Every finding on record at Visiting Angels of La Hospice Inc

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Conditions of Participation (the terms healthcare organizations must meet to participate in federally funded healthcare programs) regarding Patients Rights was met as follows: 1.  The HA failed to provide two of fourteen sampled patients (Patient 2 and Patient 8) information regarding their rights as a hospice patient in a language that would be understood and preferred by the patient. This failure resulted in the patient not fully understanding or knowing their rights as a hospice patient. (Refer to L502) 2.  The HA failed to inform four of fourteen sampled patients (Patient 1, Patient 2, Patient 9, and Patient 10) about the services the HA provided and the limitations of these services. This deficient practice resulted in the patients to not be informed about the purpose of the hospice care services. (Refer to L519) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated Federal compliance for Patients Rights to ensure their rights are not violated and that they receive the highest quality of hospice care. --- .

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 provide two of fourteen sampled patients (Patient 2 and Patient 8), information regarding their rights as a hospice (a type of healthcare that focuses on the relief of a terminally ill patients distress and symptoms) patient in a language that would be understood and preferred by the patient. The contents in Patient 2s and Patient 8s hospice folder, which included patient consent forms and the ";Patient/Family Bill of Rights" were written in English. Patient 2s and Patient 8s preferred language was Spanish. This failure resulted in the patients (Patient 2 and Patient 8) not fully understanding or knowing their rights as a hospice patient. --- During a review of Patient 8's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 8 on 4/11/2024, with a diagnosis including atherosclerotic heart disease of native coronary artery without angina pectoris (the buildup of fats, cholesterol and other substances in and on the artery walls). During a joint home visit, on 7/24/2024 at 2:45 p.m. with the licensed vocational nurse (LVN 1) at Patient 8s residence, Patient 8 was found sitting on his computer chair using his computer, awake, alert, oriented x 3 (to person, place, and time), and ambulatory with steady gait not using any assistive device. Patient 8 was observed having normal breathing, no shortness of breath and denies any pain. Patient stated nurses visit him once a week. Patient 8 stated he does go to the market alone and is still able to drive. Patient 8 able to walk us out from his house at the back to the front gate without assistive device and no shortness of breath. Patient also point out the white car he is driving. During a concurrent interview and record review with Patient 8, Patient 8's hospice folder provided by the hospice agency located at the patients home was reviewed. Patient 8 stated the contents inside the hospice folder which includes patient consent forms were all in English. Patient 8 stated his preferred language is Spanish, and he had difficulty reading and understanding the forms inside the hospice folder and will understand everything better if it was in Spanish. Findings: a. During a review of Patient 2s admission record indicated a start of care (SOC) date of 4/11/2024 with a terminal diagnosis of atherosclerotic heart disease (a build up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of the native coronary artery without angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 7/10/2024, indicated the frequency of visits of licensed vocational nurse (LVN) was one visit per week plus one prn (pro re nata, which means as needed) visits for changes in condition. Te spiritual counselor (SC) and social worker (MSW) was to visit every certification period plus one prn visit. The Hospice aide and volunteer services were declined. During a joint home visit, on 7/24/2024 at 11:30 a.m. with the licensed vocational nurse (LVN 1) at Patient 2s residence, Patient 2 was observed awake, alert, oriented x 3 (to person, place, and time), and was ambulatory. During a concurrent interview and record review with Patient 2, Patient 2's hospice folder provided by the HA located at the patients home was reviewed. Patient 2 stated the contents inside the hospice folder which included patient consent forms and a form titled, ";Patient/Family Bill of Rights" was all in English. Patient 2 stated her preferred language was Spanish, and she had difficulty reading and understanding the forms inside her hospice folder. During an interview, on 7/25/2024 at 1:25 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated the hospice forms including the consent and patients Bill of Rights provided to the patients should be in the language the patient understands. DPCS stated and acknowledged the finding. During a review of the agencys undated policy and procedure titled, ";Patient Bill of Rights/Responsibilities", indicated each patient will be an active, informed participant in his/her plan of care. The patient Bill of Rights/Responsibilities will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand.

Based on observation, interviews, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to inform four of fourteen sampled patients (Patient 1, Patient 2, Patient 9, and Patient 10) about the services the HA provided and the limitations of these services. This deficient practice resulted in the patients (Patient 1, Patient 2, Patient 9, and Patient 10) to not be informed about the purpose of the hospice care (a specialized care that provides comfort and emotional, social, and spiritual support for people nearing the end of life) services. --- C. During a review of Patient 9's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 9 on 7/11/2024,with a diagnosis including chronic obstructive pulmonary disease ( lung disease causing restricted airflow and breathing problems) During a review of Patient 9's POC Summary form indicated an order, dated 7/11/2024, for the skilled nurse frequency of visits registered nurse (RN) to one visit per week and one visit as needed. During an interview on 7/24/24 at 4 p.m., Patient 9 stated she did not have an idea what hospice care is about. Her primary doctor did not tell her she had six months or less to live. She does not use oxygen but now they just delivered oxygen but she never use it yet. She found out about the hospice through friends. D. During a review of Patient 10's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 10 on 7/11/2024, with a diagnosis including emphysema (lung disease affecting the tiny air sacs of the lungs) During a review of Patient 10's POC Summary form, the POC indicated an order, dated 7/11/2024, for the skilled nurse frequency of visits to be conducted one per week and one visit as needed for changes in condition. The POC indicated the registered nurse (RN) was to conduct an initial evaluation, then every 30 days the License Vocational Nurse to conduct a supervisory visit and scheduled recertification for ongoing assessment and comfort management. THe POC further indicated a Spiritual counselor every certification period and as needed for support and counseling. The social worker, and hospice aide services were offered but declined. During an interview on 7/24/24 at 9:42 a.m., Patient 10 stated he did not have an idea what hospice care was about. His primary doctor did not tell him he had six months or less to live. He denied having a terminal illness, and stated he only had fibrosis, and can still drive anywhere even to Vegas. Patient 10 found out about the Hospice agency through a gentleman he met in the market, stating they can help by having a nurse visit to check his blood pressure, provide diapers and a wheelchair. Findings: a. During a review of Patient 1s admission record, the admission record indicated a start of care (SOC) date of 2/15/2024 with a terminal diagnosis of atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of the native coronary artery without angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 7/10/2024, indicated the frequency of visits of the licensed vocational nurse (LVN) was one visit per week plus one prn (pro re nata, which means as needed) visits for changes in condition,. The spiritual counselor (SC) and social worker (MSW)was to visit every certification period plus one prn visit, The Hospice aide and volunteer services were declined. During a joint home visit, on 7/24/2024 at 12:40 p.m. with the licensed vocational nurse (LVN 1) at Patient 1s residence, Patient 1 was found sitting inside his car, awake, alert, oriented x 3 (to person, place, and time), and was ambulatory. During an interview, on 7/24/2024 at 1:05 p.m. with Patient 1, Patient 1 stated his understanding about hospice care is that it was for those people like him who are old and lives alone. Patient 1 stated he was not dying nor had a terminal illness, and no doctor or nurses from the agency explained to him that hospice care was for those patients who have six months or less to live. b. During a review of Patient 2s admission record, the admission record indicated a start of care date of 4/11/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 2's POC/IDG form, dated 7/10/2024, the form indicated the frequency of visits of the licensed vocational nurse visit was one visit per week plus one prn visit for changes in condition. The spiritual counselor and social worker was to visit every certification period plus one prn visit. The Hospice aide and volunteer services were declined. During a joint home visit, on 7/24/2024 at 11:30 a.m. with the licensed vocational nurse (LVN 1) at Patient 2s residence, Patient 2 was observed awake, alert, oriented x 3 (to person, place, and time), and was ambulatory. During an interview, on 7/24/2024 at 12:05 p.m. with Patient 2, Patient 2 stated her understanding of hospice care was being visited by a nurse every week getting her medications. Patient 2 stated no doctors or nurses told her that she had a terminal illness or had six (6) months or less to live. Patient 2 stated she was not dying, that she was referred to the hospice agency by a friend that she met in the park near her house. During a review of the agencys undated policy and procedure titled, ";Patient Bill of Rights/Responsibilities", the Patient Bill of Rights indicated each patient will be an active, informed participant in his/her plan of care. The patient Bill of Rights/Responsibilities statement defines the right of the patient to be informed in advance of service about the care to be furnished, the organizations scope of services and services under the Medicare Hospice Benefit and any limitations on these services.

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Conditions of Participations regarding Initial and Comprehensive Assessments of Patients was met as follows: 1. The HA failed to conduct an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care (a specialized care that provides comfort and emotional, social, and spiritual support for people nearing the end of life) and services related to hospice eligibility and management of terminal illness for six of fourteen sample patients (Patient 1, Patient 2, Patient 4, Patient 8, Patient 9, and Patient 10). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential to result in the patients(Patient 1, Patient 2, Patient 4, Patient 8, Patient 9, and Patient 10) to not receive appropriate healthcare services that could affect their quality of life. (Refer to L 524) 2. The HA failed to conduct an initial bereavement (the experience of losing someone important to us) assessment to provide bereavement counseling in accordance with the patient/family/caregivers needs for ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This deficient practice had the potential to impact a family members' abilities to cope with the patient's' death. (Refer to L531) 3. The HA failed to ensure the interdisciplinary group (IDG - various hospice professionals [Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor], were all working together to create a comprehensive and customized hospice plan of care for each patient) met to discuss and update eight out of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, and Patient 11) comprehensive assessments at least every 15 days. This deficient practice had the potential to result in the patients (Patient 1, Patient 2, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, and Patient11) not meeting their needs and their changes of condition not identified and addressed. (Refer to L 533) . The cumulative effect of these systemic practices resulted in the failure of the Hospice Agency to deliver mandated compliance with the Federal regulations for Initial and Comprehensive Assessment of Patients to ensure provision of the highest quality of care to patients certified to receive the hospice benefits. --- Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Conditions of Participations regarding Initial and Comprehensive Assessments of Patients was met as follows: 1. The HA failed to conduct an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care (a specialized care that provides comfort and emotional, social, and spiritual support for people nearing the end of life) and services related to hospice eligibility and management of terminal illness for six of fourteen sample patients (Patient 1, Patient 2, Patient 4, Patient 8, Patient 9, and Patient 10). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential to result in the patients(Patient 1, Patient 2, Patient 4, Patient 8, Patient 9, and Patient 10) to not receive appropriate healthcare services that could affect their quality of life. (Refer to L 524) 2. The HA failed to conduct an initial bereavement (the experience of losing someone important to us) assessment to provide bereavement counseling in accordance with the patient/family/caregivers needs for ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This deficient practice had the potential to impact a family members' abilities to cope with the patient's' death. (Refer to L531) 3. The HA failed to ensure the interdisciplinary group (IDG - various hospice professionals [Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor], were all working together to create a comprehensive and customized hospice plan of care for each patient) met to discuss and update eight out of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, and Patient 11) comprehensive assessments at least every 15 days. This deficient practice had the potential to result in the patients (Patient 1, Patient 2, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, and Patient11) not meeting their needs and their changes of condition not identified and addressed. (Refer to L 533) . The cumulative effect of these systemic practices resulted in the failure of the Hospice Agency to deliver mandated compliance with the Federal regulations for Initial and Comprehensive Assessment of Patients to ensure provision of the highest quality of care to patients certified to receive the hospice benefits.

Based on observation, interview, and record review, the hospice agency (HA,agency providing care to terminally ill patients who have six months or less to live) failed to conduct 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 identified the patients needs for hospice care(a specialized care that provides comfort and emotional, social, and spiritual support for people nearing the end of life and services related to eligibility and management of the terminal illness, for six of fourteen sampled patients, (Patient 1, Patient 2, Patient 4, Patient 8, Patient 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. --- D. During a review of Patient 8's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 8 on 4/11/2024, with a diagnosis including atherosclerotic heart disease of native coronary artery without angina pectoris (the buildup of fats, cholesterol and other substances in and on the artery walls). During a review of Patient 8s Recertification Comprehensive Assessment (Re-Cert Assessment), dated 7/9/2024 for the certification period from 7/10/2024 to 10/7/2024, indicated Patient 8 had heart disease. The assessment indicated Patient 8 was awake, alert, and oriented x 3 (person, place, and time), had no cardiac-related pain, had normal respiration (breathing), had mild shortness of breath (SOB) on moderate exertion relieved by rest, and no blood pressure elevation noted. The Re-Cert Assessment indicated Patient 1 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure. The assessment also indicated Patient 8 was dependent on cane, needed maximum assistance for ambulation, toileting, transfer, and bathing, and needed moderate assistance for dressing and feeding. During a joint home visit, on 7/24/2024 at 2:45 p.m. with the Licensed vocational nurse (LVN 1) at Patient 8s residence, Patient 8 was found sitting on his computer chair using his computer, awake, alert, oriented x 3 (to person, place, and time), and ambulatory with steady gait not using any assistive device. Patient 8 was observed having normal breathing, no shortness of breath and denied any pain. Patient 8 was able to walk us out from his house at the back to the front gate without an assistive device and no shortness of breath. Patient 8 also pointed out the white car he drives. E. During a review of Patient 9's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 9 on 7/11/2024, with a diagnosis including chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems). A review of Patient 9's Physicians Certification for Hospice Benefit, dated 7/11/24 to 10/8/2024, benefit period number 1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 9 had a life expectancy of six months or less if the terminal illness runs its normal course. Patient 9's Physicians Certification for Hospice Benefit has no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During an interview on 7/24/24 at 4 p.m. with Patient 9, Patient 9 stated the primary doctor did not tell her she had six months or less to live. Se further stated "No doctor, chaplain or social worker has talked to her since her admission to hospice. F. During a review of Patient 10's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 10 on 7/11/2024, with a diagnosis including Emphysema (lung disease affecting the tiny air sacs of the lungs). A review of Patient 10s Physicians Certification for Hospice Benefit, dated 7/11/24 to 10/8/2024, benefit period number 1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 10 had a life expectancy of six months or less if the terminal illness runs its normal course. Patient 9's Physicians Certification for Hospice Benefit has no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During an interview on 7/24/24 at 9:42 p.m. with Patient 10, stated that his primary doctor did not say that he has 6 months or less to live. He stated that he still drives to the market and even to Vegas. Since admission of hospice, he still not talked to any doctor. Findings: a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 2/15/2024 with a terminal diagnosis of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery without angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 1s Recertification Comprehensive Assessment (Re-Cert Assessment), dated 5/11/2024 for certification period from 5/15/2024 to 8/12/2024, indicated Patient 1 had heart disease. The assessment indicated Patient 1 was awake, alert, and oriented x 3 (to person, place, and time), had no cardiac-related pain, had normal respiration (breathing), had mild shortness of breath (SOB) on moderate exertion relieved by rest, and no blood pressure elevation noted. The Re-Cert Assessment indicated Patient 1 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure. The assessment also indicated Patient 1 was dependent on walker or cane, needed maximum assistance for ambulation, toileting, transfer, and bathing, and needed moderate assistance for dressing and feeding. During a joint home visit, on 7/24/2024 at 12:40 p.m. with the licensed vocational nurse (LVN 1) at Patient 1s residence, Patient 1 was found sitting inside his car, awake, alert, oriented x 3 (to person, place, and time), and ambulatory with steady gait not using any assistive device. Patient 1 was observed having normal breathing, not fatigue, no SOB, and no pain. During an interview, on 7/24/2024 at 1:05 p.m. with Patient 1, Patient 1 stated his understanding of what hospice care was for those people like him who are old and lives alone. Patient 1 stated he was not dying nor had terminal illness, and no doctor or nurses from the agency explained to him that hospice care was for those patients who have 6 months or less to live. When asked what he was doing inside the car, Patient 1 stated, ";Im trying to fix it. I am going to sell the car but has multiple issues." Patient 1 further stated he was independent with all his care and does not need any assistance, still drives, and takes care of 10 cats inside his house. During a concurrent interview and record review, on 7/25/24 at 1:25 p.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 1s form titled, ";LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) Hospice Eligibility Determination, dated 5/14/2024. DPCS stated the agency used LCD assessment as basis for determining patients hospice eligibility. DPCS stated Patient 1 met the criteria for NYHA Class IV level and was hospice appropriate based on the LCD assessment but was unable to provide documented evidence Patient 1 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom occurred at rest. b. During a review of Patient 2s admission record indicated a start of care date of 4/11/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 2s Re-Cert Assessment, dated 7/9/2024 for certification period from 7/10/2024 to 10/7/2024, indicated Patient 2 had heart disease. The assessment indicated Patient 2 was awake, alert, and oriented x 3 (to person, place, and time), had no cardiac-related pain, had normal breathing, regular pulse rate (heart rate), and had mild shortness of breath with mild exertion. The Re-Cert Assessment indicated Patient 2 was on NYHA IV stage of heart failure and met the criteria for LCD eligibility. The assessment also indicated Patient 2 was dependent on walker or cane, needed maximum assistance for ambulation, toileting, transfer, and bathing, and needed moderate assistance for dressing and feeding. During a joint home visit, on 7/24/2024 at 11:30 a.m. with the licensed vocational nurse (LVN 1) at Patient 2s residence, Patient 2 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device. Patient 2 was observed having normal breathing, not fatigue, no SOB and no pain. During an interview, on 7/24/2024 at 12:05 p.m. with Patient 2, Patient 2 stated her understanding of hospice care was being visited by a nurse every week and getting her medications. Patient 2 stated no doctors or nurses told her that she had terminal illness or have 6 months or less to live. Patient 2 stated she was not dying, that she was referred to the hospice agency by a friend that she met in the park near her house. Patient 2 further stated she was independent with her ADL (activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating) care and walked outside the house regularly. During a concurrent interview and record review, on 7/25/24 at 1:25 p.m. with the DPCS, the DPCS reviewed Patient 2s form titled, ";LCD Hospice Eligibility Determination", dated 7/9/2024. DPCS stated the agency used LCD assessment as basis for determining patients hospice eligibility. DPCS stated Patient 2 met the criteria for NYHA Class IV level and was hospice appropriate based on the LCD assessment but was unable to provide documented evidence Patient 2 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom occurred at rest. c. During a review of Patient 4s admission record indicated a start of care date of 4/25/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 4s Re-Cert Assessment, dated 7/20/2024 for certification period from 7/24/2024 to 10/21/2024, indicated Patient 4 had heart disease. The assessment indicated Patient 4 was awake, alert, and oriented x 3 (to person, place, and time), had no cardiac-related pain, had normal breathing, regular heart rate, and had mild shortness of breath with mild exertion. The Re-Cert Assessment indicated Patient 4 was on NYHA IV stage of heart failure and met the criteria for LCD eligibility. The assessment also indicated Patient 4 was dependent on walker or cane, needed maximum assistance for ambulation, toileting, transfer, and bathing, and needed moderate assistance for dressing and feeding. During a telephone interview, on 7/24/2024 at 3:55 p.m., with Patient 4, Patient 4 stated he lives alone, was doing fine, independent with ADLs, does not have cardiac (relating to the heart) symptoms (chest pain, fatigue, SOB) when at rest, and still drives. During a concurrent interview and record review, on 7/25/24 at 1:25 p.m. with the DPCS, the DPCS reviewed Patient 4s form titled, ";LCD Hospice Eligibility Determination", dated 7/20/2024. DPCS stated the agency used LCD assessment as basis for determining patients hospice eligibility. DPCS stated Patient 4 met the criteria for NYHA Class IV level and was hospice appropriate based on the LCD assessment but was unable to provide documented evidence Patient 4 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom occurred at rest. During a review of the agencys policy and procedure titled "Admission Criteria and Process", revised April 2016, indicated Visiting Angels of LA Hospice, Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). During a review of the agencys policy and procedure titled "Comprehensive Assessment", dated 11/17/2022, indicated during the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient's clinical record. The Clinical Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal 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 conduct an initial bereavement (the experience of losing someone important to us) assessment to provide bereavement counseling in accordance with the patient/family/caregivers needs for ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This deficient practice had the potential to impact a family members' abilities to cope with the patient's' death. --- F. During a review of Patient 8's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 8 on 4/11/2024, with a diagnosis including atherosclerotic heart disease of native coronary artery without angina pectoris (the buildup of fats, cholesterol and other substances in and on the artery walls). During a review of Patient 8's Plan of Care (POC) Summary form indicated an order, dated 4/11/2024, for the licensed vocational nurse (LVN) frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, and the registered nurse (RN) to do an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. Spiritual counselor (SC) every certification and as needed for support and counseling. Volunteer, social worker (MSW), and hospice aide (CHHA) services were offered but declined. During a review of Patient 8's clinical record indicated that there was no initial bereavement assessment conducted. G. During a review of Patient 9's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 9 on 7/11/2024, with a diagnosis including chronic obstructive pulmonary disease ( lung disease causing restricted airflow and breathing problems) During a review of Patient 9's POC Summary form indicated an order, dated 7/11/2024, for the skilled nurse frequency of visits registered nurse (RN) to one visit per week and one visit as needed. During a review of Patient 9's clinical record indicated that there was no initial bereavement assessment conducted. H. During a review of Patient 10's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 10 on 7/11/2024, with a diagnosis including Emphysema ( lung disease affecting the tiny air sacs of the lungs). During a review of Patient 10's POC Summary form indicated an order, dated 7/11/2024, for the skilled nurse frequency of visits to one visit per week and one visit as needed for changes in condition, and the registered nurse (RN) to conduct an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. SC every certification period and as needed for support and counseling. MSW, and CHHA services were offered but declined. During a review of Patient 10's clinical record indicated that there was no initial bereavement assessment conducted. I. During a review of Patient 11's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 11 on 4/30/2024, with a diagnosis including atherosclerotic heart disease of native coronary artery without angina pectoris (the buildup of fats, cholesterol and other substances in and on the artery walls). During a review of Patient 11's POC Summary form indicated an order, dated 4/30/2024, for the skilled nurse frequency of visits to one visit per week and one visit as needed for changes in condition, and the registered nurse (RN) to conduct an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. SC every certification period and as needed for support and counseling. MSW every certification period and as needed for support and counseling. Volunteer and CHHA services were offered but declined. During a review of Patient 11's clinical record indicated that there was no initial bereavement assessment conducted. J. During a review of Patient 12's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 12 on 11/20/2023, with a diagnosis including atherosclerotic heart disease of native coronary artery without angina pectoris (the buildup of fats, cholesterol and other substances in and on the artery walls) During a review of Patient 12's POC Summary form indicated an order, dated 11/20/2024, for the skilled nurse frequency of visits to one visit per week and one visit as needed for changes in condition, and the registered nurse (RN) to conduct an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. SC every certification period and as needed for support and counseling. MSW every certification period and as needed for support and counseling. Volunteer and CHHA services were offered but declined. During a review of Patient 12's clinical record indicated that there was no initial bereavement assessment conducted. During a concurrent interview and record review on 7/25/24 at 1:30 p.m. with Director of Patient Care Services (DPCS), stated the chaplain is responsible for doing the bereavement assessment and they have 1-5 days to complete it. DPCS acknowledged that there was no evidence of bereavement assessment done for all active patients. A record review of agencys policy and procedure titled ";Bereavement Plan", undated, indicated ";Hospice bereavement services, provided by qualified staff and volunteers, begin with the initial assessment and continue through the bereavement period to help the patient/family cope with death-related grief and loss issues." Findings: a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 2/15/2024 with a terminal diagnosis of atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery without angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 2/15/2024, indicated the frequency of visits for the licensed vocational nurse (LVN) to one visit per week plus one prn (pro re nata, which means as needed) visits for changes in condition. The spiritual counselor (SC) and social worker (MSW) to visit every certification period plus one prn visit. The Hospice aide and volunteer services were declined. During a review of Patient 1's clinical record indicated there was no initial bereavement assessment conducted. b. A review of Patient 2s admission record indicated a start of care date of 4/11/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 2's POC/IDG form, dated 4/11/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week plus one prn visits for changes in condition. The spiritual counselor and social worker to visit every certification period plus one prn visit. The Hospice aide and volunteer services were declined. During a review of Patient 2's clinical record indicated there was no initial bereavement assessment conducted. c. During a review of Patient 3s admission record indicated a start of care date of 7/11/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 3's POC/IDG form, dated 7/11/2024, indicated the frequency of visits of the licensed vocational nurse was one visit per week plus one prn visit for changes in condition. The spiritual counselor to visit one per month plus one prn visit for support and counseling. The Hospice aide, volunteer and social worker services were declined. During a review of Patient 3's clinical record indicated that there was no initial bereavement assessment conducted. d. During a review of Patient 4s admission record indicated a start of care date of 4/25/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 4's POC/IDG form, dated 4/25/2024, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus one prn visit for changes in condition. The spiritual counselor and social worker to visit every certification period plus one prn visit. The Hospice aide and volunteer services were declined. During a review of Patient 4's clinical record indicated that there was no initial bereavement assessment conducted. e. During a review of Patient 5s admission record indicated a start of care date of 6/5/2024 with a terminal diagnosis of chronic combined systolic and diastolic heart failure (chronic condition in which the heart does not pump blood as well it should). During a review of Patient 5's POC/IDG form, dated 6/5/2024, indicated the frequency of visits of the licensed vocational nurse was one visit per week plus one prn visits for changes in condition. The spiritual counselor and social worker was to visit every certification period plus one prn visit. The Hospice aide and volunteer services were declined. During a review of Patient 5's clinical record indicated there was no initial bereavement assessment conducted. During a concurrent interview and record review, on 7/25/24 at 1:25 p.m., the Director of Patient Care Services (DPCS) reviewed Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12s records titled, ";History of Bereavement Assessment". DPCS stated and confirmed Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12s initial bereavement assessment was not done because there was nothing documented. The DPCS further stated that an initial bereavement assessment should be conducted within five days from the patients admission per regulations. During a review of the agency's undated policy and procedure titled "Bereavement Plan," indicated bereavement care and services are an integral part of the total hospice program. Hospice bereavement service, provided by qualified staff and volunteers, begin with the initial assessment and continue through the bereavement period to help the patient/family cope with death-related grief and loss issues.

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 - various hospice professionals [Registered Nurse [RN], Medical Doctor [MD], Medical Social Worker {MSW], and Spiritual Counselor[SC]) all working together to create a comprehensive and customized hospice plan of care for each patient) met to discuss and update eight out of fourteen sampled patients (Patient 1, Patient 2, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, and Patient 11) comprehensive assessments at least every 15 days. This deficient practice had the potential to result in the patients (Patient 1, Patient 2, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, and Patient 11) not meeting their needs and their changes of condition not identified and addressed. --- E. During a review of Patient 8's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 8 on 4/11/2024, with a diagnosis including atherosclerotic heart disease of native coronary artery without angina pectoris (the buildup of fats, cholesterol and other substances in and on the artery walls) During a record review of Patient 8s medical record form titled ";POC Summary" dated as of 4/11/2024, indicated ";IDT to review patient status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 8s medical record form titled ";POC/IDG Review" dated 4/11/2024 and 7/10/2024, indicated it was not signed by the Medical Doctor (MD), Registered Nurse (RN) and Social worker (MSW). F. During a review of Patient 9's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 9 on 7/11/2024, with a diagnosis including chronic obstructive pulmonary disease ( lung disease causing restricted airflow and breathing problems). During a record review of Patient 9s medical record form titled ";POC/IDG Review" dated 7/11/2024, indicated it was not signed by the MD, RN, MSW and Chaplain. G. During a review of Patient 10's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 10 on 7/11/2024, with a diagnosis including Emphysema ( lung disease affecting the tiny air sacs of the lungs). During a record review of Patient 10s medical record form titled ";POC Summary" dated as of 7/11/2024, indicated ";IDT to review patient status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 10s medical record form titled ";POC/IDG Review" dated 7/11/2024, indicated it was not signed by the RN and MSW. H. During a review of Patient 11's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 11 on 4/30/2024, with a diagnosis including atherosclerotic heart disease of native coronary artery without angina pectoris (the buildup of fats, cholesterol and other substances in and on the artery walls). During a record review of Patient 11s medical record form titled ";POC Summary" dated as of 4/30/2024, indicated ";IDT to review patient status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 11s medical record form titled ";POC/IDG Review" dated 4/30/2024 and 6/26/2024, indicated it was not signed by the RN and MSW. Findings: a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 2/15/2024 with a terminal diagnosis of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery without angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 1's Plan of Care (POC) Summary form, it included an order dated 2/15/2024, that indicated ";IDT to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 1s medical record form titled, POC/IDG Review form, dated 6/12/2024, 6/26/2024, and 7/10/2024, indicated it was not signed by the MD, Rn, and SC. b. During a review of Patient 2s admission record indicated a start of care date of 4/11/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 2's POC Summary form, it included an order dated 4/11/2024, that indicated ";IDT to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 2s medical record form titled, POC/IDG Review form, dated 6/12/2024, 6/26/2024, and 7/10/2024, indicated it was not signed by the MD, Rn, and SC. c. During a review of Patient 4s admission record indicated a start of care date of 4/25/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 4's POC Summary form, it included an order dated 4/25/2024, that indicated ";IDT to review patients status every 14 days and as needed to evaluate changes in condition." During a review of Patient 4's POC/IDG Review form, dated 6/26/2024 and 7/10/2024, indicated it was not signed by the Rn. d. During a review of Patient 5s admission record indicated a start of care date of 6/5/2024 with a terminal diagnosis of chronic combined systolic and diastolic heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 5's POC Summary form, it included an order dated 6/5/2024, that indicated ";IDT to review patients status every 14 days and as needed to evaluate changes in condition." During a review of Patient 5's POC/IDG Review form, dated 6/12/2024, 6/26/2024 and 7/10/2024, indicated it was not signed by the Rn. During an interview, on 7/25/2024 at 1:25 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated the MD, SC, MSW, and Rn met in the office, and some online, every two weeks to go over the care of all the patients. The DPCS stated each individual discipline was responsible in documenting their input under their own discipline in the IDG meeting form. The disciplines had to document the same day and sign by the end of the day. DPCS stated the discipline signatures indicated they were present and verified their documentation. During a record review of the agencys policy and procedure titled, ";Ongoing Assessments", dated 11/17/2022, indicated ";Based on the assessments, the plan of care including problems, needs, goals, and outcomes will be reviewed and updated by the interdisciplinary group members responsible for the case. Based upon the findings of the assessment, change/verbal orders will be generated and forwarded to the physician (or other authorized independent practitioner) as needed." During a record review of the agencys policy and procedure titled, ";Interdisciplinary Group Meeting", revised April 2016, indicated ";Each patient plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. The hospice Medical Director and all hospice interdisciplinary group members will be present... Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor."

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Medical Director was met as evidenced by: 1. The hospice agency failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice care and services for two of fourteen sampled patients (Patient 9 and Patient 10). (Refer to L667) 2. The hospice agency failed to ensure the Medical Director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for four of fourteen sampled patients (Patient 1, Patient 2, Patient 4, and Patient 8). (Refer to L668) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory (written rules or law) mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was provided to the patients certified to receive hospice services. --- Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Medical Director was met as evidenced by: 1. The hospice agency failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice care and services for two of fourteen sampled patients (Patient 9 and Patient 10). (Refer to L667) 2. The hospice agency failed to ensure the Medical Director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for four of fourteen sampled patients (Patient 1, Patient 2, Patient 4, and Patient 8). (Refer to L668) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory (written rules or law) mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was provided to the patients certified to receive hospice services.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for two out of 14 sampled patients (Patient 9 and Patient 10). This deficient practice resulted in Patient 9 and Patient 10, being admitted for hospice care with no documented evidence of patients written clinical information was being reviewed and evaluated by the Medical Director and/or physician designee to support their diagnoses of terminal illness. --- A. During a review of Patient 9's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 9 on 7/11/2024, with a diagnosis that included chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems). A review of Patient 9's Physicians Certification for Hospice Benefit, dated 7/11/24 to 10/8/2024, benefit period number 1, indicated Physician 1 signed the attending physician referral section to indicate Patient 9 had a life expectancy of six months or less if the terminal illness runs its normal course. Patient 9's Physicians Certification for Hospice Benefit has no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During an interview on 7/24/24 at 4 p.m. with Patient 9, Patient 9 stated the primary doctor did not tell Patient 9 she had six months or less to live. No doctor, chaplain and social worker has talked to Patient 9 since admission. B. During a review of Patient 10's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 10 on 7/11/2024, with a diagnosis that included emphysema (lung disease affecting the tiny air sacs of the lungs). A review of Patient 10s Physicians Certification for Hospice Benefit, dated 7/11/24 to 10/8/2024, Benefit Period Number 1, indicated Physician 1 signed the attending physician referral section to indicate Patient 10 had a life expectancy of six months or less if the terminal illness runs its normal course. Patient 10's Physicians Certification for Hospice Benefit had no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. A record review of Patient 10s medical record form ";LCD Hospice Eligibility Determination" indicated ";Patient does not qualify per LCD (Local Coverage Determination) Guidelines." During an interview on 7/24/24 at 9:42 p.m. with Patient 10, Patient 10 stated that his primary doctor did not say that he had six months or less to live. He stated that he still drives to the market and even to Vegas. Since admission to hospice, he still had not talked to any doctor. During a Telephone interview on 7/25/2024 at 12 p.m. with the Medical Director (MD), the MD stated he would be the attending physician for the patients once admitted to the hospice service. When asked how he determined patients were eligible for hospice service, the MD stated he discussed each patients case with the Registered Nurse (RN) assigned and will do a face to face via facetime visit with the patient. The MD stated he also was supposed to review the patient's previous medical records, and their history and physical. The MD admitted the agency did not have patients previous medical records from hospitals, facilities or from doctors offices. The MD stated he used LCD criteria as a basis for certifying a patient for hospice care. During a review of the agencys policy and procedure titled "Admission Criteria and Process", revised April 2016, indicated Visiting Angels of LA Hospice, Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of six months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). During a review of the agencys undated policy and procedure titled Medical Director, the policy indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by completing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care and providing written certification of the terminal illness for all subsequent benefit periods.

Based on observation, interview and record review, the hospice agency (HA) failed to ensure the medical director and/or physician designee conducted a review and verified the patients clinical information to determine the patient needs of recertification of terminal illness for continued hospice care and services for four of fourteen sampled patients (Patient 1, Patient 2, Patient 4, and Patient 8). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- Findings: a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 2/15/2024 with a terminal diagnosis of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery without angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 1s Recertification Comprehensive Assessment (Re-Cert Assessment), dated 5/11/2024 for certification period from 5/15/2024 to 8/12/2024, indicated Patient 1 had heart disease. The assessment indicated Patient 1 was awake, alert, and oriented x 3 (to person, place, and time), had no cardiac-related pain, had normal respiration (breathing), had mild shortness of breath (SOB) on moderate exertion relieved by rest, and no blood pressure elevation noted. The Re-Cert Assessment indicated Patient 1 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure. The assessment also indicated Patient 1 was dependent on walker or cane, needed maximum assistance for ambulation, toileting, transfer, and bathing, and needed moderate assistance for dressing and feeding. During a joint home visit, on 7/24/2024 at 12:40 p.m. with the licensed vocational nurse (LVN 1) at Patient 1s residence, Patient 1 was found sitting inside his car, awake, alert, oriented x 3 (to person, place, and time), and ambulatory with steady gait not using any assistive device. Patient 1 was observed having normal breathing, not fatigue, no SOB, and no pain. During an interview, on 7/24/2024 at 1:05 p.m. with Patient 1, Patient 1 stated his understanding of what hospice care was for those people like him who are old and lives alone. Patient 1 stated he was not dying nor had terminal illness, and no doctor or nurses from the agency explained to him that hospice care was for those patients who have 6 months or less to live. When asked what he was doing inside the car, Patient 1 stated, ";Im trying to fix it. I am going to sell the car but has multiple issues." Patient 1 further stated he was independent with all his care and does not need any assistance, still drives, and takes care of 10 cats inside his house. During a concurrent interview and record review, on 7/25/24 at 1:25 p.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 1s form titled, ";LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) Hospice Eligibility Determination, dated 5/14/2024. DPCS stated the agency used LCD assessment as basis for determining patients hospice eligibility. DPCS stated Patient 1 met the criteria for NYHA Class IV level and was hospice appropriate based on the LCD assessment but was unable to provide documented evidence Patient 1 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom occurred at rest. The DPCS also reviewed Patient 1 form titled, ";Physicians Certification for Hospice Benefit (or CTI, Physician's certification of the patient being terminally ill to have Medicare hospice benefit)," for the 2nd benefit period from 5/15/2024 to 8/12/2024. The DPCS stated the hospice Medical Director (MD) recertified that Patient 1 has a life expectancy of six months or less, if the terminal illness runs its normal course. The DPCS stated and confirmed the section under ";Certifying Physician Narrative" was left blank, and the form was not signed and dated by the MD. DPCS stated the agencys MD should have provided supporting narrative that included patients history and physical to support Patient 1s terminal illness diagnosis. b. During a review of Patient 2s admission record indicated a start of care date of 4/11/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 2s Re-Cert Assessment, dated 7/9/2024 for certification period from 7/10/2024 to 10/7/2024, indicated Patient 2 had heart disease. The assessment indicated Patient 2 was awake, alert, and oriented x 3 (to person, place, and time), had no cardiac-related pain, had normal breathing, regular pulse rate (heart rate), and had mild shortness of breath with mild exertion. The Re-Cert Assessment indicated Patient 2 was on NYHA IV stage of heart failure and met the criteria for LCD eligibility. The assessment also indicated Patient 2 was dependent on walker or cane, needed maximum assistance for ambulation, toileting, transfer, and bathing, and needed moderate assistance for dressing and feeding. During a joint home visit, on 7/24/2024 at 11:30 a.m. with the licensed vocational nurse (LVN 1) at Patient 2s residence, Patient 2 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device. Patient 2 was observed having normal breathing, not fatigue, no SOB, and no pain. During an interview, on 7/24/2024 at 12:05 p.m. with Patient 2, Patient 2 stated her understanding of hospice care was being visited by a nurse every week and getting her medications. Patient 2 stated no doctors or nurses told her that she had terminal illness or have 6 months or less to live. Patient 2 stated she was not dying, that she was referred to the hospice agency by a friend that she met in the park near her house. Patient 2 further stated she was independent with her ADL (activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating) care and walked outside the house regularly. During a concurrent interview and record review, on 7/25/2024 at 1:25 p.m. with the DPCS, the DPCS reviewed Patient 2s form titled, ";LCD Hospice Eligibility Determination", dated 7/9/2024. DPCS stated the agency used LCD assessment as basis for determining patients hospice eligibility. DPCS stated Patient 2 met the criteria for NYHA Class IV level and was hospice appropriate based on the LCD assessment but was unable to provide documented evidence Patient 2 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom occurred at rest. The DPCS also reviewed Patient 2s CTI form for the 2nd benefit period from 7/10/2024 to 10/7/2024. The DPCS stated the hospice MD recertified that Patient 2 has a life expectancy of six months or less, if the terminal illness runs its normal course. The DPCS stated and confirmed the section under ";Certifying Physician Narrative" was left blank, and the form was not signed and dated by the MD. DPCS stated the agencys MD should have provided supporting narrative that included patients history and physical to support Patient 2s terminal illness diagnosis. c. During a review of Patient 4s admission record indicated a start of care date of 4/25/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 4s Re-Cert Assessment, dated 7/20/2024 for certification period from 7/24/2024 to 10/21/2024, indicated Patient 4 had heart disease. The assessment indicated Patient 4 was awake, alert, and oriented x 3 (to person, place, and time), had no cardiac-related pain, had normal breathing, regular heart rate, and had mild shortness of breath with mild exertion. The Re-Cert Assessment indicated Patient 4 was on NYHA IV stage of heart failure and met the criteria for LCD eligibility. The assessment also indicated Patient 4 was dependent on walker or cane, needed maximum assistance for ambulation, toileting, transfer, and bathing, and needed moderate assistance for dressing and feeding. During a telephone interview, on 7/24/2024 at 3:55 p.m., with Patient 4, Patient 4 stated he lives alone, was doing fine, independent with ADLs, does not have cardiac (relating to the heart) symptoms (chest pain, fatigue, SOB) when at rest, and still drives. During a concurrent interview and record review, on 7/25/2024 at 1:25 p.m. with the DPCS, the DPCS reviewed Patient 4s form titled, ";LCD Hospice Eligibility Determination", dated 7/20/2024. DPCS stated the agency used LCD assessment as basis for determining patients hospice eligibility. DPCS stated Patient 4 met the criteria for NYHA Class IV level and was hospice appropriate based on the LCD assessment but was unable to provide documented evidence Patient 4 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom occurred at rest. The DPCS also reviewed Patient 4s CTI form for the 2nd benefit period from 7/24/2024 to 10/21/2024. The DPCS stated the hospice MD recertified that Patient 4 has a life expectancy of six months or less, if the terminal illness runs its normal course. The DPCS stated and confirmed the section under ";Certifying Physician Narrative", did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 4s terminal illness diagnosis. During a telephone interview on 7/25/2024 at 12:15 p.m. with the hospice Medical Director (MD), MD stated he was not the attending physician and did not know who the attending physician was for Patient 1, Patient 2, Patient 4, and Patient 8. MD stated he would be the attending physician for the patients once admitted to the hospice service. When asked how he determine patients were eligible for hospice service, MD stated he discussed each patients case with the Rn assigned and perform face to face visit with the patient. MD stated he also was supposed to review patients previous medical records, and their history and physical but in this case, MD admitted the agency do not have patients previous medical records from hospitals, facilities or from doctors offices. MD stated he used LCD criteria as basis for certifying patient for hospice care. During a review of the agencys policy and procedure titled "Admission Criteria and Process", revised April 2016, indicated Visiting Angels of LA Hospice, Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). During a review of the agencys undated policy and procedure titled Medical Director, indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care and providing written certification of the terminal illness for all subsequent benefit periods. C. During a review of Patient 8's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 8 on 4/11/2024, with a diagnosis including atherosclerotic heart disease of native coronary artery without angina pectoris (the buildup of fats, cholesterol and other substances in and on the artery walls). During a review of Patient 8s Recertification Comprehensive Assessment (Re-Cert Assessment), dated 7/9/2024 for certification period from 7/10/2024 to 10/7/2024, indicated Patient 8 had heart disease. The assessment indicated Patient 8 was awake, alert, and oriented x 3 (to person, place, and time), had no cardiac-related pain, had normal respiration (breathing), had mild shortness of breath (SOB) on moderate exertion relieved by rest, and no blood pressure elevation noted. The Re-Cert Assessment indicated Patient 1 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure. The assessment also indicated Patient 8 was dependent on cane, needed maximum assistance for ambulation, toileting, transfer, and bathing, and needed moderate assistance for dressing and feeding. During a joint home visit, on 7/24/2024 at 2:45 p.m. with the licensed vocational nurse (LVN 1) at Patient 8s residence, Patient 8 was found sitting on his computer chair using his computer, awake, alert, oriented x 3 (to person, place, and time), and ambulatory with steady gait not using any assistive device. Patient 8 was observed having normal breathing, no shortness of breath and denies any pain. Patient 8 stated nurses visit him once a week. Patient 8 stated he does go to the market alone and is still able to drive. Patient able to walk us out from his back house to the front gate without assistive device and no shortness of breath. Patient also point out the white car he is driving. Findings: a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 2/15/2024 with a terminal diagnosis of atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery without angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 1s Recertification Comprehensive Assessment (Re-Cert Assessment), dated 5/11/2024 for certification period from 5/15/2024 to 8/12/2024, indicated Patient 1 had heart disease. The assessment indicated Patient 1 was awake, alert, and oriented x 3 (to person, place, and time), had no cardiac-related pain, had normal respiration (breathing), had mild shortness of breath (SOB) on moderate exertion relieved by rest, and no blood pressure elevation noted. The Re-Cert Assessment indicated Patient 1 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure. The assessment also indicated Patient 1 was dependent on walker or cane, needed maximum assistance for ambulation, toileting, transfer, and bathing, and needed moderate assistance for dressing and feeding. During a joint home visit, on 7/24/2024 at 12:40 p.m. with the licensed vocational nurse (LVN 1) at Patient 1s residence, Patient 1 was found sitting inside his car, awake, alert, oriented x 3 (person, place, and time), and was ambulatory with a steady gait without using any assistive device. Patient 1 was observed having normal breathing, no fatigue, no SOB, and no pain. During an interview, on 7/24/2024 at 1:05 p.m. with Patient 1, Patient 1 stated his understanding of hospice care is that it is for those people like him who are old and live alone. Patient 1 stated he was not dying nor had terminal illness, and no doctor or nurse from the agency explained to him that hospice care was for those patients who have six months or less to live. When asked what he was doing inside the car, Patient 1 stated, ";Im trying to fix it. I am going to sell the car but it has multiple issues." Patient 1 further stated he was independent with all his care and does not need any assistance, still drives, and takes care of 10 cats inside his house. During a concurrent interview and record review, on 7/25/24 at 1:25 p.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 1s form titled, ";LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) Hospice Eligibility Determination, dated 5/14/2024. The DPCS stated the agency used LCD assessment as a basis for determining a patients hospice eligibility. The DPCS stated Patient 1 met the criteria for NYHA Class IV level and was hospice appropriate based on the LCD assessment, but was unable to provide documented evidence that Patient 1 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom occurred at rest. The DPCS also reviewed Patient 1's form titled, ";Physicians Certification for Hospice Benefit (or CTI, Physician's certification of the patient being terminally ill to have Medicare hospice benefit)," for the 2nd benefit period from 5/15/2024 to 8/12/2024. The DPCS stated the hospice Medical Director (MD) recertified that Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. The DPCS stated and confirmed the section under ";Certifying Physician Narrative" was left blank, and the form was not signed and dated by the MD. The DPCS stated the agencys MD should have provided supporting narrative that included Patient 1's history and physical to support Patient 1s terminal illness diagnosis. b. During a review of Patient 2s admission record indicated a start of care date of 4/11/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 2s Re-Cert Assessment, dated 7/9/2024 for certification period from 7/10/2024 to 10/7/2024, indicated Patient 2 had heart disease. The assessment indicated Patient 2 was awake, alert, and oriented x 3 (to person, place, and time), had no cardiac-related pain, had normal breathing, regular pulse rate (heart rate), and had mild shortness of breath with mild exertion. The Re-Cert Assessment indicated Patient 2 was on NYHA IV stage of heart failure and met the criteria for LCD eligibility. The assessment also indicated Patient 2 was dependent on a walker or cane, needed maximum assistance for ambulation, toileting, transfer, and bathing, and needed moderate assistance for dressing and feeding. During a joint home visit, on 7/24/2024 at 11:30 a.m. with the licensed vocational nurse (LVN 1) at Patient 2s residence, Patient 2 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without using an assistive device. Patient 2 was observed having normal breathing, not fatigue, no SOB, and no pain. During an interview, on 7/24/2024 at 12:05 p.m. with Patient 2, Patient 2 stated her understanding of hospice care was being visited by a nurse every week and getting her medications. Patient 2 stated no doctors or nurses told her that she had terminal illness or have 6 months or less to live. Patient 2 stated she was not dying, that she was referred to the hospice agency by a friend that she met in the park near her house. Patient 2 further stated she was independent with her ADL (activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating) care and walked outside the house regularly. During a concurrent interview and record review, on 7/25/2024 at 1:25 p.m. with the DPCS, the DPCS reviewed Patient 2s form titled, ";LCD Hospice Eligibility Determination", dated 7/9/2024. DPCS stated the agency used LCD assessment as basis for determining patients hospice eligibility. DPCS stated Patient 2 met the criteria for NYHA Class IV level and was hospice appropriate based on the LCD assessment but was unable to provide documented evidence Patient 2 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom occurred at rest. The DPCS also reviewed Patient 2s CTI form for the 2nd benefit period from 7/10/2024 to 10/7/2024. The DPCS stated the hospice MD recertified that Patient 2 has a life expectancy of six months or less, if the terminal illness runs its normal course. The DPCS stated and confirmed the section under ";Certifying Physician Narrative" was left blank, and the form was not signed and dated by the MD. DPCS stated the agencys MD should have provided supporting narrative that included patients history and physical to support Patient 2s terminal illness diagnosis. c. During a review of Patient 4s admission record indicated a start of care date of 4/25/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 4s Re-Cert Assessment, dated 7/20/2024 for certification period from 7/24/2024 to 10/21/2024, indicated Patient 4 had heart disease. The assessment indicated Patient 4 was awake, alert, and oriented x 3 (to person, place, and time), had no cardiac-related pain, had normal breathing, regular heart rate, and had mild shortness of breath with mild exertion. The Re-Cert Assessment indicated Patient 4 was on NYHA IV stage of heart failure and met the criteria for LCD eligibility. The assessment also indicated Patient 4 was dependent on walker or cane, needed maximum assistance for ambulation, toileting, transfer, and bathing, and needed moderate assistance for dressing and feeding. During a telephone interview, on 7/24/2024 at 3:55 p.m., with Patient 4, Patient 4 stated he lives alone, was doing fine, independent with ADLs, does not have cardiac (relating to the heart) symptoms (chest pain, fatigue, SOB) when at rest, and still drives. During a concurrent interview and record review, on 7/25/2024 at 1:25 p.m. with the DPCS, the DPCS reviewed Patient 4s form titled, ";LCD Hospice Eligibility Determination", dated 7/20/2024. DPCS stated the agency used LCD assessment as basis for determining patients hospice eligibility. DPCS stated Patient 4 met the criteria for NYHA Class IV level and was hospice appropriate based on the LCD assessment but was unable to provide documented evidence Patient 4 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom occurred at rest. The DPCS also reviewed Patient 4s CTI form for the 2nd benefit period from 7/24/2024 to 10/21/2024. The DPCS stated the hospice MD recertified that Patient 4 has a life expectancy of six months or less, if the terminal illness runs its normal course. The DPCS stated and confirmed the section under ";Certifying Physician Narrative", did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 4s terminal illness diagnosis. d. During a review of Patient 8's Demographics (identifying information such as patients name, date of birth and address, along with insurance information) notes, the Demographics notes indicated the HA admitted Patient 8 on 4/11/2024, with a diagnosis including atherosclerotic heart disease of native coronary artery without angina pectoris (the buildup of fats, cholesterol and other substances in and on the artery walls). During a review of Patient 8s Recertification Comprehensive Assessment (Re-Cert Assessment), dated 7/9/2024 for certification period from 7/10/2024 to 10/7/2024, indicated Patient 8 had heart disease. The assessment indicated Patient 8 was awake, alert, and oriented x 3 (to person, place, and time), had no cardiac-related pain, had normal respiration (breathing), had mild shortness of breath (SOB) on moderate exertion relieved by rest, and no blood pressure elevation noted. The Re-Cert Assessment indicated Patient 1 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure. The assessment also indicated Patient 8 was dependent on cane, needed maximum assistance for ambulation, toileting, transfer, and bathing, and needed moderate assistance for dressing and feeding. During a joint home visit, on 7/24/2024 at 2:45 p.m. with the licensed vocational nurse (LVN 1) at Patient 8s residence, Patient 8 was found sitting on his computer chair using his computer, awake, alert, oriented x 3 (to person, place, and time), and ambulatory with steady gait not using any assistive device. Patient 8 was observed having normal breathing, no shortness of breath and denies any pain. Patient 8 stated nurses visit him once a week. Patient 8 stated he does go to the market alone and is still able to drive. Patient able to walk us out from his back house to the front gate without assistive device and no shortness of breath. Patient also point out the white car he is driving. During a telephone interview on 7/25/2024 at 12:15 p.m. with the hospice Medical Director (MD), MD stated he was not the attending physician and did not know who the attending physician was for Patient 1, Patient 2, Patient 4, and Patient 8. MD stated he would be the attending physician for the patients once admitted to the hospice service. When asked how he determine patients were eligible for hospice service, MD stated he discussed each patients case with the Rn assigned and perform face to face visit with the patient. MD stated he also was supposed to review patients previous medical records, and their history and physical but in this case, MD admitted the agency do not have patients previous medical records from hospitals, facilities or from doctors offices. MD stated he used LCD criteria as basis for certifying patient for hospice care. During a review of the agencys policy and procedure titled "Admission Criteria and Process", revised April 2016, indicated Visiting Angels of LA Hospice, Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). During a review of the agencys undated policy and procedure titled Medical Director, indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care and providing written certification of the terminal illness for all subsequent benefit periods.

Based on interview and record review the Hospice Agency (HA) failed to follow their policy and procedure to ensure that discharge summaries were complete for 4 out of 4 patients (Patient 6, 7, 13 and 14). Patient 6, 7, 13 and 14s discharge summary did not have the name and signature of the nurse that completed the record. This deficient practice had the potential to result in questionable accuracy and validity of the patients discharge summary documentation which could potentially lead to miscommunication that can affect the continuation of care for the affected patients. --- c. A review of Patient 13s Personal Information sheet (face sheet) indicated a SOC (start of care) date of 5/24/2023 and EOC (end of care) date on 8/21/2023, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (the accumulation of plaque in the normal blood vessels of the heart without chest pain). A review of Patient 13s medical record titled ";Discharge Summary", dated 8/21/23, indicated Patient 13 prognosis extended. The discharge summary does not indicate the name and signature of the skilled nurse that completed the record. d. A review of Patient 14s Personal Information sheet (face sheet) indicated a SOC date of 8/26/2023 and EOC date on 11/23/2023, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (the accumulation of plaque in the normal blood vessels of the heart without chest pain). A review of Patient 14s medical record titled ";Discharge Summary", dated 11/23/23, indicated Patient 14 prognosis extended. The discharge summary does not indicate the name and signature of the skilled nurse that completed the record. During an interview on 7/25/2024 at 1:30 p.m. with Director of Patient Care Services (DPCS), stated that discharge summary should be signed, if it is not signed means it is not complete, DPCS stated it needs to be signed within the same day. A review of the HA policy titled ";Discharge Summary", (undated), indicated, ";All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record. Procedures...6. Hospice will complete all necessary audits to determine the completeness of the patients clinical record within 30 days of the last hospice visit and discharge date. The discharge record will be organized according to policy for clinical records contents and removed from the active files." a. A review of Patient 6s Personal Information sheet (face sheet) indicated a SOC (start of care) date of 3/7/2024 and EOC (end of care) date on 5/24/2024, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (the accumulation of plaque in the normal blood vessels of the heart without chest pain) and secondary diagnosis of essential primary hypertension (high blood pressure). A review of Patient 6s medical record titled ";Discharge Summary", dated 5/24/24, indicated Patient 6 moved out of the area as the reason for discharge. The discharge summary does not indicate the name and signature of the skilled nurse that completed the record. b. A review of Patient 7s Personal Information sheet (face sheet) indicated a SOC (start of care) date of 3/7/2024 and EOC (end of care) date on 5/24/2024, with a primary diagnosis of angina pectoris (the accumulation of plaque in the normal blood vessels of the heart without chest pain) and secondary diagnosis of essential primary hypertension (high blood pressure). A review of Patient 7s medical record titled ";Discharge Summary", dated 5/24/24, indicated ";revocation of hospice" as the reason for discharge. The discharge summary does not indicate the name and signature of the skilled nurse that completed the record. During an interview on 7/25/2024, at 12:45 p.m., the Director of Patient Care Services (DPCS), stated that the discharge summary should be signed by the nurse. If its not signed, it is considered incomplete. The discharge summary should be completed and signed the same day of the discharge.