Pillars Hospice Care, LLC

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed with hospice aide services provided it was revealed that the agency did not ensure that all patient care instructions were included in the aide care plan. CLINICAL RECORD 3: The patient elected the hospice benefit on 01/25/2022. The plan of care dated 03/12/2025-05/10/2025 included physician orders for wound care with a wound dressing to a wound on the patient’s right hip. The plan of care dated 03/12/2025-05/10/2025 ordered “Hospice Aide 3 times per week.” The aide care plan dated 03/12/2025 included relevant instructions of “bed bath every visit.” The aide care plan lacked instructions regarding the wound dressing on the right hip should it become dislodged or wet during the bed bath. CLINICAL RECORD 8: The patient elected the hospice benefit on 09/03/2022. The plan of care dated 02/19/2025-04/19/2025 included physician orders for wound care with a wound dressing to a wound on the patient’s right leg. The plan of care dated 02/19/2025-04/19/2025 ordered “Hospice Aide 2 times per week.” The aide care plan dated 02/19/2025 included relevant instructions of “shower every visit.” The aide care plan was not updated until 03/18/2025 to include instructions regarding the wound dressing on the right leg should it become dislodged or wet during the shower. During a joint record review on 03/19/2025, the Administrator confirmed the above findings that wound dressing instructions were not included in the aide care plan.”

“Based on facility policies and procedures, interview and review of facility documents, the Department has determined the Administrator failed to ensure that direct-care volunteer services were provided to patients in accordance with facility policy. Failure to ensure that direct-care services are appropriately provided and recorded by volunteers in accordance with facility policies can result in systemic abuse and services not being provided to patients. Findings include: Facility policy titled, “...Volunteer Services....” revised 11/01/2020 revealed: “...Pillars Hospice Care, LLC Volunteers are unpaid employees...Volunteers will be non-paid employees of Pillars Hospice Care...With training, hospice volunteers may be used to provide direct patient care services to patients and their loved ones, assistance in office activities, expand on the availability of ancillary services, or assist with bereavement program...Volunteers utilized in direct patient care roles may include...Providing emotional support to patients/families...Providing personal care to patients...Assisting families with household chores...Assisting patients with shopping...Attending IDT (interdisciplinary team) meetings as appropriate...Reporting responses of patient/family to IDT....” “...Consolo Volunteer Care and Services...” reports revealed: January 2023 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0.54 Employee #11 1 4.0 94.24 12 6.48 Employee #1 18 12.5 294.50 68 36.72 February 2023 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0.54 Employee #11 2 8.0 188.48 24 12.96 Employee #1 16 11.3 266.23 57 30.78 March 2023 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0.54 Employee #6 5 16.0 376.96 108 58.32 Employee #8 4 17.0 400.52 150 81.00 Employee #11 11 30.45 717.40 270 145.80 Employee #2 3 13.0 306.28 118 63.72 Employee #1 17 13.0 306.28 32 17.28 April 2023 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0.54 Employee #6 3 12.0 282.72 96 51.84 Employee #8 1 1.3 30.63 12 6.48 Employee #11 5 10.15 239.13 110 59.40 Employee #1 16 8.0 188.48 0 0.00 Employee #5 2 2.0 47.12 6 3.24 May 2023 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0.54 Employee #6 1 4.0 94.24 12 6.48 Employee #11 4 12.0 282.72 126 68.04 Employee #1 15 7.45 175.52 0 0.00 Employee #5 2 2.0 47.12 4 2.16 Employee #10 3 6.0 141.36 66 35.64 June 2023 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0.54 Employee #11 2 8.0 188.48 82 44.28 Employee #1 12 7.0 164.92 0 0.00 Employee #5 1 2.0 47.12 2 1.08 Employee #10 2 8.0 188.48 44 23.76 July 2023 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0.54 Employee #11 4 14.25 335.73 129 69.66 Employee #1 9 7.15 168.45 0 0.00 Employee #5 2 2.3 54.19 4 2.16 Employee #10 4 13.0 306.28 102 55.28 August 2023 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0.54 Employee #11 4 14.25 335.73 128 69.12 Employee #1 9 7.15 168.45 0 0.00 Employee #5 2 2.3 54.19 4 2.16 Employee #10 3 12.0 282.72 66 35.64 September 2023 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0.54 Employee #11 2 8.0 188.48 84 45.36 Employee #1 10 6.3 148.43 0 0.00 Employee #5 2.0 4.0 94.24 5 2.70 Employee #10 3.0 10.0 235.60 66 35.64 October 2023 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0.54 Employee #11 2 8.0 188.48 84 45.36 Employee #1 11 9.3 219.11 8 4.32 Employee #5 4 8.0 188.48 88 47.52 November 2023 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0.54 Employee #8 13 13.0 306.28 36 19.44 Employee #1 14 7.3 171.99 0 0.00 Employee #5 2 2.0 47.12 4 2.16 December 2023 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0.54 Employee #8 14 23.45 552.48 181 97.74 Employee #1 12 7.0 164.92 0 0.00 Employee #5 3 9.0 212.04 0 0.00 January 2024 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0.54 Employee #8 1 1.15 27.09 28 25.92 Employee #1 15 15.45 364.00 0 0.00 Employee #5 1 1.0 23.56 9 4.86 February 2024 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0.54 Employee #11 1 0.5 11.78 9 4.86 Employee #1 20 21.56 507.95 118 63.72 Employee #5 1 1.0 23.56 9 4.86 March 2024 Volunteer Assigned Care Visits Total Hours Value 23.56 Miles Value 0,54 Employee #8 2 4.0 94.24 28 15.12 Employee #7 2 1.0 23.56 0 0.00 Employee #1 10 7.45 175.52 0 0.00 Employee #5 1 1.0 23.56 12 6.48 An example of documentation of services provided was found in the medical record of Patient #6. Patient #6 “Volunteer Notes” were found dated 3/12/22, 5/2/22, 6/6/22, 7/1/22, 9/1/22, 10/4/22, 11/3/22, 1/3/23, 3/14/23, 6/3/23, 10/6/23, 11/3/23 and 1/5/24. When these notes were opened, a generic mailed .pdf flyer with a picture and a quote could be found. No other documentation was attached. A cross-reference of the “Volunteer Care and Services” documentation provided, which was broken down by individual patient, indicated that Employee #1 reported 15 minutes of direct-care activity on 1/2/23, 3/11/23, 6/3/23, 10/7/23, 11/4/23 and 1/6/24. In a subsequent interview conducted with Employee #1 on May 1, 2024, Employee #1 confirmed there were no other unpaid volunteers providing services for the agency and that the services documented in the “Volunteer Care and Services” sheets provided are utilized to calculate total volunteer hours provided by the agency.”

“Based on facility policy and procedure and review of medical records, the Department has determined the Administrator has failed to ensure that pain was effectively managed for Patients #2 and #4. Failure to ensure a patient’s pain is managed timely and in accordance with facility policies and practices can result in severe decline in the quality of the patient experience of care an exacerbate the patient’s condition. Findings include: Facility policy titled, “;Pain and Symptom Management Assessment....” revised 11/1/2020 revealed, “;...Nurses, CNAs, Chaplains and Social Workers will inquire about and assess the patients pain/comfort level at every visit....” Facility policy titled, “Control of Narcotics,” revised 11/1/2020 revealed, “...If pain control is not effective, the Nurse will collaborate with the Medical Director/Physician/Nurse Practitioner for titration of medications after medication review....” Patient #2 Hospital History & Physical dated 2/7/2024 8:01 a.m. revealed: “;...Patient...presents with back and hip pain and abdominal pain...Principal problem: Generalized abdominal pain....” Nursing Summary Note dated 1/31/2024 revealed: “;...Reports generalized pain and mentioned it is not being relieved through her medications....” IDG assessment dated 2/6/2024 revealed: “;...Received TC (telephone call) at 1039, 1107, 1130, 1240, 1315 regarding “;terrible pain” and requesting extra dose of ibuprofen. Contacted...at 1045 with request to administer PRN dose of ibuprofen...medication administered at 1120...LE edema worsening as day progresses...TC at 1315...reporting “;medication not working.” Instructed to lay down in bed for 2 hours; as she has schedule Oxy dose at 1400. She reported she does not like to lay down during the day. Encouraged to lay down and rest and not focus on pain and increased pain can be from LE edema...[Patient #2] had gone to the ER last nigh (sic) due to unrelieved pain...she stated her 10 mg of Oxycodone was not relieving her pain and she needed her dose increased to 15 mg “;now....”given her 1400 dose of 10mg and 5mg was administered at 1515, a total of 15mg administered.... General visit note completed by Employee #1 on 2/7/2024 revealed: “;...Time of Event: 0800...Arrived at facility to find pt. had called 911 and been taken to ER after contacting On-Call Nurse and reporting chest pain and difficulty breathing...Awaiting return call to discuss POC....” General visit note completed by Employee #1 on 2/8/2024 revealed: “;...Visit to pt. in Scottsdale Osborn Hospital room 310 for signature on Revocation of Hospice benefit due to seeking aggressive treatment. Signature obtained. Explained to [patient #2] re-admission guidelines/Palliative Care guidelines. Spoke with Hospital Nurse...and informed of revocation from Hospice....” Skilled nursing pain observation #1 dated 1/24/2024 revealed: “;...Patient stated she has mild pain in her lower extremities...Was comprehensive pain assessment done? No....” Skilled nursing pain observation #1 dated 1/31/2024 revealed: “;...Patient is content with pain management and reports generalized pain...Was comprehensive pain assessment done?...No....” Patient #4 “...Comprehensive RN Admission Assessment” dated November 1, 2023 11:00 a.m. revealed: “...[Patient #4] reports her neuropathic and wound pain from fungating breast Cancer (sic) 20/10 at time of admit. She had previously been on Fentanyl patch 100mcg prior to last Chemo (sic) but dc’d by last oncologist with Chemo (sic) and using oxycodone 5mg 1-2 tabs po q 6 hours for pain management. Order received at admission and Fentanyl patch 25mcg applied. Oxy to continue for BT (breakthrough) pain....” “...Pain assessment....” dated November 2, 2023 revealed: “...Pain rating...10....” “...Pain assessment....” dated November 3, 2023 revealed: “...Pain rating...7....” “...Pain assessment....” dated November 5, 2023 revealed: “...Pain rating...7....” “...Comprehensive RN Admission Assessment....” dated November 5, 2023 revealed: “...Time of visit...11/01/2023 11:00 a.m. “...RN Routine Assessment....” dated November 10, 2023 revealed: “...The patient stated the increased dose has relieved her pain...Was a comprehensive pain assessment done?...No....” “...RN Routine Assessment....” dated November 14, 2024 revealed: “...The patient presents her fungating wounds located on her chest, under her breasts and on her upper back. The wounds have a foul odor with a purulent, bloody drainage. The patient states the wounds are very painful...The patient states the wounds on her chest are extremely painful and it is sometimes managed through medications. However, at times she mentions that not even medications are helping...The patient was sent to the ER for he (sic) wounds and was treated with Amoxicillin, IV fluids and Z-pack...Was comprehensive pain assessment done?...No....” “...Pain Assessment....” dated November 17, 2023 revealed: “...The patient’s skin has the fungating wounds located on the upper body. There is redness to the wounds and there is serious leakage from under the left axilla and the wounds on her upper back...The patient verbalized pain from her wounds...Was a comprehensive pain assessment done?...No...The wounds are swollen, red and the patient verbalizes severe pain from her wounds....””

“Based on interview, review of policy and procedures and review of facility documents, the Department has determined the Administrator failed to ensure that viable and ongoing efforts to recruit volunteers were taking place. Failure to conduct ongoing and vigorous volunteer recruitment can result in the stagnation and failure of volunteer services, resulting in less services or poorer quality services being provided to patients. Findings include: Facility policy titled, “...Volunteer Services....” revised 11/01/2020 revealed: “...The volunteer coordinator will recruit volunteers....” A review of the facility volunteer services documentation, QAPI (quality performance indicators) reports from the previous year and governing body minutes from the previous year revealed no documentation of any efforts for volunteer recruitment. In a subsequent interview conducted with Employee #1 on May 1, 2024, Employee #1 confirmed there was no further documentation to provide regarding volunteer recruitment efforts.”

“Based review of facility policy and procedure and medical record reviews, the Department has determined the Administrator failed to ensure that an initial certification anticipating the patient’s life expectancy is 6 months or less to live was based on review of the current medical findings, medication and treatment orders, information provided about the management of the patient’s conditions unrelated to the terminal illness and the patient’s current diagnoses, for Patients #1 and #2. Failure to accurately assess the initial certification of a patient based on current medical information provided can result in a patient being placed on hospice inappropriately. Findings include: Facility policy titled, “;...Admission Criteria....” revised 11/1/2020 revealed: “;...The patient has a terminal prognosis of six months or less to live if the disease progresses in its normal course, as certified by the Pillars Hospice Care medical director and the attending physician...A patient shall not be admitted to services without a signed Pillars Hospice Care Informed Consent/Conditions of Service form....” Facility policy titled, “;Hospice Admission Guidelines....” revealed: “;...Heart Disease...Angina at rest/not surgical candidate, NYHA Class IV with signs of CHF and/or angina at rest, Inability to carry out minimal activity without dyspnea or angina OR ejection fraction of <20%...Supportive factors...treatment resistant symptomatic supraventricular or ventricular arrhythmias, history of cardiac arrest or resuscitation, history of unexplained syncope, brain embolism of cardiac origin, concomitant HIV....” Patient #1 “;...Patient Notification of Hospice Non-Covered Items, Services and Drugs....” revealed: No diagnosis was entered on the form under “;...Diagnosis Related to Terminal Illness and Related Conditions....” or under “;...Diagnosis Unrelated to Terminal Illness and Related Conditions....” “;...History and Physical....” dated October 15, 2022 revealed: “;...The patient is a 79-year-old woman with history of Parkinsons Disease...social history...denies any tobacco alcohol or illicit drug use history...BP: 177/89...Final report...October 16, 2022...Systolic supine 162...Diastolic 79...Heart Rate...83...Systolic standing...136...Diastolic sitting...68...Heart rate standing...97...General: Alert and oriented to person and place...Psychiatric: Cooperative, appropriate mood and affect...final diagnoses...Colonic mass, status post colonoscopy with biopsy. NO overt mass noted...Generalized weakness and fall...Orthostasis...Hyponatremia, resolved...Hypokalemia, repleted...Advanced Parkinson Disease...Nausea and vomiting, resolved, Anxiety and depression and hypothyroidism....” “;...Hospice Certification of Terminal Illness....” dated 12/6/2022 revealed: “;...79 yo lady with history of Parkinsons disease. Other health matters include anxiety, depression, alcoholism, cirrhosis, dyslipidemia and hypothyroidism...On Exam Vitals...BP116/69, pulse77...CV RR. No murmur noted (sic). Radial pulses are 1+...A and O x4 Answered questions appropriately. Able to make needs known...At this juncture her recent past course appears to suggest she will not survive another 6 months.... Patient #2 Hospital admission assessment dated May 6, 2023 revealed: “;...Patient is a 86 y.o. female with a complicated past medical history of chronic pain syndrome right below-the-knee amputation history of DVT, history of atrial fibrillation...she is on a pain contract...Patient is unable to contribute to her history at this time because of the fentanyl and Ativan combination...Pain in her left thigh with bruising no acute fracture seen patient is on chronic opiates high-dose under a pain contract....BP 130/65...physical exam...cardiovascular...rate and rhythm: Normal rate and regular rhythm...Heart sounds: Normal heart sounds....” “;...Hospice Certification of Terminal Illness....” dated 8/23/2023 revealed: “;...87 yo female w CHF (Congestive Heart Failure) HTN (hypertension) Chronic pain bed bound on fentanyl oxy 94 prn wears briefs and protective pad two falls in the past two weeks rt leg several abrasions noted over shin, discoloration around ankle and shin difficulty chewing 12-14 hours per night and naps frequently. Pt is appropriate for hospice...BP 132/74....Cardiovascular: Regular rate, S1S2 present, no murmur, no LE edema....””

“Based on review of policy and procedure and review of medical records, the Department has determined the Administrator failed to ensure that a patient’s clinical information was reviewed prior to the medical director or physician designee completing a recertification to ensure congruency of information and proper recertification of patients. Failure to review patient medical information when determining recertification can result in inconsistencies when reporting patient information or misdiagnosis. Findings include: Patient #1 “;...Patient Notification of Hospice Non-Covered Items, Services and Drugs....” revealed: No diagnosis was entered on the form under “;...Diagnosis Related to Terminal Illness and Related Conditions....” or under “;...Diagnosis Unrelated to Terminal Illness and Related Conditions....” “;...History and Physical....” dated October 15, 2022 revealed: “;...The patient is a 79-year-old woman with history of Parkinsons Disease...social history...denies any tobacco alcohol or illicit drug use history...BP: 177/89...Final report...October 16, 2022...Systolic supine 162...Diastolic 79...Heart Rate...83...Systolic standing...136...Diastolic sitting...68...Heart rate standing...97...General: Alert and oriented to person and place...Psychiatric: Cooperative, appropriate mood and affect...final diagnoses...Colonic mass, status post colonoscopy with biopsy. NO overt mass noted...Generalized weakness and fall...Orthostasis...Hyponatremia, resolved...Hypokalemia, repleted...Advanced Parkinson Disease...Nausea and vomiting, resolved, Anxiety and depression and hypothyroidism....” “;...Hospice Certification of Terminal Illness....” dated 12/6/2022 revealed: “;...79 yo lady with history of Parkinsons disease. Other health matters include anxiety, depression, alcoholism, cirrhosis, dyslipidemia and hypothyroidism...On Exam Vitals...BP116/69, pulse77...CV RR. No murmur noted (sic). Radial pulses are 1+...A and O x4 Answered questions appropriately. Able to make needs known...At this juncture her recent past course appears to suggest she will not survive another 6 months.... “;...Hospice Certification of Terminal Illness....” dated 3/6/2023 revealed: “;...80 year old lady. Multiple medical issues. These include: Parkinsons disease, anxiety, depression, Alcoholism, cirrhosis and hypothyroidism...On exam VS BP 116/69, pulse 88....” “;...Hospice Certification of Terminal Illness....” dated 6/4/2023 revealed: “;...80 you (sic) lady with history of essential hypertension. Other health issues include alcohol abuse, liver cirrhosis, depression/anxiety, generalized weakness and hypothyroidism...On exam, BP 150/78, pulse 64...Terminal dx: Hypertensive heart disease.... “;...Hospice Certification of Terminal Illness....” dated 8/3/2023 revealed: “;...80 year old lady. History includes Alcoholism with cirrhosis and ascites. She does HTN, anxiety, depression and hypothyroidism. She requires some assistance with ADLs...BP 162/80...A and O to self and surroundings Able to make needs known. Does repeat herself...At present she appears unlikely to survive another 6 months...Terminal DX: Hypertensive heart disease “;...Hospice Certification of Terminal Illness....” dated 10/02/2023 revealed: “;...80 year old lady. History includes Alcoholism with cirrhosis and ascites. She does HTN, anxiety, depression and hypothyroidism...She is reported to be eating well...BP 162/80...A and O to self and surroundings...Able to make needs known. Does repeat self...At present she appears unlikely to survive another 6 months...Terminal DX: Hypertensive heart disease....” “;...Hospice Certification of Terminal Illness....” dated 12/1/2023 revealed: “;...80 year old lady. Has end stage heart disease. Other medical issues include HTN, anxiety, alcoholism, cirrhosis of the liver, depression, hypothyroidism...She is able to feed herself. She ambulates with a new walker...BP175/85...CV irregular rhythm, murmur noted and O x2-3. Some forgetfulness, able to make needs known...It does not appear at this point that [Patient] is likely to survive another 6 months...Terminal DX: Hypertensive heart disease....” “;...Hospice Certification of Terminal Illness....” dated 1/30/2024 revealed: “;...80 year old female w HTN (hypertension) in ALF (assisted living facility) PD (Parkinsons Disease) and depression has increased fatigue continues decline needs assistances (sic) with ADL; wears briefs remains appropriate for hospice...cardiovascular: irregular rhythm, S1S2 present + murmur, 2+ pitting bilateral LE edema...Terminal DX: Hypertensive Heart Disease....” It should be noted there was no documentation of vitals taken during this certification period. IDG Comprehensive Assessment dated 12/13/2022 revealed: “;...[Patient #1] is a 79-year-old female with history of Parkinsons Disease...HR: 77 BP: 116/69 heart tones regular to auscultation, no edema present, radial and pedal pulses strong to palpation, no complaints of chest pain at this time...IDT: Per discussion and agreement, [Patient #1] is appropriate for hospice due to Parkinsons as evidenced by: declining; no longer seeking aggressive treatment; fall risk due to activity intolerance; dyspnea with exertion; has increased need for assistance with ADLs; appetite has decreased; forgetful; tremors; thin; pale; weakness; and fatigue....” Patient #3 “;...Hospice Certification of Terminal Illness....” dated 12/23/2022 revealed: “;91 yo male admitted with HTN history. He does have history of PAD with R. carotid stenosis, AF, dyslipidemia, type 2 diabetes, cognitive decline, macular degeneration and history of prostate cancer treated some 20 yr ago...BP 161/72...At this juncture it appears unlikely he will survive 6 months....” “;...Hospice Certification of Terminal Illness....” dated 3/23/2023 revealed: “;...91 yo male. Admitted with HTN history...BP 140/68...CV: Normal S1 and S2. No murmur noted, Good radial and pedal pulses...It remains unlikely at this point that [pt] will survive another 6 months....” “;...Hospice Certification of Terminal Illness....” dated 6/21/2023 revealed: “;...91 y/o male Essential (primary) hypertension Hypertensive urgency, Occlusion and stenosis of the right carotid artery...Hes (sic) forgetful but not demented and remains appropriate for hospice...BP: 132/76...Cardiovascular: regular rate, tachycardic, S1S2 present, -murmur, mild bilateral edema, psychiatric: affect pleasant and talkative, A/O (alert and oriented) to self and surroundings, able to let his needs be known...Terminal DX: Essential (primary) hypertension....” “;...Hospice Certification of Terminal Illness....” dated 8/20/2023 revealed: “;91 yo male w htn & hypertension urgency and hypertension chronic kidney disease & encycloycathy (sic) sleeping more than 12 a day he is thin and fail (sic) w/tacky pt remains a hospice candidate...BP 136/72...Cardiovascular: regular rate, S1S2 present, -murmur, mild bilateral edema...Terminal DX: Essential (primary) hypertension....” “;...Hospice Certification of Terminal Illness....” dated 10/19/2023 revealed: “;...92 yo male. Admitted with HTN. Has PVD with R carotid occlusion. Also has arrhythmia with PMR...BP 146/72...It is unlikely this man will survive another 6 months...Terminal DX: Essential (primary) hypertension....” “;...Hospice Certification of Terminal Illness....” dated 12/18/2023 revealed: “;...92 Male DX Hypertensive urgency right carotid artery pulse 67...slow decline irregular rate S1S2 present, -murmur no LE edema present...cardiac pacer left anterior chest wall Patient appropriate for hospice...BP 156/78...Terminal DX: Essential (primary) hypertension....” “;...Hospice Certification of Terminal Illness....” dated 2/16/2024 revealed: “;...92 yo male. Admitted with chronic HTN...BO 137/66, Pulse 63 and irregular...Given some declines it remains unlikely he will survive another 6 months.... Patient #8 Admission order dated, 7/22/19 to 10/19/19 revealed: “...terminal diagnosis...cardiovascular disease....” Recertification period 10/20/19-1/17/20 revealed: “...83 y/o female with COPD and cardiomyopathy....” Recertification period 1/18/20-3/17/20 revealed: “...83 y/o [symbol for female] adm [admitted] for cmp [cardiomyopathy].....” Recertification period 3/18/20-5/16/20 revealed: “...83 y/o f [female] with cmp [cardiomyopathy]....” Recertification period 5/17/20-7/15/20 revealed: “...84 y/o female with history of CAD (coronary artery disease), & chest pain & a-fib. Has severe COPD and CHF with pedal edema....” Recertification period 7/16/20-9/13/20 revealed: “...83 y/0 f [female] admitted with end-stage cardiomyopathy. She is rapidly declining....” Recertification period 9/14/20-11/12/20 revealed: “...84 year old female with cardiomyopathy....” Recertification period 1/12/21-3/12/21 revealed: “...84 y/o female with...COPD....” Recertification period 3/13/21-5/11/21 revealed: “...84 y/o with cardiomyopathy. Still with palpitations. A-fib....” Recertification period 5/12/21-7/10/21 revealed: “...85 y/o female with COPD, CHF....” Recertification period 7/11/21-9/8/21 revealed: “...85 y/o with hx of CM [cardiomyopathy], COPD and CHF....” “ Recertification period 9/9/21-11/7/21 revealed: “...85 y/o female with COPD and CHF....” Recertification period 1/7/22-3/7/22 revealed: “...85 y/o female with end stage CHF (congestive heart failure) and COPD (chronic obstructive pulmonary disease)....” Recertification period 5/7/22-7/5/22 revealed: “...85 y/o female with end stage COPD and CHF....” Recertification period 7/6/22-9/3/22 revealed: “...86 y/o female with COPD and end stage CHF....” Recertification period 11/3/22-1/1/23 revealed: “...86 y/o with cardiomyopathy and dyspnea. Some anxiety. Anorexic....” Recertification period 1/2/23-3/2/23 revealed: “...86 y/o female declining and weaker. Not leaving home. Appetite decreased. Breathing ok. Some wheezing. Pt. continues to decline, appropriate for hospice....” No diagnosis was included in the recertification.”

“A review of policy and procedure and the medical record indicated the administrator failed to ensure the patient or patient’s representative either consented to or refused treatment in three of three patients reviewed, Patients #1, #2 and #3 and failed to obtain a signature of consent on the Notification of Hospice in Change in Attending Physician form for Patient #4. Failure to ensure patients fully consent or refuse treatment can result in patients not understanding what they are consenting to or refusing, creating a danger to the patient. Findings include: Facility policy titled, “...Admission Criteria....” revised 11/1/2020 revealed: “...A patient shall not be admitted to services without a signed Pillars Hospice Care Informed Consent/Conditions of Service form....The Pillars Hospice Care medical director may serve as the patient’s attending physician if the patient chooses....” Patient #1 “;...Patient Notification of Hospice Non-Covered Items, Services and Drugs....” revealed: No diagnosis was entered on the form under “;...Diagnosis Related to Terminal Illness and Related Conditions....” or under “;...Diagnosis Unrelated to Terminal Illness and Related Conditions....” The patient did not sign the form. Instead, it is marked, “;Unable to sign” and the form is signed by a representative on December 6, 2022. An informed consent form could not be found signed by the patient. “;...History and Physical....” dated October 15, 2022 revealed: “;...General: Alert and oriented to person and place...Psychiatric: Cooperative, appropriate mood and affect...” Patient #2 General visit note completed by Employee #1 on 2/8/2024 revealed: “;...Visit to pt. in Scottsdale Osborn Hospital room 310 for signature on Revocation of Hospice benefit due to seeking aggressive treatment. Signature obtained. Explained to [patient #2] re-admission guidelines/Palliative Care guidelines. Spoke with Hospital Nurse...and informed of revocation from Hospice....” Emergency Department Initial Assessment dated 2/7/2024 revealed: Met patient at the bedside just after [Pillars staff] had patient sign paperwork. Asked if she knew what paperwork she just signed. Pt. states, “;No, I dont even know who the person was.” When asked why she signed the paperwork, patient states, “;She wanted me to.” Patient #4 “...Notification of Hospice in Change in Attending Physician....” has no patient or patient representative signature but is signed by a hospice representative and dated November 1, 2023. The form designated Employee #3 as Patient #4’s attending physician.”

“Based on interview, review of policy and procedure and review of patient records, the Department has determined the Administrator has failed to ensure that stamped physician signatures do not appear on patient orders or other documents that are a part of the patient’s clinical record or that a physician’s electronic signature could not be misused. Failure to safeguard the signature of physicians can result in services or goods not being provided to patients or services being provided improperly to patients. Findings include: Facility policy titled, “...Medication Administration....” revised 11/1/2020 revealed: “...All verbal changes in medication orders will be taken by the nurse and signed by the physician or nurse practitioner....” Facility policy titled, “...Referral and Admission Process....” revised 11/1/2020 revealed: “...The medical decision maker must sign the following forms...Informed Consent/Conditions of Service...This references review of the following...Informed Consent for Psychotropic Medications....” An admission packet was provided. Inside the packet was a form titled, “...Informed Consent for Psychotropic Medication Treatment....” that contained the stamped or electronic signature of Employee #3. The form indicated the signatory, Employee #3 as the prescriber of any medications that would be listed on the form. The completed form was found in the medical record of Patient #4. Two additional stamped signatures for Employee #3 appeared on this form indicating that Employee #3 had provided in-person counseling to Patient #5 regarding potential side effects for Lorazepam and for Morphine. In an interview conducted with Employee #1, Employee #1 confirmed the pre-stamped forms were currently put in the admission packets for use by the admission staff. Facility policy titled, “...Medication Administration....” revised 11/1/2020 revealed: “...All verbal changes in medication orders will be taken by the nurse and signed by the physician or nurse practitioner....” Facility policy titled, “...Referral and Admission Process....” revised 11/1/2020 revealed: “...The medical decision maker must sign the following forms...Informed Consent/Conditions of Service...This references review of the following...Informed Consent for Psychotropic Medications....” An admission packet was provided. Inside the packet was a form titled, “...Informed Consent for Psychotropic Medication Treatment....” that contained the stamped or electronic signature of Employee #3. The form indicated the signatory, Employee #3 as the prescriber of any medications that would be listed on the form. The completed form was found in the medical record of Patient #4. Two additional stamped signatures for Employee #3 appeared on this form indicating that Employee #3 had provided in-person counseling to Patient #5 regarding potential side effects for Lorazepam and for Morphine. In an interview conducted with Employee #1, Employee #1 confirmed the pre-stamped forms were currently put in the admission packets for use by the admission staff. Facility policy titled, “...Medication Administration....” revised 11/1/2020 revealed: “...All verbal changes in medication orders will be taken by the nurse and signed by the physician or nurse practitioner....” Facility policy titled, “...Referral and Admission Process....” revised 11/1/2020 revealed: “...The medical decision maker must sign the following forms...Informed Consent/Conditions of Service...This references review of the following...Informed Consent for Psychotropic Medications....” An admission packet was provided. Inside the packet was a form titled, “...Informed Consent for Psychotropic Medication Treatment....” that contained the stamped or electronic signature of Employee #3. The form indicated the signatory, Employee #3 as the prescriber of any medications that would be listed on the form. The completed form was found in the medical record of Patient #4. Two additional stamped signatures for Employee #3 appeared on this form indicating that Employee #3 had provided in-person counseling to Patient #5 regarding potential side effects for Lorazepam and for Morphine. In an interview conducted with Employee #1, Employee #1 confirmed the pre-stamped forms were currently put in the admission packets for use by the admission staff. Facility policy titled, “...Medication Administration....” revised 11/1/2020 revealed: “...All verbal changes in medication orders will be taken by the nurse and signed by the physician or nurse practitioner....” Facility policy titled, “...Referral and Admission Process....” revised 11/1/2020 revealed: “...The medical decision maker must sign the following forms...Informed Consent/Conditions of Service...This references review of the following...Informed Consent for Psychotropic Medications....” An admission packet was provided. Inside the packet was a form titled, “...Informed Consent for Psychotropic Medication Treatment....” that contained the stamped or electronic signature of Employee #3. The form indicated the signatory, Employee #3 as the prescriber of any medications that would be listed on the form. The completed form was found in the medical record of Patient #4. Two additional stamped signatures for Employee #3 appeared on this form indicating that Employee #3 had provided in-person counseling to Patient #5 regarding potential side effects for Lorazepam and for Morphine. In an interview conducted with Employee #1, Employee #1 confirmed the pre-stamped forms were currently put in the admission packets for use by the admission staff.”

“Based on record review and staff interviews it was determined the hospice failed to ensure adequate precautions were taken to prevent physical or electronic altering of patient medical records. This deficient and negligent practice has the potential that documents were being fraudulently altered without the consent or authorization of the patient or the patient’s representatives posing the risk of both the falsification of records and fraudulent billing practices. Findings include: A review of Patient #1’s medical record revealed a document titled, “Prehospital Medical Care Directive” for Pillars Palliative Care Program, with a handwritten signature of Patient #1, Licensed Health Care Provider #14, and Witness, dated 10/24/2022. A second document with all three signatures identical to the first “Prehospital Medical Care Directive... Pillars Hospice Care...”, revealed alterations to the date to reflect a new date of 12/06/2022. Observation of the second document revealed evidence that corrective fluid/tape or electronic changes had been made. A review of Patient #10’s medical record revealed an altered document titled, “RELEASE OF PATIENT RECORDS”. The document was signed on 10/10/2023 by Patient #10 and Employee #9. The patient did not check any of the requested medical information boxes listed in the document, “... Current History and Physical... X-ray Report...EKG Report...Consultation Report...Discharge Summary...Lab Report...Surgical Report...Previous Hospice Records...Chemotherapy Summary...Radiation Therapy...Pathology Report...Other...” specifying what records were to be released. Another copy of this document was found that had been altered. All of the boxes had “x” marked next to all aforementioned medical information. Patient information was electronically altered or by using a corrective fluid/tape. In an interview conducted on 05/01/2024, with Employee #1, he/she confirmed that evidence of alterations were made to the original document to reflect a change in the date and program without Patient #1’s consent. Employee #1 further confirmed that it is the practice of Pillars Hospice to alter the “RELEASE OF PATIENT RECORDS” when requesting information. In an interview conducted on 05/01/2024, with Employee #2, he/she confirmed that alterations were made to the document titled, “RELEASE OF MEDICAL RECORDS”.”

“Based on record review and staff interview it was determined the hospice failed to discharge patient(s) that had been admitted to the hospital and continued to bill for hospice services not being provided. This fraudulent and negligent practice has the potential that the hospice is not discharging patients when hospice services are no longer or cannot be provided to the patient posing the risk of fraud. Findings include: A review of Pillars Hospice Care Policy 4.18.1, titled, “Discharge Criteria”, revealed, “...The reasons for discharge are as follows:...(2) If hospitalization is not appropriate as hospice in-patient care, discharge the patient effective on the date of hospital admission....”. A review of Patient #10’s medical record revealed the patient was admitted to the hospital for surgery on 02/13/2024. A document titled, “Communication Note”, dated 02/15/2024, written by Employee #8, revealed,”... TC with CG... was on the way to the hospital to visit...”, Patient #10. Discharge paperwork from the hospital reflected hospitalization dates 02/13/2024 through 02/19/2024. There was no evidence in the medical record that Patient #10 had been discharged from hospice during the hospitalization dates. In an interview conducted on 05/01/2024 with Employee #1, he/she confirmed that the hospice does not discharge patients from hospice when patients are hospitalized. No further documentation that Patient #10 was discharged could be provided.”