Every finding on record at Vesper Hospice Care, Inc

Based on interview, and record review, the hospice agency (HA) failed to inform three of ten patients, (Patients 8, 9 and 10), of his or her rights to decline the hospice services, before admission, by providing written notice of information in a language the patient could understand. This deficient practice resulted in the the patients lack of understanding and information for the care and services available, and not being able to exercise their right to decline the hospice services. --- a. A review of Patient 8s Patient Information Sheet indicated a Start of Care (SOC) of 6/9/2022 with a primary diagnosis of heart disease. A review of Patient 8s Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less), Certification #3: Re-Certification Statement for Next 60-day period from 12/6/2022 to 2/3/2023 indicated Patient 8s primary diagnosis was heart disease. A review of Patient 8s Statement of Consent and Election of Benefits dated 6/9/2022, indicated a different hospice agency (HA2). During a phone interview on 3/30/2023 at 10:35 am, Patient 8 stated, she did not know what company enrolled her into hospice. She stated she believes it was sometime last year someone came and said they would get a free ensure box if they signed for hospice and she signed. Patient 8 stated she thought having hospice was to get ensure and after she got it she didnt need it anymore. Patient 8 stated she didnt know what hospice was, she stated she does not have a terminal illness or heart disease and she works. Patient 8s stated she was referred by the neighbor and thought hospice was a benefit to get free supplies like ensure drinks. Patient 8 stated she never saw a doctor, nurse, or social worker. she stated no one ever came to see them. Patient 8 stated she does not want to lose her job. b. A review of Patient 9s Patient Information Sheet indicated Start of Care (SOC) date of 10/18/22, with a primary diagnosis acute ischemic heart disease, (a term given to heart problems caused by narrowing heart arteries that supply blood to the heart muscle). There were two phone numbers listed for Patient 9, but they were not working. Unable to reach Patient 9. A review of Patient 9s CTI #2, Re-certification Statement for the next 90-day period for 1/3/23 to 4/2/23, indicated that Patient 9 had a secondary diagnoses of hypertension (high blood pressure). A review of the Patient 9s clinical records, there was no Statement of Consent and Election of Benefits in the electronic medical record. c. A review of Patient 10s Patient Information sheet indicted a SOC date of 10/1/22, with a primary diagnosis of heart disease unspecified. The phone number listed for Patient 10 was not a working number. A review of Patient 10s CTI # 2, Certification Statement for First 90-day period, 10/1/22 to 12/29/22, indicated a secondary diagnosis of hypertension (high blood pressure). During an interview on 3/30/2023 at 2:35 pm, with owner, she stated she was not aware Patient 8 had a consent from HA2. She stated she doesnt know what the field staff did and none of the staff that were working for her prior to March 2023 are working any longer. She stated the staff before were hiding things from her and she is not aware what happened in the field and what was uploaded in the computer before. During a phone interview on 5/9/2023 at 1:30 p.m. with Administrator, the administrator stated he is on leave of absence for a month and wont be available. When asked about the POC which was submitted to our department by the consultant, he stated he is not clinical and was not a part of the in services. He stated he does not have access to Hospice MD either. During an interview on 5/9/2023 at 2:25 p.m. with DPCS, the DPCS stated she has only used Hospice MD once during her training on 1/17/23 but is not familiar with it. She stated she does not have hospice MD access and does not remember her password since she only used it during her training. She stated she is not computer savvy and doesnt really know how to even use the email or check it. She stated from what she knows only the owner has access to Hospice MD. She stated she hasnt looked at any patient files since she does not know how to operate Hospice MD. During an interview on 5/10/2023 at 12:15 p.m. with DPCS, the DPCS asked if she reviewed any patient files or comprehensive patient assessments as part of the POC for this agency, she stated no, she has not looked at any patient files since she doesnt have any access to Hospice MD. When asked if there were any in-services done recently, she stated no because they dont have any patients and they are not operating right now and dont have any new hires.

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Initial and Comprehensive Assessment of the Patient was met as evidenced by: 1. The Hospice Agency (HA) failed to conduct an accurate and complete comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patients current health status and identified the patients needs for hospice care and services related to eligibility and management of the terminal illness, for two of ten sampled patients, (Patients 9 and Patient 10). This deficient practice resulted in the provision of hospice services to patients who were not clinically eligible to receive hospice care and services. (Refer to L524). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Patient's Rights to protect and promote the rights of the patient in the hospice agency. --- .

Based on interview and record review, the hospice agency failed to conduct an accurate and complete comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patients current health status and failed to identify the patients needs for hospice care and services related to eligibility and management of the terminal illness, for two of ten sampled patients, (Patients 9 and Patient 10). This deficient practice resulted in the provision of hospice services to patients who were not clinically eligible to receive hospice care and services which can affect the quality of care and quality of life to all the patients under the agencys care. --- a. A review of Patient 9s Patient Information Sheet indicated Start of Care (SOC) date of 10/5/2022, with a primary diagnosis of acute ischemic heart disease (heart problems caused by narrowing heart arteries that supply blood to the heart muscle). A telephone call was placed to Patient 9, but the two phone numbers listed in the face sheet were not working. A review of Patient 9s electronic medical record did not contain the Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), Psychosocial Assessment, or Spiritual Assessment. b. A review of Patient 10s Patient Information sheet indicated an SOC date of 10/1/2022, with a primary diagnosis of heart disease. The phone number listed in Patient 10's face sheet was not a working number. A review of Patient 10s electronic medical record did not contain Comprehensive Nursing Assessment, Psychosocial Assessment, or Spiritual Assessment. During an interview on 3/30/2023 at 2:45 p.m., the Owner stated she doesnt know what the field staff did and that staff members that were working prior March 2023, does not work for the agency anymore. She stated that previous staff members were hiding things from her and she was not aware what happened in the field and what was uploaded in the computer before. During an interview on 3/30/2023 at 4:20 p.m. with the former Medical Director (FMD), FMD stated she never certified any patients for this agency and was unaware of any of the patients in the agency. FMD stated she did not even know this agency was a hospice agency. FMD stated when she started in June 2022, she thought it was a home health agency. FMD stated she never wrote any orders for any patients and never participated in any interdisciplinary team group (team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings. FMD stated she never saw any patients for this agency and cannot state anything regarding any patients since she was told there were no patients during the time she was employed with this agency. FMD stated she will send signed affidavit (a written declaration of a statement) of the facts she is stating. A review of FMDs signed affidavit of truth dated 3/31/2023, indicated, ";I have just been informed by officials that my name, was being used for Vesper Hospice with names of patient that I am not familiar with, and that there were CTIs (Certification of Terminal Illness [CTI], a brief summary designed to explain clinical findings that support a life expectancy of six months or less) completed in my name, which I never knew about until today. I have never conducted any IDT (Interdisciplinary) meetings, admitted or discharged patients or signed any orders or ordered any medications or DME (Durable Medical Equipment) supplies. It was my understanding upon being hired by the owner that Vesper was a home health and not hospice. It was not until many months later that I found out that Vesper was a hospice. I started asking for access to HospiceMD (an electronic charting system) and calling for IDT meetings. I was told that the meetings would be scheduled when all others could find a good time, but that was never done. In addition, I was told I would be given access to Hospice MD. However, the access would not come to the email. Then, due to other obligations, I would forget to follow up. When I would ask again, the owner would say," The office didnt send it? I will have to remind them". That was never done. The owner was my main contact because the person that I met in the office on my first day that I went to visit, the Director of Nurses, was not available. The following times that I asked, she was on vacation and then no longer working there. I was told by the owner that she added my name to many patients without the owners knowledge or permission and did not know why this was done and was apologetic, but assures me that she did not know this was happening and did not approve this. She also explained that it was not a big deal for Vesper hospice because they were not able to bill for these patients anyway and there were only a few patients on service. I have had the same or with Hospice Agency (HA2) in that I do not know the extent of the use of my name since I could not get access of the Hospice MD and had to rely on the word of the owner. However, the information was often inconsistent or incomplete or both. I was given a letter of termination of services effective March 19, 2023. I prepared my own letter, but it was not submitted, as I received news of the termination letter". During a phone interview on 5/9/2023 at 1:30 p.m. with Administrator, the Administrator stated he is on leave of absence for a month and wont be available. When asked about the Plan of Corrections (POC, a document submitted by a licensed healthcare facility to respond to the deficiencies identified in a survey) which was submitted to the Health Department by the consultant, he stated he is not clinical professional and was not part of the in-services. He stated he does not have access to the Hospice MD either. During an interview on 5/9/2023 at 2:25 p.m. with Director of Patient Care Services (DPCS), the DPCS stated she only used HospiceMD once during her training on 1/17/2023, but she is not familiar with it. The DPCS stated she does not have HospiceMD access and does not remember her password since she only used the HospiceMD during her training. The DPCS stated she is not a computer savvy and doesnt really know how to even use or check the email. The DPCS stated from what she knows, only the owner has access to the HospiceMD. The DPCS stated she hasnt looked at any patient files since she does not know how to operate HospiceMD. During an interview on 5/10/2023 at 12:15 p.m. asked DPCS if she reviewed any patient files or comprehensive patient assessments as part of the POC for Vesper hospice, she stated "no" and added that she has not looked at any patient files since she doesnt have any access to HospiceMD. When asked the DPCS if there were any in-services done recently, the DPCS stated "no" and added because they dont have any patients, they are not operating right now, and dont have any new hires.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Organization and Administration of Services was met as follows: 1. The hospice agency failed to ensure that the Administrator and Director of Patient Care Services (DPCS) were knowledgeable regarding hospice regulations and that the agency was operational. (Refer to L651). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with Federal regulations for Organization and Administration of Services to protect and promote the rights of the patient in the hospice agency.

Based on observation, interview, and record review, the hospice agency failed to ensure that the Administrator and Director of Patient Care Services (DPCS) were knowledgeable regarding hospice regulations and that the agency was operational. The deficient practice resulted in the Administrator and the DPCS of being unaware regarding hospice regulations and agency was not being operational. --- On 5/9/2023 and 5/10/2023, full survey was initiated at the hospice agency. The hospice agency did not have hired office staff at the agency to assist in operation of the agency. On 05/09/2023 and 5/10/2023, the survey team requested the DPCS to provide access to surveyors to the agencys electronic charting system, the HospiceMD, to conduct record reviews. The DPCS stated she does not have access to the HospiceMD and does not know how to use the HospiceMD. The DPCS stated the only person who knows how to use the HospicMD is the Assistant Administrator Designee and he is off work because he is sick. During a telephone interview with the Administrator (ADM) on 05/09/2023 at 1:30p.m, the ADM stated that the DPCS and him does not have access to HospiceMD and unaware when access will be available. The Administrator stated that the only person who has access to HospiceMD is the Owner. The Administrator stated that he was still on a leave of absence effective 05/04/2023 to 06/04/2023. ADM's email further indicated that any work-related questions or queries may be directed to his email. On 05/10/2023 at 10:37 a.m., during an interview in the agency's office with the DPCS, the DPCS stated that she contacted HospiceMD the night before trying to get access and was informed by the HospiceMD that the Chief Executive Officer (CEO) is the only one who has access. During the full survey conducted by the survey team from 5/9/2023 to 5/10/2023, the CEO was not available due to family member being in a general acute care hospital (GACH). The survey team was unable to conduct the full survey due to the agency not having access to HospiceMD and DPCS unable to provide documentation.

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Clinical Records was met as evidenced by: 1. The Hospice Agency (HA) failed to ensure the Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less) for 5 of ten sampled patients, (Patients 6, 7, 8, 9, and Patient 10) was completed and signed by the Medical Director. This deficient practice resulted in the failure to document patient information and ensure authenticity of the patients clinical records. (Refer L679) 2. The hospice agency (HA) failed to ensure a complete discharge summary was created upon discharge for one of five sampled patients, Patient 10. This deficient practice had the potential to result in miscommunication and poor hand off patient's medical status and can affect the care and services needed in the continuation of care for the affected patient. (Refer to L684) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for clinical records to ensure the highest quality of patient care are provided to the patients certified to receive hospice services. --- .

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less) for 5 of ten sampled patients, (Patients 6, 7, 8, 9, and Patient 10) was completed and signed by the Medical Director. This deficient practice resulted in the failure to document accurate patient information and ensure authenticity of the patients clinical records. --- a. A review of Patient 6s Patient Information Sheet indicated a Start of Care (SOC) of 6/9/2022 with a primary diagnosis of hypertensive heart disease (high blood pressure resulting in heart disease). A review of Patient 6s Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less), Certification #3: Re-Certification Statement for Next 60-day period from 12/6/2022 to 2/3/2023 indicated Patient 8s primary diagnosis was hypertensive heart disease. During the review, the CTI had the former Medical Directors name, however, it was not signed. The signature box is blank. During a phone interview on 3/30/2023 at 10:20 am, Patient 6s daughter stated, she did not know what hospice company enrolled her mom into. Sometime last year, someone came and said they would get a free ensure box if they signed for hospice and so, she signed. Patient 6s daughter stated she thought having hospice was to get ensure and after she got it, she didnt need it anymore. Patient 6s daughter stated she didnt know whats the hospice agency name was, and nothing was explained to them. Patient 6s daughter stated Patient 6 does not have a terminal illness or heart disease and that she was referred by the neighbor and thought hospice was a benefit to get free supplies like ensure drinks. Patient 6s daughter further stated Patient 6 never saw a doctor, nurse, or social worker. b. A review of Patient 7s Patient Information Sheet indicated a Start of Care (SOC) of 7/23/2022 with a primary diagnosis of chronic ischemic heart disease (long term disease of the heart caused by narrowing heart arteries that supply blood to the heart muscle). A review of Patient 7s CTI, Certification #3: Re-Certification Statement for Next 60-day period from 1/19/2022 to 3/19/2023 indicated Patient 7s primary diagnosis was chronic ischemic heart disease. The CTI lists former Medical Directors name, however, it was not signed. The signature box is blank. During a phone interview on 3/30/2023 at 11:25 a.m., Patient 7s sister stated she did not know what company enrolled her sister into hospice. Patient 7s sister stated Patient 7 lives in Hawaii and had lived there since March 2022. Patient 7s sister stated Patient 7 goes to Delano to visit sometimes and goes back to Hawaii and stated she remember something about a hospice last year where the agency was advertising hospice as a benefit to get free ensure and they signed up to get the supplies and that was it. Patient 7s sister stated she does not know what hospice is and that one person came once and no one else came after that. Patient 7s sister said no doctor, nurse or social worker ever visited. During an interview on 3/30/2023 at 2:35 p.m., with owner, she stated she was not aware Patient 8 had a consent from another hospice agency (HA2). She stated she didnt know what the field staffs were doing and none of the staff that worked prior to March 2023 are working for the agency. She stated the staff before were hiding things from her and she was not aware what happened in the field and what were uploaded in the computer. c. A review of Patient 8s Patient Information Sheet indicated a Start of Care (SOC) of 6/9/2022 with a primary diagnosis of heart disease. A review of Patient 8s CTI, Certification #3: Re-Certification Statement for next 60-day period from 12/6/2022 to 2/3/2023 indicated Patient 8s primary diagnosis was heart disease. The CTI lists Former Medical Directors name but it was not signed. The signature box is blank. During a phone interview on 3/30/2023 at 10:35 a.m., Patient 8 stated, she did not know what company enrolled her into hospice. She stated she believed it was sometime last year someone came and said they would get a free ensure box if they signed up for hospice and so she signed. Patient 8 stated she thought having hospice was to get ensure and after she got it, she didnt need it anymore. Patient 8 stated she didnt know what hospice was, she stated she does not have a terminal illness or heart disease and she still works. Patient 8 stated she was referred by the neighbor and thought hospice was a benefit to get free supplies like ensure drinks. Patient 8 stated she never saw a doctor, nurse, or social worker. she stated no one ever came to see them. Patient 8 stated she does not want to lose her job. d. A review of Patient 9s Patient Information Sheet indicated Start of Care (SOC) date of 10/18/22, with a primary diagnosis acute ischemic heart disease, (heart problems caused by narrowing heart arteries that supply blood to the heart muscle). A telephone call was placed to Patient 9, but phone numbers were not working. A review of Patient 9s CTI, Certification #2: Re-Certification Statement for next 90-day period from 1/3/2023 to 4/2/2023 indicated Patient 9s primary diagnosis was chronic ischemic heart disease. The CTI listed former Medical Directors name, however, it was not signed. The signature box is blank. e. A review of Patient 10s Patient Information sheet indicated a SOC date of 10/1/22, with a primary diagnosis of heart disease unspecified. The phone number listed for Patient 10 did not work. A review of Patient 10s CTI, Certification #2: Re-Certification Statement for next 90-day period from 1/3/2022 to 4/2/2023 indicated Patient 7s primary diagnosis was chronic heart disease. The CTI lists Former Medical Directors name but it was not signed. The signature box is blank. During an interview on 3/30/2023 at 4:20 p.m., the former medical director (FMD) stated she never certified any patients for this agency and was unaware on any of the agency patients. FMD stated she did not even know this agency was a hospice when she started in June 2022, she thought it was a home health. FMD stated she never wrote any orders for any patients and never participated in any Interdisciplinary group meetings (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities). FMD stated she never saw any patients for this agency and cannot state anything regarding any patients since she was told there were no patients during the time she was employed with this agency. FMD stated she did not sign any CTIs for any patients, she did not write any orders for any patients, and she did not participate in any IDG meetings. FMD also stated she did not have any access to the electronic medical records since she was never granted access even though she repeatedly asked for it. FMD stated she will send signed affidavit of the facts she is stating. A review of FMDs signed affidavit of truth dated 3/31/2023, indicated, ";I have just been informed by officials that my name, and was being used for Vesper Hospice with names of patient that I am not familiar with, and that there were CTIs completed in my name, which I never knew about until today. I have never conducted any IDT meetings, admitted or discharged patients or signed any orders or ordered any medications or DME supplies. It was my understanding upon being hired by the owner that Vesper was a home health and not hospice. It was not until many months later that I found out that Vesper was a hospice. I started asking for access to Hospice MD and calling for IDT meetings. I was told that the meetings would be scheduled when all others could find a good time butt that was never done. In addition, I was told I would be given access to Hospice MD. However, the access would not come to the email. Then, due to other obligations, I would forget to follow up. When I would ask again, the owner would say," The office didnt send it? I will have to remind them". That was never done. The owner was my main contact because the person that I met in the office on my first day that I went to visit, the Director of Nurses, was not available. The following times that I asked, she was on vacation and then no longer working there. I was told by the owner that she added my name to many patients without the owners knowledge or permission and did not know why this was done and was apologetic but assures me that she did not know this was happening and did not approve this. She also explained that it was not a big deal for Vesper hospice because they were not able to bill for these patients anyway and there were only a few patients on service. I have had the same or with BC hospice in that I do not know the extent of the use of my name since I could not get access the Hospice MD and had to rely on the word of the owner. However, the information was often inconsistent or incomplete or both. I was given a letter of termination of services effective March 19, 2023. I prepared my own letter, but it was not submitted, as I received news of the termination letter". During a phone interview on 5/9/2023 at 1:30 p.m. with Administrator, the administrator stated he is on leave of absence for a month and wont be available. When asked about the POC which was submitted to our department by the consultant, he stated he is not clinical and was not a part of the in services. He stated he does not have access to Hospice MD either. During an interview on 5/9/2023 at 2:25 p.m. with DPCS, the DPCS stated she has only used Hospice MD once during her training on 1/17/23 but is not familiar with it. She stated she does not have hospice MD access and does not remember her password since she only used it during her training. She stated she is not computer savvy and doesnt really know how to even use the email or check it. She stated from what she knows only the owner has access to Hospice MD. She stated she hasnt looked at any patient files since she does not know how to operate hospice md. During an interview on 5/10/2023 at 12:15 p.m. with DPCS, the DPCS asked if she reviewed any patient files or comprehensive patient assessments as part of the POC for this hospice agency, she stated no she has not looked at any patient files since she doesnt have any access to hospice MD. When asked if there were any in-services done recently, she stated no because they dont have any patients and they are not operating right now and dont have any new hires.

Based on observation, interview and record review, the hospice agency (HA) failed to retain the Patient Clinical Records (route sheets, hospice consents, history and physical, and etc.) for their discharged patients for six years after discharge in accordance with its policy and procedure. This deficient practice resulted in the failure to safeguard, retain, and retrieve the patients' clinical records. --- On 5/9/2023 at 12:58 p.m., a full survey was conducted at the hospice agency. During the entrance conference with the Director of Patient Care Services (DPCS) at 1:20 p.m., the DPCS was informed by the survey team to provide access to Hospice MD (an electronic charting system) and to provide the requested documents of the employee files, the hospice agency's policies and procedures, and the list of employees for the review. The survey team called the Administrator, however, the Administrator stated that he was on leave since 5/4/2023 to 6/4/2023, and that he did not have access to Hospice MD and could not provide the requested documents. During an interview with DPCS on 5/9/2023 at 2:00 p.m. in the hospice agency office, the DPCS stated that she did not have access to Hospice MD, had not used Hospice MD since her orientation to the agency on 1/17/2023, did not know how to use the Hospice MD, and did not need to use Hospice MD since the agency did not have any patients. The DPCS stated she did not know where the employee files are or their policies and procedures and was unable to give the survey team access to the Hospice MD or the documents requested during the full survey conducted from 5/9/2023 to 5/10/2023. .

Based on interview and record review, the hospice agency (HA) failed to ensure a complete discharge summary was created upon discharge for one of five sampled patients, Patient 10. This deficient practice had the potential to result in miscommunication and poor hand off of patient's medical status, and can affect the care and services needed in the continuation of care for the affected patient. --- A review of Patient 10s Patient Information sheet indicated a Start of Care (SOC) date of 10/1/22, with a primary diagnosis of heart disease unspecified. The phone number listed for Patient 10 was not a working number. A review of Patient 10s Discharge summary indicated an End of Care (EOC) date of 11/18/2022, and the reason for discharge indicated that Patient 10 moved out of the area, (out of her residence). The nurses narrative note was empty. A review of Patient 10s electronic medical record (EMR) did not indicate any Interdisciplinary Group meeting (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) notes or Discharge Plan. During an interview on 3/30/2023 at 4:25 p.m., the former Medical Director stated she had never discharged or admitted any patients here in this agency. During a phone interview on 5/9/2023 at 1:30 p.m. with the Administrator, the administrator stated he is on leave of absence for a month and wont be available. When asked about the Plan of Correction (POC) which was submitted to our department by the consultant, he stated he is not clinical and was not a part of the in services. He stated he does not have access to Hospice MD either. During an interview on 5/9/2023 at 2:25 p.m. with DPCS, the DPCS stated she has only used Hospice MD once during her training on 1/17/23 but is not familiar with it. She stated she does not have hospice MD access and does not remember her password since she only used it during her training. She stated she is not computer savvy and doesnt really know how to even use the email or check it. She stated from what she knows only the owner has access to Hospice MD. She stated she hasnt looked at any patient files since she does not know how to operate Hospice MD. During an interview on 5/10/2023 at 12:15 p.m. with DPCS, the DPCS was asked if she reviewed any patient files or comprehensive patient assessments as part of the POC for this hospice agency, she stated no she has not looked at any patient files since she doesnt have any access to Hospice MD. When asked if there were any in-services done recently, she stated no because they dont have any patients and they are not operating right now and dont have any new hires.

Based on observation, interview and record review, the hospice agency (HA) failed to retain the Patient Clinical Records (route sheets, hospice consents, history and physical, etc) for their discharged patients for six years after discharge in accordance with its policy and procedure. This deficient practice resulted in the failure to safeguard, retain, and retrieve the patients' clinical records. --- On 5/9/2023 at 12:58 p.m., a full survey was conducted at the hospice agency. During the entrance conference with the Director of Patient Care Services (DPCS) at 1:20 p.m., the DPCS was informed by the survey team to provide access to the HospiceMD to conduct record review, requested to provide documents of the employee files, the hospice agency's policies and procedures, and the list of employees for the review. The DPCS informed the survey team that she had not used the HospiceMD since her orientation to the hospice agency on 1/17/2023, and that she had lost her password and did not need to utilize HospiceMD since the agency does not have any patients. The DPCS stated to the survey team when the agency gets patients, then she will learn how to use the HospiceMD. On 5/9/2023 at 1:30 p.m., call was made to the Administrator and the Administrator stated that he was on leave from 5/4/2023 to 6/4/2023, he did not have access to the HospiceMD, and could not provide the requested documents. The Administrator stated the CEO is the one who has access to the HospiceMD. During the on-site full survey, conducted from 5/09/2023 to 5/10/2023, the hospice agency was unable to provide the survey team with access to HospiceMD to review records, and unable to provide the employee files and policy and procedures for review. The survey team could not conduct the full survey due to the hospice agency being un-operational.

Based on interview, and record review, the hospice agency (HA) failed to inform three of ten patients, (Patients 8, 9 and 10), of his or her rights to decline the hospice services, before admission, by providing written notice of information in a language the patient could understand. This deficient practice resulted in the the patients lack of understanding and information for the care and services available, and not being able to exercise their right to decline the hospice services. --- a. A review of Patient 8s Patient Information Sheet indicated a Start of Care (SOC) of 6/9/2022 with a primary diagnosis of heart disease. A review of Patient 8s Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less), Certification #3: Re-Certification Statement for Next 60-day period from 12/6/2022 to 2/3/2023 indicated Patient 8s primary diagnosis was heart disease. A review of Patient 8s Statement of Consent and Election of Benefits dated 6/9/2022, indicated a hospice agency name BC Hospice, Inc. During a phone interview on 3/30/2023 at 10:35 am, Patient 8 stated, she did not know what company enrolled her into hospice. She stated she believes it was sometime last year someone came and said they would get a free ensure box if they signed for hospice and she signed. Patient 8 stated she thought having hospice was to get ensure and after she got it she didnt need it anymore. Patient 8 stated she didnt know what hospice was, she stated she does not have a terminal illness or heart disease and she works. Patient 8s stated she was referred by the neighbor and thought hospice was a benefit to get free supplies like ensure drinks. Patient 8 stated she never saw a doctor, nurse, or social worker. she stated no one ever came to see them. Patient 8 stated she does not want to lose her job. b. A review of Patient 9s Patient Information Sheet indicated Start of Care (SOC) date of 10/18/22, with a primary diagnosis acute ischemic heart disease, (a term given to heart problems caused by narrowing heart arteries that supply blood to the heart muscle). There were two phone numbers listed for Patient 9, but they were not working. Unable to reach Patient 9. A review of Patient 9s CTI #2, Re-certification Statement for the next 90-day period for 1/3/23 to 4/2/23, indicated that Patient 9 had a secondary diagnoses of hypertension (high blood pressure). A review of the Patient 9s clinical records, there was no Statement of Consent and Election of Benefits in the electronic medical record. c. A review of Patient 10s Patient Information sheet indicted a SOC date of 10/1/22, with a primary diagnosis of heart disease unspecified. The phone number listed for Patient 10 was not a working number. A review of Patient 10s CTI # 2, Certification Statement for First 90-day period, 10/1/22 to 12/29/22, indicated a secondary diagnosis of hypertension (high blood pressure). During an interview on 3/30/2023 at 2:35 pm, with owner, she stated she was not aware Patient 8 had a consent from BC Hospice. She stated she doesnt know what the field staff did and none of the staff that were working for her prior to March 2023 are working any longer. She stated the staff before were hiding things from her and she is not aware what happened in the field and what was uploaded in the computer before.

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Initial and Comprehensive Assessment of the Patient was met as evidenced by: 1. The Hospice Agency (HA) failed to conduct an accurate and complete comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patients current health status and identified the patients needs for hospice care and services related to eligibility and management of the terminal illness, for two of ten sampled patients, (Patients 9 and 10 ). This deficient practice resulted in the provision of hospice services to patients who were not clinically eligible to receive hospice care and services. (Refer to L524). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Patient's Rights to protect and promote the rights, of the patient in the hospice agency.

Based on interview, and record review, the hospice agency failed to conduct an accurate comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patients current health status and failed to identify the patients needs for hospice care and services related to eligibility of the terminal illness, for two of ten sampled patients, (Patients 9 and 10). This deficient practice resulted in the provision of hospice services to patients who were not clinically eligible to receive hospice care and services which can affect the quality of care and quality of life to all the patients under the agencys care. --- a. A review of Patient 9s Patient Information Sheet indicated Start of Care (SOC) date of 10/18/22, with a primary diagnosis acute ischemic heart disease, (heart problems caused by narrowing heart arteries that supply blood to the heart muscle). A telephone call was placed to Patient 9, but the two phone numbers listed in the face sheet were not working. A review of Patient 9s electronic medical record did not contain the Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), Psychosocial Assessment or Spiritual Assessment. b. A review of Patient 10s Patient Information sheet indicated a SOC date of 10/1/22, with a primary diagnosis of heart disease. The phone number listed for Patient 10 was not a working number. A review of Patient 10s electronic medical record did not indicate Comprehensive Nursing Assessment, Psychosocial Assessment or Spiritual Assessment were available Patient 10s file. During an interview on 3/30/2023 at 2:45 p.m., the owner stated she doesnt know what the field staffs did and that staffs that were working prior to March 2023 does not work for her anymore. She stated the staff before were hiding things from her and she is not aware what happened in the field and what was uploaded in the computer before. During an interview on 3/30/2023 at 4:20 p.m. with former medical director (FMD), she stated she never certified any patients for this agency and is unaware of any of the patients in the agency. FMD stated she did not even know this agency was a hospice when she started in June 2022, she thought it was a home health. FMD stated she never wrote any orders for any patients and never participated in any interdisciplinary team group (team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings. FMD stated she never saw any patients for this agency and cannot state anything regarding any patients since she was told there were no patients during the time she was employed with this agency. FMD stated she will send signed affidavit of the facts she is stating. A review of FMDs signed affidavit of truth dated 3/31/2023, indicated, ";I have just been informed by officials that my name, was being used for Vesper Hospice with names of patient that I am not familiar with, and that there were CTIs completed in my name, which I never knew about until today. I have never conducted any IDT meetings, admitted or discharged patients or signed any orders or ordered any medications or DME supplies. It was my understanding upon being hired by the owner that Vesper was a home health and not hospice. It was not until many months later that I found out that Vesper was a hospice. I started asking for access to Hospice MD and calling for IDT meetings. I was told that the meetings would be scheduled when all others could find a good time but that was never done. In addition, I was told I would be given access to Hospice MD. However, the access would not come to the email. Then, due to other obligations, I would forget to follow up. When I would ask again, the owner would say," The office didnt send it? I will have to remind them". That was never done. The owner was my main contact because the person that I met in the office on my first day that I went to visit, the Director of Nurses, was not available. The following times that I asked, she was on vacation and then no longer working there. I was told by the owner that she added my name to many patients without the owners knowledge or permission and did not know why this was done and was apologetic but assures me that she did not know this was happening and did not approve this. She also explained that it was not a big deal for Vesper hospice because they were not able to bill for these patients anyway and there were only a few patients on service. I have had the same or with BC hospice in that I do not know the extent of the use of my name since I could not get access of the Hospice MD and had to rely on the word of the owner. However, the information was often inconsistent or incomplete or both . I was given a letter of termination of services effective March 19, 2023. I prepared my own letter, but it was not submitted, as I received news of the termination letter".

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows: The hospice agency failed to ensure the recertification of terminal illness for nine of ten sampled patients, (Patients 2, 3, 4, 5, 6, 7, 8, 9 and 10) were signed by the medical director and/or physician designee. This deficient practice had the potential that recertified patients clinical information were unverified and did not meet the criteria to continue hospice care and services which can affect the necessary care needed to maintain the quality of life of the affected patients. (Refer to L668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on interview and record review, the hospice agency failed to ensure the recertification of terminal illness for nine of ten sampled patients, (Patients 2, 3, 4, 5, 6, 7, 8, 9 and 10) were signed by the medical director and/or physician designee. This deficient practice had the potential that recertified patients clinical information were unverified and did not meet the criteria to continue hospice care and services which can affect the necessary care needed to maintain the quality of life of the affected patients. --- 1.A review of Patient 2s Patient Information Sheet indicated a Start of Care (SOC) date of 7/15/2022, with a primary diagnosis of Heart disease, unspecified (a heart disease describes a range of conditions that affects the heart and how it operates). A review of Patient 2s Certification of Terminal illness (CTI) # 1s Certification of Terminal Illness (CTI) for the first 90 days from 7/15/2022 to 10/12/2022, the Certifying physicians summary indicated, ";per the IDT (Interdisciplinary group, team who is responsible for the holistic care of the hospice beneficiary) discussion, and recommendations, the patient determined appropriate for hospice services". Review of patient 2s Recertification Statement for the Second 90-day period of 10/13/2022 to 1/10/2023, indicated the registered nurses prognosis summary and the physician's Face-to face and narrative summary were blank. 2. A review of patient 3s Patient Information Sheet indicated an SOC date of 10/26/2022, with a primary diagnosis of hypertensive heart disease without heart failure (a long term condition that develops over many years with people who have high blood pressure which result in a group of heart problems). A review of Patient 3s Certification of Terminal illness (CTI) # 1s Certification of Terminal Illness (CTI) for the first 90 days from 10/26/2022 to 1/23/2022, the Certifying physicians summary indicated, ";per the IDT discussion, and recommendations, the patient determined appropriate for hospice services with the registered nurses prognosis summary". The physicians Face-to face and narrative summary were blank. 3. A review of patient 4s Certification of Terminal illness (CTI) # 1s Certification of Terminal Illness (CTI) for the first 90 days from 6/8/2022 to 9/5/2022, the Certifying physicians summary indicated, ";per the IDT discussion and recommendations, the patient determined appropriate for hospice services". A review of patient 4s Certification Terminal Illness (CTI) #2 for the Second 90-day period of 9/6/2022 to 12/4/2023, indicated the registered nurses prognosis summary and the physician's Face-to face and narrative summary were blank. A review of patient 4s Re-certification Statement for the next 60 day period of 12/5/2022 to 2/2/2023, indicated the registered nurses prognosis and the physicians face-to-face and narrative summary were blank. 4. A review of patient 5s Certification of Terminal illness (CTI) # 1s Certification of Terminal Illness (CTI) for the first 90 days from 6/8/2022 to 9/5/2022, the Certifying physician's summary indicated, ";per the IDT discussion, and recommendations, the patient determined appropriate for hospice services". Review of patient 5s Recertification Statement for the Second 90-day period of 9/6/2022 to 12/4/2022, indicated the registered nurses prognosis summary and the physicians Face-to face and narrative summary were blank. A review of patient 5s Re-certification Statement for the next 60-day period of 12/5/2022 to 2/2/2023, indicated the registered nurses prognosis summary and the physicians face-to-face and narrative summary were blank. All Certifications of terminal illness were electronically signed by he former medical director (FMD). During a telephone interview with the former medical director on 3/30/2023, at 3:30 p.m., she stated that she was informed by the owner of the hospice that she was the medical director and thought the agency was a Home Health Agency (HHA). The FMD stated she has never seen the patients, had interdisciplinary groups with this agency, and reviewed any charts or signed any documentation with this agency. During an interview with the owner of the hospice agency, she stated she did not know what happened. a. A review of Patient 6s Patient Information Sheet indicated a Start of Care (SOC) of 6/9/2022 with a primary diagnosis of hypertensive heart disease (high blood pressure resulting in heart disease). A review of Patient 6s Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less), Certification #3: Re-Certification Statement for Next 60-day period from 12/6/2022 to 2/3/2023 indicated Patient 8s primary diagnosis was hypertensive heart disease. During the review, the CTI had the former Medical Directors name, however, it was not signed. The signature box is blank. During a phone interview on 3/30/2023 at 10:20 am, Patient 6s daughter stated, she did not know what hospice company enrolled her mom into. Sometime last year, someone came and said they would get a free ensure box if they signed for hospice and so, she signed. Patient 6s daughter stated she thought having hospice was to get ensure and after she got it, she didnt need it anymore. Patient 6s daughter stated she didnt know whats the hospice agency name was, and nothing was explained to them. Patient 6s daughter stated Patient 6 does not have a terminal illness or heart disease and that she was referred by the neighbor and thought hospice was a benefit to get free supplies like ensure drinks. Patient 6s daughter further stated Patient 6 never saw a doctor, nurse, or social worker. b. A review of Patient 7s Patient Information Sheet indicated a Start of Care (SOC) of 7/23/2022 with a primary diagnosis of chronic ischemic heart disease (long term disease of the heart caused by narrowing heart arteries that supply blood to the heart muscle). A review of Patient 7s CTI, Certification #3: Re-Certification Statement for Next 60-day period from 1/19/2022 to 3/19/2023 indicated Patient 7s primary diagnosis was chronic ischemic heart disease. The CTI lists former Medical Directors name, however, it was not signed. The signature box is blank. During a phone interview on 3/30/2023 at 11:25 a.m., Patient 7s sister stated she did not know what company enrolled her sister into hospice. Patient 7s sister stated Patient 7 lives in Hawaii and had lived there since March 2022. Patient 7s sister stated Patient 7 goes to Delano to visit sometimes and goes back to Hawaii and stated she remember something about a hospice last year where the agency was advertising hospice as a benefit to get free ensure and they signed up to get the supplies and that was it. Patient 7s sister stated she does not know what hospice is and that one person came once and no one else came after that. Patient 7s sister said no doctor, nurse or social worker ever visited. During an interview on 3/30/2023 at 2:35 p.m., with owner, she stated she was not aware Patient 8 had a consent from BC Hospice. She stated she didnt know what the field staffs were doing and none of the staff that worked prior to March 2023 are working for the agency. She stated the staff before were hiding things from her and she was not aware what happened in the field and what were uploaded in the computer. c. A review of Patient 8s Patient Information Sheet indicated a Start of Care (SOC) of 6/9/2022 with a primary diagnosis of heart disease. A review of Patient 8s CTI, Certification #3: Re-Certification Statement for next 60-day period from 12/6/2022 to 2/3/2023 indicated Patient 8s primary diagnosis was heart disease. The CTI lists Former Medical Directors name but it was not signed. The signature box is blank. During a phone interview on 3/30/2023 at 10:35 a.m., Patient 8 stated, she did not know what company enrolled her into hospice. She stated she believed it was sometime last year someone came and said they would get a free ensure box if they signed up for hospice and so she signed. Patient 8 stated she thought having hospice was to get ensure and after she got it, she didnt need it anymore. Patient 8 stated she didnt know what hospice was, she stated she does not have a terminal illness or heart disease and she still works. Patient 8s stated she was referred by the neighbor and thought hospice was a benefit to get free supplies like ensure drinks. Patient 8 stated she never saw a doctor, nurse, or social worker. she stated no one ever came to see them. Patient 8 stated she does not want to lose her job. d. A review of Patient 9s Patient Information Sheet indicated Start of Care (SOC) date of 10/18/22, with a primary diagnosis acute ischemic heart disease, (heart problems caused by narrowing heart arteries that supply blood to the heart muscle). A telephone call was placed to Patient 9, but phone numbers were not working. A review of Patient 9s CTI, Certification #2: Re-Certification Statement for next 90-day period from 1/3/2023 to 4/2/2023 indicated Patient 9s primary diagnosis was chronic ischemic heart disease. The CTI listed former Medical Directors name, however, it was not signed. The signature box is blank. e. A review of Patient 10s Patient Information sheet indicated a SOC date of 10/1/22, with a primary diagnosis of heart disease unspecified. The phone number listed for Patient 10 did not work. A review of Patient 10s CTI, Certification #2: Re-Certification Statement for next 90-day period from 1/3/2022 to 4/2/2023 indicated Patient 7s primary diagnosis was chronic heart disease. The CTI lists Former Medical Directors name but it was not signed. The signature box is blank. During an interview on 3/30/2023 at 4:20 p.m., the former medical director (FMD) stated she never certified any patients for this agency and was unaware on any of the agency patients. FMD stated she did not even know this agency was a hospice when she started in June 2022, she thought it was a home health. FMD stated she never wrote any orders for any patients and never participated in any Interdisciplinary group meetings (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities). FMD stated she never saw any patients for this agency and cannot state anything regarding any patients since she was told there were no patients during the time she was employed with this agency. FMD stated she did not sign any CTIs for any patients, she did not write any orders for any patients, and she did not participate in any IDG meetings. FMD also stated she did not have any access to the electronic medical records since she was never granted access even though she repeatedly asked for it. FMD stated she will send signed affidavit of the facts she is stating. A review of FMDs signed affidavit of truth dated 3/31/2023, indicated, ";I have just been informed by officials that my name, and was being used for Vesper Hospice with names of patient that I am not familiar with, and that there were CTIs completed in my name, which I never knew about until today. I have never conducted any IDT meetings, admitted or discharged patients or signed any orders or ordered any medications or DME supplies. It was my understanding upon being hired by the owner that Vesper was a home health and not hospice. It was not until many months later that I found out that Vesper was a hospice. I started asking for access to Hospice MD and calling for IDT meetings. I was told that the meetings would be scheduled when all others could find a good time butt that was never done. In addition, I was told I would be given access to Hospice MD. However, the access would not come to the email. Then, due to other obligations, I would forget to follow up. When I would ask again, the owner would say," The office didnt send it? I will have to remind them". That was never done. The owner was my main contact because the person that I met in the office on my first day that I went to visit, the Director of Nurses, was not available. The following times that I asked, she was on vacation and then no longer working there. I was told by the owner that she added my name to many patients without the owners knowledge or permission and did not know why this was done and was apologetic but assures me that she did not know this was happening and did not approve this. She also explained that it was not a big deal for Vesper hospice because they were not able to bill for these patients anyway and there were only a few patients on service. I have had the same or with BC hospice in that I do not know the extent of the use of my name since I could not get access the Hospice MD and had to rely on the word of the owner. However, the information was often inconsistent or incomplete or both. I was given a letter of termination of services effective March 19, 2023. I prepared my own letter, but it was not submitted, as I received news of the termination letter".

Based on interview and record review, the hospice agency (HA) failed to maintain patient clinical records in accordance to the Federal guidelines as evidenced by the following. 1. The Hospice Agency (HA) failed to ensure the Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less) for 5 of ten sampled patients, (Patients 6, 7, 8, 9, and Patient 10) was completed and signed. This deficient practice resulted in the failure to document patient informations and ensure authenticity of the patients clinical records. (Refer L679) 2. The hospice agency (HA) failed to ensure a complete discharge summary was created upon discharge for one of five sampled patients, Patient 10. This deficient practice had the potential to result in miscommunication and poor hand off of patient's medical status and can affect the care and services needed in the continuation of care for the affected patient. (Refer to L684) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for clinical records to ensure the highest quality of patient care are provided to the patients certified to receive hospice services.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less) for 5 of ten sampled patients, (Patients 6, 7, 8, 9, and Patient 10) was completed and signed. This deficient practice resulted in the failure to document accurate patient informations and ensure authenticity of the patients clinical records. --- a. A review of Patient 6s Patient Information Sheet indicated a Start of Care (SOC) of 6/9/2022 with a primary diagnosis of hypertensive heart disease (high blood pressure resulting in heart disease). A review of Patient 6s Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less), Certification #3: Re-Certification Statement for Next 60-day period from 12/6/2022 to 2/3/2023 indicated Patient 8s primary diagnosis was hypertensive heart disease. During the review, the CTI had the former Medical Directors name, however, it was not signed. The signature box is blank. During a phone interview on 3/30/2023 at 10:20 am, Patient 6s daughter stated, she did not know what hospice company enrolled her mom into. Sometime last year, someone came and said they would get a free ensure box if they signed for hospice and so, she signed. Patient 6s daughter stated she thought having hospice was to get ensure and after she got it, she didnt need it anymore. Patient 6s daughter stated she didnt know whats the hospice agency name was, and nothing was explained to them. Patient 6s daughter stated Patient 6 does not have a terminal illness or heart disease and that she was referred by the neighbor and thought hospice was a benefit to get free supplies like ensure drinks. Patient 6s daughter further stated Patient 6 never saw a doctor, nurse, or social worker. b. A review of Patient 7s Patient Information Sheet indicated a Start of Care (SOC) of 7/23/2022 with a primary diagnosis of chronic ischemic heart disease (long term disease of the heart caused by narrowing heart arteries that supply blood to the heart muscle). A review of Patient 7s CTI, Certification #3: Re-Certification Statement for Next 60-day period from 1/19/2022 to 3/19/2023 indicated Patient 7s primary diagnosis was chronic ischemic heart disease. The CTI lists former Medical Directors name, however, it was not signed. The signature box is blank. During a phone interview on 3/30/2023 at 11:25 a.m., Patient 7s sister stated she did not know what company enrolled her sister into hospice. Patient 7s sister stated Patient 7 lives in Hawaii and had lived there since March 2022. Patient 7s sister stated Patient 7 goes to Delano to visit sometimes and goes back to Hawaii and stated she remember something about a hospice last year where the agency was advertising hospice as a benefit to get free ensure and they signed up to get the supplies and that was it. Patient 7s sister stated she does not know what hospice is and that one person came once and no one else came after that. Patient 7s sister said no doctor, nurse or social worker ever visited. During an interview on 3/30/2023 at 2:35 p.m., with owner, she stated she was not aware Patient 8 had a consent from BC Hospice. She stated she didnt know what the field staffs were doing and none of the staff that worked prior to March 2023 are working for the agency. She stated the staff before were hiding things from her and she was not aware what happened in the field and what were uploaded in the computer. c. A review of Patient 8s Patient Information Sheet indicated a Start of Care (SOC) of 6/9/2022 with a primary diagnosis of heart disease. A review of Patient 8s CTI, Certification #3: Re-Certification Statement for next 60-day period from 12/6/2022 to 2/3/2023 indicated Patient 8s primary diagnosis was heart disease. The CTI lists Former Medical Directors name but it was not signed. The signature box is blank. During a phone interview on 3/30/2023 at 10:35 a.m., Patient 8 stated, she did not know what company enrolled her into hospice. She stated she believed it was sometime last year someone came and said they would get a free ensure box if they signed up for hospice and so she signed. Patient 8 stated she thought having hospice was to get ensure and after she got it, she didnt need it anymore. Patient 8 stated she didnt know what hospice was, she stated she does not have a terminal illness or heart disease and she still works. Patient 8s stated she was referred by the neighbor and thought hospice was a benefit to get free supplies like ensure drinks. Patient 8 stated she never saw a doctor, nurse, or social worker. she stated no one ever came to see them. Patient 8 stated she does not want to lose her job. d. A review of Patient 9s Patient Information Sheet indicated Start of Care (SOC) date of 10/18/22, with a primary diagnosis acute ischemic heart disease, (heart problems caused by narrowing heart arteries that supply blood to the heart muscle). A telephone call was placed to Patient 9, but phone numbers were not working. A review of Patient 9s CTI, Certification #2: Re-Certification Statement for next 90-day period from 1/3/2023 to 4/2/2023 indicated Patient 9s primary diagnosis was chronic ischemic heart disease. The CTI listed former Medical Directors name, however, it was not signed. The signature box is blank. e. A review of Patient 10s Patient Information sheet indicated a SOC date of 10/1/22, with a primary diagnosis of heart disease unspecified. The phone number listed for Patient 10 did not work. A review of Patient 10s CTI, Certification #2: Re-Certification Statement for next 90-day period from 1/3/2022 to 4/2/2023 indicated Patient 7s primary diagnosis was chronic heart disease. The CTI lists Former Medical Directors name but it was not signed. The signature box is blank. During an interview on 3/30/2023 at 4:20 p.m., the former medical director (FMD) stated she never certified any patients for this agency and was unaware on any of the agency patients. FMD stated she did not even know this agency was a hospice when she started in June 2022, she thought it was a home health. FMD stated she never wrote any orders for any patients and never participated in any Interdisciplinary group meetings (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities). FMD stated she never saw any patients for this agency and cannot state anything regarding any patients since she was told there were no patients during the time she was employed with this agency. FMD stated she did not sign any CTIs for any patients, she did not write any orders for any patients, and she did not participate in any IDG meetings. FMD also stated she did not have any access to the electronic medical records since she was never granted access even though she repeatedly asked for it. FMD stated she will send signed affidavit of the facts she is stating. A review of FMDs signed affidavit of truth dated 3/31/2023, indicated, ";I have just been informed by officials that my name, and was being used for Vesper Hospice with names of patient that I am not familiar with, and that there were CTIs completed in my name, which I never knew about until today. I have never conducted any IDT meetings, admitted or discharged patients or signed any orders or ordered any medications or DME supplies. It was my understanding upon being hired by the owner that Vesper was a home health and not hospice. It was not until many months later that I found out that Vesper was a hospice. I started asking for access to Hospice MD and calling for IDT meetings. I was told that the meetings would be scheduled when all others could find a good time butt that was never done. In addition, I was told I would be given access to Hospice MD. However, the access would not come to the email. Then, due to other obligations, I would forget to follow up. When I would ask again, the owner would say," The office didnt send it? I will have to remind them". That was never done. The owner was my main contact because the person that I met in the office on my first day that I went to visit, the Director of Nurses, was not available. The following times that I asked, she was on vacation and then no longer working there. I was told by the owner that she added my name to many patients without the owners knowledge or permission and did not know why this was done and was apologetic but assures me that she did not know this was happening and did not approve this. She also explained that it was not a big deal for Vesper hospice because they were not able to bill for these patients anyway and there were only a few patients on service. I have had the same or with BC hospice in that I do not know the extent of the use of my name since I could not get access the Hospice MD and had to rely on the word of the owner. However, the information was often inconsistent or incomplete or both. I was given a letter of termination of services effective March 19, 2023. I prepared my own letter, but it was not submitted, as I received news of the termination letter".

Based on interview and record review, the hospice agency (HA) failed to ensure a complete discharge summary was created upon discharge for one of five sampled patients, Patient 10. This deficient practice had the potential to result in miscommunication and poor hand off of patient's medical status, and can affect the care and services needed in the continuation of care for the affected patient. --- A review of Patient 10s Patient Information sheet indicated a Start of Care (SOC) date of 10/1/22, with a primary diagnosis of heart disease unspecified. The phone number listed for Patient 10 was not a working number. A review of Patient 10s Discharge summary indicated an End of Care (EOC) date of 11/18/2022, and the reason for discharge indicated that Patient 10 moved out of the area. The nurses narrative note was empty. A review of Patient 10s electronic medical record (EMR) did not indicate any (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) notes or Discharge Plan. During an interview on 3/30/2023 at 4:25 p.m., the former Medical Director stated she had never discharged or admitted any patients here in this agency.