The Comprehensive Nursing Assessment further indicated Patient 8 was on NYHA Stage IV of heart failure (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). During a review of Patient 8's "Physician Certification for Hospice Benefit" for the first benefit period from 9/6/2023 to 12/4/2023, indicated Patient 8's terminal diagnoses was heart disease, unspecified. The Medical Director indicated Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 8s terminal illness diagnosis. During a review of Patient 8s LCD Hospice Eligibility Determination form for Heart Disease, dated 9/6/2023, indicated Patient 8 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 8 had been ruled out as a candidate for surgical procedures. Section 2 was marked "yes" that Patient 12s heart disease met the criteria for NYHA Class IV level. During a review of Patient 8's clinical record indicated there was no documented evidence Patient 8 had been ruled out as a candidate for surgical procedures. There was also no documentation Patient 8 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a home visit at Patient 8s residence, on 11/22/2023 at 11:15 a.m., Patient 8 was observed laying on a couch, awake, alert, oriented, was on oxygen via a nasal canula (a device that delivers extra oxygen through a tube and into your nose), having no shortness of breath and not complaining of any chest pain. Upon close observation of the Patient 8s oxygen tank (metal cylinders that store oxygen under pressure), the oxygen was not on. During a concurrent interview, Patient 8 stated he had no surgery scheduled in the past, nor had been ruled out as a candidate for any surgical procedures. During a concurrent interview and record review on 11/23/2023 at 12:15 p.m. with the DPCS, the DPCS stated she was not able to find documented evidence Patient 8 had been ruled out as a candidate for surgical procedures. The DPCS further stated there was no documented evidence Patient 8 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. g. During a review of Patient 9s admission record indicated a start of care date of 9/5/2023 with a terminal diagnosis of heart disease, unspecified. Patient 9's face sheet indicated the patients referring/attending physician was the agencys previous Medical Director. During a review of Patient 9's Comprehensive Assessment, dated 9/5/2023, indicated Patient 9 was awake, alert, oriented to person, place, and time, had no cardiac-related pain, no edema, had normal respirations, regular pulse, and ambulatory using a walker. The Comprehensive Nursing Assessment further indicated Patient 9 was on NYHA Stage IV of heart failure. During a review of Patient 9's "Physician Certification for Hospice Benefit" for the first benefit period from 9/5/2023 to 12/3/2023, indicated Patient 9's terminal diagnoses was heart disease, unspecified. The Medical Director indicated Patient 9 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 9 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 8s terminal illness diagnosis. During a review of Patient 9s LCD Hospice Eligibility Determination form for Heart Disease, dated 9/5/2023, indicated Patient 9 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 9 had been ruled out as a candidate for surgical procedures. Section 2 was marked "yes" that Patient 12s heart disease met the criteria for NYHA Class IV level. During a review of Patient 9's clinical record indicated there was no documented evidence Patient 9 had been ruled out as a candidate for surgical procedures. There was also no documentation Patient 9 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 11/22/2023 at 12:31 p.m. with Patient 9, Patient 9 stated he can walk around his neighborhood, had no chest pain, had no surgery scheduled or had been ruled out as a candidate for any surgical procedures, and was not referred by his primary physician to hospice. During a concurrent interview and record review on 11/23/2023 at 12:15 p.m. with the DPCS, the DPCS stated she was not able to find documented evidence Patient 9 had been ruled out as a candidate for surgical procedures. The DPCS further stated there was no documented evidence Patient 9 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. h. During a closed record review of Patient 10s admission record indicated a start of care date of 3/6/2023 with a terminal diagnosis of heart disease, unspecified. Patient 10's face sheet indicated the patients referring/attending physician was the agencys previous Medical Director. During a review of Patient 10's Comprehensive Assessment, dated 3/6/2023, indicated Patient 10 was awake, alert, oriented to person, place, and time, had no cardiac-related pain, had normal respirations, regular pulse, and ambulatory using a cane or walker. The Comprehensive Nursing Assessment further indicated Patient 10 was on NYHA Stage IV of heart failure. During a review of Patient 10's "Physician Certification for Hospice Benefit" for the first benefit period from 3/6/2023 to 6/3/2023 signed by the agencys previous Medical Director (Physician 3), indicated ";Patient does not meet criteria for admission to hospice with unspecified heart disease and does not have a specified qualifying heart condition or any other hospice qualifying condition. Life expectancy exceeds six months." During a telephone interview on 11/23/2023, at 12:30 p.m. with the Medical Director (Physician 1), he stated that he was not the attending physician, and he does not know who the attending physicians for Patients 6, 7, 8,9 and 10. Physician 1 stated he does not know the previous Medical Director (Physician 2) of the agency and have not discussed Patients 6, 7, 8, 9, and 10's case with Physician 2 or any of their primary physician. Physician 1 further stated that he determined the patients were eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. During a review of the agencys policy and procedure titled ";Certification of Terminal Illness", revised May 2022, 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. a. A review of Patient 1's clinical record indicated Patient 1 was admitted to the hospice agency on 4/5/23, with a terminal diagnosis of chronic obstructive pulmonary disease (group of lung disease that block airflow and make it difficult to breathe). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 4/5/23 to 7/3/23, 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 results showing evidence to support the terminal illness diagnosis. On 11/23/23, at 11:30 a.m., a joint home visit was conducted to Patient 1's residence, with the License Vocational Nurse (LVN 1). Patient 1 was observed awake, alert, oriented, and ambulatory using a cane without any assistance from family members. At 12 p.m., during an interview, when Patient 1 was asked if her attending physician referred her to hospice services, she stated she did not have an attending physician at this time and her friend referred her to the hospice agency. b. A review of Patient 2's clinical record indicated a start of care (SOC) date of 8/21/23, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and important mental function). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 8/21/23 to 11/18/23, 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 results showing evidence to support the terminal illness diagnosis. On 11/22/23, at 4 p.m., during a phone interview with Family Member 1, she stated, Patient 2's attending physician did not refer him to the hospice agency but by a friend that worked in their hospice agency. c. A review of Patient 5's clinical record indicated a start of care (SOC) date of 9/3/23, with a terminal diagnosis of chronic obstructive pulmonary disease (group of lung disease that block airflow and make it difficult to breathe). A review of Patient 5's Physicians Certification for Hospice Benefit, dated 9/3/23 to 12/1/23, benefit period #1, indicated the Medical Director 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 was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 11/23/23, at 1 p.m., during an interview with the DPCS, she stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital where the patient gets discharged from. On 11/23/23, at 12:30 p.m., during a phone interview with Physician 1, she stated that she was not the attending physician, and she does not know who the attending physicians for Patients 1,2, and 5. Physician 1 stated since Patients 1, 2 and 5 were admitted for hospice service, she now becomes the patient's attending physician, signed the referral attending physician section because no one would sign it. Physician 1 further stated that she determined the patients were eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. During a review of the agencys undated policy and procedure titled ";Physician Services-Medical Director", indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. 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.

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 Medical Director assume overall responsibility for the medical component of the hospices' patient care program for all patients admitted in the hospice program. This deficient practice resulted in the patients care not being evaluated to ensure the care provided by the HA met the patients and familys needs. --- During a telephone interview on 11/23/2023 at the agency office with the Medical Director (MD) at 11:59 a.m., the MD stated the development of the plan of care is based on medical records, discussion with family, knowing their wishes and talking to the patient, if they are able to communicate. The MD stated he had not been communicating with patients primary physician. MD stated he became the attending physician once they go palliative care. When the surveyor asked why the MDs notes were not in the patient record, the MD stated, "Currently, I havent been able to do that. I have not signed any of the patients charts." During a telephone interview with the current owner/CEO of the hospice agency on 11/23/2023 at 12:55 p.m., CEO stated he monitors the day to day operations of the agency. CEO also stated he should have overseen the new staff in managing the agency. A review of the HAs policy and procedure titled, ";Job Descriptions Hospice Medical Director", revised 5/22, indicated, ";The hospice Medical Director will have overall responsibility for the medical component of the hospice program. 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 Medical director will serve as a hospice champion - promoting and representing the program to physicians, physician groups, discharge planners, other referral sources, community health organizations, and potential donors, as appropriate. The duties and responsibilities of the Medical Director will include, but not be limited to, the following: 1. Devoting his/her best ability to the proper management of the program2. Providing overall medical direction to the program3. Assuring that the established policies, bylaws, rules, and regulations of the organization are followed in the program4. Adhering to requirements, terms, and conditions required by Medicare Conditions of Participation, accrediting body, and federal and state statutes governing the provision of services5. Establishing and continually reviewing policies and procedures related to patient care, medical education, and emergency procedures6. Developing and continually reviewing, in cooperation with the CEO/ExecutiveDirector/Administrator and/or Chief Clinical Officer/Clinical Director, criteria to monitor the quality of the education programs provided to physicians, personnel, and volunteers7. Evaluating quality assessment performance improvement (QAPI) plans and monitoring to identify medical education needs in cooperation with the CEO/Executive Director/Administrator and/or Chief Clinical Officer/Clinical Director. Participates in QAPI teams and activities, as needed8. Proposing organizational programs to address __ the needs identified _(with the assistance and input of consultants of the specialties where medical education needs were identified)9. Working with the CEO/Executive Director/Administrator and/or CCC/Clinical Director, after implementation of the programs, to determine the impact of said programs on the quality of care.

Based on interview and record review, the hospice agency (HA) failed to ensure a completed discharge summary was created upon discharge for four of four sampled discharged patients (Patient 10, Patient 12, Patient 13, and Patient 14). This deficient practice had the potential to result in miscommunication and poor hand-off and can affect the care and services needed in the continuation of care for the affected patient. --- Findings: a. During a closed record review of Patient 10's admission record indicated a start of care date of 3/6/2023, with a terminal diagnosis of heart disease, unspecified. During a review of Patient 10s Discharge summary form indicated Patient 10 was discharged from the HA due to prognosis (a medical term for predicting the likelihood or expected development of a disease) extended, and hospice services end of care (EOC) date was on 7/31/2023. The nurses narrative note was empty, and the discharge summary was not signed by the documenting nurse. During a concurrent interview and record review on 11/23/23 at 12:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated all patients discharged from hospice care should have a completed discharge summary which includes the nurses narrative notes and the signature of the documenting nurse. DPCS stated and acknowledged the findings. During a review of the agency's policy and procedure titled "Discharge Summary," revised May 2022, indicated all patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. b. During a closed record review of Patient 12's admission record indicated a start of care date of 7/27/2023, with a terminal diagnosis of heart disease, unspecified. During a review of Patient 12s Discharge summary form indicated Patient 12 was discharged from the HA was on 10/26/2023. The nurses narrative note was empty, and the discharge summary was not signed by the documenting nurse. c. During a closed record review of Patient 13's admission record indicated a start of care date of 5/2/2023, with a terminal diagnosis of malignant neoplasm of the prostate (cancer of the prostate). During a review of Patient 13's Discharge summary form indicated Patient 13 was discharged from the HA due to prognosis (a medical term for predicting the likelihood or expected development of a disease) extended, and hospice services end of care (EOC) date was on 5/2/2023. The nurses narrative note was empty, and the discharge summary was not signed by the documenting nurse. d. During a closed record review of Patient 14's admission record indicated a start of care date of 4/1/2022, with a terminal diagnosis of senile degeneration(memory loss) of the brain. During a review of Patient 14s Discharge summary form indicated Patient 10 was discharged from the HA due to prognosis (a medical term for predicting the likelihood or expected development of a disease) extended, and hospice services end of care (EOC) date was on 1/4/2023. The nurses narrative note was empty, and the discharge summary was not signed by the documenting nurse. During a concurrent interview and record review on 11/23/23 at 12:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated all patients discharged from hospice care should have a completed discharge summary which includes the nurses narrative notes and the signature of the documenting nurse. DPCS stated and acknowledged the findings. During a review of the agency's policy and procedure titled "Discharge Summary," revised May 2022, indicated all patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. During a review of the HA's policy titled " Job Description Summary: Director of Patient Care Services" revised May 2022 indicated The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy. Oversees the maintenance of patient clinical records, statistics, reports and records for purposes of evaluation and reporting of organization activities.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) clinical records reviewed revealed the hospice did not ensure the clinical records contained the initial bereavement assessment. Record #76952 was reviewed and identified the patient elected hospice care on 11/6/2021. The clinical record did not contain an initial bereavement assessment. The Alternate Administrator was interviewed on 4/15/2022 and agreed that there was no initial bereavement in the record.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness including intervention to manage pain and symptoms and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 6 of 11 (54%) clinical records reviewed revealed the hospice did not ensure plans of care included outcomes that were defined and measurable. Record #76952: Start of Care (SOC) 11/6/2021, Plan of Care (POC) on 11/6/2021 reviewed. Diagnosis Alzheimer’s disease with late onset. Goals: Pain will remain in a comfortable level during care. Record #76517: SOC 3/17/21, POC on 1/11/2022 reviewed. Diagnosis Dementia with Lewy bodies. Goals: Pain will remain in a comfortable level during care. Record #83536: SOC 4/13/21. POC on 4/13/2022 reviewed. Diagnosis Atherosclerosis heart disease of native coronary artery without angina pectoris. Goals: Pain will remain in a comfortable level during care. Record #31460: SOC 6/24/21. POC on 2/19/2022 reviewed. Diagnosis Malignant neoplasm of uterus. Goals: Pain will remain in a comfortable level during care. Record #97623: SOC 11/22/2020. POC on 1/20/2022 reviewed. Diagnosis Cerebral Atherosclerosis. Goals: Pain will remain in a comfortable level during care. Record #57577: SOC 2/23/2021. POC on 3/20/2022 reviewed. Diagnosis Hypertensive heart disease with heart failure. Goals: Pain will remain in a comfortable level during care. The Alternate Administrator was interviewed on 4/15/2022. She agreed with the finding that the patient’s acceptable pain level was not identified.

It is required that a hospice aide provides services are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 4 of 10 (40%) patients reviewed with a hospice aide ordered revealed the hospice did not ensure that the hospice aide followed the plan of care as ordered. Record #76952 was reviewed and identified a hospice aide plan of care on 2/22/2022 assigned a bath: shower chair. For the hospice aide visit on 4/8/2022, the aide narrative stated, “pt was able to tolerated sponge bath.” Record #83536 was reviewed and identified a hospice aide plan of care on 1/25/2022 assigned a bed bath. For the hospice aide visit on 3/30/2022, the aide narrative stated, “pt was able to tolerated shower.” Record #49832 was reviewed and identified a hospice aide plan of care on 1/27/2022 assigned a shower. For the hospice aide visit on 1/31/2022, the aide narrative stated, “pt was able to tolerated sponge bath.” Record #31460 was reviewed and identified a hospice aide plan of care on 6/24/2021 assigned a shower. For the hospice aide visit on 3/31/2022, the aide narrative stated, “pt tolerated sponge bath.” The Alternate Administrator was interviewed on 4/15/2022. She agreed with the finding that the aide did not follow the plan of care.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. 3 of 8 (27%) patients reviewed with recertification periods revealed the hospice did not ensure that the recertifications were completed no later than two (2) calendar days after the first day of each benefit period. Record #76517 was reviewed and identified the patient elected hospice care on 3/17/2021. For benefit period 5, 1/11/2022-3/11/2022, the recertification was completed on 1/18/2022, seven days after the first day of the benefit period. Record #31460 was reviewed and identified the patient elected hospice care on 6/24/2021. For benefit period 3, 2/19/2022-4/19/2022, the recertification was completed on 3/10/2022, nineteen days after the first day of the benefit period. Record #31942 was reviewed and identified the patient elected hospice care on 1/31/2022. For benefit period 10, 4/1/2022- 5/30/2022, the recertification was completed on 4/15/2022, fourteen days after the first day of the benefit period. The Hospice Medical Director was interviewed on 4/15/2022 and stated, “I am aware there are some that are being missed.” The Alternate Administrator was interviewed on 4/15/2022. She agreed with the finding that the face to face and recertification's were completed late.

If a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) records of a patient discharged from hospice revealed the hospice did not ensure that the patient's discharge summary was sent to the attending physician. Record #83500 was reviewed and identified a discharge summary on 2/3/2022. The summary which did not include the patient’s current plan of care or latest physician's orders was not sent to the attending physician. The Alternate Administrator was interviewed on 4/15/2022. She agreed with the finding that there was no evidence of the discharge summary being sent to the attending physician, and that the summary in the record did not include the patient’s current plan of care or latest physician orders.

It is required that the Interdisciplinary Group ensures instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies. Persons under contract with the hospice may instruct the patient and/or family. Instruction is documented in the patient record. The patient, family and/or other caregiver must be able to demonstrate the appropriate use of the DME to the satisfaction of the IDG. The IDG documents that the patient, family, and/or caregivers can demonstrate appropriate use. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) patients reviewed with DME delivered, revealed the hospice did not ensure the caregiver was instructed on the safe utilization of the suction machine. Record#57577 was reviewed and identified a suction machine was delivered on 3/3/2022. The caregiver was interviewed on 4/14/2022 and stated, “we use it when she chokes or aspirates” and confirmed no education had been received. The Alternate Administrator was interviewed on 4/15/2022. She agreed with the finding that no education was documented as having been provided to the caregiver on the use of the suction machine.