Western Palliative Care, Inc.

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participations regarding initial and Comprehensive Assessments of Patients was met as follows: 1. The HA staff failed to conduct and document an accurate initial assessment that reflected the patient’s current health status and identify patients’ need for hospice care and services related to hospice eligibility and management of terminal illness for three of fourteen sampled patients (Patient 1, Patient 2, and Patient 8). (Refer to L 522). 2. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after election of hospice care for five of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 9, and Patient 10). (Refer to L 523). 3. The HA staff failed to review all medications three of fourteen sampled patients (Patient 1, Patient 2, and Patient 9) were taking and update their medication profiles with the currently used medications. (Refer to L 530). 4. The HA failed to ensure an initial bereavement assessment was done for nine of fourteen sample selected patients (Patient 1, Patient 2, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14), which focused on the social, spiritual, and cultural factors that may affect the ability of the family and other individuals involved in the care, to cope with the patients death. (Refer to L 531). 5. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days eight of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 7, Patient 9, Patient 10, and Patient 11). (Refer to L 533). The cumulative effect of these systemic practices resulted in the hospice agency admitting patients who did not meet admission criteria and did not qualify for the Medicare hospice benefit.”

“Based on interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation regarding care planning and coordination of services for patients was met as follows: 1. The HA failed to ensure six of fourteen sampled patients (Patient 1, Patient 2, Patient 9, Patient 10, Patient 11, and Patient 14) had an individualized written plan of care. (Refer to L545). 2. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) reviewed and revised seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 7, Patient 9, and Patient 10) plan of care (POC- an individualized care planned). (Refer to L552). The cumulative effect of these systemic practices resulted in the HA not providing the services and care as ordered and had the potential for the patients to not receive appropriate healthcare services that could affect their quality of life.”

“This CONDITION is not met as evidenced by: Based on interview and record review, the hospice agency failed to: 1. Provide evidence that quality assessment and performance improvement (QAPI, a coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI), which are critical to improving the quality of life, and quality of care and services delivered in a healthcare facility) system was formulated and ensure its program objectives, patient care disciplines, description of how the program will be administered and coordinated, methodology for monitoring and evaluating the quality of care, priorities for resolution of problems, monitoring to determine effectiveness of action, oversight responsibility reports to governing body, and documentation of the review of its own QAPI program were implemented for fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This deficient practice resulted in the inability of the agency to identify issues, improve health outcomes, patient safety, and quality patient care. (Refer to L561). The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of a quality health care in a safe environment.”

“Based on interview and record review the Hospice Agency (HA) failed to ensure the Condition of Participation for License Professional Services was met as evidence by: 1. The HA failed to ensure their Medical Social Worker, Physicians, and Spiritual Counselor participated in the planning of patients hospice care by not attending IDT meetings and not contributing to the development of their individualized plan of care for five of fourteen sampled patients (Patient 1, Patient 2, Patient 9, Patient 10, and Patient 11). (Refer to L585). 2. The HA failed to provide evidence their licensed professionals were involved and participated in the HAs quality assessment and performance improvement program (QAPI) for fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 5, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L586). The cumulative effect of these systemic practices resulted in the HA not ensuring their license personnel were providing services/care as required and had the potential to result in patients not receiving appropriate healthcare services that could affect their quality of life.”

“Based on interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Medical Director was met as evidenced by: 1. The HA failed to ensure, the medical director and/or physician designee conducted an accurate assessment, reviewed, and verified the patient clinical information, necessary for initial certifications for fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The agency failed to: Ensure there was a physicians signature and documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice are and services. (Refer to L 667). 2. The HA failed to ensure the medical director and/or physician designee conducted a review and verified the patients clinical information to determine the patient needs for recertification of a terminal illness for continued hospice care and services for eight of fourteen sampled patients (Patient 1, Patient 2, Patient 6, Patient 7, Patient 9, Patient 11, Patient 12, and Patient 13). (Refer to L 668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure the highest quality of patient care is provided to the patients certified to receive hospice services.”

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Clinical Records was met as follows: 1. The HA failed to ensure five of fourteen sampled patients (Patient 1, Patient 2, Patient 9, Patient 10, and Patient 11) medical records included comprehensive assessments, plan of care, and clinical notes to reflect the care provided. (Refer to L672). 2. The HA failed to ensure three of fourteen sampled patients (Patient 1, Patient 2, and Patient 3) medical records included written certification of terminal illness. (Refer to L676). 3. The HA failed to ensure any amendments, correction or late entries within an electronic health record clearly identified the original content, the modified content, date, and authorship of each record modification for thirteen of fourteen sampled patients (Patient 1, Patient 2, Patient 4, Patient 5, Patient 7, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L679). 4. The HA failed to ensure five of fourteen sampled patients (Patient 1, Patient 10, Patient 12, Patient 13, and Patient 14) records were safeguarded against unauthorized access. (Refer to L680). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records are safeguarded from unauthorized access by any individuals or hospice staff.”

“Based on interview, and record review, the Hospice Agency (HA) failed to ensure patient rights were exercised by the patients themselves or their legal representative for one of 14 sampled patients (Patient 2). This deficient practice resulted in a violation of patient rights. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). Further review of the record indicated Patient 1 was listed as the emergency contact. During an interview on 7/24/2024, at 1:15 p.m., Patient 1 stated Patient 2 was “;My brother in laws stepfather”. Patient 1 stated she lived with Patient 2 in the same home. Patient 1 stated she was not aware that Patient 2 was diagnosed with Alzheimers disease. Patient 1 stated Patient 2 was alert and able to make his own decisions. Patient 1 stated Patient 2 had a primary doctor, whom he saw about a month ago. Patient 1 stated Patient 2s primary doctor said he was healthy. During a concurrent interview and record review on 7/25/2024, at 3:04 p.m., the Director of Patient Care Services (DPCS) reviewed Patient 2s record titled, “;Election of Hospice Medicare Benefit and Patient Authorization”, dated 12/21/2023. The DPCS stated Patient 1, Patient 2s partner, had signed the consent. The DPCS stated Patient 1 always says Patient 1 is not partner with Patient 2, but they sleep in the same bed, and they live in the same house. The DPCS stated Patient 1 was not the power of attorney for Patient 2, but she was the one responsible for him because Patient 2 did not have family. During an interview on 7/26/2024, at 10:40 a.m., the DPCS stated Patient 2 was admitted to the HA for a terminal diagnosis of Alzheimers disease. The DPCS stated he determined Patient 2s diagnosis when Patient 1 told him. The DPCS stated he determined the diagnosis also by reviewing the medications Patient 2 was taking. The DPCS reviewed Patient 2s medications and stated he was not on any medications for dementia. When asked how he determined Patient 2 had Alzheimers disease, the DPCS stated, “;I asked him questions during the assessment. His answers were out of this world. So based on my assessment, and his age, I determined he had dementia. I asked (Patient 1) if she could ask Patient 2s primary doctor to place him on dementia medications.” The DPCS stated he did not know if a doctor had diagnosed Patient 2 with Alzheimers disease, because the HA did not have any medical documents from his primary doctor or any other doctor to say Patient 2 had the disease. A record review of the HAs policy and procedure titled, “;Admission Criteria & Process”, indicated, “;...4. The patient must desire hospice services and be aware of the diagnosis and prognosis...10. The patient or his/her representative will sign the required forms indicating election of hospice...””

“Based on interview and record review the Hospice Agency (HA) staff failed to conduct and document an accurate initial assessment that reflected the patient’s current health status and identify patients’ need for hospice care and services related to hospice eligibility and management of terminal illness for three of fourteen sampled patients (Patient 1, Patient 2, and Patient 8). This failure resulted in patients being admitted without addressing all their immediate needs which is necessary to gather the essential information necessary to begin the plan of care and provide the immediate necessary care and services. 1. 1a. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. Further review of the record indicated Patient 1 was referred to the HA on 12/15/2023. A record review of Patient 1s “;RN (RN-Registered Nurse) Initial Assessment”, dated 12/22/2023, indicated Patient 1 was assessed by the RN. 1b. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). Further review of the record indicated Patient 2 was referred to the HA on 12/15/2023. During a concurrent interview and record review on 7/26/2024, at 10:35 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 2s medical records. The DPCS stated Patient 2 was supposed to be assessed within 24 to 48 hours of the referral date. The DPCS stated Patient 2 was assessed late and did not recall why the visit was late. The DPCS stated Patient 2s medical record did not indicate why the assessment was done late. The DPCS stated it was important to see the patient sooner because many things can happen during the time, like death. The HA needed to assess what the needs were, to provide the care based on the needs of the patient. 2. 2a. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. During an interview on 7/24/2024, at 1 p.m., Patient 1 stated she became aware of the HA through a vendor in downtown. There was a tent with information. Patient 1 stated she had a primary doctor and had an upcoming appointment in August 2024. Patient 1 stated she had a primary doctor and a neurologist (a doctor who specializes in the nervous system). Patient 1 stated no doctor had told her she was terminal, and she had six months or less to live. Patient 1 stated her doctor wanted her to see an occupational therapist (OT) because her stability was getting worse. Patient 1 stated if the OT didnt help, more steps were going to take place to see if she had another medical condition. Patient 1 stated Patient 1 used a cane to walk, had COPD, and used oxygen therapy about 3 times a week. During a concurrent interview and record review on 7/25/2024, at 2:26 p.m., the DPCS reviewed Patient 1s record titled “;RN Initial Assessment”, dated 12/22/2023. The DPCS stated Patient 1s terminal diagnosis was COPD and there where guidelines that were used to determine hospice eligibility. The DPCS stated those guidelines were in his car, and not in Patient 1s medical record. The DPCS stated the HA always asked for the history and physical (a medical document that explains a doctors exam, the medical history, and treatment plan of a patient) but did not have the document in Patient 1s medical record. The DPCS was asked to provide written evidence Patient 1 was terminal. The DPCS stated the evidence was Patient 1s weakness, shortness of breath, and that she didnt want to eat sometimes. The DPCS stated there was no medical documents to indicate Patient 1 was terminal and had six months or less to live. The DPCS stated the only documents available were the nursing assessments. The DPCS stated he did not have knowledge if the medical director had assessed Patient 1. When asked if the DPCS knew who referred the patient to HA, the DPCS stated, “;I have no idea. It is not part of my duty.” A record review of Patient 1s record titled, “;RN Initial Assessment”, dated 12/22/2023, indicated Patients oxygen saturation (the percentage of oxygen the body) was 92% breathing in normal environment air. The record also indicated Patient 1 had a KPS (Karnofsky Performance Status Scale) of 30%, which meant “;severely disabled; hospital admission is indicated although death not imminent”. Further review of the record indicated Patient 1 to be exhibiting hypoxemia as evidenced by oxygen saturation of equal to or less than 88%, determined by arterial blood gases or oxygen saturation monitors. 2b. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). Further review of the record indicated Patient 2 was referred to the HA on 12/15/2023. During an interview on 7/24/2024, at 1:15 p.m., Patient 1 stated she was not aware that Patient 2 was diagnosed with Alzheimers disease. Patient 1 stated Patient 2 was alert and able to make his own decisions. Patient 1 stated Patient 2 had a primary doctor, whom he saw about a month ago. Patient 1 stated Patient 2s primary doctor said he was pretty healthy. During an interview on 7/26/2024, at 10:40 a.m., the DPCS stated Patient 2 was admitted to the HA for a terminal diagnosis of Alzheimers disease. The DPCS stated he determined Patient 2s diagnosis when Patient 1 told him. The DPCS stated he determined the diagnosis also by reviewing the medications Patient 2 was taking. The DPCS reviewed Patient 2s medications and stated he was not on any medications for dementia. When asked how he determined Patient 2 had Alzheimers disease, the DPCS stated, “;I asked him questions during assessment. His answers were out of this world. So based on my assessment, and his age, I determined he had dementia. I asked (Patient 1) if she could ask Patient 2s primary doctor to place him on dementia medications.” The DPCS stated he did not know if a doctor had diagnosed Patient 2 with Alzheimers disease, because the HA did not have any medical documents from his primary doctor or any other doctor to say Patient 2 had the disease. During a continued interview on 7/26/2024, at 10:40 a.m., the DPCS stated Patient 2 had been admitted to hospice care with a diagnosis of Alzheimers disease without written confirmation of the disease. The DPCS stated the medical director had not seen or examined Patient 2. The DPCS stated he was supposed to report the assessment findings with either Patient 2s primary care doctor or to the HAs medical director, to inform the concerns with the mental assessment. The DPCS stated he assumed the administrator (ADM) had informed the doctor. The DPCS stated the ADM was not a nurse. A record review of Patient 2s “;RN Initial Assessment” dated 12/21/2023, indicated Patient 2 had progressive decline in functional, cognitive, and physical status as evidenced by increased confusion, generalized weakness, poor oral intake, and dependency on activities of daily living (bathing, eating, walking, etc.). 3. During a record review of Patient 8’s medical record form titled “;Patient Information” indicated “;current benefit period – begin date 7/6/2024 end date 9/3/2024” with a diagnosis of unspecified cirrhosis of liver. During an interview on 7/23/2024 at 12:20 p.m. with the Administrator (ADM), the ADM stated Patient 8 was an active patient. During a concurrent interview and record review on 7/23/2024 at 1 p.m. with the ADM of Patient 8s medical record, the ADM stated she was unable to pull up Patient 8s electronic medical record (EMR) and will be calling their EMR company for assistance. During an interview on 7/23/2024 at 5:12 p.m. with the Administrator Designee (AD), the AD stated Patient 8s Benefit Period ended on 7/5/2024 and was not sure if Patient 8 was an active patient or not. During an interview on 7/24/2024 at 10:30 a.m. with Patient 8, Patient 8 stated she has been in and out of the hospital, her last hospitalization was during the week of 7/14/2024. Patient 8 stated she was seen by the Director of Patient Care Services (DPCS) once in January 2024, after Christmas. Patient 8 stated she was no longer receiving services from the HA. During a concurrent interview and record review on 7/24/2024 at 2 p.m. with the AD of Patient 8s medical record, the AD stated “;The daughter takes her back and forth to the hospital.” During a concurrent interview and record review on 7/25/2024 at 10:40 a.m. with the DPCS of Patient 8s medical record, the DPCS stated Patient 8s start of care date was on 1/8/2024. The DPCS stated Patient 8 was hospitalized twice since her start of care. The DPCS stated Patient 8 needs to be recertified and reassessed because she started their services again. The DPCS stated he was unable to locate Patient 8s admission assessments after her hospitalizations. The DPCS stated he hand wrote the assessments and handed them to the ADM or the AD to log into Patient 8s electronic medical record (EMR) system. The DPCS stated he does not know where his written admission assessments were. A record review of the HAs undated policy and procedure titled, “;Initial Assessment”, indicated, “;Policy: An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care... in less than 48 hours. A record review of the HAs policy and procedure titled, “;Admission Criteria & Process”, indicated, “;Policy...The patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determinations (LCDs)...3. The patient must have a life-limiting illness with a life expectancy of six (6) months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria...”.”

“Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after election of hospice care for 5 of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 9, and Patient 10). This failure resulted in patients not being properly evaluated which resulted in not being provided the individualized focused care. During an interview on 7/23/2024 at 1:45 p.m. with the Medical Director (MD1), MD1 stated he documents the IDG discussion in writing on paper. During an interview on 7/23/2024 at 2:08 p.m. with the Administrator (ADM), ADM stated they hold IDG meetings every two weeks. The ADM stated their last IDG meeting was held during the last week of May 2024. The ADM stated they were supposed to have another IDG meeting in June, but MD1 was hospitalized. The ADM stated they do not document their IDG meeting discussions unless there is a problem with a patient. The ADM stated the IDG members sign an IDG attendance sheet. During an interview on 7/23/2024 at 3:50 p.m. with the Director of Patient Care Services Designee (DD), DD stated she did not attend the HAs IDG meeting that was held in May 2024. DD stated she has not been assigned any patients since she started working at the HA three months ago. During an interview on 7/23/2024, at 3:59 p.m., the Director of Patient Care Services Designee (DD) stated the plan of care was developed during the admission process. The registered nurse (RN) assesses to see what the patient needs are. The DD stated the RN was responsible in doing the plan of care, although the nursing assistant and licensed vocational nurse could participate. The DD stated the Chaplains role in the development of the plan of care was to assess if the patient needed a clergy, depending on their religion. The DD stated the Chaplain was responsible for assessing to see if the patient was depressed and to see if the family was involved. The DD stated the Chaplain was not responsible for assessing the spiritual needs, that responsibility belonged to the church. The DD stated the Chaplain or the MSW were not responsible for assessing the spiritual needs of the patients. During an interview on 7/24/2024 at 2:28 p.m. with the Spiritual Counselor (SC), the SC stated he was not part of the HAs IDG. The SC stated he saw one patient since he started working at the HA in March. The SC stated he does not know how long or how often the IDG meetings are done. During an interview on 7/25/2024, at 11 a.m., the MSW stated the initial psychosocial assessment was supposed to be done within five days of admission. The MSW stated that the service was offered by the Director of Patient Care Services (DPCS) or herself. The MSW stated if she had called the patient to offer the services, she would have documented the call in the communication tab of the medical record. The MSW stated she had been working for the HA for almost a year, since August 2024, and she had not seen any patient because they had all declined the service. During an interview on 7/25/2024, at 11:11 a.m., the MSW stated the purpose of the psychosocial assessment was to identify psychosocial concerns, meet with family and patient, assess coping, and to determine a frequency on how often they should be seen. The risk of not having a psychosocial assessment would result in patients not having identified psychosocial concerns, not being made aware of their resources, and they would be missing out on extra psychosocial support they can get through a social worker. During an interview on 7/25/2024 at 11:15 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated the Medical Director, MSW, SC and himself were part of the IDG. The DPCS stated in their IDG meetings they discuss patients conditions, family, or patient complaints. The DPCS stated “;We have to gather everybodys feedback which should be recorded.” The DPCS stated IDG members signatures indicate their attendance. The DPCS stated he did not know where the IDG members sign. 1. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. During a concurrent interview and record review on 7/25/2025, at 2:47 p.m., the DPCS reviewed Patient 1s medical records. The DPCS stated Patient 1 declined Spiritual Care (SC) services, and he had not asked her again because Patient 1 had already told him she had declined. The DPCS stated he did not want Patient 1 to be bothered to be asked again because he knew the patient and her reaction. During an interview on 7/25/2024, at 2:53 p.m., the DPCS stated he had asked Patient 1 about MSW services, and the patient had declined. The DPCS stated he did not ask her again about MSW services because she said she didnt need it. A record review of Patient 1s “;Physician Order”, dated 12/27/2024, indicated the family had declined SC services. A record review of Patient 1s “;Physician Order”, dated 12/27/2024, indicated the family had declined MSW services. 2. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During an interview on 7/25/2024 at 2:50 p.m., the DPCS stated Patient 2 was not religious and had declined SC services from the beginning of services. The DPCS stated he did not ask him again because he had the type of reaction that he would get upset if you kept asking, so he was trying to avoid it. 3. A record review of Patient 3s “;Patient Profile”, indicated an admission date of 10/6/2023, with a terminal diagnosis of cerebral vascular accident (brain attack). The record also indicated Patient 3 was discharged on 1/7/2024. A record review of Patient 3s record did not indicate Patient 3 was assessed by the MSW. 4. During a record review of Patient 9’s medical record form titled “;Patient Information” indicated “;current benefit period – begin date 4/22/2024 end date 7/20/2024” with a diagnosis of end stage renal disease. During a concurrent interview and record review on 7/25/2024 at 1: 25 p.m. with the DPCS of Patient 9s medical record, the DPCS stated Patient 9 has not had a comprehensive assessment. The DPCS stated when patients decline certain disciplines, he does not conference them during the patients comprehensive assessment. The DPCS stated it was important to have a comprehensive assessment with all the IDG members, so all are aware of what is going on with the patients. 5. During a record review of Patient 10’s medical record form titled “;Patient Information” indicated “;current benefit period – begin date 5/20/2024 end date 6/26/2024” with a diagnosis of hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following unspecified cerebrovascular disease affecting left dominant side. During a concurrent interview and record review on 7/26/2024 at 11:31 a.m. with the DPCS of Patient 10s medical record, the DPCS stated Patient 10 did not have a IDG meeting. The DPCS stated he completed Patient 10s individualized plan of care (POC) three days after he was admitted. The DPCS was unable to locate Patient 10s POC. DPCS stated he hand wrote Patient 10s POC and handed it over to the Administrator Designee (AD) to be inputted into their electronic medical record (EMR) system. The DPCS stated patient notes should be kept in patients medical records because it was part of their care. A record review of the HAs undated policy and procedure titled, “;Admission Criteria & Process”, indicated, “;...17. If the patient is accepted for hospice care, a comprehensive assessment of the patient will be performed no later than five (5) calendar days after the election of hospice care. A record review of the HAs undated policy and procedure titled, “;Spiritual Care Counseling Services”, indicated, “;Procedure...2. The Hospice Chaplain will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient and family.” A record review of the HAs undated policy and procedure titled, “;Psychosocial Services”, indicated, “;Procedure 1. The social worker will contribute to the comprehensive assessment and ongoing update to the comprehensive assessment based on the needs of the patient.””

“Based on interview, and record review the Hospice Agency (HA) staff failed to review all medications three of fourteen sampled patients (Patient 1, Patient 2, and Patient 9) were taking and update their medication profiles with the currently used medications. This failure had the potential to place patients at risk for medication errors and adverse drug reactions. 1. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. During a concurrent interview and record review on 7/23/2024, at 12:28 p.m., the administrator designee (AD) reviewed Patient 1s records and stated there was no medication list for the current episode 3 of 6/19/2024 to 8/17/2024. The AD stated the medications were listed in the plan of care from the previous episodes. 2. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During a concurrent interview and record review on 7/23/2024, at 12:29 p.m., the AD reviewed Patient 1s records and stated there was no medication list for the current episode 3 of 6/18/2024 to 8/16/2024. The AD stated the medications were listed in the plan of care from the previous episodes. 3. During a record review of Patient 9’s medical record form titled “;Patient Information” indicated “;current benefit period – begin date 4/22/2024 end date 7/20/2024” with a diagnosis of end stage renal disease. During a concurrent interview and record review on 7/25/2024 at 1: 25 p.m. with the DPCS of Patient 9s medical record, the medical record indicated there was no documented medication list for Patient 9. DPCS stated he was in the process of completing Patient 9s medication list. A record review of the HAs undated policy and procedure titled, “;Medication Profile”, indicated, “;Procedure: 1. For accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patients current medication upon the patients entry to the organization...2. The admitting nurse will initiate a medication profile to document the current medication regimen, including a diagnosis, condition, or indication for use for each medication ordered.””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure an initial bereavement assessment was done for nine of fourteen sample selected patients (Patient 1, Patient 2, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14), which focused on the social, spiritual, and cultural factors that may affect the ability of the family and other individuals involved in the care, to cope with the patients death. This failure had the potential for the patient/family not being provided social, spiritual, and cultural support related to the patient’s death. During an interview on 7/23/2024 at 11:50 a.m. with the Administrator (ADM), Administrator Designee (AD), and the Director of Patient Care Services (DPCS), the DPCS and ADM stated their Bereavement Coordinator was the Spiritual Counselor (SC). During an interview on 7/24/2024 at 2:28 p.m. with the Spiritual Counselor (SC), the SC stated he was not part of the HAs interdisciplinary group (IDG). The SC stated he saw one patient since he started working at the HA in March. The SC stated the HA told him that no other patients wanted his services. The SC stated he did not reach out to any other patients because the HA told him that the patients did not want any contact with him. During an interview on 7/25/2024 at 10:59 a.m. with the Medical Social Worker (MSW), the MSW stated “;Thinking about it now, I dont believe I have seen none of their patients.” During an interview on 7/25/2024, at 11:11 a.m., the Medical Social Worker stated she was not the bereavement coordinator. During an interview on 7/25/2024 at 1:25 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated they only call the Spiritual Counselor (SC) or the Medical Social Worker when their services are needed or requested. During an interview on 7/26/2024 at 11:45 a.m. with the Medical Director (MD1), the MD1 stated he has not met the SC or the MSW. 1. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. A record review of Patient 1s record titled, “;RN Initial Assessment”, dated 12/22/2023, did not indicate an initial bereavement assessment was documented. 2. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A record review of Patient 2s “;RN Initial Assessment”, dated 12/21/2023, did not indicate an initial bereavement assessment was documented. 3. During a record review of Patient 8 medical record form titled “;Patient Information” indicated “;current benefit period – begin date 7/6/2024 end date 9/3/2024” with a diagnosis of unspecified cirrhosis of liver. During a record review of Patient 8s medical record form titled “;Plan of Care Order” dated 1/8/2024, indicated “;MSW - for initial assessment and every recertification and as needed; Chaplain – Decline.” During an interview on 7/24/2024 at 10:30 a.m. with Patient 8, Patient 8 stated she did not receive a call from the HAs MSW. Patient 8 stated she saw a spiritual counselor three months ago that was sent by another agency. 4. During a record review of Patient 9’s medical record form titled “;Patient Information” indicated “;current benefit period – begin date 4/22/2024 end date 7/20/2024” with a diagnosis of end stage renal disease. 5. During a record review of Patient 10’s medical record form titled “;Patient Information” indicated “;current benefit period – begin date 5/20/2024 end date 6/26/2024” with a diagnosis of hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following unspecified cerebrovascular disease affecting left dominant side. During a concurrent interview and record review on 7/26/2024 at 11:31 a.m. with the DPCS stated he completed Patient 10s individualized plan of care (POC) three days after he was admitted. The DPCS was unable to locate Patient 10s POC. The DPCS stated he hand wrote Patient 10s POC and handed it over to the Administrator Designee (AD) to be inputted into their electronic medical record (EMR) system. The DPCS stated patient notes should be kept in patients medical records because it was part of their care. 6. During a record review of Patient 11’s medical record form titled “;Patient Information” indicated “;current benefit period – begin date 5/16/2024 end date 8/13/2024” with a diagnosis of chronic obstructive pulmonary disease (difficulty breathing). 7. During a record review of Patient 12 medical record form titled “;Patient Information” indicated “;current benefit period – begin date 2/9/2024 end date 5/8/2024” with a diagnosis of unspecified malignant neoplasm of skin of left lower limb, including hip (skin cancer). 8. During a record review of Patient 13’s medical record form titled “;Patient Information” indicated “;current benefit period – begin date 2/17/2024 end date 5/16/2024” with a diagnosis of Alzheimers Disease (gradual memory loss). 9. During a record review of Patient 14 medical record form titled “;Patient Information” indicated “;current benefit period – begin date 2/20/2024 end date 5/19/2024” with a diagnosis of Alzheimers Disease (gradual memory loss). A record review of the HAs undated policy and procedure titled, “;Bereavement Services”, indicated, “;Procedure: 1. A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care.”

“Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for eight of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 7, Patient 9, Patient 10, and Patient 11). This failure resulted in patients not being properly evaluated which resulted in patients not being provided individualized focused care. During an interview on 7/23/2024 at 1:45 p.m. with the Medical Director (MD1), the MD1 stated he documents the IDG discussion in writing on paper. During an interview on 7/23/2024 at 2:08 p.m. with the Administrator (ADM), the ADM stated they hold IDG meetings every two weeks. The ADM stated their last IDG meeting was held during the last week of May 2024. The ADM stated they were supposed to have another IDG meeting in June, but MD1 was hospitalized. The ADM stated they do not document their IDG meeting discussions unless there is a problem with a patient. The ADM stated the IDG members sign an IDG attendance sheet. During an interview on 7/23/2024, at 2:09 p.m., the administrator (ADM) stated the last IDG meeting was in May 2024. The ADM stated the Medical Doctor (MD1) did not attend the January and March 2024 IDG meetings because he was hospitalized himself. The ADM tried to contact another doctor, but it did not workout. The ADM stated the IDG members met every two weeks either in the office or through zoom (a telephone-camera method of communication). The ADM stated the IDG members signed the attendance sheet but did not document any discussions in the medical records. The ADM stated there was supposed to be an IDG meeting in June, but the HA was busy moving office space. During an interview on 7/23/2024 at 3:50 p.m. with the Director of Patient Care Services Designee (DD), the DD stated she did not attend the HAs IDG meeting that was held in May 2024. The DD stated she has not been assigned any patients since she started working at the HA three months ago. During an interview on 7/24/2024 at 2:28 p.m. with the Spiritual Counselor (SC), the SC stated he was not part of the HAs IDG. The SC stated he saw one patient since he started working at the HA in March. The SC stated he does not know how long or how often the IDG meetings are done. During an interview on 7/25/2024, at 11:11 a.m., the MSW stated she did not document about the IDG meeting she attended because the case manager documented. The MSW stated if she attended the IDG meeting, she would validate her attendance by signing an attendance sheet if she was in the office. She did not sign any medical record documents, including the electronic medical record. During an interview on 7/25/2024 at 11:15 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated the Medical Director, MSW, SC and himself were part of the IDG. The DPCS stated in their IDG meetings they discuss patients conditions, family, or patient complaints. The DPCS stated “;We have to gather everybodys feedback which should be recorded.” The DPCS stated IDG members signatures indicate their attendance. The DPCS stated he did not know where the IDG members sign. 1. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. A record review of Patient 1s medical records did not indicate any IDG meetings for the 3rd certification period of 6/19/2024 to 8/17/2024. During a concurrent interview and record review on 7/23/2024, at 12:28 p.m., the administrator designee (AD) reviewed Patient 1s records. The ADM stated there was no IDG notes. 2. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A record review of Patient 2s medical records did not indicate any IDG meetings for the 3rd certification period of 6/18/2024 to 8/16/2024. During a concurrent interview and record review on 7/23/2024, at 12:40 p.m., the AD reviewed Patient 2s records. During an interview on 7/23/2024, at 3:54 p.m., the Director of Patient Care Services designee (DD), stated the last IDG meeting was in May 2024. During a concurrent interview and record review on 7/26/2024, at 10:33 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 2s medical records. The DPCS stated the last IDG meeting documented was on 1/8/2024. When asked where the rest of the IDG notes were, the DPCS stated, “;I cannot answer that. I dont know. I know it is my responsibility to check on that. But I trust them. They (office staff) know what they are supposed to do.” 3. A record review of Patient 3s “;Patient Profile”, indicated an admission date of 10/6/2023, with a terminal diagnosis of cerebral vascular accident (brain attack). The record also indicated Patient 3 was discharged on 1/7/2024. During a record review of 7/24/2024, at 1:55 p.m., Patient 3s medical records were reviewed for certification period 10/6/2023 to 1/3/2024. There was only one IDG meeting documented, dated 1/1/2024. 4. A record review of Patient 5s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease. The record also indicated Patient 5 was discharged on 3/8/2024. During a record review on 7/24/2024, at 2:59 p.m., Patient 5s medical records were reviewed for certification period 12/21/2023 to 3/8/2024. There was only one IDG meeting documented, dated 12/21/2024. 5. A record review of Patient 7s “;Patient Profile”, indicated an admission date of 1/2/2024. The record also indicated Patient 7 was discharged on 6/25/2024. During a record review of 7/24/2024, at 3:14 p.m., Patient 7s medical records were reviewed for certification period 4/1/2024 to 6/25/2024. There was only one IDG meeting documented, dated 4/1/2024. 6. During a record review of Patient 9’s medical record form titled “;Patient Information” the information indicated “;current benefit period – begin date 4/22/2024 end date 7/20/2024” with a diagnosis of end stage renal disease. During a record review of Patient 9s medical record form titled “;IDG Meeting” dated from 4/22/2024 to 7/20/2024, the IDG Meeting form indicated there were no IDG meeting documented. 7. During a record review of Patient 10’s medical record form titled “;Patient Information” indicated “;current benefit period – begin date 5/20/2024 end date 6/26/2024” with a diagnosis of hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following unspecified cerebrovascular disease affecting left dominant side. During a concurrent interview and record review on 7/24/2024 at 11:31 a.m. with the DPCS of Patient 10s electronic medical record (EMR) medical record form titled “;IDG Meeting” dated from 5/20/2024 to 6/26/2024, there were no IDG meetings documented under section “;IDG/POC”. The DPCS stated Patient 10 was to have IDG meetings every other week to discuss his condition. 8. During a record review of Patient 11’s medical record form titled “;Patient Information” the patient information form indicated the “;current benefit period – begin date 5/16/2024 end date 8/13/2024” with a diagnosis of chronic obstructive pulmonary disease (difficulty breathing). During a record review on 7/24/2024 at 3:06 p.m. of Patient 11s electronic medical record (EMR) medical record form titled “;IDG Meeting” dated from 5/16/2024 to 6/28/2024, there was nothing documented under section “;IDG/POC”. A record review of the HAs undated policy and procedure titled, “;Interdisciplinary Group Membership & Responsibilities”, indicated, “;Procedure: 1. The hospice interdisciplinary team/group members will include, at a minimum: A. Physician (doctor) B. Registered Nurse C. Social Worker D. Pastoral or other counselor. A record review of the HAs undated policy and procedure titled, “;Interdisciplinary Group Meeting”, indicated, “;Policy...Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires...6. An interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician.””

“Based on interview, and record review the Hospice Agency (HA) failed to ensure six of fourteen sampled patients (Patient 1, Patient 2, Patient 9, Patient 10, Patient 11, and Patient 14) had an individualized written plan of care. This failure had the potential to result in unmanaged needs due to not having a plan of care to follow. During an interview on 7/23/2024, at 3:59 p.m. with the Director of Patient Care Services Designee (DD), the DD stated the plan of care was expected to be developed during the admission. The DD stated it was the registered nurse’s responsibility to develop the plan of care, with involvement from the certified nursing assistant and licensed vocational nurse a day or two after admission. During an interview on 7/23/2024, at 4:11 p.m., the DD stated the plan of care for the certification period had to be completed a day to two days before or the day of the certification due date. The purpose is to know what is going on with the patient . If there is no POC, the DD stated, “;We are in the cloud”, and we dont know what to do with the patient. During an interview on 7/25/2024 at 11:15 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated the patients POC needs to be completed within 24-48 hours of admission. The DPCS stated the patients POC indicate their physical condition and their needs and needs to be followed. The DPCS stated POCs are a guide for the patients care. The DPCS stated without guidelines it will be hard to guess what interventions are needed. 1. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. During a concurrent interview and record review on 7/23/2024, at 12:28 p.m., the administrator designee (AD) stated there was no plan of care in the medical records of Patient 1, for certification period 3, dated 6/19/2024 to 8/17/2024. 2. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During a concurrent interview and record review on 7/23/2024, at 12:40 p.m., the AD stated there was no plan of care in the medical records of Patient 2, for certification period 3, dated 6/18/2024 to 8/16/2024. The AD stated the HA was working on it. 3. During a record review of Patient 9’s medical record form titled “;Patient Information” indicated a “;current benefit period – begin date of 4/22/2024 and an end date 7/20/2024” with a diagnosis of end stage renal disease. During a concurrent interview and record review on 7/25/2024 at 1:25 p.m. with the DPCS of Patient 9s medical record, the DPCS stated Patient 9 did not have a documented POC for certification period 7/21/2024 to 10/18/2024. The DPCS stated DPCS completed Patient 9s POC in writing and provided his documentation to the Administrator Designee (AD) to upload into their EMR system. During an interview on 7/25/2024 at 1:25 p.m. with the AD, the AD stated that the DPCS had not provided her with Patient 9s POC to be able to upload into their EMR system. 4. During a record review of Patient 10’s medical record form titled “;Patient Information” indicated a “;current benefit period – begin date of 5/20/2024 and an end date of 6/26/2024” with a diagnosis of hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following unspecified cerebrovascular disease affecting left dominant side. During a concurrent interview and record review on 7/26/2024 at 11:31 a.m. with the DPCS of Patient 10s medical record, the DPCS stated Patient 10 did not have an IDG meeting. The DPCS stated he completed Patient 10s individualized plan of care (POC) three days after he was admitted. The DPCS was unable to locate Patient 10s POC. The DPCS stated he hand wrote Patient 10s POC and handed it over to the Administrator Designee (AD) to be inputted into their electronic medical record (EMR) system. The DPCS stated patient’s notes should be kept in the patients medical records because it was part of their care. 5. During a record review of Patient 11 medical record form titled “;Patient Information” indicated a “;current benefit period – begin date of 5/16/2024 and an end date of 8/13/2024” with a diagnosis of chronic obstructive pulmonary disease (difficulty breathing). During a record review on 7/24/2024 at 3:06 p.m. of Patient 11s EMR medical record form titled “;IDG Meeting” dated from 5/16/2024 to 6/28/2024, indicated there was no documented POC. 6. During a record review of Patient 14’s medical record form titled “;Patient Information” indicated a “;current benefit period – begin date of 2/20/2024 and an end date 5/19/2024” with a diagnosis of Alzheimers Disease (gradual memory loss). During a record review on 7/24/2024 at 2:46 p.m. of Patient 14s EMR medical record form titled “;IDG Meeting” dated from 5/20/2024 to 6/30/2024, indicated there was no documented POC. A record review of the HAs undated policy and procedure titled, “;The Plan of Care”, indicated, “;Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will be the documentation requirements of the physician-directed medical orders and the care planning process. The plan 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 (15) days. A record review of the HAs undated policy and procedure titled, “;Interdisciplinary Group Meeting”, indicated, “;Policy: The interdisciplinary group will meet on a regular basis to discuss patient/caregiver changes and progress and updates to the plan of care...admission/certification and recertification of patient in the hospice program. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment...”.”

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) reviewed and revised seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 7, Patient 9, and Patient 10) plans of care. This failure resulted in the patients not being properly evaluated which resulted in the patients not being provided individualized focused care. During an interview on 7/23/2024, at 2:09 p.m., the administrator (ADM) stated the last IDG meeting was in May 2024. The ADM stated the Medical Doctor (MD) did not attend the January and March 2024 IDG meetings because he was hospitalized himself. The ADM tried to contact another doctor, but it did not workout. The ADM stated the IDG members met every two weeks either in the office or through zoom (a telephone-camera method of communication). The ADM stated the IDG members signed the attendance sheet but did not document any discussions in the medical records. The ADM stated there was to be an IDG meeting in June, but the HA was busy moving office space. During an interview on 7/24/2024 at 2:28 p.m. with the Spiritual Counselor (SC), the SC stated he was not part of the HAs IDG. The SC stated he saw one patient since he started working at the HA in March. The SC stated he does not know how long or how often the IDG meetings are held. During an interview on 7/25/2024, at 11:11 a.m., the MSW stated she did not document regarding the IDG meeting she attended because the case manager documented. The MSW stated if she attended the IDG meeting, she would validate her attendance by signing an attendance sheet if she was in the office. She did not sign any medical record documents, including the electronic medical record. During an interview on 7/25/2024 at 11:15 a.m. with the Director of Patient Care Services (DPCS), DPCS stated the Medical Director, MSW, SC and himself were part of the IDG. DPCS stated in their IDG meetings they discuss patients conditions, family, or patient complaints. DPCS stated “;we have to gather everybodys feedback which should be recorded.” DPCS stated IDG members signatures indicate their attendance. DPCS stated he did not know where the IDG members sign. 1. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. A record review of Patient 1s medical records did not indicate any IDG meetings for the 3rd certification period of 6/19/2024 to 8/17/2024. During a concurrent interview and record review on 7/23/2024, at 12:28 p.m., the administrator designee (AD) reviewed Patient 1s records. The ADM stated there was no IDG notes. 2. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A record review of Patient 2s medical records did not indicate any IDG meetings for the 3rd certification period of 6/18/2024 to 8/16/2024. During a concurrent interview and record review on 7/23/2024, at 12:40 p.m., the AD reviewed Patient 2s records. The ADM stated there was no IDG notes. During an interview on 7/23/2024, at 3:54 p.m., the Director of Patient Care Services designee (DD), stated the last IDG meeting was in May 2024. During a concurrent interview and record review on 7/26/2024, at 10:33 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 2s medical records. The DPCS stated the last IDG meeting documented was on 1/8/2024. When asked where the rest of the IDG notes were, the DPCS stated, “;I cannot answer that. I dont know. I know it is my responsibility to check on that. But I trust them. They (office staff) know what they are supposed to do.” 3. A record review of Patient 3s “;Patient Profile”, indicated an admission date of 10/6/2023, with a terminal diagnosis of cerebral vascular accident (brain attack). The record also indicated Patient 3 was discharged on 1/7/2024. During a record review of 7/24/2024, at 1:55 p.m., Patient 3s medical records were reviewed for the certification period 10/6/2023 to 1/3/2024. There was only one IDG meeting documented, dated 1/1/2024. 4. A record review of Patient 5s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease. The record also indicated Patient 5 was discharged on 3/8/2024. During a record review of 7/24/2024, at 2:59 p.m., Patient 5s medical records were reviewed for the certification period 12/21/2023 to 3/8/2024. There was only one IDG meeting documented, dated 12/21/2024. 5. A record review of Patient 7s “;Patient Profile”, indicated an admission date of 1/2/2024. The record also indicated Patient 7 was discharged on 6/25/2024. During a record review of 7/24/2024, at 3:14 p.m., Patient 7s medical records were reviewed for the certification period 4/1/2024 to 6/25/2024. There was only one IDG meeting documented, dated 4/1/2024. 6. During a record review of Patient 9’s medical record form titled “;Patient Information” indicated a “;current benefit period – begin date of 4/22/2024 end date 7/20/2024” with a diagnosis of end stage renal disease. During a concurrent interview and record review on 7/25/2024 at 1: 25 p.m. with the DPCS of Patient 9s medical record, the DPCS stated Patient 9 has not had a comprehensive assessment. The DPCS stated when patients decline certain disciplines, he does not conference them during the patients comprehensive assessment. The DPCS stated it was important to have a comprehensive assessment with all the IDG members, so all are aware of what is going on with the patients. 7. During a record review of Patient 10’s medical record form titled “;Patient Information” indicated a “;current benefit period – begin date of 5/20/2024 and an end date 6/26/2024” with a diagnosis of hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following unspecified cerebrovascular disease affecting left dominant side. During a concurrent interview and record review on 7/26/2024 at 11:31 a.m. with the DPCS of Patient 10s medical record, the DPCS stated Patient 10 did not have an IDG meeting. The DPCS stated he completed Patient 10s individualized plan of care (POC) three days after he was admitted. The DPCS was unable to locate Patient 10s POC. The DPCS stated he hand wrote Patient 10s POC and handed it over to the Administrator Designee (AD) to be inputted into their electronic medical record (EMR) system. The DPCS stated patient notes should be kept in the patients medical records because it was part of their care. A record review of the HAs undated policy and procedure titled, “;Interdisciplinary Group Membership & Responsibilities”, indicated, “;Procedure: 1. The hospice interdisciplinary team/group members will include, at a minimum: A. Physician (doctor) B. Registered Nurse C. Social Worker D. Pastoral or other counselor. A record review of the HAs undated policy and procedure titled, “;Interdisciplinary Group Meeting”, indicated, “;Policy...Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires...6. An interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician.””

“Based on interview and record review, the hospice agency (HA) failed to provide evidence that quality assessment and performance improvement (QAPI, a coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI), which are critical to improving the quality of life, and quality of care and services delivered in a healthcare facility) system was formulated and ensure its program objectives, patient care disciplines, description of how the program will be administered and coordinated, methodology for monitoring and evaluating the quality of care, priorities for resolution of problems, monitoring to determine effectiveness of action, oversight responsibility reports to governing body, and documentation of the review of its own QAPI program were implemented for fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This deficient practice resulted in the inability of the agency to identify issues, improve health outcomes, patient safety, and quality patient care. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A record review of Patient 3s “;Patient Profile”, indicated an admission date of 10/6/2023, with a terminal diagnosis of cerebral vascular accident (brain attack). The record also indicated Patient 3 was discharged on 1/7/2024. A record review of Patient 4s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of Alzheimers disease. The record also indicated Patient 4 was discharged on 1/29/2024. A record review of Patient 5s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease. The record also indicated Patient 5 was discharged on 3/8/2024. A record review of Patient 6s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of Secondary malignant neoplasm of the breast (breast cancer). The record also indicated Patient 6 was discharged on 5/31/2024. A record review of Patient 7s “;Patient Profile”, indicated an admission date of 1/2/2024. The record also indicated Patient 7 was discharged on 6/25/2024. During a record review of Patient 8’s medical record form titled “;Patient Information” indicated a “;current benefit period – begin date of 7/6/2024 and an end date 9/3/2024” with a diagnosis of unspecified cirrhosis of liver. During a record review of Patient 9’s medical record form titled “;Patient Information” indicated a “;current benefit period – begin date of 4/22/2024 and an end date 7/20/2024” with a diagnosis of end stage renal disease. During a record review of Patient 10’s medical record form titled “;Patient Information” indicated a “;current benefit period – begin date of 5/20/2024 and an end date 6/26/2024” with a diagnosis of hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following unspecified cerebrovascular disease affecting left dominant side. During a record review of Patient 11’s medical record form titled “;Patient Information” indicated a “;current benefit period – with a begin date of 5/16/2024 and an end date 8/13/2024” with a diagnosis of chronic obstructive pulmonary disease (difficulty breathing). During a record review of Patient 12’s medical record form titled “;Patient Information” indicated a “;current benefit period – with a begin date of 2/9/2024 and an end date 5/8/2024” with a diagnosis of unspecified malignant neoplasm of the skin of the left lower limb, including hip (skin cancer). During a record review of Patient 13’s medical record form titled “;Patient Information” indicated a “;current benefit period – with a begin date of 2/17/2024 and an end date 5/16/2024” with a diagnosis of Alzheimers Disease (gradual memory loss). During a record review of Patient 14’s medical record form titled “;Patient Information” indicated a “;current benefit period – with a begin date of 2/20/2024 and an end date 5/19/2024” with a diagnosis of Alzheimers Disease (gradual memory loss). During an interview on 7/23/2024, at 1:45 p.m., the Medical Director (MD) stated he was not sure if he worked for the HA. The MD stated some of the hospice agencies hire him for consultation services or assistant to the director. The MD stated he was not sure what his position was for this HA. When asked how long he had been working at this HA, the MD stated, “;I need to go back to my records and check. Im not sure how to answer this question because I dont have a good memory.” During an interview on 7/25/2024 at 3:15 p.m., the administrator designee (AD) stated the QAPI program met 2 to 3 times a year, based on the consultants availability. The AD stated she did not remember when the QAPI program last met. During a concurrent interview and record review on 7/25/2024, at 3:16 p.m., the AD reviewed the HAs four binders titled, “;QAPI”. The AD stated the agenda, meeting minutes, sign in sheet was not in the binders. The AD stated the binders did not have any QAPI information, there was no date inside the documents in the binder, and the binders only contained policies. The AD stated the importance of the QAPI program was to assess to improve the services with the staff and outside providers. A record review of the HAs policy and procedure titled, “;Job Description Hospice Medical Director”, dated April 2019, indicated, “;Essential job functions/responsibilities...7. Evaluating quality assessment performance improvement (QAPI) plans and monitoring to identify medical education needs in cooperation with the CEO/Executive Director/Administrator and/or Clinical Director/Director of Patient Care Services. Participates in QAPI teams and activities, as needed.” A record review of the HAs undated policy and procedure titled, “;Interdisciplinary Group Membership & Responsibilities”, indicated, “;Procedure...3. The interdisciplinary group will...G. Participate in quality assessment performance improvement activities.” A record review of the HAs undated policy and procedure titled, “;Interdisciplinary Group Membership & Responsibilities”, indicated, “;Procedure: 1. The hospice interdisciplinary team/group members will include, at a minimum: A. Physician (doctor) B. Registered Nurse C. Social Worker D. Pastoral or other counselor.”

“Based on interview and record review, the Hospice Agency (HA) failed to ensure their Medical Social Worker (MSW), Physicians, and Spiritual Counselor (SC) participated in the planning of patients hospice care by not attending IDT meetings and not contributing to the development of their individualized plan of care for five of fourteen sampled patients (Patient 1, Patient 2, Patient 9, Patient 10, and Patient 11) plan of care (POC- an individualized care planned). This failure resulted in patients not being properly evaluated which resulted in not being provided individualized focused care. During an interview on 7/23/2024, at 2:09 p.m., the administrator (ADM) stated the last IDG meeting was in May 2024. The ADM stated the Medical Doctor (MD) did not attend the January and March 2024 IDG meetings because he was hospitalized himself. The ADM tried to contact another doctor, but it did not workout. The ADM stated the IDG members met every two weeks either in the office or through zoom (a telephone-camera method of communication). The ADM stated the IDG members signed the attendance sheet but did not document any discussions in the medical records. The ADM stated there was to be an IDG meeting in June, but the HA was busy moving office space. During an interview on 7/23/2024, at 3:59 p.m., the Director of Patient Care Services designee (DD) stated the plan of care was supposed to be developed during admission. The DD stated it was the registered nurse’s responsibility to develop the plan of care, with participation from the certified nursing assistant and licensed vocational nurse. During an interview on 7/23/2024, at 4:11 p.m., the DD stated the plan of care for the certification period had to be completed a day to two days before or the day of the certification due date. The purpose of doing this was to know what is going on with the patient. If there is no POC, the DD stated, “;We are in the cloud and we dont know what to do with the patient. During an interview on 7/24/2024 at 2:28 p.m. with the Spiritual Counselor (SC), the SC stated he was not part of the HAs IDG. The SC stated he saw one patient since he started working at the HA in March. The SC stated he does not know how long or how often the IDG meetings are held. During an interview on 7/25/2024, at 11 a.m., the MSW stated she had been working for the HA for almost a year, since August 2024, and she had not seen any patient because they had all declined the service. During an interview on 7/25/2024, at 11:11 a.m., the MSW stated she did not document regarding the IDG meeting she attended because the case manager documented. The MSW stated if she attended the IDG meeting, she would validate her attendance by signing an attendance sheet if she was in the office. She did not sign any medical record documents, including the electronic medical record. 1. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. A record review of Patient 1s medical records did not indicate any IDG meetings for the 3rd certification period of 6/19/2024 to 8/17/2024. During a concurrent interview and record review on 7/23/2024, at 12:28 p.m., the administrator designee (AD) reviewed Patient 1s records. The ADM stated there were no IDG notes. 2. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During a concurrent interview and record review on 7/23/2024, at 12:40 p.m., the AD stated there was no plan of care in the medical records of Patient 2, for certification period 3, dated 6/18/2024 to 8/16/2024. The AD stated the HA was working on it. 3. During a record review of Patient 9’s medical record form titled “;Patient Information” indicated a “;current benefit period – with a begin date of 4/22/2024 and an end date 7/20/2024” with a diagnosis of end stage renal disease. A record review of Patient 9s medical record form titled “;IDG Meeting” dated from 4/22/2024 to 7/20/2024, indicated there were no IDG meetings documented. 4. During a record review of Patient 10’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 5/20/2024 and an end date 6/26/2024” with a diagnosis of hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following unspecified cerebrovascular disease affecting left dominant side. During a concurrent interview and record review on 7/24/2024 at 11:31 a.m. with the DPCS of Patient 10s electronic medical record (EMR) medical record form titled “;IDG Meeting” dated from 5/20/2024 to 6/26/2024, indicated there were no IDG meetings documented under section “;IDG/POC”. The DPCS stated Patient 10 was supposed to have IDG meetings every other week to discuss his condition. 5. During a record review of Patient 11 medical record form titled “;Patient Information” indicated “;current benefit period – begin date 5/16/2024 end date 8/13/2024” with a diagnosis of chronic obstructive pulmonary disease (difficulty breathing). During a record review on 7/24/2024 at 3:06 p.m. of Patient 11s electronic medical record (EMR) medical record form titled “;IDG Meeting” dated from 5/16/2024 to 6/28/2024, indicated there was nothing documented under section “;IDG/POC”. A record review of the HAs undated policy and procedure titled, “;The Plan of Care”, indicated, “;Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will be the documentation requirements of the physician-directed medical orders and the care planning process. The plan 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 (15) days.”

“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 provide evidence their licensed professional staff were involved and participated in the HA’s quality assessment and performance improvement program (QAPI – a data driven and proactive approach to quality improvement) for fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 5, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in the HA being unaware if their quality standards of care being met. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A record review of Patient 3s “;Patient Profile”, indicated an admission date of 10/6/2023, with a terminal diagnosis of cerebral vascular accident (brain attack). The record also indicated Patient 3 was discharged on 1/7/2024. A record review of Patient 4s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of Alzheimers disease. The record also indicated Patient 4 was discharged on 1/29/2024. A record review of Patient 5s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease. The record also indicated Patient 5 was discharged on 3/8/2024. A record review of Patient 6s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of secondary malignant neoplasm of breast (breast cancer). The record also indicated Patient 6 was discharged on 5/31/2024. A record review of Patient 7s “;Patient Profile”, indicated an admission date of 1/2/2024. The record also indicated Patient 7 was discharged on 6/25/2024. During a record review of Patient 8’s medical record form titled “;Patient Information” indicated a “;current benefit period – with a begin date of 7/6/2024 and an end date of 9/3/2024” with a diagnosis of unspecified cirrhosis of liver. During a record review of Patient 9’s medical record form titled “;Patient Information” indicated a “;current benefit period – with a begin date of 4/22/2024 and an end date of 7/20/2024” with a diagnosis of end stage renal disease. During a record review of Patient 10’s medical record form titled “;Patient Information” indicated a “;current benefit period – with a begin date of 5/20/2024 and an end date of 6/26/2024” with a diagnosis of hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following unspecified cerebrovascular disease affecting left dominant side. During a record review of Patient 11’s medical record form titled “;Patient Information” indicated a “;current benefit period – with a begin date of 5/16/2024 and an end date 8/13/2024” with a diagnosis of chronic obstructive pulmonary disease (difficulty breathing). During a record review of Patient 12’s medical record form titled “;Patient Information” indicated a “;current benefit period – with a begin date of 2/9/2024 and an end date 5/8/2024” with a diagnosis of unspecified malignant neoplasm of skin of left lower limb, including hip (skin cancer). During a record review of Patient 13’s medical record form titled “;Patient Information” indicated a “;current benefit period – with a begin date of 2/17/2024 and an end date 5/16/2024” with a diagnosis of Alzheimers Disease (gradual memory loss). During a record review of Patient 14’s medical record form titled “;Patient Information” indicated a “;current benefit period – with a begin date of 2/20/2024 and an end date of 5/19/2024” with a diagnosis of Alzheimers Disease (gradual memory loss). During an interview on 7/25/2024 at 3:15 p.m., the administrator designee (AD) stated the QAPI program met 2 to 3 times a year, based on the consultants availability. The AD stated she did not remember when the QAPI program last met. During a concurrent interview and record review on 7/25/2024, at 3:16 p.m., the AD reviewed the HAs four binders titled, “;QAPI”. The AD stated the agenda, meeting minutes and sign in sheet were not in the binders. The AD stated the binders did not have any QAPI information. There was no date inside the documents in the binder, and the binders only contained policies. The AD stated the importance of the QAPI program was to assess to improve the services with the staff and outside providers. A record review of the HAs undated policy and procedure titled, “;Interdisciplinary Group Membership & Responsibilities”, indicated, “;Procedure...3. The interdisciplinary group will...G. Participate in quality assessment performance improvement activities.” A record review of the HAs undated policy and procedure titled, “;Interdisciplinary Group Membership & Responsibilities”, indicated, “;Procedure: 1. The hospice interdisciplinary team/group members will include, at a minimum: A. Physician (doctor) B. Registered Nurse C. Social Worker D. Pastoral or other counselor.”

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure, the medical director and/or physician designee conducted an accurate assessment, reviewed, and verified the patient clinical information, necessary for initial certifications for fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The agency failed to: Ensure there was a physicians signature and documentation of clinical information that included the patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice are and services. This failure resulted in the hospice medical director and/or the designee certifying patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses. It also resulted in patients not being certified by a medical doctor for hospice care, which can result in a lack of care and inappropriate care being provided to the patients. During an interview on 7/26/2024 at 11:45 a.m. with the Medical Director (MD1), MD1 stated the Administrator (ADM) calls him to discuss patients. MD1 stated the admitting nurse calls him to discuss the patients diagnoses then he gives his recommendations. MD1 stated when “;Someone” hands him 20-30 pages to sign, he signs them but does not date them sometimes. MD1 stated he sometimes does not date them because he does not know the date to put. MD1 stated that legally he needs to sign the forms. MD1 stated he determines patients hospice eligibility by the information given to him by the nurse. MD1 stated he does not speak with the patients primary physician. MD1 stated the HAs staff documents in the electronic medical record (EMR) and prints the form out. He reviews the forms, and if he agrees then he signs them. 1. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. During an interview on 7/24/2024, at 1 p.m., Patient 1 stated she became aware of the HA through a vendor in downtown. There was a tent with information. Patient 1 stated she had a primary doctor and had an upcoming appointment in August 2024. Patient 1 stated she had a primary doctor and a neurologist (a doctor who specializes in the nervous system). Patient 1 stated no doctor had told her she was terminal and that she had six months or less to live. Patient 1 stated her doctor wanted her to see an occupational therapist (OT) because her stability was getting worse. Patient 1 stated if the OT didnt help, more steps were going to take place to see if she had another medical condition. Patient 1 stated used a cane to walk, had COPD, and used oxygen therapy about three times a week. During a concurrent interview and record review on 7/25/2024, at 2:28 p.m., the Director of Patient Care services (DPCS) reviewed Patient 1s records titled, “;Written Certification” dated 12/22/2023 to 3/20/2024 and “;Task Details for Written Certification”, dated 12/22/2023. The “;Task Details” document indicated the DPCS had created and completed the document on 4/3/2024. The DPCS reviewed the document “;Written Certification” and stated he wrote the certification on paper. The QA (quality assurance) audits this. They add or take away if needed. If it should not be there, they eliminate it. The QA person is the one who audits it. I dont know the name of the person. The person who does it is our relatives too. Thats why I feel safe to share my user ID and password. No, the doctor did not write this. This is not the doctors assessment. This is the nursing assessment. The DPCS stated the certification for terminal illness was to be done within 24 to 48 hours of the admission date because that was the guidelines to follow; the condition of the patient, the safety of the patients, and how the patients are cared for. During an interview on 7/26/2024, at 12:32 p.m., the Medical Director (MD) stated Patient 1s diagnosis came with the patient and was obtained from the nurses assessment and records. The MD stated he did not have medical records, the HA had it. The MD stated everything that was written in the certification form was written from the nurses assessments. The MD stated he had not spoken to Patient 1. The MD stated he had not seen Patient 1 through a picture, phone, or computer. A record review of Patient 1s “;Written Certification”, for certification period 12/22/2023 to 3/20/2024, indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient”. Further review of the record indicated the MDs name. However, there was no signature on the document. 2. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During an interview on 7/24/2024, at 1:15 p.m., Patient 1 stated she was not aware that Patient 2 was diagnosed with Alzheimers disease. Patient 1 stated Patient 2 was alert and able to make his own decisions. Patient 1 stated Patient 2 had a primary doctor, whom he saw about a month ago. Patient 1 stated Patient 2s primary doctor said he was healthy. During an interview on 7/26/2024, at 10:40 a.m., the DPCS stated Patient 2 was admitted to the HA for a terminal diagnosis of Alzheimers disease. The DPCS stated he determined Patient 2s diagnosis when Patient 1 told him. The DPCS stated he determined the diagnosis also by reviewing the medications Patient 2 was taking. The DPCS reviewed Patient 2s medications and stated he was not on any medications for dementia. When asked how he determined Patient 2 had Alzheimers disease, the DPCS stated, “;I asked him questions during the assessment. His answers were out of this world. So based on my assessment, and his age, I determined he had dementia. I asked (Patient 1) if she could ask Patient 2s primary doctor to place him on dementia medications.” The DPCS stated he did not know if a doctor had diagnosed Patient 2 with Alzheimers disease, because the HA did not have any medical documents from his primary doctor or any other doctor to say Patient 2 had the disease. during a continued interview on 7/26/2024, at 10:40 a.m., the DPCS stated Patient 2 had been admitted to hospice care with a diagnosis of Alzheimers disease without written confirmation of the disease. The DPCS stated the medical director had not seen or examined Patient 2. The DPCS stated he was supposed to report the assessment findings with either Patient 2s primary care doctor or to the HAs medical director, to inform the concerns with the mental assessment. The DPCS stated he assumed the administrator (ADM) had informed the doctor. The DPCS stated the ADM was not a nurse. During a concurrent interview and record review on 7/26/2024, at 11:01 a.m., the DPCS reviewed Patient 1s records titled, “;Written Certification”, dated 12/21/2023 to 3/19/2024 and “;Task Details for written certification”, dated 12/21/2023. The “;Task Details” document indicated the DPCS had created the document on April 3, 2024, and completed the document on April 3, 2024, and April 21, 2024. The DPCS stated he wrote the notes on paper and gave it to the administrator designee (AD) to type into the computer, for the doctor to review and sign. The DPCS stated he did not have the paper document, as it was somewhere in the boxes. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. During an interview on 7/26/2024, at 12:38 p.m., the MD stated he determined Patient 2s diagnosis based by his age and behavior. The MD stated his behavior was abnormal behavior, all of that, like nervousness, agitation, unexplained behaviors. When the MD was asked how he determined this, he stated: “;Can I ask you for a favor? Can you text me the information of the papers you are seeing? I signed a lot of papers, Im not sure. I need to go and look at what I signed. I have unsigned papers. Alzheimers comes with age. But I dont see the papers with my signature to speak about it.” A record review of Patient 2s “;Written Certification”, for certification period 12/21/2023 to 3/19/2024, indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient.” Further review of the record indicated the MDs name. However, there was no signature on the document. 3. A record review of Patient 3s “;Patient Profile”, indicated an admission date of 10/6/2023, with a terminal diagnosis of cerebral vascular accident (brain attack). The record also indicated Patient 3 was discharged on 1/7/2024. During an interview on 7/25/2024, at 1:05 p.m., the office staff (OS) stated there was no written certification for the start of care beginning 10/6/2023. The only document the HA had was the doctors order for hospice care. A record review of Patient 3s “;Physician Order” dated 10/6/2023, indicated an order for admission to hospice care. A record review of Patient 3s “;Task Details for the Physician order” dated 10/6/2023, indicated the order was completed on 12/4/2023 and 12/5/2023. 4. A record review of Patient 4s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of Alzheimers disease. The record also indicated Patient 4 was discharged on 1/29/2024. During a concurrent interview and record review on 7/26/2024, at 11:03 a.m., the DPCS reviewed Patient 4s records titled, “;Written Certification”, dated 12/22/2023 to 1/29/2024 and “;Task Details for the Written Certification”, dated 12/22/2023. The “;Task Details” document indicated the DPCS had created and completed the document on 4/21/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into the computer, for the doctor to review and sign. The DPCS stated he did not have the paper document, as it was somewhere in the boxes. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. A record review of Patient 4s “;Written Certification” for certification period 12/22/2023 to 1/29/2024, indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient.” Further review of the record indicated the MDs name. However, there was no signature on the document. 5. A record review of Patient 5s “;Patient Profile” indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease. The record also indicated Patient 5 was discharged on 3/8/2024. During a concurrent interview and record review on 7/26/2024, at 11:04 a.m., the DPCS reviewed Patient 5s records titled, “;Written Certification”, dated 12/21/2023 to 3/8/2024 and “;Task Details for the Written Certification” dated 12/21/2023. The “;Task Details” document indicated the DPCS had created and completed the document on 4/28/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into the computer, for the doctor to review and sign. The DPCS stated he did not have the paper document, as it was somewhere in the boxes. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. A record review of Patient 5s “;Written Certification”, for certification period 12/21/2023 to 3/8/2024, indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient” Further review of the record indicated the MDs name. However, there was no signature on the document. 6. A record review of Patient 6s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of secondary malignant neoplasm of the breast (breast cancer). The record also indicated Patient 6 was discharged on 5/31/2024. During a concurrent interview and record review on 7/26/2024, at 11:05 a.m., the DPCS reviewed Patient 6s records titled, “;Written Certification” dated 12/22/2023 to 3/30/2024 and “;Task Details for the Written Certification”, dated 12/22/2023. The “;Task Details” document indicated the DPCS had created and completed the document on 4/3/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into the computer, for the doctor to review and sign. The DPCS stated he did not have the paper document, as it was somewhere in the boxes. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. A record review of Patient 6s “;Written Certification” for certification period 12/22/2023 to 3/30/2024, indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient.” Further review of the record indicated the MDs name. However, there was no signature on the document. 7. A record review of Patient 7s “;Patient Profile” indicated an admission date of 1/2/2024. The record also indicated Patient 7 was discharged on 6/25/2024. During a concurrent interview and record review on 7/26/2024, at 11:06 a.m., the DPCS reviewed Patient 7s records titled, “;Written Certification”, dated 1/2/2024 to 3/31/2024 and “;Task Details for the Written Certification”, dated 1/2/2024. The “;Task Details” document indicated the DPCS had created and completed the document on 4/3/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into the computer, for the doctor to review and sign. The DPCS stated he did not have the paper document, as it was somewhere in the boxes. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. A record review of Patient 7s “;Written Certification” for certification period 1/2/2024 to 3/31/2024, indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient.” Further review of the record indicated the MDs name. However, there was no signature on the document. 8. During a record review of Patient 8’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 7/6/2024 and an end date of 9/3/2024” with a diagnosis of unspecified cirrhosis of liver. During a record review of Patient 8s medical record titled “;Written Certification” dated 1/8/2024 to 4/6/2024, indicated Medical Director 1 (MD1)s signature was written on the form. The form was not dated. During a record review of Patient 8s medical record titled “;Written Certification” dated 1/8/2024 to 4/6/2024, indicated Medical Director 1 (MD1)s signature and date of 1/8/2024 was written on the form. During a concurrent interview and record review on 7/26/2024, at 2:30 p.m. with the DPCS of Patient 8s medical record form titled “;Written Certification”, dated 1/8/2024 to 4/6/2024 and “;Task Details for the Written Certification” dated 1/8/2024 was reviewed. The “;Task Details” document indicated the DPCS had created the document on 1/30/2024 and completed it on 2/6/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into their EMR system. The DPCS stated he does not have his written documentation because he did not receive them back from the AD. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. During a record review of Patient 8s medical record titled “;Verbal Certification” dated 1/8/2024, indicated the Medical Director 1 (MD1)s signature was written on the form. The form was not dated. During a record review of Patient 8s medical record titled “;Verbal Certification” dated 1/8/2024, indicated the Medical Director 1 (MD1)s signature and date of 1/8/2024 was written on form. During a concurrent interview and record review on 7/26/2024, at 2:30 p.m. with the DPCS of Patient 8s medical record form titled “;Verbal Certification”, dated 1/8/2024 and “;Task Details for the Verbal Certification”, dated 1/8/2024 was reviewed. The “;Task Details” document indicated the DPCS had created the document on 1/30/2024 and completed it on 2/6/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into their EMR system. The DPCS stated he does not have his written documentation because he did not receive them back from the AD. The DPCS stated the information in the “;Verbal Certification” was based on the doctors orders. 9. During a record review of Patient 9’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 4/22/2024 and an end date 7/20/2024” with a diagnosis of end stage renal disease. During a concurrent interview and record review on 7/26/2024 at 11:45 a.m. with the Medical Director (MD1), of Patient 9s medical record, the MD1 stated he was not able to log into their EMR system but he had Patient 9s physical medical records to review. MD1 stated Patient 9 was discharged a few days ago. MD1 stated he based Patient 9s admission on her diagnoses, medications, and the nurses assessment. During a record review of Patient 9s medical record titled “;Written Certification” dated 4/22/2024 to 7/20/2024, indicated the Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. The form also indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient.” During a concurrent interview and record review on 7/26/2024, at 2:40 p.m. with the DPCS of Patient 9s medical record form titled “;Written Certification”, dated 4/22/2024 to 7/20/2024 and “;Task Details for the Written Certification”, dated 4/22/2024 was reviewed. The “;Task Details” document indicated the DPCS had created the document on 7/23/2024 and completed it on 7/24/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into their EMR system. The DPCS stated he does not have his written documentation because he did not receive them back from the AD. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. During a record review of Patient 9s medical record titled “;Verbal Certification” dated 4/22/2024 to 7/20/2024, indicated Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. During a concurrent interview and record review on 7/26/2024, at 2:40 p.m. with the DPCS of Patient 9s medical record form titled “;Verbal Certification”, dated 4/22/2024 to 7/20/2024 and “;Task Details for the Verbal Certification”, dated 4/22/2024 was reviewed. The “;Task Details” document indicated the DPCS had created the document on 7/23/2024 and completed it on 7/24/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into their EMR system. The DPCS stated he does not have his written documentation because he did not receive them back from the AD. The DPCS stated the information in the “;Verbal Certification” was based on the doctors orders. 10. During a record review of Patient 10’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 5/20/2024 and an end date 6/26/2024” with a diagnosis of hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following unspecified cerebrovascular disease affecting left dominant side. During a record review of Patient 10s medical record titled “;Written Certification” dated 5/20/2024 to 8/17/2024, indicated the Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. The form also indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient.” During a record review of Patient 10s medical record titled “;Written Certification” dated 5/20/2024 to 8/17/2024, indicated Medical Director 1 (MD1)s signed the form on 5/30/2024. During a concurrent interview and record review on 7/26/2024, at 2:48 p.m. with the DPCS of Patient 10s medical record form titled “;Written Certification”, dated 5/20/2024 to 8/17/2024 and “;Task Details for the Written Certification”, dated 5/20/2024 was reviewed. The “;Task Details” document indicated the DPCS had created the document on 7/23/2024 and completed it on 7/24/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into their EMR system. The DPCS stated he does not have his written documentation because he did not receive them back from the AD. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. The DPCS stated MD1 signed the form late. During a record review of Patient 10s medical record titled “;Verbal Certification” dated 5/20/2024 to 8/17/2024, indicated Medical Director 1 (MD1)s signed the form on 5/30/2024. During a concurrent interview and record review on 7/26/2024, at 2:48 p.m. with the DPCS of Patient 10s medical record form titled “;Verbal Certification”, dated 5/20/2024 to 8/17/2024 and “;Task Details for the Verbal Certification”, dated 5/20/2024 was reviewed. The “;Task Details” document indicated the DPCS had created and completed the document on 7/23/2024. The DPCS confirmed he created the form on 7/23/2024. DPCS stated MD1 singed the form late. 11. During a record review of Patient 11’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 5/16/2024 and an end date 8/13/2024” with a diagnosis of chronic obstructive pulmonary disease (difficulty breathing). During a record review of Patient 11s medical record titled “;Written Certification” dated 2/16/2024 to 5/15/2024, indicated the Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. The form also indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient”. During a record review of Patient 11s medical record form titled “;Task Details - Written Certification”, dated 2/16/2024, indicated MD1 created the form on 4/3/2024 and the AD completed the form on 5/31/2024. During a record review of Patient 11s medical record titled “;Verbal Certification” dated 2/16/2024 to 5/15/2024, indicated the Medical Director 1 (MD1)s signed the form on 2/23/2024. During a record review of Patient 11s medical record form titled “;Task Details - Verbal Certification”, dated 2/16/2024, indicated MD1 created the form on 4/3/2024 and Hospice Staff (HS) completed the form on 7/23/2024. 12. During a record review of Patient 12’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 2/9/2024 and an end date 5/8/2024” with a diagnosis of unspecified malignant neoplasm of skin of left lower limb, including hip (skin cancer). During a record review of Patient 12s medical record titled “;Written Certification” dated 2/9/2024 to 5/8/2024, indicated Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. The form also indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient.” During a record review of Patient 12s medical record titled “;Written Certification” dated 2/9/2024 to 5/8/2024, indicated the Medical Director 1 (MD1)s signed the form on 2/16/2024. During a record review of Patient 12s medical record form titled “;Task Details - Written Certification”, dated 2/9/2024, indicated DPCS created and completed the form on 2/26/2024. 13. During a record review of Patient 13’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 2/17/2024 and an end date 5/16/2024” with a diagnosis of Alzheimers Disease (gradual memory loss). During a record review of Patient 13s medical record titled “;Written Certification” dated 2/17/2024 to 5/16/2024, indicated Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. The form also indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient”. During a record review of Patient 13s medical record titled “;Written Certification” dated 2/17/2024 to 5/16/2024, indicated the Medical Director 1 (MD1)s signed the form on 2/23/2024. During a record review of Patient 13s medical record form titled “;Task Details - Written Certification”, dated 2/17/2024, indicated DPCS created the form on 4/3/2024 and completed it on 5/31/2024. 14. During a record review of Patient 14’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 2/20/2024 and an end date 5/19/2024” with a diagnosis of Alzheimers Disease (gradual memory loss). During a record review of Patient 14s medical record titled “;Written Certification” dated 2/20/2024 to 5/19/2024, indicated Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. The form also indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient.” During a record review of Patient 14s medical record titled “;Written Certification” dated 2/20/2024 to 5/19/2024, indicated Medical Director 1 (MD1)s signed the form on 2/26/2024. During a record review of Patient 14s medical record form titled “;Task Details - Written Certification”, dated 2/20/2024, indicated DPCS created the form on 3/27/2024 and completed the form on 4/1/2024. During a record review of Patient 14s medical record titled “;Verbal Certification” dated 2/20/2024 to 5/19/2024, indicated Medical Director 1 (MD1)s signed the form on 2/26/2024. During a record review of Patient 14s medical record form titled “;Task Details - Verbal Certification”, dated 2/20/2024, indicated DPCS created the form on 3/27/2024 and Hospice Staff (HS) completed the form on 7/23/2024. A record review of the HAs undated policy and procedure titled, “;Certification of Terminal Illness”, indicated at the time of admission the MD or the patients attending doctor would complete a certification narrative that reflected the patients circumstance based on the review of the patients medical record or if applicable, examination of the patient. Further review of the record indicated, “;Procedure...2. If written certification cannot be obtained within two (2) calendar days following the start of care, verbal certification must be obtained and documented in the clinical record within two (2) days following initiation of care. 3. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification.” A record review of the HAs policy and procedure titled, “;Job Descriptions Hospice Medical Director”, dated April 2019, indicated, “;Essential Job Functions/Responsibilities: The duties and responsibilities of the Medical Director will include, but not limited to the following...3. Assuring that the established policies, bylaws, rules and regulations of the organization are followed in the program....14. Reviewing patients medical eligibility for hospice services, in accordance with the hospice program policies and procedures...””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the medical director and/or physician designee conducted a review and verified the patients clinical information to determine the patient’s need of recertification of terminal illness for continued hospice care and services for eight of fourteen sampled patients (Patient 1, Patient 2, Patient 6, Patient 7, Patient 9, Patient 11, Patient 12, and Patient 13). This failure resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential to result in the patients not receiving appropriate healthcare services that could affect their quality of life. During an interview on 7/26/2024 at 11:45 a.m. with the Medical Director (MD1), MD1 stated the Administrator (ADM) calls him to discuss patients. MD1 stated the admitting nurse calls him to discuss the patients diagnoses then he gives his recommendations. MD1 stated when “;Someone” hands him 20-30 pages to sign, he signs them but does not date them sometimes. MD1 stated he sometimes does not date them because he does not know the date to put. MD1 stated that legally he needs to sign the forms. MD1 stated he determines patients hospice eligibility by the information given to him by the nurse. MD1 stated he does not speak with patients primary physician. MD1 stated the HAs staff documents in their electronic medical record (EMR), prints the form out, reviews the forms, and if he agrees then he signs them. 1. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. During a concurrent interview and record review on 7/23/2024, at 12:28 p.m., the administrator designee (AD) reviewed Patient 1s medical records. The AD stated there was no recertification for hospice care for this patients current episode of 6/19/2024 to 8/17/2024. During an interview on 7/24/2024, at 1 p.m., Patient 1 stated she became aware of the HA through a vendor in downtown. There was a tent with information. Patient 1 stated she had a primary doctor and had an upcoming appointment in August 2024. Patient 1 stated she had a primary doctor and a neurologist (a doctor who specializes in the nervous system). Patient 1 stated no doctor had told her she was terminal and she had 6 months or less to live. Patient 1 stated her doctor wanted her to see an occupational therapist (OT) because her stability was getting worse. Patient 1 stated if the OT didnt help, more steps were going to take place to see if she had another medical condition. Patient 1 stated used a cane to walk, had COPD, and used oxygen therapy about three times a week. On 7/25/2024, at 10:45 a.m., the AD provided Patient 1s record titled, “;Written Recertification” for period 6/19/2024 to 8/17/2024. The document had a narrative and a manual signature. The signature did not have a date indicated. During an interview on 7/25/2024, at 2:45 p.m., the Director of Patient Care services (DPCS) stated the recertification assessment had not been done for Patient 1 because the agency was moving at the time. The focus was moving offices. A record review of Patient 1s “;Task details for Written Recertification”, dated 6/19/2024, indicated the form was completed on 7/23/2024 and 7/24/2024. During an interview on 7/26/2024, at 12:32 p.m., the Medical Director (MD) stated Patient 1s diagnosis came with the patient and was obtained from the nurses assessment and records. The MD stated he did not have medical records, the HA had it. The MD stated everything that was written in the certification form was written from the nurses assessments. The MD stated he had not spoken to Patient 1. The MD stated he had not seen Patient 1 through a picture, phone, or computer. 2. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During a concurrent interview and record review on 7/23/2024, at 12:40 p.m., the AD reviewed Patient 2s medical records. The AD stated there was no re-certification for hospice care for this patients current episode of 6/18/2024 to 8/16/2024. During an interview on 7/24/2024, at 1:15 p.m., Patient 1 stated she was not aware that Patient 2 was diagnosed with Alzheimers disease. Patient 1 stated Patient 2 was alert and able to make his own decisions. Patient 1 stated Patient 2 had a primary doctor, whom he saw about a month ago. Patient 1 stated Patient 2s primary doctor said he was pretty healthy. On 7/25/2024, at 10:45 a.m., the AD provided Patient 2s record titled, “;Written Recertification” for period 6/18/2024 to 8/16/2024. The document had a narrative and a manual signature. The signature did not have a date indicated. During an interview on 7/26/2024, at 10:40 a.m., the DPCS stated Patient 2 had been admitted to hospice care with a diagnosis of Alzheimers disease without written confirmation of the disease. The DPCS stated the medical director had not seen or examined Patient 2. The DPCS stated he was supposed to report the assessment findings with either Patient 2s primary doctor or the MD. During a concurrent interview and record review on 7/26/2024, at 11:00 a.m., the DPCS reviewed Patient 2s records titled, “;Written Recertification”, dated 6/18/2023 to 8/16/2024 and “;Task Details for written recertification”, dated 6/18/2024. The “;Task Details” document indicated the DPCS had created the document on 7/23/2024, and completed the document on 7/23/2024 and 7/24/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into the computer, for the doctor to review and sign. The DPCS stated he did not have the paper document, as it was somewhere in the boxes. The DPCS stated the information in the “;Written recertification” was based on the nursing assessment. During an interview on 7/26/2024, at 12:38 p.m., the MD stated he determined Patient 2s diagnosis based by his age and behavior. The MD stated his behavior was abnormal behavior, all of that, like nervousness, agitation, unexplained behaviors. When the MD was asked how he determined this, he stated: “;Can I ask you for a favor? Can you text me the information of the papers you are seeing? I signed a lot of papers, Im not sure. I need to go and look at what I signed. I have unsigned papers. Alzheimers comes with age. But I dont see the papers with my signature to speak about it.” 3. A record review of Patient 6s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of secondary malignant neoplasm of breast (breast cancer). The record also indicated Patient 6 was discharged on 5/31/2024. During a concurrent interview and record review on 7/26/2024, at 11:05 a.m., the DPCS reviewed Patient 6s records titled, “;Written Recertification”, dated 3/21/2024 to 6/18/2024 and “;Task Details for the Written recertification”, dated 3/21/2023. The “;Task Details” document indicated the DPCS had created the document on 4/3/2024 and completed the document on 4/3/2024 and 7/23/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into the computer, for the doctor to review and sign. The DPCS stated he did not have the paper document, as it was somewhere in the boxes. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. A record review of Patient 6s “;Written Recertification”, for certification period 3/21/2024 to 6/18/2024, indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient”. Further review of the record indicated the MDs name. However, there was no signature on the document. 4. A record review of Patient 7s “;Patient Profile”, indicated an admission date of 1/2/2024. The record also indicated Patient 7 was discharged on 6/25/2024. During a concurrent interview and record review on 7/26/2024, at 11:06 a.m., the DPCS reviewed Patient 7s records titled, “;Written Recertification”, dated 4/1/2024 to 6/29/2024 and “;Task Details for the Written Recertification”, dated 4/1/2024. The “;Task Details” document indicated the DPCS had created and completed the document on 4/28/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into the computer, for the doctor to review and sign. The DPCS stated he did not have the paper document, as it was somewhere in the boxes. The DPCS stated the information in the “;Written Recertification” was based on the nursing assessment. A record review of Patient 7s “;Written Recertification”, for certification period /1/2024 to 6/29/2024, indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient”. Further review of the record indicated the MDs name. However, there was no signature on the document. 5. During a record review of Patient 9’s medical record form titled “;Patient Information” indicated “;current benefit period – begin date 4/22/2024 end date 7/20/2024” with a diagnosis of end stage renal disease. During a concurrent interview and record review on 7/26/2024 at 11:45 a.m. with the Medical Director (MD1), of Patient 9s medical record, MD1 stated he was not able to log into their EMR system but he had Patient 9s physical medical records to review. MD1 stated Patient 9 was discharged a few days ago. MD1 stated he based Patient 9s admission on her diagnoses, medications, and the nurses assessment. During a record review of Patient 9s medical record titled “;Written Certification” dated 7/21/2024 to 10/18/2024, indicated the Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. The form also indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient”. During a concurrent interview and record review on 7/26/2024, at 2:40 p.m. with the DPCS of Patient 9s medical record form titled “;Written Certification”, dated 7/21/2024 to 10/18/2024 and “;Task Details for the Written Certification”, dated 7/21/2024 was reviewed. The “;Task Details” document indicated the DPCS had created and completed the document on 7/24/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into their EMR system. The DPCS stated he does not have his written documentation because he did not receive them back from the AD. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. During a record review of Patient 9s medical record titled “;Verbal Certification” dated 7/21/2024 to 10/18/2024, indicated the Medical Director 1 (MD1) signed and dated the form on 7/21/2024. During a concurrent interview and record review on 7/26/2024, at 2:40 p.m. with the DPCS of Patient 9s medical record form titled “;Verbal Certification”, dated 7/21/2024 to 10/18/2024 and “;Task Details for the Verbal Certification”, dated 7/21/2024 was reviewed. The “;Task Details” document indicated the DPCS had created the document on 7/24/2024 and completed it on 7/25/2024. The DPCS stated the doctor signed it late. The DPCS stated form should have read “;late entry”. 6. During a record review of Patient 11 medical record form titled “;Patient Information” indicated “;current benefit period – begin date 5/16/2024 end date 8/13/2024” with a diagnosis of chronic obstructive pulmonary disease (difficulty breathing). During a record review of Patient 11s medical record titled “;Written Certification” dated 5/16/2024 to 8/13/2024, indicated the Medical Director 1 (MD1) signed the form on 5/24/2024. During a record review of Patient 11s medical record form titled “;Task Details - Written Certification”, dated 5/16/2024, indicated the DPCS created the form on 7/23/2024 and completed the form on 7/24/2024. During a record review of Patient 11s medical record titled “;Verbal Certification” dated 5/16/2024 to 8/13/2024, indicated the Medical Director 1 (MD1)s signed the form on 5/24/2024. During a record review of Patient 11s medical record form titled “;Task Details - Verbal Certification”, dated 5/16/2024, indicated DPCS created and completed the form on 7/23/2024. 7. During a record review of Patient 12’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 2/9/2024 and an end date 5/8/2024” with a diagnosis of unspecified malignant neoplasm of skin of left lower limb, including hip (skin cancer). During a record review of Patient 12s medical record titled “;Written Certification” dated 5/9/2024 to 6/28/2024, indicated the Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. The form also indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient”. During a record review of Patient 12s medical record titled “;Written Certification” dated 5/9/2024 to 6/28/2024, indicated the Medical Director 1 (MD1)s signed the form on 5/17/2024. During a record review of Patient 12s medical record form titled “;Task Details - Written Certification”, dated 5/9/2024, indicated DPCS created and completed the form on 2/24/2024. 8. During a record review of Patient 13’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 2/17/2024 and an end date 5/16/2024” with a diagnosis of Alzheimers Disease (gradual memory loss). During a record review of Patient 13s medical record titled “;Written Certification” dated 5/17/2024 to 6/29/2024, indicated Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. The form also indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient”. During a record review of Patient 13s medical record titled “;Written Certification” dated 5/17/2024 to 6/29/2024, indicated the Medical Director 1 (MD1)s signed the form on 5/23/2024. During a record review of Patient 13s medical record form titled “;Task Details - Written Certification”, dated 5/17/2024, indicated DPCS created and completed the form on 7/24/2024. A record review of the HAs policy and procedure titled, “;Job Descriptions Hospice Medical Director”, dated April 2019, indicated, “;Essential Job Functions/Responsibilities: The duties and responsibilities of the Medical Director will include, but not limited to the following...3. Assuring that the established policies, bylaws, rules and regulations of the organization are followed in the program....14. Reviewing patients medical eligibility for hospice services, in accordance with the hospice program policies and procedures...15. Providing written certification of the terminal illness for all subsequent benefit periods. 16. Perform face-to-face encounters within thirty (30) days of the third and subsequent hospice benefit certification periods and attest to the encounter.” A record review of the HAs undated policy and procedure titled, “;Certification of Terminal Illness”, indicated, “;Procedure...5. A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patients medical record or, if applicable, examination of the patient...the signed and dated certification must be present prior to billing for each recertification period.””

“Based on interview and record review the Hospice Agency (HA) failed to ensure five of fourteen sampled patients (Patient 1, Patient 2, Patient 9, Patient 10, and Patient 11) medical records included comprehensive assessments, plan of care, and clinical notes to reflect the care provided. This failure resulted in incomplete clinical records. During an interview on 7/23/2024, at 3:59 p.m., the Director of Patient Care Services designee (DD) stated the plan of care was supposed to be developed during the admission. The DD stated it was the registered nurse responsibility to do the plan of care, with involvement from the certified nursing assistant and licensed vocational nurse. During an interview on 7/23/2024, at 4:11 p.m., the DD stated the plan of care had for the certification period had to be completed again a day to two days before or the day of when the certification was due. The purpose of doing this was to know what is going on with the patient. If there is no POC, the DD stated, “;We are in the cloud.” “We dont know what to do with the patient.” 1. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. During a concurrent interview and record review on 7/23/2024, at 12:28 p.m., the administrator designee (AD) reviewed Patient 1s records. The AD stated there was no IDG notes. The AD stated there was no plan of care in the medical records of Patient 1, for certification period 3, dated 6/19/2024 to 8/17/2024. During a concurrent interview and record review on 7/23/2024, at 12:40 p.m., the AD reviewed Patient 1s records. The AD stated there was no nursing recertification assessment for certification period 3, 6/19/2024 to 8/17/2024. A record review of Patient 1s record titled, “;RN Recertification”, dated 6/13/2024, did not indicate any entries in the template. 2. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During a concurrent interview and record review on 7/23/2024, at 12:28 p.m., the AD reviewed Patient 2s records. The AD stated there was no nursing recertification assessment for certification period 3, 6/18/2024 to 8/16/2024. During a concurrent interview and record review on 7/23/2024, at 12:40 p.m., the AD stated there was no plan of care in the medical records of Patient 2, for certification period 3, dated 6/18/2024 to 8/16/2024. The AD stated the HA was working on it. The AD stated there were no IDG notes for the current certification period. 3. During a record review of Patient 9’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 4/22/2024 and an end date 7/20/2024” with a diagnosis of end stage renal disease. During a concurrent interview and record review on 7/25/2024 at 1: 25 p.m. with the DPCS of Patient 9s medical record, the medical record indicated there was no documented medication list for Patient 9. DPCS stated he was in the process of completing Patient 9s medication list. 4. During a record review of Patient 10’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 5/20/2024 and an end date 6/26/2024” with a diagnosis of hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following unspecified cerebrovascular disease affecting left dominant side. During a concurrent interview and record review on 7/26/2024 at 11:31 a.m. with the DPCS of Patient 10s medical record, the DPCS stated Patient 10 did not have a IDG meeting. DPCS stated he completed Patient 10s individualized plan of care (POC) three days after he was admitted. DPCS was unable to locate Patient 10s POC. DPCS stated he hand wrote Patient 10s POC and handed it over to the Administrator Designee (AD) to be inputted into their electronic medical record (EMR) system. DPCS stated patient notes should be kept in patients medical records because it was part of their care. 5. During a record review of Patient 11’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 5/16/2024 and an end date of 8/13/2024” with a diagnosis of chronic obstructive pulmonary disease (difficulty breathing). During a record review on 7/24/2024 at 3:06 p.m. of Patient 11s electronic medical record (EMR) medical record form titled “;IDG Meeting” dated from 5/16/2024 to 6/28/2024, indicated there was nothing documented under section “;IDG/POC”. A record review of the HAs undated policy and procedure titled, “;The Plan of Care”, indicated, “;Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan 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 (15) days.”

“Based on interview and record review, the HA failed to ensure three of fourteen sampled patients (Patient 1, Patient 2, and Patient 3) medical records included written certification of terminal illness. (Refer to L676). This failure resulted in an incomplete clinical record. 1. A record review of Patient 1s “;Patient Profile” indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. During a concurrent interview and record review on 7/23/2024, at 12:28 p.m., the administrator designee (AD) reviewed Patient 1s medical records. The AD stated there was no recertification for hospice care for this patients current episode of 6/19/2024 to 8/17/2024. 2. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During a concurrent interview and record review, on 7/23/2024, at 12:40 p.m., the AD reviewed Patient 2s medical records. The AD stated there was no re-certification for hospice care for this patients current episode of 6/18/2024 to 8/16/2024. 3. A record review of Patient 3s “;Patient Profile” indicated an admission date of 10/6/2023, with a terminal diagnosis of cerebral vascular accident (brain attack). The record also indicated Patient 3 was discharged on 1/7/2024. During an interview on 7/25/2024, at 1:05 p.m., the office staff (OS) stated there was no written certification for the start of care beginning 10/6/2023. The only document the HA had was the doctors order for hospice care. A record review of the HAs policy and procedure titled, “;Job Descriptions Hospice Medical Director”, dated April 2019, indicated, “;Essential Job Functions/Responsibilities: The duties and responsibilities of the Medical Director will include, but not limited to the following...3. Assuring that the established policies, bylaws, rules and regulations of the organization are followed in the program....15. Providing written certification of the terminal illness for all subsequent benefit periods.” A record review of the HAs undated policy and procedure titled, “;Certification of Terminal Illness”, indicated, “;Procedure...5. A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patients medical record or, if applicable, examination of the patient...the signed and dated certification must be present prior to billing for each recertification period.””

“Based on interview and record review the Hospice Agency (HA) failed to ensure any amendments, correction or late entries within an electronic health record clearly identified the original content, the modified content, date, and authorship of each record modification for thirteen of fourteen sampled patients (Patient 1, Patient 2, Patient 4, Patient 5, Patient 7, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in inaccurate patient information or assessment to be entered in the patients clinical record that could affect the patients quality of care and well-being. During an interview on 7/26/2024 at 11:45 a.m. with the Medical Director (MD1), MD1 stated the Administrator (ADM) calls him to discuss patients. MD1 stated the admitting nurse calls him to discuss the patients diagnoses then he gives his recommendations. MD1 stated when “;Someone” hands him 20-30 pages to sign, he signs them but does not date them sometimes. MD1 stated he sometimes does not date them because he does not know the date to put. MD1 stated that legally he needs to sign the forms. MD1 stated he determines patients hospice eligibility by the information given to him by the nurse. MD1 stated he does not speak with patients primary physician. MD1 stated the HAs staff documents in their electronic medical record (EMR), print the form out, he reviews the forms, and if he agrees then he signs them. 1. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. During a concurrent interview and record review on 7/25/2024, at 2:28 p.m., the Director of Patient Care services (DPCS) reviewed Patient 1s records titled, “;Written Certification”, dated 12/22/2023 to 3/20/2024 and “;Task Details for Written Certification”, dated 12/22/2023. The “;Task Details” document indicated the DPCS had created and completed the document on 4/3/2024. The DPCS reviewed the document “;Written Certification” and stated: he wrote the certification on paper. The DPCS stated that the doctor did not write this. This is not the doctors assessment. This is the nursing assessment. During an interview on 7/26/2024, at 12:32 p.m., the Medical Director (MD) stated Patient 1s diagnosis came with the patient and was obtained from the nurses assessment and records. The MD stated he did not have medical records, the HA had it. The MD stated everything that was written in the certification form was written from the nurses assessments. The MD stated he had not spoken to Patient 1. The MD stated he had not seen Patient 1 through a picture, phone, or computer. A record review of Patient 1s “;Written Certification”, for certification period 12/22/2023 to 3/20/2024, indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient”. Further review of the record indicated the MDs name. However, there was no signature on the document. 2. A record review of Patient 2s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During a concurrent interview and record review on 7/26/2024, at 11:01 a.m., the DPCS reviewed Patient 1s records titled, “;Written Certification”, dated 12/21/2023 to 3/19/2024 and “;Task Details for written certification”, dated 12/21/2023. The “;Task Details” document indicated the DPCS had created the document on April 3, 2024, and completed the document on April 3, 2024 and April 21, 2024. The DPCS stated he wrote the notes on paper and gave it to the administrator designee (AD) to type into the computer, for the doctor to review and sign. The DPCS stated he did not have the paper document, as it was somewhere in the boxes. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. During an interview on 7/26/2024, at 12:38 p.m., when the MD was asked how he determined Patient 2s diagnosis, he stated: “;Can I ask you for a favor? Can you text me the information of the papers you are seeing? I signed a lot of papers, Im not sure. I need to go and look at what I signed. I have unsigned papers. Alzheimers comes with age. But I dont see the papers with my signature to speak about it.” A record review of Patient 2s “;Written Certification”, for certification period 12/21/2023 to 3/19/2024, indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient”. Further review of the record indicated the MDs name. However, there was no signature on the document. 3. A record review of Patient 4s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of Alzheimers disease. The record also indicated Patient 4 was discharged on 1/29/2024. During a concurrent interview and record review on 7/26/2024, at 11:03 a.m., the DPCS reviewed Patient 4s records titled, “;Written Certification”, dated 12/22/2023 to 1/29/2024 and “;Task Details for the Written Certification”, dated 12/22/2023. The “;Task Details” document indicated the DPCS had created and completed the document on 4/21/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into the computer, for the doctor to review and sign. The DPCS stated he did not have the paper document, as it was somewhere in the boxes. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. A record review of Patient 4s “;Written Certification”, for certification period 12/22/2023 to 1/29/2024, indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient”. Further review of the record indicated the MDs name. However, there was no signature on the document. 4. A record review of Patient 5s “;Patient Profile”, indicated an admission date of 12/21/2023, with a terminal diagnosis of Alzheimers disease. The record also indicated Patient 5 was discharged on 3/8/2024. During a concurrent interview and record review on 7/26/2024, at 11:04 a.m., the DPCS reviewed Patient 5s records titled, “;Written Certification”, dated 12/21/2023 to 3/8/2024 and “;Task Details for the Written Certification”, dated 12/21/2023. The “;Task Details” document indicated the DPCS had created and completed the document on 4/28/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into the computer, for the doctor to review and sign. The DPCS stated he did not have the paper document, as it was somewhere in the boxes. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. A record review of Patient 5s “;Written Certification”, for certification period 12/21/2023 to 3/8/2024, indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient”. Further review of the record indicated the MDs name. However, there was no signature on the document. 5. A record review of Patient 6s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of secondary malignant neoplasm of breast (breast cancer). The record also indicated Patient 6 was discharged on 5/31/2024. During a concurrent interview and record review on 7/26/2024, at 11:05 a.m., the DPCS reviewed Patient 6s records titled, “;Written Certification”, dated 12/22/2023 to 3/30/2024 and “;Task Details for the Written Certification”, dated 12/22/2023. The “;Task Details” document indicated the DPCS had created and completed the document on 4/3/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into the computer, for the doctor to review and sign. The DPCS stated he did not have the paper document, as it was somewhere in the boxes. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. A record review of Patient 6s “;Written Certification”, for certification period 12/22/2023 to 3/30/2024, indicated “;Attestation: I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient.” Further review of the record indicated the MDs name. However, there was no signature on the document. 6. A record review of Patient 7s “;Patient Profile”, indicated an admission date of 1/2/2024. The record also indicated Patient 7 was discharged on 6/25/2024. During a concurrent interview and record review on 7/26/2024, at 11:06 a.m., the DPCS reviewed Patient 7s records titled, “;Written Certification”, dated 1/2/2024 to 3/31/2024 and “;Task Details for the Written Certification”, dated 1/2/2024. The “;Task Details” document indicated the DPCS had created and completed the document on 4/3/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into the computer, for the doctor to review and sign. The DPCS stated he did not have the paper document, as it was somewhere in the boxes. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. 7. During a record review of Patient 8 medical record form titled “;Patient Information” indicated “;current benefit period – begin date 7/6/2024 end date 9/3/2024” with a diagnosis of unspecified cirrhosis of liver. During a record review of Patient 8s medical record titled “;Written Certification” dated 1/8/2024 to 4/6/2024, indicated the Medical Director 1 (MD1)s signature was written on the form. The form was not dated. During a concurrent interview and record review on 7/26/2024, at 2:30 p.m. with the DPCS of Patient 8s medical record form titled “;Written Certification”, dated 1/8/2024 to 4/6/2024 and “;Task Details for the Written Certification”, dated 1/8/2024 was reviewed. The “;Task Details” document indicated the DPCS had created the document on 1/30/2024 and completed it on 2/6/2024. During a record review of Patient 8s medical record titled “;Verbal Certification” dated 1/8/2024, indicated the Medical Director 1 (MD1)s signature was written on the form. The form was not dated. During a record review of Patient 8s medical record titled “;Verbal Certification” dated 1/8/2024, indicated the Medical Director 1 (MD1)s signature and date of 1/8/2024 was written on form. During a concurrent interview and record review on 7/26/2024, at 2:30 p.m. with the DPCS of Patient 8s medical record form titled “;Verbal Certification”, dated 1/8/2024 and “;Task Details for the Verbal Certification”, dated 1/8/2024 was reviewed. The “;Task Details” document indicated the DPCS had created the document on 1/30/2024 and completed it on 2/6/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into their EMR system. The DPCS stated he does not have his written documentation because he did not receive them back from the AD. The DPCS stated the information in the “;Verbal Certification” was based on the doctors orders. 8. During a record review of Patient 9’s medical record form titled “;Patient Information” indicated a “current benefit period – begin date 4/22/2024 end date 7/20/2024” with a diagnosis of end stage renal disease. During a record review of Patient 9s medical record titled “;Written Certification” dated 4/22/2024 to 7/20/2024, indicated the Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. During a concurrent interview and record review on 7/26/2024, at 2:40 p.m. with the DPCS of Patient 9s medical record form titled “;Written Certification”, dated 4/22/2024 to 7/20/2024 and “;Task Details for the Written Certification”, dated 4/22/2024 was reviewed. The “;Task Details” document indicated the DPCS had created the document on 7/23/2024 and completed it on 7/24/2024. During a record review of Patient 9s medical record titled “;Verbal Certification” dated 4/22/2024 to 7/20/2024, indicated the Medical Director 1 (MD1)s name written on the form. The form was not signed or dated. During a concurrent interview and record review on 7/26/2024, at 2:40 p.m. with the DPCS of Patient 9s medical record form titled “;Verbal Certification”, dated 4/22/2024 to 7/20/2024 and “;Task Details for the Verbal Certification”, dated 4/22/2024 was reviewed. The “;Task Details” document indicated the DPCS had created the document on 7/23/2024 and completed it on 7/24/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into their EMR system. 9. During a record review of Patient 10’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 5/20/2024 and an end date 6/26/2024” with a diagnosis of hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following unspecified cerebrovascular disease affecting left dominant side. During a record review of Patient 10s medical record titled “;Written Certification” dated 5/20/2024 to 8/17/2024, indicated Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. During a record review of Patient 10s medical record titled “;Written Certification” dated 5/20/2024 to 8/17/2024, indicated Medical Director 1 (MD1)s signed the form on 5/30/2024. During a concurrent interview and record review on 7/26/2024, at 2:48 p.m. with the DPCS of Patient 10s medical record form titled “;Written Certification”, dated 5/20/2024 to 8/17/2024 and “;Task Details for the Written Certification”, dated 5/20/2024 was reviewed. The “;Task Details” document indicated the DPCS had created the document on 7/23/2024 and completed it on 7/24/2024. The DPCS stated he wrote the notes on paper and gave it to the AD to type into their EMR system. The DPCS stated he does not have his written documentation because he did not receive them back from the AD. The DPCS stated the information in the “;Written Certification” was based on the nursing assessment. The DPCS stated MD1 signed the form late. During a record review of Patient 10s medical record titled “;Verbal Certification” dated 5/20/2024 to 8/17/2024, indicated the Medical Director 1 (MD1)s signed the form on 5/30/2024. During a concurrent interview and record review on 7/26/2024, at 2:48 p.m. with the DPCS of Patient 10s medical record form titled “;Verbal Certification”, dated 5/20/2024 to 8/17/2024 and “;Task Details for the Verbal Certification”, dated 5/20/2024 was reviewed. The “;Task Details” document indicated the DPCS had created and completed the document on 7/23/2024. The DPCS confirmed he created the form on 7/23/2024. DPCS stated MD1 singed the form late. 10. During a record review of Patient 11’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 5/16/2024 and an end date 8/13/2024” with a diagnosis of chronic obstructive pulmonary disease (difficulty breathing). During a record review of Patient 11s medical record titled “;Written Certification” dated 2/16/2024 to 5/15/2024, indicated Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. During a record review of Patient 11s medical record titled “;Written Certification” dated 2/16/2024 to 5/15/2024, indicated the Medical Director 1 (MD1)s signed the form on 2/25/2024. During a record review of Patient 11s medical record form titled “;Task Details - Written Certification”, dated 2/16/2024, indicated MD1 created the form on 4/3/2024 and the AD completed the form on 5/31/2024. During a record review of Patient 11s medical record titled “;Verbal Certification” dated 2/16/2024 to 5/15/2024, indicated the Medical Director 1 (MD1)s signed the form on 2/23/2024. During a record review of Patient 11s medical record form titled “;Task Details - Verbal Certification”, dated 2/16/2024, indicated MD1 created the form on 4/3/2024 and Hospice Staff (HS) completed the form on 7/23/2024. 11. During a record review of Patient 12 medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 2/9/2024 and an end date 5/8/2024” with a diagnosis of unspecified malignant neoplasm of skin of left lower limb, including hip (skin cancer). During a record review of Patient 12s medical record titled “;Written Certification” dated 2/9/2024 to 5/8/2024, indicated the Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. During a record review of Patient 12s medical record titled “;Written Certification” dated 2/9/2024 to 5/8/2024, indicated Medical Director 1 (MD1)s signed the form on 2/16/2024. During a record review of Patient 12s medical record form titled “;Task Details - Written Certification”, dated 2/9/2024, indicated DPCS created and completed the form on 2/26/2024. 12. During a record review of Patient 13’s, medical record form titled “;Patient Information” indicated a “;current benefit period be with a begin date of 2/17/2024 and an end date of 5/16/2024” with a diagnosis of Alzheimers Disease (gradual memory loss). During a record review of Patient 13s medical record titled “;Written Certification” dated 2/17/2024 to 5/16/2024, indicated Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. During a record review of Patient 13s medical record titled “;Written Certification” dated 2/17/2024 to 5/16/2024, indicated the Medical Director 1 (MD1)s signed the form on 2/23/2024. During a record review of Patient 13s medical record form titled “;Task Details - Written Certification”, dated 2/17/2024, indicated DPCS created the form on 4/3/2024 and completed it on 5/31/2024. 13. During a record review of Patient 14 medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 2/20/2024 and an end date of 5/19/2024” with a diagnosis of Alzheimers Disease (gradual memory loss). During a record review of Patient 14s medical record titled “;Written Certification” dated 2/20/2024 to 5/19/2024, indicated Medical Director 1 (MD1)s name was written on the form. The form was not signed or dated. During a record review of Patient 14s medical record titled “;Written Certification” dated 2/20/2024 to 5/19/2024, indicated Medical Director 1 (MD1)s signed the form on 2/26/2024. During a record review of Patient 14s medical record form titled “;Task Details - Written Certification” dated 2/20/2024, indicated DPCS created the form on 3/27/2024 and completed the form on 4/1/2024. During a record review of Patient 14s medical record titled “;Verbal Certification” dated 2/20/2024 to 5/19/2024, indicated Medical Director 1 (MD1)s signed the form on 2/26/2024. During a record review of Patient 14s medical record form titled “;Task Details - Verbal Certification”, dated 2/20/2024, indicated DPCS created the form on 3/27/2024 and Hospice Staff (HS) completed the form on 7/23/2024. A record review of the HAs policy and procedure titled, “;Job Descriptions Hospice Medical Director”, dated April 2019, indicated, “;Essential Job Functions/Responsibilities: The duties and responsibilities of the Medical Director will include, but not limited to the following...3. Assuring that the established policies, bylaws, rules and regulations of the organization are followed in the program....15. Providing written certification of the terminal illness for all subsequent benefit periods.” A record review of the HAs undated policy and procedure titled, “;Certification of Terminal Illness”, indicated, “;Procedure...5. A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patients medical record or, if applicable, examination of the patient...the signed and dated certification must be present prior to billing for each recertification period.””

“Based on interview and record review, the HA failed to ensure five of fourteen sampled patients (Patient 1, Patient 10, Patient 12, Patient 13, and Patient 14) records were safeguarded against unauthorized access This failure resulted in clinical records being accessed by unauthorized persons and HIPPA violation. During an interview on 7/26/2024 at 1 p.m. with the Administrator Designee (AD), AD stated the DPCS asks her, the Office Staff (OS) or the Director of Patient Care Services Niece (DN) for assistance to upload his documentation into their Electronic Medical Record (EMR) system. The AD stated she gave DN access to their EMR system because the DPCS requested. The AD stated DN is not an employee at the HA. The AD stated DN is employed in the home health agency next door. The AD stated DN does not have and employee file or signed an EMR confidentiality form. The AD stated a breach in patients information may lead to fraud or something else. 1. A record review of Patient 1s “;Patient Profile”, indicated an admission date of 12/22/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD- the lungs do not work well, making it difficult to breathe) with lower respiratory infection. During a concurrent interview and record review on 7/25/2024, at 2:28 p.m., the Director of Patient Care services (DPCS) reviewed Patient 1s records titled, “;Written Certification”, dated 12/22/2023 to 3/20/2024 and “;Task Details for Written Certification”, dated 12/22/2023. The “;Task Details” document indicated the DPCS had created and completed the document on 4/3/2024. The DPCS reviewed the document “;Written Certification” and stated: he wrote the certification on paper. The QA (quality assurance) audits this. They add or take away if needed. If it should not be there, they eliminate it. The QA person is the one who audits it. I dont know the name of the person. The person who does it is our relatives too. Thats why I feel safe to share my user id and password. No, the doctor did not write this. This is not the doctors assessment. This is the nursing assessment. The DPCS stated the certification for terminal illness was supposed to be done within 24 to 48 hours of the admission date because that was the guidelines to follow, the condition of the patient, the safety of the patients, and how the patients are cared for. 2. During a record review of Patient 10’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 5/20/2024 and an end date of 6/26/2024” with a diagnosis of hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following unspecified cerebrovascular disease affecting left dominant side. During a record review of Patient 10s medical record form titled “;Discharge Live” dated 6/26/2024, indicated the form was signed and dated by the DPCS on 6/26/2024. During a record review of Patient 10s medical record form titled “;Task Details – RN Initial Assessment” dated 5/20/2024, indicated the form was created by DN on 6/3/2024. During a concurrent interview and record review on 7/26/2024 at 11:31 a.m. with the Director of Patient Care Services (DPCS) of Patient 10s medical record form titled “;Task Details - Discharge Live” dated 6/26/2024, the DPCS stated his niece (DN) created the form on 7/23/2024. The DPCS stated DN does not work for the HA. The DPCS stated DN is a nurse in their country but has not passed her nursing exams in the United States. The DPCS stated the DN has her personal log in information to their electronic medical record (EMR) system and that he also gave her his log in information. The DPCS stated he writes down his assessments on paper and ask DN to help him upload his documentation into the EMR. 3. During a record review of Patient 12 medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 2/9/2024 and an end date of 5/8/2024” with a diagnosis of unspecified malignant neoplasm of skin of left lower limb, including hip (skin cancer). During a record review of Patient 12s medical record form titled “;Discharge Live” dated 6/28/2024, indicated the form was signed and dated by the DPCS on 6/28/2024. During a record review of Patient 12s medical record form titled “;Task Details - Discharge Live” dated 6/28/2024, indicated the form was created by DN on 7/23/2024. 4. During a record review of Patient 13’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 2/17/2024 and an end date 5/16/2024” with a diagnosis of Alzheimers Disease (gradual memory loss). During a record review of Patient 13s medical record form titled “;Discharge Live” dated 6/29/2024, indicated the form was signed and dated by the DPCS on 6/29/2024. During a record review of Patient 13s medical record form titled “;Task Details - Discharge Live” dated 6/29/2024, indicated the form was created by DN on 7/23/2024. 5. During a record review of Patient 14’s medical record form titled “;Patient Information” indicated a “;current benefit period with a begin date of 2/20/2024 and an end date 5/19/2024” with a diagnosis of Alzheimers Disease (gradual memory loss). During a record review of Patient 14s medical record form titled “;Discharge Live” dated 6/30/2024, indicated the form was signed and dated by the DPCS on 6/30/2024. During a record review of Patient 14s medical record form titled “;Task Details - Discharge Live” dated 6/30/2024, indicated the form was created by DN on 7/23/2024.”

“Based on interview, and record review, the Hospice Agency (HA) failed to notify Medicare services of a change of location. This failure had the potential to result in the HA providing services from an unknown location and causing confusion to patients, staff and the public. On 7/23/2024, at 10:15 a.m., the survey team arrived at the address listed on record. There was no signage, no one present at the location, and the doors were locked. During an observation on 7/23/2024, at 10:45 a.m., the agency was located at the unlisted location. The door had suite 530 listed on it. There was no signage of the HA. The signage present read, “;530 Space Available for information, please call...”. The office was in disarray. There were boxes everywhere. During an interview on 7/23/2024, at 10:45 a.m., the administrator designee (AD) stated the HA shared the office space with a home health agency. The AD stated the HA moved into the new space a month ago and are still unloading boxes. During an interview on 7/26/2024, at 3:33 p.m., the AD stated the HA moved in June 2024, but did not remember exactly which date. The AD stated she submitted the change of location application to the central application branch sometime in July 2024, and had not received the approval for change of location. The AD stated she was not aware that she had to wait for the approval to move to the new location. During a concurrent interview and record review on 7/26/2024, at 4:51 p.m., the AD submitted record titled, “;United States Postal Service” dated 7/15/2024. The AD stated the application for change of location was sent on 7/15/2024.”