La Hospice Services, Inc.

“Upon patient record review, 6 of 14 (Patient #1,3,4,6,8,10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: On the medication profile, “Diclofenac Sodium 1% topical gel Apply to effected are twice daily” . No evidence of where to apply medication. Corrected on site Patient 3: On the medication profile, “Hydrogen Peroxide topical solution: “apply to effected are as needed”. No evidence of where to apply medication. “Mometasone Furoate topical cream apply to the effected are as needed for eczema”, effected are is not clear and complete. Corrected on Site Patient 4: On the medication profile, “Diclofenac Sodium 3% gel topical twice daily as needed”. The order does not state where to apply medication. Corrected on Site. Patient 6: On the Medication profile, “Voltaren Arthritis Pain 1%Topical Gel Topical twice daily as needed”, the order does not state where to apply Voltaren topical gel. Corrected on site. Patient 8:On the medication profile, “ Nasal allergy 24 hour Nasal Spray “spray twice daily on each nose as needed”. Mediation is a once daily spray, frequency says twice daily and in each nose instead of nostril. Corrected on Site. Patient 10: On the medication profile, “Diclofenac Sodium 1% gel topical every 12 hours daily as needed” order does not state where to apply medication.”

“Upon personnel record review, 1 of 11 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 05: On the aide competency 1/12/25 there is no evidence of Shampoo, sink, tub, and bed, tub, and shower bath on the competency.”

“Upon patient client record review, 4 of 14 (Patient #1,3,8,10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: On the medication profile, “Diclofenac Sodium 1% topical gel Apply to effected are twice daily” apply to effected are is not clear. Corrected on site. Patient 3: On the medication profile, “Hydrogen Peroxide topical solution: “apply to effected are as needed”. Apply to effected are is not clear. “Mometasone Furoate topical cream apply to the effected are as needed for eczema”, effected are is not clear and complete. Corrected on Site Patient 8: On the POC, “ Tylenol Extra Strength 500mg “1 tablet ever 6 hours as needed”, Ever is misspelled and is not clear. On the plan of care there is an order that states, “Kane 1 each support, as needed, ambulation” Kane is misspelled and is not clear. On the POC, “Nebulizer 1 each Respiratory, evrey 6 hours as needed”, every is misspelled and not clear. RN comp assessment on 1/21/25 states”, Covid-19 precautions reinforced to PCG and instructed to report hospice for any untoward incident may happen immediately”. This statement is not clear or complete. Corrected on Site. On the medication profile, “ Nasal allergy 24 hour Nasal Spray “spray twice daily on each nose as needed”. Each nose is not clear on the medication order. Corrected on site. Patient 10: On the POC 10/10/24 “SN- 1 every recertification, initial assessment +2 visits as needed to provide spiritual care to patient and family” is ordered, this should be for spiritual care instead of SN, the order is not clear. On the POC, “Lidocaine patches 1 film applay on film every 12 hours as needed in the effected area.” Apply is misspelled and “affected” is not clear. Corrected on Site”

“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 for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met as follows: 1. The HA failed to implement the Plan of Care/Interdisciplinary Group (POC/IDG) Review (a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) and physicians order for two of fourteen sampled patients (Patient 2 and Patient 11) and failed to ensure the Director of Patient Care Services Designee (DPCSD) performed the medication reconciliation (a formal process for creating the most complete and accurate list possible of a patients current medications and comparing the list to those in the patient record or medication orders) for Patient 2s and Patient 11s medications. a. Patient 2s physicians order on 5/8/2024, indicated for Patient 2 to take Escitalopram (medication to help treat depression [a mood disorder marked by varying degrees of sadness], and anxiety [nervousness]) 5 milligrams (mg, a unit of measurement, one tablet once a day for anxiety. Patient 2s primary caregiver (PCG 1) administered Escitalopram 20 mg to Patient 2 because the Escitalopram 5 mg was not available in Patient 2s home. The HA was not aware that Patient 2 was receiving Escitalopram 20 mg and that the Escitalopram 5 mg was not available despite skilled nurse visits on 7/12/2024, 7/19/2024, 7/26/2024, and 7/29/2024. This deficient practice placed Patient 2 at risk for overdose and adverse side effects (undesirable effect), that could lead to serious harm, hospitalization, and/or death. (Refer to L543). b. Patient 11s physicians order on 3/8/2024, indicated for Patient 11 to receive lidocaine (medication to help relieve pain) 5 percent (%) transdermal (the application of a medicine or drug through the skin), apply to the affected area every twelve hours as needed (PRN) for mild pain. Patient 11s physicians orders on 8/2/2024 indicated for Patient 11 to take Percocet (medication used for the management of moderate to severe pain) 10 mg-325 mg one tablet every six hours as needed for severe pain, and Xanax (medication that is used to treat anxiety and depression or panic disorders and works to balance out the chemicals in our brain) 1 mg one tablet every six hours as needed. The HA failed to ensure Patient 11 had the lidocaine 5% transdermal patch, Percocet 10 mg-325mg, and the Xanax 1 mg available at his residence and there was no medication reconciliation completed during the home visits. 2. The HA failed to ensure that one of fourteen sampled patients (Patient 11) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care. (Refer to L544). This deficient practice had the potential for Patient 11 to experience uncontrolled pain that could lead to serious harm, hospitalization, and/or death. (Refer to L543). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients.”

“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 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 hospice agency (HA, agency providing care to terminally ill patients who have seven months or less to live) failed to provide one of fourteen sampled patients (Patient 8) information of their rights and responsibilities, home care instructions in a language the patient/patients caregiver preferred and understood. This deficient practice resulted for the patients not being able to exercise of his or her rights as a patient of the hospice agency. Refer to L 502. 2. The Hospice Agency failed to ensure that three of 14 sampled patients (Patient 2, Patient 8, and Patient 11) had the rights to access and be involved of their plans of care. This deficient practice had the potential to result in patient and/or their family member/caregiver unable to be an active participant in his/her care. Refer to L513. 3. The Hospice Agency failed to ensure content and information in the patients medical records were safeguarded from unauthorized access for one of fourteen sample selected patients (Patient 13). This failure has the potential to result in an unauthorized disclosure of the patient’s information violating the patient’s right to confidentiality of his/her clinical record. Refer to L516. The cumulative effect of these systemic practice resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Patients Rights to ensure their rights are not violated and ensured to receive the highest quality of hospice care.”

“Based on interview and record review, the hospice agency (HA; agency providing care to terminally ill patients) failed to ensure the Condition of Participation (condition that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Initial and Comprehensive Assessment of the patient was met as follows: 1. The HA failed to complete a spiritual assessment, as part of the comprehensive assessment (an evaluation of the patient’s physical, psychosocial [mental, social, and spiritual aspects) related to the terminal illness [illness with a prognosis of having six months of life or less to live]) within five calendar days since the election of hospice care, in order to develop and implement an individualized plan of care to address the physical, emotional, and spiritual needs for one of fourteen sampled patients (Patient 1). (Refer to L523). 2. The HA failed to review of all of the patient’s prescription and over-the-counter drugs that could affect drug therapy for two of fourteen sampled patients (Patient 2 and Patient 11). (Refer to L530). 3. The HA failed to conduct an initial bereavement assessment to one of fourteen sampled patients (Patient 1). (Refer to L531). This deficient practice had the potential to cause delay of patient care, uncontrolled patient pain, and undetected signs of physical, emotional, and spiritual needs when transitioning to final stages of dying process. The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (State Law) compliance with Federal Regulations for Initial and Comprehensive Assessment of Patient to ensure the highest quality health care is provided to patients assessed to receive hospice services.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation for Medical Director was met as follow: 1. The HA failed to ensure that the Medical Director conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial certifications for seven out of fourteen sampled patients (Patient 1, Patient 4, Patient 5, Patient 9, Patient 10, Patient 11, and Patient 12) to support the diagnosis of the patients’ terminal illnesses (a health condition that cannot be cured) 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. The HA failed to ensure there were documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice care and services. (Refer to L667). This deficient practice resulted in patient being enrolled in hospice and receiving care without a proper verification of patient eligibility and had the potential for Patient 1, Patient 4, Patient 5, Patient 9, Patient 10, Patient 11, and Patient 12 not receiving necessary care and healthcare resources to meet their care goals. (Refer to L667). 2. The HA failed to ensure, the Medical Director assumed overall responsibility for the medical component of the hospices patient care program for seven out of fourteen sampled patients (Patient 1, Patient 4, Patient 5, Patient 9, Patient 10, Patient 11, and Patient 12), which included overseeing the eligibility criteria to ensure patients qualified and received appropriate hospice services. (Refer to L669). This deficient practice resulted in patients being enrolled to the HA without oversight of the implementation of the hospice services to ensure the patients and patients familys needs were being met. (Refer to L 669). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory (written law) mandated compliance with Federal regulation for Medical Director services to ensure 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 seven months or less to live) failed to provide one of fourteen sampled patients (Patient 8) information of their rights and responsibilities, home care instructions in a language the patient/patients caregiver preferred and understood. This deficient practice resulted for the patients not being able to exercise of his or her rights as a patient of the hospice agency. A review of Patient 8s untitled admission sheet, indicated a start of care date on 5/13/2024 with a primary diagnosis of Hypertensive Heart Disease (a disease which refers to heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure ( a condition where the heart muscle becomes weak and unable to pump blood and oxygen around the body as well as it usually does). During a joint home visit with the Licensed Vocational Nurse (LVN1) on 8/7/2024 at 12 p.m., Patient 8 was observed sitting on the sofa, awake, alert, and oriented. Patient 8s primary caregiver (PCG 2) was present in Patient 8s living room. During a concurrent review of Patient 8s home folder with LVN 1 at 12:30 p.m., as part of the home visit, it was noted that the following documents provided to Patient 8 and her caregiver were not written in their native language: - Oxygen Use Safety instructions -Home Care instructions -Emergency Preparedness Plan -Hand Washing Instructions -Copy of Patient Rights -Admission Assessment dated 5/13/2024 -Patient 8s signed Election of Hospice Benefit dated 5/13/2024 On 8/7/2024, at 12:21 p.m., during interview with PCG2 in her native language, she stated that her friend (PCG3) who also sometimes helped her to take care of Patient 8, would also helped her to translate the instructions. PCG2 stated that it would be better and helpful to understand if the home instructions and contents of the agencys folder are in our native language. On 8/7/2024, at 12:24 p.m., during interview with PCG3, he stated that sometimes he helped PCG2 in taking care of Patient 8, especially when they need some interpretations or instructions, stated he also helped them in calling the agency if they need something. PCG3 stated that it would be better if the contents of the folder are in their native language so it could better understand by PCG2. PCG3 stated that if PCG2 forgot the teachings from the nurse, she can refer to the agencys folder and she could better understand it if written in their native language. On 8/7/2024, at 12:32 p.m., during an interview with LVN1, he stated that he provided translation and instructions to Patient 8 and PCG2 in their native language and stated he ensure that they understood it. LVN1 stated the contents of Patient 8s folder is not written in their native language although I provide interpretation for them. LVN1 stated that he is unsure if he documented the teachings were provided in Patient 8 and PCG2s native language. A review of Patient 8s clinical record titled “;Visit Note LVN”, dated 6/24/2024, 7/5/2024, 7/12/2024, 7/19/2024 and 7/27/2024, indicated no documented evidence that LVN 1 provided teachings and instructions to Patient 8 and PCG2 in their native language. On 8/9/2024, at 2:33 p.m., during an interview with the Director of Patient Care Services Designee (DPCSD), she stated that if Patients primary language is other than English Language, the nurses seek help of fellow nurses in the agency or patients family members for translation. DPCSD stated that they do not have translation services. DPCSD stated that it is important to provide copies of instructions and documents to patients in their primary native language for them to fully understand the hospices services and home instructions. DPCSD stated that patients, family members and caregivers will not fully understand the service if instructions and documents are not in their native language, and they should receive instructions in language that they could understand. DPCSD stated that she does not speak Patient 8s native language but when she visited Patient 8 for admission, she seeks the assistance of the agencys owner (CEO) to translate. DPCSD stated that she is unsure if she documented that CEO provided translation assistance to her, Patient 8 and PCG2. A review of Patient 8s clinical record titled “;Comprehensive Nursing Assessment”, dated 5/13/2024, indicated no documented evidence that DPCSD conducted assessment questionnaires, provided teachings and instructions to Patient 8 and PCG2 in their native language with the CEOs translation assistance. During a review of the HAs policy, titled “;Patient Bill of Rights/Responsibilities,” (Policy No. 2-002.1), revised April 2020, indicated 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, 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 that three of 14 sampled patients (Patient 2, Patient 8, and Patient 11) had the right to access and be involved of their plans of care. This deficient practice had the potential to result in patient and/or their family member/caregiver unable to be an active participant in his/her care. a. A review of Patient 2s Personal Information indicated that Patient 2 was admitted on 5/8/2024 with a primary diagnosis of alcoholic cirrhosis of liver (alcohol-induced liver disease) with ascites (abdominal swelling caused by accumulation of fluid, most often related to liver disease). During a joint home visit with the Director of Patient Care Services (DPCSD) on 8/8/2024 at 1 p.m., observed Patient 2 lying in bed, awake, alert, and oriented. Patient 2s primary caregiver (PCG 1) was present in Patient 2s bedroom. During a review of Patient 2s home folder with the DPCSD at 1:30 p.m., as part of the home visit, it was noted the HA did not provide Patient 2 with a copy of the Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient’s family/caregiver). During an interview with the DPCSD on 8/8/2024 at 2 p.m., the DPCSD stated the HA was supposed to provide a copy of the POC to its patients. The DPCSD stated the purpose of providing patient with a copy of the POC was to ensure the patient and his or her family or caregiver could review the POC and be familiar with it. The DPCSD stated if the patient and/or family understood about their plan of care, they would be able to participate more. The DPCSD stated the HA would provide Patient 2 with a copy of the POC with the next home visit. A review of the HAs policy, titled “;Patient Bill of Rights/Responsibilities,” revised April 2020, indicated that each patient will be an active, informed participant in his/her plan of care. The policy indicated that patient had the right to: - Be informed in advance of the right to participate in planning the care or service and in planning changes in the care and service. - Be informed of disciplines furnishing care and the frequency of visits. b. A review of Patient 8s untitled clinical record, indicated a start of care date on 5/13/2024 with a primary diagnosis of Hypertensive Heart Disease (a disease which refers to heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure ( a condition where the heart muscle becomes weak and unable to pump blood and oxygen around the body as well as it usually does). During a joint home visit with the Licensed Vocational Nurse (LVN1) on 8/7/2024 at 12 p.m., Patient 2 was observed sitting on the sofa, awake, alert, and oriented. Patient 8s primary caregiver (PCG 2) was present in Patient 8s living room. During a review of Patient 8s home folder with LVN 1 at 12:30 p.m., as part of the home visit, it was noted the HA did not provide Patient 8 with a copy of the Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient’s family/caregiver). During interview with LVN1 at 12:41 p.m., he stated that he does not know if the POC was provided to patients. c. A review of Patient 11s untitled clinical record indicated a Start of Care (SOC) dated 11/16/2023 with a primary diagnosis Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing) unspecified, and a secondary diagnosis of Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). During a joint home visit with the Licensed Vocational Nurse (LVN 1) on 8/8/2024 at 2:15 p.m., Patient 11 was observed laying on the sofa, awake but stated feels weak and sleepy, his both eyes closed but speak when ask questions. Patient 11 on oxygen therapy, connected to oxygen tank with current setting at 2liters/minute via nasal cannula (is a device that gives additional oxygen (supplemental oxygen or oxygen therapy) through the nose which is a thin, flexible tube that goes around the head and into the nose, there are two prongs that go inside the nostrils that deliver the oxygen). Patient 11 appeared comfortable and denies any pain or discomfort. During a review of Patient 11s home folder with LVN 1 at 2:30 p.m., as part of the home visit, it was noted the HA did not provide Patient 11 with a copy of the Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient’s family/caregiver). During interview with LVN1 at 12:41 p.m., he stated that he does not know if the POC was provided to patients, he further stated that he is not aware if they have to provide copies of POC to patients. During an interview with the DPCSD on 8/9/2024 at 2:33 p.m., the DPCSD stated the HA was supposed to provide a copy of the POC to its patients. The DPCSD stated the purpose of providing patient with a copy of the POC was to ensure the patient and his or her family or caregiver could review the POC and be familiar with it. The DPCSD stated if the patient and/or family understood about their plan of care, they would be able to participate more. The DPCSD stated the HA would provide Patient 8 with a copy of the POC with the next home visit. b. A review of Patient 8s untitled clinical record, indicated a start of care date on 5/13/2024 with a primary diagnosis of Hypertensive Heart Disease (a disease which refers to heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure (a condition where the heart muscle becomes weak and unable to pump blood and oxygen around the body as well as it usually does). During a joint home visit with the Licensed Vocational Nurse (LVN1) on 8/7/2024 at 12 p.m., Patient 2 was observed sitting on the sofa, awake, alert, and oriented. Patient 8s primary caregiver (PCG 2) was present in Patient 8s living room. During a review of Patient 8s home folder with LVN 1 at 12:30 p.m., as part of the home visit, it was noted the HA did not provide Patient 8 with a copy of the Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient’s family/caregiver). During interview with LVN1 at 12:41 p.m., he stated that he does not know if the POC was provided to patients. c. A review of Patient 11s untitled clinical record indicated a Start of Care (SOC) dated 11/16/2023 with a primary diagnosis Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing) unspecified, and a secondary diagnosis of Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). During a joint home visit with the Licensed Vocational Nurse (LVN 1) on 8/8/2024 at 2:15 p.m., Patient 11 was observed laying on the sofa, awake but stated feels weak and sleepy, his both eyes closed but speak when ask questions. Patient 11 on oxygen therapy, connected to oxygen tank with current setting at 2liters/minute via nasal cannula (is a device that gives additional oxygen (supplemental oxygen or oxygen therapy) through the nose which is a thin, flexible tube that goes around the head and into the nose, there are two prongs that go inside the nostrils that deliver the oxygen). Patient 11 appeared comfortable and denies any pain or discomfort. During a review of Patient 11s home folder with LVN 1 at 2:30 p.m., as part of the home visit, it was noted the HA did not provide Patient 11 with a copy of the Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient’s family/caregiver). During interview with LVN1 at 12:41 p.m., he stated that he does not know if the POC was provided to patients, he further stated that he is not aware if they have to provide copies of POC to patients. During an interview with the DPCSD on 8/9/2024 at 2:33 p.m., the DPCSD stated the HA was supposed to provide a copy of the POC to its patients. The DPCSD stated the purpose of providing patient with a copy of the POC was to ensure the patient and his or her family or caregiver could review the POC and be familiar with it. The DPCSD stated if the patient and/or family understood about their plan of care, they would be able to participate more. The DPCSD stated the HA would provide Patient 8 with a copy of the POC with the next home visit. a. A review of Patient 2s Personal Information indicated that Patient 2 was admitted on 5/8/2024 with a primary diagnosis of alcoholic cirrhosis of liver (alcohol-induced liver disease) with ascites (abdominal swelling caused by accumulation of fluid, most often related to liver disease). During a joint home visit with the Director of Patient Care Services (DPCSD) on 8/8/2024 at 1 p.m., observed Patient 2 lying in bed, awake, alert, and oriented. Patient 2s primary caregiver (PCG 1) was present in Patient 2s bedroom. During a review of Patient 2s home folder with the DPCSD at 1:30 p.m., as part of the home visit, it was noted the HA did not provide Patient 2 with a copy of the Plan of Care (POC, a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient’s family/caregiver). During an interview with the DPCSD on 8/8/2024 at 2 p.m., the DPCSD stated the HA was supposed to provide a copy of the POC to its patients. The DPCSD stated the purpose of providing patient with a copy of the POC was to ensure the patient and his or her family or caregiver could review the POC and be familiar with it. The DPCSD stated if the patient and/or family understood about their plan of care, they would be able to participate more. The DPCSD stated the HA would provide Patient 2 with a copy of the POC with the next home visit. A review of the HAs policy, titled “;Patient Bill of Rights/Responsibilities,” revised April 2020, indicated that each patient will be an active, informed participant in his/her plan of care. The policy indicated that patient had the right to: - Be informed in advance of the right to participate in planning the care or service and in planning changes in the care and service. - Be informed of disciplines furnishing care and the frequency of visits.”

“Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure content and information in the patients medical records were safeguarded from unauthorized access for one of fourteen sample selected patients (Patient 13). This failure has the potential to result in an unauthorized disclosure of the patient’s information violating the patient’s right to confidentiality of his/her clinical record. During a home visit and review of Patient 8s home folder with LVN 1 on 8/8/2024 at 2:28 p.m., it was noted Patient 13s clinical record titled “;Treatment/Medication/DME (Durable Medical Equipment) List was inside and included in Patient 8s agency folder. At 2:33 p.m., during interview with Patient 8, he stated that Patient13 was his friend, and she comes to his house. Patient 8 stated that he did not know why her (Patient 13) medication list was in his agencys folder. Patient 8 stated that Patient 13 was his emergency contact. During an interview with LVN 1 on 8/8/2024 at 247 p.m., he stated that he did not know Patient 13, and he was unsure why Patient 13s medication list was mixed with Patient 8s agency folder. LVN 1 stated that it was important to protect patients medical information including the list of medications the patients are taking to prevent confusion when conducting medication reconciliation and to ensure patients records are safe. A closed record review of Patient 13s untitled admission record indicated a start of care of 1/20/22 and an end of care of 10/26/2023, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing). A review of Patient 13s clinical record titled “;Visit Note LVN” indicated that LVN1 conducted visits and entered documentations dated 10/19/2023, 10/24/2023 and 10/26/2023. A review of Patient 13s clinical record titled “;Discharge Summary” dated 10/26/2023, indicated that Patient 13 was discharged from HA due to revocation of hospice benefits on 10/26/2023. Patient 13 chose aggressive treatment. On 8/8/2024 at 3:48 p. m., a telephone call was made to Patient13 but was unsuccessful. During an interview with the Director of Patient Care Services Designee (DPCSD) on 8/9/2024 at 3:22 p.m., DPCSD stated that Patient 13 was discharged already. DPCSD stated that Patient 13s clinical record should not be mixed up with Patient 8s clinical records. DPCSD stated that the visiting nurses should check patients folder on each visit to ensure that the documents of patients were properly secured and reviewed. DPCSD stated that mixed clinical records of different patients violate the confidentiality and safety of records. DPCSD stated that mixed clinical records of patients can also result in wrong medication reconciliations and wrong references. During a review of the HAs policy, titled “;Patient Bill of Rights/Responsibilities,” (Policy No. 2-002.1), revised April 2020, indicated the Patient Bill of Rights/Responsibilities statement defines the right of the patient to: H. Confidentiality of the patient and clinical records maintained by the organization and the policies and procedures regarding disclosure. A review of the HAs policy titled “;Uses and Disclosures of PHI” (Policy No. 2-015.1), revised April 2020, indicated that the purpose of the agency is to safeguard protected health information (PHI) against unauthorized use.”

“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 complete the spiritual assessment as part of the comprehensive assessment within five calendar days after hospice election for one of fourteen sampled patients (Patient 1). This deficient practice had the potential to result in the patients spiritual needs unidentified and unmet. A review of Patient 1s Personal Information indicated that Patient 1 was admitted on 7/20/2024 with a primary diagnosis of acute kidney failure (a sudden episode when a persons kidneys are not able to filter waste products from the blood). During a concurrent record review and interview with the Director of Patient Care Services (DPCSD) on 8/6/2024 at 3:20 p.m., the DPCSD reviewed the History of Spiritual Assessment, printed by the HA staff on 8/6/2024, for Patient 1. The Director of Patient Care Services Designee (DPCSD) stated the History of Spiritual Assessment was blank, which meant there was no spiritual assessment documented since admission. The DPCSD stated if it was not documented then it was not done. The DPCSD stated that spiritual assessment should have been completed the same week of Comprehensive Nursing Assessment, which was completed on 7/29/2024. The DPCSD stated it was important to complete the spiritual assessment within 5 calendar days after admission, because a lot of hospice patients have anxiety and stress related to their terminal diagnosis. Per DPCSD, if the assessment was not done timely, patient could become more anxious and stressed, and the HA would not be able to provide appropriate interventions. A review of Communication Log for Patient 1 did not indicate that Patient 1 refused the spiritual assessment. A review of the HAs policy, titled “;Spiritual Assessment,” revised April 2020, indicated that a spiritual assessment will be completed for each patient/family by the Hospice Chaplain. The assessment will include, but not be limited to, evaluation of the following: 1. Coping with and adjusting to the patients terminal illness. 2. Assessing bereavement needs. 3. Religious and/or spiritual reactions to terminal illness.”

“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) staff failed to review all the medications and update the medication profile with currently used medications for two of fourteen sampled patients (Patient 2 and Patient 11). This deficient practice resulted in Patient 2 receiving incorrect and expired medication that could potentially place Patient 2 at high risk for adverse drug reactions and Patient 11 medications not readily available when needed which could resulted to prolong uncontrolled symptoms that can affect his/her quality of life. b. A review of Patient 11s untitled clinical record indicated a Start of Care (SOC) dated 11/16/2023 with a primary diagnosis Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing) unspecified, and a secondary diagnosis of Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). During a joint home visit with the Licensed Vocational Nurse (LVN 1) on 8/8/2024 at 2:15 p.m., Patient 11 was observed laying on the sofa, awake but stated feels weak and sleepy, his both eyes closed but speak when ask questions. Patient 11 on oxygen therapy, connected to oxygen tank with current setting at 2liters/minute via nasal cannula (is a device that gives additional oxygen (supplemental oxygen or oxygen therapy) through the nose which is a thin, flexible tube that goes around the head and into the nose, there are two prongs that go inside the nostrils that deliver the oxygen). Patient 11 appeared comfortable and denies any pain or discomfort. During medication review/reconciliation with LVN 1 on 8/8/2024 at 2:28 p.m., The following medications: Lidocaine 5% Transdermal Patch, Percocet 10mg-325mg tablet and Xanax 1mg tablet were missing and not on Patient 11s on hand medications. During an interview with Patient 11 on 8/8/2024 at 2:32 p.m., Patient 11 stated he hid his Xanax and Percocet medications somewhere inside his residence but forgot where he placed it. Patient 11 stated he kept the medications whenever his friends visited him but forgets where he put the medications. Patient 11 stated that he takes Xanax if he feels anxious and take Percocet if the Ibuprofen does not work for his chronic body pain. Patient 11 stated he was unable to remember when the last time he took the medications (Xanax and Percocet), but he takes both medications frequently. Patient 11 stated that he does not remember when the last time the medications were refilled and delivered. Patient 11 stated that he is out of Lidocaine patch for a week now. Patient 11 stated he lives alone but he has a friend that comes to help him but stated she does not know where he kept the medications either. Patient 11 stated that he does not know his friends contact number. Patient 11 stated he does not know when the last time that he took his Percocet and Xanax, stated he used the medications for severe pain and stated if he ran out of it, he used the Ibuprofen but did not help him much. Patient 11 stated he used Xanax if he feels anxious. During an interview with LVN 1 on 8/8/2024 at 2:45 p.m., LVN 1 stated he was not aware of the missing medications (Lidocaine patch, Xanax tablets and Percocet Tablets). LVN 1 stated that he performed medication reconciliation last week and saw the missing medications, stated he would find out if certain medications had to be refilled. LVN 1 stated it was very important that Patient 11 did not run out of pain medications and anti-anxiety medications to better control the pain symptoms and his anxiety as well. LVN 1 stated that he provided teachings to Patient 11 regarding proper storage and safe keeping of controlled medications, stated he was unsure if he documented it to his skilled nurse notes. A review of Patient 11s clinical record titled “;Visit Nurse Note LVN” for Patient 11, dated 6/26/2024, indicated in the narrative section “;medications and supplies checked for refill.” There was no documentation that which medications were checked for refills and no documentation that LVN 1 conducted Patient 11s medication reconciliation. A review of Patient 11s clinical record titled “;Visit Note RN”, dated 7/19/2024 and 7/25/2024, did not mention if medication reconciliation was completed. During an interview with the DPCSD on 8/9/2024, at 1:38 p.m., DPCSD stated that she conducted an SN visit with Patient 11 on 7/29/2024. DPCSD stated that she reconciled P11s medications and saw no missing medications. DPCSD stated she saw Xanax, Lidocaine Transdermal Patch and Percocet tablets bottles. DPCSD stated that she reviewed with Patient 11 regarding importance of pain management, safe and proper storage of controlled substances medications and importance of not using it more than required frequency. DPCSD stated that pain and other PRN (as needed) medications should be readily accessible for use of patients in order to prevent patients prolong uncontrolled symptoms. DPCSD stated that she does not remember if the agency provided a copy of written instructions, policies and procedures regarding management and disposal of controlled drugs to the patient/patients caregiver. DPSCD stated that it is important to provide frequent teachings to Patient 11 regarding effective pain management and use of controlled pain medications. DPCSD stated that she is unsure if agency has system in place to effectively monitor patients use of controlled pain medications and proper safekeeping. DPCSD stated that medication reconciliation should be done on each nurses visit to be able to determine the current medication supplies, patients proper usage of medications and to ensure patients access to medications. The DPCSD stated that the nurses who visited Patient 11 had the responsibility to check all the patients medications to make sure the patient had all medications in the medication list. The DPCSD stated that it is important for the patients to safeguard and keep their controlled medications so they will know where to get it and to protect from other people that visits the patient. At 2:43 p.m., during a concurrent review with the DPCSD of Patient 11s clinical record, titled Visit Note RN” dated 7/29/2024, DPCSD acknowledged and stated that she conducted the visit with Patient 11 on 7/29/2024. a. A review of Patient 2s Personal Information indicated that Patient 2 was admitted on 5/8/2024 with a primary diagnosis of alcoholic cirrhosis of liver (alcohol-induced liver disease) with ascites (abdominal swelling caused by accumulation of fluid, most often related to liver disease). A review of Patient 2s most recent POC/IDG Review, dated 8/7/2024, indicated that the visit frequency of Skilled Nurse (SN, in general) was once a week and two as needed visits. A review of Patient 2s Current Treatment/Medication/DME (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living) indicated that Patient 2 was on Escitalopram 5 mg, one tablet, once a day, for anxiety. During a joint home visit with the DPCSD on 8/8/2024 at 1 p.m., observed Patient 2 lying in bed, awake, alert, and oriented. Patient 2s primary caregiver (PCG 1) was present in Patient 2s bedroom. During medication review with the DPCSD on 8/8/2024 at 1:30 p.m., it was noted that Escitalopram 5 mg was not available in Patient 2s home. Instead, Escitalopram 20 mg, with the instruction to take one tablet, once a day, was available in Patient 2s home. The expiration date on the container of Escitalopram 20 mg was 7/7/2024, and the filled date was 7/7/2023. During an interview with PCG 1 on 8/8/2024 at 1:35 p.m., PCG 1 stated that Escitalopram 20 mg was the only Escitalopram that Patient 2 had in the home. PCG 1 stated that he had been administering Escitalopram 20 mg one tablet, once a day, as instructed on the medication label, to Patient 2. When PCG 1 was asked how long he had been administering Escitalopram 20 mg to Patient 2, PCG 1 stated he was not sure. PCG 1 stated, “;I follow the instruction on the bottle.” During an interview with the DPCSD on 8/8/2024 at 1:45 p.m., the DPCSD stated that Escitalopram 20 mg did not come from the HAs pharmacy. The DPCSD stated that Patient 2 had been moving to three different homes since he was admitted to the HA, and that Escitalopram 5 mg might have been left in the previous home. The DPCSD stated she was not aware that PCG 1 had been administering Escitalopram 20 mg, or that Escitalopram 5 mg was not available in the home. The DPCSD stated that the nurse who visited Patient 2 had the responsibility to check all the patient’s medications to make sure the patient had all medications available in the medication list. The DPCSD stated that taking Escitalopram 20 mg instead of the prescribed Escitalopram 5 mg might overdose the patient and cause serious adverse effects. On 8/8/2024, at 1:55 p.m., when PCG 1 was asked how long Patient 2 had been residing in the current home, PCG 1 stated that Patient 2 had been at the current address for one month. A review of Visit Note Registered Nurse (RN) for Patient 2, dated 7/29/2024, indicated medication was checked and reviewed. The visit note RN did not mention what medication was checked and reviewed. A review of Visit Note RN, dated 7/26/2024, did not mention if medication reconciliation was completed. A review of Visit Note RN, dated 7/19/2024, indicated that medication reconciliation was completed. A review of Visit Note RN, dated 7/12/2024, indicated medications were reconciled. A review of the HAs policy, titled “;Medication Profile,” revised April 2020, indicated that during subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate the use of the drugs in the home setting. The medication profile includes, but is not limited to all current medications, date prescribed, name of medication, dose, frequency, drug classification, and date discontinued. B. Using the medication profile to teach purpose of medication, dosages, routes, administration times, side effects, and contraindications. The “;Medication Profile” policy indicated that deviations from taking medications as ordered will be documented in clinical notes, and the physician will be notified. b. A review of Patient 11s untitled clinical record indicated a Start of Care (SOC) dated 11/16/2023 with a primary diagnosis Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing) unspecified, and a secondary diagnosis of Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). During a joint home visit with the Licensed Vocational Nurse (LVN 1) on 8/8/2024 at 2:15 p.m., Patient 11 was observed laying on the sofa, awake but stated feels weak and sleepy, his both eyes closed but speak when ask questions. Patient 11 on oxygen therapy, connected to oxygen tank with current setting at 2liters/minute via nasal cannula (is a device that gives additional oxygen (supplemental oxygen or oxygen therapy) through the nose which is a thin, flexible tube that goes around the head and into the nose, there are two prongs that go inside the nostrils that deliver the oxygen). Patient 11 appeared comfortable and denies any pain or discomfort. During medication review/reconciliation with LVN 1 on 8/8/2024 at 2:28 p.m., The following medications: Lidocaine 5% Transdermal Patch, Percocet 10mg-325mg tablet and Xanax 1mg tablet were missing and not on Patient 11s on hand medications. During an interview with Patient 11 on 8/8/2024 at 2:32 p.m., Patient 11 stated he hid his Xanax and Percocet medications somewhere inside his residence but forgot where he placed it. Patient 11 stated he kept the medications whenever his friends visited him but forgets where he put the medications. Patient 11 stated that he takes Xanax if he feels anxious and take Percocet if the Ibuprofen does not work for his chronic body pain. Patient 11 stated he was unable to remember when the last time he took the medications (Xanax and Percocet), but he takes both medications frequently. Patient 11 stated that he does not remember when the last time the medications were refilled and delivered. Patient 11 stated that he is out of Lidocaine patch for a week now. Patient 11 stated he lives alone but he has a friend that comes to help him but stated she does not know where he kept the medications either. Patient 11 stated that he does not know his friends contact number. Patient 11 stated he does not know when the last time that he took his Percocet and Xanax, stated he used the medications for severe pain and stated if he ran out of it, he used the Ibuprofen but did not help him much. Patient 11 stated he used Xanax if he feels anxious. During an interview with LVN 1 on 8/8/2024 at 2:45 p.m., LVN 1 stated he was not aware of the missing medications (Lidocaine patch, Xanax tablets and Percocet Tablets). LVN 1 stated that he performed medication reconciliation last week and saw the missing medications, stated he would find out if certain medications had to be refilled. LVN 1 stated it was very important that Patient 11 did not run out of pain medications and anti-anxiety medications to better control the pain symptoms and his anxiety as well. LVN 1 stated that he provided teachings to Patient 11 regarding proper storage and safe keeping of controlled medications, stated he was unsure if he documented it to his skilled nurse notes. A review of Patient 11s clinical record titled “;Visit Nurse Note LVN” for Patient 11, dated 6/26/2024, indicated in the narrative section “;medications and supplies checked for refill.” There was no documentation that which medications were checked for refills and no documentation that LVN 1 conducted Patient 11s medication reconciliation. A review of Patient 11s clinical record titled “;Visit Note RN”, dated 7/19/2024 and 7/25/2024, did not mention if medication reconciliation was completed. During an interview with the DPCSD on 8/9/2024, at 1:38 p.m., DPCSD stated that she conducted an SN visit with Patient 11 on 7/29/2024. DPCSD stated that she reconciled P11s medications and saw no missing medications. DPCSD stated she saw Xanax, Lidocaine Transdermal Patch and Percocet tablets bottles. DPCSD stated that she reviewed with Patient 11 regarding importance of pain management, safe and proper storage of controlled substances medications and importance of not using it more than required frequency. DPCSD stated that pain and other PRN (as needed) medications should be readily accessible for use of patients in order to prevent patients prolong uncontrolled symptoms. DPCSD stated that she does not remember if the agency provided a copy of written instructions, policies and procedures regarding management and disposal of controlled drugs to the patient/patients caregiver. DPSCD stated that it is important to provide frequent teachings to Patient 11 regarding effective pain management and use of controlled pain medications. DPCSD stated that she is unsure if agency has system in place to effectively monitor patients use of controlled pain medications and proper safekeeping. DPCSD stated that medication reconciliation should be done on each nurses visit to be able to determine the current medication supplies, patients proper usage of medications and to ensure patients access to medications. The DPCSD stated that the nurses who visited Patient 11 had the responsibility to check all the patients medications to make sure the patient had all medications in the medication list. The DPCSD stated that it is important for the patients to safeguard and keep their controlled medications so they will know where to get it and to protect from other people that visits the patient. At 2:43 p.m., during a concurrent review with the DPCSD of Patient 11s clinical record, titled Visit Note RN” dated 7/29/2024, DPCSD acknowledged and stated that she conducted the visit with Patient 11 on 7/29/2024.”

“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 assessment for one of fourteen sampled patients (Patient 1). This deficient practice had the potential for the patient/family not being provided social, spiritual, and cultural support related to the patients anticipated death. A review of Patient 1s Personal Information indicated that Patient 1 was admitted on 7/20/2024 with a primary diagnosis of acute kidney failure (a sudden episode when a persons kidneys are not able to filter waste products from the blood). A review of Patient 1 Comprehensive Nursing Assessment, dated 7/29/2024, section “;Bereavement Screening,” had the “;Bereavement Counselor (BC) Visit needed” blank. During a concurrent record review and interview with the Director of Patient Care Services (DPCSD) on 8/6/2024 at 3:30 p.m., the DPCSD reviewed the History of Bereavement Assessment, printed by the HA staff on 8/6/2024, for Patient 1. The DPCSD stated the History of Bereavement Assessment was blank, which meant there was no bereavement assessment documented since admission. The DPCSD stated if it was not documented then it was not done. The DPCSD stated that she was not sure when initial bereavement assessment should have been completed. The DPCSD stated that without an initial bereavement assessment, the HA would not be able to assess patients and/or familys concerns regarding death, patients support system, and how the HA could provide support for the patient and family. A review of the HAs policy, titled “;Bereavement Assessment,” revised April 2020, indicated that the hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during the course of care, and at the time of the patients death as part of the comprehensive assessment. on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator. At a minimum it will include: A. Patient and family/caregiver loss issues. B. Survivor needs. C. Social, spiritual, and cultural factors. D. Services to be provided including individual counseling, support groups, and letters, and cards. E. Referrals to be made. F. Grief risk factors and potential for pathological grief reactions.”

“Based on observation, interview, and record review, the Hospice Agency (HA, providing care to terminally ill patients who have six months or less to live) failed to follow the individualized plan of care for two of fourteen sampled patients (Patient 2 and Patient 11) by failing to: 1. Ensure to implement the Plan of Care/Interdisciplinary Group (POC/IDG) Review (a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) and the physicians order for Patient 2 and Patient 11 a. Patient 2s physicians order on 5/8/2024, indicated for Patient 2 to take Escitalopram (medication to help treat depression [a mood disorder marked by varying degrees of sadness], and anxiety [nervousness]) 5 milligrams (mg, a unit of measurement, one tablet once a day for anxiety. Patient 2s primary caregiver (PCG 1) administered Escitalopram 20 mg to Patient 2 because the Escitalopram 5 mg was not available in Patient 2s home. The HA was not aware that Patient 2 was receiving Escitalopram 20 mg and that the Escitalopram 5 mg was not available despite skilled nurse visits on 7/12/2024, 7/19/2024, 7/26/2024, and 7/29/2024. This deficient practice placed Patient 2 at risk for overdose and adverse side effects (undesirable effect), that could lead to serious harm, hospitalization, and/or death. b. Patient 11s physicians order on 3/8/2024, indicated for Patient 11 to receive lidocaine (medication to help relieve pain) 5 percent (%) transdermal (the application of a medicine or drug through the skin), apply to the affected area every twelve hours as needed (PRN) for mild pain. Patient 11s physicians orders on 8/2/2024 indicated for Patient 11 to take Percocet (medication used for the management of moderate to severe pain) 10 mg-325 mg one tablet every six hours as needed for severe pain, and Xanax (medication that is used to treat anxiety and depression or panic disorders and works to balance out the chemicals in our brain) 1 mg one tablet every six hours as needed. The HA failed to ensure Patient 11 had the lidocaine 5% transdermal patch, Percocet 10 mg-325mg, and the Xanax 1 mg available at his residence and there was no medication reconciliation completed during the home visits. This deficient practice had the potential for Patient 11 to experience uncontrolled pain that could lead to serious harm, hospitalization, and/or death. On 8/9/2024, at 5:10 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency’s Chief Executive Officer (CEO) and the Administrator Designee/Director of Patient Care Services Designee (ADMD/DPCSD) related to the agency’s failure to ensure to follow the plan of care and implement the physicians orders for Patient 2 and Patient 11. As a result of the noncompliance, Patient 2 received Escitalopram 20 mg, more dosage than what was ordered by Patient 2s physician which placed Patient 2 at risk for an overdose and adverse side effects that could lead to serious harm, hospitalization, and/or death, and Patient 11 did not receive lidocaine 5% transdermal patch, Percocet 10 mg-325 mg, and Xanax 1 mg as ordered by Patient 11s physician which had the potential for Patient 11 to experience uncontrolled pain and adverse effects and could lead to serious harm, hospitalization, and/or death. On 8/9/2024 at 6:30 p.m., the agency was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team completed the survey tasks and conducted an exit conference, with the CEO, Director of Patient Care Services/Administrator Designee, Administrator Assistant, and Office Manager/Intake Coordinator, and exited the agency with the IJ situation not removed. On 8/26/2024 the agency submitted an acceptable IJ Removal plan. The IJ removal plan included the following: 1. On 8/10/2024 the Registered Nurse went to Patient 2s house and verified there was a physical bottle of Escitalopram 5 mg in the patients home. The RN instructed and witnessed the Patient Care Giver (PCG) discarded the Escitalopram 20 mg so that the patient no longer uses it. 2. On 8/11/2024, the patient and the patients caregiver were instructed to continue with the hospice-ordered plan of care and take Escitalopram 5 mg 1 tablet by mouth once a day for anxiety. Patient/PCG verbalized understanding 3. Patient 2 was not discharged from the hospice agency as his hospitalization was not related to the hospice diagnosis. 4. The agency conducted focused supervisory visits for all active patients and determined that no other patients were affected. Please see the attached documentation and monthly compliance calculator. 5. The agency created a custom focused medication reconciliation supervisory visit form in order to continuously assess the compliance of medication reconciliation every visit. 6. On 8/10/2024, the agency verified that the medications were sent to Patient 1 by the Pharmacy on 8/3/2024. The RN verified that the patient had the medications at home. 7. The lidocaine patch for Patient 11 was not discontinued as it was ordered PRN and the patient wished to keep the medication active to be able to use on an as needed basis. 8. On 8/11/2024, the agency hired a nurse educator to assist the organization in regaining compliance with following the hospice plan of care and proper medication reconciliation during home visits, care planning, following physician orders, and following the plan of care, as well as ensuring the policies and procedures for care planning and medication management were followed. 9.On 8/11/2024, the nurse educator provided in-service and trained all agency staff on medication management, policies and procedures, the importance of following physician orders, proper care planning, safe medication administration, accurate medication profiles, and medication reconciliation every nursing visit to ensure the safe and effective care provided to patients. 10.On 8/11/2024, the agency conducted supervisory visits to active patients and ensured that all medication profiles and care plans were accurate and current. The agency validated that no other patients were affected by this finding. 11.On 8/11/2024 - The agency created a supervisory visit audit sheet to maintain the corrective action plan and prevent future noncompliance. To ensure sustained compliance with this plan of correction, a supervisory RN will complete the audits every two weeks for the next quarter. The audit will be compiled into a compliance sheet, and a compliance rate will be calculated quarterly, with the denominator being the number of supervisory visits and the numerator being the number of supervisory visits with accurate medication profiles and evidence of following physician orders and care plan. The goal of compliance is 100%. On 8/27/2024, at 1:30 pm, the Department verified the agencys IJ removal plan implementation onsite through observation, interview, record review, and removed the IJ situation in the presence of the CEO and Office Manager. b. A review of Patient 11s untitled clinical record indicated a Start of Care (SOC) dated 11/16/2023 with a primary diagnosis Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing) unspecified, and a secondary diagnosis of Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). A review of Patient 11’s clinical record titled “;Plan of Care/Interdisciplinary Group Review” (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 6/12/2024, 6/26/2024, 7/10/2024 and 7/24/2024, indicated in the medication section, Patient 11s listed medications include is Xanax 1mg tablet, to take one tablet every six (6) hours as needed for anxiety attack and Percocet 10mg-325mg tablet, 1 (one) tablet every 6 (six) hours as needed for severe pain. It further indicated in the Plan of Care (Problem/Intervention/Goals/Status) Pain section that the goal is to resolve onset of pain within 30 minutes after administration of pain medication and the patient will remain comfortable within the next 48 hours as evidenced by absence of physical signs/symptoms of pain and intervention include to instruct the patient/patient caregiver (PCG) to give pain medications when pain level is >(greater than) 2 or above SIT level, to teach patient/patient caregiver (PCG) on immediate use, efficacy and precautions on prescribed medications, and instruct the patient/patient caregiver (PCG) regarding prescribed medications and side effects-monitor assess effectiveness of current medication. A review of Patient 11s clinical record titled “;POC/IDG Review” for Patient 11, dated 7/24/2024, indicated a Registered Nurse (RN) supervisory visit every 14 (fourteen) days + (plus) PRN (as needed) for clinical care and address concerns or evaluate and changes of condition and Skilled Nurse (SN) visit of once per week and 2 (two) as needed visits for change of condition. A review of Patient 11s clinical record “;Current Treatment/Medication/DME (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living)” indicated listed medications which include: - Lidocaine 5% Transdermal Patch (it is mainly used for relief of neuropathic (nerve) pain, especially in areas where it is particularly sensitive to touch) one (1) patch apply to the affected area every twelve (12) hours PRN (as needed) for mild pain. - Percocet (is a combination drug consisting of an opioid, a pain reliever and fever reducer (analgesic and antipyretic) used for the management of moderate to severe pain, usually for an extended time) 10mg-325mg tablet, one (1) tablet every six (6) hours as needed for severe pain. - Xanax (is a type of medication that is used to treat anxiety, depression or panic disorders and works to balance out the chemicals in our brain) 1 mg tablet, take one (1) tablet every six (6) hours as needed. During a joint home visit with the Licensed Vocational Nurse (LVN 1) on 8/8/2024 at 2:15 p.m., Patient 11 was observed laying on the sofa, awake but stated feels weak and sleepy, his both eyes closed but speak when ask questions. Patient 11 on oxygen therapy, connected to oxygen tank with current setting at 2liters/minute via nasal cannula (is a device that gives additional oxygen (supplemental oxygen or oxygen therapy) through the nose which is a thin, flexible tube that goes around the head and into the nose, there are two prongs that go inside the nostrils that deliver the oxygen). Patient 11 appeared comfortable and denies any pain or discomfort. During medication review/reconciliation with LVN 1 on 8/8/2024 at 2:28 p.m., The following medications: Lidocaine 5% Transdermal Patch, Percocet 10mg-325mg tablet and Xanax 1mg tablet were missing and not on Patient 11s on hand medications. During an interview with Patient 11 on 8/8/2024 at 2:32 p.m., Patient 11 stated he hid his Xanax and Percocet medications somewhere inside his residence but forgot where he placed it. Patient 11 stated he kept the medications whenever his friends visited him but forgets where he put the medications. Patient 11 stated that he takes Xanax if he feels anxious and take Percocet if the Ibuprofen does not work for his chronic body pain. Patient 11 stated he was unable to remember when the last time he took the medications (Xanax and Percocet), but he takes both medications frequently. Patient 11 stated that he does not remember when the last time the medications were refilled and delivered. Patient 11 stated that he is out of Lidocaine patch for a week now. Patient 11 stated he lives alone but he has a friend that comes to help him but stated she does not know where he kept the medications either. Patient 11 stated that he does not know his friends contact number. Patient 11 stated he does not know when the last time that he took his Percocet and Xanax, stated he used the medications for severe pain and stated if he ran out of it, he used the Ibuprofen but did not help him much. Patient 11 stated he used Xanax if he feels anxious. During an interview with LVN 1 on 8/8/2024 at 2:45 p.m., LVN 1 stated he was not aware of the missing medications (Lidocaine patch, Xanax tablets and Percocet Tablets). LVN 1 stated that he performed medication reconciliation last week and saw the missing medications, stated he would find out if certain medications had to be refilled. LVN 1 stated it was very important that Patient 11 did not run out of pain medications and anti-anxiety medications to better control the pain symptoms and his anxiety as well. LVN 1 stated that he provided teachings to Patient 11 regarding proper storage and safe keeping of controlled medications, stated he was unsure if he documented it to his skilled nurse notes. A review of Patient 11s clinical records titled “;History of Visit Notes”, indicated that the last visit of LVN 1 to Patient 11 was dated 6/26/2024. A further review indicated that the most recent visit prior to 8/8/2024 home visit was 7/29/2024 by a Registered Nurse/Director of Patient Care Services Designee (DPCSD). A review of the Patient 11s “;Monthly Schedule” indicated no scheduled visit with LVN 1 from 7/28/2024 to 8/3/2024. During an interview with the DPCSD on 8/9/2024, at 1:38 p.m., DPCSD stated that she conducted an SN visit with Patient 11 on 7/29/2024. DPCSD stated that she reconciled P11s medications and saw no missing medications. DPCSD stated she saw Xanax, Lidocaine Transdermal Patch and Percocet tablets bottles. DPCSD stated that she reviewed with Patient 11 regarding importance of pain management, safe and proper storage of controlled substances medications and importance of not using it more than required frequency. DPCSD stated that pain and other PRN (as needed) medications should be readily accessible for use of patients in order to prevent patients prolong uncontrolled symptoms. DPCSD stated that she does not remember if the agency provided a copy of written instructions, policies and procedures regarding management and disposal of controlled drugs to the patient/patients caregiver. DPSCD stated that it is important to provide frequent teachings to Patient 11 regarding effective pain management and use of controlled pain medications. DPCSD stated that she is unsure if agency has system in place to effectively monitor patients use of controlled pain medications and proper safekeeping. DPCSD stated that medication reconciliation should be done on each nurses visit to be able to determine the current medication supplies, patients proper usage of medications and to ensure patients access to medications. The DPCSD stated that the nurses who visited Patient 11 had the responsibility to check all the patients medications to make sure the patient had all medications in the medication list. The DPCSD stated that it is important for the patients to safeguard and keep their controlled medications so they will know where to get it and to protect from other people that visits the patient. At 2:43 p.m., during a concurrent review with the DPCSD of Patient 11s clinical record, titled Visit Note RN” dated 7/29/2024, DPCSD acknowledged and stated that she conducted the visit with Patient 11 on 7/29/2024. Upon further review, there was no documented evidence of DPCSD that medication reconciliation and patient teachings regarding proper storage and safekeeping of controlled medications were provided to Patient 11. The DPCSD stated that the Lidocaine Transdermal Patch 5% was already discontinued. At 2: 57 p.m., during a concurrent review with the DPCSD of Patient 11s “;Current Treatment/Medication/DME”, it indicated that Lidocaine 5% Transdermal Patch has an order date of 3/8/2024 with no stop date and listed as active medications. The DPCSD was unable to provide any documented evidence that the Lidocaine 5% Transdermal Patch was discontinued. A review of Patient 11s clinical record titled “;Visit Nurse Note LVN” for Patient 11, dated 6/26/2024, indicated in the narrative section “;medications and supplies checked for refill.” There was no documentation that which medications were checked for refills and no documentation that LVN 1 conducted Patient 11s medication reconciliation. A review of Patient 11s clinical record titled “;Visit Note RN”, dated 7/19/2024 and 7/25/2024, did not mention if medication reconciliation was completed. During a telephone interview with Pharmacist 1 on 8/9/2024 at 11:33 a.m., Pharmacist 1 verified that his pharmacy was supplying the medications to the HAs patients. Pharmacist 1 stated that Patient 11s medications of Lidocaine 5% Transdermal Patch, Xanax 1mg tablets and Percocet 10mg-325mg tablets were refilled, and the last refill date was 8/2/2024, and delivered to Patient 11s residence on 8/3/2024. Pharmacist 1 stated there are 45 tablets of Xanax 1mg and 45 tablets of Percocet 10-325mg in each order, which covered twelve (12) day supply. Pharmacist 1 stated there was a receipt for each medication delivered and received by Patient 11. Per Pharmacist 1, the person who received the medication would sign on the signature line on the delivery receipt. Pharmacist 1 stated that the Lidocaine 5% Transdermal Patch was last refilled on 3/8/2024 with thirty (30) day supply. Pharmacist 1 stated that they have not receive any refill order or discontinued order for Lidocaine 5% Transdermal Patch. A review of the delivery receipt, dated 8/3/2024, indicated that two medications were delivered to Patient 11, to the current address where Patient 11 is residing. The medications delivered were Percocet 10-325 mg quantity of 45 tablets and Xanax 1mg quantity of 45 tablets. The delivery receipt had a signature of Patient 11 on the signature line, indicating the medication was received. On 8/9/2024, at 3:37 p.m., a telephone call was made to Patient 11s Emergency contact/Domestic-Partner (FM1) but was unsuccessful. A review of Patient 11’s POC/IDG Review, dated 6/12/2024, 6/26/2024, 7/10/2024 and 7/24/2024, did not specify teachings in regard to proper storage and safekeeping of controlled pain medication. A review of the HAs policy and procedure, titled “;Home Use and Disposal of Controlled Substances”, revised date of April 2020, indicated that the Admitting Nurse/Case Manager will provide a copy of the written policies and procedures on the management and disposal of controlled drugs to the patient/representative and family. a. A review of Patient 2s Personal Information indicated that Patient 2 was admitted on 5/8/2024 with a primary diagnosis of alcoholic cirrhosis of liver (alcohol-induced liver disease) with ascites (abdominal swelling caused by accumulation of fluid, most often related to liver disease). A review of Patient 2’s POC/IDG Review, dated 5/8/2024, 5/15/2024, 6/12/2024, 7/10/2024, and 8/7/2024, indicated that Patient 2 was supposed to take Escitalopram 5 mg, one tablet, once a day, for anxiety. A review of Patient 2s most recent POC/IDG Review, dated 8/7/2024, indicated that the visit frequency of Skilled Nurse (SN, in general) was once a week and two as needed visits. A review of Patient 2s Current Treatment/Medication/DME (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living) indicated that Patient 2 was on Escitalopram 5 mg, one tablet, once a day, for anxiety. During a joint home visit with the DPCSD on 8/8/2024 at 1 p.m., observed Patient 2 lying in bed, awake, alert, and oriented. Patient 2s primary caregiver (PCG 1) was present in Patient 2s bedroom. During medication review with the DPCSD on 8/8/2024 at 1:30 p.m., it was noted that Escitalopram 5 mg was not available in Patient 2s home. Instead, Escitalopram 20 mg, with the instruction to take one tablet, once a day, was available in Patient 2s home. The expiration date on the container of Escitalopram 20 mg was 7/7/2024, and the filled date was 7/7/2023. During an interview with PCG 1 on 8/8/2024 at 1:35 p.m., PCG 1 stated that Escitalopram 20 mg was the only Escitalopram that Patient 2 had in the home. PCG 1 stated that he had been administering Escitalopram 20 mg one tablet, once a day, as instructed on the medication label, to Patient 2. When PCG 1 was asked how long he had been administering Escitalopram 20 mg to Patient 2, PCG 1 stated he was not sure. PCG 1 stated, “;I follow the instruction on the bottle.” During an interview with the DPCSD on 8/8/2024 at 1:45 p.m., the DPCSD stated that Escitalopram 20 mg did not come from the HAs pharmacy. The DPCSD stated that Patient 2 had been moving to three different homes since he was admitted to the HA, and that Escitalopram 5 mg might have been left in the previous home. The DPCSD stated she was not aware that PCG 1 had been administering Escitalopram 20 mg, or that Escitalopram 5 mg was not available in the home. The DPCSD stated that the nurse who visited Patient 2 had the responsibility to check all the patients medications to make sure the patient had all medications in the medication list. The DPCSD stated that taking Escitalopram 20 mg instead of the prescribed Escitalopram 5 mg might overdose the patient and cause serious adverse effects. On 8/8/2024, at 1:55 p.m., when PCG 1 was asked how long Patient 2 had been residing in the current home, PCG 1 stated that Patient 2 had been at the current address for one month. A review of Visit Note RN for Patient 2, dated 7/29/2024, indicated medication was checked and reviewed. The visit note RN did not mention what medication was checked and reviewed. A review of Visit Note RN, dated 7/26/2024, did not mention if medication reconciliation was completed. A review of Visit Note RN, dated 7/19/2024, indicated that medication reconciliation was completed. A review of Visit Note RN, dated 7/12/2024, indicated medications were reconciled. During a telephone interview with Pharmacist 1 on 8/9/2024 at 11:33 a.m., Pharmacist 1 verified that his pharmacy was supplying the medications to the HAs patients. Pharmacist 1 stated that an order for Escitalopram 5 mg was placed by the HA on 5/8/2024, 6/7/2024, 7/5/2024, and 8/2/2024. Pharmacist 1 stated there are 30 tablets of Escitalopram 5 mg in each order, which covered thirty day supply. Pharmacist 1 stated there was a receipt for each medication delivered and received by the patient. Per Pharmacist 1, the person who received the medication would sign on the signature line on the delivery receipt. A review of the delivery receipt, dated 8/3/2024, indicated that six medications were delivered to Patient 2 on that date, to the current address where Patient 2 was residing. One of the medications was Escitalopram 5 mg (Rx #141109-00). The delivery receipt had a signature on the signature line, indicating the medication was received. During an interview with the DPCSD on 8/9/2024 at 2:10 p.m., the DPCSD stated that some patients would keep old medications that were prescribed by previous physician before they were admitted to the HA. The DPCSD stated that Escitalopram 20 mg might have been prescribed by Patient 2s previous physician, however, according to the DPCSD, Patient 2 was not supposed to take Escitalopram 20 mg because the medication ordered by the HAs physician was Escitalopram 5 mg. A review of Patient 2’s POC/IDG Review, dated 5/8/2024, 5/15/2024, 6/12/2024, 7/10/2024, and 8/7/2024, did not specify teaching in regard to patients old medications prescribed by previous physicians. A review of the HAs policy, titled “;The Plan of Care,” revised April 2020, indicated the care provided to the patient must be in accordance with the plan of care. The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen days. The policy indicated the written plan of care will contain, but will not be limited to, the following: P. Patient and family/caregiver educational needs and assessments of their ability to learn and understand teaching and their ability to safely self-administer drugs and biologicals. A review of the HAs policy, titled “;Medication Profile,” revised April 2020, indicated that during subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate the use of the drugs in the home setting. The medication profile includes, but is not limited to all current medications, date prescribed, name of medication, dose, frequency, drug classification, and date discontinued. B. Using the medication profile to teach purpose of medication, dosages, routes, administration times, side effects, and contraindications. The “;Medication Profile” policy indicated that deviations from taking medications as ordered will be documented in clinical notes, and the physician will be notified.”

“Based on observation, interview and record review, the Hospice Agency (HA) failed to provide education and training as appropriate to their responsibilities for the care and services for one of fourteen sampled patients (Patient 11). This failure resulted in the HAs inability to ensure Patient 11s understanding regarding importance of proper storage and safekeeping of controlled medications and readily available when needed. A review of Patient 11s untitled clinical record indicated a Start of Care (SOC) dated 11/16/2023 with a primary diagnosis Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing) unspecified, and a secondary diagnosis of Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). A review of Patient 11’s clinical record titled “;Plan of Care/Interdisciplinary Group Review” (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 6/12/2024, 6/26/2024, 7/10/2024 and 7/24/2024, indicated in the medication section, Patient 11s listed medications include is Xanax 1mg tablet, to take one tablet every six (6) hours as needed for anxiety attack and Percocet 10mg-325mg tablet, 1 (one) tablet every 6 (six) hours as needed for severe pain. It further indicated in the Plan of Care (Problem/Intervention/Goals/Status) Pain section that the goal is to resolve onset of pain within 30 minutes after administration of pain medication and the patient will remain comfortable within the next 48 hours as evidenced by absence of physical signs/symptoms of pain and intervention include to instruct the patient/patient caregiver (PCG) to give pain medications when pain level is >(greater than) 2 or above SIT level, to teach patient/patient caregiver (PCG) on immediate use, efficacy and precautions on prescribed medications, and instruct the patient/patient caregiver (PCG) regarding prescribed medications and side effects-monitor assess effectiveness of current medication. A review of Patient 11s clinical record titled “;POC/IDG Review” for Patient 11, dated 7/24/2024, indicated a Registered Nurse (RN) supervisory visit every 14 (fourteen) days + (plus) PRN (as needed) for clinical care and address concerns or evaluate and changes of condition and Skilled Nurse (SN) visit of once per week and 2 (two) as needed visits for change of condition. A review of Patient 11s clinical record “;Current Treatment/Medication/DME (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living)” indicated listed medications which include: - Lidocaine 5% Transdermal Patch (it is mainly used for relief of neuropathic (nerve) pain, especially in areas where it is particularly sensitive to touch) one (1) patch apply to the affected area every twelve (12) hours PRN (as needed) for mild pain. - Percocet (is a combination drug consisting of an opioid, a pain reliever and fever reducer (analgesic and antipyretic) used for the management of moderate to severe pain, usually for an extended time) 10mg-325mg tablet, one (1) tablet every six (6) hours as needed for severe pain. - Xanax (is a type of medication that is used to treat anxiety, depression or panic disorders and works to balance out the chemicals in our brain) 1 mg tablet, take one (1) tablet every six (6) hours as needed. During a joint home visit with the Licensed Vocational Nurse (LVN 1) on 8/8/2024 at 2:15 p.m., Patient 11 was observed laying on the sofa, awake but stated feels weak and sleepy, his both eyes closed but speak when ask questions. Patient 11 on oxygen therapy, connected to oxygen tank with current setting at 2liters/minute via nasal cannula (is a device that gives additional oxygen (supplemental oxygen or oxygen therapy) through the nose which is a thin, flexible tube that goes around the head and into the nose, there are two prongs that go inside the nostrils that deliver the oxygen). Patient 11 appeared comfortable and denies any pain or discomfort. During medication review/reconciliation with LVN 1 on 8/8/2024 at 2:28 p.m., The following medications: Lidocaine 5% Transdermal Patch, Percocet 10mg-325mg tablet and Xanax 1mg tablet were missing and not on Patient 11s on hand medications. During an interview with Patient 11 on 8/8/2024 at 2:32 p.m., Patient 11 stated he hid his Xanax and Percocet medications somewhere inside his residence but forgot where he placed it. Patient 11 stated he kept the medications whenever his friends visited him but forgets where he put the medications. Patient 11 stated that he takes Xanax if he feels anxious and take Percocet if the Ibuprofen does not work for his chronic body pain. Patient 11 stated he was unable to remember when the last time he took the medications (Xanax and Percocet), but he takes both medications frequently. Patient 11 stated that he does not remember when the last time the medications were refilled and delivered. Patient 11 stated that he is out of Lidocaine patch for a week now. Patient 11 stated he lives alone but he has a friend that comes to help him but stated she does not know where he kept the medications either. Patient 11 stated that he does not know his friends contact number. Patient 11 stated he does not know when the last time that he took his Percocet and Xanax, stated he used the medications for severe pain and stated if he ran out of it, he used the Ibuprofen but did not help him much. Patient 11 stated he used Xanax if he feels anxious. During an interview with LVN 1 on 8/8/2024 at 2:45 p.m., LVN 1 stated he was not aware of the missing medications (Lidocaine patch, Xanax tablets and Percocet Tablets). LVN 1 stated that he performed medication reconciliation last week and saw the missing medications, stated he would find out if certain medications had to be refilled. LVN 1 stated it was very important that Patient 11 did not run out of pain medications and anti-anxiety medications to better control the pain symptoms and his anxiety as well. LVN 1 stated that he provided teachings to Patient 11 regarding proper storage and safe keeping of controlled medications, stated he was unsure if he documented it to his skilled nurse notes. A review of Patient 11s clinical records titled “;History of Visit Notes”, indicated that the last visit of LVN 1 to Patient 11 was dated 6/26/2024. A further review indicated that the most recent visit prior to 8/8/2024 home visit was 7/29/2024 by a Registered Nurse/Director of Patient Care Services Designee (DPCSD). A review of the Patient 11s “;Monthly Schedule” indicated no scheduled visit with LVN 1 from 7/28/2024 to 8/3/2024. During an interview with the DPCSD on 8/9/2024, at 1:38 p.m., DPCSD stated that she conducted an SN visit with Patient 11 on 7/29/2024. DPCSD stated that she reconciled P11s medications and saw no missing medications. DPCSD stated she saw Xanax, Lidocaine Transdermal Patch and Percocet tablets bottles. DPCSD stated that she reviewed with Patient 11 regarding importance of pain management, safe and proper storage of controlled substances medications and importance of not using it more than required frequency. DPCSD stated that pain and other PRN (as needed) medications should be readily accessible for use of patients in order to prevent patients prolong uncontrolled symptoms. DPCSD stated that she does not remember if the agency provided a copy of written instructions, policies and procedures regarding management and disposal of controlled drugs to the patient/patients caregiver. DPSCD stated that it is important to provide frequent teachings to Patient 11 regarding effective pain management and use of controlled pain medications. DPCSD stated that she is unsure if agency has system in place to effectively monitor patients use of controlled pain medications and proper safekeeping. DPCSD stated that medication reconciliation should be done on each nurses visit to be able to determine the current medication supplies, patients proper usage of medications and to ensure patients access to medications. The DPCSD stated that the nurses who visited Patient 11 had the responsibility to check all the patients medications to make sure the patient had all medications in the medication list. The DPCSD stated that it is important for the patients to safeguard and keep their controlled medications so they will know where to get it and to protect from other people that visits the patient. At 2:43 p.m., during a concurrent review with the DPCSD of Patient 11s clinical record, titled Visit Note RN” dated 7/29/2024, DPCSD acknowledged and stated that she conducted the visit with Patient 11 on 7/29/2024. Upon further review, there was no documented evidence of DPCSD that medication reconciliation and patient teachings regarding proper storage and safekeeping of controlled medications were provided to Patient 11. The DPCSD stated that the Lidocaine Transdermal Patch 5% was already discontinued. At 2: 57 p.m., during a concurrent review with the DPCSD of Patient 11s “;Current Treatment/Medication/DME”, it indicated that Lidocaine 5% Transdermal Patch has an order date of 3/8/2024 with no stop date and listed as active medications. The DPCSD was unable to provide any documented evidence that the Lidocaine 5% Transdermal Patch was discontinued. A review of Patient 11s clinical record titled “;Visit Nurse Note LVN” for Patient 11, dated 6/26/2024, indicated in the narrative section “;medications and supplies checked for refill.” There was no documentation that which medications were checked for refills and no documentation that LVN 1 conducted Patient 11s medication reconciliation. A review of Patient 11s clinical record titled “;Visit Note RN”, dated 7/19/2024 and 7/25/2024, did not mention if medication reconciliation was completed. During a telephone interview with Pharmacist 1 on 8/9/2024 at 11:33 a.m., Pharmacist 1 verified that his pharmacy was supplying the medications to the HAs patients. Pharmacist 1 stated that Patient 11s medications of Lidocaine 5% Transdermal Patch, Xanax 1mg tablets and Percocet 10mg-325mg tablets were refilled, and the last refill date was 8/2/2024, and delivered to Patient 11s residence on 8/3/2024. Pharmacist 1 stated there are 45 tablets of Xanax 1mg and 45 tablets of Percocet 10-325mg in each order, which covered twelve (12) day supply. Pharmacist 1 stated there was a receipt for each medication delivered and received by Patient 11. Per Pharmacist 1, the person who received the medication would sign on the signature line on the delivery receipt. Pharmacist 1 stated that the Lidocaine 5% Transdermal Patch was last refilled on 3/8/2024 with thirty (30) day supply. Pharmacist 1 stated that they have not receive any refill order or discontinued order for Lidocaine 5% Transdermal Patch. A review of the delivery receipt, dated 8/3/2024, indicated that two medications were delivered to Patient 11, to the current address where Patient 11 is residing. The medications delivered were Percocet 10-325 mg quantity of 45 tablets and Xanax 1mg quantity of 45 tablets. The delivery receipt had a signature of Patient 11 on the signature line, indicating the medication was received. On 8/9/2024, at 3:37 p.m., a telephone call was made to Patient 11s Emergency contact/Domestic-Partner (FM1) but was unsuccessful. A review of Patient 11’s POC/IDG Review, dated 6/12/2024, 6/26/2024, 7/10/2024 and 7/24/2024, did not specify teachings in regard to proper storage and safekeeping of controlled pain medication. A review of the HAs policy and procedure, titled “;Home Use and Disposal of Controlled Substances”, revised date of April 2020, indicated that the Admitting Nurse/Case Manager will provide a copy of the written policies and procedures on the management and disposal of controlled drugs to the patient/representative and family, the Admitting Nurse /Case Manager will verbally discuss the policy with the patient/representative and family/caregiver in a language and manner that they understand to ensure the safe use and disposal of controlled drugs. The Admitting Nurse /Case Manager will document in the clinical record that the patient/representative and family have received a copy of the policies and procedures, and organizations will monitor for suspected drug diversion, including opioids, depressants, hallucinogens, stimulants and anabolic steroids.”

“Based on observation and interview, the Hospice Agency (HA; agency providing care to terminally ill patients who have six months or less to live) failed to follow accepted standards of practice related to disposal of contaminated waste for one of fourteen sampled patients (Patient 2). This deficient practice had the potential to expose patient and/or caregiver to infection caused by blood-borne pathogens. A review of Patient 2s Personal Information indicated that Patient 2 was admitted on 5/8/2024 with a primary diagnosis of alcoholic cirrhosis of liver (alcohol-induced liver disease) with ascites (abdominal swelling caused by accumulation of fluid, most often related to liver disease). During a joint home visit with the Director of Patient Care Services (DPCSD) on 8/8/2024 at 1 p.m., observed Patient 2 lying in bed, awake, alert, and oriented. Patient 2s primary caregiver (PCG 1) was present in Patient 2s bedroom. During an interview with Patient 2 on 8/8/2024 at 1:40 p.m., Patient 2 stated he would check his blood sugar every night prior to administering the Lantus (a type of insulin to help manage blood sugar levels) 100 units/ml solution for injection for eight units as prescribed. Patient 2 stated his blood sugar levels range were usually between 120 mg/dL to 130 mg/dL, but Patient 2 stated he never recorded the readings. A glucometer (a medical device for determining the approximate concentration of glucose in the blood), lancet device (a small, sharp, spring-loaded device that takes small blood samples), and glucometer strips (disposable strips that react with blood glucose and are used with a glucometer to measure blood glucose levels) were observed at Patient 2s residence. There was no sharps container (containers made from rigid puncture-resistant plastic or metal with leak-resistant sides and bottom, and a tight-fitting, puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter) observed. When Patient 2 was asked where he disposed the used lancets after he checked his blood sugar, Patient 2 stated that he disposed them in the trash can, while pointing to the open trash can in his room. Patient 2 stated the HA did not provide him with a sharps container. During an interview with the DPCSD on 8/8/2024 at 2:05 p.m., the DPCSD stated that she had advised Patient 2 and PCG 1 to dispose his used lancets inside a plastic bottle with a lid on while waiting for a sharps container. The DPCSD stated that disposing used lancet in the trash can presented a risk for injury and infection. The DPCSD stated that Patient 2 should have been provided with a sharps container to prevent injury and infection. A review of the HAs policy, titled “;Contaminated Waste Disposal,” revised April 2020, indicated the following: - Personnel will teach patients and family/caregivers proper contaminated waste disposal. - Needles, syringes, and razor blades should be placed in a puncture-proof container. In the event patient does not have a sharps container, patient can utilize a glass jar.”

“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 Medical Director conducted an accurate assessment, review, and verified the patient clinical information, necessary for Initial Certification of Terminal Illness (CTI) to support diagnosis of the patients’ terminal illnesses and to qualify for hospice care for seven out of fourteen sampled patients (Patient 1, Patient 4, Patient 5, Patient 9, Patient 10, Patient 11, and Patient 12). The HA has no documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, et cetera, necessary for initial certification of hospice care and services. This deficient practice resulted in patients being enrolled in hospice and receiving care without a proper verification of patients’ eligibility and had the potential for Patient 1, Patient 4, Patient 5, Patient 9, Patient 10, Patient 11, and Patient 12 not receiving necessary care and healthcare resources to meet their care goals. a. A review of Patient 1s Personal Information indicated that Patient 1 was admitted on 7/20/2024 with a primary diagnosis of acute kidney failure (a sudden episode when a persons kidneys are not able to filter waste products from the blood). During a concurrent interview and record review with the Director of Patient care Services (DPCSD) on 8/6/2024, at 3:50 p.m., the DPCSD reviewed Patient 1s LCD (Local Coverage Determination) Hospice Eligibility Determination, dated 7/29/2024. LCD is used by hospice providers to determine eligibility for beneficiaries for hospice benefits. The DPCSD The DPCS verified that the LCD for Patient 1 was not completed (blank), which caused the LCD to indicate that Patient 1 did not qualify per LCD Guidelines. When the DPCSD was asked when the LCD Hospice Eligibility Determination was supposed to be completed, the DPCSD stated that it was supposed to be completed by QA (Quality Assurance) after the Registered Nurse completed the Comprehensive Nursing Assessment. A review of Patient 1s Physicians Certification for Hospice Benefit, dated 7/30/2024, indicated that Patient 1 was admitted to hospice with primary diagnosis of acute kidney failure. The document also indicated that Patient 1 had a terminal illness and a life expectancy of six months or less if the disease runs its normal course. During a telephone interview with Patient 1 on 8/7/2024 at 1:57 p.m., Patient 1 stated he had never been diagnosed with a terminal illness, nor had he been diagnosed with having a life expectancy of 6 months or less by a physician. Patient 1 stated that he was diagnosed with prostate cancer (a cancer in a man’s prostate, a small walnut-sized gland that produces seminal fluid) in 2022, and he had to undergo radiation therapy to treat the prostate cancer. According to Patient 1, his physician informed him in December 2023 that his cancer was in remission. Patient 1 stated, “;Im not dying, thank God.” When Patient 1 was asked who referred him to hospice, Patient 1 stated it was his brother-in-law who previously had hospice service. Patient 1 stated that it was good to be able to have nurses come and check on him once a week and helped him get his medication refills. During a concurrent record review and interview with the DPCSD on 8/9/2024 at 12:30 p.m., the DPCSD reviewed Patient 1s Ambulatory Visit Instructions from Hospital 1, for visit date 5/1/2024. The DPCSD verified the Ambulatory Visit Instructions indicated that Patient 1 had the following scheduled follow-up appointments: Oncology (a branch of medicine that specializes in the diagnosis and treatment of cancer) Nurse on 5/17/2024, Eye Optometry (a specialized health care profession that involves examining the eyes and related structures for defects or abnormalities) on 6/21/2024, and Urology (a branch of medicine that focuses on surgical and medical diseases of the urinary system and the reproductive organs) on 7/1/2024. The DPCSD stated the documents from Hospital 1 did not have any lab results or studies that support the terminal diagnosis of acute kidney failure. The DPCSD stated that the Ambulatory Visit Instructions did not contain hospice referral. The HA was not able to provide further clinical documentations that support Patient 1s terminal diagnosis of acute kidney failure. b. A review of Patient 4s Personal Information indicated that Patient 4 was admitted on 6/12/2024 with a primary diagnosis of hypertensive heart disease (a number of complications of high blood pressure that affect the heart) without heart failure (a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 4s Visit Note LVN, dated 7/3/2024, indicated that oxygen saturation was 95% on room air (no supplemental oxygen). The narrative section indicated that vital signs were within normal limits, no shortness of breath with rest, per patient shortness of breath on exertion (the use of a lot of physical or mental effort). Per National Council on Aging, an ideal oxygen level is between 95% and 100%. A review of Patient 4s Visit Note LVN, dated 7/10/2024, indicated that oxygen saturation was 95% on room air. The respiratory section indicated Patient 4 had light difficulty. A review of Patient 4s Visit Note LVN, dated 7/17/2024, indicated that oxygen saturation was 95% on room air. ). The narrative section indicated no respiratory distress noted. A review of Patient 4s Visit Note LVN, dated 7/30/2024, indicated that oxygen saturation was 95% on room air. The respiratory section indicated Patient 4 had light difficulty. During a concurrent record review and interview with the DPCSD on 8/9/2024 at 12:45 p.m., the DPCSD reviewed Patient 4s LCD Hospice Eligibility Determination. The DPCSD verified that based on the LCD Hospice Eligibility Determination, Patient 4 is optimally treated with for heart disease with diuretics (medicines that help reduce fluid buildup in the body) and vasodilators (medicines that dilate/widen blood vessels, allowing blood to flow more easily) and met the criteria for NYHA Class IV. NYHA Class IV is a classification of the most severe type of heart failure by the New York Heart Association. The DPCSD verified there were no clinical documents to support the NYHA Class IV in Patient 4s record. c. A review of Patient 5s Personal Information indicated that Patient 5 was admitted on 6/4/2024 with a primary diagnosis of hypertensive heart disease (a number of complications of high blood pressure that affect the heart) without heart failure (a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 5s Physicians Certification for Hospice Benefit (CTI/Certification of Terminal Illness), dated 6/6/2024, signed by the Medical Director (MD), indicated that Patient 5 in the first certification episode of hospice service. The CTI also indicated that Patient 5 had NYHA Class IV (a classification of the most severe type of heart failure by the New York Heart Association. The Certifying Physician Narrative indicated that Patient 5 was generally weak and required moderate to maximum assistance with all ADL (Activities of Daily Living, activities related to personal care; they include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) function. During a telephone interview with Patient 5 on 8/7/2024 at 12:34 p.m., in his native language (Spanish), Patient 5 stated he did not have heart failure. Patient 5 stated he had high blood pressure. Patient 5 stated he had never been diagnosed with a terminal illness by a physician or told that he had six months or less to live. When Patient 5 was asked who referred him to hospice, Patient 5 stated that he and his wife were at a building office of Los Angeles County, which had like a fair going on, with multiple vendors. According to patient 5, one of the vendors approached them and told them that they would benefit from the program. Patient 5 stated he was not sure what program. Patient 5 stated, “;The next thing I know, my wife agreed to enroll. She enrolled both of us.” Patient 5 stated the LA County building was where he received a cellular phone for free by providing his Medical number. During the same interview, Patient 5 stated after his wife agreed to enroll, a nurse started coming to his home, bringing medications he was not familiar with. Patient 5 also stated the nurse brought him a “breathing machine” (nebulizer, a small machine that turns liquid medicine into a mist that can be inhaled directly into the lungs through a mouthpiece or mask) he did not need and had never used. Patient 5 stated the male nurse, which he identified as LVN 1, usually came on Friday on Saturday, depending on Patient 5s availability. Patient 5 then asked the surveyor how he could stop this program because he stated that he was fine. Patient 5 denied shortness of breath, denied needing to use supplemental oxygen, and/or breathing treatment. Patient 5 stated he was able to walk by himself without any device and without a persons assistance. Patient 5 stated, “;I work around the house, I work for my daughter, she has a decorating business.” During a telephone interview with Licensed Vocational Nurse 1 (LVN 1) on 8/8/2024 at 9:12 a.m., LVN 1 stated he was familiar with Patient 5. LVN 1 stated that Patient 5 was ambulatory with no assistive device and does not use supplemental oxygen. When LVN 1 was asked if Patient 5 had any shortness of breath, LVN 1 stated that Patient 5 would have mild shortness of breath after he walked for a bit, but not at rest. A review of Patient 1s Visit Note LVN, which was completed by LVN 1, dated 6/26/2024, 7/5/2024, 7/12/2024, 7/19/2024, and 7/26/2024, indicated that Patient 5 had an oxygen saturation (the amount of oxygen circulating in blood) of 95% on room air (without supplemental oxygen). Per National Council on Aging, an ideal oxygen level is between 95% and 100%. During a concurrent record review and interview with the Director of Patient Care Services (DPCSD) on 8/9/2024 at 12:55 p.m., the DPCSD reviewed the CTI and LCD Hospice Eligibility Determination for Patient 5. The DPCSD verified that based on the LCD, Patient 5 was optimally treated with diuretics and vasodilators, and met the criteria for NYHA Class IV. The DPCSD was not able to provide the clinical records of Patient 5 to support the primary diagnosis, as requested by the survey team. During a telephone interview with the Medical Director (MD) on 8/9/2024 at 2:22 p.m., the MD stated that a person with NYHA Class IV would have shortness of breath at rest and would require assistance with ADLs around the clock. When asked what diagnostics would support the diagnosis of NYHA Class IV, the MD stated that echocardiogram (an ultrasound test that checks the structure and function of the heart could determine if a person had NYHA Class IV by measuring the ejection fraction (a measurement of the percentage of blood leaving the heart each time it squeezes). According to the MD, a person with NYHA Class IV would have an ejection fraction between 15% to 20%. When the MD was asked if Patient 5, who was able to ambulate unassisted and go to an LA County event with his wife, helped his daughter working at home, and had no diagnostics or history and physical on file, would meet the criteria of NYHA Class IV, the MD stated, “;Absolutely not.” The MD stated that Patient 5 did not meet the hospice criteria under heart disease. During the same interview, the MD was asked on the process of admitting a patient to the hospice agency. The MD stated that patient had to be referred by a physician and had to have a terminal illness with life expectancy of 6 months or less. The MD stated the diagnosis had to be supported by clinical documents, such as history and physicals, laboratory, and imaging data. The MD stated the HA had the responsibility to ensure patients had the clinical documents, which he would review. The MD stated he tried to review all the clinical documents and see the patients in person, but until he had an opportunity for that, he would base the CTI narrative on the Registered Nurse report, who had seen and assessed the patient first. The MD stated he would need to personally see all the patients to ensure their eligibility for hospice. A review of the HAs document, titled “;Job Description Summary” for Hospice Medical Director, revised April 2020, indicated that the hospice Medical director will have overall responsibility for the medical component of the hospice program. The document indicated the duties and responsibilities of the Medical Director will include, but not be limited to, the following: 14. 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 written certification of terminal illness. A review of the HAs policy, titled “;Certification of Terminal Illness,” revised April 2020, indicated that clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. d. A review of Patient 9s (P9) untitled admission record indicated a start of care (SOC) of 7/5/2024 with a primary diagnosis of Malignant Neoplasm of unspecified site of left female breast ( a cancerous tumor that grows in or around the breast tissue, mainly in the milk ducts and glands). A review of Patient 9s clinical record titled “;Physicians Certification for Hospice Benefit”, dated 7/5/2024, indicated that Patient 9 was admitted to hospice with primary diagnosis of Malignant Neoplasm of unspecified site of Left Female Breast. It further indicated in the “;Certifying Physician Narrative” section note that P9 has a clinical history which include Gait Instability and her ADLS (Activity of Daily Living, The tasks of everyday life which include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) indicated that P9 is ambulatory with cane, caregiver provides moderate to maximum assistance with all activities of daily living and P9 reports SOB (Shortness of Breath) with moderate exertion and even at rest managed with respiratory inhaler and per caregiver, P9 is ambulatory and due to altered balance, P9 is using cane as assistive device, able to tolerate less than 10 steps before stopping, needs assistance, high risk for fall due to weakness and impaired balance. The document also indicated that Patient 9 had a terminal illness and a life expectancy of six months or less if the disease runs its normal course. On 8/8/2024, at 11:00 a.m., during a telephone interview with Patient 9, she stated that she called the hospice agency to cancel the skilled nurses home visit today because of her toothache and stated she is on her way to her dentist by herself and she is about to ride on a bus. Patient 9 stated that she has no terminal illness, she has no breast cancer anymore and that was years ago. Patient 9 declined to tell who referred her to hospice agency and she stated she needs to go and ended the telephone conversation. During telephone conversation with P9, she speaks clearly with no difficulties and does not stop in between sentences. On 8/8/2024, at 11:05 a.m., during a telephone interview with Patient 9s caregiver (PCG4)11:05 a.m., PCG4 stated that she is the caregiver for Patient 9. PCG4 stated she worked for P9, three (3) times a week, she stated that P9 has no immediate relative or family. PCG4 stated that P9 was picked up by her friend today at P9s house to bring her to dentist. PCG4 stated her friend provided a ride for P9 today. PCG4 stated that she referred P9 to hospice agency and P9 was not referred by her doctors. PCG4 stated that she was approached by a lady from Social Services and asked her if she know someone that has Medicare/Medical insurance and told her that they can provide free medical services which includes free nurse visits, free medications, and supplies. PCG4 stated that she does not know that hospice is for patients that has terminal illness and for dying patients. PCG4 stated the agency did not explain to her or to P9 regarding hospice services and its program. PCG4 stated that P9 has a breast cancer many years ago but not anymore, stated that P9 can walk by herself without using any mechanical devices, she walks around the neighborhood to buy ice cream, she does not have any difficulties in moving around. PCG4 stated P9 has no terminal illness anymore and she accompanies her to go to her doctors regularly. PCG4 stated that P9 will live way longer than 6 months with her current health status. During a concurrent interview and record review with the Director of Patient care Services (DPCSD) on 8/9/2024, at 4:20 p.m., the DPCSD reviewed Patient 9s LCD (Local Coverage Determination) Hospice Eligibility Determination, dated 7/5/2024 (LCD is used by hospice providers to determine eligibility for beneficiaries for hospice benefits). The DPCSD verified that the LCD indicated in the following questionnaires “;a. Has the cancer metastasized and is untreatable at presentation?” was documented as “;Yes”, “;a. Has the Cancer metastasized regardless of therapy?” was documented as “;Yes”, “;a. Patient has suspicious large tumor and refuses definitive diagnosis?” was documented as “;Yes”, “;Patient has declined in functional status?” was documented as “;Yes” and “;Patient has significant, unintentional weight loss?”, was documented as “;Yes”. DPCSD stated that the documents from hospital did not have any lab results or studies that support the terminal diagnosis of P9. The DPCSD stated that she does not know that P9 can tolerate such activities like walking around the neighborhood or going to her dentist by herself, she stated that P9 should be homebound given her health situation. The HA was not able to provide further clinical documentations that support Patient 9s terminal diagnosis of Malignant Neoplasm of unspecified site of Left Female Breast. e. A review of Patient 10s (P10) untitled admission record indicated a start of care (SOC) of 7/11/2024 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing) unspecified, and a secondary diagnosis of Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) without Heart Failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). A review of Patient 10s clinical record titled “;Physicians Certification for Hospice Benefit”, dated 7/11/2024, indicated that Patient 10 was admitted to hospice with primary diagnosis of Chronic Obstructive Pulmonary Disease, unspecified. It further indicated in the “;Certifying Physician Narrative” section note that P10 has a clinical history which include Gait Instability and per P10s caregiver, it indicated that P10 is ambulatory and due to altered balance, P10 is using cane as assistive device, able to tolerate less than 10 steps before stopping, needs assistance, high risk for fall due to weakness and impaired balance. The document also indicated that Patient 10 had a terminal illness and a life expectancy of six months or less if the disease runs its normal course. A review of Patient 10s clinical records titled “;Visit Note LVN”, dated 7/12/2024, indicated that oxygen saturation was 94% on room air (no supplemental oxygen). It further indicated in the “;Narrative section” that vital signs were within normal limits, no shortness of breath with rest, per patient shortness of breath on exertion (the use of a lot of physical or mental effort). Per National Council on Aging, an ideal oxygen level is between 95% and 100%. A review of Patient 10s clinical record titled “;Visit Note LVN”, dated 7/19/2024, indicated that oxygen saturation was 95% on room air. The respiratory section indicated Patient 10 had light difficulty. A review of Patient 10s clinical record titled “;Visit Note LVN”, dated 7/25/2024, indicated that oxygen saturation was 90% on room air (no supplemental oxygen). The respiratory section indicated Patient 10 had heavy breathing. A review of Patient 10s clinical note titled “;Visit Note LVN” dated 7/26/2024, indicated that oxygen saturation was 94% on room air (no supplemental oxygen). The respiratory section indicated Patient 4 had light difficulty. It further indicated in the “;Narrative section” that no respiratory distress noted. On 8/6/2024, at 12:51 p.m. and 8/7/2024 at 4:37 p.m., telephone calls were made to contact P10 but were unsuccessful. On 8/6/2024, at 12:53 p.m., during interview with P9, she stated that she was unaware she is listed as the “;Authorized Representative/Emergency Contact. P9 stated that P10 is currently not at home, and she does not know where he went and with whom. P9 stated that P10 walks with no mechanical device and goes out daily, uses Uber as his transportation. P9 stated that P10 only lives and renting a room from her. P9 stated she does not want to talk regarding P10 because she does not want them to be in trouble and she does not want to elaborate further. On 8/8/2024, at 11:05 a.m., during a telephone interview with Patient 9s caregiver (PCG4), PCG4 stated that she is the caregiver for Patient 9. PCG4 stated that she also referred P10 to hospice agency as she met him in P9s home. PCG4 stated that P10 lives and renting a room at P9s home. PCG4 stated that she also referred patient 10 to the agency, she stated that patient 10 has no caregiver and lives by himself. PCG4 stated that P10 is doing his own errands and goes out using Uber as his of transportation. During a concurrent interview and record review with the Director of Patient care Services (DPCSD) on 8/9/2024, at 4:32 p.m., the DPCSD reviewed Patient 10s LCD (Local Coverage Determination) Hospice Eligibility Determination, dated 7/11/2024 (LCD is used by hospice providers to determine eligibility for beneficiaries for hospice benefits). The DPCSD verified that the LCD indicated in the following questionnaires “;a.i. Poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways (bronchi)), resulting in decreased functional capacity (e.g. bed to chair existence, fatigue and cough)? Was documented as “;Yes” and “;b. O2 (Oxygen) Sat (saturation) less than or equal to 88% determined either by arterial blood gases (measures the balance of oxygen and carbon dioxide in the blood to see how well the lungs are working and it also measures the acid-base balance in the blood) or O2 saturation monitors?” was documented as “;Yes”. DPCSD stated that the documents from hospital did not have any lab results or studies that support the terminal diagnosis of P10. The DPCSD stated that she does not know that P10 can tolerate such activities like going out and doing his own errands with no difficulties, she stated that P10 should be homebound given his health situation. The HA was not able to provide further clinical documentations that support Patient 10s terminal diagnosis of Chronic Obstructive Pulmonary Disease for hospice admission. f. A review of Patient 11s (P11) untitled admission record indicated a start of care (SOC) of 11/16/2023 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing) unspecified, and a secondary diagnosis of Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). A review of Patient 11s clinical records titled “;Visit Note LVN”, dated 6/26/2024, indicated that oxygen saturation was 95% on room air (no supplemental oxygen). It further indicated in the “;Respiratory section” that P11 has light difficulty and no abnormal lung sounds. Per National Council on Aging, an ideal oxygen level is between 95% and 100%. A review of Patient 11s clinical record titled “;Visit Note RN”, dated 7/19/2024, indicated that oxygen saturation was 95% on room air. The “;respiratory section” indicated Patient 11 had light difficulty. It further indicated in the “;Narrative Section” that P11 has “;No respiratory distress noted”. A review of Patient 11s clinical record titled “;Visit Note RN”, dated 7/26/2024, indicated that oxygen saturation was 95% on room air (no supplemental oxygen). The respiratory section indicated Patient 11 had light difficulty. It further indicated in the “;Narrative Section” that P11s “;Breathing pattern even, regular, shallow, lung sounds clear and diminished bilaterally, no respiratory or any other distress”. During a joint home visit with the Licensed Vocational Nurse (LVN 1) on 8/8/2024 at 2:15 p.m., Patient 11 was observed laying on the sofa, awake but stated feels weak and sleepy, his both eyes closed but speak when ask questions. Patient 11 on oxygen therapy, connected to oxygen tank with current setting at 2liters/minute via nasal cannula (is a device that gives additional oxygen (supplemental oxygen or oxygen therapy) through the nose, which is a thin, flexible tube that goes around the head and into the nose, there are two prongs that go inside the nostrils that deliver the oxygen). Patient 11 appeared comfortable, denies any pain or discomfort, and does not present any respiratory distress, P11 has no audible crackles when breathing, speaks clearly and does not stop in between sentences. During a concurrent interview and record review with the Director of Patient care Services (DPCSD) on 8/9/2024, at 4:35 p.m., the DPCSD reviewed Patient 11s LCD (Local Coverage Determination) Hospice Eligibility Determination, dated 11/16/2023 (LCD is used by hospice providers to determine eligibility for beneficiaries for hospice benefits). The DPCSD verified that the LCD indicated in the following questionnaires “;a.i. Poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways (bronchi)), resulting in decreased functional capacity (e.g. bed to chair existence, fatigue and cough)? Was documented as “;Yes” and “;b. O2 (Oxygen) Sat (saturation) less than or equal to 88% determined either by arterial blood gases (measures the balance of oxygen and carbon dioxide in the blood to see how well the lungs are working and it also measures the acid-base balance in the blood) or O2 saturation monitors?” was documented as “;Yes”. DPCSD stated that the documents from hospital did not have any lab results or studies that support the terminal diagnosis of P11. The DPCSD stated that the oxygen saturation for COPD patients are normally below 92% on room air and lung sounds are with crackles. The HA was not able to provide further clinical documentations that support Patient 11s terminal diagnosis of Chronic Obstructive Pulmonary Disease for hospice admission. g. A review of Patient 12s untitled admission record indicated a Start of Care (SOC) dated 5/31/2024 with a primary diagnosis of Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath) and a secondary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing) unspecified. A review of Patient 12s clinical record titled “;Physicians Certification for Hospice Benefit”, dated 5/31/2024, indicated that Patient 12 was admitted to hospice with primary diagnosis of Hypertensive Heart Disease with Heart Failure. It further indicated in the “;Medical Director Attestation/Certification - I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient”, electronically signed by the Medical Director (MD). The document also indicated that Patient 12 had a terminal illness and a life expectancy of six months or less if the disease runs its normal course. During a telephone interview with P12 on 8/7/2024 at 4:38 p.m., P12 stated that he was referred by a hospital doctor when he got discharged. P12 stated that he does not have any terminal illness, stated that he has Hypertension (also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure) and a broken collar bone from previous accident. P12 stated that he can walk fine without using any mechanical devices, he is not short of breath. P12 stated he lives by himself and does his errands. P12 stated that nurses come to his place to check his vital signs and provide his medications. P12 stated he does not use any oxygen to help him to breathe, stated he does not have any oxygen tanks or machine at his home and stated he does not need it. P12 stated that Hospice Services were not explained to him during his admission when a nurse came to visit him and he does not know about the terminal illness. During a concurrent record review and interview with the DPCSD on 8/9/2024 at 4:45 p.m., the DPCSD reviewed Patient 12s LCD Hospice Eligibility Determination. The DPCSD verified that based on the LCD Hospice Eligibility Determination, Patient 12 is optimally treated with for heart disease with diuretics (medicines that help reduce fluid buildup in the body) and vasodilators (medicines that dilate/widen blood vessels, allowing blood to flow more easily) and met the criteria for NYHA Class IV. NYHA Class IV is a classification of the most severe type of heart failure by the New York Heart Association. The DPCSD verified there were no clinical documents to support the NYHA Class IV in Patient 12s record. The agency was unable to provide previous medical records to support patients diagnosis for hospice admission. During a telephone interview with the Medical Director (MD) on 8/9/2024 at 2:22 p.m., the MD stated that a person with NYHA Class IV would have shortness of breath at rest and would require assistance with ADLs around the clock. When asked what diagnostics would support the diagnosis of NYHA Class IV, the MD stated that echocardiogram (an ultrasound test that checks the structure and function of the heart could determine if a person had NYHA Class IV by measuring the ejection fraction (a measurement of the percentage of blood leaving the heart each time it squeezes). According to the MD, a person with NYHA Class IV would have an ejection fraction between 15% to 20%. When the MD was asked if Patient 12, who was able to ambulate unassisted and do his personal errands with no assistance and had no diagnostics or history and physical on file, would meet the criteria of NYHA Class IV, the MD stated, “;Absolutely not.” The MD stated that Patient 12 did not meet the hospice criteria under heart disease. The MD stated that patient had to be referred by a physician and had to have a terminal illness with life expectancy of 6 months or less. The MD stated the diagnosis had to be supported by clinical documents, such as history and physicals, laboratory, and imaging data. The MD stated the HA had the responsibility to ensure patients had the clinical documents, which he would review. The MD stated he tried to review all the clinical documents and see the patients in person, but until he had an opportunity for that, he would base the CTI narrative on the Registered Nurse report, who had seen and assessed the patient first. The MD stated he would need to personally see all the patients to ensure their eligibility for hospice. The MD stated that hospice patients should be home bound since they are too weak to do their errands and ADLs by themselves. The MD stated that for COPD patients, they are mostly dependent on their oxygen therapy, their oxygen saturation are around less than 92% and with crackle lungs sounds, he stated that it would be difficult for COPD patients to walk around as they get tired easily. Findings: a.During a review of Patient 1s Personal Information, the Personal Information indicated Patient 1 was admitted to HA on 7/29/2024 with a primary diagnosis of acute kidney failure (a sudden episode when a persons kidneys are not able to filter waste products from the blood). During an interview and concurrent record review with the Director of Patient care Services (DPCSD) on 8/6/2024, at 3:50 p.m., the DPCSD reviewed Patient 1s LCD (Local Coverage Determination, it is used by hospice providers to determine eligibility for beneficiaries for hospice benefits) Hospice Eligibility Determination, dated 7/29/2024. The DPCSD verified that the LCD for Patient 1 was not completed (it was blank), which indicated that Patient 1 did not qualify per LCD Guidelines. The DPCSD stated that the LCD Hospice Eligibility Determination form supposed to be completed by QA (Quality Assurance) after the Registered Nurse (RN) completed the Comprehensive Nursing Assessment. During a review of Patient 1s Physicians Certification for Hospice Benefit, dated 7/30/2024, the Physicians Certification for Hospice Benefit indicated that Patient 1 was admitted to the hospice with primary diagnosis of acute kidney failure. The document indicated that Patient 1 had a terminal illness and a life expectancy of six months or less if the disease runs its normal course. During a telephone interview with Patient 1 on 8/7/2024 at 1:57 p.m., Patient 1 stated he had never been diagnosed with a terminal illness, nor had diagnoses of having a life expectancy of six months or less by the physician. Patient 1 stated that he was diagnosed with prostate cancer (a cancer in a man’s prostate, a small walnut-sized gland that produces seminal fluid) in 2022, and he had to undergo radiation therapy to treat the prostate cancer. Patient 1 stated that his physician informed him in December 2023 that his cancer was in remission (a decrease in or disappearance of signs and symptoms of cancer). Patient 1 stated, “;Im not dying, thank God.” Patient 1 stated it was his brother-in-law who previously had hospice service, referred him to hospice. Patient 1 stated that it was good to be able to have nurses come and check on him once a week and help him to get his medication refills. During an interview and concurrent record review with the DPCSD on 8/9/2024 at 12:30 p.m., the DPCSD reviewed Patient 1s Ambulatory Visit Instructions from Hospital 1, for visit date 5/1/2024. The DPCSD verified that the Ambulatory Visit Instructions indicated that Patient 1 had the following scheduled follow-up appointments: Oncology (a branch of medicine that specializes in the diagnosis and treatment of cancer) Nurse on 5/17/2024, Eye Optometry (a specialized health care profession that involves examining the eyes and related structures for defects or abnormalities) on 6/21/2024, and Urology (a branch of medicine that focuses on surgical and medical diseases of the urinary system and the reproductive organs) on 7/1/2024. The DPCSD stated that the documents from Hospital 1 did not have any lab results or studies that support the terminal diagnosis of acute kidney failure. The DPCSD stated that the Ambulatory Visit Instructions did not contain hospice referral. The HA was not able to provide clinical documentation that supports Patient 1s terminal diagnosis of acute kidney failure. b.During a review of Patient 4s Personal Information, the Personal Information indicated Patient 4 was admitted to HA on 6/12/2024 with a primary diagnosis of hypertensive heart disease (a number of complications of high blood pressure that affect the heart) without heart failure (a chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 4s “Visit Note LVN” form, dated 7/3/2024, the “Visit Note LVN” form’s Narrative section indicated that Patient 4s vital signs (measurements of the body’s most basic functions, such as breathing, heart rate, and temperature) were within normal limits, no SOB with rest, and per patient SOB on exertion (physical effort). During a review of Patient 4s “Visit Note LVN” form, dated 7/10/2024, the “Visit Note LVN” form indicated that Patient 4s oxygen saturation (refers to the percentage of oxygen [a gas essential to living organisms] in a persons blood. An ideal oxygen saturation level is in between 95% to 100 %) was 95% on room air (no supplemental oxygen). The Respiratory section indicated Patient 4 had dyspnea (shortness of breath) - light difficulty. During a review of Patient 4s “Visit Note LVN” form, dated 7/17/2024, the “Visit Note LVN” form indicated that Patient 4s oxygen saturation was 95% on room air. The narrative section indicated no respiratory distress noted. During a review of Patient 4s “Visit Note LVN” form, dated 7/30/2024, the “Visit Note LVN” form indicated that Patient 4s oxygen saturation was 95% on room air. The Respiratory section indicated Patient 4 had dyspnea-light difficulty. During an interview and concurrent record review with the DPCSD on 8/9/2024 at 12:45 p.m., the DPCSD reviewed Patient 4s LCD Hospice Eligibility Determination form. The DPCSD verified that based on the LCD Hospice Eligibility Determination, Patient 4 was optimally treated for heart disease with diuretics (medicines that help reduce fluid buildup in the body) and vasodilators (medicines that dilate/widen blood vessels, allowing blood to flow more easily) and met the criteria for NYHA Class IV (NYHA Class IV, a classification of the most severe type of heart failure by the New York Heart Association). The DPCSD verified that there were no clinical documents to support the NYHA Class IV in Patient 4s record. c. During a review of Patient 5s Personal Information, the Personal Information indicated that Patient 5 was admitted to HA on 6/4/2024 with a primary diagnosis of hypertensive heart disease without heart failure. During a review of Patient 5s Physicians Certification for Hospice Benefit (CTI/Certification of Terminal Illness), dated 6/6/2024, signed by the Medical Director (MD), the Physicians Certification for Hospice Benefit indicated that Patient 5 was in the first certification episode of hospice service. The CTI indicated that Patient 5 had NYHA Class IV. The Certifying Physician Narrative section indicated that Patient 5 was generally weak and required moderate to maximum assistance with all ADLs (Activities of Daily Living, activities related to personal care; they include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During a telephone interview with Patient 5 on 8/7/2024 at 12:34 p.m., in his native language (Spanish), Patient 5 stated he did not have heart failure. Patient 5 stated he had high blood pressure and that he never diagnosed with a terminal illness by a physician or has been told that he had six months or less to live. During a telephone interview with Patient 5 on 8/7/2024 at 12:34 p.m., Patient 5 stated that he and his wife were at the fair with multiple vendors and one of the vendors approached them and told them that they would benefit from the program. Patient 5 stated he was not sure what program it was. Patient 5 stated, “;The next thing I know, my wife agreed to enroll. She enrolled both of us.” Patient 5 stated he received a cellular phone for free by providing his Medical number. During a telephone interview with Patient 5 on 8/7/2024 at 12:34 p.m., Patient 5 stated after his wife agreed to enroll, a nurse started coming to his home, bringing medications he was not familiar with. Patient 5 stated the nurse brought him a “breathing machine” (nebulizer, a small machine that turns liquid medicine into a mist that can be inhaled directly into the lungs through a mouthpiece or mask) he did not need and had never used. Patient 5 stated the male nurse, which he identified as LVN 1, usually came on Friday on Saturday, depending on Patient 5s availability. Patient 5 asked the surveyor how this program could be stopped since he stated he was fine. Patient 5 denied shortness of breath, denied needing to use supplemental oxygen, and/or breathing treatment. Patient 5 stated he was able to walk by himself without any device and without a persons assistance. Patient 5 stated, “;I work around the house, I work for my daughter in her decorating business.” During a telephone interview with Licensed Vocational Nurse 1 (LVN 1) on 8/8/2024 at 9:12 a.m., LVN 1 stated he was familiar with Patient 5. LVN 1 stated that Patient 5 was ambulatory without needing any assistive device and did not use supplemental oxygen. LVN 1 stated that Patient 5 would have mild shortness of breath after he walked for a bit, but not at rest. During a review of Patient 5s “Visit Note LVN”, which was completed by LVN 1, dated 6/26/2024, 7/5/2024, 7/12/2024, 7/19/2024, and 7/26/2024, the visit notes indicated that Patient 5 had an oxygen saturation of 95% on room air (without supplemental oxygen). During an interview and concurrent record review with the Director of Patient Care Services (DPCSD) on 8/9/2024 at 12:55 p.m., the DPCSD reviewed the CTI and LCD Hospice Eligibility Determination for Patient 5. The DPCSD verified that based on the LCD, Patient 5 was optimally treated with diuretics and vasodilators, and met the criteria for NYHA Class IV. The DPCSD was not able to provide clinical records of Patient 5 to support the primary diagnosis, as requested by the survey team. During a telephone interview with the Medical Director (MD) on 8/9/2024 at 2:22 p.m., the MD stated that a person with NYHA Class IV would have shortness of breath at rest and would require assistance with ADLs around the clock. The MD stated that echocardiogram (an ultrasound test that checks the structure and function of the heart) could determine and support the diagnoses of NYHA Class IV by measuring the ejection fraction (a measurement of the percentage of blood leaving the heart each time it squeezes). According to the MD, a person with NYHA Class IV would have an ejection fraction between 15% to 20%. When asked the MD if Patient 5, who was able to ambulate unassisted and go to an LA County event with his wife, who helped his daughter working at home, and who had no diagnostics or history and physical on file, would meet the criteria of NYHA Class IV, the MD stated, “;Absolutely not.” The MD stated that Patient 5 did not meet the hospice criteria under heart disease. During a telephone interview with the Medical Director (MD) on 8/9/2024 at 2:22 p.m., asked MD about the process of admitting patient to the hospice agency. The MD stated that patient had to be referred by a physician and had to have a terminal illness with life expectancy of six months or less. The MD stated the diagnosis had to be supported by clinical documents, such as history and physicals, laboratory, and imaging data. The MD stated the HA had the responsibility to ensure patients had the clinical documents, which he would review. The MD stated he tried to review all the clinical documents and see the patients in person, but until he had an opportunity for that, he would base the CTI narrative on the Registered Nurse report, who had seen and assessed the patient first. The MD stated he would need to personally see all the patients to ensure their eligibility for hospice. d. During a review of Patient 9s Personal Information, the Personal Information indicated a start of care (SOC) date of 7/5/2024 with a primary diagnosis of malignant neoplasm of unspecified site of left female breast (a cancerous tumor that grows in or around the breast tissue, mainly in the milk ducts and glands). During a review of Patient 9s clinical record titled “;Physicians Certification for Hospice Benefit”, dated 7/5/2024, the “;Physicians Certification for Hospice Benefit” indicated that Patient 9 was admitted to hospice with primary diagnosis of malignant neoplasm of unspecified site of left female breast. The record indicated in the “;Certifying Physician Narrative” section note that Patient 9 has a clinical history which included gait instability with her ADL. The record indicated that Patient 9 was ambulatory with cane and that caregiver provides moderate to maximum assistance with all activities of daily living. The record indicated that Patient 9 reports shortness of breath (SOB) with moderate exertion and even at rest managed with respiratory inhaler. The record indicated per caregiver, Patient 9 was ambulatory and due to altered balance, Patient 9 was using cane as an assistive device, able to tolerate less than 10 steps before stopping, needed assistance, and was high risk for fall due to weakness and impaired balance. The record also indicated that Patient 9 had a terminal illness and a life expectancy of six months or less if the disease runs its normal course. During a telephone interview with Patient 9 on 8/8/2024, at 11:00 a.m., Patient 9 stated that she called the hospice agency to cancel the skilled nurses home visit today because of her toothache. Patient 9 stated that she is on her way to her dentist by herself and she is about to ride on a bus. Patient 9 stated that she has no terminal illness, she has no breast cancer anymore and that was years ago. Patient 9 declined to tell who referred her to hospice agency and she stated she needs to go and ended the telephone conversation. During telephone conversation with Patient 9, she spoke clearly with no difficulties and did not stop in between sentences. During a telephone interview with Patient 9s caregiver (PCG4) on 8/8/2024 at 11:05 a.m., PCG4 stated that she is the caregiver for Patient 9. PCG4 stated that she worked for Patient 9 three (3) times a week and that Patient 9 has no immediate relative or family. PCG4 stated that Patient 9 was picked up by her friend today at Patient 9s house to take her to the dentist. PCG4 stated that her friend provided a ride to Patient 9 today. PCG4 stated that she referred Patient 9 to hospice agency and Patient 9 was not referred by her doctors. PCG4 stated that she was approached by a lady from Social Services and asked her if she knows someone that has Medicare/Medical insurance and told her that they can provide free medical services which includes free nurse visits, free medications, and supplies. PCG4 stated that she did not know that hospice was for patients who had terminal illness and or who were dying. PCG4 stated the agency did not explain to her or to Patient 9 regarding hospice services and its program. PCG4 stated that Patient 9 has a breast cancer many years ago, but not anymore. PCG4 also added that Patient 9 can walk by herself without using any mechanical device, she walks around the neighborhood to buy ice cream, and that she does not have any difficulties in moving around. PCG4 stated that Patient 9 does not have terminal illness anymore and she accompanies her to go to her doctors regularly. PCG4 stated that Patient 9 will live way longer than six months with her current health status. During an interview and concurrent record review with the Director of Patient care Services (DPCSD) on 8/9/2024, at 4:20 p.m., the DPCSD reviewed Patient 9s LCD Hospice Eligibility Determination, dated 7/5/2024. The DPCSD verified that the LCD indicated in the following questionnaires: “;a. Has the cancer metastasized and is untreatable at presentation?,” it was documented as “;Yes”; “;a. Has the Cancer metastasized regardless of therapy?,” it was documented as “;Yes”; “;a. Patient has suspicious large tumor and refuses definitive diagnosis?,” it was documented as “;Yes”; “;Patient has declined in functional status?,” it was documented as “;Yes”, and “;Patient has significant, unintentional weight loss?,” it was documented as “;Yes”. DPCSD stated that the documents from hospital did not have any lab results or studies that support the terminal diagnosis of Patient 9. The DPCSD stated that she does not know that Patient 9 can tolerate such activities like walking around the neighborhood or going to her dentist by herself, and that Patient 9 should be homebound given her health situation. The HA was not able to provide further clinical documentations that support Patient 9s terminal diagnosis of malignant neoplasm of unspecified site of left female breast. e. During a review of Patient 10s (P10) Personal Information, the Personal Information indicated a start of care (SOC) date of 7/11/2024 with a primary diagnosis of unspecified Chronic Obstructive Pulmonary Disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing) and a secondary diagnosis of hypertensive heart disease without heart failure. During a review of Patient 10s clinical record titled “ ;Physicians Certification for Hospice Benefit”, dated 7/11/2024, the “;Physicians Certification for Hospice Benefit” indicated that Patient 10 was admitted to hospice with primary diagnosis of unspecified COPD. The record indicated in the “;Certifying Physician Narrative” section note that Patient 10 has a clinical history which included gait instability, that per Patient 10s caregiver Patient 10 is ambulatory and due to altered balance Patient 10 is using cane as an assistive device, able to tolerate less than 10 steps before stopping, needs assistance, and was high risk for fall due to weakness and impaired balance. The record also indicated that Patient 10 had a terminal illness and a life expectancy of six months or less if the disease runs its normal course. During a review of Patient 10s clinical records titled “;Visit Note LVN”, dated 7/12/2024, the “;Visit Note LVN” indicated that Patient 10s oxygen saturation was 94% on room air (no supplemental oxygen). The record indicated in the “;Narrative section” that Patient 10’s vital signs were within normal limits, patient did not have shortness of breath with rest, and per patient, he had shortness of breath on exertion (the use of a lot of physical or mental effort). During a review of Patient 10s clinical record titled “;Visit Note LVN”, dated 7/19/2024, “;Visit Note LVN” indicated that Patient 10s oxygen saturation was 95% on room air. The respiratory section indicated Patient 10 had dyspnea-light difficulty. During a review of Patient 10s clinical record titled “;Visit Note LVN”, dated 7/25/2024, “;Visit Note LVN” indicated that Patient 10’s oxygen saturation was 90 % on room air (no supplemental oxygen). The respiratory section indicated Patient 10 had heavy breathing. During a review of Patient 10s clinical note titled “;Visit Note LVN” dated 7/26/2024, “;Visit Note LVN” indicated that Patient 10s oxygen saturation was 94% on room air (no supplemental oxygen). The respiratory section indicated Patient 4 had dyspnea - light difficulty. The record indicated in the “;Narrative section” that no respiratory distress noted. On 8/6/2024, at 12:51 p.m. and on 8/7/2024 at 4:37 p.m., telephone calls were made to contact Patient 10 but were unsuccessful. During an interview with Patient 9 on 8/6/2024, at 12:53 p.m., Patient 9 stated that she was unaware that she was listed as the “;Authorized Representative/Emergency Contact. Patient 9 stated that Patient 10 is currently not at home, and she does not know where he went and with whom. Patient 9 stated that Patient 10 walks without assistive device and goes out daily, uses Uber as his transportation. Patient 9 stated that Patient 10 only lives and rents a room from her. Patient 9 stated she does not want to talk regarding Patient 10 because she does not want them to be in trouble. During a telephone interview with Patient 9s caregiver (PCG4) on 8/8/2024, at 11:05 a.m., PCG4 stated that she is the caregiver for Patient 9. PCG4 stated that she also referred Patient 10 to hospice agency as she met him in Patient 9s home. PCG4 stated that Patient 10 lives and rents a room at Patient 9s home. PCG4 stated that Patient 10 has no caregiver, lives by himself, is doing his own errands, and goes out using Uber for transportation. During an interview and concurrent record review with the Director of Patient care Services (DPCSD) on 8/9/2024, at 4:32 p.m., the DPCSD reviewed Patient 10s LCD Hospice Eligibility Determination, dated 7/11/2024. The DPCSD verified that the LCD indicated in the following questionnaires “;a.i. Poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways (bronchi)), resulting in decreased functional capacity (e.g. bed to chair existence, fatigue and cough),? it was documented as “;Yes”, and “;b. O2 (Oxygen) Sat (saturation) less than or equal to 88% determined either by arterial blood gases (measures the balance of oxygen and carbon dioxide in the blood to see how well the lungs are working and it also measures the acid-base balance in the blood) or O2 saturation monitors,?” it was documented as “;Yes”. DPCSD stated that the documents from hospital did not have any lab results or studies that support the terminal diagnosis of Patient 10. The DPCSD stated that she does not know that Patient 10 can tolerate such activities like going out and doing his own errands with no difficulties. DPCSD stated that Patient 10 should be homebound given his health situation. The HA was not able to provide further clinical documentations that support Patient 10s terminal diagnosis of COPD for hospice admission. f. During a review of Patient 11s Patient Information, the Patient Information indicated a start of care (SOC) date of 11/16/2023 with a primary diagnosis of unspecified COPD and a secondary diagnosis of hypertensive heart disease with heart failure. During a review of Patient 11s clinical records titled “;Visit Note LVN”, dated 6/26/2024, the “;Visit Note LVN” indicated that Patient 11s oxygen saturation was 95% on room air (no supplemental oxygen). The record indicated in the Respiratory section that Patient 11 has dyspnea-light difficulty and no abnormal lung sounds. During a review of Patient 11s clinical record titled “;Visit Note RN”, dated 7/19/2024, the “;Visit Note RN” indicated that Patient 11s oxygen saturation was 95% on room air. The Respiratory section indicated that Patient 11 had dyspnea-light difficulty. The record indicated in the “;Narrative Section” that “;No respiratory distress noted”. During a review of Patient 11s clinical record titled “;Visit Note RN”, dated 7/26/2024, the “;Visit Note RN” indicated that Patient 11s oxygen saturation was 95% on room air (no supplemental oxygen). The Respiratory section indicated Patient 11 had dyspnea-light difficulty. The record indicated in the Narrative Section that Patient 11s “;Breathing pattern even, regular, shallow, lung sounds clear and diminished bilaterally, no respiratory or any other distress”. During a joint home visit with the Licensed Vocational Nurse (LVN 1) on 8/8/2024 at 2:15 p.m., Patient 11 was observed laying on the sofa, awake but stated feels weak and sleepy, his both eyes were closed but he was responding to questions. Patient 11 was on oxygen therapy, was connected to the oxygen tank with current setting at two liters/minute via nasal cannula (a device that gives additional oxygen [supplemental oxygen or oxygen therapy] through the nose, which is a thin, flexible tube that goes around the head and into the nose with two prongs that go inside the nostrils to deliver the oxygen). Patient 11 appeared comfortable, denied any pain or discomfort, and did not present any respiratory distress. Patient 11 had no audible crackles when breathing, spoke clearly, and did not stop in between sentences. During an interview and concurrent record review with the Director of Patient Care Services (DPCSD) on 8/9/2024, at 4:35 p.m., the DPCSD reviewed Patient 11s LCD Hospice Eligibility Determination, dated 11/16/2023. The DPCSD verified that the LCD indicated in the following questionnaires “;a.i. Poorly responsive or unresponsive to bronchodilators,? it was documented as “;Yes”, and “;b. O2 (Oxygen) Sat (saturation) less than or equal to 88% determined either by arterial blood gases or O2 saturation monitors,?” it was documented as “;Yes”. The DPCSD stated that the documents from hospital did not have any lab results or studies that support the terminal diagnosis of Patient 11. The DPCSD stated that the oxygen saturation for COPD patients are normally below 92% on room air and lung sounds are with crackles. The HA was not able to provide further clinical documentations that support Patient 11s terminal diagnosis of COPD for hospice admission. g. During a review of Patient 12s Patient Information, the Patient Information indicated a Start of Care (SOC) date on 5/31/2024 with a primary diagnosis of hypertensive heart disease with heart failure and a secondary diagnosis of unspecified COPD. During a review of Patient 12s clinical record titled “;Physicians Certification for Hospice Benefit”, dated 5/31/2024, the “;Physicians Certification for Hospice Benefit” indicated that Patient 12 was admitted to hospice with primary diagnosis of hypertensive heart disease with heart failure. The record indicated in the Medical Director Attestation/Certification section: “;I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient”, electronically signed by the Medical Director (MD). The record indicated that Patient 12 had a terminal illness and a life expectancy of six months or less if the disease runs its normal course. During a telephone interview with Patient 12 on 8/7/2024 at 4:38 p.m., Patient 12 stated that he was referred by a hospital doctor when he got discharged. Patient 12 stated that he does not have any terminal illness and that he has hypertension (also known as high blood pressure, a condition in which the blood vessels have persistently raised pressure) and a broken collar bone from previous accident. Patient 12 stated that he can walk fine without using any assistive devices and that he is not short of breath. Patient 12 stated he lives by himself and does his errands. Patient 12 stated that nurses come to his place to check his vital signs and provide his medications. Patient 12 stated he does not use any oxygen to help him to breathe, he does not have any oxygen tanks or machine at his home, and he does not need it. Patient 12 stated that hospice services were not explained to him during his admission when a nurse came to visit him and he does not know about the terminal illness. During an interview and concurrent record review with the DPCSD on 8/9/2024 at 4:45 p.m., the DPCSD reviewed Patient 12s LCD Hospice Eligibility Determination. The DPCSD verified that based on the LCD Hospice Eligibility Determination, Patient 12 is optimally treated for heart disease with diuretics and vasodilators and met the criteria for NYHA Class IV. The DPCSD verified there were no clinical documents to support the NYHA Class IV in Patient 12s record. The agency was unable to provide previous medical records to support patients diagnosis for hospice admission. During a telephone interview with the Medical Director (MD) on 8/9/2024 at 2:22 p.m., the MD stated that a person with NYHA Class IV would have shortness of breath at rest and would require assistance with ADLs around the clock. The MD stated that echocardiogram could determine and support the diagnosis of NYHA Class IV by measuring the ejection fraction. According to the MD, a person with NYHA Class IV would have an ejection fraction between 15% to 20%. When asked the MD if Patient 12, who was able to ambulate unassisted and do his personal errands with no assistance and had no diagnostics or history and physical on file, would meet the criteria of NYHA Class IV, the MD stated, “;Absolutely not.” The MD stated that Patient 12 did not meet the hospice criteria under heart disease. The MD stated that patient had to be referred by a physician and had to have a terminal illness with life expectancy of six months or less. The MD stated that the diagnosis had to be supported by clinical documents, such as history and physicals, laboratory, and imaging data. The MD stated the HA had the responsibility to ensure patients had the clinical documents, which he would review. The MD stated he tried to review all the clinical documents and see the patients in person, but until he had an opportunity for that, he would base the CTI narrative on the Registered Nurse report, who had seen and assessed the patient first. The MD stated he would need to personally see all the patients to ensure their eligibility for hospice. The MD stated that hospice patients should be home bound since they are too weak to do their errands and ADLs by themselves. The MD stated that for COPD patients, they are mostly dependent on their oxygen therapy, their oxygen saturation are around or less than 92% and with crackle lungs sounds. The MD stated that it would be difficult for COPD patients to walk around as they get tired easily. During a review of the HAs document, titled “;Job Description Summary” for Hospice Medical Director, revised April 2020, the document indicated that the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The document indicated the duties and responsibilities of the Medical Director will include, but not be limited to, the following: 14. 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 written certification of terminal illness. During a review of the HAs policy, titled “;Certification of Terminal Illness,” revised April 2020, the policy indicated that clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification.”

“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 Medical Director assumed overall responsibility for the medical component of the hospices patient care program for seven out of fourteen sampled patients (Patient 1, Patient 4, Patient 5, Patient 9, Patient 10, Patient 11, and Patient 12), which included overseeing the eligibility criteria to ensure patients qualified and received appropriate hospice services. This deficient practice resulted in patient being enrolled to the HA without oversight of the implementation of the hospice services to ensure the patients and patients familys needs were being met. a. A review of Patient 1s Personal Information indicated that Patient 1 was admitted on 7/20/2024 with a primary diagnosis of acute kidney failure (a sudden episode when a persons kidneys are not able to filter waste products from the blood). During a concurrent interview and record review with the Director of Patient care Services (DPCSD) on 8/6/2024, at 3:50 p.m., the DPCSD reviewed Patient 1s LCD (Local Coverage Determination) Hospice Eligibility Determination, dated 7/29/2024. LCD is used by hospice providers to determine eligibility for beneficiaries for hospice benefits. The DPCSD The DPCS verified that the LCD for Patient 1 was not completed (blank), which caused the LCD to indicate that Patient 1 did not qualify per LCD Guidelines. When the DPCSD was asked when the LCD Hospice Eligibility Determination was supposed to be completed, the DPCSD stated that it was supposed to be completed by QA (Quality Assurance) after the Registered Nurse completed the Comprehensive Nursing Assessment. A review of Patient 1s Physicians Certification for Hospice Benefit, dated 7/30/2024, indicated that Patient 1 was admitted to hospice with primary diagnosis of acute kidney failure. The document also indicated that Patient 1 had a terminal illness and a life expectancy of six months or less if the disease runs its normal course. During a telephone interview with Patient 1 on 8/7/2024 at 1:57 p.m., Patient 1 stated he had never been diagnosed with a terminal illness, nor had he been diagnosed with having a life expectancy of 6 months or less by a physician. Patient 1 stated that he was diagnosed with prostate cancer (a cancer in a man’s prostate, a small walnut-sized gland that produces seminal fluid) in 2022, and he had to undergo radiation therapy to treat the prostate cancer. According to Patient 1, his physician informed him in December 2023 that his cancer was in remission. Patient 1 stated, “;Im not dying, thank God.” When Patient 1 was asked who referred him to hospice, Patient 1 stated it was his brother-in-law who previously had hospice service. Patient 1 stated that it was good to be able to have nurses come and check on him once a week and helped him get his medication refills. During a concurrent record review and interview with the DPCSD on 8/9/2024 at 12:30 p.m., the DPCSD reviewed Patient 1s Ambulatory Visit Instructions from Hospital 1, for visit date 5/1/2024. The DPCSD verified the Ambulatory Visit Instructions indicated that Patient 1 had the following scheduled follow-up appointments: Oncology (a branch of medicine that specializes in the diagnosis and treatment of cancer) Nurse on 5/17/2024, Eye Optometry (a specialized health care profession that involves examining the eyes and related structures for defects or abnormalities) on 6/21/2024, and Urology (a branch of medicine that focuses on surgical and medical diseases of the urinary system and the reproductive organs) on 7/1/2024. The DPCSD stated the documents from Hospital 1 did not have any lab results or studies that support the terminal diagnosis of acute kidney failure. The DPCSD stated that the Ambulatory Visit Instructions did not contain hospice referral. The HA was not able to provide further clinical documentations that support Patient 1s terminal diagnosis of acute kidney failure. b. A review of Patient 4s Personal Information indicated that Patient 4 was admitted on 6/12/2024 with a primary diagnosis of hypertensive heart disease (a number of complications of high blood pressure that affect the heart) without heart failure (a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 4s Visit Note LVN, dated 7/3/2024, indicated that oxygen saturation was 95% on room air (no supplemental oxygen). The narrative section indicated that vital signs were within normal limits, no shortness of breath with rest, per patient shortness of breath on exertion (the use of a lot of physical or mental effort). Per National Council on Aging, an ideal oxygen level is between 95% and 100%. A review of Patient 4s Visit Note LVN, dated 7/10/2024, indicated that oxygen saturation was 95% on room air. The respiratory section indicated Patient 4 had light difficulty. A review of Patient 4s Visit Note LVN, dated 7/17/2024, indicated that oxygen saturation was 95% on room air. ). The narrative section indicated no respiratory distress noted. A review of Patient 4s Visit Note LVN, dated 7/30/2024, indicated that oxygen saturation was 95% on room air. The respiratory section indicated Patient 4 had light difficulty. During a concurrent record review and interview with the DPCSD on 8/9/2024 at 12:45 p.m., the DPCSD reviewed Patient 4s LCD Hospice Eligibility Determination. The DPCSD verified that based on the LCD Hospice Eligibility Determination, Patient 4 is optimally treated with for heart disease with diuretics (medicines that help reduce fluid buildup in the body) and vasodilators (medicines that dilate/widen blood vessels, allowing blood to flow more easily) and met the criteria for NYHA Class IV. NYHA Class IV is a classification of the most severe type of heart failure by the New York Heart Association. The DPCSD verified there were no clinical documents to support the NYHA Class IV in Patient 4s record. c. A review of Patient 5s Personal Information indicated that Patient 5 was admitted on 6/4/2024 with a primary diagnosis of hypertensive heart disease (a number of complications of high blood pressure that affect the heart) without heart failure (a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 5s Physicians Certification for Hospice Benefit (CTI/Certification of Terminal Illness), dated 6/6/2024, signed by the Medical Director (MD), indicated that Patient 5 in the first certification episode of hospice service. The CTI also indicated that Patient 5 had NYHA Class IV (a classification of the most severe type of heart failure by the New York Heart Association. The Certifying Physician Narrative indicated that Patient 5 was generally weak and required moderate to maximum assistance with all ADL (Activities of Daily Living, activities related to personal care; they include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) function. During a telephone interview with Patient 5 on 8/7/2024 at 12:34 p.m., in his native language (Spanish), Patient 5 stated he did not have heart failure. Patient 5 stated he had high blood pressure. Patient 5 stated he had never been diagnosed with a terminal illness by a physician or told that he had six months or less to live. When Patient 5 was asked who referred him to hospice, Patient 5 stated that he and his wife were at a building office of Los Angeles County, which had like a fair going on, with multiple vendors. According to patient 5, one of the vendors approached them and told them that they would benefit from the program. Patient 5 stated he was not sure what program. Patient 5 stated, “;The next thing I know, my wife agreed to enroll. She enrolled both of us.” Patient 5 stated the LA County building was where he received a cellular phone for free by providing his Medical number. During the same interview, Patient 5 stated after his wife agreed to enroll, a nurse started coming to his home, bringing medications he was not familiar with. Patient 5 also stated the nurse brought him a “breathing machine” (nebulizer, a small machine that turns liquid medicine into a mist that can be inhaled directly into the lungs through a mouthpiece or mask) he did not need and had never used. Patient 5 stated the male nurse, which he identified as LVN 1, usually came on Friday on Saturday, depending on Patient 5s availability. Patient 5 then asked the surveyor how he could stop this program because he stated that he was fine. Patient 5 denied shortness of breath, denied needing to use supplemental oxygen, and/or breathing treatment. Patient 5 stated he was able to walk by himself without any device and without a persons assistance. Patient 5 stated, “;I work around the house, I work for my daughter, she has a decorating business.” During a telephone interview with Licensed Vocational Nurse 1 (LVN 1) on 8/8/2024 at 9:12 a.m., LVN 1 stated he was familiar with Patient 5. LVN 1 stated that Patient 5 was ambulatory with no assistive device and does not use supplemental oxygen. When LVN 1 was asked if Patient 5 had any shortness of breath, LVN 1 stated that Patient 5 would have mild shortness of breath after he walked for a bit, but not at rest. A review of Patient 1s Visit Note LVN, which was completed by LVN 1, dated 6/26/2024, 7/5/2024, 7/12/2024, 7/19/2024, and 7/26/2024, indicated that Patient 5 had an oxygen saturation (the amount of oxygen circulating in blood) of 95% on room air (without supplemental oxygen). Per National Council on Aging, an ideal oxygen level is between 95% and 100%. During a concurrent record review and interview with the Director of Patient Care Services (DPCSD) on 8/9/2024 at 12:55 p.m., the DPCSD reviewed the CTI and LCD Hospice Eligibility Determination for Patient 5. The DPCSD verified that based on the LCD, Patient 5 was optimally treated with diuretics and vasodilators, and met the criteria for NYHA Class IV. The DPCSD was not able to provide the clinical records of Patient 5 to support the primary diagnosis, as requested by the survey team. During a telephone interview with the Medical Director (MD) on 8/9/2024 at 2:22 p.m., the MD stated that a person with NYHA Class IV would have shortness of breath at rest and would require assistance with ADLs around the clock. When asked what diagnostics would support the diagnosis of NYHA Class IV, the MD stated that echocardiogram (an ultrasound test that checks the structure and function of the heart could determine if a person had NYHA Class IV by measuring the ejection fraction (a measurement of the percentage of blood leaving the heart each time it squeezes). According to the MD, a person with NYHA Class IV would have an ejection fraction between 15% to 20%. When the MD was asked if Patient 5, who was able to ambulate unassisted and go to an LA County event with his wife, helped his daughter working at home, and had no diagnostics or history and physical on file, would meet the criteria of NYHA Class IV, the MD stated, “;Absolutely not.” The MD stated that Patient 5 did not meet the hospice criteria under heart disease. During the same interview, the MD was asked on the process of admitting a patient to the hospice agency. The MD stated that patient had to be referred by a physician and had to have a terminal illness with life expectancy of 6 months or less. The MD stated the diagnosis had to be supported by clinical documents, such as history and physicals, laboratory, and imaging data. The MD stated the HA had the responsibility to ensure patients had the clinical documents, which he would review. The MD stated he tried to review all the clinical documents and see the patients in person, but until he had an opportunity for that, he would base the CTI narrative on the Registered Nurse report, who had seen and assessed the patient first. The MD stated he would need to personally see all the patients to ensure their eligibility for hospice. A review of the HAs document, titled “;Job Description Summary” for Hospice Medical Director, revised April 2020, indicated that the hospice Medical director will have overall responsibility for the medical component of the hospice program. The document indicated the duties and responsibilities of the Medical Director will include, but not be limited to, the following: 14. 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 written certification of terminal illness. A review of the HAs policy, titled “;Certification of Terminal Illness,” revised April 2020, indicated that clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. d. A review of Patient 9s (P9) untitled admission record indicated a start of care (SOC) of 7/5/2024 with a primary diagnosis of Malignant Neoplasm of unspecified site of left female breast (a cancerous tumor that grows in or around the breast tissue, mainly in the milk ducts and glands). A review of Patient 9s clinical record titled “;Physicians Certification for Hospice Benefit”, dated 7/5/2024, indicated that Patient 9 was admitted to hospice with primary diagnosis of Malignant Neoplasm of unspecified site of Left Female Breast. It further indicated in the “;Certifying Physician Narrative” section note that P9 has a clinical history which include Gait Instability and her ADLS (Activity of Daily Living, The tasks of everyday life which include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) indicated that P9 is ambulatory with cane, caregiver provides moderate to maximum assistance with all activities of daily living and P9 reports SOB (Shortness of Breath) with moderate exertion and even at rest managed with respiratory inhaler and per caregiver, P9 is ambulatory and due to altered balance, P9 is using cane as assistive device, able to tolerate less than 10 steps before stopping, needs assistance, high risk for fall due to weakness and impaired balance. The document also indicated that Patient 9 had a terminal illness and a life expectancy of six months or less if the disease runs its normal course. On 8/8/2024, at 11:00 a.m., during a telephone interview with Patient 9, she stated that she called the hospice agency to cancel the skilled nurses home visit today because of her toothache and stated she is on her way to her dentist by herself and she is about to ride on a bus. Patient 9 stated that she has no terminal illness, she has no breast cancer anymore and that was years ago. Patient 9 declined to tell who referred her to hospice agency and she stated she needs to go and ended the telephone conversation. During telephone conversation with P9, she speaks clearly with no difficulties and does not stop in between sentences. On 8/8/2024, at 11:05 a.m., during a telephone interview with Patient 9s caregiver (PCG4)11:05 a.m., PCG4 stated that she is the caregiver for Patient 9. PCG4 stated she worked for P9, three (3) times a week, she stated that P9 has no immediate relative or family. PCG4 stated that P9 was picked up by her friend today at P9s house to bring her to dentist. PCG4 stated her friend provided a ride for P9 today. PCG4 stated that she referred P9 to hospice agency and P9 was not referred by her doctors. PCG4 stated that she was approached by a lady from Social Services and asked her if she know someone that has Medicare/Medical insurance and told her that they can provide free medical services which includes free nurse visits, free medications, and supplies. PCG4 stated that she does not know that hospice is for patients that has terminal illness and for dying patients. PCG4 stated the agency did not explain to her or to P9 regarding hospice services and its program. PCG4 stated that P9 has a breast cancer many years ago but not anymore, stated that P9 can walk by herself without using any mechanical devices, she walks around the neighborhood to buy ice cream, she does not have any difficulties in moving around. PCG4 stated P9 has no terminal illness anymore and she accompanies her to go to her doctors regularly. PCG4 stated that P9 will live way longer than 6 months with her current health status. During a concurrent interview and record review with the Director of Patient care Services (DPCSD) on 8/9/2024, at 4:20 p.m., the DPCSD reviewed Patient 9s LCD (Local Coverage Determination) Hospice Eligibility Determination, dated 7/5/2024 (LCD is used by hospice providers to determine eligibility for beneficiaries for hospice benefits). The DPCSD verified that the LCD indicated in the following questionnaires “;a. Has the cancer metastasized and is untreatable at presentation?” was documented as “;Yes”, “;a. Has the Cancer metastasized regardless of therapy?” was documented as “;Yes”, “;a. Patient has suspicious large tumor and refuses definitive diagnosis?” was documented as “;Yes”, “;Patient has declined in functional status?” was documented as “;Yes” and “;Patient has significant, unintentional weight loss?”, was documented as “;Yes”. DPCSD stated that the documents from hospital did not have any lab results or studies that support the terminal diagnosis of P9. The DPCSD stated that she does not know that P9 can tolerate such activities like walking around the neighborhood or going to her dentist by herself, she stated that P9 should be homebound given her health situation. The HA was not able to provide further clinical documentations that support Patient 9s terminal diagnosis of Malignant Neoplasm of unspecified site of Left Female Breast. e. A review of Patient 10s (P10) untitled admission record indicated a start of care (SOC) of 7/11/2024 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing) unspecified, and a secondary diagnosis of Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) without Heart Failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). A review of Patient 10s clinical record titled “;Physicians Certification for Hospice Benefit”, dated 7/11/2024, indicated that Patient 10 was admitted to hospice with primary diagnosis of Chronic Obstructive Pulmonary Disease, unspecified. It further indicated in the “;Certifying Physician Narrative” section note that P10 has a clinical history which include Gait Instability and per P10s caregiver, it indicated that P10 is ambulatory and due to altered balance, P10 is using cane as assistive device, able to tolerate less than 10 steps before stopping, needs assistance, high risk for fall due to weakness and impaired balance. The document also indicated that Patient 10 had a terminal illness and a life expectancy of six months or less if the disease runs its normal course. A review of Patient 10s clinical records titled “;Visit Note LVN”, dated 7/12/2024, indicated that oxygen saturation was 94% on room air (no supplemental oxygen). It further indicated in the “;Narrative section” that vital signs were within normal limits, no shortness of breath with rest, per patient shortness of breath on exertion (the use of a lot of physical or mental effort). Per National Council on Aging, an ideal oxygen level is between 95% and 100%. A review of Patient 10s clinical record titled “;Visit Note LVN”, dated 7/19/2024, indicated that oxygen saturation was 95% on room air. The respiratory section indicated Patient 10 had light difficulty. A review of Patient 10s clinical record titled “;Visit Note LVN”, dated 7/25/2024, indicated that oxygen saturation was 90% on room air (no supplemental oxygen). The respiratory section indicated Patient 10 had heavy breathing. A review of Patient 10s clinical note titled “;Visit Note LVN” dated 7/26/2024, indicated that oxygen saturation was 94% on room air (no supplemental oxygen). The respiratory section indicated Patient 4 had light difficulty. It further indicated in the “;Narrative section” that no respiratory distress noted. On 8/6/2024, at 12:51 p.m. and 8/7/2024 at 4:37 p.m., telephone calls were made to contact P10 but were unsuccessful. On 8/6/2024, at 12:53 p.m., during interview with P9, she stated that she was unaware she is listed as the “;Authorized Representative/Emergency Contact. P9 stated that P10 is currently not at home, and she does not know where he went and with whom. P9 stated that P10 walks with no mechanical device and goes out daily, uses Uber as his transportation. P9 stated that P10 only lives and renting a room from her. P9 stated she does not want to talk regarding P10 because she does not want them to be in trouble and she does not want to elaborate further. On 8/8/2024, at 11:05 a.m., during a telephone interview with Patient 9s caregiver (PCG4), PCG4 stated that she is the caregiver for Patient 9. PCG4 stated that she also referred P10 to hospice agency as she met him in P9s home. PCG4 stated that P10 lives and renting a room at P9s home. PCG4 stated that she also referred patient 10 to the agency, she stated that patient 10 has no caregiver and lives by himself. PCG4 stated that P10 is doing his own errands and goes out using Uber as his of transportation. During a concurrent interview and record review with the Director of Patient care Services (DPCSD) on 8/9/2024, at 4:32 p.m., the DPCSD reviewed Patient 10s LCD (Local Coverage Determination) Hospice Eligibility Determination, dated 7/11/2024 (LCD is used by hospice providers to determine eligibility for beneficiaries for hospice benefits). The DPCSD verified that the LCD indicated in the following questionnaires “;a.i. Poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways (bronchi)), resulting in decreased functional capacity (e.g. bed to chair existence, fatigue and cough)? Was documented as “;Yes” and “;b. O2 (Oxygen) Sat (saturation) less than or equal to 88% determined either by arterial blood gases (measures the balance of oxygen and carbon dioxide in the blood to see how well the lungs are working and it also measures the acid-base balance in the blood) or O2 saturation monitors?” was documented as “;Yes”. DPCSD stated that the documents from hospital did not have any lab results or studies that support the terminal diagnosis of P10. The DPCSD stated that she does not know that P10 can tolerate such activities like going out and doing his own errands with no difficulties, she stated that P10 should be homebound given his health situation. The HA was not able to provide further clinical documentations that support Patient 10s terminal diagnosis of Chronic Obstructive Pulmonary Disease for hospice admission. f. A review of Patient 11s (P11) untitled admission record indicated a start of care (SOC) of 11/16/2023 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing) unspecified, and a secondary diagnosis of Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). A review of Patient 11s clinical records titled “;Visit Note LVN”, dated 6/26/2024, indicated that oxygen saturation was 95% on room air (no supplemental oxygen). It further indicated in the “;Respiratory section” that P11 has light difficulty and no abnormal lung sounds. Per National Council on Aging, an ideal oxygen level is between 95% and 100%. A review of Patient 11s clinical record titled “;Visit Note RN”, dated 7/19/2024, indicated that oxygen saturation was 95% on room air. The “;respiratory section” indicated Patient 11 had light difficulty. It further indicated in the “;Narrative Section” that P11 has “;No respiratory distress noted”. A review of Patient 11s clinical record titled “;Visit Note RN”, dated 7/26/2024, indicated that oxygen saturation was 95% on room air (no supplemental oxygen). The respiratory section indicated Patient 11 had light difficulty. It further indicated in the “;Narrative Section” that P11s “;Breathing pattern even, regular, shallow, lung sounds clear and diminished bilaterally, no respiratory or any other distress”. During a joint home visit with the Licensed Vocational Nurse (LVN 1) on 8/8/2024 at 2:15 p.m., Patient 11 was observed laying on the sofa, awake but stated feels weak and sleepy, his both eyes closed but speak when ask questions. Patient 11 on oxygen therapy, connected to oxygen tank with current setting at 2liters/minute via nasal cannula (is a device that gives additional oxygen (supplemental oxygen or oxygen therapy) through the nose, which is a thin, flexible tube that goes around the head and into the nose, there are two prongs that go inside the nostrils that deliver the oxygen). Patient 11 appeared comfortable, denies any pain or discomfort, and does not present any respiratory distress, P11 has no audible crackles when breathing, speaks clearly and does not stop in between sentences. During a concurrent interview and record review with the Director of Patient care Services (DPCSD) on 8/9/2024, at 4:35 p.m., the DPCSD reviewed Patient 11s LCD (Local Coverage Determination) Hospice Eligibility Determination, dated 11/16/2023 (LCD is used by hospice providers to determine eligibility for beneficiaries for hospice benefits). The DPCSD verified that the LCD indicated in the following questionnaires “;a.i. Poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways (bronchi)), resulting in decreased functional capacity (e.g. bed to chair existence, fatigue and cough)? Was documented as “;Yes” and “;b. O2 (Oxygen) Sat (saturation) less than or equal to 88% determined either by arterial blood gases (measures the balance of oxygen and carbon dioxide in the blood to see how well the lungs are working and it also measures the acid-base balance in the blood) or O2 saturation monitors?” was documented as “;Yes”. DPCSD stated that the documents from hospital did not have any lab results or studies that support the terminal diagnosis of P11. The DPCSD stated that the oxygen saturation for COPD patients are normally below 92% on room air and lung sounds are with crackles. The HA was not able to provide further clinical documentations that support Patient 11s terminal diagnosis of Chronic Obstructive Pulmonary Disease for hospice admission. g. A review of Patient 12s untitled admission record indicated a Start of Care (SOC) dated 5/31/2024 with a primary diagnosis of Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time) with Heart Failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath) and a secondary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing) unspecified. A review of Patient 12s clinical record titled “;Physicians Certification for Hospice Benefit”, dated 5/31/2024, indicated that Patient 12 was admitted to hospice with primary diagnosis of Hypertensive Heart Disease with Heart Failure. It further indicated in the “;Medical Director Attestation/Certification - I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient”, electronically signed by the Medical Director (MD). The document also indicated that Patient 12 had a terminal illness and a life expectancy of six months or less if the disease runs its normal course. During a telephone interview with P12 on 8/7/2024 at 4:38 p.m., P12 stated that he was referred by a hospital doctor when he got discharged. P12 stated that he does not have any terminal illness, stated that he has Hypertension (also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure) and a broken collar bone from previous accident. P12 stated that he can walk fine without using any mechanical devices, he is not short of breath. P12 stated he lives by himself and does his errands. P12 stated that nurses come to his place to check his vital signs and provide his medications. P12 stated he does not use any oxygen to help him to breathe, stated he does not have any oxygen tanks or machine at his home and stated he does not need it. P12 stated that Hospice Services were not explained to him during his admission when a nurse came to visit him and he does not know about the terminal illness. During a concurrent record review and interview with the DPCSD on 8/9/2024 at 4:45 p.m., the DPCSD reviewed Patient 12s LCD Hospice Eligibility Determination. The DPCSD verified that based on the LCD Hospice Eligibility Determination, Patient 12 is optimally treated with for heart disease with diuretics (medicines that help reduce fluid buildup in the body) and vasodilators (medicines that dilate/widen blood vessels, allowing blood to flow more easily) and met the criteria for NYHA Class IV. NYHA Class IV is a classification of the most severe type of heart failure by the New York Heart Association. The DPCSD verified there were no clinical documents to support the NYHA Class IV in Patient 12s record. The agency was unable to provide previous medical records to support patients diagnosis for hospice admission. During a telephone interview with the Medical Director (MD) on 8/9/2024 at 2:22 p.m., the MD stated that a person with NYHA Class IV would have shortness of breath at rest and would require assistance with ADLs around the clock. When asked what diagnostics would support the diagnosis of NYHA Class IV, the MD stated that echocardiogram (an ultrasound test that checks the structure and function of the heart could determine if a person had NYHA Class IV by measuring the ejection fraction (a measurement of the percentage of blood leaving the heart each time it squeezes). According to the MD, a person with NYHA Class IV would have an ejection fraction between 15% to 20%. When the MD was asked if Patient 12, who was able to ambulate unassisted and do his personal errands with no assistance and had no diagnostics or history and physical on file, would meet the criteria of NYHA Class IV, the MD stated, “;Absolutely not.” The MD stated that Patient 12 did not meet the hospice criteria under heart disease. The MD stated that patient had to be referred by a physician and had to have a terminal illness with life expectancy of 6 months or less. The MD stated the diagnosis had to be supported by clinical documents, such as history and physicals, laboratory, and imaging data. The MD stated the HA had the responsibility to ensure patients had the clinical documents, which he would review. The MD stated he tried to review all the clinical documents and see the patients in person, but until he had an opportunity for that, he would base the CTI narrative on the Registered Nurse report, who had seen and assessed the patient first. The MD stated he would need to personally see all the patients to ensure their eligibility for hospice. The MD stated that hospice patients should be home bound since they are too weak to do their errands and ADLs by themselves. The MD stated that for COPD patients, they are mostly dependent on their oxygen therapy, their oxygen saturation are around less than 92% and with crackle lungs sounds, he stated that it would be difficult for COPD patients to walk around as they get tired easily.”

“Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure content and information in the patients medical records were safeguarded from unauthorized access for one of fourteen sample selected patients (Patient 13). This failure has the potential to result in an unauthorized and inaccurate patient information or clinical record that could affect the patients quality of care and well-being. A record review of Patient 13 (P13)s untitled admission record indicated a start of care of 1/20/22 and an end of care of 10/26/2023, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing). A review of P13s clinical record titled “;Discharge Summary” dated 10/26/2023, indicated that Patient 13 discharged from HA due to revocation of hospice on 10/26/2023 and P13 chose aggressive treatment. During a joint home visit with the Licensed Vocational Nurse (LVN 1) on 8/8/2024 at 2:15 p.m., Patient 11 was observed laying on the sofa, awake but stated feels weak and sleepy, his both eyes closed but speak when ask questions. Patient 11 on oxygen therapy, connected to oxygen tank with current setting at 2liters/minute via nasal cannula (is a device that gives additional oxygen (supplemental oxygen or oxygen therapy) through the nose which is a thin, flexible tube that goes around the head and into the nose, there are two prongs that go inside the nostrils that deliver the oxygen). Patient 11 appeared comfortable and denies any pain or discomfort. During a review of Patient 8s home folder with LVN 1 on 8/8/2024 at 2:28 p.m, P13s clinical record titled “;Treatment/Medication/DME (Durable Medical Equipment) List was inside and included in P8s agency folder. At 2:33 p.m., during interview with P8, he stated that P13 is his friend, and she comes to his house. P8 stated that he does not know why her (P13) medication list was in his agencys folder. P8 stated that P13 is his emergency contact. During an interview with LVN 1 on 8/8/2024 at 247 p.m., he stated that he does not know P13, and he was unsure why P13s medication list was mixed with P8s agency folder. LVN 1 stated that it is important to protect patients medical information including the list of medications the patients are taking to prevent confusion when conducting medication reconciliation and to ensure patients records are safe. A review of P13s clinical record titled “;Visit Note LVN” indicated that LVN1 conducted a visit and entered documentations dated 10/19/2023, 10/24/2023 and 10/26/2023. On 8/8/2024 at 3:48 p. m., a telephone call was made to P13 but was unsuccessful. During an interview with the Director of Patient Care Services Designee (DPCSD) on 8/9/2024 at 3:22 p.m., DPCSD stated that P13 was discharged already, and she is the domestic partner and emergency contact of P8. DPCSD stated that she does not know if they still live in the same address. DPCSD stated that P13s clinical record should not be mixed up with P8s clinical records. DPCSD stated that the visiting nurses should check patients folder on each visit to ensure that the documents of patients were properly secured and reviewed. DPCSD stated that mixed clinical records of different patients violate the confidentiality and safety of records. DPCSD stated that mixed clinical records of patients can also result in wrong medication reconciliations and wrong references. During a review of the HAs policy, titled “;Patient Bill of Rights/Responsibilities,” (Policy No. 2-002.1), revised April 2020, indicated the Patient Bill of Rights/Responsibilities statement defines the right of the patient to: H. Confidentiality of the patient and clinical records maintained by the organization and the policies and procedures regarding disclosure. A review of the HAs policy titled “;Uses and Disclosures of PHI” (Policy No. 2-015.1), revised April 2020, indicated that the purpose of the agency is to safeguard protected health information (PHI) against unauthorized use.”