Bradford Healthcare

“The agency failed to ensure that the Condition of Participation: E 001 §418.113 Establishment of the Emergency Program (EP) was in compliance as follows: 1. Based on interview and record review, the agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to E 004) 2. Based on interview and record review, the agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to E 009) 3. Based on interview and record review the agency failed to develop a procedure and/or process to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to E 016) 4. Based on interview and record review, the agency failed to create and implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to E 019) 5. Based on interview and record review, the agency failed to create a plan and implement a procedure to provide for emergency staffing during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to E 024) 6. Based on interview and record review, the agency failed to develop a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to E 032) 7. Based on interview and record review, the agency failed to conduct full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency operation centers, etc.] and “;boots on the ground” response [for example, firefighters decontaminating mock victims]) or tabletop emergency preparedness exercises (an exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and set a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan), for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to E 039) The cumulative effect of these systemic practices resulted in the potential to cause the Emergency Preparedness Program (EPP) to indicate ineffective procedures and outdated information. In addition, the potential to place the agencys patients at risk when: the agency was not prepared to respond to the hazards most likely to occur in the community, the agency was not prepared to work with the emergency management office during an emergency or disaster, the agency did not have a back-up communication plan for governmental agencies able to provide assistance to the agencys patients during an emergency or disaster, and problems within the Emergency Preparedness Plan had the potential to go unrecognized and unaddressed.”

“The agency failed to ensure that the Condition of Participation: L 536 §418.56 Interdisciplinary group, care planning, and coordination of services was in compliance as follows: 1. Based on observation, interview, and record review, the agency failed to develop an individualized plan of care for three of three sampled patients (Patients 1, 2, 3) when: 1a. For Patient 1: The Hospice Aide (HA 1) did not follow the HA care plan for providing range of motion exercises (ROM-the HA moves a limb or body part around a joint, gently stretching muscles and reminding them how to move correctly), the HA care plan was not updated at each recertification assessment, the HA care plan indicated supplemental oxygen (a treatment that provides extra oxygen to patients who have breathing problems or lung diseases) use when Patient 1 was not using supplemental oxygen, and the HA care plan indicated blood pressure (a measurement of the pressure of blood in the body’s arteries) and heart rate (the number of times a patients heart beats in a given period of time, usually a minute) reporting parameters (a blood pressure or heart rate measurement where the physician wanted to be notified) when HAs did not take patients blood pressures or heart rates. (Refer to L 545) 1b. For Patient 2: There were no reporting parameters for blood pressure or heart rate indicated on Patient 2s care plan or in Patient 2s physicians orders. And LVN 1 determined reporting parameters were unnecessary because Patient 2s slow heart rate of 56 beats per minute (bradycardia-heart beats fewer than 60 times a minute) was considered normal due to Patient 2 taking a medication which lowered a patients heart rate. (Refer to L 545) 1c. For Patient 3: there were no physicians orders to update the care plan, in order to: a. conduct Patient 3’s pulse oximeter readings (a percentage measurement that indicates the amount of oxygen in the patient’s blood) or reporting parameters for pulse oximeter readings. b. conduct Patient 3’s blood sugar readings (a measurement of the amount of sugar in the patient’s blood) or reporting parameters for blood sugar readings. c. report parameters for blood pressure and/or heart rate measurements. There was no care planning: d. For diabetes mellitus (a chronic disease where the body cannot control blood sugar levels) management (a written plan that indicates to: monitor blood glucose levels, educate patient on diabetes management, and monitor for signs and symptoms of high and low blood sugar). e. For digoxin medication management (a written plan that indicates to: assess apical heart rate (using a stethoscope to listen to the heart and count the number of beats for one minute), assess how much digoxin medication and the mineral potassium are in the patient’s blood and assess for signs and symptoms of digoxin toxicity (when there is too much digoxin medication in the patient’s body and causes confusion, irregular pulse, loss of appetite, nausea, vomiting, diarrhea, fast heartbeat, and vision changes). (Refer to L 545) 2. Based on interview, and record review, the hospice interdisciplinary group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) failed to review, revise, and document the individualized care plan as frequently as the patients condition required, but no less frequently than every 15 calendar days, for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14). (Refer to L 552) The cumulative effect of these systemic practices resulted in the potential to cause Patient 1 to suffer loss of muscle strength and endurance, and absence of needed hospice aide care services, Patient 2 to suffer frequent fainting, the inability of the heart to pump enough blood (heart failure) and sudden cardiac arrest or sudden death, Patient 3 to suffer low oxygen saturation levels, too low or high blood sugar levels, too low or high blood pressure levels, too slow or rapid heart rates, diabetes mellitus mismanagement and digoxin mismanagement and toxicity. In addition, this failure had the potential for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 responses to care, treatment and services to go unaddressed.”

“The agency failed to ensure that the Condition of Participation: L 559 §418.58 Quality assessment and performance improvement (QAPI) was in compliance as follows: 1. Based on interview, and record review, the agency failed to measure and analyze quality indicators (a measurable element of the agencys practice that can be used to assess the quality of care provided) to assess the agencys processes of care, services, and operations, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to L 562) 2. Based on interview, and record review, the agency failed to ensure the agencys Governing Body approved the frequency and detail of the Quality Assessment Performance Improvement (QAPI) programs data collection, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to L 565) 3. Based on interview and record review, the agency failed to conduct and document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had undertaken, the reasons for conducting the PIP and measurable goals to show progress achieved, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to L 573) 4. Based on interview, and record review, the agencys Governing Body (GB) failed to provide oversight for its Quality Assessment and Performance Improvement (QAPI) Program for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients when: a. Based on interview, and record review, the agency failed to measure and analyze quality indicators (a measurable element of the agencys practice that can be used to assess the quality of care provided) to assess the agencys processes of care, services, and operations, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to L 574) b. Based on interview, and record review, the agency failed to ensure the agencys Governing Body approved the frequency and detail of the Quality Assessment Performance Improvement (QAPI) programs data collection, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to L 574) c. Based on interview and record review, the agency failed to conduct and document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had undertaken, the reasons for conducting the PIP and measurable goals to show progress achieved, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to L 574) The cumulative effect of these systemic practices resulted in the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized and unaddressed, and the potential for the agency to provide inferior care and services to its patients.”

“The agency failed to ensure that the Condition of Participation: L 577 §418.60 Infection control was in compliance as follows: Based on interview, and record review, the agency failed to maintain an infection control program that was integrated into the agencys Quality Assessment Performance Improvement (QAPI) program in order to: identify infection trends (analysis of a pattern), develop action plans and improve disease prevention, from October 1, 2021 (the date the Owner purchased the agency) to October 17, 2024, in a universe of 14 patients. (Refer to L 580) The cumulative effect of these systemic practices resulted in the potential to cause trends in infections to go unrecognized, unaddressed and patients to suffer repeated and prolonged infections.”

“The agency failed to ensure that the Condition of Participation: L 587 §418.64 Core services was in compliance as follows: Based on interview and record review, the agency failed to ensure a Bereavement (the experience of losing someone important) Program (a program providing an initial bereavement assessment, a bereavement plan of care, a post-death assessment, mailing of bereavement letters, and post-death support assistance) was maintained to provide bereavement services to family, loved ones and caregivers for one year following the death of a patient, for two of two sampled patients (Patients 13 and 14), in a universe of 14 patients. (Refer to L 596) The cumulative effect of these systemic practices resulted in the potential to cause individuals experiencing grief to suffer a lack of support and guidance leading to complications with their grief and impacting their mental and physical health.”

“The agency failed to ensure that the Condition of Participation: L 641 §418.78 Volunteers was in compliance as follows: 1. Based on interview, and record review, the agency failed to maintain a volunteer program that utilized volunteers in day-to-day administrative duties and/or direct patient care, in a universe of 14 patients. (Refer to L 644) 2. Based on interview, and record review, the agency failed to maintain a volunteer program by actively recruiting volunteers, in a universe of 14 patients. (Refer to L 645) 3. Based on interview, and record review, the agency failed to document the cost savings achieved through the use of volunteers by the identification of each position that was occupied by a volunteer, the work time spent by volunteers occupying those positions and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions, in a universe of 14 patients. (Refer to L 646) 4. Based on interview, and record review, the agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services to equal five percent of the total patient care hours of all paid hospice employees and contract staff, in a universe of 14 patients. (Refer to L 647) The cumulative effect of these systemic practices resulted in the potential to cause patients and families to go without assistance in daily tasks, running errands or a reassuring presence to ease stress and provide much-needed comfort. In addition, this failure resulted in the agency suffering additional costs when paid employees provided volunteer services. The agency failed to ensure that the Condition of Participation: L 641 §418.78 Volunteers was in compliance as follows: 1. Based on interview, and record review, the agency failed to maintain a volunteer program that utilized volunteers in day-to-day administrative duties and/or direct patient care, in a universe of 14 patients. (Refer to L 644) 2. Based on interview, and record review, the agency failed to maintain a volunteer program by actively recruiting volunteers, in a universe of 14 patients. (Refer to L 645) 3. Based on interview, and record review, the agency failed to document the cost savings achieved through the use of volunteers by the identification of each position that was occupied by a volunteer, the work time spent by volunteers occupying those positions and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions, in a universe of 14 patients. (Refer to L 646) 4. Based on interview, and record review, the agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services to equal five percent of the total patient care hours of all paid hospice employees and contract staff, in a universe of 14 patients. (Refer to L 647) The cumulative effect of these systemic practices resulted in the potential to cause patients and families to go without assistance in daily tasks, running errands or a reassuring presence to ease stress and provide much-needed comfort. In addition, this failure resulted in the agency suffering additional costs when paid employees provided volunteer services.”

“The agency failed to ensure the Condition of Participation: L 648 §418.100 Organization and administration of services was in compliance when: 1. Based on observation, interview, and record review, the agency failed to develop an individualized plan of care for three of three sampled patients (Patients 1, 2, 3) when: a. For Patient 1: The Hospice Aide (HA 1) did not follow the HA care plan for providing range of motion exercises (ROM-the HA moves a limb or body part around a joint, gently stretching muscles and reminding them how to move correctly), the HA care plan was not updated at each recertification assessment, the HA care plan indicated supplemental oxygen (a treatment that provides extra oxygen to patients who have breathing problems or lung diseases) use when Patient 1 was not using supplemental oxygen, and the HA care plan indicated blood pressure (a measurement of the pressure of blood in the body’s arteries) and heart rate (the number of times a patients heart beats in a given period of time, usually a minute) reporting parameters (a blood pressure or heart rate measurement where the physician wanted to be notified) when HAs did not take patients blood pressures or heart rates. (Refer to L 651). b. For Patient 2: There were no reporting parameters for blood pressure or heart rate indicated on Patient 2s care plan or in Patient 2s physicians orders and LVN 1 determined reporting parameters were unnecessary because Patient 2s slow heart rate of 56 beats per minute (bradycardia-heart beats fewer than 60 times a minute) was considered normal due to Patient 2 taking a medication which lowered a patients heart rate. (Refer to L 651) c. For Patient 3: there were no physicians orders to update the care plan, in order to: i. conduct Patient 3’s pulse oximeter readings (a percentage measurement that indicates the amount of oxygen in the patient’s blood) or reporting parameters for pulse oximeter readings. ii. conduct Patient 3’s blood sugar readings (a measurement of the amount of sugar in the patient’s blood) or reporting parameters for blood sugar readings. iii. report parameters for blood pressure and/or heart rate measurements. There was no care planning: iv. For diabetes mellitus (a chronic disease where the body cannot control blood sugar levels) management (a written plan that indicated to monitor blood glucose levels, educate patient on diabetes management, and monitor for signs and symptoms of high and low blood sugar). v. For digoxin medication management (a written plan that indicated to assess apical heart rate (using a stethoscope to listen to the heart and count the number of beats for one minute), assess how much digoxin medication and the mineral potassium were in the patient’s blood and assess for signs and symptoms of digoxin toxicity (when there is too much digoxin medication in the patient’s body and causes confusion, irregular pulse, loss of appetite, nausea, vomiting, diarrhea, fast heartbeat, and vision changes). (Refer to L 651). 2. Based on interview, and record review, the hospice interdisciplinary group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) failed to review, revise, and document the individualized care plan as frequently as the patients condition required, but no less frequently than every 15 calendar days, for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14). (Refer to L 651) 3. Based on interview, and record review, the agency failed to maintain an infection control program that was integrated into the agencys Quality Assessment Performance Improvement (QAPI) program in order to: identify infection trends (analysis of a pattern), develop action plans and improve disease prevention, from October 1, 2021 (the date the Owner purchased the agency) to October 17, 2024, in a universe of 14 patients. (Refer to L 651) 4. Based on interview and record review, the agency failed to ensure a Bereavement (the experience of losing someone important) Program (a program providing an initial bereavement assessment, a bereavement plan of care, a post-death assessment, mailing of bereavement letters, and post-death support assistance) was maintained to provide bereavement services to family, loved ones and caregivers for one year following the death of a patient, for two of two sampled patients (Patients 13 and 14), in a universe of 14 patients. (Refer to L 651) 5. Based on interview, and record review, the agency failed to maintain a volunteer program that utilized volunteers in day-to-day administrative duties and/or direct patient care, in a universe of 14 patients. (Refer to L 651) 6. Based on interview, and record review, the agency failed to maintain a volunteer program by actively recruiting volunteers, in a universe of 14 patients. (Refer to L 651) 7. Based on interview, and record review, the agency failed to document the cost savings achieved through the use of volunteers by the identification of each position that was occupied by a volunteer, the work time spent by volunteers occupying those positions and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions, in a universe of 14 patients. (Refer to L 651) 8. Based on interview, and record review, the agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services to equal five percent of the total patient care hours of all paid hospice employees and contract staff, in a universe of 14 patients. (Refer to L 651) 9. Based on interview, and record review, the agency failed to ensure the Medical Director (MD) certified the patients’ terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) when: a. For Patients 1, 2, 4, 5, 6, 7, 8, 9, 10, 12, 13, and 14 the Medical Director (MD) failed to certify the patients as terminally ill. (Refer to L 651) b. For Patients 1, 3 and 14, the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. (Refer to L 651) c. For Patient 11, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. (Refer to L 651) 10. Based on interview and record review, the agency failed to follow Federal Law [42 Code of Federal Regulations (CFR) § 418.25(a)], requiring a written physicians referral order, when the patients clinical record did not contain a physician’s referral order for hospice services, a confirmation of service needs, a verification of the patients’ medical prognosis and supporting documentation for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14). (Refer to L 651) 11. Based on interview and record review, the agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to L 651) 12. Based on interview and record review, the agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to L 651) 13. Based on interview and record review, the agency failed to develop a procedure and/or process to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to L 651) 14. Based on interview and record review, the agency failed to create and implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to L 651) 15. Based on interview and record review, the agency failed to create a plan and implement a procedure to provide for emergency staffing during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to L 651) 16. Based on interview and record review, the agency failed to develop a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to L 651) 17. Based on interview and record review, the agency failed to conduct full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency operation centers, etc.] and “;boots on the ground” response [for example, firefighters decontaminating mock victims]) or tabletop emergency preparedness exercises (an exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and set a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan), for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. (Refer to L 651) The cumulative effect of these systemic practices resulted in the potential: 1a. For Patient 1 to suffer loss of muscle strength and endurance, and absence of needed hospice aide care services. 1b. To cause Patient 2 to suffer frequent fainting, the inability of the heart to pump enough blood (heart failure) and sudden cardiac arrest or sudden death. 1c. To cause Patient 3 to suffer low oxygen saturation levels, too low or high blood sugar levels, too low or high blood pressure levels, too slow or rapid heart rates, diabetes mellitus mismanagement and digoxin mismanagement and toxicity. 2. For Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 responses to care, treatment, and services to go unaddressed. 3. To cause trends in infections to go unrecognized, unaddressed and patients to suffer repeated and prolonged infections. 4. To cause individuals experiencing grief to suffer a lack of support and guidance leading to complications with their grief and impacting their mental and physical health. 5. To cause patients, and families to go without assistance in daily tasks, running errands or a reassuring presence to ease stress and provide much-needed comfort. 6. To cause patients and families to go without assistance in daily tasks, running errands or a reassuring presence to ease stress and provide much-needed comfort. 7, 8. In the agency suffering additional costs when paid employees provided volunteer services. 9. To cause Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 to not be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to not being properly evaluated as terminally ill. 10. To cause Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 to not be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and referring to hospice care. 11. To cause the EPP to indicate ineffective procedures and outdated information. 12. To place the agencys patients at risk when the agency was not prepared to work with the emergency management office during an emergency or disaster. 13. To cause a hindering of crucial response efforts and leaving patients in life-threatening situations. In addition, not informing officials about staff members who were unable to be contacted during a disaster, can significantly hinder emergency response efforts by creating confusion, delaying critical decision-making, and potentially leaving individuals at risk without necessary assistance. 14. To place the agencys patients at risk when the agency was not prepared to inform emergency management officials about patients in need of evacuation and the needs the patients would require during the evacuation process. 15. To cause patients to suffer an absence of care due to a staff shortage. 16. To place the agencys patients at risk when the agency could not communicate with Federal, State, tribal, regional, and local emergency management agencies in the event of a communications failure. 17. To cause problems within the Emergency Preparedness Program to go unrecognized and unaddressed.”

“The agency failed to ensure that the Condition of Participation: L 664 §418.102 Medical director was in compliance as follows: Based on interview, and record review, the agency failed to ensure the Medical Director (MD) certified the patients’ terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) when: 1. For Patients 1, 2, 4, 5, 6, 7, 8, 9, 10, 12, 13, and 14 the Medical Director (MD) failed to certify the patients as terminally ill. (Refer to L 667) 2. For Patients 1, 3 and 14, the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. (Refer to L 667) 3. For Patient 11, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. (Refer to L 667) The cumulative effect of these systemic practices resulted in the potential to cause Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 to not be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to not being properly evaluated as terminally ill.”

“The agency failed to ensure that the Condition of Participation: L 670 §418.104 Clinical records was in compliance as follows: Based on interview and record review, the agency failed to follow Federal Law [42 Code of Federal Regulations (CFR) § 418.25(a)], requiring a written physicians referral order, when the patients clinical record did not contain a physician’s referral order for hospice services, a confirmation of service needs, a verification of the patients’ medical prognosis and supporting documentation for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14). (Refer to L 678) The cumulative effect of these systemic practices resulted in the potential to cause Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 to not be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and referring to hospice care.”

“Based on interview and record review, the agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to cause the EPP to indicate ineffective procedures and outdated information. During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 9:30 AM, the Owner stated she purchased the agency on October 1, 2021, owned 100% (percent) and was the sole member of the Governing Body. She went into business with her brother who was the Administrator/Director of Patient Care Services (Admin/DPCS). She did not hold a nursing license and had no experience with running a hospice agency. The Owner stated the Admin/DPCS had been responsible for running the agency, taking care of the patients and running the Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) meetings. The Admin/DPCS suffered a devastating family tragedy between April 2023 to June 2023 and stopped fulfilling the Admin/DPCS responsibilities. The Admin/DPCS had not appointed an Administrator Designee or Director of Patient Care Services Designee, so she took over and began looking for someone to help her. She met the AD/DPCSD on August 1, 2024, and hired her as a visiting nurse and the AD/DPCSD started giving her advice on how to run the agency. The AD/DPCSD stated she had been offered and accepted the AD/DPCSD position on October 14, 2024, “;The day you [Surveyor] arrived.” A review of the agencys Emergency Preparedness Binder, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show the Governing Body had reviewed its contents. A review of the agencys policy and procedure titled, “Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a review had been conducted. A review of the agencys Governing Body Meeting Minutes, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show the Governing Body had reviewed the Emergency Preparedness Program. During an interview with the Owner and the Administer Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 11:57 AM, the Owner stated the Admin/DPCS had been responsible for the EPP but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the EPP had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024, and there was no safety committee. The Owner stated she was the sole member of the Governing Body, and she could not show documented evidence the agency’s EPP had been reviewed by the Governing Body for the three years the agency had been operational from October 1, 2021, through October 17, 2024. A review of the agencys policy and procedure titled “;Emergency Management Plan,” undated, indicated, “;The Emergency Management Plan is reviewed by the Safety Committee on an annual basis. The committee shall meet on an as-needed basis during the year to keep the Emergency. Management Plan up-to-date and make any revisions necessary including the incorporation of new staff members.””

“Based on interview and record review, the agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to place the agencys patients at risk when the agency was not prepared to work with the emergency management office during an emergency or disaster. A review of the agencys Emergency Preparedness Binder, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show the agency had reached out to and collaborated with local, regional, State, and Federal emergency preparedness officials. A review of the agencys policy and procedure titled, “Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a contact number for the (name of county the agency is currently located) emergency management office. During an interview with the Owner and the Administer Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 11:57 AM, the Owner stated the Admin/DPCS had been responsible for the Emergency Preparedness Program (EPP) but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the EPP had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024, and there was no safety committee. The Owner stated the Emergency Management Plan had been put together by the previous agencys owner and at that time the agency was located in Orange County. The Owner stated references in the Emergency Management Plan were for (name of previous county where the agency was located), not (name of county the agency was currently located). A review of the agencys policy and procedure titled, “;Emergency Management Plan.” undated, indicated, “;... 3. Establishing, in coordination with county emergency management planning, priorities among potential emergencies identified in the hazard vulnerability analysis for which mitigation, preparation, response and recovery activities will need to be undertaken. ...””

“Based on interview and record review, the agency failed to develop a procedure and/or process to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to cause a hindering of crucial response efforts and leaving patients in life-threatening situations. In addition, not informing officials about staff members who were unable to be contacted during a disaster, can significantly hinder emergency response efforts by creating confusion, delaying critical decision-making, and potentially leaving individuals at risk without necessary assistance. A review of the agencys Emergency Preparedness Binder, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show a process to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency. There was no documented evidence to show contact information for the emergency management offices in the counties and cities were the agencys patients lived. A review of the agencys policy and procedure titled, “Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a plan to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency. During an interview with the Owner and the Administer Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 11:57 AM, the Owner stated the Administrator/Director of Patient Care Services (Admin/DPCS) had been responsible for the Emergency Preparedness Plan (EPP) but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the EPP had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024, and there was no safety committee. The AD/DPCSD verified there was no plan to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency and there was no contact information for the emergency management offices in the counties and cities were the agencys patients lived. A review of the agencys policy and procedure titled, “;Emergency Management Plan,” undated was conducted. There was no documented evidence to show a plan or procedure to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency.”

“Based on interview and record review, the agency failed to create and implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to place the agencys patients at risk when the agency was not prepared to inform emergency management officials about patients in need of evacuation and the needs the patients would require during the evacuation process. A review of the agencys Emergency Preparedness Binder, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show a process to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, and there was no documented evidence to show contact information for the emergency management offices in the counties and cities were the agencys patients lived. A review of the agencys policy and procedure titled, “Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a plan to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process. During an interview with the Owner and the Administer Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 11:57 AM, the Owner stated the Administrator/Director of Patient Care Services (Admin/DPCS) had been responsible for the Emergency Preparedness Plan (EPP) but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the EPP had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024, and there was no safety committee. The AD/DPCSD verified there was no plan or process to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process. The AD/DPCSD verified there was no contact information for the emergency management offices in the counties and cities were the agencys patients lived. A review of the agencys policy and procedure titled, “;Emergency Management Plan,” undated was conducted. There was no documented evidence to show a plan or procedure to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process.”

“Based on interview and record review, the agency failed to create a plan and implement a procedure to provide for emergency staffing during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to cause patients to suffer an absence of care due to a staff shortage. A review of the agencys Emergency Preparedness Binder, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show a process to provide for emergency staffing during a disaster or emergency. A review of the agencys policy and procedure titled, “Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a plan to provide for emergency staffing during a disaster or emergency. During an interview with the Owner and the Administer Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 11:57 AM, the Owner stated the Administrator/Direction of Patient Care Services (Admin/DPCS) had been responsible for the Emergency Preparedness Program (EPP) but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the EPP had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024, and there was no safety committee. The AD/DPCSD verified there was no plan or process to provide for emergency staffing during a disaster or emergency. A review of the agencys policy and procedure titled, “;Emergency Management Plan,” undated was conducted. There was no documented evidence to show a plan or procedure to provide for emergency staffing during a disaster or emergency.”

“Based on interview and record review, the agency failed to develop a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to place the agencys patients at risk when the agency could not communicate with Federal, State, tribal, regional, and local emergency management agencies in the event of a communications failure. A review of the agencys Emergency Preparedness Binder, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show a process for a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency. A review of the agencys policy and procedure titled, “Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency. During an interview with the Owner and the Administer Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 11:57 AM, the Owner stated the Administrator/Director of Patient Care Services (Admin/DPCS) had been responsible for the Emergency Preparedness Program (EPP) but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the EPP had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024, and there was no safety committee. The AD/DPCSD verified there was no back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency. A review of the agencys policy and procedure titled, “;Emergency Management Plan,” undated was conducted. There was no documented evidence to show a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency.”

“Based on interview and record review, the agency failed to conduct full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency operation centers, etc.] and “;boots on the ground” response [for example, firefighters decontaminating mock victims]) or tabletop emergency preparedness exercises (an exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and set a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan), for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to cause problems within the Emergency Preparedness Program to go unrecognized and unaddressed. A review of the agencys Emergency Preparedness Binder, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show a full-scale community based or tabletop emergency preparedness exercise had been conducted. During an interview with the Owner and the Administer Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 11:57 AM, the Owner stated the Administrator/Director of Patient Care Services (Admin/DPCS) had been responsible for the Emergency Preparedness Program (EPP) but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the EPP had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024, and there was no safety committee. The AD/DPCSD verified no full-scale community based or tabletop emergency preparedness exercise had been conducted. A review of the agencys policy and procedure titled “;Emergency Management Plan,” undated, indicated, “;... 12. [Name of the agency] will test the emergency management plan at least annually, either in response to an actual emergency or in a planned exercise. Planned exercises are realistic scenarios and related to the priority emergencies defined by leadership and DO NOT include tabletop drills nor are they required to be performed in patients’ homes. All actual responses and exercises will be documented and critiqued through a multidisciplinary process that includes administrative, clinical and support staff. Documentation will be used to identify deficiencies and opportunities for improvement based on all monitoring activities and observations during the exercise. 13. [Name of the agency] will modify the emergency management plan in response to the critiques of the exercise. Next scheduled planned exercise will evaluate the effectiveness of the improvements that were made in response to the critiques of the previous exercise. If improvements require substantive recourses that can’t be accomplished by next planned exercise, interim improvements must be put in place until final resolution. ...””

“Based on observation, interview, and record review, the agency failed to develop an individualized plan of care for three of three sampled patients (Patients 1, 2, 3) when: 1. For Patient 1: The Hospice Aide (HA 1) did not follow the HA care plan for providing range of motion exercises (ROM-the HA moves a limb or body part around a joint, gently stretching muscles and reminding them how to move correctly), the HA care plan was not updated at each recertification assessment, the HA care plan indicated supplemental oxygen (a treatment that provides extra oxygen to patients who have breathing problems or lung diseases) use when Patient 1 was not using supplemental oxygen, and the HA care plan indicated blood pressure (a measurement of the pressure of blood in the body’s arteries) and heart rate (the number of times a patients heart beats in a given period of time, usually a minute) reporting parameters (a blood pressure or heart rate measurement where the physician wanted to be notified) when HAs did not take patients blood pressures or heart rates. This failure had the potential for Patient 1 to suffer loss of muscle strength and endurance, and absence of needed hospice aide care services. 2. For Patient 2: There were no reporting parameters for blood pressure or heart rate indicated on Patient 2s care plan or in Patient 2s physicians orders. And LVN 1 determined reporting parameters were unnecessary because Patient 2s slow heart rate of 56 beats per minute (bradycardia-heart beats fewer than 60 times a minute) was considered normal due to Patient 2 taking a medication which lowered a patients heart rate. This failure had the potential to cause Patient 2 to suffer frequent fainting, the inability of the heart to pump enough blood (heart failure) and sudden cardiac arrest or sudden death. 3. For Patient 3: there were no physicians orders to update the care plan, in order to: a. conduct Patient 3’s pulse oximeter readings (a percentage measurement that indicates the amount of oxygen in the patient’s blood) or reporting parameters for pulse oximeter readings. b. conduct Patient 3’s blood sugar readings (a measurement of the amount of sugar in the patient’s blood) or reporting parameters for blood sugar readings. c. report parameters for blood pressure and/or heart rate measurements. There was no care planning: d. For diabetes mellitus (a chronic disease where the body cannot control blood sugar levels) management (a written plan that indicated to monitor blood glucose levels, educate patient on diabetes management, and monitor for signs and symptoms of high and low blood sugar). e. For digoxin medication management (a written plan that indicated to assess apical heart rate (using a stethoscope to listen to the heart and count the number of beats for one minute), assess how much digoxin medication and the mineral potassium were in the patient’s blood and assess for signs and symptoms of digoxin toxicity (when there is too much digoxin medication in the patient’s body and causes confusion, irregular pulse, loss of appetite, nausea, vomiting, diarrhea, fast heartbeat, and vision changes). This failure had the potential to cause Patient 3 to suffer low oxygen saturation levels, too low or high blood sugar levels, too low or high blood pressure levels, too slow or rapid heart rates, diabetes mellitus mismanagement and digoxin mismanagement and toxicity. 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 27, 2024, with a benefit period of September 23, 2024, to November 21, 2024 (Benefit Period Three). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). During Patient 1s home visit on October 15, 2024, at 10:06 AM, with a Hospice Aide (HA 1), HA 1 prepared and gave Patient 1 a bed bath. HA 1 changed Patient 1’s bedding and dressed Patient 1. HA 1 did not provide ROM exercises. During an observation and interview with Patient 1s Caregiver (CG), on October 15, 2024, at 10:06 AM, an oxygen concentrator (a machine that supplied supplemental oxygen) was observed unplugged and stored in Patient 1’s closet. Patient 1 was not using supplemental oxygen. Patient 1’s CG stated Patient 1 had never used supplemental oxygen because she did not need it. The CG stated it was just there in case Patient 1 needed it. The CG stated HA 1 had never performed ROM exercises for Patient 1. During an interview with HA 1 on October 15, 2024, at 11:19 AM, HA 1 stated she knew what an Aide Care Plan was but had not read it. HA 1 stated she did not know she was supposed to provide Patient 1 with ROM exercises. HA 1 stated Patient 1 did not use supplemental oxygen. HA 1 stated she did not take the patients’ vital signs; therefore, she would not report on blood pressure, or pulse rate. A review of Patient 3s Aide Care Plan, dated March 27, 2024, indicated, Patient status: oxygen at two to five liters ( a unit of measurement) per minute. Exercise: ROM active passive every visit. Registered Nurse (RN) additional instructions: Notify RN/CM (Case Manager) or office if any of the following: blood pressure above 160/90 or below 90/60, pulse rate above 100 or below 60. During an interview with a Registered Nurse (RN 1) on October 15, 2024, at 4:36 PM, RN 1 stated she had conducted Patient 1’s admission assessment and recertification assessments. RN 1 stated she had completed Patient 1’s care plan and hospice aide care plan. RN 1 stated she had not re-evaluated Patient 1’s hospice aide care needs at recertification and had not updated Patient 1’s hospice aide care plan. RN 1 stated she did not know she needed to. RN 1 stated she should not have checked the box next to the supplemental oxygen as Patient 1 did not use supplemental oxygen. RN 1 stated hospice aides did not take patients’ vital signs, so blood pressure and heart rate reporting parameters were not needed. RN 1 stated HA 1 should have read Patient 1’s hospice aide care plan before providing services. RN 1 stated HA 1 should have provided ROM exercises for Patient 1. During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 10:51 AM, the AD/DPCSD stated RN 1 should have re-evaluated Patient 1’s hospice aide care needs at each recertification and updated Patient 1’s hospice aide care plan. The AD/DPCSD stated HA 1 should have read Patient 1’s hospice aide care plan before providing services and provided ROM exercises for Patient 1. The AD/DPCSD stated RN 1 should have created a hospice aide care plan specific to Patient 1s needs. 2. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 20, 2024, with a benefit period of August 20, 2024, to November 17, 2024 (First 90-day benefit period). Patient 2 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During Patient 2s home visit on October 15, 2024, at 12:09 PM, with a Licensed Vocational Nurse (LVN 1), LVN 1 took Patient 2’s vital signs: blood pressure: 118 (Systolic blood pressure, the pressure in the arteries when the heart beats and the ventricles contract) over 60 (diastolic blood pressure, the minimum pressure in the arteries when the heart is relaxed between beats), heart rate: 56 beats per minute (bpm), temperature: 97.3 degrees Fahrenheit, Respirations: 16 breaths per minute (bpm), No pain. LVN 1 reviewed Patient 2’s care plan and physician’s orders, no reporting parameters were indicated. LVN 1 stated she was not going to report Patient 2’s heart rate of 56 bpm because Patient 2 was on a medication that lowered the heart rate, so Patient 2’s slow heart rate was normal. A review of Patient 2’s physician’s medication orders from August 20, 2024, to October 15, 2024, indicated Patient 2 was taking the following medication:a. Physician’s order dated August 20, 2024, furosemide (a medication that lowers blood pressure), 40 mg (milligrams-a unit of measurement), one tablet, two times a day.b Physician’s order dated August 20, 2024, spironolactone (a medication that lowers blood pressure) 25 mg, half a tablet, once a day.c. Physician’s order dated August 20, 2024, losartan potassium (a medication that lowers blood pressure) 25 mg, one tablet, once a day.d. Physician’s order dated August 20, 2024, metoprolol tartrate (a medication that lowers blood pressure and heart rate) 25 mg, one tablet, two times a day. During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 11:15 AM, The AD/DPCSD stated she had conducted Patient 2’s admission assessment. The AD/DPCSD stated she had completed Patient 2’s care plan and had not requested an order for reporting parameters from the Medical Director (MD). The AD/DPCSD stated she had never attended an Interdisciplinary Group Meeting (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient). The AD/DPCSD stated it was inappropriate for a Licensed Vocational Nurse (LVN) to decide when and what to report to a Registered Nurse (RN) and/or physician. During an interview with the Medical Director (MD) on October 17, 2024, at 10:10 AM, the MD stated he did not know Patient 2 had been admitted to the agency. The MD stated he had not attended any IDG meetings because he thought the agency had put patient admissions on hold due to the agency going through “hard times.” The MD stated the admitting Registered Nurse (RN) should have requested an order with reporting parameters during the first IDG meeting after admission. The MD stated it was inappropriate for an LVN to decide when and what to report to a physician. The MD stated he needed to review Patient 2’s clinical history and current medication regime to determine if something needed to be done to address Patient 2’s 56 bpm heart rate. The MD stated this was something he would do during an IDG meeting if he had known they were being conducted. 3. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, with a benefit period of September 26, 2024, to November 24, 2024 (Benefit Period Eight). Patient 3 had diagnoses that included congestive heart failure (a condition where the heart does not pump enough blood to meet the body’s needs). During Patient 3s home visit on October 15, 2024, at 4:08 PM, with a Registered Nurse (RN 1), RN 1 took Patient 3’s vital signs: temperature: 97.7 degrees Fahrenheit, oxygen saturation (amount of oxygen in the blood) 95% (percent), radial heart rate (the rate at which your heart beats, as measured by feeling the radial pulse at the wrist) 67 beats per minute (BPM), blood pressure 132 over 82, blood sugar (BS) 111 milligrams per deciliter (mg/dL). RN 1 stated Patient 3 did not like taking his own BS and always waited for her to come and take his BS reading. During an interview with RN 1 on October 15, 2024, at 4:36 PM, RN 1 stated she had conducted Patient 3’s admission assessment and created Patient 3’s care plan. RN 1 reviewed Patient 3’s physician’s orders from March 30, 2024, to October 15, 2024, and confirmed the following: a. No physician’s order to conduct Patient 3’s pulse oximeter reading (a percentage measurement that indicates the amount of oxygen in the patient’s blood) or reporting parameters for pulse oximeter readings. b. No physician’s order to conduct Patient 3’s blood sugar reading (a measurement of the amount of sugar in the patient’s blood) or reporting parameters for blood sugar readings. c. No physician’s order with reporting parameters for blood pressure and/or heart rate measurements. d. Physician’s order dated March 30, 2024, carvedilol (a medication that lowers heart rate and blood pressure) 25 mg (milligrams-a unit of measurement), one tablet once per day. e. Physician’s order dated March 30, 2024, digoxin (a medication that lowers heart rate and helps heart pump more efficiently), 0.125 mg, take one tablet, once per day. f. spironolactone (a medication that lowers blood pressure), 25 mg, half a tablet, once per day. g. Physician’s order dated March 30, 2024, metformin hydrochloride (a medication that lowers blood sugar), 500 mg, one tablet, two times a day. RN 1 reviewed Patient 3’s care plan from March 30, 2024, to October 15, 2024, and confirmed the following: a. No reporting parameters for pulse oximeter readings. b. No reporting parameters for blood sugar readings. c. No reporting parameters for blood pressure and/or heart rate measurements. d. No care plan for diabetes (a chronic disease where the body cannot control blood sugar levels) management (a written plan that indicates to: monitor blood glucose levels, educate patient on diabetes management, and monitor for signs and symptoms of high and low blood sugar). e. No care plan for digoxin medication management (a written plan that indicates to: assess apical heart rate (using a stethoscope to listen to the heart on the chest and count the number of beats for one minute), assess how much digoxin medication and the mineral potassium are in the patient’s blood and assess for signs and symptoms of digoxin toxicity (when there is too much digoxin medication in the patient’s body and causes confusion, irregular pulse, loss of appetite, nausea, vomiting, diarrhea, fast heartbeat, and vision changes). In a continued interview with RN 1, RN 1 stated she had not created a care plan for Patient 3 to address: a. Reporting parameters for pulse oximeter readings. b. Reporting parameters for blood sugar readings. c. Reporting parameters for blood pressure and/or heart rate measurements. d. Diabetes management e. Digoxin medication management RN 1 stated she had not contacted the Medical Director (MD) to obtain orders to: a. Conduct Patient 3’s pulse oximeter readings and reporting parameters for pulse oximeter readings. b. Conduct Patient 3’s blood sugar readings and reporting parameters for blood sugar readings. c. Obtain reporting parameters for blood pressure and/or heart rate measurements. RN 1 stated she had not consulted with the MD on Patient 3’s care at the Interdisciplinary Group Meetings (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) because he never attended. During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 11:40 AM, The AD/DPCSD stated RN 1 should have consulted with the MD on Patient 3’s care at the IDG meetings. The AD/DPCSD stated she had never attended an IDG meeting. The AD/DPCSD stated RN 1 should have obtained physician orders to: a. Conduct Patient 3’s pulse oximeter readings and reporting parameters for pulse oximeter readings. b. Conduct Patient 3’s blood sugar readings and reporting parameters for blood sugar readings. c. Obtain reporting parameters for blood pressure and/or heart rate measurements. The AD/DPCSD stated RN 1 should have created Patient 3’s care plan to include: a. Reporting parameters for pulse oximeter readings. b. Reporting parameters for blood sugar readings. c. Reporting parameters for blood pressure and/or heart rate measurements. d. Diabetes management e. Digoxin medication management During an interview with the Medical Director (MD) on October 17, 2024, at 10:10 AM, The MD stated he had not attended any IDG meetings because he thought the agency had put patient admissions on hold due to the agency going through “hard times.” The MD stated the admitting Registered Nurse (RN) should have requested an order to: a. Conduct Patient 3’s pulse oximeter readings and reporting parameters for pulse oximeter readings. b. Conduct Patient 3’s blood sugar readings and reporting parameters for blood sugar readings. c. Obtain reporting parameters for blood pressure and/or heart rate measurements. The MD stated he should have been present at the IDG meetings to discuss Patient 3’s diabetes and digoxin medication management as well as other care needs. The MD stated he would have attended if he had known the agency was not “on hold.” A review of the agencys policy and procedure titled, “;The Plan of Care,” undated, indicated, “;PURPOSE: To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. POLICY: Each patient must have a written plan of care that specifies the care and services necessary to meet the patient’s specific needs as identified in the comprehensive assessment. 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 of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. This plan of care must be initiated at start of care. ...””

“Based on interview, and record review, the hospice interdisciplinary group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) failed to review, revise, and document the individualized care plan as frequently as the patients condition required, but no less frequently than every 15 calendar days, for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14). This failure had the potential for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 responses to care, treatment, and services to go unaddressed. A review of the agencys policy and procedure titled “;Interdisciplinary Group Membership and Responsibilities,” undated, indicated, “;The hospice interdisciplinary team/group members will include, at a minimum, A. Physician, B. Registered nurse, C. Social worker, D. Pastoral or other counselor.” During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 9: 30 AM, the Owner stated she purchased the agency on October 1, 2021, owned 100% (percent) and was the sole member of the Governing Body. The Owner stated she went into business with her brother who was the Administrator/Director of Patient Care Services (Admin/DPCS). The Owner stated she did not hold a nursing license and had no experience with running a hospice agency. The Owner stated the Admin/DPCS had been responsible for running the agency, taking care of the patients and running the IDG meetings. The Owner stated the Admin/DPCS suffered a devastating family tragedy between April 2023 to June 2023 and stopped fulfilling the Admin/DPCS responsibilities. The Owner stated she noticed the IDG meetings had stopped in July 2023. The Owner stated the Admin/DPCS had not appointed an Administrator Designee or Director of Patient Care Services Designee, so she took over and began looking for someone to help her. The Owner stated she met the AD/DPCSD on August 1, 2024, and hired her as a visiting nurse and the AD/DPCSD started giving her advice on how to run the agency. The AD/DPCSD stated she had been offered and accepted the AD/DPCSD position on October 14, 2024, “;The day you [Surveyor] arrived.” The AD/DPCSD stated she had never attended an IDG meeting. 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 27, 2024, with a benefit period of September 23, 2024, to November 21, 2024 (Benefit Period Three). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 1s IDG meeting notes from September 23, 2024, to October 17, 2024, indicated, two IDG meetings on September 30, 2024, and October 14, 2024. There was no documented evidence to show the Medical Director (MD) or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. 2. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 20, 2024, with a benefit period of August 20, 2024, to November 17, 2024 (First 90-day benefit period). Patient 2 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 2s IDG meeting notes from August 20, 2024, to October 17, 2024, indicated, four IDG meetings on September 2, 16, 30, 2024, and October 14, 2024. There was no documented evidence to show the Medical Director (MD) or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. 3. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, with a benefit period of September 26, 2024, to November 24, 2024 (Benefit Period Eight). Patient 3 had diagnoses that included congestive heart failure (a condition where the heart does not pump enough blood to meet the body’s needs). A review of Patient 3s IDG meeting notes from September 26, 2024, to October 17, 2024, was conducted. There was no documented evidence to show IDG meetings had been conducted. 4. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 6, 2024, with a benefit period of September 6, 2024, to December 4, 2024 (First 90-day benefit period). Patient 4 had diagnoses that included heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). A review of Patient 4s IDG meeting notes from September 6, 2024, to October 17, 2024, indicated, three IDG meetings on September 9, and 23, 2024, and October 7, 2024. There was no documented evidence to show the Medical Director (MD) or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. 5. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 12, 2024, with a benefit period of September 12, 2024, to December 10, 2024 (First 90-day benefit period). Patient 5 had diagnoses that included Parkinsonism (another name for Parkinson’s disease-a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 5s IDG meeting notes from September 12, 2024, to October 17, 2024, indicated, three IDG meetings on September 6, and 30, 2024, and October 14, 2024. There was no documented evidence to show the Medical Director (MD) or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. 6. A review of Patient 6s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 30, 2024, with a benefit period of August 30, 2024, to November 27, 2024 (First 90-day benefit period). Patient 6 had diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 6s IDG meeting notes from August 30, 2024, to October 17, 2024, indicated, two IDG meetings on September 2, and 16, 2024. An IDG meeting was due on September 30, 2024, but there was no documented evidence to show it had been conducted. In addition, there was no documented evidence to show the Medical Director (MD), or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. 7. A review of Patient 7s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 30, 2024, with a benefit period of August 30, 2024, to November 27, 2024 (First 90-day benefit period). Patient 7 had diagnoses that included hypertensive heart disease (a group of heart problems that develop due to chronic high blood pressure). A review of Patient 7s IDG meeting notes from August 30, 2024, to October 17, 2024, indicated, two IDG meetings on September 2, and 16, 2024. An IDG meeting was due on September 30, 2024, but there was no documented evidence to show it had been conducted. In addition, there was no documented evidence to show the Medical Director (MD), or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. 8. A review of Patient 8s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 28, 2024, with a benefit period of August 28, 2024, to November 25, 2024 (First 90-day benefit period). Patient 8 had diagnoses that included hypertensive heart disease (a group of heart problems that develop due to chronic high blood pressure). A review of Patient 8s IDG meeting notes from August 28, 2024, to October 17, 2024, indicated, two IDG meetings on September 2, and 16, 2024. An IDG meeting was due on September 30, 2024, but there was no documented evidence to show it had been conducted. In addition, there was no documented evidence to show the Medical Director (MD), or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. 9. A review of Patient 9s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 28, 2024, with a benefit period of August 28, 2024, to November 25, 2024 (First 90-day benefit period). Patient 9 had diagnoses that included atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries of the heart). A review of Patient 9s IDG meeting notes from August 28, 2024, to October 17, 2024, indicated, two IDG meetings on September 2, and 16, 2024. An IDG meeting was due on September 30, 2024, but there was no documented evidence to show it had been conducted. In addition, there was no documented evidence to show the Medical Director (MD), or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. 10. A review of Patient 10s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 23, 2024, with a benefit period of August 23, 2024, to November 20, 2024 (First 90-day benefit period). Patient 10 had diagnoses that included systolic heart failure (a condition that occurs when the heart’s left ventricle is too weak to pump enough blood throughout the body). A review of Patient 10s IDG meeting notes from August 23, 2024, to October 17, 2024, indicated, three IDG meetings on August 26, 2024, September 2, and 16, 2024. An IDG meeting was due on September 30, 2024, but there was no documented evidence to show it had been conducted. In addition, there was no documented evidence to show the Medical Director (MD), or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. 11. A review of Patient 11s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 1, 2024, with a benefit period of July 1, 2024, to September 28, 2024 (First 90-day benefit period). Patient 11 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 11s IDG meeting notes from July 1, 2024, to October 17, 2024, indicated, one IDG meeting was supposed to be conducted on July 22, 2024, but there was no documented evidence to show the IDG meeting had been conducted. 12. A review of Patient 12s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of February 1, 2024, with a benefit period of February 1, 2024, to April 30, 2024 (Second 90-day benefit period). Patient 12 had diagnoses that included atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries of the heart). A review of Patient 12s IDG meeting notes from February 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show IDG meetings had been conducted. 13. A review of Patient 13s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 10, 2024, with a benefit period of July 10, 2024, to October 7, 2024 (First 90-day benefit period). Patient 13 had diagnoses that included heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). A review of Patient 13s IDG meeting notes from July 10, 2024, to October 17, 2024, indicated, one IDG meetings on July 10, 2024. There was no documented evidence to show the Medical Director (MD) or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. 14. A review of Patient 14s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 1, 2024, with a benefit period of March 1, 2024, to April 29, 2024 (Benefit Period Seven). Patient 14 had diagnoses that included Moderate protein-calorie malnutrition (is the state of inadequate intake of food such as protein, calories, and other essential nutrients). A review of Patient 14s IDG meeting notes from March 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show IDG meetings had been conducted. During an interview with the MD on October 17, 2024, at 10:10 AM, the MD stated he had been the Medical Director for the agency since October 15, 2020. The MD stated he had never attended the IDG meetings at the agency. The MD stated the agency had been going through “;hard times” and he thought patient admissions had been put “;on hold.” The MD stated it was his responsibility to attend the IDG meetings and provide medical oversight for the patients, but he had not been informed the agency was admitting patients and holding IDG meetings. During an interview with a Medical Social Worker (MSW) on October 17, 2024, at 2:41 PM, the MSW stated the IDG meetings were just her and a Registered Nurse (RN 1) discussing the patients. The MSW stated a physician never attended. The MSW stated she did not know who the Admin/DPCS was. A review of the agencys policy and procedure titled “;Interdisciplinary Group Meeting,” undated, indicated, “;PURPOSE: To define the process for interdisciplinary group meetings and documenting patient status in the clinical record. POLICY: Responsibilities A. The program shall establish an interdisciplinary team whose responsibility shall include but not be limited to 1. Establishment of a plan of care. 2. Provision, and/or supervision and coordination of care services. 3. Review and/or revision, on a regular basis, of the plan of care for each patient and family receiving care. 4. Implementation of policies governing the day-to-day provision of care and services. B. The interdisciplinary team shall make use of consultants and community resources as necessary and appropriate. C. Any unusual change in the patient’s physical, mental, spiritual or emotional status shall be reported to the primary caregiver(s), the attending physician and the interdisciplinary team. ... The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s 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 patient’s condition requires. The meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The patient and family/caregiver will be informed of the schedule for this meeting, its purpose, and that the discussion is confidential. ...””

“Based on interview, and record review, the agency failed to measure and analyze quality indicators (a measurable element of the agencys practice that can be used to assess the quality of care provided) to assess the agencys processes of care, services, and operations, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized and unaddressed. During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 9:30 AM, the Owner stated she purchased the agency on October 1, 2021, owned 100% (percent) and was the sole member of the Governing Body. She went into business with her brother who was the Admin/DPCS. She did not hold a nursing license and had no experience with running a hospice agency. The Owner stated the Admin/DPCS had been responsible for running the agency, taking care of the patients and running the Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) meetings. The Admin/DPCS suffered a devastating family tragedy between April 2023 to June 2023 and stopped fulfilling the Admin/DPCS responsibilities. The Admin/DPCS had not appointed an Administrator Designee or Director of Patient Care Services Designee, so she took over and began looking for someone to help her. She met the AD/DPCSD on August 1, 2024, and hired her as a visiting nurse and the AD/DPCSD started giving her advice on how to run the agency. The AD/DPCSD stated she had been offered and accepted the AD/DPCSD position on October 14, 2024, “;The day you [Surveyor] arrived.” A review of the agencys “;Quality Assessment and Performance Improvement (QAPI)” binder, undated, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show quality indicators had been selected, tracked, measured, or analyzed. The QAPI binder did not contain documented evidence to show data had been, collected, assembled or analyzed, for the three years the agency had been operational from October 1, 2021, through October 17, 2024. There was no documented evidence to show statistical techniques such as controls charts (a graph used to study how a process changes over time), histograms (a graphical representation that organizes a group of data points into user-specified ranges), bar graphs (a chart that plots data using rectangular bars or columns) or pareto charts (a chart that contains both bars and a line graph, where individual values are represented in descending order by bars, and the cumulative total is represented by the line) had been indicated to use for analysis once data had been collected. The QAPI binder did not contain documented evidence to show the agency had developed mechanisms such as thresholds (a value), setting upper and lower control limits (identifies what value is acceptable), percentages (numbers that summarize data), ratios (the relationship in quantity, amount, or size between two or more things) or performance goals in order to identify levels, patterns or trends in the agencys provision of care for the three years the agency had been operational from October 1, 2021, through October 17, 2024. During a concurrent record review and interview, on October 17, 2024, at 11:46 AM, with the Owner and the AD/DPCSD, the contents of the QAPI binder were reviewed. The Owner stated the Admin/DPCS had been responsible for the QAPI program but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the QAPI Program had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024. A review of the agencys policy and procedure titled “;Improving Organizational Performance,” undated, indicated, “;POLICY: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT: A. Each program shall have an organized system for assessing and improving the quality of care and services. This system shall be designed to improve performance on a systematic and continuous basis. The system shall consist of planned and measurable mechanisms for data collection, analysis and a process for improvement within specified time frames. B. The organization shall implement performance improvement processes that routinely assess and improve all services provided directly and by written agreement. C. Each organization shall have a written plan reviewed and revised at least annually for improving the organization’s performance. This plan shall include, but not be limited to, assessment and improvement of the quality and efficiency of governance; management; and clinical and support processes. D. The organization must have a process for assessing employee competence; measuring consumer satisfaction; and investigating, addressing and documenting complaints and grievances. ... G. All performance improvement activities will be documented on a quarterly basis and maintained on file. H. Utilization review shall include criteria for each discipline providing care, Criteria shall include: 1. Appropriateness of the level of care to protect the health and safety of patients. 2. Timeliness of care. 3. Adequacy of care to meet patients’ needs. 4. Appropriateness of specific services provided. 5. Whether standards of practice for patient care were observed. ... PROCEDURE: 1. Senior management with Governing Body oversight will: A. Participate in educational activities to increase their level of understanding and ability to implement quality assessment and performance improvement activities. The educational activities may include seminars, consultations, readings, periodicals, benchmarking, and review of available information from other organizations regarding the occurrence of sentinel events to reduce the risk of similar sentinel events within the organization. B. Set expectations for performance improvement and manage processes to improve organization performance. C. Adopt a scientific, problem-solving, data driven approach to quality assessment and performance improvement (QAPI). The scientific, problem-solving approach will include, minimally: 1. Planning for performance improvement with integration of information from other relevant activities that focus on high risk, high volume or problem prone areas. These may include a. Risk management, such as adverse pain events and medication management. b. Utilization management 1. Utilizing appropriate statistical technicians to analyze and display data a. Statistical tools to include 1. Run charts that display summary and comparison data. 2. Scatter diagrams. 3. Control charts that display variations and trends over time. 4. Histograms. 5. Pareto charts. 6. Cause-and-effect or fishbone diagrams. 7. Process flowcharts ...””

“Based on interview, and record review, the agency failed to ensure the agencys Governing Body approved the frequency and detail of the Quality Assessment Performance Improvement (QAPI) programs data collection, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure caused the GB to miss an opportunity to correct ineffective data collection. A review of the agency’s “Governing Body Minutes,” binder, undated, was conducted for the three years the agency had been operational from October 1, 2021, through October 17, 2024. There was no documented evidence to show the Governing Body (GB) approved the frequency and detail of the QAPI programs data collection. There was no documented evidence to show the QAPI Committee had provided the detail and frequency of data collection to the GB for review and approval. During an interview with the Owner on October 17, 2024, at 11:46 AM, the Owner stated she was the sole member of the Governing Body (GB) and the GB had not approved the frequency and detail of data collection for the QAPI program for the three years the agency had been operational from October 1, 2021, through October 17, 2024. A review of the agencys policy and procedure titled “;Quality Assessment Performance Improvement (QAPI) Plan,” undated, indicated, “;Assignment of Responsibility ... The Governing Body is ultimately responsible for the QAPI Plan and for ensuring: That the QAPI Plan is ongoing, implemented and maintained. That implemented QAPI activities address the appropriate priorities for the improved quality of care and patient safety. Clear expectations for patient safety are met. That all QAPI actions/changes are evaluated for effectiveness. ...””

“Based on interview and record review, the agency failed to conduct and document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had undertaken, the reasons for conducting the PIP and measurable goals to show progress achieved, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to cause problems in health outcomes, patient safety, and quality of care to go unaddressed and continue. A review of the agencys “;Quality Assessment and Performance Improvement (QAPI)” binder, undated, was conducted for the three years the agency had been operational from October 1, 2021, through October 17, 2024. There was no documented evidence to show performance improvement projects had been initiated, were in process or had been completed for the three years (from October 1, 2021, through October 17, 2024) reviewed. During a concurrent record review and interview, on October 17, 2024, at 11:46 AM, with the Owner and the AD/DPCSD, the contents of the QAPI binder were reviewed. The Owner stated the Admin/DPCS had been responsible for the QAPI program but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated a PIP had not been initiated or conducted for the three years the agency had been operational from October 1, 2021, through October 17, 2024. A review of the agencys policy and procedure titled “;Quality Assessment Performance Improvement (QAPI) Plan,” undated, indicated, “;OBJECTIVES: ... To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that it is sustained. To document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projects. ...””

“Based on interview, and record review, the agencys Governing Body (GB) failed to provide oversight for its Quality Assessment and Performance Improvement (QAPI) Program for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients when: 1. Based on interview, and record review, the agency failed to measure and analyze quality indicators (a measurable element of the agencys practice that can be used to assess the quality of care provided) to assess the agencys processes of care, services, and operations, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. 2. Based on interview, and record review, the agency failed to ensure the agencys Governing Body approved the frequency and detail of the Quality Assessment Performance Improvement (QAPI) programs data collection, for the for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. 3. Based on interview and record review, the agency failed to conduct and document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had planned to undertake, the reasons for conducting the PIP and measurable goals to show progress achieved, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to cause the agency to provide inferior care and services to its patients. 1. During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 9:30 AM, the Owner stated she purchased the agency on October 1, 2021, owned 100% (percent) and was the sole member of the Governing Body. A review of the agencys “;Quality Assessment and Performance Improvement (QAPI)” binder, undated, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show quality indicators had been selected, tracked, measured, or analyzed. The QAPI binder did not contain documented evidence to show data had been assembled and analyzed, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, There was no documented evidence to show statistical techniques such as controls charts (a graph used to study how a process changes over time), histograms (a graphical representation that organizes a group of data points into user-specified ranges), bar graphs (a chart that plots data using rectangular bars or columns) or pareto charts (a chart that contains both bars and a line graph, where individual values are represented in descending order by bars, and the cumulative total is represented by the line) had been used to analyze data if the agency had been collecting it. The QAPI binder did not contain documented evidence to show the agency had developed mechanisms such as thresholds (a value), setting upper and lower control limits (identifies what value is acceptable), percentages (numbers that summarize data), ratios (the relationship in quantity, amount, or size between two or more things) or performance goals in order to identify levels, patterns or trends in the agencys provision of care for the three years the agency had been operational from October 1, 2021, through October 17, 2024. During a concurrent record review and interview, on October 17, 2024, at 11:46 AM, with the Owner and the AD/DPCSD, the contents of the QAPI binder were reviewed. The Owner stated the Admin/DPCS had been responsible for the QAPI program but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the QAPI Program had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024. A review of the agencys policy and procedure titled “;Improving Organizational Performance,” undated, indicated, “;POLICY: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT: A. Each program shall have an organized system for assessing and improving the quality of care and services. This system shall be designed to improve performance on a systematic and continuous basis. The system shall consist of planned and measurable mechanisms for data collection, analysis and a process for improvement within specified time frames. B. The organization shall implement performance improvement processes that routinely assess and improve all services provided directly and by written agreement. C. Each organization shall have a written plan reviewed and revised at least annually for improving the organization’s performance. This plan shall include, but not be limited to, assessment and improvement of the quality and efficiency of governance; management; and clinical and support processes. D. The organization must have a process for assessing employee competence; measuring consumer satisfaction; and investigating, addressing and documenting complaints and grievances. ... G. All performance improvement activities will be documented on a quarterly basis and maintained on file. H. Utilization review shall include criteria for each discipline providing care, Criteria shall include: 1. Appropriateness of the level of care to protect the health and safety of patients. 2. Timeliness of care. 3. Adequacy of care to meet patients’ needs. 4. Appropriateness of specific services provided. 5. Whether standards of practice for patient care were observed. ... PROCEDURE: 1. Senior management with Governing Body oversight will: A. Participate in educational activities to increase their level of understanding and ability to implement quality assessment and performance improvement activities. The educational activities may include seminars, consultations, readings, periodicals, benchmarking, and review of available information from other organizations regarding the occurrence of sentinel events to reduce the risk of similar sentinel events within the organization. B. Set expectations for performance improvement and manage processes to improve organization performance. C. Adopt a scientific, problem-solving, data driven approach to quality assessment and performance improvement (QAPI). The scientific, problem-solving approach will include, minimally: 1. Planning for performance improvement with integration of information from other relevant activities that focus on high risk, high volume or problem prone areas. These may include a. Risk management, such as adverse pain events and medication management. b. Utilization management 1. Utilizing appropriate statistical technicians to analyze and display data a. Statistical tools to include 1. Run charts that display summary and comparison data. 2. Scatter diagrams. 3. Control charts that display variations and trends over time. 4. Histograms. 5. Pareto charts. 6. Cause-and-effect or fishbone diagrams. 7. Process flowcharts ...” 2. A review of the agency’s “Governing Body Minutes,” binder, undated, was conducted for the three years the agency had been operational from October 1, 2021, through October 17, 2024. There was no documented evidence to show the Governing Body (GB) approved the frequency and detail of the QAPI programs data collection. There was no documented evidence to show the QAPI Committee had provided the detail and frequency of data collection to the GB for review and approval. During an interview with the Owner on October 17, 2024, at 11:46 AM, the Owner stated she was the sole member of the Governing Body (GB) and the GB had not approved the frequency and detail of data collection for the QAPI program for the three years the agency had been operational from October 1, 2021, through October 17, 2024. A review of the agencys policy and procedure titled “;Quality Assessment Performance Improvement (QAPI) Plan,” undated, indicated, “;Assignment of Responsibility ... The Governing Body is ultimately responsible for the QAPI Plan and for ensuring: That the QAPI Plan is ongoing, implemented and maintained. That implemented QAPI activities address the appropriate priorities for the improved quality of care and patient safety. Clear expectations for patient safety are met. That all QAPI actions/changes are evaluated for effectiveness. ...” 3. A review of the agencys “;Quality Assessment and Performance Improvement (QAPI)” binder, undated, was conducted for the three years the agency had been operational from October 1, 2021, through October 17, 2024. There was no documented evidence to show performance improvement projects had been initiated, were in process or had been completed for the three years (from October 1, through October 17, 2024) reviewed. During a concurrent record review and interview, on October 17, 2024, at 11:46 AM, with the Owner and the AD/DPCSD, the contents of the QAPI binder were reviewed. The Owner stated the Admin/DPCS had been responsible for the QAPI program but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated a PIP had not been initiated or conducted for the three years the agency had been operational from October 1, 2021, through October 17, 2024. A review of the agencys policy and procedure titled “;Quality Assessment Performance Improvement (QAPI) Plan,” undated, indicated, “;OBJECTIVES: ... To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that it is sustained. To document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projects. ...” During an interview with the Owner on October 17, 2024, at 11:46 AM, the Owner stated she was the sole member of the Governing Body (GB). The Owner stated the GB had not identified the QAPI committees failure to collect, measure and analyze quality indicator data, or conduct performance improvement projects for the three years the agency had been operational from October 1, 2021, through October 17, 2024. The Owner stated the GB had not approved the frequency and detail of the QAPI programs data collection for the three years the agency had been operational from October 1, 2021, through October 17, 2024. The Owner stated the GB failed to define, implement, maintain, and evaluate the QAPI program. A review of the agencys policy and procedure titled “;Improving Organizational Performance,” undated, indicated, “;The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually.””

“Based on interview, and record review, the agency failed to maintain an infection control program that was integrated into the agencys Quality Assessment Performance Improvement (QAPI) program in order to: identify infection trends (analysis of a pattern), develop action plans and improve disease prevention, from October 1, 2021 (the date the Owner purchased the agency) to October 17, 2024, in a universe of 14 patients. This failure had the potential to cause trends in infections to go unrecognized, unaddressed and patients to suffer repeated and prolonged infections. During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 9:30 AM, the Owner stated she purchased the agency on October 1, 2021, owned 100% (percent) and was the sole member of the Governing Body. She went into business with her brother who was the Admin/DPCS. She did not hold a nursing license and had no experience with running a hospice agency. The Owner stated the Admin/DPCS had been responsible for running the agency, taking care of the patients and running the Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) meetings. The Admin/DPCS suffered a devastating family tragedy between April 2023 to June 2023 and stopped fulfilling the Admin/DPCS responsibilities. The Admin/DPCS had not appointed an Administrator Designee or Director of Patient Care Services Designee, so she took over and began looking for someone to help her. She met the AD/DPCSD on August 1, 2024, and hired her as a visiting nurse and the AD/DPCSD started giving her advice on how to run the agency. The AD/DPCSD stated she had been offered and accepted the AD/DPCSD position on October 14, 2024, “;The day you [Surveyor] arrived.” A review of the agency’s infection control binder from October 1, 2021 (the date the Owner purchased the agency) to October 17, 2024, was conducted. The binder did not contain any data collection on the patients’ infections for three years. A review of the agency’s QAPI binder from October 1, 2021 (the date the Owner purchased the agency) to October 17, 2024, was conducted. The QAPI binder did not contain documentation showing infection control data had been received, aggregated or analyzed by the QAPI Committee. A review of the agency’s in-service binder from October 1, 2021 (the date the Owner purchased the agency) to October 17, 2024, did not indicate staff had received any infection control in-services. A review of the agencys Governing Body (GB) meeting minutes from October 1, 2021 (the date the Owner purchased the agency) to October 17, 2024, was conducted. There was no documented evidence of GB meeting minutes, oversight of the Infection Control Program or oversight for the QAPI Program. During an interview with the Owner and AD/DPCS on October 17, 2024, at 11:30 AM, the Owner stated she had hired a nurse consultant to help run the agency. The Owner thought the nurse consultant had been working on the infection control program but “;apparently had not.” The Owner stated, “;She just took the money and left without doing anything.” The AD/DPCSD confirmed the agency had no active Infection Control Program. A review of the agencys policy and procedure titled “;Infection Control Plan,” undated, indicated, “;PURPOSE: To delineate an infection control plan to meet the following goals: 1. Establish the mechanisms by which the organization will address surveillance, prevention, identification, control and reporting of infections. 2. Guide organization personnel in the care and services they provide in relation to infection control practices. A. Set goals for improving influenza infection rates. B. Set goals for compliance with hand hygiene guidelines. 3. Educate organization personnel, patients and family/caregivers, and others in the prevention and control of infections. 4. Provide for surveillance systems to track the occurrence and transmission of infections. 5. Respond to outbreaks of infectious diseases and prepare for potential influx of infectious patients as part of emergency management activities. ... POLICY: [name of agency] is committed to reducing the risk of acquisition and transmission of health care associated infections (HAIs). Recognized prevention and control mechanisms will be implemented for planning, surveillance, identification, prevention/control, and reporting procedures. To determine the effectiveness of the infection control plan, [name of agency] will measure, assess, improve, and redesign (as appropriate) the surveillance, identification, prevention, and control function annually through its performance improvement program. ...””

“Based on interview and record review, the agency failed to ensure a Bereavement (the experience of losing someone important) Program (a program providing an initial bereavement assessment, a bereavement plan of care, a post-death assessment, mailing of bereavement letters, and post-death support assistance) was maintained to provide bereavement services to family, loved ones and caregivers for one year following the death of a patient, for two of two sampled patients (Patients 13 and 14), in a universe of 14 patients. This failure had the potential to cause individuals experiencing grief to suffer a lack of support and guidance leading to complications with their grief and impacting their mental and physical health. During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 9:30 AM, the Owner stated she purchased the agency on October 1, 2021, owned 100% (percent) and was the sole member of the Governing Body. She went into business with her brother who was the Admin/DPCS. She did not hold a nursing license and had no experience with running a hospice agency. The Owner stated the Admin/DPCS had been responsible for running the agency, taking care of the patients and running the Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) meetings. The Admin/DPCS suffered a devastating family tragedy between April 2023 to June 2023 and stopped fulfilling the Admin/DPCS responsibilities. The Admin/DPCS had not appointed an Administrator Designee or Director of Patient Care Services Designee, so she took over and began looking for someone to help her. She met the AD/DPCSD on August 1, 2024, and hired her as a visiting nurse and the AD/DPCSD started giving her advice on how to run the agency. The AD/DPCSD stated she had been offered and accepted the AD/DPCSD position on October 14, 2024, “;The day you [Surveyor] arrived.” 1. A review of Patient 13s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 10, 2024, with a benefit period of July 10, 2024, to October 7, 2024 (First 90-day benefit period). Patient 13 had diagnoses that included heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). Patient 13 expired on July 20, 2024. A review of Patient 13s bereavement assessments (a tool used to evaluate the risk of a person experiencing a negative bereavement experience. It can help identify factors that may contribute to a difficult bereavement and is used to create a bereavement care plan) from July 10, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a bereavement assessment had been performed. A review of Patient 13s bereavement care plans (a document that outlines a person’s goals, interventions, and services for dealing with bereavement) from July 10, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a bereavement care plan had been created. A review of Patient 13s post-death assessments (a professional evaluation of a person’s grief reaction after a loved one has died) from July 10, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a post-death assessment had been performed. A review of Patient 13s bereavement letter mailings (a way to provide support and comfort to those who are grieving with emotional support letters, educational enclosures, and community service resources) from July 10, 2024, to October 17, 2024, was conducted. There was no documented evidence to show bereavement letter mailings had occurred. A review of Patient 13s post-death support assistance (a service that helps people deal with the loss of a loved one by providing emotional, psychosocial, and spiritual support through counseling, support groups, educational forums and memorial services) from July 10, 2024, to October 17, 2024, was conducted. There was no documented evidence to show post-death support assistance had been offered. During an interview with the Owner and AD/DPCSD on October 17, 2024, at 1:03 PM, the Owner stated a Bereavement Coordinator (BC) was responsible for the Bereavement Program and she thought the BC was taking care of it. The Owner stated she did not know anything about what to do with a hospice Bereavement Program and had relied on the BC. The AD/DPCSD stated she had reviewed the documentation for the Bereavement Program and concluded it was not an active program. The AD/DPCSD verified Patient 13s family had not received bereavement services. The Owner and AD/DPCSD stated they had repeatedly tried to contact the BC but there had been no response. The BC was unavailable for interview. 2. A review of Patient 14s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 1, 2024, with a benefit period of March 1, 2024, to April 29, 2024 (Benefit Period Seven). Patient 14 had diagnoses that included Moderate protein-calorie malnutrition (is the state of inadequate intake of food such as protein, calories, and other essential nutrients). Expired March 21, 2024. A review of Patient 14s bereavement care plans from March 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a bereavement care plan had been created. A review of Patient 14s post-death assessments from March 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a post-death assessment had been performed. A review of Patient 14s bereavement letter mailings from March 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show bereavement letter mailings had occurred. A review of Patient 14s post-death support assistance from March 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show post-death support assistance had been offered. During an interview with the Owner and AD/DPCSD on October 17, 2024, at 1:03 PM, the Owner stated a Bereavement Coordinator (BC) was responsible for the Bereavement Program and she thought the BC was taking care of it. The Owner stated she did not know anything about what to do with a hospice Bereavement Program and had relied on the BC. The AD/DPCSD stated she had reviewed the documentation for the Bereavement Program and concluded it was not an active program. The AD/DPCSD verified Patient 14s family had not received bereavement services. The Owner and AD/DPCSD stated they had repeatedly tried to contact the BC but there had been no response. The BC was unavailable for interview. A review of the agencys policy and procedure titled “;Bereavement Services,” undated, indicated, “;POLICY: [name of agency] will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one year following the death of the patient. Services will be provided by personnel who have received training and have experience dealing with grief. The duties and responsibilities of the Bereavement Coordinator and bereavement counselors will be specified in appropriate job descriptions. The program will provide bereavement services to the family/caregivers of hospice patients, before and after the patient’s death, in accordance with the plan of care. The purpose of these services will be to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions that may interfere with the eventual resolution and integration of their losses. The purpose will also be to prepare the individual to function independently of hospice and to identify a support system with the individual. Bereavement services will be coordinated, if possible, with the individual’s clergy, if any, as well as with other community resources judged to be useful and beneficial to the family/caregiver. 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. ... 2. After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented and updated as needed. 3. Depending on the patient and family/caregiver needs identified in the bereavement assessment, bereavement counselors may need to contact and/or provide supportive counseling to the patient and family/caregiver prior to the patient’s death. 4. The bereavement counselors may provide supportive counseling to the patient and family/caregiver prior to the death. 5. After a death has occurred, the bereavement assessment will be updated, and the family/caregiver needs will be discussed at the next interdisciplinary group meeting. 6. Bereavement interventions will reflect the family/caregiver’s choices to participate in the bereavement program. 7. Families/caregivers who choose to participate in a bereavement program will be accorded the same confidentiality and privacy rights as a hospice patient. 8. Within two (2) weeks after the death of a patient, a sympathy card will be sent to the bereaved. 9. After three (3) weeks, a bereavement letter will be sent to the bereaved, offering support and outlining the hospice bereavement services. 10. Within three (3) to five (5) weeks after the patient’s death, a bereavement assessment ... will be completed by the bereavement counselor following the family/caregiver. This assessment will identify grief issues. The bereavement counselor will render a professional judgment as to whether the bereaved is experiencing normal grief, moderate grief, or a severe grief reaction. 11. If a person is noted as experiencing normal grief, the bereavement counselor will contact the bereaved person for ongoing assessment and support at three (3), six (6), and nine (9) months after the patient’s death and at the anniversary of the patient’s death. The bereavement counselor will make information available to the bereaved person regarding bereavement support groups, other support groups available in the community, and the availability of individual counseling by the hospice personnel. 12. In addition to the services outlined above, persons deemed to be experiencing moderate or severe grief will be followed by the bereavement program with increased services and contact offered at intervals defined in the plan of care. Persons identified will be referred to the Bereavement Coordinator, and intervention will be provided as follows: A. The Bereavement Coordinator will evaluate each bereaved person on a case-by-case basis and evaluate the need for individual counseling. If necessary, the bereavement, spiritual care, or social work hospice personnel will provide individual counseling to the bereaved. Referrals to outside professionals may also be required. B. A bereavement volunteer who has received additional training in bereavement support may be assigned to make regular contact with those bereaved individuals and work under supervision of the Bereavement Coordinator. 13. A bereavement file will be maintained on each family/caregiver unit of care. Each file will contain the following information: A. Copy of the patient referral and initial bereavement assessment. B. Bereavement service report. C. All bereavement assessments made. D. A bereavement plan of care. E. All bereavement clinical notes that have been written and/or letters sent to the bereaved. 14. Ongoing bereavement contact will be concluded at the end of one year, if the bereaved is no longer in need of hospice bereavement services. A. A letter will be sent indicating completion of bereavement services. B. A copy of the letter will be placed in the bereavement file and the file retained. 15. If, at one year, grieving is still perceived as acute, the Bereavement Coordinator will attempt to reassess what additional professional services may be necessary and make appropriate referrals as indicated. 16. Bereavement assessment and clinical notes will be submitted to the patient’s permanent clinical record.””

“Based on interview, and record review, the agency failed to maintain a volunteer program that utilized volunteers in day-to-day administrative duties and/or direct patient care, in a universe of 14 patients. This failure had the potential to cause patients, and families to go without assistance in daily tasks, running errands or a reassuring presence to ease stress and provide much-needed comfort. During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 9:30 AM, the Owner stated she purchased the agency on October 1, 2021, owned 100% (percent) and was the sole member of the Governing Body. She went into business with her brother who was the Admin/DPCS. She did not hold a nursing license and had no experience with running a hospice agency. The Owner stated the Admin/DPCS had been responsible for running the agency, taking care of the patients and running the Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) meetings. The Admin/DPCS suffered a devastating family tragedy between April 2023 to June 2023 and stopped fulfilling the Admin/DPCS responsibilities. The Admin/DPCS had not appointed an Administrator Designee or Director of Patient Care Services Designee, so she took over and began looking for someone to help her. She met the AD/DPCSD on August 1, 2024, and hired her as a visiting nurse and the AD/DPCSD started giving her advice on how to run the agency. The AD/DPCSD stated she had been offered and accepted the AD/DPCSD position on October 14, 2024, “;The day you [Surveyor] arrived.” A review of the facilitys staff roster, undated, was conducted. There was no documented evidence to show the agency had volunteer staff. A review of the volunteer program binder from October 1, 2021, (the day the Owner purchased the agency) to October 17, 2024, was conducted. There was no documented evidence to show records on the use of volunteers for patient care or administrative services. There was no documented evidence to show volunteer visit notes indicating the type of service provided, or time worked. During an interview with the Owner and AD/DPCSD on October 17, 2024, at 12:17 PM, the Owner stated a Volunteer Coordinator (VC) was responsible for the Volunteer Program and she thought the VC was taking care of it. The Owner stated she did not know anything about what to do with a hospice Volunteer Program and had relied on the VC. The AD/DPCSD stated she had reviewed the documentation for the Volunteer Program and concluded it was not an active program. The AD/DPCSD verified the agency had no volunteers to provide services for their patients. The Owner and AD/DPCSD stated they had repeatedly tried to contact the VC but there had been no response. The VC was unavailable for interview. A review of the agencys policy and procedure titled, “;Volunteer Services,” undated, indicated, “;PURPOSE: To ensure that qualified volunteers provide appropriate services in accordance with the interdisciplinary plan of care and hospice program needs. A. Volunteer services are provided under the direction of a staff member responsible for planning, organizing and directing a comprehensive volunteer services program. Volunteer services must be sufficient to meet the needs of the patient and family. B. Volunteer services include but are not limited to 1. The provision of support and companionship to the patient and his/her family. 2. Caregiver relief. 3. Light chores. 4. Running errands. 5. Visiting. 6. Bereavement services. 7. Other practical activities of daily living.””

“Based on interview, and record review, the agency failed to maintain a volunteer program by actively recruiting volunteers, in a universe of 14 patients. This failure had the potential to cause patients and families to go without assistance in daily tasks, running errands or a reassuring presence to ease stress and provide much-needed comfort. A review of the facilitys staff roster, undated, was conducted. There was no documented evidence to show the agency had volunteer staff. A review of the volunteer program binder from October 1, 2021, (the day the Owner purchased the agency) to October 17, 2024, was conducted. There was no documented evidence to show volunteer recruitment had been attempted or maintained. During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 12:17 PM, the Owner stated a Volunteer Coordinator (VC) was responsible for the Volunteer Program and she had thought the VC was taking care of it. The Owner stated she did not know anything about what to do with a hospice Volunteer Program and had relied on the VC. The AD/DPCSD stated she had reviewed the documentation for the Volunteer Program and there was no evidence of volunteer recruitment. The AD/DPCSD verified the agency had no volunteers to provide services for their patients. The Owner and AD/DPCSD stated they had repeatedly tried to contact the VC but there had been no response. The VC was unavailable for interview. A review of the agencys policy and procedure titled, “;Volunteer Services,” undated, indicated, “;PROCEDURE: ... 6. The volunteer coordinator will document ongoing efforts to recruit, train, and retain volunteers of all ages and ethnic backgrounds.””

“Based on interview, and record review, the agency failed to document the cost savings achieved through the use of volunteers by the identification of each position that was occupied by a volunteer, the work time spent by volunteers occupying those positions and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions, in a universe of 14 patients. This failure resulted in the agency suffering additional costs when paid employees provided volunteer services. A review of the facilitys staff roster, undated, was conducted. There was no documented evidence to show the agency had volunteer staff. A review of the volunteer program binder from October 1, 2021, (the day the Owner purchased the agency) to October 17, 2024, was conducted. There was no documented evidence to show documentation of cost savings achieved through the use of volunteers by the identification of each position that was occupied by a volunteer, the work time spent by volunteers occupying those positions and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions. During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 12:17 PM, the Owner stated a Volunteer Coordinator (VC) was responsible for the Volunteer Program and she had thought the VC was taking care of it. The Owner stated she did not know anything about what to do with a hospice Volunteer Program and had relied on the VC. The AD/DPCSD stated she had reviewed the documentation for the Volunteer Program and there was no evidence of cost savings documentation. The AD/DPCSD verified the agency had no volunteers to provide cost savings for the agency. The Owner and AD/DPCSD stated they had repeatedly tried to contact the VC but there had been no response. The VC was unavailable for interview. A review of the agencys policy and procedure titled, “;Volunteer Services,” undated, indicated, “;PROCEDURE: ... 5. The volunteer coordinator will track the use of volunteers, cost savings achieved, and that hours of volunteer services exceed 5% of the total patient care hours of paid and contracted hospice personnel. ... 7. The hospice documents the cost savings achieved through the use of volunteers. The documentation includes the following: The positions occupied by volunteers, The work time spent by volunteers occupying those positions, estimated dollar costs that the hospice would have incurred if paid employees occupied those positions for the same amount of time that volunteers spent working in those positions.””

“Based on interview, and record review, the agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services to equal five percent of the total patient care hours of all paid hospice employees and contract staff, in a universe of 14 patients. This failure resulted in the agency incurring additional costs when paid employees provided volunteer services. A review of the facilitys staff roster, undated, was conducted. There was no documented evidence to show the agency had volunteer staff. A review of the volunteer program binder from October 1, 2021, (the day the Owner purchased the agency) to October 17, 2024, was conducted. There was no documented evidence to show volunteers provided day-to-day administrative and/or direct patient care services to equal five percent of the total patient care hours of all paid hospice employees and contract staff. During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 12:17 PM, the Owner stated a Volunteer Coordinator (VC) was responsible for the Volunteer Program and she had thought the VC was taking care of it. The Owner stated she did not know anything about what to do with a hospice Volunteer Program and had relied on the VC. The AD/DPCSD stated she had reviewed the documentation for the Volunteer Program and there was no evidence to show volunteers provided day-to-day administrative and/or direct patient care services to equal five percent of the total patient care hours of all paid hospice employees and contract staff. The AD/DPCSD verified the agency had no volunteers to provide cost savings for the agency. The Owner and AD/DPCSD stated they had repeatedly tried to contact the VC but there had been no response. The VC was unavailable for interview. A review of the agencys policy and procedure titled, “;Volunteer Services,” undated, indicated, “;PROCEDURE: ... 5. The volunteer coordinator will track the use of volunteers, cost savings achieved, and that hours of volunteer services exceed 5% of the total patient care hours of paid and contracted hospice personnel. ... 7. The hospice documents the cost savings achieved through the use of volunteers. The documentation includes the following: The positions occupied by volunteers, The work time spent by volunteers occupying those positions, estimated dollar costs that the hospice would have incurred if paid employees occupied those positions for the same amount of time that volunteers spent working in those positions.””

“Based on observation, interview, and record review, the Governing Body (GB) failed to operate and manage the agency for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients when: 1. The agency failed to develop an individualized plan of care for three of three sampled patients (Patients 1, 2, 3) when: a. For Patient 1: The Hospice Aide (HA 1) did not follow the HA care plan for providing range of motion exercises (ROM-the HA moves a limb or body part around a joint, gently stretching muscles and reminding them how to move correctly), the HA care plan was not updated at each recertification assessment, the HA care plan indicated supplemental oxygen (a treatment that provides extra oxygen to patients who have breathing problems or lung diseases) use when Patient 1 was not using supplemental oxygen, and the HA care plan indicated blood pressure (a measurement of the pressure of blood in the body’s arteries) and heart rate (the number of times a patients heart beats in a given period of time, usually a minute) reporting parameters (a blood pressure or heart rate measurement where the physician wanted to be notified) when HAs did not take patients blood pressures or heart rates. This failure had the potential for Patient 1 to suffer loss of muscle strength and endurance, and absence of needed hospice aide care services. b. For Patient 2: There were no reporting parameters for blood pressure or heart rate indicated on Patient 2s care plan or in Patient 2s physicians orders. And LVN 1 determined reporting parameters were unnecessary because Patient 2s slow heart rate of 56 beats per minute (bradycardia-heart beats fewer than 60 times a minute) was considered normal due to Patient 2 taking a medication which lowered a patients heart rate. This failure had the potential to cause Patient 2 to suffer frequent fainting, the inability of the heart to pump enough blood (heart failure) and sudden cardiac arrest or sudden death. c. For Patient 3: there were no physicians orders to update the care plan, in order to: i. conduct Patient 3’s pulse oximeter readings (a percentage measurement that indicates the amount of oxygen in the patient’s blood) or reporting parameters for pulse oximeter readings. ii. conduct Patient 3’s blood sugar readings (a measurement of the amount of sugar in the patient’s blood) or reporting parameters for blood sugar readings. iii. report parameters for blood pressure and/or heart rate measurements. There was no care planning: iv. For diabetes mellitus (a chronic disease where the body cannot control blood sugar levels) management (a written plan that indicated to monitor blood glucose levels, educate patient on diabetes management, and monitor for signs and symptoms of high and low blood sugar). v. For digoxin medication management (a written plan that indicated to assess apical heart rate (using a stethoscope to listen to the heart and count the number of beats for one minute), assess how much digoxin medication and the mineral potassium were in the patient’s blood and assess for signs and symptoms of digoxin toxicity (when there is too much digoxin medication in the patient’s body and causes confusion, irregular pulse, loss of appetite, nausea, vomiting, diarrhea, fast heartbeat, and vision changes). This failure had the potential to cause Patient 3 to suffer low oxygen saturation levels, too low or high blood sugar levels, too low or high blood pressure levels, too slow or rapid heart rates, diabetes mellitus mismanagement and digoxin mismanagement and toxicity. 2. The hospice interdisciplinary group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) failed to review, revise, and document the individualized care plan as frequently as the patients condition required, but no less frequently than every 15 calendar days, for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14). This failure had the potential for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 responses to care, treatment, and services to go unaddressed. 3. The agency failed to maintain an infection control program that was integrated into the agencys Quality Assessment Performance Improvement (QAPI) program in order to: identify infection trends (analysis of a pattern), develop action plans and improve disease prevention, from October 1, 2021 (the date the Owner purchased the agency) to October 17, 2024, in a universe of 14 patients. This failure had the potential to cause trends in infections to go unrecognized, unaddressed and patients to suffer repeated and prolonged infections. 4. The agency failed to ensure a Bereavement (the experience of losing someone important) Program (a program providing an initial bereavement assessment, a bereavement plan of care, a post-death assessment, mailing of bereavement letters, and post-death support assistance) was maintained to provide bereavement services to family, loved ones and caregivers for one year following the death of a patient, for two of two sampled patients (Patients 13 and 14), in a universe of 14 patients. This failure had the potential to cause individuals experiencing grief to suffer a lack of support and guidance leading to complications with their grief and impacting their mental and physical health. 5. The agency failed to maintain a volunteer program that utilized volunteers in day-to-day administrative duties and/or direct patient care, in a universe of 14 patients. This failure had the potential to cause patients, and families to go without assistance in daily tasks, running errands or a reassuring presence to ease stress and provide much-needed comfort. 6. The agency failed to maintain a volunteer program by actively recruiting volunteers, in a universe of 14 patients. This failure had the potential to cause patients and families to go without assistance in daily tasks, running errands or a reassuring presence to ease stress and provide much-needed comfort. 7. The agency failed to document the cost savings achieved through the use of volunteers by the identification of each position that was occupied by a volunteer, the work time spent by volunteers occupying those positions and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions, in a universe of 14 patients. This failure resulted in the agency suffering additional costs when paid employees provided volunteer services. 8. The agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services to equal five percent of the total patient care hours of all paid hospice employees and contract staff, in a universe of 14 patients. This failure resulted in the agency incurring additional costs when paid employees provided volunteer services. 9. The agency failed to ensure the Medical Director (MD) certified the patients’ terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) when: a. For Patients 1, 2, 4, 5, 6, 7, 8, 9, 10, 12, 13, and 14 the Medical Director (MD) failed to certify the patients as terminally ill. b. For Patients 1, 3 and 14, the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. c. For Patient 11, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. These failures had the potential to cause Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 to not be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to not being properly evaluated as terminally ill. 10. The agency failed to follow Federal Law [42 Code of Federal Regulations (CFR) § 418.25(a)], requiring a written physicians referral order, when the patients clinical record did not contain a physician’s referral order for hospice services, a confirmation of service needs, a verification of the patients’ medical prognosis and supporting documentation for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14). This failure had the potential to cause Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 to not be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and referring to hospice care. 11. The agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to cause the EPP to indicate ineffective procedures and outdated information. 12. The agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to place the agencys patients at risk when the agency was not prepared to work with the emergency management office during an emergency or disaster. 13. The agency failed to develop a procedure and/or process to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to cause a hindering of crucial response efforts and leaving patients in life-threatening situations. In addition, not informing officials about staff members who were unable to be contacted during a disaster, can significantly hinder emergency response efforts by creating confusion, delaying critical decision-making, and potentially leaving individuals at risk without necessary assistance. 14. The agency failed to create and implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to place the agencys patients at risk when the agency was not prepared to inform emergency management officials about patients in need of evacuation and the needs the patients would require during the evacuation process. 15. The agency failed to create a plan and implement a procedure to provide for emergency staffing during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to cause patients to suffer an absence of care due to a staff shortage. 16. The agency failed to develop a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to place the agencys patients at risk when the agency could not communicate with Federal, State, tribal, regional, and local emergency management agencies in the event of a communications failure. 17. The agency failed to conduct full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency operation centers, etc.] and “;boots on the ground” response [for example, firefighters decontaminating mock victims]) or tabletop emergency preparedness exercises (an exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and set a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan), for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. This failure had the potential to cause problems within the Emergency Preparedness Program to go unrecognized and unaddressed. 1a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 27, 2024, with a benefit period of September 23, 2024, to November 21, 2024 (Benefit Period Three). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). During Patient 1s home visit on October 15, 2024, at 10:06 AM, with a Hospice Aide (HA 1), HA 1 prepared and gave Patient 1 a bed bath. HA 1 changed Patient 1’s bedding and dressed Patient 1. HA 1 did not provide ROM exercises. During an observation and interview with Patient 1s Caregiver (CG), on October 15, 2024, at 10:06 AM, an oxygen concentrator (a machine that supplied supplemental oxygen) was observed unplugged and stored in Patient 1’s closet. Patient 1 was not using supplemental oxygen. Patient 1’s CG stated Patient 1 had never used supplemental oxygen because she did not need it. The CG stated it was just there in case Patient 1 needed it. The CG stated HA 1 had never performed ROM exercises for Patient 1. During an interview with HA 1 on October 15, 2024, at 11:19 AM, HA 1 stated she knew what an Aide Care Plan was but had not read it. HA 1 stated she did not know she was supposed to provide Patient 1 with ROM exercises. HA 1 stated Patient 1 did not use supplemental oxygen. HA 1 stated she did not take the patients’ vital signs; therefore, she would not report on blood pressure, or pulse rate. A review of Patient 1s Aide Care Plan, dated March 27, 2024, indicated, Patient status: oxygen at two to five liters (a unit of measurement) per minute. Exercise: ROM active passive every visit. Registered Nurse (RN) additional instructions: Notify RN/CM (Case Manager) or office if any of the following: blood pressure above 160/90 or below 90/60, pulse rate above 100 or below 60. During an interview with a Registered Nurse (RN 1) on October 15, 2024, at 4:36 PM, RN 1 stated she had conducted Patient 1’s admission assessment and recertification assessments. RN 1 stated she had completed Patient 1’s care plan and hospice aide care plan. RN 1 stated she had not re-evaluated Patient 1’s hospice aide care needs at recertification and had not updated Patient 1’s hospice aide care plan. RN 1 stated she did not know she needed to. RN 1 stated she should not have checked the box next to the supplemental oxygen as Patient 1 did not use supplemental oxygen. RN 1 stated hospice aides did not take patients’ vital signs, so blood pressure and heart rate reporting parameters were not needed. RN 1 stated HA 1 should have read Patient 1’s hospice aide care plan before providing services. RN 1 stated HA 1 should have provided ROM exercises for Patient 1. During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 10:51 AM, the AD/DPCSD stated RN 1 should have re-evaluated Patient 1’s hospice aide care needs at each recertification and updated Patient 1’s hospice aide care plan. The AD/DPCSD stated HA 1 should have read Patient 1’s hospice aide care plan before providing services and provided ROM exercises for Patient 1. The AD/DPCSD stated RN 1 should have created a hospice aide care plan specific to Patient 1s needs. 1b. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 20, 2024, with a benefit period of August 20, 2024, to November 17, 2024 (First 90-day benefit period). Patient 2 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During Patient 2s home visit on October 15, 2024, at 12:09 PM, with a Licensed Vocational Nurse (LVN 1), LVN 1 took Patient 2’s vital signs: blood pressure: 118 (Systolic blood pressure, the pressure in the arteries when the heart beats and the ventricles contract) over 60 (diastolic blood pressure, the minimum pressure in the arteries when the heart is relaxed between beats), heart rate: 56 beats per minute (bpm), temperature: 97.3 degrees Fahrenheit, Respirations: 16 breaths per minute (bpm), No pain. LVN 1 reviewed Patient 2’s care plan and physician’s orders, no reporting parameters were indicated. LVN 1 stated she was not going to report Patient 2’s heart rate of 56 bpm because Patient 2 was on a medication that lowered the heart rate, so Patient 2’s slow heart rate was normal. A review of Patient 2’s physician’s medication orders from August 20, 2024, to October 15, 2024, indicated Patient 2 was taking the following medication:i. Physician’s order dated August 20, 2024, furosemide (a medication that lowers blood pressure), 40 mg (milligrams-a unit of measurement), one tablet, two times a day.ii. Physician’s order dated August 20, 2024, spironolactone (a medication that lowers blood pressure) 25 mg, half a tablet, once a day.iii. Physician’s order dated August 20, 2024, losartan potassium (a medication that lowers blood pressure) 25 mg, one tablet, once a day.iv. Physician’s order dated August 20, 2024, metoprolol tartrate (a medication that lowers blood pressure and heart rate) 25 mg, one tablet, two times a day. During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 11:15 AM, The AD/DPCSD stated she had conducted Patient 2’s admission assessment. The AD/DPCSD stated she had completed Patient 2’s care plan and had not requested an order for reporting parameters from the Medical Director (MD). The AD/DPCSD stated she had never attended an Interdisciplinary Group Meeting (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient). The AD/DPCSD stated it was inappropriate for a Licensed Vocational Nurse (LVN) to decide when and what to report to a Registered Nurse (RN) and/or physician. During an interview with the Medical Director (MD) on October 17, 2024, at 10:10 AM, the MD stated he did not know Patient 2 had been admitted to the agency. The MD stated he had not attended any IDG meetings because he thought the agency had put patient admissions on hold due to the agency going through “hard times.” The MD stated the admitting Registered Nurse (RN) should have requested an order with reporting parameters during the first IDG meeting after admission. The MD stated it was inappropriate for an LVN to decide when and what to report to a physician. The MD stated he needed to review Patient 2’s clinical history and current medication regime to determine if something needed to be done to address Patient 2’s 56 bpm heart rate. The MD stated this was something he would do during an IDG meeting if he had known they were being conducted. 1c. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, with a benefit period of September 26, 2024, to November 24, 2024 (Benefit Period Eight). Patient 3 had diagnoses that included congestive heart failure (a condition where the heart does not pump enough blood to meet the body’s needs). During Patient 3s home visit on October 15, 2024, at 4:08 PM, with a Registered Nurse (RN 1), RN 1 took Patient 3’s vital signs: temperature: 97.7 degrees Fahrenheit, oxygen saturation (amount of oxygen in the blood) 95% (percent), radial heart rate (the rate at which your heart beats, as measured by feeling the radial pulse at the wrist) 67 beats per minute (BPM), blood pressure 132 over 82, blood sugar (BS) 111 milligrams per deciliter (mg/dL). RN 1 stated Patient 3 did not like taking his own BS and always waited for her to come and take his BS reading. During an interview with RN 1 on October 15, 2024, at 4:36 PM, RN 1 stated she had conducted Patient 3’s admission assessment and created Patient 3’s care plan. RN 1 reviewed Patient 3’s physician’s orders from March 30, 2024, to October 15, 2024, and confirmed the following:i. No physician’s order to conduct Patient 3’s pulse oximeter reading (a percentage measurement that indicates the amount of oxygen in the patient’s blood) or reporting parameters for pulse oximeter readings.ii. No physician’s order to conduct Patient 3’s blood sugar reading (a measurement of the amount of sugar in the patient’s blood) or reporting parameters for blood sugar readings.iii. No physician’s order with reporting parameters for blood pressure and/or heart rate measurements.iv. Physician’s order dated March 30, 2024, carvedilol (a medication that lowers heart rate and blood pressure) 25 mg (milligrams-a unit of measurement), one tablet once per day.v. Physician’s order dated March 30, 2024, digoxin (a medication that lowers heart rate and helps heart pump more efficiently), 0.125 mg, take one tablet, once per day.vi. spironolactone (a medication that lowers blood pressure), 25 mg, half a tablet, once per day.vii. Physician’s order dated March 30, 2024, metformin hydrochloride (a medication that lowers blood sugar), 500 mg, one tablet, two times a day.RN 1 reviewed Patient 3’s care plan from March 30, 2024, to October 15, 2024, and confirmed the following:i. No reporting parameters for pulse oximeter readings.ii. No reporting parameters for blood sugar readings.iii. No reporting parameters for blood pressure and/or heart rate measurements.iv. No care plan for diabetes (a chronic disease where the body cannot control blood sugar levels) management (a written plan that indicates to: monitor blood glucose levels, educate patient on diabetes management, and monitor for signs and symptoms of high and low blood sugar).v. No care plan for digoxin medication management (a written plan that indicates to: assess apical heart rate (using a stethoscope to listen to the heart on the chest and count the number of beats for one minute), assess how much digoxin medication and the mineral potassium are in the patient’s blood and assess for signs and symptoms of digoxin toxicity (when there is too much digoxin medication in the patient’s body and causes confusion, irregular pulse, loss of appetite, nausea, vomiting, diarrhea, fast heartbeat, and vision changes). In a continued interview with RN 1, RN 1 stated she had not created a care plan for Patient 3 to address:i. Reporting parameters for pulse oximeter readings.ii. Reporting parameters for blood sugar readings.iii. Reporting parameters for blood pressure and/or heart rate measurements.iv. Diabetes managementv. Digoxin medication managementRN 1 stated she had not contacted the Medical Director (MD) to obtain orders to:vi. Conduct Patient 3’s pulse oximeter readings and reporting parameters for pulse oximeter readings.vii. Conduct Patient 3’s blood sugar readings and reporting parameters for blood sugar readings.viii. Obtain reporting parameters for blood pressure and/or heart rate measurements. RN 1 stated she had not consulted with the MD on Patient 3’s care at the Interdisciplinary Group Meetings (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) because he never attended. During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 11:40 AM, The AD/DPCSD stated RN 1 should have consulted with the MD on Patient 3’s care at the IDG meetings. The AD/DPCSD stated she had never attended an IDG meeting. The AD/DPCSD stated RN 1 should have obtained physician orders to:i. Conduct Patient 3’s pulse oximeter readings and reporting parameters for pulse oximeter readings.ii. Conduct Patient 3’s blood sugar readings and reporting parameters for blood sugar readings.iii. Obtain reporting parameters for blood pressure and/or heart rate measurements.The AD/DPCSD stated RN 1 should have created Patient 3’s care plan to include:i. Reporting parameters for pulse oximeter readings.ii. Reporting parameters for blood sugar readings.iii. Reporting parameters for blood pressure and/or heart rate measurements.iv. Diabetes managementv. Digoxin medication management During an interview with the Medical Director (MD) on October 17, 2024, at 10:10 AM, The MD stated he had not attended any IDG meetings because he thought the agency had put patient admissions on hold due to the agency going through “hard times.” The MD stated the admitting Registered Nurse (RN) should have requested an order to:i. Conduct Patient 3’s pulse oximeter readings and reporting parameters for pulse oximeter readings.ii. Conduct Patient 3’s blood sugar readings and reporting parameters for blood sugar readings.iii. Obtain reporting parameters for blood pressure and/or heart rate measurements.The MD stated he should have been present at the IDG meetings to discuss Patient 3’s diabetes and digoxin medication management as well as other care needs. The MD stated he would have attended if he had known the agency was not “on hold.” A review of the agencys policy and procedure titled, “;The Plan of Care,” undated, indicated, “;PURPOSE: To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. POLICY: Each patient must have a written plan of care that specifies the care and services necessary to meet the patient’s specific needs as identified in the comprehensive assessment. 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 of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. This plan of care must be initiated at start of care. ...” 2. A review of the agencys policy and procedure titled “;Interdisciplinary Group Membership and Responsibilities,” undated, indicated, “;The hospice interdisciplinary team/group members will include, at a minimum, A. Physician, B. Registered nurse, C. Social worker, D. Pastoral or other counselor.” During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 9:30 AM, the Owner stated she purchased the agency on October 1, 2021, owned 100% (percent) and was the sole member of the Governing Body. She went into business with her brother who was the Admin/DPCS. She did not hold a nursing license and had no experience with running a hospice agency. The Owner stated the Admin/DPCS had been responsible for running the agency, taking care of the patients, and running the Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) meetings and she noticed the IDG meetings had stopped in July 2023. The Admin/DPCS suffered a devastating family tragedy between April 2023 to June 2023 and stopped fulfilling the Admin/DPCS responsibilities. The Admin/DPCS had not appointed an Administrator Designee or Director of Patient Care Services Designee, so she took over and began looking for someone to help her. She met the AD/DPCSD on August 1, 2024, and hired her as a visiting nurse and the AD/DPCSD started giving her advice on how to run the agency. The AD/DPCSD stated she had been offered and accepted the AD/DPCSD position on October 14, 2024, “;The day you [Surveyor] arrived.” a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 27, 2024, with a benefit period of September 23, 2024, to November 21, 2024 (Benefit Period Three). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 1s IDG meeting notes from September 23, 2024, to October 17, 2024, indicated, two IDG meetings on September 30, 2024, and October 14, 2024. There was no documented evidence to show the Medical Director (MD) or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. b. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 20, 2024, with a benefit period of August 20, 2024, to November 17, 2024 (First 90-day benefit period). Patient 2 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 2s IDG meeting notes from August 20, 2024, to October 17, 2024, indicated, four IDG meetings on September 2, 16, 30, 2024, and October 14, 2024. There was no documented evidence to show the Medical Director (MD) or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. c. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, with a benefit period of September 26, 2024, to November 24, 2024 (Benefit Period Eight). Patient 3 had diagnoses that included congestive heart failure (a condition where the heart does not pump enough blood to meet the body’s needs). A review of Patient 3s IDG meeting notes from September 26, 2024, to October 17, 2024, was conducted. There was no documented evidence to show IDG meetings had been conducted. d. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 6, 2024, with a benefit period of September 6, 2024, to December 4, 2024 (First 90-day benefit period). Patient 4 had diagnoses that included heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). A review of Patient 4s IDG meeting notes from September 6, 2024, to October 17, 2024, indicated, three IDG meetings on September 9, and 23, 2024, and October 7, 2024. There was no documented evidence to show the Medical Director (MD) or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. e. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 12, 2024, with a benefit period of September 12, 2024, to December 10, 2024 (First 90-day benefit period). Patient 5 had diagnoses that included Parkinsonism (another name for Parkinson’s disease-a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 5s IDG meeting notes from September 12, 2024, to October 17, 2024, indicated, three IDG meetings on September 6, and 30, 2024, and October 14, 2024. There was no documented evidence to show the Medical Director (MD) or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. f. A review of Patient 6s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 30, 2024, with a benefit period of August 30, 2024, to November 27, 2024 (First 90-day benefit period). Patient 6 had diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 6s IDG meeting notes from August 30, 2024, to October 17, 2024, indicated, two IDG meetings on September 2, and 16, 2024. An IDG meeting was due on September 30, 2024, but there was no documented evidence to show it had been conducted. In addition, there was no documented evidence to show the Medical Director (MD), or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. g. A review of Patient 7s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 30, 2024, with a benefit period of August 30, 2024, to November 27, 2024 (First 90-day benefit period). Patient 7 had diagnoses that included hypertensive heart disease (a group of heart problems that develop due to chronic high blood pressure). A review of Patient 7s IDG meeting notes from August 30, 2024, to October 17, 2024, indicated, two IDG meetings on September 2, and 16, 2024. An IDG meeting was due on September 30, 2024, but there was no documented evidence to show it had been conducted. In addition, there was no documented evidence to show the Medical Director (MD), or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. h. A review of Patient 8s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 28, 2024, with a benefit period of August 28, 2024, to November 25, 2024 (First 90-day benefit period). Patient 8 had diagnoses that included hypertensive heart disease (a group of heart problems that develop due to chronic high blood pressure). A review of Patient 8s IDG meeting notes from August 28, 2024, to October 17, 2024, indicated, two IDG meetings on September 2, and 16, 2024. An IDG meeting was due on September 30, 2024, but there was no documented evidence to show it had been conducted. In addition, there was no documented evidence to show the Medical Director (MD), or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. i. A review of Patient 9s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 28, 2024, with a benefit period of August 28, 2024, to November 25, 2024 (First 90-day benefit period). Patient 9 had diagnoses that included atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries of the heart). A review of Patient 9s IDG meeting notes from August 28, 2024, to October 17, 2024, indicated, two IDG meetings on September 2, and 16, 2024. An IDG meeting was due on September 30, 2024, but there was no documented evidence to show it had been conducted. In addition, there was no documented evidence to show the Medical Director (MD), or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. j. A review of Patient 10s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 23, 2024, with a benefit period of August 23, 2024, to November 20, 2024 (First 90-day benefit period). Patient 10 had diagnoses that included systolic heart failure (a condition that occurs when the heart’s left ventricle is too weak to pump enough blood throughout the body). A review of Patient 10s IDG meeting notes from August 23, 2024, to October 17, 2024, indicated, three IDG meetings on August 26, 2024, September 2, and 16, 2024. An IDG meeting was due on September 30, 2024, but there was no documented evidence to show it had been conducted. In addition, there was no documented evidence to show the Medical Director (MD), or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. k. A review of Patient 11s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 1, 2024, with a benefit period of July 1, 2024, to September 28, 2024 (First 90-day benefit period). Patient 11 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 11s IDG meeting notes from July 1, 2024, to October 17, 2024, indicated, one IDG meeting was supposed to be conducted on July 22, 2024, but there was no documented evidence to show the IDG meeting had been conducted. l. A review of Patient 12s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of February 1, 2024, with a benefit period of February 1, 2024, to April 30, 2024 (Second 90-day benefit period). Patient 12 had diagnoses that included atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries of the heart). A review of Patient 12s IDG meeting notes from February 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show IDG meetings had been conducted. m. A review of Patient 13s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 10, 2024, with a benefit period of July 10, 2024, to October 7, 2024 (First 90-day benefit period). Patient 13 had diagnoses that included heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). A review of Patient 13s IDG meeting notes from July 10, 2024, to October 17, 2024, indicated, one IDG meetings on July 10, 2024. There was no documented evidence to show the Medical Director (MD) or other physician had attended. The IDG meeting document indicated a space for the MD to sign. There was no signature from the MD. n. A review of Patient 14s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 1, 2024, with a benefit period of March 1, 2024, to April 29, 2024 (Benefit Period Seven). Patient 14 had diagnoses that included Moderate protein-calorie malnutrition (is the state of inadequate intake of food such as protein, calories, and other essential nutrients). A review of Patient 14s IDG meeting notes from March 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show IDG meetings had been conducted. During an interview with the MD on October 17, 2024, at 10:10 AM, the MD stated he had been the Medical Director for the agency since October 15, 2020. The MD stated he had never attended the IDG meetings at the agency. The MD stated the agency had been going through “;hard times” and he thought patient admissions had been put “;on hold.” The MD stated it was his responsibility to attend the IDG meetings and provide medical oversight for the patients, but he had not been informed the agency was admitting patients and holding IDG meetings. During an interview with a Medical Social Worker (MSW) on October 17, 2024, at 2:41 PM, the MSW stated the IDG meetings were just her and a Registered Nurse (RN 1) discussing the patients. The MSW stated a physician never attended. The MSW stated she did not know who the Admin/DPCS was. A review of the agencys policy and procedure titled “;Interdisciplinary Group Meeting,” undated, indicated, “;PURPOSE: To define the process for interdisciplinary group meetings and documenting patient status in the clinical record. POLICY: Responsibilities A. The program shall establish an interdisciplinary team whose responsibility shall include but not be limited to 1. Establishment of a plan of care. 2. Provision, and/or supervision and coordination of care services. 3. Review and/or revision, on a regular basis, of the plan of care for each patient and family receiving care. 4. Implementation of policies governing the day-to-day provision of care and services. B. The interdisciplinary team shall make use of consultants and community resources as necessary and appropriate. C. Any unusual change in the patient’s physical, mental, spiritual or emotional status shall be reported to the primary caregiver(s), the attending physician and the interdisciplinary team. ... The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s 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 patient’s condition requires. The meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The patient and family/caregiver will be informed of the schedule for this meeting, its purpose, and that the discussion is confidential. ...” 3. During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 9:30 AM, the Owner stated she purchased the agency on October 1, 2021, owned 100% (percent) and was the sole member of the Governing Body. She went into business with her brother who was the Admin/DPCS. She did not hold a nursing license and had no experience with running a hospice agency. The Owner stated the Admin/DPCS had been responsible for running the agency, taking care of the patients and running the Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) meetings. The Admin/DPCS suffered a devastating family tragedy between April 2023 to June 2023 and stopped fulfilling the Admin/DPCS responsibilities. The Admin/DPCS had not appointed an Administrator Designee or Director of Patient Care Services Designee, so she took over and began looking for someone to help her. She met the AD/DPCSD on August 1, 2024, and hired her as a visiting nurse and the AD/DPCSD started giving her advice on how to run the agency. The AD/DPCSD stated she had been offered and accepted the AD/DPCSD position on October 14, 2024, “;The day you [Surveyor] arrived.” A review of the agency’s infection control binder from October 1, 2021 (the date the Owner purchased the agency) to October 17, 2024, was conducted. The binder did not contain any data collection on the patients’ infections for three years. A review of the agency’s QAPI binder from October 1, 2021 (the date the Owner purchased the agency) to October 17, 2024, was conducted. The QAPI binder did not contain documentation showing infection control data had been received, aggregated or analyzed by the QAPI Committee. A review of the agency’s in-service binder from October 1, 2021 (the date the Owner purchased the agency) to October 17, 2024, did not indicate staff had received any infection control in-services. A review of the agencys Governing Body (GB) meeting minutes from October 1, 2021 (the date the Owner purchased the agency) to October 17, 2024, was conducted. There was no documented evidence of GB meeting minutes, oversight of the Infection Control Program or oversight for the QAPI Program. During an interview with the Owner and AD/DPCS on October 17, 2024, at 11:30 AM, the Owner sta ted she had hired a nurse consultant to help run the agency. The Owner thought the nurse consultant had been working on the infection control program but “;apparently had not.” The Owner stated, “;She just took the money and left without doing anything.” The AD/DPCSD confirmed the agency had no active Infection Control Program. A review of the agencys policy and procedure titled “;Infection Control Plan,” undated, indicated, “;PURPOSE: To delineate an infection control plan to meet the following goals: 1. Establish the mechanisms by which the organization will address surveillance, prevention, identification, control and reporting of infections. 2. Guide organization personnel in the care and services they provide in relation to infection control practices. A. Set goals for improving influenza infection rates. B. Set goals for compliance with hand hygiene guidelines. 3. Educate organization personnel, patients and family/caregivers, and others in the prevention and control of infections. 4. Provide for surveillance systems to track the occurrence and transmission of infections. 5. Respond to outbreaks of infectious diseases and prepare for potential influx of infectious patients as part of emergency management activities. ... POLICY: [name of agency] is committed to reducing the risk of acquisition and transmission of health care associated infections (HAIs). Recognized prevention and control mechanisms will be implemented for planning, surveillance, identification, prevention/control, and reporting procedures. To determine the effectiveness of the infection control plan, [name of agency] will measure, assess, improve, and redesign (as appropriate) the surveillance, identification, prevention, and control function annually through its performance improvement program. ...” 4. a. A review of Patient 13s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 10, 2024, with a benefit period of July 10, 2024, to October 7, 2024 (First 90-day benefit period). Patient 13 had diagnoses that included heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). Patient 13 expired on July 20, 2024. A review of Patient 13s bereavement assessments (a tool used to evaluate the risk of a person experiencing a negative bereavement experience. It can help identify factors that may contribute to a difficult bereavement and is used to create a bereavement care plan) from July 10, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a bereavement assessment had been performed. A review of Patient 13s bereavement care plans (a document that outlines a person’s goals, interventions, and services for dealing with bereavement) from July 10, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a bereavement care plan had been created. A review of Patient 13s post-death assessments (a professional evaluation of a person’s grief reaction after a loved one has died) from July 10, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a post-death assessment had been performed. A review of Patient 13s bereavement letter mailings (a way to provide support and comfort to those who are grieving with emotional support letters, educational enclosures, and community service resources) from July 10, 2024, to October 17, 2024, was conducted. There was no documented evidence to show bereavement letter mailings had occurred. A review of Patient 13s post-death support assistance (a service that helps people deal with the loss of a loved one by providing emotional, psychosocial, and spiritual support through counseling, support groups, educational forums and memorial services) from July 10, 2024, to October 17, 2024, was conducted. There was no documented evidence to show post-death support assistance had been offered. During an interview with the Owner and AD/DPCSD on October 17, 2024, at 1:03 PM, the Owner stated a Bereavement Coordinator (BC) was responsible for the Bereavement Program and she thought the BC was taking care of it. The Owner stated she did not know anything about what to do with a hospice Bereavement Program and had relied on the BC. The AD/DPCSD stated she had reviewed the documentation for the Bereavement Program and concluded it was not an active program. The AD/DPCSD verified Patient 13s family had not received bereavement services. The Owner and AD/DPCSD stated they had repeatedly tried to contact the BC but there had been no response. The BC was unavailable for interview. b. A review of Patient 14s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 1, 2024, with a benefit period of March 1, 2024, to April 29, 2024 (Benefit Period Seven). Patient 14 had diagnoses that included Moderate protein-calorie malnutrition (is the state of inadequate intake of food such as protein, calories, and other essential nutrients). Expired March 21, 2024. A review of Patient 14s bereavement care plans from March 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a bereavement care plan had been created. A review of Patient 14s post-death assessments from March 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a post-death assessment had been performed. A review of Patient 14s bereavement letter mailings from March 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show bereavement letter mailings had occurred. A review of Patient 14s post-death support assistance from March 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show post-death support assistance had been offered. During an interview with the Owner and AD/DPCSD on October 17, 2024, at 1:03 PM, the Owner stated a Bereavement Coordinator (BC) was responsible for the Bereavement Program and she thought the BC was taking care of it. The Owner stated she did not know anything about what to do with a hospice Bereavement Program and had relied on the BC. The AD/DPCSD stated she had reviewed the documentation for the Bereavement Program and concluded it was not an active program. The AD/DPCSD verified Patient 14s family had not received bereavement services. The Owner and AD/DPCSD stated they had repeatedly tried to contact the BC but there had been no response. The BC was unavailable for interview. A review of the agencys policy and procedure titled “;Bereavement Services,” undated, indicated, “;POLICY: [name of agency] will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one year following the death of the patient. Services will be provided by personnel who have received training and have experience dealing with grief. The duties and responsibilities of the Bereavement Coordinator and bereavement counselors will be specified in appropriate job descriptions. The program will provide bereavement services to the family/caregivers of hospice patients, before and after the patient’s death, in accordance with the plan of care. The purpose of these services will be to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions that may interfere with the eventual resolution and integration of their losses. The purpose will also be to prepare the individual to function independently of hospice and to identify a support system with the individual. Bereavement services will be coordinated, if possible, with the individual’s clergy, if any, as well as with other community resources judged to be useful and beneficial to the family/caregiver. 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. ... 2. After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented and updated as needed. 3. Depending on the patient and family/caregiver needs identified in the bereavement assessment, bereavement counselors may need to contact and/or provide supportive counseling to the patient and family/caregiver prior to the patient’s death. 4. The bereavement counselors may provide supportive counseling to the patient and family/caregiver prior to the death. 5. After a death has occurred, the bereavement assessment will be updated, and the family/caregiver needs will be discussed at the next interdisciplinary group meeting. 6. Bereavement interventions will reflect the family/caregiver’s choices to participate in the bereavement program. 7. Families/caregivers who choose to participate in a bereavement program will be accorded the same confidentiality and privacy rights as a hospice patient. 8. Within two (2) weeks after the death of a patient, a sympathy card will be sent to the bereaved. 9. After three (3) weeks, a bereavement letter will be sent to the bereaved, offering support and outlining the hospice bereavement services. 10. Within three (3) to five (5) weeks after the patient’s death, a bereavement assessment ... will be completed by the bereavement counselor following the family/caregiver. This assessment will identify grief issues. The bereavement counselor will render a professional judgment as to whether the bereaved is experiencing normal grief, moderate grief, or a severe grief reaction. 11. If a person is noted as experiencing normal grief, the bereavement counselor will contact the bereaved person for ongoing assessment and support at three (3), six (6), and nine (9) months after the patient’s death and at the anniversary of the patient’s death. The bereavement counselor will make information available to the bereaved person regarding bereavement support groups, other support groups available in the community, and the availability of individual counseling by the hospice personnel. 12. In addition to the services outlined above, persons deemed to be experiencing moderate or severe grief will be followed by the bereavement program with increased services and contact offered at intervals defined in the plan of care. Persons identified will be referred to the Bereavement Coordinator, and intervention will be provided as follows: A. The Bereavement Coordinator will evaluate each bereaved person on a case-by-case basis and evaluate the need for individual counseling. If necessary, the bereavement, spiritual care, or social work hospice personnel will provide individual counseling to the bereaved. Referrals to outside professionals may also be required. B. A bereavement volunteer who has received additional training in bereavement support may be assigned to make regular contact with those bereaved individuals and work under supervision of the Bereavement Coordinator. 13. A bereavement file will be maintained on each family/caregiver unit of care. Each file will contain the following information: A. Copy of the patient referral and initial bereavement assessment. B. Bereavement service report. C. All bereavement assessments made. D. A bereavement plan of care. E. All bereavement clinical notes that have been written and/or letters sent to the bereaved. 14. Ongoing bereavement contact will be concluded at the end of one year, if the bereaved is no longer in need of hospice bereavement services. A. A letter will be sent indicating completion of bereavement services. B. A copy of the letter will be placed in the bereavement file and the file retained. 15. If, at one year, grieving is still perceived as acute, the Bereavement Coordinator will attempt to reassess what additional professional services may be necessary and make appropriate referrals as indicated. 16. Bereavement assessment and clinical notes will be submitted to the patient’s permanent clinical record.” 5. A review of the facilitys staff roster, undated, was conducted. There was no documented evidence to show the agency had volunteer staff. A review of the volunteer program binder from October 1, 2021, (the day the Owner purchased the agency) to October 17, 2024, was conducted. There was no documented evidence to show records on the use of volunteers for patient care or administrative services. There was no documented evidence to show volunteer visit notes indicating the type of service provided, or time worked. During an interview with the Owner and AD/DPCSD on October 17, 2024, at 12:17 PM, the Owner stated a Volunteer Coordinator (VC) was responsible for the Volunteer Program and she thought the VC was taking care of it. The Owner stated she did not know anything about what to do with a hospice Volunteer Program and had relied on the VC. The AD/DPCSD stated she had reviewed the documentation for the Volunteer Program and concluded it was not an active program. The AD/DPCSD verified the agency had no volunteers to provide services for their patients. The Owner and AD/DPCSD stated they had repeatedly tried to contact the VC but there had been no response. The VC was unavailable for interview. A review of the agencys policy and procedure titled, “;Volunteer Services,” undated, indicated, “;PURPOSE: To ensure that qualified volunteers provide appropriate services in accordance with the interdisciplinary plan of care and hospice program needs. A. Volunteer services are provided under the direction of a staff member responsible for planning, organizing and directing a comprehensive volunteer services program. Volunteer services must be sufficient to meet the needs of the patient and family. B. Volunteer services include but are not limited to 1. The provision of support and companionship to the patient and his/her family. 2. Caregiver relief. 3. Light chores. 4. Running errands. 5. Visiting. 6. Bereavement services. 7. Other practical activities of daily living.” 6. A review of the facilitys staff roster, undated, was conducted. There was no documented evidence to show the agency had volunteer staff. A review of the volunteer program binder from October 1, 2021, (the day the Owner purchased the agency) to October 17, 2024, was conducted. There was no documented evidence to show volunteer recruitment had been attempted or maintained. During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 12:17 PM, the Owner stated a Volunteer Coordinator (VC) was responsible for the Volunteer Program and she had thought the VC was taking care of it. The Owner stated she did not know anything about what to do with a hospice Volunteer Program and had relied on the VC. The AD/DPCSD stated she had reviewed the documentation for the Volunteer Program and there was no evidence of volunteer recruitment. The AD/DPCSD verified the agency had no volunteers to provide services for their patients. The Owner and AD/DPCSD stated they had repeatedly tried to contact the VC but there had been no response. The VC was unavailable for interview. A review of the agencys policy and procedure titled, “;Volunteer Services,” undated, indicated, “;PROCEDURE: ... 6. The volunteer coordinator will document ongoing efforts to recruit, train, and retain volunteers of all ages and ethnic backgrounds.” 7. A review of the facilitys staff roster, undated, was conducted. There was no documented evidence to show the agency had volunteer staff. A review of the volunteer program binder from October 1, 2021, (the day the Owner purchased the agency) to October 17, 2024, was conducted. There was no documented evidence to show documentation of cost savings achieved through the use of volunteers by the identification of each position that was occupied by a volunteer, the work time spent by volunteers occupying those positions and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions. During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 12:17 PM, the Owner stated a Volunteer Coordinator (VC) was responsible for the Volunteer Program and she had thought the VC was taking care of it. The Owner stated she did not know anything about what to do with a hospice Volunteer Program and had relied on the VC. The AD/DPCSD stated she had reviewed the documentation for the Volunteer Program and there was no evidence of cost savings documentation. The AD/DPCSD verified the agency had no volunteers to provide cost savings for the agency. The Owner and AD/DPCSD stated they had repeatedly tried to contact the VC but there had been no response. The VC was unavailable for interview. A review of the agencys policy and procedure titled, “;Volunteer Services,” undated, indicated, “;PROCEDURE: ... 5. The volunteer coordinator will track the use of volunteers, cost savings achieved, and that hours of volunteer services exceed 5% of the total patient care hours of paid and contracted hospice personnel. ... 7. The hospice documents the cost savings achieved through the use of volunteers. The documentation includes the following: The positions occupied by volunteers, The work time spent by volunteers occupying those positions, estimated dollar costs that the hospice would have incurred if paid employees occupied those positions for the same amount of time that volunteers spent working in those positions.” 8. A review of the facilitys staff roster, undated, was conducted. There was no documented evidence to show the agency had volunteer staff. A review of the volunteer program binder from October 1, 2021, (the day the Owner purchased the agency) to October 17, 2024, was conducted. There was no documented evidence to show volunteers provided day-to-day administrative and/or direct patient care services to equal five percent of the total patient care hours of all paid hospice employees and contract staff. During an interview with the Owner and Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 12:17 PM, the Owner stated a Volunteer Coordinator (VC) was responsible for the Volunteer Program and she had thought the VC was taking care of it. The Owner stated she did not know anything about what to do with a hospice Volunteer Program and had relied on the VC. The AD/DPCSD stated she had reviewed the documentation for the Volunteer Program and there was no evidence to show volunteers provided day-to-day administrative and/or direct patient care services to equal five percent of the total patient care hours of all paid hospice employees and contract staff. The AD/DPCSD verified the agency had no volunteers to provide cost savings for the agency. The Owner and AD/DPCSD stated they had repeatedly tried to contact the VC but there had been no response. The VC was unavailable for interview. A review of the agencys policy and procedure titled, “;Volunteer Services,” undated, indicated, “;PROCEDURE: ... 5. The volunteer coordinator will track the use of volunteers, cost savings achieved, and that hours of volunteer services exceed 5% of the total patient care hours of paid and contracted hospice personnel. ... 7. The hospice documents the cost savings achieved through the use of volunteers. The documentation includes the following: The positions occupied by volunteers, The work time spent by volunteers occupying those positions, estimated dollar costs that the hospice would have incurred if paid employees occupied those positions for the same amount of time that volunteers spent working in those positions.” 9 a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 27, 2024, with a benefit period of September 23, 2024, to November 21, 2024 (Benefit Period Three). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 1s “;Physicians Certification for Hospice Benefit,” dated September 23, 2024, to November 21, 2024, indicated the MD as the certifying physician. There was no documented evidence to show a “;Face to Face Narrative,” or a “;Certifying Physician Narrative,” or a physicians signature. A review of Patient 1s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:23 AM, the MD stated he was the Medical Director for the agency. The MD stated the agency had been going through some difficult times and he thought the agencys services had been put “;on hold.” The MD stated he did not know Patient 1 had been admitted to the agency and did not know he needed to complete a CTI. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 20, 2024, with a benefit period of August 20, 2024, to November 17, 2024 (First 90-day benefit period). Patient 2 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 2s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated August 20, 2024, to November 17, 2024, indicated the MDs electronic signature. A review of Patient 2s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated August 20, 2024, to November 17, 2024, indicated the MDs electronic signature. A review of Patient 2s claims for payment, indicated a claim for payment was submitted on September 4, 2024. During an interview with the MD on October 17, 2024, at 10:41 AM, the MD stated the electronic signature was not his. The MD stated he did not certify Patient 2. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 6, 2024, with a benefit period of September 6, 2024, to December 4, 2024 (First 90-day benefit period). Patient 4 had diagnoses that included heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). A review of Patient 4s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated September 6, 2024, to December 4, 2024, indicated a Medical Director Designee (MDD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDDs signature. A review of Patient 4s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated September 6, 2024, to December 4, 2024, indicated a Medical Director Designee (MDD) as the certifying physician. There was no documented evidence to show the MDDs signature. A review of Patient 4s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:47 AM, the MD stated he did not know the MDD nor ever met the MDD. The MD stated he did not know Patient 4 had been admitted to the agency and did not know he needed to complete a CTI. The MDD was unavailable for interview. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 12, 2024, with a benefit period of September 12, 2024, to December 10, 2024 (First 90-day benefit period). Patient 5 had diagnoses that included Parkinsonism (another name for Parkinson’s disease-a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 5s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated September 12, 2024, to December 10, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDs signature. A review of Patient 5s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated September 12, 2024, to December 10, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show the MDs signature. A review of Patient 5s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:48 AM, the MD stated he did not know Patient 5 had been admitted to the agency and did not know he needed to complete a CTI. A review of Patient 6s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 30, 2024, with a benefit period of August 30, 2024, to November 27, 2024 (First 90-day benefit period). Patient 6 had diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 6s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated August 30, 2024, to November 27, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDs signature. A review of Patient 6s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated August 30, 2024, to November 27, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show the MDs signature. A review of Patient 6s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:49 AM, the MD stated he did not know Patient 6 had been admitted to the agency and did not know he needed to complete a CTI. A review of Patient 7s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 30, 2024, with a benefit period of August 30, 2024, to November 27, 2024 (First 90-day benefit period). Patient 7 had diagnoses that included hypertensive heart disease (a group of heart problems that develop due to chronic high blood pressure). A review of Patient 7s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated August 30, 2024, to November 27, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDs signature. A review of Patient 7s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated August 30, 2024, to November 27, 2024, indicated the Medical Director Designee (MDD) as the certifying physician. There was no documented evidence to show the MDDs signature. A review of Patient 7s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:50 AM, the MD stated he did not know the MDD nor ever met the MDD. The MD stated he did not know Patient 7 had been admitted to the agency and did not know he needed to complete a CTI. The MDD was unavailable for interview. A review of Patient 8s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 28, 2024, with a benefit period of August 28, 2024, to November 25, 2024 (First 90-day benefit period). Patient 8 had diagnoses that included hypertensive heart disease (a group of heart problems that develop due to chronic high blood pressure). A review of Patient 8s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated August 28, 2024, to November 25, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDs signature. A review of Patient 8s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated August 28, 2024, to November 25, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show the MDs signature. A review of Patient 8s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:51 AM, the MD stated he did not know Patient 8 had been admitted to the agency and did not know he needed to complete a CTI. A review of Patient 9s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 28, 2024, with a benefit period of August 28, 2024, to November 25, 2024 (First 90-day benefit period). Patient 9 had diagnoses that included atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries of the heart). A review of Patient 9s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated August 28, 2024, to November 25, 2024, indicated a Medical Director Designee (MDD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDDs signature. A review of Patient 9s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated August 28, 2024, to November 25, 2024, indicated a Medical Director Designee (MDD) as the certifying physician. There was no documented evidence to show the MDDs signature. A review of Patient 9s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:52 AM, the MD stated he did not know the MDD nor ever met the MDD. The MD stated he did not know Patient 9 had been admitted to the agency and did not know he needed to complete a CTI. The MDD was unavailable for interview. A review of Patient 10s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 23, 2024, with a benefit period of August 23, 2024, to November 20, 2024 (First 90-day benefit period). Patient 10 had diagnoses that included systolic heart failure (a condition that occurs when the heart’s left ventricle is too weak to pump enough blood throughout the body). A review of Patient 10s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated August 23, 2024, to November 20, 2024, indicated the Medic al Director (MD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDs signature. A review of Patient 10s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated August 23, 2024, to November 20, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show the MDs signature. A review of Patient 10s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:53 AM, the MD stated he did not know Patient 10 had been admitted to the agency and did not know he needed to complete a CTI. A review of Patient 12s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of February 1, 2024, with a benefit period of February 1, 2024, to April 30, 2024 (Second 90-day benefit period). Patient 12 had diagnoses that included atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries of the heart). A review of Patient 12s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated February 1, 2024, to April 30, 2024, indicated a Medical Director Designee (MDD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDDs signature. A review of Patient 12s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated February 1, 2024, to April 30, 2024, indicated a Medical Director Designee (MDD) as the certifying physician and an electronic signature. Patient 12s claims for payment were not provided by the agency. During an interview with the MD on October 17, 2024, at 10:56 AM, the MD stated he did not know the MDD nor ever met the MDD. The MD stated he did not know Patient 12 had been admitted to the agency and did not know he needed to complete a CTI. The MDD was unavailable for interview. A review of Patient 13s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 10, 2024, with a benefit period of July 10, 2024, to October 7, 2024 (First 90-day benefit period). Patient 13 had diagnoses that included heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). A review of Patient 13s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated July 10, 2024, to October 7, 2024, indicated a Medical Director (MD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDs signature. A review of Patient 13s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated July 10, 2024, to October 7, 2024, indicated a Medical Director (MD) as the certifying physician and an electronic signature. Patient 13s claims for payment were not provided by the agency. During an interview with the MD on October 17, 2024, at 11:01 AM, the MD stated the electronic signature was not his. The MD stated he did not certify Patient 13. A review of Patient 14s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 1, 2024, with a benefit period of March 1, 2024, to April 29, 2024 (Benefit Period Seven). Patient 14 had diagnoses that included Moderate protein-calorie malnutrition (is the state of inadequate intake of food such as protein, calories, and other essential nutrients). A review of Patient 14s “;Physicians Certification for Hospice Benefit,” dated March 1, 2024, to April 29, 2024, indicated the MD as the certifying physician. There was no documented evidence to show a “;Face to Face Narrative,” or a “;Certifying Physician Narrative,” or a physicians signature. Patient 14s claims for payment were not provided by the agency. During an interview with the MD on October 17, 2024, at 11:04 AM, the MD stated he did not know the MDD nor ever met the MDD. The MD stated he did not know Patient 14 had been admitted to the agency and did not know he needed to complete a CTI. The MDD was unavailable for interview. A review of the agencys policy and procedure titled “;Certification of Terminal Illness,” undated, indicated, “;PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient’s attending physician, if any, will certify the patient’s terminal illness. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. ...” 9b. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 27, 2024, with a benefit period of September 23, 2024, to November 21, 2024 (Benefit Period Three). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 1s “;Physicians Certification for Hospice Benefit,” dated September 23, 2024, to November 21, 2024, indicated the MD as the certifying physician. There was no documented evidence to show a “;Face to Face Narrative.” A review of Patient 1s “;Face to Face Encounters,” from March 27, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a face-to-face encounter had been performed. A review of Patient 1s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:23 AM, the MD stated a face-to-face encounter was required in a patients third benefit period. The MD stated a face-to-face encounter had not been performed for Patient 1. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, with a benefit period of September 26, 2024, to November 24, 2024 (Benefit Period Eight). Patient 3 had diagnoses that included congestive heart failure (a condition where the heart does not pump enough blood to meet the body’s needs). A review of Patient 3s “;Physicians Certification for Hospice Benefit,” dated September 26, 2024, to November 24, 2024 (Benefit Period Eight), indicated a signature by the Medical Director (MD). A review of Patient 3s face-to-face encounter for the eighth benefit period dated September 17, 2024, indicated the face-to-face encounter had been conducted by the MD. A review of Patient 3s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:43 AM, the MD stated he had certified Patient 3s terminal illness and performed the face-to-face encounter. The MD stated he did not know the certifying doctor could not conduct the face-to-face encounter. A review of Patient 14s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 1, 2024, with a benefit period of March 1, 2024, to April 29, 2024 (Benefit Period Seven). Patient 14 had diagnoses that included Moderate protein-calorie malnutrition (is the state of inadequate intake of food such as protein, calories, and other essential nutrients). A review of Patient 14s “;Physicians Certification for Hospice Benefit,” dated March 1, 2024, to April 29, 2024, indicated a Medical Director Designee (MDD) as the certifying physician. There was no documented evidence to show a “;Face to Face Narrative.” A review of Patient 14s “;Face to Face Encounters,” from March 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a face-to-face encounter had been performed. Patient 14s claims for payment were not provided by the agency. During an interview with the MD on October 17, 2024, at 11:04 AM, the MD stated a face-to-face encounter was required in a patients seventh benefit period. The MD stated a face-to-face encounter had not been performed for Patient 14. A review of the agencys policy and procedure titled “;Face to Face Encounter,” undated, indicated, PURPOSE: To establish a process to comply with the Face-to-Face Encounter requirement. POLICY: A face-to-face encounter will be performed for patients entering the third and all subsequent benefit periods. PROCEDURE: 1. The hospice director (employed, volunteer, or under contract) or a hospice employed nurse practitioner (NP) will perform a face-to-face encounter within 30 days of a hospice recertification for the third and all subsequent benefit periods. 2. Face-to-Face must gather and document clinical findings to determine continued hospice eligibility. 3. The physician/NP who performs the face-to-face encounter will attest in writing that he/she had the face-to-face encounter, including the date of the visit. The NP must also attest that the clinical findings were provided to the certifying physician. 4. The face-to-face attestation must be signed and dated by the individual who performed the visit. ...” 9c. A review of Patient 11s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 1, 2024, with a benefit period of July 1, 2024, to September 28, 2024 (First 90-day benefit period). Patient 11 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 11s physicians orders from July 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a physicians referral order for hospice services. A review of Patient 11s “;Physicians Certification for Hospice Benefit,” dated July 1, 2024, to September 28, 2024 indicated Patient 11 was in his first 90-day benefit period. Patient 11s “;Physicians Certification for Hospice Benefit,” indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP) should sign. Patient 11s “;Physicians Certification for Hospice Benefit,” indicated a Medical Director Designees (MDD)s signature on both lines There was no documented evidence to show an AP had signed Patient 11s “;Physicians Certification for Hospice Benefit.” Patient 11s claims for payment were not provided by the agency. During an interview with the MD on October 17, 2024, at 10:54 AM, the MD stated he did not know the MDD nor ever met the MDD. The MD stated the MDD should not have signed Patient 11s CTI as the Medical Director and the Attending Physician. The MDD was unavailable for interview. A review of the agencys policy and procedure titled “;Certification of Terminal Illness,” undated, indicated, “;PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. ... PROCEDURE: 1. ... (The hospice Medical Director and the patient’s attending physician will sign the certification of terminal illness and authorization for hospice services forms.) ... 4. Both the attending physician’s and Medical Director’s signed and dated initial certification forms must be on file prior to billing the first claim. ...” 10a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 27, 2024, with a benefit period of September 23, 2024, to November 21, 2024 (Benefit Period Three). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 1s physicians orders from March 27, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 1:33 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:23 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 1s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 10 b. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 20, 2024, with a benefit period of August 20, 2024, to November 17, 2024 (First 90-day benefit period). Patient 2 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 2s physicians orders from August 20, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 1:52 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:41 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 2s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 10 c. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, with a benefit period of September 26, 2024, to November 24, 2024 (Benefit Period Eight). Patient 3 had diagnoses that included congestive heart failure (a condition where the heart does not pump enough blood to meet the body’s needs). A review of Patient 3s physicians orders from March 30, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 2:06 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:43 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 3s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 10 d. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 6, 2024, with a benefit period of September 6, 2024, to December 4, 2024 (First 90-day benefit period). Patient 4 had diagnoses that included heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). A review of Patient 4s physicians orders from September 6, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 2:30 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:47 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 4s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 10 e. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 12, 2024, with a benefit period of September 12, 2024, to December 10, 2024 (First 90-day benefit period). Patient 5 had diagnoses that included Parkinsonism (another name for Parkinson’s disease-a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 5s physicians orders from September 12, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 2:54 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:48 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 5s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 10 f. A review of Patient 6s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 30, 2024, with a benefit period of August 30, 2024, to November 27, 2024 (First 90-day benefit period). Patient 6 had diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 6s physicians orders from August 30, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 3:06 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:49 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 6s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 10 g. A review of Patient 7s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 30, 2024, with a benefit period of August 30, 2024, to November 27, 2024 (First 90-day benefit period). Patient 7 had diagnoses that included hypertensive heart disease (a group of heart problems that develop due to chronic high blood pressure). A review of Patient 7s physicians orders from August 30, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 3:19 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:50 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 7s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 10 h. A review of Patient 8s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 28, 2024, with a benefit period of August 28, 2024, to November 25, 2024 (First 90-day benefit period). Patient 8 had diagnoses that included hypertensive heart disease (a group of heart problems that develop due to chronic high blood pressure). A review of Patient 8s physicians orders from August 28, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 3:35 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:51 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 8s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 10 i. A review of Patient 9s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 28, 2024, with a benefit period of August 28, 2024, to November 25, 2024 (First 90-day benefit period). Patient 9 had diagnoses that included atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries of the heart). A review of Patient 9s physicians orders from August 28, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 3:52 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:52 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 9s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 10 j. A review of Patient 10s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 23, 2024, with a benefit period of August 23, 2024, to November 20, 2024 (First 90-day benefit period). Patient 10 had diagnoses that included systolic heart failure (a condition that occurs when the heart’s left ventricle is too weak to pump enough blood throughout the body). A review of Patient 10s physicians orders from August 23, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 4:06 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:53 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 10s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 10 k. A review of Patient 11s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 1, 2024, with a benefit period of July 1, 2024, to September 28, 2024 (First 90-day benefit period). Patient 11 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). Discharged July 29, 2024. A review of Patient 11s physicians orders from July 1, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 4:38 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:54 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 11s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 10 l. A review of Patient 12s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of February 1, 2024, with a benefit period of February 1, 2024, to April 30, 2024 (Second 90-day benefit period). Patient 12 had diagnoses that included atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries of the heart). Discharged March 4, 2024. A review of Patient 12s physicians orders from February 1, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 4:48 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:56 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 12s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 10 m. A review of Patient 13s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 10, 2024, with a benefit period of July 10, 2024, to October 7, 2024 (First 90-day benefit period). Patient 13 had diagnoses that included heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). Expired July 20, 2024. A review of Patient 13s physicians orders from July 10, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 9 AM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 11:01 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 13s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 10 n. A review of Patient 14s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 1, 2024, with a benefit period of March 1, 2024, to April 29, 2024 (Benefit Period Seven). Patient 14 had diagnoses that included Moderate protein-calorie malnutrition (is the state of inadequate intake of food such as protein, calories, and other essential nutrients). Expired March 21, 2024. A review of Patient 14s physicians orders from March 1, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 9:15 AM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 11:04 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 14s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. A review of the agencys policy and procedure titled “;Intake Process,” undated, indicated, “;PURPOSE: To establish the process for acceptance and entry of patients into hospice. ... PROCEDURE: ... D. If the referral call is not from a physician, the physician (or other authorized licensed independent practitioner) will be contacted to confirm service needs, as well as the patient’s medical prognosis and supporting documentation, and to obtain verbal orders. ...” “;§ 418.25 Admission to hospice care.(a) The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient’s attending physician (if any). (b) In reaching a decision to certify that the patient is terminally ill, the hospice medical director must consider at least the following information: (1) Diagnosis of the terminal condition of the patient. (2) Other health conditions, whether related or unrelated to the terminal condition. (3) Current clinically relevant information supporting all diagnoses.” 11. A review of the agencys Emergency Preparedness Binder, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show the Governing Body had reviewed its contents. A review of the agencys policy and procedure titled, “Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a review had been conducted. A review of the agencys Governing Body Meeting Minutes, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show the Governing Body had reviewed the Emergency Preparedness Program. During an interview with the Owner and the Administer Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 11:57 AM, the Owner stated the Admin/DPCS had been responsible for the EPP but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the EPP had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024, and there was no safety committee. The Owner stated she was the sole member of the Governing Body, and she could not show documented evidence the agency’s EPP had been reviewed by the Governing Body for the three years the agency had been operational from October 1, 2021, through October 17, 2024. A review of the agencys policy and procedure titled “;Emergency Management Plan,” undated, indicated, “;The Emergency Management Plan is reviewed by the Safety Committee on an annual basis. The committee shall meet on an as-needed basis during the year to keep the Emergency. Management Plan up-to-date and make any revisions necessary including the incorporation of new staff members.” 12. A review of the agencys Emergency Preparedness Binder, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show the agency had reached out to and collaborated with local, regional, State, and Federal emergency preparedness officials. A review of the agencys policy and procedure titled, “Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a contact number for the San Bernardino County emergency management office. During an interview with the Owner and the Administer Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 11:57 AM, the Owner stated the Admin/DPCS had been responsible for the EPP but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the EPP had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024, and there was no safety committee. The Owner stated the Emergency Management Plan had been put together by the previous agencys owner and at that time the agency was located in Orange County. The Owner stated references in the Emergency Management Plan were for Orange County, not San Bernardino County. A review of the agencys policy and procedure titled, “;Emergency Management Plan.” undated, indicated, “;... 3. Establishing, in coordination with county emergency management planning, priorities among potential emergencies identified in the hazard vulnerability analysis for which mitigation, preparation, response and recovery activities will need to be undertaken. ...” 13. A review of the agencys Emergency Preparedness Binder, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show a process to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency. There was no documented evidence to show contact information for the emergency management offices in the counties and cities were the agencys patients lived. A review of the agencys policy and procedure titled, “Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a plan to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency. During an interview with the Owner and the Administer Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 11:57 AM, the Owner stated the Admin/DPCS had been responsible for the EPP but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the EPP had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024, and there was no safety committee. The AD/DPCSD verified there was no plan to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency and there was no contact information for the emergency management offices in the counties and cities were the agencys patients lived. A review of the agencys policy and procedure titled, “;Emergency Management Plan,” undated was conducted. There was no documented evidence to show a plan or procedure to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency. 14. A review of the agencys Emergency Preparedness Binder, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show a process to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, and there was no documented evidence to show contact information for the emergency management offices in the counties and cities were the agencys patients lived. A review of the agencys policy and procedure titled, “Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a plan to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process. During an interview with the Owner and the Administer Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 11:57 AM, the Owner stated the Admin/DPCS had been responsible for the EPP but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the EPP had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024, and there was no safety committee. The AD/DPCSD verified there was no plan or process to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process. The AD/DPCSD verified there was no contact information for the emergency management offices in the counties and cities were the agencys patients lived. A review of the agencys policy and procedure titled, “;Emergency Management Plan,” undated was conducted. There was no documented evidence to show a plan or procedure to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process. 15. A review of the agencys Emergency Preparedness Binder, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show a process to provide for emergency staffing during a disaster or emergency. A review of the agencys policy and procedure titled, “Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a plan to provide for emergency staffing during a disaster or emergency. During an interview with the Owner and the Administer Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 11:57 AM, the Owner stated the Admin/DPCS had been responsible for the EPP but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the EPP had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024, and there was no safety committee. The AD/DPCSD verified there was no plan or process to provide for emergency staffing during a disaster or emergency. A review of the agencys policy and procedure titled, “;Emergency Management Plan,” undated was conducted. There was no documented evidence to show a plan or procedure to provide for emergency staffing during a disaster or emergency. 16. A review of the agencys Emergency Preparedness Binder, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show a process for a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency. A review of the agencys policy and procedure titled, “Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency. During an interview with the Owner and the Administer Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 11:57 AM, the Owner stated the Admin/DPCS had been responsible for the EPP but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the EPP had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024, and there was no safety committee. The AD/DPCSD verified there was no back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency. A review of the agencys policy and procedure titled, “;Emergency Management Plan,” undated was conducted. There was no documented evidence to show a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency. 17. A review of the agencys Emergency Preparedness Binder, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, was conducted. There was no documented evidence to show a full-scale community based or tabletop emergency preparedness exercise had been conducted. During an interview with the Owner and the Administer Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 17, 2024, at 11:57 AM, the Owner stated the Admin/DPCS had been responsible for the EPP but had not fulfilled his responsibilities. The Owner and AD/DPCSD stated the EPP had not been functioning for the three years the agency had been operational from October 1, 2021, through October 17, 2024, and there was no safety committee. The AD/DPCSD verified no full-scale community based or tabletop emergency preparedness exercise had been conducted. A review of the agencys policy and procedure titled “;Emergency Management Plan,” undated, indicated, “;... 12. [Name of the agency] will test the emergency management plan at least annually, either in response to an actual emergency or in a planned exercise. Planned exercises are realistic scenarios and related to the priority emergencies defined by leadership and DO NOT include tabletop drills nor are they required to be performed in patients’ homes. All actual responses and exercises will be documented and critiqued through a multidisciplinary process that includes administrative, clinical and support staff. Documentation will be used to identify deficiencies and opportunities for improvement based on all monitoring activities and observations during the exercise.13. [Name of the agency] will modify the emergency management plan in response to the critiques of the exercise. Next scheduled planned exercise will evaluate the effectiveness of the improvements that were made in response to the critiques of the previous exercise. If improvements require substantive recourses that can’t be accomplished by next planned exercise, interim improvements must be put in place until final resolution. ...” During an interview with the Owner on October 17, 2024, at 3:45 PM, The Owner stated she was the sole member of the Governing Body (GB) and assumed full legal authority and responsibility for the operation of the agency, and for the quality of care and services provided. The Owner stated the GB had not identified: a. The agency failed to develop an individualized plan of care for Patients 1, 2, 3. b. The hospice interdisciplinary group (IDG) failed to review, revise, and document the individualized care plan as frequently as the patients condition required, but no less frequently than every 15 calendar days, for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14. c. The agency failed to maintain an infection control program that was integrated into the agencys Quality Assessment Performance Improvement (QAPI) program in order to: identify infection trends, develop action plans and improve disease prevention, from October 1, 2021 (the date the Owner purchased the agency) to October 17, 2024, in a universe of 14 patients. d. The agency failed to ensure a Bereavement Program was maintained to provide bereavement services to family, loved ones and caregivers for one year following the death of a patient, for Patients 13 and 14, in a universe of 14 patients. e. The agency failed to maintain a volunteer program that utilized volunteers in day-to-day administrative duties and/or direct patient care, in a universe of 14 patients. f. The agency failed to maintain a volunteer program by actively recruiting volunteers, in a universe of 14 patients. g. The agency failed to document the cost savings achieved through the use of volunteers by the identification of each position that was occupied by a volunteer, the work time spent by volunteers occupying those positions and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions, in a universe of 14 patients. h. The agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services to equal five percent of the total patient care hours of all paid hospice employees and contract staff, in a universe of 14 patients. i. The agency failed to ensure the Medical Director (MD) certified the patients’ terminal illnesses before the agency submitted a claim for payment, for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14. j. The agency failed to follow Federal Law [42 Code of Federal Regulations (CFR) § 418.25(a)], requiring a written physicians referral order, when the patients clinical record did not contain a physician’s referral order for hospice services, a confirmation of service needs, a verification of the patients’ medical prognosis and supporting documentation for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14. k. The agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. l. The agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. m. The agency failed to develop a procedure and/or process to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. n. The agency failed to create and implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. o. The agency failed to create a plan and implement a procedure to provide for emergency staffing during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. p. The agency failed to develop a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. q. The agency failed to conduct full-scale emergency preparedness exercises that were community based or tabletop emergency preparedness exercises, for the three years the agency had been operational from October 1, 2021, through October 17, 2024, in a universe of 14 patients. A review of the agencys policy and procedure titled, “;Governing Body,” undated, indicated, “;PURPOSE: To outline the roles and responsibilities of the Governing Body. POLICY: A. The hospice agency shall have a governing body. B. The governing body shall: ... 2. Assume full legal authority and responsibility for the operation of the program. ...””

“Based on interview, and record review, the agency failed to ensure the Medical Director (MD) certified the patients’ terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) when: 1. For Patients 1, 2, 4, 5, 6, 7, 8, 9, 10, 12, 13, and 14 the Medical Director (MD) failed to certify the patients as terminally ill. 2. For Patients 1, 3 and 14, the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. 3. For Patient 11, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. These failures had the potential to cause Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 to not be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to not being properly evaluated as terminally ill. 1a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 27, 2024, with a benefit period of September 23, 2024, to November 21, 2024 (Benefit Period Three). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 1s “;Physicians Certification for Hospice Benefit,” dated September 23, 2024, to November 21, 2024, indicated the MD as the certifying physician. There was no documented evidence to show a “;Face to Face Narrative,” or a “;Certifying Physician Narrative,” or a physicians signature. A review of Patient 1s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:23 AM, the MD stated he was the Medical Director for the agency. The MD stated the agency had been going through some difficult times and he thought the agencys services had been put “;on hold.” The MD stated he did not know Patient 1 had been admitted to the agency and did not know he needed to complete a CTI. 1b. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 20, 2024, with a benefit period of August 20, 2024, to November 17, 2024 (First 90-day benefit period). Patient 2 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 2s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated August 20, 2024, to November 17, 2024, indicated the MDs electronic signature. A review of Patient 2s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated August 20, 2024, to November 17, 2024, indicated the MDs electronic signature. A review of Patient 2s claims for payment, indicated a claim for payment was submitted on September 4, 2024. During an interview with the MD on October 17, 2024, at 10:41 AM, the MD stated the electronic signature was not his. The MD stated he did not certify Patient 2. 1c. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 6, 2024, with a benefit period of September 6, 2024, to December 4, 2024 (First 90-day benefit period). Patient 4 had diagnoses that included heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). A review of Patient 4s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated September 6, 2024, to December 4, 2024, indicated a Medical Director Designee (MDD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDDs signature. A review of Patient 4s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated September 6, 2024, to December 4, 2024, indicated a Medical Director Designee (MDD) as the certifying physician. There was no documented evidence to show the MDDs signature. A review of Patient 4s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:47 AM, the MD stated he did not know the MDD nor ever met the MDD. The MD stated he did not know Patient 4 had been admitted to the agency and did not know he needed to complete a CTI. The MDD was unavailable for interview. 1d. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 12, 2024, with a benefit period of September 12, 2024, to December 10, 2024 (First 90-day benefit period). Patient 5 had diagnoses that included Parkinsonism (another name for Parkinson’s disease-a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 5s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated September 12, 2024, to December 10, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDs signature. A review of Patient 5s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated September 12, 2024, to December 10, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show the MDs signature. A review of Patient 5s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:48 AM, the MD stated he did not know Patient 5 had been admitted to the agency and did not know he needed to complete a CTI. 1e. A review of Patient 6s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 30, 2024, with a benefit period of August 30, 2024, to November 27, 2024 (First 90-day benefit period). Patient 6 had diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 6s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated August 30, 2024, to November 27, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDs signature. A review of Patient 6s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated August 30, 2024, to November 27, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show the MDs signature. A review of Patient 6s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:49 AM, the MD stated he did not know Patient 6 had been admitted to the agency and did not know he needed to complete a CTI. 1f. A review of Patient 7s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 30, 2024, with a benefit period of August 30, 2024, to November 27, 2024 (First 90-day benefit period). Patient 7 had diagnoses that included hypertensive heart disease (a group of heart problems that develop due to chronic high blood pressure). A review of Patient 7s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated August 30, 2024, to November 27, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDs signature. A review of Patient 7s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated August 30, 2024, to November 27, 2024, indicated the Medical Director Designee (MDD) as the certifying physician. There was no documented evidence to show the MDDs signature. A review of Patient 7s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:50 AM, the MD stated he did not know the MDD nor ever met the MDD. The MD stated he did not know Patient 7 had been admitted to the agency and did not know he needed to complete a CTI. The MDD was unavailable for interview. 1g. A review of Patient 8s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 28, 2024, with a benefit period of August 28, 2024, to November 25, 2024 (First 90-day benefit period). Patient 8 had diagnoses that included hypertensive heart disease (a group of heart problems that develop due to chronic high blood pressure). A review of Patient 8s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated August 28, 2024, to November 25, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDs signature. A review of Patient 8s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated August 28, 2024, to November 25, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show the MDs signature. A review of Patient 8s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:51 AM, the MD stated he did not know Patient 8 had been admitted to the agency and did not know he needed to complete a CTI. 1h. A review of Patient 9s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 28, 2024, with a benefit period of August 28, 2024, to November 25, 2024 (First 90-day benefit period). Patient 9 had diagnoses that included atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries of the heart). A review of Patient 9s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated August 28, 2024, to November 25, 2024, indicated a Medical Director Designee (MDD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDDs signature. A review of Patient 9s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated August 28, 2024, to November 25, 2024, indicated a Medical Director Designee (MDD) as the certifying physician. There was no documented evidence to show the MDDs signature. A review of Patient 9s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:52 AM, the MD stated he did not know the MDD nor ever met the MDD. The MD stated he did not know Patient 9 had been admitted to the agency and did not know he needed to complete a CTI. The MDD was unavailable for interview. 1i. A review of Patient 10s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 23, 2024, with a benefit period of August 23, 2024, to November 20, 2024 (First 90-day benefit period). Patient 10 had diagnoses that included systolic heart failure (a condition that occurs when the heart’s left ventricle is too weak to pump enough blood throughout the body). A review of Patient 10s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated August 23, 2024, to November 20, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDs signature. A review of Patient 10s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated August 23, 2024, to November 20, 2024, indicated the Medical Director (MD) as the certifying physician. There was no documented evidence to show the MDs signature. A review of Patient 10s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:53 AM, the MD stated he did not know Patient 10 had been admitted to the agency and did not know he needed to complete a CTI. 1j. A review of Patient 12s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of February 1, 2024, with a benefit period of February 1, 2024, to April 30, 2024 (Second 90-day benefit period). Patient 12 had diagnoses that included atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries of the heart). A review of Patient 12s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated February 1, 2024, to April 30, 2024, indicated a Medical Director Designee (MDD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDDs signature. A review of Patient 12s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated February 1, 2024, to April 30, 2024, indicated a Medical Director Designee (MDD) as the certifying physician and an electronic signature. Patient 12s claims for payment were not provided by the agency. During an interview with the MD on October 17, 2024, at 10:56 AM, the MD stated he did not know the MDD nor ever met the MDD. The MD stated he did not know Patient 12 had been admitted to the agency and did not know he needed to complete a CTI. The MDD was unavailable for interview. 1k. A review of Patient 13s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 10, 2024, with a benefit period of July 10, 2024, to October 7, 2024 (First 90-day benefit period). Patient 13 had diagnoses that included heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). A review of Patient 13s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Medical Director) dated July 10, 2024, to October 7, 2024, indicated a Medical Director (MD) as the certifying physician. There was no documented evidence to show a “;Certifying Physician Narrative,” or the MDs signature. A review of Patient 13s “;Physicians Certification for Hospice Benefit,” (which was to be completed by the Attending Physician) dated July 10, 2024, to October 7, 2024, indicated a Medical Director (MD) as the certifying physician and an electronic signature. Patient 13s claims for payment were not provided by the agency. During an interview with the MD on October 17, 2024, at 11:01 AM, the MD stated the electronic signature was not his. The MD stated he did not certify Patient 13. 1l. A review of Patient 14s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 1, 2024, with a benefit period of March 1, 2024, to April 29, 2024 (Benefit Period Seven). Patient 14 had diagnoses that included Moderate protein-calorie malnutrition (is the state of inadequate intake of food such as protein, calories, and other essential nutrients). A review of Patient 14s “;Physicians Certification for Hospice Benefit,” dated March 1, 2024, to April 29, 2024, indicated the MD as the certifying physician. There was no documented evidence to show a “;Face to Face Narrative,” or a “;Certifying Physician Narrative,” or a physicians signature. Patient 14s claims for payment were not provided by the agency. During an interview with the MD on October 17, 2024, at 11:04 AM, the MD stated he did not know the MDD nor ever met the MDD. The MD stated he did not know Patient 14 had been admitted to the agency and did not know he needed to complete a CTI. The MDD was unavailable for interview. A review of the agencys policy and procedure titled “;Certification of Terminal Illness,” undated, indicated, “;PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient’s attending physician, if any, will certify the patient’s terminal illness. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. ...” 2a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 27, 2024, with a benefit period of September 23, 2024, to November 21, 2024 (Benefit Period Three). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 1s “;Physicians Certification for Hospice Benefit,” dated September 23, 2024, to November 21, 2024, indicated the MD as the certifying physician. There was no documented evidence to show a “;Face to Face Narrative.” A review of Patient 1s “;Face to Face Encounters,” from March 27, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a face-to-face encounter had been performed. A review of Patient 1s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:23 AM, the MD stated a face-to-face encounter was required in a patients third benefit period. The MD stated a face-to-face encounter had not been performed for Patient 1. 2b. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, with a benefit period of September 26, 2024, to November 24, 2024 (Benefit Period Eight). Patient 3 had diagnoses that included congestive heart failure (a condition where the heart does not pump enough blood to meet the body’s needs). A review of Patient 3s “;Physicians Certification for Hospice Benefit,” dated September 26, 2024, to November 24, 2024 (Benefit Period Eight), indicated a signature by the Medical Director (MD). A review of Patient 3s face-to-face encounter for the eighth benefit period dated September 17, 2024, indicated the face-to-face encounter had been conducted by the MD. A review of Patient 3s claims for payment, indicated a claim for payment was submitted on October 3, 2024. During an interview with the MD on October 17, 2024, at 10:43 AM, the MD stated he had certified Patient 3s terminal illness and performed the face-to-face encounter. The MD stated he did not know the certifying doctor could not conduct the face-to-face encounter. 2c. A review of Patient 14s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 1, 2024, with a benefit period of March 1, 2024, to April 29, 2024 (Benefit Period Seven). Patient 14 had diagnoses that included Moderate protein-calorie malnutrition (is the state of inadequate intake of food such as protein, calories, and other essential nutrients). A review of Patient 14s “;Physicians Certification for Hospice Benefit,” dated March 1, 2024, to April 29, 2024, indicated a Medical Director Designee (MDD) as the certifying physician. There was no documented evidence to show a “;Face to Face Narrative.” A review of Patient 14s “;Face to Face Encounters,” from March 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a face-to-face encounter had been performed. Patient 14s claims for payment were not provided by the agency. During an interview with the MD on October 17, 2024, at 11:04 AM, the MD stated a face-to-face encounter was required in a patients seventh benefit period. The MD stated a face-to-face encounter had not been performed for Patient 14. A review of the agencys policy and procedure titled “;Face to Face Encounter,” undated, indicated, PURPOSE: To establish a process to comply with the Face-to-Face Encounter requirement. POLICY: A face-to-face encounter will be performed for patients entering the third and all subsequent benefit periods. PROCEDURE: 1. The hospice director (employed, volunteer, or under contract) or a hospice employed nurse practitioner (NP) will perform a face-to-face encounter within 30 days of a hospice recertification for the third and all subsequent benefit periods. 2. Face-to-Face must gather and document clinical findings to determine continued hospice eligibility. 3. The physician/NP who performs the face-to-face encounter will attest in writing that he/she had the face-to-face encounter, including the date of the visit. The NP must also attest that the clinical findings were provided to the certifying physician. 4. The face-to-face attestation must be signed and dated by the individual who performed the visit. ...” 3. A review of Patient 11s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 1, 2024, with a benefit period of July 1, 2024, to September 28, 2024 (First 90-day benefit period). Patient 11 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 11s physicians orders from July 1, 2024, to October 17, 2024, was conducted. There was no documented evidence to show a physicians referral order for hospice services. A review of Patient 11s “;Physicians Certification for Hospice Benefit,” dated July 1, 2024, to September 28, 2024 indicated Patient 11 was in his first 90-day benefit period. Patient 11s “;Physicians Certification for Hospice Benefit,” indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP) should sign. Patient 11s “;Physicians Certification for Hospice Benefit,” indicated a Medical Director Designees (MDD)s signature on both lines There was no documented evidence to show an AP had signed Patient 11s “;Physicians Certification for Hospice Benefit.” Patient 11s claims for payment were not provided by the agency. During an interview with the MD on October 17, 2024, at 10:54 AM, the MD stated he did not know the MDD nor ever met the MDD. The MD stated the MDD should not have signed Patient 11s CTI as the Medical Director and the Attending Physician. The MDD was unavailable for interview. A review of the agencys policy and procedure titled “;Certification of Terminal Illness,” undated, indicated, “;PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. ... PROCEDURE: 1. ... (The hospice Medical Director and the patient’s attending physician will sign the certification of terminal illness and authorization for hospice services forms.) ... 4. Both the attending physician’s and Medical Director’s signed and dated initial certification forms must be on file prior to billing the first claim. ...””

“Based on interview and record review, the agency failed to follow Federal Law [42 Code of Federal Regulations (CFR) § 418.25(a)], requiring a written physicians referral order, when the patients clinical record did not contain a physician’s referral order for hospice services, a confirmation of service needs, a verification of the patients’ medical prognosis and supporting documentation for 14 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14). This failure had the potential to cause Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 to not be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and referring to hospice care. 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 27, 2024, with a benefit period of September 23, 2024, to November 21, 2024 (Benefit Period Three). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 1s physicians orders from March 27, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 1:33 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:23 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 1s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 2. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 20, 2024, with a benefit period of August 20, 2024, to November 17, 2024 (First 90-day benefit period). Patient 2 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 2s physicians orders from August 20, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 1:52 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:41 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 2s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 3. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 30, 2024, with a benefit period of September 26, 2024, to November 24, 2024 (Benefit Period Eight). Patient 3 had diagnoses that included congestive heart failure (a condition where the heart does not pump enough blood to meet the body’s needs). A review of Patient 3s physicians orders from March 30, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 2:06 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:43 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 3s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 4. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 6, 2024, with a benefit period of September 6, 2024, to December 4, 2024 (First 90-day benefit period). Patient 4 had diagnoses that included heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). A review of Patient 4s physicians orders from September 6, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 2:30 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:47 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 4s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 5. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of September 12, 2024, with a benefit period of September 12, 2024, to December 10, 2024 (First 90-day benefit period). Patient 5 had diagnoses that included Parkinsonism (another name for Parkinson’s disease-a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 5s physicians orders from September 12, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 2:54 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:48 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 5s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 6. A review of Patient 6s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 30, 2024, with a benefit period of August 30, 2024, to November 27, 2024 (First 90-day benefit period). Patient 6 had diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 6s physicians orders from August 30, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 3:06 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:49 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 6s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 7. A review of Patient 7s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 30, 2024, with a benefit period of August 30, 2024, to November 27, 2024 (First 90-day benefit period). Patient 7 had diagnoses that included hypertensive heart disease (a group of heart problems that develop due to chronic high blood pressure). A review of Patient 7s physicians orders from August 30, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 3:19 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:50 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 7s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 8. A review of Patient 8s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 28, 2024, with a benefit period of August 28, 2024, to November 25, 2024 (First 90-day benefit period). Patient 8 had diagnoses that included hypertensive heart disease (a group of heart problems that develop due to chronic high blood pressure). A review of Patient 8s physicians orders from August 28, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 3:35 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:51 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 8s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 9. A review of Patient 9s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 28, 2024, with a benefit period of August 28, 2024, to November 25, 2024 (First 90-day benefit period). Patient 9 had diagnoses that included atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries of the heart). A review of Patient 9s physicians orders from August 28, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 3:52 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:52 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 9s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 10. A review of Patient 10s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of August 23, 2024, with a benefit period of August 23, 2024, to November 20, 2024 (First 90-day benefit period). Patient 10 had diagnoses that included systolic heart failure (a condition that occurs when the heart’s left ventricle is too weak to pump enough blood throughout the body). A review of Patient 10s physicians orders from August 23, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 4:06 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:53 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 10s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 11. A review of Patient 11s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 1, 2024, with a benefit period of July 1, 2024, to September 28, 2024 (First 90-day benefit period). Patient 11 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). Discharged July 29, 2024. A review of Patient 11s physicians orders from July 1, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 4:38 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:54 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 11s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 12. A review of Patient 12s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of February 1, 2024, with a benefit period of February 1, 2024, to April 30, 2024 (Second 90-day benefit period). Patient 12 had diagnoses that included atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries of the heart). Discharged March 4, 2024. A review of Patient 12s physicians orders from February 1, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 4:48 PM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 10:56 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 12s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 13. A review of Patient 13s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 10, 2024, with a benefit period of July 10, 2024, to October 7, 2024 (First 90-day benefit period). Patient 13 had diagnoses that included heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). Expired July 20, 2024. A review of Patient 13s physicians orders from July 10, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 9 AM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 11:01 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 13s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 14. A review of Patient 14s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 1, 2024, with a benefit period of March 1, 2024, to April 29, 2024 (Benefit Period Seven). Patient 14 had diagnoses that included Moderate protein-calorie malnutrition (is the state of inadequate intake of food such as protein, calories, and other essential nutrients). Expired March 21, 2024. A review of Patient 14s physicians orders from March 1, 2024, to October 16, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with an Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on October 16, 2024, at 9:15 AM, the AD/DPCSD verified there was no documented evidence to show a physicians referral order had been received. The AD/DPCSD verified there was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 17, 2024, at 11:04 AM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 14s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. A review of the agencys policy and procedure titled “;Intake Process,” undated, indicated, “;PURPOSE: To establish the process for acceptance and entry of patients into hospice. ... PROCEDURE: ... D. If the referral call is not from a physician, the physician (or other authorized licensed independent practitioner) will be contacted to confirm service needs, as well as the patient’s medical prognosis and supporting documentation, and to obtain verbal orders. ...” “;§ 418.25 Admission to hospice care.(a) The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient’s attending physician (if any). (b) In reaching a decision to certify that the patient is terminally ill, the hospice medical director must consider at least the following information: (1) Diagnosis of the terminal condition of the patient. (2) Other health conditions, whether related or unrelated to the terminal condition. (3) Current clinically relevant information supporting all diagnoses.””