Lakeview Hospice Care Inc.

“Observed in Record Review. In 3 of 19 patient records reviewed, the organization failed to assess and reassess its patients. For example in HOSRRNHV #5 the patient had wounds to her sacro-coccyx area and the wounds were not measured with each visit. In HOSRRHV #1 the patient had wounds to her right heel and left sole of foot and neither had wound measurements documented with each visit per organizational requirements. In HOSRRNHV #6 the patient had 7 wounds and there were no wound measurements done at start of care per organizational requirements. In HOSRRNHV #10 the patient had a wound to her left heel and there were no wound measurements done at start of care, per organizational requirements. This was reviewed and validated with the Administrator.”

“Observed in Record Review. In 9 of 19 patient records reviewed, the hospice surveyor observed that the organization did not ensure that the goals established on the plan of care were measurable and individualized. In HOSRRNHV #1 the Chaplain goal stated, Daughter will verbalize that patient’s essential needs are being met or identify were they are not met and the MSW goal for this patient stated, The patient and family will verbalize enjoyment in daily life These goals are not measurable. In HOSRRNHV #2 the MSW care plan stated, Patient and family will verbalize and or have an ability to set appropriate professional boundaries. This goal is not measurable. In HOSRRNHV #4 the Chaplain goal stated, The daughter will verbalize understanding that the spiritual counselor is available for spiritual support and the MSW goal stated, Family will verbalize understanding that assistance from MSW is available. These are not measurable goals. In HOSRRHV #2, 3, 4, and HOSRRNHV #7 the RN goal stated, Patient will verbalize that medications are effective within one hour of administration. The goal is not measurable. In HOSRRHV #3 the MSW care plan stated, patent will verbalize minimal feelings of depression. These are not measurable goals. In HOSRRHV #4, HOSRRNHV #8, and HOSRRNHV #9 the MSW goal stated, Patient and family will verbalize enjoyment in daily life. This was not a measurable goal. This was reviewed and validated with the Director of Quality.”

“Observed in Record Review. In 16 of 19 patient records reviewed, the nurse surveyor observed that the organization failed to plan the patient’s care. In HOSRRNHV 1, 2, 3, 4,,5, 6, 7, 8, 9, 10 and HOSRRHV #1, 2, 3, 4 the patient’s had an order for Oxygen 2-5 liters as needed for shortness of breath. The nurse failed to dcoumnt when the patient should use 2, 3, 4, and 5 liters of oxygen. In HOSRRNHV #3 the patient had duplicate medications ordered for pain and it was not clear as to which one to take. For example the patient had an order for Acetaminophen 325 mg every 6 hours and as needed for pain and Acetaminophen 500 mg one by mouth every 8 hours for pain. In HOSRRNHV #3 the patient was assessed for pain using an observational tool and was positive for symptoms of pain but the RN failed to enter interventions addressing the patient’s pain.In HOSRRHV #1 there were no orders for wound care to the sole of the left foot. The surveyor observed a dressing to the foot on the home visit. In HOSRRNHV #9 the patient had a foley catheter present and the provider submitted an order that did not identify the frequency of when to change the catheter. The order was incomplete. In HOSRRNHV #6, #7, #8, HOSRRDC #1, and HOSRRBRV #1 and HOSRRBRV #3 the patients were on an anticoagulant and the RN did not create a care plan addressing the bleeding risk. This was reviewed and validated with the Administrator.”

“Observed in Record Review. In 13 of 19 patient records reviewed, the organization failed to provide written patient care instructions for the hospice aide. In HOSRRNHV #1 and HOSRRNHV #8 the patient was on an anticoagulant and oxygen and there were no specific instructions on these precautions in the aide assignment. In HOSRRNHV #2 and HOSRRNHV #3 these patients were on oxygen and the aide assignments did not include specific instructions on what the aide’s should do with the oxygen when bathing the patient. In HOSRRNHV #3 the patient was an aspiration risk and this precaution was not entered into the aide assignment. In HOSRRNHV #4, HOSRRNHV #7, HOSRRDC #1, HOSRRBRV #1, and HOSRRBRV #3 the patient was on an anticoagulant and there were no bleeding precautions entered into the aide assignment. In HOSRRNHV #5 the patient had wounds to the right and left sacrococcyx area and there were no instructions as to what the aide should do in the event that the dressings became soiled and or dislodged. In HOSRRHV #1 the patient had wounds to her right and left foot and there was no documentation as to what the aide should do if the dressings became soiled or dislodged. In HOSRRNHV #6 the patient had a G-tube, and 7 wounds one of which had a wound vac and was taking an anticoagulant and there were instructions on bleeding precautions and what the aide should do with the G tube and wounds when bathing the patient. In HOSRRNHV #9 the patient had a colostomy, foley catheter, and there were no instructions for the home health aide as to what she should do when bathing the patient. This was reviewed and validated with the Administrator.”

“Based on interview and record review, the hospice agency failed to ensure to complete wound assessments that included wound size in accordance with the hospice policy and procedure for one of 14 sampled patients (Patient 4). This deficient practice had the potential for infection and deterioration of Patient 4’s wounds and had the potential for Patient 4 to feel discomfort and/or pain. Findings: During a review of Patient 4’s admission record, the admission record indicated the start of care date on 11/24/2023, 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 4’s Registered nurse (RN) Supervisory Visit note conducted RN 1, dated 7/23/2024, indicated Patient 4 had a left chest open wound. The Supervisory Visit Note indicated the wound assessment was not completed and there was no wound size. During a phone interview on 8/9/2024, at 10:40 a.m., with RN 1, RN 1 stated every wound should have a complete wound assessment on every visit which includes wound description, location, color, presence of drainage, and wound size. RN 1 stated she did not measure Patient 4s left chest open wound during her visit on 7/23/2024. During an interview on 8/9/2024, at 12:10 p.m., with the Director of Patient Care Services Designee (DD), the DD stated Patient 4’s wound should have been assessed completely on every nurse visit that includes wound measurement. The DD stated it was important to measure the wound to monitor if the wound is healing or not, and if treatment plan was effective. During a review of the agencys policy and procedure titled, “;Contents of the Clinical Record Skin Integrity”, revised April 2021, indicated the clinical records will maintain records on skin integrity and any skin integrity issues identified for each patient receiving care. The following information will be included in the clinical record: a. Assessment of skin integrity b. Any alteration in skin integrity will be documented and classified appropriately c. Physician will be notified and physician orders will be obtained for any treatments/interventions d. Any treatments performed during visits e. Patients response to treatment f. Wound measurements will documented at least once a month g. Plan of care will be updated.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to conduct an updated re-assessment of the patients left chest open wound for one of 14 sampled patients (Patient 4). This deficient practice may result in the failure to identify changes in Patient 4s needs and inability to provide the care and services. Findings: During a review of Patient 4’s admission record, the admission record indicated the patient start of care date on 11/24/2023, 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 4’s Current Care Plan Problems form indicated a care plan titled, Impaired skin integrity as evidenced by open wound to left chest with possible maggots, was initiated on 7/23/2024. The goal indicated that by 10/30/2024, no signs or symptoms of infection would be reported or noted. One of the care plan problem interventions indicated was to perform an assessment of the patients skin integrity on every visit. During a concurrent interview and record review with the Director of Patient Care Services Designee (DD), on 8/9/2024, at 12:10 p.m., the DD reviewed Patient 4s LVN (Licensed vocational nurse) Visit Note dated 7/26/2024 and 7/29/2024. The DD stated there was no documented evidence the visiting nurse performed reassessment of Patient 4s left chest open wound on 7/26/2024 and 7/29/2024. The DD stated the agencys license nurses (in general) should assess the patients wounds on every visit to monitor for wound healing and for signs and symptoms of wound infection. During a review of the agencys policy and procedure titled, “;Ongoing Comprehensive Assessments”, revised October 2015, indicated the scope and intensity of ongoing hospice patient assessments will be determined by the patients prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. The nurse will assess the patient on each visit, for skin integrity. During a review of the agencys policy and procedure titled, “;Contents of the Clinical Record Skin Integrity”, revised April 2021, indicated the clinical records will maintain records on skin integrity and any skin integrity issues identified for each patient receiving care. The following information will be included in the clinical record: a. Assessment of skin integrity b. Any alteration in skin integrity will be documented and classified appropriately c. Physician will be notified and physician orders will be obtained for any treatments/interventions d. Any treatments performed during visits e. Patients response to treatment f. Wound measurements will documented at least once a month g.Plan of care will be updated.”

“Based on observation, interview, and record review, the hospice agency failed to provide services as indicated in the plan of care for two of fourteen sampled patients (Patient 4 and Patient 6). For Patient 4, the hospice skilled nurse failed to provide wound care treatment during visits as ordered. This deficient practice placed the patient at a potential risk for a delay of wound healing. For Patient 6, the hospice skilled nurse failed to perform medication reconciliation (process of identifying the most accurate list of all medications that the patient is taking) during the visit. This deficient practice had the potential to place the patient at risk for medication errors and adverse drug reactions. A review of Patient 6’s medical record form “;General Patient Details”, indicated a start of care date of 05/14/2024, with a primary diagnosis of, with a primary diagnosis of Hypertensive heart (heart issue in result of high blood pressure) and chronic kidney disease (a loss of kidney function) with heart failure (the heart is unable to properly pump blood around the body). During a review of Patient 6’s Current Care Plan Problems form indicated a care plan titled, Alteration in comfort: Dyspnea as evidence by deficit related to shortness of breath. The goal indicated that by 8/28/24, no signs or symptoms of infection will be reported or noted. One of the care plan interventions indicated provide education regarding prescribed medications including side effects. During joint home visit with Registered Nurse (RN) 1 for patient 6 on 8/7/24 at 9:27 a.m., observed RN1 started charting in hospice binder and confirmed that she is done with her visit. RN 1 did not check patients medication and medication reconciliation was not done. During an interview with RN1 on 8/7/24 at 9:30a.m., RN1 acknowledged and stated she was supposed to do the medication reconciliation during nurse visits. RN1 stated the importance of medication reconciliation is to make sure medications are available and monitored. During an interview with the Director of Patient Care Services Designee (DD), on 8/08/24 at 11:45a.m., the DD stated that medication reconciliation should be done every nurse visits. DD stated the importance of medication reconciliation is for continuity of care, that the medications are given appropriately, for refills and for medication safety. Findings: a. During a review of Patient 4’s admission record indicated the patient start of care date on 11/24/23, 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 4’s Current Care Plan Problems form indicated a care plan titled, Impaired skin integrity as evidenced by open wound to left chest with possible maggots was initiated on 7/23/2024. The goal indicated that by 10/30/24, no signs or symptoms of infection will be reported or noted. One of the care plan interventions indicated was medication therapy per physician order. A wound care treatment was ordered on 7/23/2024, to cleanse the open wound on the left chest with Dakin’s solution, pat dry, close with island bordered dressing daily and as needed for soiling/loss of integrity. During a concurrent interview and record review with the Director of Patient Care Services Designee (DD), on 8/09/24 at 12:10 p.m., the DD reviewed Patient 4s LVN (Licensed vocational nurse) Visit Note dated 7/26/24 and 7/29/24. The DD stated and confirmed there was no documented evidence wound care was provided as ordered to Patient 4s left chest open wound on 7/26/24 and 7/29/24. The DD stated the license nurse should perform the wound care treatment during the home visit and document the care that was done in the patients clinical record. During a review of the agencys policy and procedure titled, “;The Plan of Care”, revised October 2015, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has 6 months or less to live) failed to ensure a patient care plan was developed and completed that included problems, interventions, and goals, for one of 14 sampled patients (Patient 6). This deficient practice had the potential to affect Patient 6’s necessary care and services. During a review of Patient 6’s General Patient Details, the General Patient Details indicated a start of care date of 5/14/2024, with a primary diagnosis of hypertensive heart (heart issue in result of high blood pressure) and chronic kidney disease (a loss of kidney function) with heart failure (the heart is unable to properly pump blood around the body). During a review of Patient 6’s Medications Physician’s Order dated 5/15/2024, the Medications Physician’s Order indicated for Patient 6 to receive Mirtazapine (anti-depressant (medication) 15mg (milligrams, a unit of measurement) for mood and appetite management at bedtime. The Medications Physician’s Order indicated for Patient 6 to receive Quetiapine Fumarate (psychotropic medication [any drug that affects mental function, behavior, and mood]) for management of agitation and sleeplessness at bedtime (0.5 tablet = 12.5mg). The Medications Physician’s Order indicated for Patient 6 to receive Lantus flex pen (medication to lower blood sugar) 100units/3ml (milliliter, unit of measurement), 3 units subcutaneous (under the skin) one time a day for diabetes mellitus (a medical condition characterized by the body’s inability to regulate blood sugar levels) at bedtime. During a concurrent interview and record review with Director of Patient Care Services Designee (DD) on 8/8/2024 at 1:11p.m., DD reviewed the plan of care for patient 6 and stated there was no care plan for the use of psychotropic medication management (Seroquel and Mirtazapine) and diabetic management (Lantus) for Patient 6. The DD stated the nurses needed to create a care plan. The DD stated the importance of a care plan was for the continuity of care and for everyone to be aware of the patients issues. During a review of the agency’s policy and procedure titled, “The Plan of Care”, revised October 2015, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.”

“Based on interview and record review the Hospice Agency (HA) failed to ensure to develop a care plan for one of fourteen sample patients (Patient 13) to address the patient’s ear infection. This failure had the potential to result in missed medication treatment and missed assessment to show an improvement or deterioration of Patient 13s ear infection which could have led to worsening of symptoms. During a record review of Patient 13s medical record form titled “;General Patient Details” undated, indicated a start of care date of 10/23/2020, with a primary diagnosis of chronic obstructive pulmonary disease (difficulty breathing due to lung issues). During a record review of Patient 13s medical record form titled “;General Details” dated 7/17/2024, indicated “;Ciprofloxacin (antibiotic medication)... give twice a day for 10 days for suspected ear infection.” During a record review of Patient 13s medical record form titled “;IDG Comprehensive Assessment Details” dated 8/7/2024, indicated “;Ear Infection – Patient reports she had an infected abscess in her mouth on the left side. Had yellow drainage coming out of right ear.” During a concurrent interview and record review on 8/8/2024, at 12:30 p.m. with the Director of Patient Care Services Designee (DD) of Patient 13s Electronic Medical Record (EMR), the DD stated the HA would add new care plans if issues arose. The DD stated the nurses (unidentified) did not develop a care plan for Patient 13s ear infection. The DD stated it was important to care plan the patients care for continuity of care, so that everyone was aware of the patients issues. During an interview on 8/8/2024, at 12:40 p.m. with the Quality Assurance and Performance Improvement nurse (QAPI), the QAPI stated she trained the Administrative Assistant 1 (AA1) to create, and updated patients care plans. QAPI stated AA1 does not have nursing training. QAPI stated patient care plans direct patients care. QAPI stated the benefits of having nursing personnel create and update patients care plans was to make better updates.”

“Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure the skilled nursing facility (SNF) where one of fourteen sample patients (Patient 13) resided was provided with the patients individualized Plan of Care (POC) and current medication list. This failure had the potential to result in the SNF staff not to be aware of the individualized planned care for the patient. It also had the potential to result in the SNF not to know which discipline and their frequency to expect for the patient. During a record review of Patient 13s medical record form titled “;General Patient Details” undated, indicated a start of care date of 10/23/2020, with a primary diagnosis of chronic obstructive pulmonary disease (difficulty breathing due to lung issues). During a joint home visit on 8/7/2024, at 9 a.m. with the Director of Patient Care Services Designee (DD) at Patient 13s residence (Skilled Nursing Facility – SNF), Patient 13s SNF did not have her individualized hospice plan of care or current medication list. The DD stated both patients individualized plan of care and current medication list should be at the patients SNF to make sure all of the patients issues are being addressed. The DD stated the patients SNF staff might not be aware Patient 13 was a fall risk and could easily have skin breakdown. The DD stated the SNF needed to be aware of Patient 13s conditions to know what to look for and what to do for her.”

“Based on interview and record review the Hospice Agency (HA) failed to ensure one of 14 sampled patients (Patient 14) family had bereavement (the state of loss when someone close to an individual has died) counseling. This failure resulted for Patient 14’s family not to receive the bereavement services after Patient 14 passed away. During a record review of Patient 14s medical record form titled “;General Patient Details” undated, indicated a start of care date of 12/3/2021 with a primary diagnosis of senile degeneration of brain, not elsewhere classified. During a record review of Patient 14s medical record form titled “;General Visit Note Information” dated 8/9/2023, indicated “;Patient expired on 8/9/2023... (Caregiver 1- CG1)), wife referred for bereavement.” During a record review of Patient 14s medical record form titled “;Bereavement Care Plan Details” undated, the form indicated CG1 was to receive bereavement services at 7- and 30-days post death, and at 1, 3, 6, 9, and 12th month post death. The Bereavement Care Plan Details form indicated CG1 received two post bereavement services on 1/18/2023 and 3/29/2024. the first bereavement services at three months post death and the last bereavement services at seven months post death, 3/29/2024. During a concurrent interview and record review on 8/8/2024, at 12:21 p.m., with the Quality Assurance and Performance Improvement Nurse (QAPI) of Patient 14s Electronic Medical Record (EMR), the QAPI stated Patient 14s bereavement care was incomplete. The QAPI stated “;we want to make sure we are taking care of the family as much as possible. To provide them with support as possible to be able to provide our support and resources with other support systems. We hope that they wont be alone in their grief.” During an interview on 8/8/2024, at 1:41 p.m., with the Spiritual Counselor (SC), The SC stated his role was to provide patients and their families spiritual, religious, and psychosocial support. The SC stated his duties included to reach out to the family to give condolence for about after a year of the patients passing. The SC stated the goal was to check in with patients families every three months. During a record review of agencys policy and procedure titled “;Bereavement Services” revised 12/2021, indicated “;If a person is noted as experiencing normal low grief, the bereavement counselor will contact the bereaved person for ongoing assessment and support at three (3), six (6), and nine (9) months after the persons death. Ongoing bereavement contact will be concluded at the end of one year, if the bereaved is no longer in need of hospice bereavement services.” During a record review of agencys policy and procedure titled “;Bereavement Protocol” undated, indicated “;Ongoing bereavement services will be concluded at the end of thirteen months...””

“Based on interview and record review the Hospice Agency (HA) failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications for one of fourteen sample patients (Patient 11) to support diagnosis of the patients terminal illnesses and 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. These deficient practices resulted in the hospice medical director and/or the hospice attending physicians certified the patients for hospice care which could result in inappropriate care provided to Patient 11. During a record review of Patient 11s medical record form titled “;General Patient Details” undated, indicated a start of care date of 7/31/2024, with a primary diagnosis of cardiomyopathy unspecified (abnormal thick and stiff heart). The form also indicated the primary caregiver was Patient 11s son/caregiver 2 (CG2). During a record review of Patient 11s medical record form titled “;Hospice Certification of Terminal Illness” dated 7/31/2024 to 10/28/2024, indicated “;Attestation: I confirm that I composed this narrative and that it is based on my review of the patients medical record and/or examination of the patient.” The form indicated it was signed by the Medical Director 1 (MD1). The Hospice Certification of Terminal Illness form did not indicate Patient 11s life expectancy was six months or less if the illness runs its normal course. During an interview on 8/7/2024, at 4:26 p.m. with CG2, CG2 stated there has not been a medical doctor that has told him or his mother that she had six months or less to live. CG2 stated both his parents received hospice services. During a concurrent interview and record review on 8/9/2024, at 11:50 a.m. with the Medical Director (MD) of Patient 11s medical record, MD1 stated he certified Patient 11 for hospice services due to her functional decline. MD1 stated Patient 11 was bedbound, according to the admitting nurse. MD1 stated Patient 11s heart ejection fraction (percentage of blood pumped out of the heart) was 30-33% per hospital records. During a record review of agencys policy and procedure titled “;Certification of Terminal Illness” revised 11/2019, indicated “;Patients who elect the hospice Medicare or Medical benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course...” During a review of facilitys policy and procedure titled “;Admission Criteria and Process” revised 1/2024, indicated “;The patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs).””

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the 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 three of fourteen sampled patients (Patient 2, Patient 8, and Patient 13). This deficient practice had the potential for the patients not to receive appropriate healthcare services that could affect their quality of life. During a record review of Patient 13s medical record form titled “;General Patient Details” undated, indicated a start of care date of 10/23/2020, with a primary diagnosis of chronic obstructive pulmonary disease (difficulty breathing due to lung issues). During a record review of Patient 13s medical record form titled “;Hospice Certification of Terminal Illness” dated 8/3/2024 to 10/1/2024, indicated “;Attestation: I confirm that I composed this narrative and that it is based on my review of the patients medical record and/or examination of the patient.” The form also indicated it was signed by the Medical Director 1 (MD1). Lastly, the form does not state Patient 13s life expectancy is 6 months or less if the illness runs its normal course. During a joint home visit on 8/7/2024 at 9 a.m. with the Director of Patient Care Services Designee (DD) to Patient 13s skilled nursing facility (SNF), Patient 13 was noted laying supine in hospital bed with an air mattress, awake and alert. Patient 13 requested to have physical therapy services. Patient 13 stated that she was told she had 6 ½ months to 4 years left to live. Patient 13 stated “;I am a fighter; I want to live.” During a concurrent interview and record review on 8/8/2024 at 12:49 p.m. with DD of Patient 13s Electronic Medical Record (EMR), DD stated she completed Patient 13s nursing recertification assessment. DD stated Patient 13s criteria for recertification for hospice services were: “;increased falls increased weakness; and increased anxiety.” During a concurrent interview and record review on 8/9/2024 at 11:40 a.m. with MD1of Patient 13s EMR, MD1 stated he based Patient 13s hospice eligibility due to: social/personal issues; oxygen dependent due to shortness of breath; high fall risk; pain management; declining ability to ambulate; low heart rate. MD1 stated Patient 13 is frail and is lacking support. MD1 stated Patient 13 would benefit from hospice services “;because we never know who is going to die within 6 months.” MD1 stated “;We kind of go over the functional, cognitive and change of condition this are the primary criteria.” During a record review of agencys policy and procedure titled “;Certification of Terminal Illness” revised 11/2019, indicated “;A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patients medical record or, is applicable, examination of the patient.” During a review of facilitys policy and procedure titled “;Admission Criteria and Process” revised 1/2024, indicated “;The patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs).” During a record review of Patient 8s medical record form titled “;Hospice Certification of Terminal Illness” dated 6/13/2024 to 8/11/2024, indicated “;Attestation: I confirm that I composed this narrative and that it is based on my review of the patients medical record and/or examination of the patient.” The form also indicated it was signed on 6/3/2024 by the Medical Director 1 (MD1). During an interview on 8/7/2024 with Family Member (FM) 1, stated patient 8 is able to walk like up to10 steps, but mostly they use wheelchair. Patient 8 is very tired but does not use oxygen and stated that its been few months the last time it was used. FM1 stated that doctor did not tell them exactly that patient 8 has 6 months to live. During a concurrent interview and record review on 8/9/2024 at 12:00 p.m. with MD1 of Patient 8s electronic medical record, MD1 stated he based Patient 8s hospice eligibility due to: increase weakness on her legs, recent short of breath, refusing oxygen. Intermittent edema on lower extremity and fluid volume issues. When asked if patient is qualified for hospice MD1 stated “;I believe so based on all the symptoms.” Findings: a. During a review of Patient 2’s admission record indicated the patient start of care date on 12/30/2020, 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 2s Hospice Certification of Terminal Illness (CTI, physician’s certification of the patient being terminally ill to have Medicare hospice benefit), for benefit period 21 starting from 6/12/2024 to 8/10/2024, the Medical Director (MD1) narrative statement and attestation indicated Patient 2 was oriented to person, place and situation, able to verbalize needs, able to engage in meaningful conversation, and no recent complaints of difficulty breathing. The CTI indicated Patient 2 was on regular diet consuming 100% of 3 meals a day, can feed self, needed moderate assistance with toileting, bathing and dressing, minimal assistance with transfers and bed mobility, and transfers in and out of the wheelchair independently. There was no documented evidence Patient 2 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 significant symptoms occurs at rest) stage of heart failure, was optimally treated with diuretics (medicines that help reduce fluid buildup in the body) and vasodilators (medicines that treat high blood pressure, chest pain or heart failure), had declined invasive procedures, and had poor nutritional status. However, MD1 recertified Patient 2 for continued hospice care and service. During a phone interview, on 8/8/2024 at 12:10 p.m. with a licensed vocational nurse (LVN 1), LVN 1 stated Patient 2 was alert, awake, oriented x 2 (person and place) and was able to transfer to wheelchair with assistance. LVN 1 stated Patient 2 had no cardiac (related to heart) symptoms like chest pain, shortness of breath and palpitation while laying in bed, sitting up, or at rest. During a concurrent interview and record review on 8/9/2024 at 12:30 p.m. with MD1 of Patient 2s electronic medical record (EMR), MD1 stated he recertified Patient 2s for benefit period 21 because Patient 2 was choking. MD1 stated he was not Patient 2s attending physician prior to hospice admission and became the attending physician only after Patient 2 was admitted to hospice care. MD1 stated that he already forgot if he discussed Patient 2s medical history with her attending physician. MD1 stated he was aware about 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) assessment for hospice eligibility criteria, and further stated that the HAs nurses used LCD for their documentation. During a concurrent interview and record review with the Director of Patient Care Services Designee (DD), on 8/09/24 at 1:05 p.m., the DD reviewed Patient 2s LCD assessment documentation in EHR. DD stated the HA used LCD criteria as guideline for hospice eligibility. DD stated she was unable to provide documented evidence Patient 2 met NYHA IV stage for heart disease, was optimally treated with diuretics and vasodilators, had declined invasive procedures, and had poor nutritional status.”

“Based on interview and record review the Hospice Agency (HA) failed to ensure all skilled nursing visit notes were documented in one of fourteen sample patients (Patient 12) medical record. This failure had the potential to result in confusion among staff of not knowing the condition of Patient 12. During a record review of Patient 12s medical record form titled “;General Patient Details” undated, indicated a start of care date of 9/19/2022 with a primary diagnosis of Alzheimers Disease (slow progressing memory loss). During a record review of Patient 12s medical record form titled “;IDG Comprehensive Assessment Details” dated 8/7/2024, indicated “;Frequencies: SN (skilled nurse) frequency: 2x per week plus 3 PRN (as needed) every 7 days for symptom management.” During a concurrent interview and record review on 8/9/2024, at 1:35 p.m. with the Director of Patient Care Services Designee (DD) of Patient 12s Electronic Medical Record (EMR), the EMR indicated there was one nurse visit note on the week of 7/14/2024. The DD stated she visited Patient 12 twice that week and did not document one of her visits. The DD stated nursing visit notes should be uploaded and documented in their EMR system within 24-48 hours of the visit for continuity of care and to keep communication within the hospice team. During a record review of agencys policy and procedure titled “;Entries into the Clinical Record” revised 5/2023, indicated “;A clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies found in this manual, and will include at a minimum... clinical notes. Entries into the clinical record will be made within 48 hours from the day care is provided to the patient.”