Golden Age Hospice & Palliative Care, Inc.

“Based on observation, interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure the patients received the right to be informed of the services the HA provides and the specific limitations of these services for two of seven sampled patients (Patient 1 and Patient 7) certified to receive the hospice care benefits. This deficient practice resulted in the patients’ rights being violated and not fully informed of their admission for hospice care, scope of services, and its limitations. Findings: a. A review of Patient 1s admission record indicated an SOC date of 12/6/2023, with a terminal diagnosis of atherosclerosis heart disease (a development of lesions in walls of arteries). Patient 1’s clinical record further indicated the “;referring/attending/patient choice” physician was Physician 1. During a joint home visit on 12/30/2023, at 12:00 p.m., with LVN 1 at Patient 1s residence the patient was observed walking steadily at the living room without using an assistive device. During an interview on 12/30/2023, at 12:15 p.m., asked Patient 1 if she was informed about the purpose of the hospice care services, patient stated she was never told that she had six months or less to live. Patient 1 stated a nurse from the hospice agency came to visit every week to take her blood pressure readings. Patient 1 further stated that she never had an attending physician, that her friend referred her for hospice care, and she was not dying. A review of Patient 1’s Physicians Certification for Hospice Benefit, dated 12/6/2023 to 3/4/2024, benefit period 1, indicated Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. Patient 1 was identified as a Full Code (all resuscitation procedures will be provided to keep alive). There was no documented evidence Physician 1 was chosen by Patient 1 as her attending physician and informed Patient 1 of his admission to receive hospice services. There was no documented evidence the hospice staff informed Patient 1 of her rights to be informed of the care and services the hospice agency provides and its limitations. There was no documented evidence of a comprehensive assessment was conducted by Physician 1 that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. b. A review of Patient 7s admission record indicated an SOC date of 12/6/2023, with a terminal diagnosis of COPD (Chronic obstructive pulmonary disease, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and hypertensive heart disease. Patient 7’s clinical record further indicated the “;referring/attending/patient choice” physician was Physician 1. A review of Patient 7’s Physicians Certification for Hospice Benefit, dated 12/6/2023 to 3/4/2024, benefit period, indicated Physician 1 signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. Patient 7 was identified as a Full Code (all resuscitation procedures will be provided to keep alive). During a telephone interview with Patient 7’s niece/caregiver on 12/31/2023, at 2:40 p.m., stated that Patient 7 has never been on hospice and that the patient was not dying. Niece stated that Patient 7 had health insurance and had a nurse that came to the home but was not for hospice services. Niece stated that the name of the hospice doctor was not Patient 7s doctor and was still seeing her primary doctor from insurance who did not order hospice care. Niece stated she would file a complaint about this hospice agency for using Patient 7’s information for fraud. There was no documented evidence the hospice staff informed Patient 7 of her rights to be informed of the care and services the hospice provides and its limitations. There was no documented evidence Physician 1 coordinated with Patient 7’s primary physician of patient’s admission to receive hospice services. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient’s primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 12/31/2023, at 11 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient’s attending physician, if not a referral from a social worker or a physician from the hospital from where the patient gets discharged. During a review of the agencys undated policy and procedure titled, “;Patient Bill of Rights/Responsibilities”, indicated each patient will be an active, informed participant in his/her plan of care. The Patient Bill of Rights/Responsibilities statement defines the right of the patient to be informed in advance of service about the care to be furnished, the organizations scope of services, services under the Medicate Hospice Benefit and any limitations on these services.”

“Based on observation, interview, and record review, the Hospice Agency (HA) staff failed to conduct the comprehensive assessment of patients that reflected the patient’s current health status and identified need for hospice care and services related to hospice eligibility and management of terminal illness for two of seven sampled patients (Patient 1 and Patient 7). This deficient practice resulted in the hospice agency certifying patients who did not meet the criteria required to receive the hospice benefits and service management of terminal illness that could affect their quality of life. b. A review of Patient 7s admission record indicated an SOC date of 12/6/2023, with a terminal diagnosis of COPD (Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and hypertensive heart disease Patient 7’s clinical record further indicated the “;referring/attending/patient choice” physician was Physician 1. A review of Patient 7’s Physicians Certification for Hospice Benefit, dated 12/6/2023 to 3/4/2024, benefit period, indicated Physician 1 signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. Patient 7 is indicated as a “full code.” There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient’s primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a telephone interview with Patient 7’s niece/caregiver on 12/31/2023 at 2:40 p.m., stated that Patient 7 has never been on hospice and that the patient is not dying. Niece stated that she is under a different insurance (Kaiser) and has a nurse that comes to the home but is not under hospice. Niece stated that the name of the hospice doctor is not the patients doctor and the patient is still seeing her primary doctor who did not order hospice. Niece stated she will complaint about this agency for using her aunts information for fraud. During a review of the HA’s undated policy and procedure titled “Admission Criteria and Process”, indicated hospice agency will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of six months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). HA will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. The organization will utilize referral information provided by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician offices in the determination of eligibility for admission to the program. If the request for service is not made by the patient’s physician, he/she will be consulted prior to the evaluation visit/initiation of services. During a review of the agencys policy and procedure titled “;Certification of Terminal Illness”, revised November 2021, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. a. A review of Patient 1s admission record indicated an SOC date of 12/6/2023, with a terminal diagnosis of atherosclerosis heart disease ( a development of lesions in walls of arteries). Patient 1’s clinical record further indicated the “;referring/attending/patient choice” physician was Physician 1. A review of Patient 1’s Physicians Certification for Hospice Benefit, dated 12/6/2023 to 3/4/2024, benefit period 1, indicated Physician 1 signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. Patient 1 is indicated as a “full code.” There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient’s primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit on 12/9/23, at 12 p.m., with LVN 1 at Patient 1s residence, Patient 1 was observed walking steadily at the living room without using an assistive device. During an interview on 12/9/23, at 12:15 p.m., asked Patient 1 if she was informed about the purpose of the hospice care services, patient stated she was never told that she had six months or less to live. Patient 1 stated a nurse from the hospice agency would come visit every week to take her blood pressure readings. Patient 1 further stated that she never had an attending physician, that her friend referred her to the hospice agency and she was not dying. On 12/10/2023, at 11:00 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient’s attending physician, if not a referral from a social worker or a physician from the hospital from where the patient gets discharged.”

“Based on interview and record review, the hospice agency failed to ensure the care plans were reviewed by the interdisciplinary group (The Interdisciplinary Group (IDG) is the team responsible for the holistic care of the hospice beneficiary. It is this team which is responsible for development and review of the beneficiary’s plan of care) as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days for three out of seven sample selected patients (Patients 5, 6, and 7). This deficient practice had the potential for patient’s care not being evaluated timely to ensure their needs are met. Findings: a. A review of Patient 5’s Patient Profile indicated, an SOC date of 9/9/2023, with a diagnosis that included hypertensive heart disease without heart failure (a condition where there is thickening of the walls of the heart due to increased blood pressure) During a review of Patient 5’s Plan of Care (POC), for the re-certification period from 12/9/2023 to 3/7/2024, included an order for SN to visit once a week for week for nine weeks. IDT to review patients status every 14 days and as needed to evaluate changes in condition. A review of Patient 5’s IDT Plan of Care & Review of Comprehensive Assessment, indicated the medical director (MD), medical social worker (MSW), registered nurse (RN) did not attend the IDT meeting on 12/18/2023. b. A review of Patient 6’s Patient Profile indicated, an SOC date of 12/13/2023, with a diagnosis that included hypertensive heart disease without heart failure. During a review of Patient 6’s POC, for the certification period from 12/13/2023 to 3/11/2024, included an order for SN visits once a week for week for nine weeks. IDT to review patients status every 14 days and as needed to evaluate changes in condition. A review of Patient 6’s IDT Plan of Care & Review of Comprehensive Assessment, indicated the medical director (MD), medical social worker (MSW), registered nurse (RN) did not attend the IDT meetings on 12/13/2023. c. A review of Patient 7’s Patient Profile indicated, an SOC date of 12/6/2023, with a diagnosis that included Chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and hypertensive heart disease without heart failure. During a review of Patient 7’s POC, for the certification period from 12/6/2023 to 3/4/2024, included an order for SN to visit once a week for week for nine weeks. IDT to review patients status every 14 days and as needed to evaluate changes in condition. A review of Patient 7’s IDT Plan of Care & Review of Comprehensive Assessment, indicated the medical director (MD), medical social worker (MSW), registered nurse (RN) and chaplain (SC) did not attend the IDT meetings on 12/18/2024 and 12/6/2023. During an interview with the Chief Executive Officer/Administrator (CEO/Admin) on 12/31/2023 at 1:00 p.m., stated that the agency holds IDT meetings every two weeks. The Admin stated the IDT members attending the meetings include the RN (Registered Nurse), MSW (Medical social Worker), MD Medical Director or designee), and SC (Spiritual Counselor). The Amin stated the IDT members are expected to sign the IDT Plan of Care & Review of Comprehensive Assessment after the meeting because their signature means they attended the meeting. A review of the HAs policy no. 4.001.1 titled “;Interdisciplinary Group Membership and Responsibilities” indicated that the interdisciplinary group (IDG) will collaborate with the patients attending physician to develop an individualized written plan of care. The hospice IDG group membership includes at a minimum a physician, registered nurse, social worker, pastoral or other counselor. Additional members may include a physician assistant and or nurse practitioner, physical therapist, speech therapist, registered dietitian, pharmacist, homecare aide, volunteer, bereavement coordinator. The IDG responsibilities include but are not limited to participation in the periodic review and updating of the plan of care of each patient receiving hospice services.”

“Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Medical Director and/or physician designee conducted comprehensive assessments, reviews, and verification of the patients’ clinical information and current health condition, necessary to support the Certification of Terminal Illness (a hospice physician narrative designed to explain the clinical findings that support a life expectancy of six months or less), to qualify for hospice care and services (health care that focuses on the palliation to ease the symptoms without curing the underlying disease of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) for two of seven sampled patients (Patient 1 and Patient 7). This deficient practice resulted in the Medical Director and/or physician designee certifying these patients to receive hospice care services without clinical evidence to support the terminal illness diagnoses. Findings: a. A review of Patient 1s admission record indicated an SOC date of 12/6/2023, with a terminal diagnosis of atherosclerosis heart disease (a development of lesions in walls of arteries). Patient 1’s clinical record further indicated the “;referring/attending/patient choice” physician was Physician 1. A review of Patient 1’s Physicians Certification for Hospice Benefit, dated 12/6/2023 to 3/4/2024, benefit period #1, indicated Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. Patient 1 was identified as a Full code (all resuscitation procedures will be provided to keep patient alive). There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient’s primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit on 12/30/2023, at 12 p.m., with LVN 1 at Patient 1s residence, Patient 1 was observed walking steadily at the living room without using an assistive device. During an interview on 12/30/2023, at 12:15 p.m., asked Patient 1 if she was informed about the purpose of the hospice care services, patient stated she was never told that she had six months or less to live. Patient 1 stated a nurse from the hospice agency would come visit every week to take her blood pressure readings. Patient 1 further stated that she never had an attending physician, that her friend referred her to the hospice agency, and she was not dying. b. A review of Patient 7s admission record indicated an SOC date of 12/6/2023, with a terminal diagnosis of COPD (Chronic obstructive pulmonary disease [COPD] is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and hypertensive heart disease. Patient 7’s clinical record further indicated the “;referring/attending/patient choice” physician was Physician 1. A review of Patient 7’s Physicians Certification for Hospice Benefit, dated 12/6/2023 to 3/4/2024, benefit period, indicated Physician 1 signed the attending physician referral section to indicate Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. Patient 7 was identified as a Full Code (all resuscitation procedures will be provided to keep patient alive). There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient’s primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a telephone interview with Patient 7’s niece/caregiver on 12/31/2023, at 2:40 p.m., stated that Patient 7 has never been on hospice and that the patient was not dying. Niece stated Patient 7 had health insurance and has a nurse that comes to the home but was not under hospice. Niece stated that the name of the hospice doctor was not the patients doctor, and the patient was still seeing her primary doctor from insurance who did not order hospice. Niece stated she would file a complaint about this agency for using her aunts information for fraud. On 12/31/2023, at 11 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient’s attending physician, if not a referral from a social worker or a physician from the hospital from where the patient gets discharged. During a review of the agencys undated policy and procedure titled “;Physician Services-Medical Director”, indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care.”

“Based on observation and interview, the hospice agency failed to implement their policy and procedure on infection control by maintaining a sanitary field to place the registered nurse’s treatment bag while providing patient care to one of seven sampled patients (Patient 5). This deficient practice had the potential for increase acquisition and transmission of infection and other transmitted diseases. A review of Patient 5’s Patient Profile indicated, an SOC date of 9/9/2023, with a diagnosis that included hypertensive heart disease without heart failure (a condition where there is thickening of the walls of the heart due to increased blood pressure) During a review of Patient 5’s Plan of Care (POC), for the re-certification period from 12/9/2023 to 3/7/2024, included an order for SN to visit once a week for week for nine weeks. IDT to review patient’s status every 14 days and as needed to evaluate changes in condition. A joint home visit was conducted on 12/30/2023 at 11:30 a.m., at Patient 5s residence with RN 2. During a concurrent observation, RN 2 placed his nursing bag directly on the floor without a protective barrier at the onset of the home visit. During an interview with RN 2 on 12/31/2023 ,at 12:30 p.m., RN 2 recalled that he did place his bag on the floor during the home visit. RN 2 stated that he shouldve placed a protective barrier on a clean surface to observe proper infection control and bag technique. RN 2 stated that proper bag technique should be observed to prevent contamination and prevent the spread of infection. A review of the HA’s policy titled “ Bag Technique” revised 4/2020 indicated that The bag will be placed on a clean dry surface (i.e., a surface that can be easily disinfected) in the car and in the home. The bag will contain a designated clean and dirty area. The clean area carries unused or clean supplies/equipment, and the dirty area is designated for contaminated materials (i.e., used equipment, etc.). If paper towels or newspapers have been used as protective barrier for bag placement in the patient’s home, they will be discarded. A review of the HA’s policy titled “ Infection Control Plan” revised 4/2020 indicated to Establish the mechanism by which the organization will address surveillance, prevention, identification, control and reporting of infections, utilizing current scientific methods and epidemiologic principles the agency is committed to reducing the risk of acquisition and transmission of health care associated infections (HAI’S). Recognized prevention and control mechanisms will be implemented for planning, surveillance, identification, prevention/controls, and reporting procedures. To determine the effectiveness of the infection control plan, the agency will measure, assess, improve, and redesign as appropriate the surveillance, identification, prevention, and control function annually through its performance improvement program. [Refer to Occupational Safety and Health Administration (OSHA) website for most recent standards on occupational exposure {www.osha.gov)]”