Every finding on record at Valley Best Care, Inc

Based on observation, interview and record review, the hospice agency failed to maintain accurate and current patient medication profiles, for two of seven sampled patients, (Patients 25 and 27). This failure had the potential in placing the patients at risk for medication errors and adverse drug reactions. --- a. During a record review of Patient 25s Patient Information Sheet, the information sheet indicated a Start of Care (effective date of hospice election which is the first day a patient begins receiving hospice care) date of 12/9/2023 with a primary diagnosis of atherosclerosis (the buildup of fats, cholesterol and other substances in and on the artery walls) heart disease of the native coronary (heart) artery (blood vessel) without angina pectoris (chest pain). During a record review of Patient 25s Physicians Certification for Hospice Benefit (Certificate of Terminal Illness, CTI, a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician- a medical doctor specializing in providing palliative care to terminally ill patients) for the 12th period from 12/3/2024 to 1/31/2025, the CTI indicated a primary diagnosis of atherosclerosis heart disease of the native coronary artery without angina pectoris. The CTI indicated in the Face-to-Face narrative was an attached document titled, ";MD Recertification Visit." During a record review of Patient 25s Medication List, the medication list indicated for Gabapentin (a medication for the treatment of neuropathic [nerve] pain caused by diabetic neuropathy (a nerve condition that can cause a range of symptoms, including pain, numbness, tingling, swelling, or muscle weakness) 300 milligram (mg, unit of measurement) Capsule, one capsule, oral (by mouth), once a day bedtime for neuropathy). During a joint home visit observation and interview, on 12/17/2024 at 10:47a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 25 was observed lying in bed, oriented to person, place, and time. During an interview at 12/17/2024 at 11 a.m., the ADM/DPCS stated that Patient 25 did not have her Gabapentin medication on hand. The ADM/DPCS stated that he visited the patient every Saturday and that the last time Patient 25 had her medications checked was 11/30/2024. The ADM/DPCS stated the medication was ordered on 11/26/2024 but was not received at the assisted facility where Patient 25 resided. During an interview and record review on 12/18/2024 at 11:45 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS) and ADM Assistant, Patient 25s CTI #12 Face to Face Narrative, titled, MD Recertification Visit, dated 11/16/2024, was reviewed. The ADM/DPCS and ADM Assistant confirmed that the narrative indicated that Patient 25 had on, and off chest pain managed by nitroglycerin (a substance used as a drug to treat certain heart conditions and to widen the openings in blood vessels). During a telephone interview on 12/18/2024 at 12:45 p.m. Physician 1 stated that he recertified and performed a face-to-face exam for Patient 25. Physician 1 stated that during his exam, he did not see signs of weakness, shortness of breath, or chest pain at the time of his examination. Physician 1 stated that he visited Patient 25 with ADM/DPCS and was going to discharge the Patient but was hesitant to discharge her because the nurse reported to him that the patient had on and off chest pain. Physician 1 stated Patient 25 had an order for nitroglycerin. When Physician 1 was notified that Patient 25 did not have nitroglycerin ordered on her medication list, Physician 1 stated that it should have been ordered. Physician 1 stated that it was important that nitroglycerin be prescribed for Patient 25 because nitroglycerin was for anginal pains, and this medication would help with the patients chest pain. During an interview on 12/18/2024 at 1:15 p.m., the ADM/DPCS stated that the medications were checked every other week. The ADM/DPCS stated that the assisted facility where Patient 25 resided should have notified the hospice agency that Patient 25s Gabapentin medication ran out. The ADM/DPCS stated that the last time he was at the facility, was 12/14/2024 and that the last time he performed a medication check was 11/30/2024. The ADM/DPCS stated that the LVN should also be checking if the medications were available. The ADM/DPCS stated that it was important that the Patient 25 had their medications on hand because the patient has neuropathy and has tingling in her fingers and feet, has poor circulation, and that this medication could help her sleep. During an interview and record review on 12/18/2024 at 1:26 p.m., with the ADM/DPCS, Patient 25s Medication List was reviewed, and nitroglycerin was not prescribed. The ADM/DPCS stated that Patient 25 had chest pain on occasion, but it was not continuous. The ADM/DPCS stated he thought it was ordered and that it was important because if Patient 25 had chest pain in the future, she should have the medication on hand. The ADM/DPCS stated that nitroglycerin relieves chest pain. b. During a record review of Patient 27s Patient Information Sheet, the information sheet indicated a Start of Care date of 12/7/2023 with a primary diagnosis of dementia with Lewy bodies (a progressive brain disease that affects thinking, movement, mood, and behavior). During a record review of Patient 27s Plan of Care Summary, the summary indicated for frequency of visits; the medical director to visit on admission/recertification and as needed, The skilled nurse to visit once a week and as needed for pain and symptoms management, and the home health aide to visit once per week for activities of daily living and personal care. During a record review of Patient 27s Medication List, the medication list indicated for Lorazepam (a drug used to treat anxiety), take 1 mg, one tablet, oral, every eight hours as needed for agitation and anxiety. During a joint home visit observation and interview, on 12/17/2024 at 10:30 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 27 was observed lying in bed, oriented to person, place, and time. During an interview at 12/17/2024 at 11 a.m., the ADM/DPCS stated that Patient 27 did not have his lorazepam on hand but did not need it. The ADM/DPCS stated that he visited the patient every Saturday and that the last time Patient 27 had her medications checked was 11/30/2024. The ADM/DPCS stated the medication was ordered on 6/18/2024 but was not received at the assisted facility where Patient 27 resided. During an interview at 12/17/2024 at 11 a.m., the ADM/DPCS stated that Patient 27 did not have his lorazepam on hand but did not need it. The ADM/DPCS stated that he visited the patient every Saturday and that the last time Patient 27 had his medications checked was 11/30/2024. The ADM/DPCS stated the medication was ordered on 6/18/2024 but was not received at the assisted facility where Patient 27 resided. A review of the hospice agencys policy and procedure titled, ";Medication Profile", dated 1/2023, indicated patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met by as followed: --- The hospice agency failed to ensure that the patient's family member was updated with the patient's condition and the hospice services provided for two of seven sampled patients (Patient 25 and Patient 26). Refer to L543 The hospice agency failed to provide an individualized plan of care (a written document detailing the specific healthcare needs, goals, and interventions designed for an individual patient, outlining the services and support they will receive to address their health condition) that included continuous education and teaching for one out of seven sampled patients (Patient 28) whose primary caregivers opted to call 911 in case emergency. Refer to L544 The hospice agency failed to ensure to develop and implement a plan of care (POC) for podiatry care for two of seven sampled patients (Patient 26 and Patient 27). Refer to L545 The cumulative effects 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 are provided to the patients accurately assessed to receive hospice care and services.

Based on observation, interview, and record review, the hospice agency failed to ensure the patient's family member was updated with the patient's condition and the hospice services provided for two of seven sampled patients (Patient 25 and Patient 26). This deficient practice had the potential to lead to a lack of information resulting in the family member's increased stress due to the uncertainty about the patient's changing needs and the progression of the patient's illness, and potentially impacting the family member's ability to make informed decisions about the patient's end-of-life care. --- a. During a record review of Patient 25s Patient Information Sheet, the information sheet indicated a Start of Care (effective date of hospice election which is the first day a patient begins receiving hospice care) date of 12/9/2023 with a primary diagnosis of atherosclerosis (the buildup of fats, cholesterol and other substances in and on the artery walls) heart disease of the native coronary (heart) artery (blood vessel) without angina pectoris (chest pain). The information sheet indicated that the authorized representative/emergency contact was Family Member (FM1). During a record review of Patient 25s Plan of Care Summary, the summary indicated for frequency of visits as follows: Medical director to visit on admission/recertification and as needed. The Skilled nurse to visit once a week and as needed for pain and symptoms management, and the Home Health aide to visit once per week for activities of daily living and personal care. During a joint home visit observation and interview, on 12/17/2024 at 10:47a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 25 was observed lying in bed, oriented to person, place, and time. Patient 25 stated she did not feel good today and wanted to keep her eyes closed. During an interview on 12/17/2024 at 2:07 p.m., Family Member (FM1) stated Patient 25 had a terminal illness related to a bad heart. FM1 stated that he had never talked with the ADM/DPCS and that no one talked to him about what hospice services were provided to Patient 25. FM1 stated there was a lady who visited once a week to give Patient 25 a bed bath. FM1 he was not aware that a nurse visited Patient 25 every week. FM1 stated he was not aware that once Patient 25 enrolled in hospice care, that Physician 1 became Patient 25s doctor. During an interview on 12/18/2024 at 2:46 p.m., the ADM/DCPS stated that FM1 should know what is going on with their significant other and what hospice services are provided to Patient 25. The ADM/DCPCS stated the hospice agency should be more in contact with the family and that communications should be documented in the communication log. b. During a record review of Patient 26s Patient Information Sheet, the information sheet indicated a Start of Care (effective date of hospice election which is the first day a patient begins receiving hospice care) date of 12/9/2023 with a primary diagnosis of Alzheimers Disease (a disease characterized by a progressive decline in mental abilities). The information sheet indicated that the authorized representative/emergency contact was Family Member (FM2). During a record review of Patient 26s Plan of Care Summary, the summary indicated for frequency of visits: The Medical Director to visit on admission/recertification and as needed. The skilled nurse to visit once a week and as needed for pain and symptoms management, and the Home Health aide to visit once per week for activities of daily living and personal care. During an interview on 12/17/2024 at 3:11 p.m., Family Member (FM2) stated that she did not receive updates about Patient 26 from the hospice agency much, did not know the who the Administrator/Director of Patient Care Services (ADM/DPCS) was and did not know that the hospice medical director (Physician 1) was Patient 26s physician. FM2 stated she saw Patient 26 last week and that Patient 26s fingernails and toenails were long and needed to be cut. FM2 was concerned that Patient 26s toenails were long, curled up and would cut into her skin. During an interview on 12/18/2024 at 2:31 p.m., the ADM/DPCS stated that the case manager and the ADM/DPCS communicate with the family. The ADM/DPCS stated he had never seen FM2 at the facility and only talked to her over the phone. The DPCS stated he was not aware that FM2 was not well informed about the services that the hospice agency provided to Patient 26. The ADM/DPCS stated that the family was not normally included in the IDG meeting and that they could make more attempts to contact family. The ADM/DPCS stated that the family should have been more educated and more involved in Patient 26s care. The ADM/DPCS stated that it was important to involve family, so they know what is going on with the patient and what hospice services are provided. During a record review of the hospice agency's policy and procedure titled, ";Plan of Care," revised 1/2023, the policy indicated that a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. This plan of care must be initiated at start of care. As needed, the patient and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide or follow through with. The written plan of care will contain but will not be limited to patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching. During a record record review of the hospice agency's policy and procedure titled, "Care/Service Coordination," dated January 2023, the policy indicated that each patient will be assigned a Case Manager upon admission by the Clinical Director/Director of Patient Care Services or Clinical Supervisor. It will be the responsibility of the Case Manager to facilitate communication about changes in the patient status among assigned personnel. The policy indicated that the program supervisor will assign the patient to a Case Manager based on the patient's need and level of care required, geographic area, and qualifications of organization personnel needed. The policing indicated that a registered nurse will be assigned to a patient receiving hospice care. The policy indicated that care coordination will include, but not be limited to: A. Clearly outlining each clinician's responsibilities to avoid duplication of services,... J. Coordination of care delivery to meet the patient's needs, and involve the patient representative, and caregivers, as appropriate, in the coordination of care activities. The policy indicated that written evidence of care coordination may be found in the plan of care/service, case conference summary forms, clinical notes in the patient's clinical record or interdisciplinary group meeting notes.

Based on interview and record review, the Hospice Agency (HA- agency providing care to terminally ill patients who have six months or less to live) failed to provide an individualized plan of care (a written document detailing the specific healthcare needs, goals, and interventions designed for an individual patient, outlining the services and support they will receive to address their health condition) that included continuous education and teaching for one out of seven sampled patients (Patient 28) whose primary caregivers opted to call 911 in case emergency. This deficient practice has the potential to result in the risk that Patient 28 will not receive the necessary care and services on time that could lead to injury, harm, hospitalization or even death. --- During a review of Patient 28s document titled ";Patient Information Sheet" on 12/17/2024, the Patient Information Sheet indicated that Patient 28 had a start of care (SOC - refers to the initial point when a patient begins receiving hospice services, which typically involves a comprehensive assessment of their needs, development of a personalized care plan, and the delivery of necessary medications and medical equipment to manage their symptoms and ensure comfort, all occurring once a doctor has determined the patient has a life expectancy of six months or less and is eligible for hospice care) date of 8/23/2024 with a terminal diagnosis of Alzheimers disease (a progressive neuro-degenerative brain disorder that destroys memory and thinking skills). During a review of Patient 28s ";Physicians Certification for Hospice Benefit" for the 9th benefit period dated 10/22/2024 to 12/20/2024 indicated that Patient 28 is a 97 year old female patient with terminal diagnosis of Alzheimer" s disease, unspecified with multiple co-morbidities including but not limited to hypercholesterolemia (high cholesterol), hypothyroidism (low thyroid [an organ of the body that regulates many body functions] hormone), iron deficiency anemia (low iron) and diabetes mellitus (a disease where the body cannot process sugar). Patient with increased confusion and has periods of hallucinations(false perception of things and events), she gets easily fatigued with limited range of motion and has generalized body weakness. Patient with poor balance and unsteady gait and had a recent fall incident. Patient also has unintentional weight loss since the start of care. Patient unable to participate in any activities due to disease process and requires maximum assistance with walking, transfers, bathing, dressing, toileting and feeding. The patient continues to show cognitive and functional decline and continues to qualify for hospice services under routine level of care, patient will continue the same plan of care and extensive monitoring. A review of Patient 28s POLST (Physicians Orders for Life Sustaining Treatment- a medical order that outlines a patient's preferences for end-of-life care) dated 8/23/2024 signed by the Administrator/Director of Patient Care Services (ADM/DPCS) and Patient 28s primary family member 4 (FM4) indicated if the patient has no pulse and is not breathing the family opted to ";Attempt resuscitation" (CPR or cardiopulmonary resuscitation is an emergency lifesaving procedure performed when the heart stops beating). A joint home visit was conducted on 12/17/2024 at 10 a.m., at the Patient 28s residence with the hospice agencys care coordinator (CC). Patient 28s Family Member 5 (FM5) was present during the home visit. FM5 stated that she is looking after Patient 28 this morning while the primary family member 4 (FM4) went to the market. Patient 28 was still in bed under her covers, not in any respiratory distress and visiting nurse initiated her home visit. During the home visit observation on 12/17/2024 showed that the ";Patient Handbook" (a comprehensive guide provided by a healthcare facility to patients and their families, outlining information about the facility's services, policies, procedures, patient rights, and commonly asked question) indicated an instruction in all capital and bold letters that stated "; DO NOT CALL 911" and underneath it a statement ";Please Call the agency immediately for any change of Patients status/condition." During an interview with FM5 on 12/17/2024 during the home visit, FM5 was asked on three different occasions ";What will she do in case she finds that the patient fell, not breathing, no pulse or not conscious?" FM5 replied three times "; I will call 911" FM5 stated she knew how to do CPR but she does not want to do CPR on the patient and wants emergency services to do it instead. During a telephone interview on 12/17/2024 at 1:55 p.m., with FM4, FM4 confirmed that Patient 28 is a full code (a medical term indicating to do CPR for emergency) and gave instructions to family members that they need to call 911 for any kind of emergency to the patient. During an interview on 12/18/2024 at 1:49 p.m., with the ADM/DPCS, the ADM/DPCS stated that he conducted the initial assessment for Patient 28 and confirmed that the family wanted to do CPR for the patient. When asked about the statement they put in the front of the ";Patient Handbook" the ADM/DPCS stated the family can change their mind if they do want to call 911 in case of emergency, but we encourage them to call the agency first before they call 911. ADM/DPCS further stated that he will not train them how to perform CPR and that the patients family requires education and teaching on what to do in case of emergency. During a review of Patient 28s ";Plan Of Care" dated 12/18/2024 indicated Interventions and Goals: Environment/Safety: Patient is at risk for falls and fall related injuries due to impaired mobility and cognitive decline. Goal: -Patient will have a reduced risk of falls during the certification period with use of safety measures -Patient will remain safe from environmental hazards resulting from cognitive impairment throughout the certification period -PCG (Patient caregiver) will provide assistance with each occurrence of transfers Interventions: - Assess safety concerns/issues. -Explain and teach Pt/Family/PCG on reasons for increased risk for fall. - Instruct on safe use of DME's provided to patient. - On-going assessment of physical, cognitive and environmental factors. - On-going assessment of safety risk, history of injury and plan for emergency. - Plan to reduce risk by anticipated needs, assistance as needed and visual observation on every visit. PCG issue: Knowledge deficit related to cognitive changes and increased physical limitations: Pcg/family will exhibit an understanding of required care and appropriate coping skills -Pcg/Family will verbalize understanding of hospice philosophy and services available within the certification period -Pcg/Family will be able to provide hygiene and bathing care for the patient as needed -Demonstrates compliance with medication regimen. -Educate Pt/Family/PCG regarding hospice philosophy and services including 24 hour availability and access to on-call staff after hours. Evaluate and prioritize patient's daily goals. Instruct and assess compliance on use of medications and monitor efficacy. Provide instruction and teachings regarding disease process and plan of care and encourage family conference when appropriate. A review of the hospice agencys document titled "; Plan of Care" revised 1/2023 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. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. This plan of care must be initiated at start of care. As needed, the patient and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide or follow through with. The written plan of care will contain, but will not be limited to Patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure to develop and implement a plan of care (POC) for podiatry care for two of seven sampled patients (Patient 26 and Patient 27). This deficient practice had the potential risk for ingrown toenails, infection, and complications from overgrown toenails. --- a. During a record review of Patient 26s Patient Information Sheet, the information sheet indicated a Start of Care (effective date of hospice election which is the first day a patient begins receiving hospice care) date of 12/9/2023 with a primary diagnosis of Alzheimers Disease (a disease characterized by a progressive decline in mental abilities). The information sheet indicated that the authorized representative/emergency contact was Family Member (FM2). During a record review of Patient 26s Plan of Care (POC) Summary, the summary indicated for frequency of visits: The Medical Director on admission/recertification and as needed. The Skilled nurse once a week and as needed for pain and symptoms management, and the Home Health aide once per week for activities of daily living and personal care. The POC Summary indicated an order for podiatry consult and treatment as appropriate. During a joint home visit observation and interview, on 12/17/2024 at 11 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 26 was observed lying in bed, oriented to person and confused. Patient 26 stated the year was ";1943." During an interview on 12/17/2024 at 3:11 p.m., Family Member (FM2) stated she saw Patient 26 last week and that Patient 26s fingernails and toenails were long and needed to be cut. FM2 was concerned that Patient 26s toenails were long, curled up and would cut into her skin. During an interview on 12/18/2024 at 2:31 p.m., when ADM/DPCS was asked when the last time Patient 26 had seen a podiatrist, he stated it was probably time for Patient 26 to see a podiatrist and that it was important for good hygiene. b. During a record review of Patient 27s Patient Information Sheet, the information sheet indicated a Start of Care date of 12/7/2023 with a primary diagnosis of dementia with Lewy bodies (a progressive brain disease that affects thinking, movement, mood, and behavior). During a record review of Patient 27s Plan of Care Summary, the summary indicated for frequency of visits: The Medical director to visit on admission/recertification and as needed. The skilled nurse to visit once a week and as needed for pain and symptoms management, and the Home Health aide once per week for activities of daily living and personal care. There was no order indicated for podiatry care. During a joint home visit observation and interview, on 12/17/2024 at 10:30 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 27 was observed lying in bed, oriented to person, place and time. Patient 27s feet were dry and ashy with long and thick and yellowish discolored toenails. The ADM/DPCS stated that Patient 27s toenails were crusty and needed to be cut and that Patient 27 needed podiatry care. During an interview on 12/18/2024 at 2:55 p.m., the ADM/DPCS stated that Patient 27 did not have a podiatry order and that it should have been ordered. The ADM/DPCS stated that Patient 27 should have been seen by a podiatrist because Patient 27s feet may have a possible infection due to ingrown toenails, a risk for fungal infection, and that it was important for good hygiene. During a record review of the hospice agency's policy and procedure titled, "The Plan of Care," dated January 2023, the policy indicated that a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The policy indicated that the plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen days. The policy indicated that this plan will focus on identified problems, goals, and interventions.

Based on interview and record review, the hospice agency (HA-agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation for Quality assessment/performance improvement (QAPI-refers to a systematic process used by hospice organizations to continuously monitor, evaluate, and improve the quality of care provided to patients by identifying areas needing improvement and implementing changes to enhance patient outcomes and safety throughout their end-of-life journey) was met as follows: --- The hospice agency's governing body failed to ensure, monitor, implement evidence of a Quality Assessment and Performance Improvement Program. (Refer to L574) The hospice agency's governing body failed to ensure to appoint an individual who will operate the QAPI Program. (Refer to L576) The cumulative effect of these systemic practices resulted in the agencies failure to ensure that issues, problems and other interventions necessary to the improvement of quality patient care will not be discussed and presented to the caregivers involved in direct patient care.

Based on observation, interview and record review, the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agencys (HA, agency providing care to terminally ill patients who have six months or less to live) governing body failed to ensure, monitor, implement evidence of a Quality Assessment and Performance Improvement (QAPI-refers to a systematic process used by hospice organizations to continuously monitor, evaluate, and improve the quality of care provided to patients by identifying areas needing improvement and implementing changes to enhance patient outcomes and safety throughout their end-of-life journey) program. This failure has the potential to result in the hospice agency to not be able to assess and evaluate negative patient care outcomes, and infection control program surveillance, including the agency's operations. --- During the entrance conference on 12/16/2024 at 12:10 p.m. the Administrator/Director of Patient Care Services (ADM/DPCS) stated the hospice agencys fiscal year starts in October. A request was made to the agencys on 12/16/2024 at 12:15 p.m. for the agencys QAPI program. The ADM/DPCS went to the volunteer coordinator and stated that she is the person to ask with regards to the program book. During the record review of the QAPI program on 12/16/2024, at 12:45 p.m., it indicated the QAPI program and policy was approved, reviewed and signed by the ADM/DPCS, Medical Director (Physician 1) and Chief Finance Officer (CFO) on 3/15/2024. Record review also revealed that the agency reviewed their First Quarter QAPI on 4/2/2024. There was no documentation for the review of the second, third and fourth QAPI in the program book. During an interview on 12/16/2024 at 12:30 p.m., with the Volunteer Coordinator (VC), stated that she helps the QAPI consultant and stated that the QAPI consultant is newly hired and is a part time employee. The VC also stated that the consultant has access to the hospice electronic program to gather the data she needs for the review and evaluation of the QAPI. The VC stated that when they review the QAPI, the 1st quarter starts January-February-March is reviewed in April. April-May-June 2nd Quarter is reviewed in July, July- August- September 3rd Quarter is reviewed in October and October-November-December 4th Quarter is reviewed in January of the next year. The VC was requested to provide the employee file for the newly hired QAPI consultant and VC provided the old file of the previous QAPI consultant. VC also presented a letter dated 10/16/2024 indicating the termination of the contract of the previous consultancy service. When asked if they already hired a new QAPI consultant, VC stated she will ask the ADM/DPCS. VC returned and stated that they do have a new QAPI consultant that started today. VC stated that the newly hired consultant had no employee file in the office. A review of the hospice agencys document titled ";Improving Organizational Performance" reviewed on 3/15/2024 indicated that Senior management as designated by the Governing Body will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance; to define expectations of the performance improvement activities; and to generate the plan and processes the organization will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will be active participants in the organization's performance improvement activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented and maintained, and is evaluated annually. A review of the hospice agencys document titled "Administrative Qualifications and Responsibilities" revised 1/2023 indicated the hospice agency position descriptions will clearly define specific responsibilities and include at least:A. Organization and direction of the operations to assure availability and provision of care and servicesB. Implementing Governing Body directivesC. Implementing the organization's policies and proceduresD. Compliance with applicable law and regulationE. Maintenance of adequate staffing levels by recruiting, employing, and retaining qualified personnelF. Ensuring personnel access to continuing personnel education G. Evaluating the performance of reporting personnel according to organizational policyH. Providing leadership for performance improvement activitiesI. Managing operations in accordance with established fiscal parametersJ. Program planning, development, implementation and oversightK. Representing the organization to other groups, organizations and the general publicL. Ongoing review of marketing materials and public information documents to ensure accuracyM. Informing the Governing Body and personnel of current1organizational, community and industry trends. A review of the hospice agencys document titled "Governing Body" revised 1/2023 indicated 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) program. The Governing Body will authorize adequate resources and support to establish and maintain an organization-wide performance improvement program. Information related to the performance improvement program will be provided to the Governing Body. 10. The Governing Body will appoint a Corporate Compliance Officer who is responsible for the day-to-day oversight of the Corporate Compliance Program and coordination of all compliance initiatives. The Corporate Compliance Officer will report to the CEO/Administrator and the Governing Body. The Governing Body will appoint a Corporate Compliance Committee (The Committee) who will be charged with the support and implementation of the Corporate Compliance Program in conjunction with the Corporate Compliance Officer. The Committee will consist of members from the Governing Body and senior-level managers. The Committee members will be trained and well-informed of the policies and elements of the Compliance Program. The Committee will meet at least quarterly.

Based on observation, interview and record review, the hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agencys (HA, agency providing care to terminally ill patients who have six months or less to live) governing body failed to ensure to appoint an individual who will operate the QAPI (refers to a systematic process used by hospice organizations to continuously monitor, evaluate, and improve the quality of care provided to patients by identifying areas needing improvement and implementing changes to enhance patient outcomes and safety throughout their end-of-life journey) program for hospice. This deficient practice has the potential to result in the failure of the hospice QAPI program to address any problem areas in patient care and hospice operations, and to improve performance in these areas. --- A request was made to the agencys on 12/16/2024 at 12:15 p.m. for the agencys QAPI program. The ADM/DPCS went to the volunteer coordinator and stated that VC is the person to ask with regards to the program book. During the record review of the QAPI program on 12/16/2024, at 12:45 p.m., it indicated the QAPI program and policy was approved, reviewed and signed by the ADM/DPCS, Medical Director (Physician 1) and Chief Finance Officer (CFO) on 3/15/2024. Record review also revealed that the agency reviewed their First Quarter QAPI on 4/2/2024. There was no documentation for the review of the second, third and fourth QAPI in the program book. During an interview on 12/16/2024 at 12:30 p.m., with the Volunteer Coordinator (VC), the VC stated that she helps the QAPI consultant (QC) in doing the QAPI. The VC also stated that the consultant has access to the hospice electronic program to gather the data the QC needed for the review and evaluation of the QAPI. When asked why there was no documentation for the 2nd, 3rd and 4th QAPI, the VC stated that the agency just hired a new QAPI personnel that will monitor the hospice QAPI. VC also showed a letter that indicated the hospice agency terminated their contract with the previous consulting service last 10/16/2024. VC also confirmed that they do not have the employee file/contract of the new hired consultant. A review of the hospice agencys policy titled ";Selection/Hiring of Personnel" revised 1/2023 indicated the purpose of this policy is to specify the criteria for the recruitment and hiring of personnel to meet the care/service needs of patients. The organization will use a consistent, nondiscriminatory process for the selection of all personnel. The most qualified individuals will be employed without regard to race, hairstyle, color, religion, age, gender, sexual orientation, marital status, disability (mental or physical), communicable disease, or/ place of national origin as required by state and federal law. The organization will provide promotion and advancement opportunities in a nondiscriminatory fashion. Selection and Screening: 1. A notice of position opening will be posted in-house and published in local newspapers and/or other instruments appropriate for recruiting personnel. 2. Candidates will be screened by phone or in person to assure that the candidate meets the job requirements and qualifications. In the event there is not a qualified internal applicant, the position will be filled with an outside applicant following the organizations policy A review of the hospice agencys document titled ";Improving Organizational Performance" reviewed on 3/15/2024 indicated that Senior management as designated by the Governing Body will have the responsibility of quality management: to guide the organization's efforts in improving organizational performance; to define expectations of the performance improvement activities; and to generate the plan and processes the organization will utilize to assess, improve and maintain quality of care and service including the appropriateness and effectiveness of patient services. Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will be active participants in the organization's performance improvement activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, and maintained, and is evaluated annually. A review of the hospice agencys document titled "; Executive Director/Administrator" revised 1/2023 indicated that the Administrator reports to the Governing Body. The Executive Director/Administrator is responsible for the overall 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. Ensuring organizational compliance with legal, regulatory and accreditation requirements. Assures that all business conduct is above minimum standards required by law and will not condone any activities that achieve results through violation of the law, unethical business, or patient care practices. Ensuring adequate and appropriate staffing. Ensuring that appropriate service policies and procedures are developed and implemented to accomplish identified outcomes.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Conditions of Participations regarding Patient Rights was met as followed: --- 1. The HA failed to ensure one out of 16 sampled patients (Patient 4) received and were informed of their patient rights and responsibilities in a language the patients understood. This failure had the potential to result in patient and their family/caregivers not aware of patient rights and responsibilities. (Refer to L502). 2. The HA failed to ensure three out of 16 sampled patients (Patient 3, Patient 4, and Patient 10) were aware of all Medicare-covered hospice services (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease). This failure resulted in patients being unaware about hospice benefit services. (Refer to L518). The cumulative effect of these systemic practices resulted in patients not knowing their hospice services with their limitations and their rights as hospice patient.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure one of 16 sampled patients (Patient 4) received information regarding their right as a hospice patient in a language that would be understood and preferred by the patient. This deficient practice resulted in the patient not being informed and having a lack of understanding of the HAs care and services available for the patient and their family and which caused the patient not being able to exercise their right to decline the hospice services. --- A review of Patient 4s untitled and undated medical record indicated a Start of Care (SOC) date of 4/15/2024 with a primary diagnosis of unspecified heart disease (heart is unable to effectively pump blood to the body). The record further indicated Spanish as the primary language of Patient 4. A review of Patient 4s Informed Consent and Treatment Authorization indicated, the form was in English and Patient 4 signed the consent on 4/15/2024. During a joint home visit with Licensed Vocational Nurse (LVN 1) on 5/29/2024 at 11:45 a.m. at Patient 4s room and board, Patient 4 was observed in the living room sitting in a wheelchair, was awake, alert, and oriented. Patient was noted speaking in Spanish. During a review of Patient 4s agency folder, it contained copies of Patient 4s Informed Consent and Treatment Authorization in English dated 4/15/2024. During a concurrent interview and record review on 5/29/2024 at 11:45 a.m. with Patient 4, Patient 4s Informed Consent and Treatment form signed and dated 4/15/24 was reviewed. Patient 4 verified and stated that the forms were in English, he was unable to read them, and asked if they could be read to him. Patient 4 stated a male nurse come to see him and talked to him about the agency, but communication was not great because the nurse spoke English and the nurse had him sign many forms at once, so he did not remember being informed of what he was signing and stated he did not know what hospice program was. Patient 4 stated he can understand and speak minimal English, but prefers communicating and reading in Spanish. During an interview on 5/29/2024 at 11:50 a.m. with Patient 4, Patient 4 stated he cannot read in English, papers are usually read and explained to him if they are in English, and nurses did not offer to provide forms in Spanish. During an interview on 5/31/2024 at 11:34 a.m. with Medical Records (MR), MR stated agency consents are only in English and do not have in other languages. MR further stated ";I am outing together for you right now." During a concurrent interview and record review on 5/31/2024 at 2:30 p.m. with Administrator/Director of Patient Care Services (ADM/DPCS), Patient 4s Informed Consent and Treatment was reviewed. The ADM/DPCS stated the Informed Consent and Treatment was in English. DPCS stated he communicated with Patient 4 during home visit with translation help from room and board caregiver and explained every consent form to caregiver to be translated to Patient 4. DPCS further stated the benefit of providing patients with consents in their primary language is that they will understand what they are signing and can go back and read the consent if they forgot what it was about. A review of the HAs policy and procedure titled, ";Facilitating Communication" with a revised date of January 2023, indicated, ";Personnel will treat all patients with respect and dignity and will use forms of communication appropriate to meet the patients needs. Written materials will be made available in the recognized major languages in the area and state where the organization does business...2. All patient related forms, such as Consent for Services, Complaint/Grievance Process, etc., will be available in English, and other languages as appropriate."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure three out of 16 sampled patients (Patient 3, Patient 4, and Patient 10) were aware of what Medicare hospice services were. This failure had the potential to result in denial of medical services as a result of being under hospice services. --- A review of Patient 10s untitled admission sheet dated 10/2/2023, indicated Patient 10 was admitted to the hospice agency with a diagnosis of atherosclerotic heart disease (buildup of fats, cholesterol in artery walls, that affects the heart vessels) on 10/1/2023. A review of Patient 10's Informed Consent and Treatment Authorization form, the form indicated Patient 10 signed the consent forms, including Medicare/Medical Hospice Election on 10/1/2023. During an interview on 5/29/2024 at 12:07 p.m., Patient 10 could not state what hospice is and when asked if he knew what hospice was, he answered, "no". During an interview on 5/31/2024 at 2:25 p.m., Director of Patient Care Services (DPCS) stated that he had to have the House Manager explain what hospice is to Patient 10 because Patient 10 had difficulty understanding. A review of the facilitys policy titled, ";Admission Criteria and Process," dated January 2023, indicated that ";the patient must desire hospice services and be aware of the diagnosis and prognosis." A review of Patient 3 admission sheet, indicated Patient 3 had a Start of Care (SOC) date of 5/11/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with chest pain). A review of Patient 3's Informed Consent and Treatment Authorization form, the form indicated Patient 10 signed the consent forms, including Medicare/Medical Hospice Election on 5/11/2024. During an home visit and interview with Patient 3 in his residence on 5/29/2024 at 12:37 p.m., Patient 3 stated he did not know what hospice is and that he thought he was receiving care at home. During an interview on 5/31/2024 at 2:25 p.m., Director of Patient Care Services (DPCS) stated he could not explain the patient and he should have bee told by the House Manager what hospice to Patient 3. A review of Patient 4s medical record untitled and undated, indicated a Start of Care (SOC) date of 4/15/2024 with a primary diagnosis of heart disease, unspecified (heart is unable to effectively pump blood to the body) and indicated Spanish as the primary language. During a review of Patient 4s Informed Consent and Treatment Authorization, the Informed Consent and Treatment Authorization form indicated it was in English and Patient 4 signed the consent on 4/15/2024. During an interview on 5/29/24 at 11:45 am with Patient 4, Patient 4 stated he did not know what hospice care was, as the male nurse that came to see him and talk about the agency spoke English and the communication with nurse was not great as Patient 4 stated he understands minimal English. A review of Patient 3 admission sheet, indicated Patient 3 had a Start of Care (SOC) date of 5/11/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris (build up of fats, cholesterol in artery walls, that affects the heart vessels with chest pain). A review of Patient 3's Informed Consent and Treatment Authorization form, the form indicated Patient 10 signed the consent forms, including Medicare/Medical Hospice Election on 5/11/2024. During an home visit and interview with Patient 3 in his residence on 5/29/2024 at 12:37 p.m., Patient 3 stated he did not know what hospice is and that he thought he was receiving care at home. During an interview on 5/31/2024 at 2:25 p.m., Director of Patient Care Services (DPCS) stated he could not explain the patient and he should have been told by the House Manager what hospice to Patient 3. A review of Patient 4s medical record untitled and undated, indicated a Start of Care (SOC) date of 4/15/2024 with a primary diagnosis of heart disease, unspecified (heart is unable to effectively pump blood to the body) and indicated Spanish as the primary language. During a review of Patient 4s Informed Consent and Treatment Authorization, the Informed Consent and Treatment Authorization form indicated it was in English and Patient 4 signed the consent on 4/15/2024. During an interview on 5/29/24 at 11:45 am with Patient 4, Patient 4 stated he did not know what hospice care was, as the male nurse that came to see him and talk about the agency spoke English and the communication with nurse was not great as Patient 4 stated he understands minimal English. A review of Patient 10s untitled admission sheet dated 10/2/2023, indicated Patient 10 was admitted to the hospice agency with a diagnosis of atherosclerotic heart disease (buildup of fats, cholesterol in artery walls, that affects the heart vessels) on 10/1/2023. A review of Patient 10's Informed Consent and Treatment Authorization form, the form indicated Patient 10 signed the consent forms, including Medicare/Medical Hospice Election on 10/1/2023. During an interview on 5/29/2024 at 12:07 p.m., Patient 10 could not state what hospice is and when asked if he knew what hospice was, he answered, "no". During an interview on 5/31/2024 at 2:25 p.m., Director of Patient Care Services (DPCS) stated that he had to have the House Manager explain what hospice is to Patient 10 because Patient 10 had difficulty understanding. A review of the facilitys policy titled, ";Admission Criteria and Process," dated January 2023, indicated that ";the patient must desire hospice services and be aware of the diagnosis and prognosis."

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of the Patient was met as follows: --- 1. The HA staff failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for one of 14 sampled patients (Patient 10). (Refer to L524) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the quality of care are being provided to patients certified to receive the Medicare hospice benefits

Based on 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 Interdisciplinary Group (IDG, meeting where the Registered Nurse [RN], Medical Social Worker [MSW], Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than five calendar days after hospice election for seven of 16 sampled patients (Patient 2, Patient 3, Patient 4, Patient 5, Paient,7, Patient 8 , and Patient 12). This failure had the potential to result in patient and caregiver/family not receiving appropriate assessment and support of their needs. --- a. A review of Patient 4s medical record untitled and undated, indicated a Start of Care (SOC) date of 4/15/2024 with a primary diagnosis of heart disease, unspecified (heart is unable to effectively pump blood to the body). During a review of Patient 4s Electronic Medical Record (EMR) indicated that the Medical Social Worker (MSW) did not submit a psychosocial assessment since Start of Care (SOC) of 4/15/2024. During a concurrent interview and record review on 5/31/24 at 2:17pm with Administrator/Director of Patient Care Services (DPCS), Patient 4s Electronic Medical Record (EMR) was reviewed. DPCS stated there was no submission of a psychosocial assessment by MSW and documentation should be submitted within 48 hours. DPCS stated MSW is hard to get ahold of, and messages are sent out to staff when documentation is not complete. b. A review of Patient 12s medical record untitled and undated, indicated a SOC date of 1/13/2024 with a primary diagnosis of Alzheimers disease, unspecified (a brain condition that affects memory, thinking, and behavior). During a review of Patient 12s Electronic Medical Record (EMR) indicated that the Medical Social Worker (MSW) did not submit a psychosocial assessment since Start Of Care (SOC) OF 1/13/2024. During a concurrent interview and record review on 5/31/24 at 2:17pm with Administrator/Director of Patient Care Services (DPCS), Patient 12s Electronic Medical Record (EMR) was reviewed. DPCS stated there was no submission of a psychosocial assessment by MSW and documentation should be submitted within 48 hours. DPCS stated MSW is hard to get ahold of, and messages are sent out to staff when documentation is not complete. During a review of the Hospice Agency (HA) policy and procedure titled, ";Job Title/Position: Social Worker" with a revised date of January 2023, indicated, ";1. Assess the psychosocial status of patients and families/caregivers related to the patients terminal illness and environment and communicates findings to the registered nurse and other members of the interdisciplinary group. Provides an assessment in the patients identified residence and assistance when this is not safe, and another plan is required." During a review of the HAs policy and procedure titled, ";Comprehensive Assessment" with a revised date of January 2023, indicated ";A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician... 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant: V. The patients psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environment and other resources, coping mechanisms, and the patients and family/caregivers reaction to illness." A review of Patient 2s admission sheet, indicated Patient 2's Start of Care (SOC) date of 5/6/2024 with a primary diagnosis of heart failure (a Chronic condition in which the heart doesnt pump blood as well as it should) . During a review of Patient 2's electronic medical record (EMR), indicated that the medical social worker(MSW) did not submit a psychosocial assessment since the start of care of 5/6/2024. During a concurrent interview and record review on 5/31/24 at 3:15 p.m. with Administrator/Director of Patient Care Services (DPCS), Patient 2s Electronic Medical Record (EMR) was reviewed. DPCS stated there was no submission of initial bereavement assessment by MSW and documentation should be submitted within 48 hours to five days after the start of care. A review of Patient Patient 3s Electronic Medical Record (EMR) indicated a Start of Care (SOC) date of 5/1/2024, with a primary diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with chest pain). A review of Patient 3s EMR under psychosocial assessment indicated that the Medical Social Worker assessed the patient on 5/10/2024, nine days after the start of care of 5/1/2024. During a telephone interview with the MSW in the Hospice Agency (HA), she stated Patient 3 was one of her first visit upon being hired and she was instructed by the administrator to conduct that visit on that day. During a concurrent record review and interview of Patients 3s EMR on 5/3/2024 at 3:35p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS) The ADM/DPCS stated the MSW should submit her documentation with in 48 hours and that the assessment should have been completed within 5 days of the start of care. A review of Patient 5s EMR untitled admission sheet, indicated a start of care date on 3/08/2024 with a primary diagnosis of Chronic Obstructive Pulmonary Disease ( a chronic inflammatory lung disease that causes breathing problems and restricted airflow. During a review of Patient 5s Electronic Medical Record (EMR) indicated that the Medical Social Worker (MSW) did not submit an initial bereavement assessment since Start of Care date (SOC) of 3/8/2024. During a concurrent interview and record review on 5/31/24 at 3:25pm with Administrator/Director of Patient Care Services (DPCS), Patient 5s Electronic Medical Record (EMR). DPCS stated there was no submission of initial bereavement assessment by MSW and documentation should be submitted within 48 hours to five days after the start of care. e. A review of Patient 7s medical record, untitled admission sheet, indicated a start of care date of 12/5/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). During a review of Patient 7s Electronic Medical Record (EMR) indicated that the Medical Social Worker (MSW) did not submit an initial bereavement assessment since Start of Care date (SOC) of 5/6/2024. And that the Chaplain did not submit his spiritual assessment since the SOC date of 5/6/2024. During a concurrent interview and record review on 5/31/24 at 3:15pm with Administrator/Director of Patient Care Services (DPCS), of Patient 7s Electronic Medical Record (EMR). DPCS stated there was no submission of initial bereavement assessment by MSW and documentation should be submitted within 48 hours to five days after the SOC. f. A review of Patient 8s medical record, untitled admission sheet, indicated a start of care date of 12/5/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain. During a review of Patient 8s Electronic Medical Record (EMR) indicated that the Medical Social Worker (MSW) did not submit an initial bereavement assessment since Start of Care date (SOC) of 5/6/2024. During a concurrent interview and record review on 5/31/24 at 3:15pm with Administrator/Director of Patient Care Services (DPCS), Patient 8s Electronic Medical Record (EMR). DPCS stated there was no submission of initial bereavement assessment by MSW and documentation should be submitted within 48 hours however no later than five days after the start of care. a. A review of Patient 2s admission sheet, indicated Patient 2's Start of Care (SOC) date of 5/6/2024 with a primary diagnosis of heart failure (a Chronic condition in which the heart doesnt pump blood as well as it should). During a review of Patient 2's electronic medical record (EMR), indicated that the medical social worker (MSW) did not submit a psychosocial assessment since the start of care of 5/6/2024. During a concurrent interview and record review on 5/31/24 at 3:15 p.m. with Administrator/Director of Patient Care Services (DPCS), Patient 2s Electronic Medical Record (EMR) was reviewed. DPCS stated there was no submission of initial bereavement assessment by MSW and documentation should be submitted within 48 hours to five days after the start of care. b. A review of Patient 3s Electronic Medical Record (EMR) indicated a Start of Care (SOC) date of 5/1/2024, with a primary diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with chest pain). A review of Patient 3s EMR under psychosocial assessment indicated that the Medical Social Worker assessed the patient on 5/10/2024, nine days after the start of care of 5/1/2024. During a telephone interview with the MSW in the Hospice Agency (HA), she stated Patient 3 was one of her first visit upon being hired and she was instructed by the administrator to conduct that visit on that day. During a concurrent record review and interview of Patients 3s EMR on 5/3/2024 at 3:35p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS) The ADM/DPCS stated the MSW should submit her documentation with in 48 hours and that the assessment should have been completed within 5 days of the start of care. c. A review of Patient 4s medical record untitled and undated, indicated a Start of Care (SOC) date of 4/15/2024 with a primary diagnosis of heart disease, unspecified (heart is unable to effectively pump blood to the body). During a review of Patient 4s Electronic Medical Record (EMR) indicated that the Medical Social Worker (MSW) did not submit a psychosocial assessment since Start of Care (SOC) of 4/15/2024. During a concurrent interview and record review on 5/31/24 at 2:17pm with Administrator/Director of Patient Care Services (DPCS), Patient 4s Electronic Medical Record (EMR) was reviewed. DPCS stated there was no submission of a psychosocial assessment by MSW and documentation should be submitted within 48 hours. DPCS stated MSW is hard to get ahold of, and messages are sent out to staff when documentation is not complete. d. A review of Patient 5s EMR untitled admission sheet, indicated a start of care date on 3/08/2024 with a primary diagnosis of Chronic Obstructive Pulmonary Disease ( a chronic inflammatory lung disease that causes breathing problems and restricted airflow. During a review of Patient 5s Electronic Medical Record (EMR) indicated that the Medical Social Worker (MSW) did not submit an initial bereavement assessment since Start of Care date (SOC) of 3/8/2024. During a concurrent interview and record review on 5/31/24 at 3:25pm with Administrator/Director of Patient Care Services (DPCS), Patient 5s Electronic Medical Record (EMR). DPCS stated there was no submission of initial bereavement assessment by MSW and documentation should be submitted within 48 hours to five days after the start of care. e. A review of Patient 7s medical record, untitled admission sheet, indicated a start of care date of 12/5/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). During a review of Patient 7s Electronic Medical Record (EMR) indicated that the Medical Social Worker (MSW) did not submit an initial bereavement assessment since Start of Care date (SOC) of 5/6/2024. And that the Chaplain did not submit his spiritual assessment since the SOC date of 5/6/2024. During a concurrent interview and record review on 5/31/24 at 3:15pm with Administrator/Director of Patient Care Services (DPCS), of Patient 7s Electronic Medical Record (EMR). DPCS stated there was no submission of initial bereavement assessment by MSW and documentation should be submitted within 48 hours to five days after the SOC. f. A review of Patient 8s medical record, untitled admission sheet, indicated a start of care date of 12/5/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery w/o angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain. During a review of Patient 8s Electronic Medical Record (EMR) indicated that the Medical Social Worker (MSW) did not submit an initial bereavement assessment since Start of Care date (SOC) of 5/6/2024. During a concurrent interview and record review on 5/31/24 at 3:15pm with Administrator/Director of Patient Care Services (DPCS), Patient 8s Electronic Medical Record (EMR). DPCS stated there was no submission of initial bereavement assessment by MSW and documentation should be submitted within 48 hours however no later than five days after the start of care. g. A review of Patient 12s medical record untitled and undated, indicated a SOC date of 1/13/2024 with a primary diagnosis of Alzheimers disease, unspecified (a brain condition that affects memory, thinking, and behavior). During a review of Patient 12s Electronic Medical Record (EMR) indicated that the Medical Social Worker (MSW) did not submit a psychosocial assessment since Start Of Care (SOC) OF 1/13/2024. During a concurrent interview and record review on 5/31/24 at 2:17pm with Administrator/Director of Patient Care Services (DPCS), Patient 12s Electronic Medical Record (EMR) was reviewed. DPCS stated there was no submission of a psychosocial assessment by MSW and documentation should be submitted within 48 hours. DPCS stated MSW is hard to get ahold of, and messages are sent out to staff when documentation is not complete. During a review of the Hospice Agency (HA) policy and procedure titled, ";Job Title/Position: Social Worker" with a revised date of January 2023, indicated, ";1. Assess the psychosocial status of patients and families/caregivers related to the patients terminal illness and environment and communicates findings to the registered nurse and other members of the interdisciplinary group. Provides an assessment in the patients identified residence and assistance when this is not safe, and another plan is required." During a review of the HAs policy and procedure titled, ";Comprehensive Assessment" with a revised date of January 2023, indicated ";A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician... 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant: V. The patients psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environment and other resources, coping mechanisms, and the patients and family/caregivers reaction to illness."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for one of 16 sampled patients (Patient 10). The deficient practice had the potential for Patient 10 not receiving care and services to meet the patients care goal needs. --- A review of Patient 10s medical untitled admission sheet dated 10/2/2023, indicated that Patient 10 was admitted to the hospice agency with a diagnosis of atherosclerotic heart disease (buildup of fats, cholesterol in artery walls, that affects the heart vessels) on 10/1/2023. A review of Patient 10s medical record titled ";LCD Hospice Eligibility Determination," dated 5/17/2024, indicated that Patient 10 was a meets the criteria for NYHA scale (New York Heart Association- a tool used to classify the extent of heart failure in a patient) Class IV (4). It also indicated that Patient 10 was dependent on assistance for two or more ADLs (activities of daily living such as walking, dressing, feeding, bathing.) It further indicated that Patient 10 was a KPS score (Karnofsky Performance Scale-a functional assessment tool) less than 50 and a PPS (Palliative Performance Scale- a tool used to assess a patients ability to function) less than 70. A review of Patient 10s medical record titled, ";Comprehensive Nursing Assessment," dated 10/1/2023, performed by the Director of Patient Care Services (DPCS), indicated that that Patient 10 was, ";dependent on walker or cane." It further indicated that Patient 10 was a, ";KPS score of 50, PPS score of 50 and NYHA IV," and ";able to ambulate a few steps with walker." A review of Patient 10s medical record titled ";Re-cert Assessment," dated 5/17/2024, performed by DPCS, indicated that Patient 10 had a walker, was, ";able to ambulate a few steps with walker. Noted patient with shuffling gait, due to weakness and poor balance." It further indicated that Patient 10 was, ";dependent on walker or cane," and that Patient 10, ";unable to to provide for own care," and ";is able to stand and ambulate a 3-5 steps with walker." The document also indicated that Patient 10, ";is KPS score of 50, PPS score of 50 and NYHA IV." A review of Patient 10s medical record titled, ";Psychosocial Assessment," dated 11/28/2023, performed by Medical Social Worker 2 (MSW 2), indicated that Patient 10, ";social worker conducted visit outside of he home as the patient was about to leave to walk around the neighborhood." During an interview and observation on 5/29/2024 at 12:07 pm, Patient 10 was observed walking into the household independently, without a walker, from outside the house without a walker. Patient 10 stated that he did not have a hard time breathing and did not use oxygen. Patient 10 stated no, he does not use a walker and that he walks on his own. Patient 10 stated that yes, his room is upstairs. Patient 10 indicated that he walks around the neighborhood and goes to Circle K independently. During an observation on 5/29/2024 at 12:45 pm, Patient 10s bedroom is located on the second floor of the house. The only way to the bedroom was up a flight of stairs. Patient 10 did not have an oxygen concentrator in his room for his use. During an observation on 5/29/2024 at 1:15 pm, Patient 10 was observed walking independently, without a walker and with no difficulty or shortness of breath, to surveyors car parked on the street adjacent to his residence to say goodbye to surveyor. During an interview on 5/31/2024 at 2:25pm, DPCS stated that NYHA IV means that you can not do any kind of activity without chest pain or discomfort, including activities like showering. ADM/DPCS also stated that Patient 10 is dependent on the use of a walker for ambulating (walking). A review of the facilitys undated document titled, ";NYHA- New York Heart Association Classification," indicated that class IV was ";patients with cardiac disease resulting in inability to carry on any physical activity without discomfort." A review of the facilitys undated document titled, ";Karnofsky Scale," indicated that a patient with a score of 50, ";requires considerable assistance and frequent medical care." A review of the facilitys undated document titled, ";Palliative Performance Scale," indicated that a patient with a score of 50, ";mainly sit, lie" and, ";considerable assistance needed," with self care. It further indicated that a patient with a score of 50 is ";unable to do any work," due to extensive disease. A review of google maps (googlemaps.com) indicated that the nearest Circle K store was 0.7 miles or a 15 minute walk, one way from the residence. A review of the facilitys policy titled, ";Clinical/Service Data Collection," dated January 2023, indicated that, ";documentation in the clinical/service record will be timely, detailed, accurate and reflect the care or services provided."

Based on observation, interview and record review, the hospice agency failed to maintain an accurate and current patient medication profiles, for one of 14 sampled patients, (Patients 2). This failure had the potential in placing the patients at risk for medication errors and adverse drug reactions. --- a. A review of Patient 2's clinical record indicated he was admitted to the hospice agency on 5/1/2024, with a terminal diagnosis of heart failure disease (chronic obstructive pulmonary disease (damage from the brain from interruption of its blood supply). A review of Patient 2s POC (Plan of Care)/IDG (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) form dated 5/6/2024, indicated skilled nurse (SN) visits once per week, plus 3 as needed visits . The SN to assess pain and symptoms management. The plan of care (POC) also indicated for the hospice aid to visit one time a week for personal hygein, MSW one-time and as needed to provide resourced, psychosocial assessment and emotional support, the spiritual chaplain , to visit one-time and as needed to to provide spiritual support and prayers. Volunteer serviced indicated Patient 2 declined. On 5/29/2, at 10:00 a.m., a joint home visit was conducted at Patient 2's residence, with the License Vocational Nurse (LVN 1). During the home visit Patient 2 was observed awake, alert, oriented, sitting on his walker, and ambulatory with walker without any assistance . On 8/1/23, at 11:10 p.m., during a review of Patient 2s current medications, the Amazon Aspirin l 81 milligram (mg) (blood thinner medication for the prevention of stroke or heart attach) was found at the home. A review of Patient 2's current medication profile did not indicate Patient 2 is taking the Aspirin 81 mg. During an interview with patient 2 in his room, he stated he has been taking this Aspirin every day for years. During an interview on 8/30/24, at 1:30 p.m., the administrator /Director of Patient Care Services (DPCS) stated the visiting nurse needs to review patients current medication and should ask the patient or caregiver when and how they administer the prescribed medications every visit and update changes in the medication profile in the patient's clinical record. A review of the hospice agencys undated policy and procedure titled, ";Medication Profile", indicated, patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

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 conduct a bereavement assessment to provide bereavement counseling in accordance with the patient/familys needs for one of 16 sampled patients (Patient 4) This failure had the potential to impact the family members ability to cope with the patients death. --- A review of Patient 4s medical record untitled and undated, indicated a Start of Care (SOC) date of 4/15/2024 with a primary diagnosis of heart disease, unspecified (heart is unable to effectively pump blood to the body). During a concurrent interview and record review on 5/31/24 at 2:17pm with Administrator/Director of Patient Care Services (DPCS), Patient 4s Electronic Medical Record (EMR) was reviewed. DPCS stated there was no initial bereavement assessment submitted under Bereavement section. DPCS stated initial bereavement assessment is done by admitting nurse and should be completed within 48 hours of visit and submitted within 5 days. DPCS further stated he was Patient 4s admitting nurse and did not complete the initial bereavement assessment. A review of Patient 4s record titled, ";POC/IDG Review" dated 5/28/24, indicated ";Plan of Care (Problems/Intervention/Goals/Status)- Spiritual- Goal: To remain available to the Patient for emotional and spiritual support. Intervention: Provide spiritual support and encouragement consistent with patients belief system. Share scriptures of encouragement and hope." During a review of the Hospice Agency (HA) policy and procedure titled, ";Bereavement Assessment" with a revised date of January 2023, indicated ";The hospice bereavement plan of care will be developed based on the initial assessment of the patient and family/caregiver needs, during the course of care... 1. On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator. At minimum will include: A. Patient and family/caregiver loss issues B. Survivor needs C. Social, spiritual, and cultural factors D. Services to be provided including 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 four of 14 sampled patients, (Patients 2, 3, 7, and 8). 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 2's clinical record indicated a start of care (SOC) date of 5/1/2024, with a terminal diagnosis of heart failure (a chronic condition in which the heart does not pump blood as well as it should). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 2. A review of Patient 2's Physicians Certification for Hospice Benefit, dated 5/6/2024 to 7/4/2024, benefit period #9, 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. During an interview with patient, on 5/29/2023 at 11:00a.m., in his room of his residence, he stated he has been homeless and was sent here after being hospitalized and does not have a primary physician. Patient 2, stated the Administrator (ADM) and Director of Patient Care Services (DPCS ) came to the Residential independent facility and signed him up. During an interview, with the House Manager on 5/29/2024 at 12:00p.m., at the dining table in the living room, he was asked if Patient 2 was referred by his attending physician, House Manager stated, "No". b. A review of Patient 3's clinical record indicated Patient 3 was admitted to the hospice agency on 4/10/23, with a terminal diagnosis of the admission record indicated a start of care date on 5/1/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with chest pain) . The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 3's Physicians Certification for Hospice Benefit, dated 5/1/2024 to 7/29/24, benefit period #2, indicated the Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 5/29/24, at 11:45 a.m., a joint home visit was conducted to Patient 3's residence, with the License Vocational Nurse (LVN 1). Patient 3 was observed awake, alert, oriented, and ambulatory without any assistance . At 12:00 p.m., during an interview, House Manager was asked if Patient 3 was referred by his attending physician, House Manager stated, "No". During an interview with Patient 3 on 5/29/2024 at 11:50a.m., in the living room of his residence, he sated he has been homeless for so long and does not have a primary physician. Patient 3, stated the ADM/DPCS came to the Residential independent facility and signed him up. c. A review of Patient 7's clinical record indicated Patient 7 was admitted to the hospice agency on 12/5/23, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with chest pain) . The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 7's Physicians Certification for Hospice Benefit, dated 12/5/2023 to 3/2/24, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 7s, Office Visit forms with his primary physician, with a printed date of 12/28/2023,@11;32 a.m., did not indicated document evidence that Patient 7 had a diagnosis that required hospices services. A review of the Hospice agencys Local Coverage Determination Form ( LCD-a guideline for hospice providers to determine eligibility o f beneficiaries for hospice benefits ) with an assessment date of 5/28/2024, was blank and stipulated, "; Patient does not qualify per LCD Guidelines." 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. d . A review of Patient 8's clinical record indicated Patient 8 was admitted to the hospice agency on 12/5/23, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain) . The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 8's Physicians Certification for Hospice Benefit, dated 12/5/2023 to 3/3/24, benefit period #2, indicated the Physician 1 signed the attending physician referral section to indicate Patient 8 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.

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 five of 14 sampled patients (Patient 2, Patient 3, Patient 5, Patient 7, and Patient 8) had access to volunteer Services. This deficient practice had the potential not to meet the needs of the patients and their family/caregivers. --- Findings: a. During a review of Patient 2s untitled admission record, the admission record indicated a start of care date on 5/11/2024 with a primary diagnosis of heart failure (a condition that occurs when the heart cannot pump enough blood to meet the bodys needs.) b. During a review of Patient 3s untitled admission record, the admission record indicated a start of care date of 5/11/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (affects arteries that carry blood to the heart muscle, buildup of fats, that affects the heart vessels with angina pectoris (chest pain or discomfort). c. During a review of Patient 5s untitled admission sheet, the admission record indicated a start of care date on 3/8/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes breathing problems and restricted airflow). d. During a review of Patient 7s untitled admission record, the admission record indicated a start of care date of 12/5/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. e. During a review of Patient 8s untitled admission record, the admission record indicated a start of care date of 12/5/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During an interview on 5/31/2024, at 11 am., with the Human resource/Volunteer coordinator, the Human resource/Volunteer coordinator stated she and the volunteers did not offer visits to Patient 2, Patient 3, Patient 5, Patient 7, and Patient 8. The Human resource/Volunteer coordinator stated she did not know she had to conduct visits. During a concurrent interview and a review of the HAs volunteer coordinator and volunteers employee file, on 5/31/2024, at 11:38 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated there was no documented evidence the HA had training for their positions as volunteer coordinator and volunteer. The ADM/DPCS stated he did not know the volunteers needed to be trained. During a review of the facilitys policy titled, "Volunteer Services," dated 2018, indicated, "the hospice will provide volunteer services under the direction of the Volunteer Coordinator and with the assistance of trained hospice volunteers."

Based on interview and record review, the Hospice Agency (HA) failed to: 1. Ensure the HA was approved in providing services outside of the approved Geographic Service Area (GSA) for four of their active patients. 2. Ensure the Administrator/Director of Patient Care Services (ADM/DPCS), the Administrator Designee (ADMD), and the DPCS Designee (DPCSD) met the administrative qualifications and ensure they were approved by the California Department of Public Health to be in the administrative positions. 3. Ensure the Administrator did not co-mingle with a different agency (home health agency) that shared the space approved by the Department of Public health for their Hospice location. These deficient practices had the potential to affect the care of the HA active patients --- Findings: A review of the HAs Active Patient list indicated the two patients lived in Seeley, CA, one active patient lived in El Centro, California (Imperial County), and that another active patient lived in Chula Vista, CA. and one lived in San Diego, CA (San Diego County). During a review of the States Facility information, and Letter from the California Department of Public Health Centralizing application unit date 5/22/2024, the letter indicated the ADM/DPCS, ADMD, DPCSD had not been approved since 7/30/2024 for their current positions. During an observation on 5/28/2024, at 10 am, upon entrance to the building of the Hospice agency, observed the hospice agencys name with suite 200 listed and under the HAs name was a home health agency with suite 200A. Upon entrance inside the hospice agency in one of the mini rooms inside the HA, there was one room with the home health agencys name on the door that enters that room. During a concurrent observation during a tour of the agency, with the human resource staff, she stated the other small rooms belonged to the hospice agency however, the room for the DPCS of the hospice agency had a file cabinet that had the HA and HHA employee files. Observed in the HA was a xero machine, storage room fax machine which the staff informed the survey team they use for both the hospice agency and home health agency. During a telephone interview on 5/28/2024, at 11a.m., with the ADM/DPCS who was also the owner, he stated the hospice agency had been approved for this location however, they had not request a change of location for the home health agency even though they had moved the location inside the HA and their HHA flyers, reflected the current address. During an interview on 5/30/2024, at 2:45 p.m., with the ADM/DPCS, the ADM/DPCS stated the HA had applied to Centers of Medicaid Services (CMS) for approval to deliver services in San Bernardino, Riverside, Orange, and Los Angeles. The ADM/DPCS stated the untitled record dated 5/22/2024, indicated in section ";From section 4: Practice Location Information – Geographical Location" San Diego County and Imperial County were not included in the HAs request for coverage. The ADM/DPCS stated they were still waiting for the approval. A review of facilitys policy and procedure titled ";Admission Criteria and Process" revised 4/2020, indicated ";Once a patient is admitted to service, the organization will be responsible for providing care and services within its financial and service capabilities, mission, and applicable law and regulations. The patient must reside within the geographical area that (HHA) serves." A review of facilitys policy and procedure titled ";Scope of Services" revised 1/2023, indicated ";(HA) will provide care to persons living within the following counties: Los Angeles, Riverside, San Bernardino, Orange, San Diego, Imperial, and Venture." The CMS form for additions did not indicate San Diego and Imperial.

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 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 assessed, for four of 14 sampled patients, (Patients 2, 3, 7, and 8). This deficient practice resulted in patients admitted for hospice care without assessment and had the potential to affect the patients' quality of care. --- a. During a review of Patient 2's untitled admission record, the admission record indicated a start of care (SOC) date of 5/1/2024, with a terminal diagnosis of heart failure (a chronic condition in which the heart does not pump blood as well as it should). The admission record indicated the ";referring/attending/patient choice" physician was Physician 2. During a review of Patient 2's Physicians Certification for Hospice Benefit, dated 5/6/2024 to 7/4/2024, benefit period number 9, indicated 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. During an interview on 5/29/2024, at 11am, with Patient 2 in his room of his residence, Patient 2 stated he had been homeless and was sent to the residence after being hospitalized and did not have a primary physician. Patient 2 stated the Administrator/Director of Patient Care Services (ADM/DPCS) went to the Residential independent facility and signed him up for hospice services. During an interview on 5/29/2024, at 11:10 am at the dining table in the living room, the House Manager stated Patient 2's attending physician did not refer Patient 2 to hospice services. b. A review of Patient 3's untitled admission record, the admission record indicated a start of care date on 5/1/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with chest pain). The clinical record indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 3's Physicians Certification for Hospice Benefit, dated 5/1/2024 to 7/29/24, benefit period number 2, indicated Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit observation on 5/29/2024, at 11:45 a.m., at Patient 3's residence, with Licensed Vocational Nurse 1 (LVN 1). Patient 3 was observed awake, alert, oriented, and ambulatory (able to walk) without any assistance. During an interview on 5/29/2024, at 12 p.m., with the House Manager, the House Manager stated Patient 3's attending physician did not refer Patient 3 to hospice services. During an interview on 5/29/2024, 12:30 pm, with patient 3 in the living room of his residence, he sated he had been homeless for so long and did not have a primary physician. Patient 3 stated the ADM/DPCS came to the Residential independent facility and signed him up for hospice services. c. During a review of Patient 7's untitled admission record, the admission record indicated Patient 2 was admitted to the hospice agency on 12/5/2023, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with chest pain). The admission record indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 7's Physicians Certification for Hospice Benefit, dated 12/5/2023 to 3/2/24, benefit period number 1, indicated Physician 1 signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 7s office visit Office Visit forms with his primary physician, with a printed date of 12/28/2023, at 11:32 a.m., did not indicate Patient 7 had a diagnosis that required hospice services. A review of the Hospice agencys Local Coverage Determination Form (LCD-a guideline for hospice providers to determine eligibility of beneficiaries for hospice benefits) with an assessment date of 5/28/2024, was blank and stipulated," Patient does not qualify per LCD Guidelines." 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. d. During a review of Patient 8's untitled admission record indicated Patient 8 was admitted to the hospice agency on 12/5/2023, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 8's Physicians Certification for Hospice Benefit, dated 12/5/2023 to 3/320/24, benefit period number, indicated Physician 1 signed the attending physician referral section to indicate Patient 8 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.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation for Clinical Records was met as follows: --- T1. The HA failed to ensure the clinical records included the nursing visit notes included the plan of care and clinical notes that reflected the patients current health status for two of 14 sampled patients (Patient 4 and Patient 12). Refer to L672) (Refer to L672). 2 2. The HA failed to ensure that the electronic health record included the date, authorship, and signature of the Medical Social Worker (MSW) for three of 16 sampled patients (Patient 4, Patient 10, and Patient 12). This deficient practice had the potential to result in an unauthorized and inaccurate patient information or assessment that could affect Patient 4, Patient 10, and Patient 12 quality of care and well-being. (Refer to L679). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily (written law) mandated compliance with Federal regulations for Clinical Records to ensure patients medical records are safeguarded from unauthorized access by unauthorized personnel..

Based on interview and record review the hospice agency (HA) failed to ensure the clinical records included the nursing visit notes included the plan of care and clinical notes that reflected the patients current health status for two of 14 sampled patients (Patient 4 and Patient 12). This deficient practice resulted in incomplete clinical record and had the potential for misinformation and non-continuity of care and services provided to the patient. --- a. A review of Patient 4s clinical record untitled and undated, indicated a Start of Care (SOC) date of 4/15/2024 with a primary diagnosis of heart disease, unspecified (heart is unable to effectively pump blood to the body). A review of Patient 4s ";Plan of Care/Interdisciplinary Group (POC/IDG) Review" dated 5/28/2024, indicated the skilled nurse was to visit patient once a week and as needed. A review of Patient 4s Electronic Medical Record (EMR) indicated the nurse did not submit weekly nursing note for week of 5/19/2024-5/25/2024. During a concurrent interview and record review on 5/31/2024 at 3:10 p.m., with Administrator Designee (ADMD), Patient 4s Electronic Medical Record (EMR) was reviewed. Patient 4's EMR section titled ";Visit notes" indicated there was no notes and no submission of weekly nursing note visit for week of 5/19/2024 to 5/25/2024. The ADMD provided the monthly visit calendar on EMR for Patient 4, with a nurse visit marked for the week of 5/19/2024 to 5/25/2024 and stated there was no visit notes the nurse and the nurse (in general) had not submitted the visit note documentation. The ADMD stated the agency's staff had 48 hours to submit documentation. The ADMD stated that it has been more than 48 hours since the visit and the nurse was submitting documentation late. b. A review of Patient 12s medical record untitled and undated, indicated a SOC date of 1/13/2024 with a primary diagnosis of Alzheimers disease, unspecified (a brain condition that affects memory, thinking, and behavior). A review of Patient 12s record titled, ";POC/IDG Review" dated 5/28/2024, indicated the skilled nurse was to visit patient once a week and as needed. A review of Patient 12s Electronic Medical Record (EMR) indicated the nurse did not submit weekly nursing note for the week of 5/12/2024-5/18/2024. During a concurrent interview and record review on 5/31/2024 at 3:10 p.m., with Administrator Designee (ADMD), Patient 12s Electronic Medical Record (EMR) was reviewed. The EMR section titled ";Visit notes" indicated there was no visit notes and no submission of weekly nursing note visit for the week of 5/12/2024 to 5/18/2024. The ADMD provided the monthly visit calendar on EMR for Patient 12, with a nurse visit marked for the week of 5/12/2024 to 5/18/2024. ADMD stated there was no visit notes and the nurse had not submitted the visit note documentation. ADMD further stated staff have 48 hours to submit documentation, and ADMD stated/verified it has been more than 48 hours since the visit and the nurse was submitting documentation late. During an interview on 5/31/2024 at 2:17 p.m., with Administrator/Director of Patient Care Services (DPCS), the DPCS stated it was everyones job to verify if documentation was completed and submitted. The DPCS stated staff has to submit documentation within 48 hours from a patient home visit and initial comprehensive assessments should be completed within 24 hours of visit. During an interview on 5/31/2024 at 2:54 p.m., with Administrator/Director of Patient Care Services (DPCS), DPCS stated the documentation of every patient home visit should be submitted at all times within 48 hours, but if it is not documented then it can indicate the visit was not done. During a review of the Hospice Agency (HA) policy and procedure titled, ";Care/Service Coordination" with revised date of January 2023, indicated, ";Timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided." During a review of the HAs policy and procedure titled, ";Clinical/Service Data Collection" with revised date of January 2023 indicated, ";Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided...7. The clinical/service note will include: A. What care/service was provided B. Treatment and/or invasive procedures performed C. Patient response to treatment and/or procedures D. The date the service was provided (month, day, year) E. Signature of clinician/technician and his/her credentials".

Based on interview and record review the HA failed to ensure that the electronic health record included the date, authorship, and signature of the Medical Social Worker (MSW) for three of 16 sampled patients (Patient 4, Patient 10, and Patient 12). This deficient practice had the potential to result in an unauthorized and inaccurate patient information or assessment that could affect Patient 4, Patient 10, and Patient 12 quality of care and well-being. --- a. A review of Patient 4s medical record untitled and undated, indicated a Start of Care (SOC) date of 4/15/2024 with a primary diagnosis of heart disease, unspecified (heart is unable to effectively pump blood to the body). During a concurrent interview and record review on 5/31/2024 at 2:17 p.m., with Administrator/Director of Patient Care Services (DPCS), Patients 4s POC/IDG Review dated 5/28/2024 was reviewed. The POC/IDG Review indicated, there was no signature for Medical Social Worker (MSW) under MSW Signature. DPCS stated and verified MSW signature was missing and further stated the MSW is hard to get ahold of to remind to submit and sign documentation and are in the process of looking for another social worker that is more present and available. b. A review of Patient 12s medical record untitled and undated, indicated a SOC date of 1/13/2024 with a primary diagnosis of Alzheimers disease, unspecified (a brain condition that affects memory, thinking, and behavior). During a concurrent interview and record review on 5/31/2024 at 2:17 p.m., with Administrator/Director of Patient Care Services (DPCS), Patients 12s ";POC/IDG Review" dated 5/28/24 was reviewed. The ";POC/IDG Review" indicated, there was no signature for MSW under MSW Signature. DPCS stated and verified MSW signature was missing and further stated the MSW was hard to get ahold of to remind to submit and sign documentation and were in the process of looking for another social worker that is more present and available. During a review of the agency's policy and procedure titled, ";Clinical/Service Data Collection" with revised date of January 2023 indicated, ";Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided... 8. Signature authorization of clinical/service documentation will include the staff members name and credentials (as specified on professional licenses and/or certification.)" A review of Patient 10s admission sheet indicated that Patient 10 was admitted on 10/1/2023, with a diagnosis of atherosclerotic heart disease (buildup of fats, cholesterol in artery walls, that affects the heart vessels). During a concurrent interview and record review on 5/31/2024 at 2:20 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated that Patient 10's Plan of Care/Interdisciplinary Group Review (POC/IDG) indicated had missing signatures from the Medical Social Worker (MSW) for the following dates on 5/28/2024, 5/14/2024, 4/30/3024, 4/16/2024, and 10/1/2023. The DPCS stated it was necessary to have the disciplines sign the POC/IDT within 48 hours to verify attendance and acceptance of the document.

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. In 1 of 14 (7%) clinical records reviewed it was revealed that the hospice did not ensure that the interdisciplinary group completed the initial bereavement risk assessment. Clinical Record 14: The patient’s benefit election was dated 4/3/2023. The initial bereavement assessment was not documented until 7/15/2023. The Administrator designee who reviewed the record with this site visitor on 10/17/2023 stated that he did not know why the initial bereavement assessment was not completed as part of the comprehensive assessment. In 1 of 14 (7%) clinical records reviewed it was revealed that the hospice did not ensure that the interdisciplinary group completed the initial bereavement risk assessment.

Based on observation, interview, and record review, the facility failed to ensure the drug profile was accurate for two of 16 sampled patients (Patient 1 and Patient 3) when: 1. Patient 1's medications were placed in bottle containers showing expiration dates. The expiration dates were not reviewed by the licensed nurse during medication reconciliation (process of comparing a patient's medication orders to all of the medications the patient has been taking). This failure had the potential for Patient 1 to be administered medications that were not safe and effective. 2. There was a discrepancy in the dosage of Patient 3's medications, from the facility's current list versus the medication bottle at home for the Metoprolol Succinate (medication for treating high blood pressure) and the Metoprolol Tartrate (medication for treating high blood pressure, chest pain and heart failure). This failure had the potential in compromising the health and well-being of Patient 3. --- 2 ) During a concurrent observation and review of Patient 3's current medication reconciliation list (comparing a patient's medication orders to all of the medications that the patient has been taking), dated 8/23/2023, On 10/10/2023 at 2:35 p.m. in Patient 3's home, the label on the medication bottle read Metoprolol Tartrate, 50 milligrams (mg) tablet, take 1 and one-half tablets by mouth twice a day (1 and ½ tab=75 mg, twice a day, total 150 mg). The medication bottle was observed to have a label dated 3/20/2023 from [Hospital A]. Review of the facility's current medication reconciliation list for Patient 3 dated 8/23/2023, indicated Metoprolol Succinate 50 mg, extended release (last longer in your body), 1 tablet by mouth once a day for hypertension (high blood pressure). During an interview on 10/10/2023 at 2:40 p.m. with Patient 3's wife, Patient 3's wife stated, ";I give 1 and 1/2 tab 2 times a day. He (Patient 3) had been taking that Metoprolol Tartrate 50 mg tablet long time ago, it was issued by [Hospital A]." During an interview on 10/10/2023 at 3:00 p.m. with the hospice Licensed Vocational Nurse 1(LVN 1), LVN 1 stated, "He did reconcile the medication on 9/29/2023 and the initial visit to the patient was conducted by another nurse." During an interview on 10/10/2023 at 3:38 p.m. with the Registered Nurse 1 (RN 1), RN 1 stated, the facilitys process when ordering medications for newly admitted hospice patients; we normally check the list of medications the patients are taking. RN 1 stated, we put them in the system, then the doctor reviews them and approves the medications. RN 1 stated, the Metoprolol Succinate 50 mg extended-release tablet once a day was ordered on this particular patient upon admission. RN 1 stated, he read back the phone order to the doctor. RN 1 stated, the medication available at home and currently taken by Patient 3, which is Metoprolol Tartrate (immediate release) 50 mg tablet, taken 1 and half tablet by mouth 2 times a day is not the same. RN 1 further stated, the dosage on the new order is short compared to the dosage Patient 3 is currently taking. RN 1 stated, he made a mistake on not putting in the right dose on admission. RN 1 further stated, it's my responsibility as a nurse to ensure medications taken by patients are the right prescription. During a review of the facilitys policy and procedure (P&P) titled, ";Medication Profile," revised April 2022, the P&P indicated, ";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. Procedure 1. 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." During a review of the facilitys policy and procedure (P&P) titled, ";Medication Monitoring," revised April 2022, the P&P indicated, ";Ongoing patient medication monitoring will use a collaborative approach between the clinicians, physicians, pharmacists, patients, and families/caregivers." Findings: 1. During a review of Patient 1s face sheet (demographics), the face sheet indicated, Patient 1 was admitted to hospice with a start of care date on 7/13/2023. Patient 1s primary admitting diagnosis was atherosclerotic heart disease (damage in the heart's major blood vessels) of native coronary artery without angina pectoris (hardening or narrowing of an artery close to the heart without chest pain). During a home visit observation on 10/10/2023 at 10:15 a.m. and 10:30 a.m., in Patient 1's room, the Registered Nurse 2 (RN 2), asked Patient 1 if she had pain and Patient 1 stated she had pain in both of her knees. RN 2 was observed to perform medication reconciliation by checking Patient 1s medication bottles against the Physician ordered drug profile. RN 2 asked Patient 1, the Protonix (antacid) bottle indicated the dosage was 40 milligrams (mg), but the Physicians order indicated the dosage was 20 mg. RN 2 asked Patient 1, to refresh RN 2s memory why there was a dosage discrepancy. Patient 1 stated to RN 2, she had removed the Protonix 20 mg tablets from the bubble pack (a card that packaged individual doses of medication within small, clear plastic bubbles) and placed them into an old Protonix bottle. RN 2 was observed to cross off the 40 on the Protonix bottle and write 20. In addition, RN 2 stated to Patient 1, missing from the medications was benzonate (cough suppressant). Patient 1 stated to RN 2, she had removed the benzonate pills from the bubble pack and placed them in a medication bottle in the refrigerator. The expiration date on the benzonate bottle was noted as not legible. During a concurrent interview with Patient 1 and review of Patient 1s medication bottles on 10/10/2023 at 10:40 a.m. the following medication bottles had expired dates: 1. Rosuvastatin (medication to lower cholesterol) 20 mg, use before 7/14/2022, 2. Montelukast (asthma medication) 10 mg, use before 4/25/2023, 3. Amlodipine (antihypertensive medication) 2.5 mg, use before 9/25/2023, 4. Naproxen (pain medication) 500 mg, use before 4/25/2023, 5. Diclofenac Sodium Topical Gel, dated 6/2022. Patient 1 stated, she had removed her medications from the bubble packs and placed them into the bottles. During an interview on 10/11/2023 at 11:06 a.m. with RN 2, RN 2 stated, during the home visit on 10/10/2023, ";I didnt really see any expired medication bottles. I saw the Protonix dose and cough medicine, other than those I didnt see any others." RN 2 stated, she should have looked at the expiration dates as part of the medication reconciliation. RN 2 stated, Patient 1 did not like the bubble packs. RN 2 stated, ";I dont think I specifically did educate the patient not to take medications out of the bubble packs and put them into the expired bottles. No, I didnt educate the patient." During a review of the facilitys policy and procedure (P&P) titled, ";MEDICATION PROFILE," revised April 2022, the P&P indicated, ";Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record... during... home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen..." During a review of the facility's policy and procedure (P&P) titled, ";IDENTIFICATION OF MEDICATION FOR ADMINISTRATION," revised April 2022, the P&P indicated, ";Medications will be properly labeled with the patients name, an additional patient identifier, name of drug, dosage, diluent, date of preparation, expiration date, initials of preparer, and any special instructions, as applicable... The nurse will document medication teaching..."

Based on interview and record review, the facility failed to ensure Patient 14's discharge summary (synopsis of a patients course of treatment) was complete. This failure resulted in Patient 14s healthcare information not being available to providers, and the potential to affect continuity of care. --- Findings: During a review of Patient 14s face sheet (demographics), the face sheet indicated, Patient 14 was admitted to hospice with start of care on 7/3/2023. The primary diagnosis was atherosclerotic heart disease (damage in the heart's major blood vessels) of native coronary artery without angina pectoris (hardening or narrowing of an artery close to the heart without chest pain). During a review of Patient 14s ";Discharge Summary," dated 10/6/2023 and signed by Registered Nurse 1 (RN 1), the ";Discharge Summary" indicated, Patient 14 had requested to transfer to another hospice. The document further indicated, ";MD (Medical Doctor) notified and ordered the discharge of the patient from hospice services..." The ";Discharge Summary" did not include a summary of Patient 14s stay which included treatments, symptoms and pain management, current plan of care and the patients latest physicians orders. During a concurrent interview and record review on 10/11/2023 at 2 p.m. with RN 1, Patient 14's Discharge Summary, dated 10/6/2023 was reviewed. RN 1 stated, he had written Patient 14s ";Discharge Summary" on 10/6/2023. RN 1 stated, when a hospice patient requested to be transferred to another hospice, the MD would write the discharge order. RN 1 stated, when the reason for discharge was for transfer to another hospice, ";I dont go into all that detail when the patient was transferring to another hospice. They need to start their own plan of care based on their own assessment, otherwise theyll just go off of ours and thats not fair to the patient." During a review of the facilitys policy and procedure (P&P) titled, ";DISCHARGE SUMMARY," revised April 2022, the P&P indicated, ";Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include, as appropriate... Significant health history... Discharge orders, instructions, medication profile and allergies... The status of problems identified at admission and during the provision of care... The resolution of identified problems... Continuing pain and symptom management needs... The overall status of the patient at discharge... A summary of the care or services provided and ongoing needs that cannot be met... The patients current plan of care... The patients latest physician orders... A copy of the discharge summary will be provided to the patients attending physician..."