Fast Care Hospice, Inc.

“Upon patient record review, 1 of 14 (Patient #9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #9: There is evidence on the medication record, Nitroglycerine 0.4 mg q 5 min as needed for chest pain. There are no directions how many times to repeat the dose and what to do if ineffective.”

“Upon patient record review, 3 of 14 (Patient #1,6,9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: There was evidence of a wound order 4/10/25, clean the wound with cleanser, pat dry, apply ointment, apply Medi honey, cover with a foam dressing 3x a week. The order did not identify who would complete the dressing change. Patient #6: There was evidence of a wound order 10/26/24, clean the wound with cleanser, pat dry, apply peri-wound prep, apply betadine soaked gauze, cover with a gauze dressing daily. The order did not identify who would complete the dressing change. Patient #9: There is an order for Nitroglycerine 0.4 mg q 5 min as needed for chest pain. There are no directions how many times to repeat the dose and what to do if ineffective.”

“Upon patient record review, 2 of 14 (Patient #2,3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: There is evidence of an order, 3/12/25, MSW follow-up once a month. There was not an MSW visit within one month. Additionally, on 3/12/25, Chaplain to follow-up once a month. There was not a Chaplain visit within one month. Patient #3: There is evidence of an order, 3/8/25, MSW follow-up once a month. There was not an MSW visit within one month. Additionally, on 3/5/25, Chaplain to follow-up once a month. There was not an Chaplain visit within one month.”

“Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: There is evidence in the medical record the patient is on Seizure precautions. Seizure precautions was not on the aide plan of care.”

“Upon patient record review, 3 of 14 (Patient #4,5,9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4: There is evidence in the medical record the Nurse signing the Election statement and informed consent on admission used a stamp in place of a signature with credentials as per agency policy. Patient #5,9: There is evidence in the medical record the Nurse signing the Election statement and informed consent on admission used initials in place of a signature with credentials as per agency policy.”

“Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met for one of 14 sampled patients (Patient 1) as follows: 1. The HA failed to ensure to follow Patient 1s physicians order for Patient 1 to take Metformin (a medication used to treat high blood sugar levels) 500 milligram (mg, a unit of measurement), one tablet once a day, for diabetes (a medical condition characterized by the body’s inability to regulate blood sugar levels). 2. The Skilled Nurses (SNs in general) failed to perform medication reconciliation (a formal process for creating the most complete and accurate list possible of a patients current medications and comparing the list to those in the patient record or medication orders) for Patient 1s medications with each home visit. 3. Licensed Vocational Nurse 2 (LVN 2), Director of Patient Care Services Designee (DPCSD), and Skilled Nurses (SNs, in general) failed to provide teaching to Patient 1s caregiver to perform a blood sugar test with a glucometer (an instrument for measuring the concentration of glucose in the blood) and to report if Patient 1s blood sugar value was below 60 (mg/dl, which is a unit of measurement) or above 350 mg/dl. These deficient practices resulted in Patient 1 not receiving Metformin 500 mg one tablet once a day as prescribed, and unmonitored blood sugar level, that could place Patient 1 at risk for hypoglycemia (low blood sugar levels), confusion (lack of understanding), and unresponsiveness (loss of consciousness [the state of being aware]) or hyperglycemia (high blood sugar levels, headache, blurred vision, confusion, and loss of consciousness) that could result to hospitalization or death.. (Refer to L543) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the quality of care was provided to the patients who were assessed to receive hospice care and services.”

“Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Conditions of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) regarding Patients Rights was met as follows: The HA failed to provide one of fourteen sampled patients (Patient 1) information of her rights and responsibilities in a language preferred and understood by the patient. (Refer to L502) The cumulative effects of these systemic practice resulted in the failure of the hospice to deliver statutorily mandated federal compliance for Patients Rights to ensure their rights are not violated and receive the highest quality of hospice care.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation on Clinical Records was met as follows: 1.The HA failed to ensure contents and information in the patients medical records were safeguarded from unauthorized access by HA staff and/or contracted staff to make any alterations or modifications for ten of fourteen sampled selected patients (Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 13, and Patient 14). (Refer to L680). The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records are safeguarded from unauthorized access by any individuals or hospice staff.”

“Based on 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 provide one of fourteen sampled patients (Patient 1) information regarding their rights as a hospice patient in a language that would be understood and preferred by the patient. This deficient practice resulted in the patient not being informed and having a lack of understanding of the HAs care and services available for the patients and their family and caused the patient not to be able to exercise their right to decline the hospice services. A review of Patient 1s admission record indicated Patient 1 was admitted on 12/30/2023 with a primary diagnosis of heart failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). During a joint home visit with LVN 1 on 5/14/2024 at 1 p.m., Patient 1 was observed sitting in a wheelchair, awake, alert, and oriented. Patient 1 was observed wearing dark sunglasses. When LVN 1 removed Patient 1s sunglasses to check her vision, there was no eye movement observed. Patient 1s eyes were observed to be absent of irises (the colored part of the eye that surrounds the pupil). When Patient 1 was asked if she could sign the consent for the home visit, Patient 1 stated she was unable to. A review of Patient 1s “;Comprehensive Nursing Assessment,” dated 12/30/2023, indicated Patient 1 was blind. The assessment also indicated that Patient 1 was oriented to person (the person knows his/her name and usually can recognize significant others) and place (the person knows where he/she is, such as the hospital, clinic, or town). A review of the “;Informed Consent and Treatment Authorization” for Patient 1, dated 12/30/2023, was initialed by Patient 1. The “;Patients Signature” space had the patients initial instead of signature. The consent was also signed by the Director of Patient Care Services Designee (DPCSD) as a representative of the HA. A review of the “;Patient/Family Bill of Rights” for Patient 1, dated 12/30/2023, indicated it was signed by Patient 1. The “;Patient/Family Bill of Rights” had the DPCSDs name and signature, indicating the DPCSD was the staff representing the HA. During a telephone interview with the DPCSD on 5/15/2024 at 3:22 p.m., the DPCSD stated that she admitted Patient 1 to the HA on 12/30/2023. The DPCSD stated Patient 1 was blind in both eyes. When the DPCSD was asked how Patient 1 was able to sign the consent and bill of rights if she was unable to see, the DPCSD stated that she put the pen in Patient 1s hand and placed her hand on the paper where she needed to sign. The DPCSD stated that she told Patient 1 whether to put her initial or signature. The DPCSD stated, “;I guided her hand, but she formed the letters herself.” The DPCSD stated that Patient 1 “;was not all there” during her visit. During a telephone interview with Patient 1s family member (FM 1) on 5/16/2024 at 2:14 p.m., FM 1 stated she was the primary caregiver for Patient 1. FM 1 stated she had never been notified regarding Patient 1s enrollment to hospice. FM 1 stated Patient 1 should have not signed anything without her presence or the other family members presence (FM 2). FM 1 stated Patient 1 was blind and could not have known what she signed. FM 1 also stated she was never provided a copy of the paperwork signed by Patient 1. During a concurrent interview and record review with the Administrator Designee (AD) on 5/17/2024 at 1:55 p.m., the AD reviewed the “;Informed Consent and Treatment Authorization” and “;Patient/Family Bill of Rights” for Patient 1. The AD stated he was not aware that Patient 1 was the one signing both forms. The AD stated, “;I thought a family member or representative signed the consent.” The AD stated that Patient 1 should not have signed the forms herself since she was blind. The AD also stated that based on his interaction with Patient 1, he believed Patient 1 was not cognitively competent to sign the consent and bill of rights. A review of the HAs policy titled “;Patient Bill of Rights/Responsibilities,” revised November 2021, indicated that a patient may designate someone to act as his/her representative. This representative, on behalf of the patient, may exercise any of the rights provided by the policies and procedures established by the organization.”

“Based on observation, interview, and record review, the Hospice Agency failed to ensure that one of fourteen sampled patients (Patient 1) had access to their plan of care at all times. This deficient practice had the potential to result in the patient and/or their family member/caregiver being unable to be an active participant in his/her care. A review of Patient 1s admission record indicated Patient 1 was admitted on 12/30/2023 with a primary diagnosis of heart failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). During a joint home visit with LVN 1 on 5/14/2024 at 1 p.m., Patient 1 was observed sitting in a wheelchair, awake, alert, and oriented. When the surveyor requested to review the patients home folder as part of the home visit, the home folder was not available. The facility staff was not able to find the home folder in Patient 1s room. Patient 1 was not sure where it was kept. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 5/14/24 at 2:15 p.m., LVN 1 stated that she had never visited Patient 1 before. LVN 1 stated she did not know if Patient 1 had a home folder or not. LVN 1 stated that all patients should have been provided with a home folder that contains information pertinent to their care. During a telephone interview with LVN 2 on 5/15/2024 at 3:07 p.m., LVN 2 stated she had been visiting Patient 1 weekly. LVN 2 stated she had never seen a home folder during her visits. LVN 2 stated she asked the facility staff for the home folder, but the staff was never able to find it. LVN 2 also stated that she notified the HA to provide Patient 1 with a home folder, but the HA had never provided one. LVN 2 stated the home folder had important information for the patient and their family, such as a copy of their plan of care and medication profile. LVN 2 stated that if patient was not provided with the plan of care, they would not be able to see the services they received, the visit frequency, the goals, and the interventions planned for them. A policy regarding the Plan of Care was not provided by the HA as requested by the survey team. A review of the HAs policy titled “;Patient Bill of Rights/Responsibilities,” revised November 2021, indicated the patient has the right to be advised in advance of the right to participate in the planning of care or service and in planning changes in care and services.”

“Based on interview and record review, the hospice agency (HA) staff failed to review all medications and update the medication profile with the currently used medications for three of fourteen sampled patients (Patient 1, Patient 6, and Patient 7). This deficient practice resulted in Patient 1s medications being unavailable to the patient, and had the potential to place Patient 1, Patient 6, and Patient 7 at risk for medication errors and adverse drug reactions. b. A review of Patient 6s admission record indicated a start of care (SOC) date of 2/13/2024 with a primary diagnosis of hypertensive heart disease with heart Failure (is a long-term condition that develops over many years in people who have high blood pressure, it is a group of medical problems including heart failure and irregular heartbeat that can happen when an individuals high blood pressure (hypertension) is unmanaged). During a joint home visit observation with Licensed Vocational Nurse (LVN1) on 5/14/2024, at 10:00 a.m., at Patient 6s boarding care home (a residential care option catering to individuals requiring assistance with daily living activities), Patient 6 was awake, alert and oriented, resting on his bed comfortably. LVN1 performed hand washing prior to conducting an assessment with Patient 6. While conducting a medication reconciliation with LVN1, there was no updated copy of Patient 6s current medication profile available into Patient 6’s hospice agency folder. c. A review of Patient 7s admission record indicated a start of care (SOC) date of 12/30/2023 with a primary diagnosis of Cerebral Infarction, unspecified (refers to damage to tissues in the brain due to the loss of oxygen in the area). During a joint home visit observation with Licensed Vocational Nurse (LVN1) on 5/14/2024, at 11 a.m., at Patient 7s boarding care home (a residential care option catering to individuals requiring assistance with daily living activities), Patient 7 was awake, alert and oriented, resting on his bed comfortably. LVN1 performed hand washing prior to conducting an assessment with Patient 7. While conducting a medication reconciliation with LVN1, there was no updated copy of Patient 7s current medication profile available into his hospice agency folder. During an interview with LVN1 on 5/14/2024, at 11:50 a.m., LVN 1 stated that this is the first time she saw Patient 6 and Patient 7. LVN1 stated she is not the regular visiting nurse. LVN 1 stated that an updated medication profile should have been provided to the patients and/or the patients caregiver to ensure that current medications Patient 6 and Patient 7 are taking were listed to prevent confusion and inaccurate information. a. A review of Patient 1s admission record indicated Patient 1 was admitted on 12/30/2023 with a primary diagnosis of heart failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). A review of the most recent “;Plan of Care/Interdisciplinary Group Review” (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) for Patient 1, dated 5/6/24, indicated the Licensed Vocational Nurse (LVN; skilled nurse) visit frequency for Patient 1 was once per week and three as needed visits. Patient 1 also had an order for Registered Nurse (RN) visits once every two weeks and three as needed visits. The POC/IDG Review indicated the nursing staff would be responsible to continue scheduled visits, reinforce education on caregiver for pain regimen, breathing treatment regimen, skin care regimen, diet regimen, and to report any changes in patients condition. During a joint home visit with LVN 1 on 5/14/2024 at 1 p.m., Patient 1 was observed sitting in a wheelchair, awake, alert, and oriented. Patient 1 was observed wearing dark sunglasses. When LVN 1 removed Patient 1s sunglasses to check her vision, there was no eye movement observed. Patient 1s eyes were observed to be absent of irises (the colored part of the eye that surrounds the pupil). A review of Patient 1s “;Current Treatment/Medication/DME (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living)” indicated that Patient 1 was on the following medications: - Metformin (a medication used to treat high blood sugar levels/diabetes) 500 mg tablet, one tablet, once a day, for diabetes (a chronic disease characterized by elevated levels of blood glucose in the blood). - Oxycodone Hydrochloride (a prescription medication to treat moderate to severe pain) 5 mg tablet, one tablet every six hours as needed for moderate to severe pain. - Acetaminophen (an over-the-counter medication to treat mild pain or fever) 500 mg tablet, one tablet every six hours as needed for mild pain or fever over 100.4 F. - Furosemide (a medication to treat fluid retention and swelling caused by heart failure) 40 mg tablet, one tablet daily for edema (swelling). During a medication review with LVN 1 on 5/14/24 at 1:55 p.m., it was noted the Metformin 500 mg bottle was empty. The filled date on the label was 3/29/24 and the quantity was 30. Oxycodone Hydrochloride 5 mg and Acetaminophen 500 mg were not available at the facility where Patient 1 was residing. Furosemide 20 mg was found in Patient 1s medication basket; the label indicated it was filled on 4/4/2024. During an interview with Patient 1 on 5/14/24 at 2:10 p.m., Patient 1 stated she was not aware that she no longer had Metformin 500 mg. Patient 1 stated she did not know where the Oxycodone Hydrochloride and Acetaminophen were. Patient 1 stated she did not remember the last time she took Metformin, Oxycodone, or Acetaminophen. Patient 1 stated she was not aware regarding the dose change for furosemide. During an interview with LVN 1 on 5/14/24 at 2:15 p.m., LVN 1 stated that she had never visited Patient 1 before, so she did not know if another nurse had ordered a refill for the Metformin. LVN 1 stated she also did not know if Patient 1 had run out of the Oxycodone and Acetaminophen, or when the Furosemide dose was changed. LVN 1 stated the visiting nurse needed to perform medication reconciliation during every visit, so the nurse would find out if certain medications had to be refilled. LVN 1 stated it was very important that Patient 1 did not run out of Metformin since she was diabetic. A review of Patient 1s “;Comprehensive Nursing Assessment,” dated 12/30/2023, indicated that patient was uncomfortable due to pain. The nurses narrative indicated Patient 1 was laying down with distress and discomfort or pain. A review of Patient 1s “;Visit Note LVN,” dated 5/2/2024, 4/25/2024, and 4/18/2024, indicated Patient 1 was experiencing pain. The visit note on 4/25/2024 indicated that Patient 1 reported pain 6 out of 10 upon assessment and frequent lower back pain 5 out of 10. The numeric pain scale consists of the numbers 0 to 10, where 0 means no pain and 10 means the worst pain possible. A review of Patient 1s “;Visit Note RN,” dated 4/20/2024, indicated that Patient 1 reported pain upon assessment. During a telephone interview on 5/14/24 at 4:14 p.m. with LVN 2, who had been visiting Patient 1 weekly, LVN 2 stated she last checked Patient 1s Metformin on 5/2/24. According to LVN 2, the Metformin bottle was not empty at that time. LVN 2 stated she did not recall ordering a Metformin refill for Patient 1. LVN 2 stated she did not pay attention to the pain medication. According to LVN 2, she only paid attention to furosemide because Patient 1 had severe swelling on both of her legs. According to LVN 2, she only requested a refill for furosemide on 5/2/2024. During a telephone interview with the DPCSD on 5/15/2024 at 2:55 p.m., the DPCSD stated the visiting nurse was responsible to check the patients medications with each visit to find out if patient needed refill, or if there were any changes. Per DPCSD, not reconciling patients medication during every visit could lead to inaccurate medication profile, patient taking the wrong medication dose, or patient not taking medication because there was no more medication. A review of the HAs policy titled “;Medication Profile,” revised November 2021, indicated the medication profile will be updated for each change to reflect current medications and new and/or discontinued medications.”

“Based on observation, interview, and record review, the Hospice Agency (HA, providing care to terminally ill patients who have six months or less to live) failed to follow the plan of care for one of 14 sampled patients (Patient 1) by failing to: 1. Ensure to follow Patient 1s physicians order for Patient 1 to take Metformin (a medication used to treat high blood sugar levels) 500 milligram (mg, a unit of measurement), one tablet once a day, for diabetes (a medical condition characterized by the body’s inability to regulate blood sugar levels). 2. Ensure the Skilled Nurses (SNs, in general) performed medication reconciliation (a formal process for creating the most complete and accurate list possible of a patients current medications and comparing the list to those in the patient record or medication orders) for Patient 1s medications with each home visit. 3.Ensure Licensed Vocational Nurse 2 (LVN 2), Director of Patient Care Services Designee (DPCSD), and Skilled Nurses (SNs, in general) provided teaching to Patient 1s caregiver to perform a blood sugar test with a glucometer (an instrument for measuring the concentration of glucose in the blood) and to report if Patient 1s blood sugar value was below 60 (mg/dl, which is a unit of measurement) or above 350 mg/dl. As a result, Patient 1 did not receive Metformin 500 mg, one tablet, once a day, as ordered by the physician, and unmonitored blood sugar levels, that could place Patient 1 at risk for hypoglycemia (low blood sugar levels), confusion (lack of understanding), and unresponsiveness (loss of consciousness [the state of being aware]) or hyperglycemia (high blood sugar levels, headache, blurred vision, confusion, and loss of consciousness) that could result to hospitalization or death. On 5/16/2024, at 12:31 p.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was called in the presence of the agencys Administrator Designee related to the agencys failures of not following Patient 1’s plan of care to follow the physicians order to ensure Patient 1 would receive Metformin (a medication to treat elevated blood sugar levels), ensure Licensed Vocational Nurse 2 (LVN 1) monitored Patient 1s blood sugar levels during each home visits, conducted medication reconciliation (a process of comparing medications), and provided teaching to Patient 1s Caregiver on blood sugar monitoring. On 5/17/2024 at 2:30 p.m., the survey team completed the survey tasks, and conducted an exit conference with the HA’s Administrator Designee with the IJ situation not removed. The HA was informed to submit an acceptable IJ Removal Plan. The HA did not submit an IJ Removal Plan. Findings: During a review of Patient 1s Admission Record, the Admission Record indicated the HA admitted Patient 1 on 12/30/2023 with a primary diagnosis of heart failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). During a review of Patient 1’s Plan of Care/Interdisciplinary Group Review (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 12/30/2023, 1/1/2024, 1/15/2024, 1/29/2024, 2/12/2024, 2/26/2024, 3/25/2024, 4/8/2024, 4/22/2024, and 5/6/2024, the Plan of Care/Interdisciplinary Group Review indicated Patient 1s blood sugar level would be controlled with current medications and symptoms of hypoglycemia (low blood sugar level) and hyperglycemia (high blood sugar level) would be detected early for timely intervention. The POC/IDG Review with the dates above indicated Patient 1s caregiver was to report blood sugar below 60 mg/dl or above 350 mg/dl. During a review of “;Visit Note RN,” for Patient 1, dated 4/6/2024 and 4/20/2024, completed by the Director of Patient Care Services Designee (DPCSD), indicated the “;diabetes-blood sugar,” section was marked “;none.” The Visit Note RN indicated the DPCSD did not inquire about the blood sugar monitoring from Patient 1s caregiver or provided education regarding blood sugar monitoring. During review of “;Visit Note LVN” for Patient 1, dated 4/18/2024, 4/25/2024, and 5/2/2024, completed by LVN 2, indicated the “;diabetes-blood sugar,” section was marked “;none.” The Visit Note did not indicate LVN 2 inquire about the blood sugar monitoring from Patient 1s caregiver. On the visit note dated 5/2/2024, LVN 2 documented that Patient 1s caregiver reported that Patient 1s blood sugar levels were well-controlled; however, there was no documentation of the blood sugar range. During a review of Patient 1’s POC/IDG, dated 5/6/2024, the POC/IDG, indicated the Licensed Vocational Nurse (LVN; skilled nurse) visit frequency for Patient 1 was once per week as and three as needed visits. The POC/IDG indicated Patient 1 had an order for a Registered Nurse (RN) to visit once every two weeks and three as needed visits. During a review of Patient 1s undated “;Current Treatment/Medication/DME (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living)” indicated for Patient 1 to take Metformin 500 mg, one tablet, once a day, for diabetes. During a joint home visit observation with LVN 1 on 5/14/2024, at 1 p.m., at Patient 1s boarding care home (a residential care option catering to individuals requiring assistance with daily living activities), Patient 1 was sitting on a wheelchair, awake, alert, and oriented. Patient 1 stated she was blind in both eyes. During a medication review and an observation with LVN 1, on 5/14/2024, at 1:55 p.m., LVN 1 stated Patient 1s Metformin 500 mg bottle was empty and the filled date on the label was 3/29/2024. During an interview and an observation, on 5/14/2024, at 2:10 p.m., with Patient 1, Patient 1 stated she was not aware that she no longer had Metformin 500 mg. Patient 1 stated her caregiver did not check her blood sugar. There was no glucometer observed in the basket where Patient 1s medications were stored and no blood sugar log for Patient 1. Patient 1 stated she did not remember when the last time she took Metformin. During an interview on 5/14/2024, at 2:15 p.m., with LVN 1, LVN 1 stated she had never visited Patient 1 before and did not know if another nurse had ordered a refill for the Metformin. LVN 1 stated the visiting nurses (in general) needed to perform medication reconciliation with every visit, so the nurse would find out if certain medications had to be refilled. LVN 1 stated it was very important Patient 1 did not run out of Metformin since Patient 1 had a diagnosis of diabetes. During the concurrent joint home visit, on 5/14/2024, at 2:15 pm, there was no caregiver for Patient 1. There were two men observed in the facility, both did not speak English. One of the men, who appeared to oversee the facility, stated to LVN 1, who spoke the same language as him, that he did not work for the facility, and refused to provide his name. Patient 1s primary language was English. During a telephone interview on 5/14/2024, at 4:14 p.m., with LVN 2, who had been visiting Patient 1 weekly, LVN 2 stated she last checked Patient 1s Metformin on 5/2/2024. According to LVN 2, the Metformin bottle was not empty at that time. LVN 2 stated she did not recall ordering a Metformin refill for Patient 1. During a telephone interview with LVN 2 on 5/15/24, at 3:07 p.m., LVN 2 stated she would ask the caregiver regarding Patient 1s blood sugar during her visits, and she was always told that Patient 1s blood sugar was “;okay.” LVN 2 stated the caregiver did not inform her regarding Patient 1s blood sugar numbers. LVN 2 stated when she asked for documentation of Patient 1s blood sugar, the caregiver was not able to provide any. LVN 2 stated she did not observe a glucometer during her visits. LVN 2 stated she did not check Patient 1s blood sugars. During a telephone interview with the Director of Patient Care Services Designee (DPCSD), on 5/15/2024, at 2:55 p.m., the DPCSD stated she carried a glucometer with her, and she would always check Patient 1s blood sugar during her visits. The DPCSD stated she asked Patient 1s caregiver about her blood sugar and was told that Patient 1s blood sugar was “;good.” The DPCSD stated the caregiver was not able to provide her with a blood sugar log. The DPCSD also stated she had never seen a glucometer for Patient 1 at the facility. The DPCS stated there was no fasting blood sugar and no A1C (glycated hemoglobin test, measures the average amount of sugar in your blood over the past few months) results for Patient 1. During an interview on 5/16/2024, at 11 am, with the HA’s Administrator Designee, the survey team requested a policy on Plan of Care and diabetes management. The Administrator Designee stated the HA did not have a policy on diabetes management. The Administrator Designee did not provide a policy on Plan of Care.”

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to provide education and training to Caregiver regarding blood sugar result and management as indicated in the plan of care for one of fourteen sampled patients (Patient 1). This deficient practice resulted in the HAs did not monitor Patient 1s blood sugar levels and had the potential for Patient 1 to experience side effect from high blood sugar level such as weight loss, blurred vision, and recurrent infection, and side effect from low blood sugar level such as dizziness, lightheadedness, and fast heart beat. Findings: A review of Patient 1s admission record indicated Patient 1 was admitted on 12/30/2023 with a primary diagnosis of heart failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). A review of Patient 1’s Plan of Care/Interdisciplinary Group Review (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 12/30/2023, 1/1/2024, 1/15/2024, 1/29/2024, 2/12/2024, 2/26/2024, 3/25/2024, 4/8/2024, 4/22/2024, and 5/6/2024, indicated that patients blood sugar level would be controlled with current medications and symptoms of hypoglycemia (low blood sugar level) and hyperglycemia (high blood sugar level) would be detected early for timely intervention. The POC/IDG Review with the dates above also indicated that Patient 1s caregiver was to report blood sugar below 60 mg/dl or above 350 mg/dl. A review of Patient 1’s “;Visit Note RN” dated 4/6/2024 and 4/20/2024, completed by the Director of Patient Care Services Designee (DPCSD), indicated the “;diabetes-blood sugar” section was marked “;none.” There was no documented evidence on both notes the DPCSD inquired about the blood sugar monitoring from Patient 1s caregiver or provided education regarding blood sugar monitoring. A review of “;Visit Note LVN” for Patient 1, dated 4/18/2024, 4/25/2024, and 5/2/2024, completed by LVN 2, indicated the “;diabetes-blood sugar” section was marked “;none.” There was no documented evidence on the notes dated 4/18/2024 and 4/25/2024 that LVN 2 inquired about the Patient 1’s blood sugar monitoring from Patient 1s caregiver. The visit note dated 5/2/2024, indicated that LVN 2 documented that Patient 1s caregiver reported that Patient 1s blood sugar levels were well-controlled; however, there was no documentation of the blood sugar levels. A review of Patient 1’s POC/IDG Review dated 5/6/24, indicated the Licensed Vocational Nurse (LVN) visit frequency for Patient 1 was once per week and three as needed visits. Patient 1’s POC/IDG Review indicated an order for Registered Nurse (RN) visit once every two weeks and three as needed visits. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 5/14/2024 at 1 p.m., at Patient 1’s residence, Patient 1 was observed sitting in a wheelchair, awake, alert, and oriented. There was no caregiver observed for Patient 1. During a telephone interview on 5/15/2024 at 3:07 p.m., with LVN 2, LVN 2 stated she would ask the caregiver regarding Patient 1s blood sugar levels during visits, and she was always told that Patient 1s blood sugar was “;okay.” LVN 2 stated the caregiver was never able to inform her regarding Patient 1s blood sugar numbers. LVN 2 also stated when she asked for documentation of Patient 1s blood sugar, the caregiver was not able to provide any. LVN 2 stated she had never observed a glucometer during her visits. During a telephone interview on 5/15/2024 at 2:55 p.m., with the DPCSD, the DPCSD stated she carried a glucometer with her, and she would always check Patient 1s blood sugar during her visits. The DPCSD stated she asked Patient 1s caregiver about her blood sugar and was told that Patient 1s blood sugar was “;good.” The DPCSD stated the caregiver was not able to provide her with a blood sugar log. The DPCSD also stated she had never seen a glucometer for Patient 1 at the facility. The HA did not provide the survey team the requested policy and procedure on Plan of Care during the survey visit. The HA did not provide the survey team the requested policy and procedure regarding patient/caregiver education.”

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure medications were available as indicated in the plan of care (POC) for one of fourteen sampled patients (Patient 1). For Patient 1, metformin 500 mg bottle was empty, oxycodone hydrochloride 5 mg and acetaminophen 500 mg was not available. This deficient practice had the potential to result in uncontrolled symptoms, which could affect the patients quality of life. Findings: A review of Patient 1s admission record indicated Patient 1 was admitted on 12/30/2023 with a primary diagnosis of heart failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). A review of Patient 1s “;Comprehensive Nursing Assessment,” dated 12/30/2023, indicated that patient was uncomfortable due to pain. The nurses narrative indicated Patient 1 was laying down with distress and discomfort or pain. A review of Patient 1s “;Visit Note RN,” dated 4/20/2024, indicated that Patient 1 reported pain upon assessment. A review of Patient 1s “;Visit Note LVN,” dated 5/2/2024, 4/25/2024, and 4/18/2024, indicated Patient 1 was experiencing pain. The visit note on 4/25/2024 indicated that Patient 1 reported pain 6 out of 10 upon assessment and frequent lower back pain 5 out of 10. The numeric pain scale consists of the numbers 0 to 10, where 0 means no pain and 10 means the worst pain possible. A review of Patient 1’s “;Plan of Care/Interdisciplinary Group Review” (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) for Patient 1, dated 5/6/2024, indicated the Licensed Vocational Nurse (LVN; skilled nurse) visit frequency for Patient 1 was once per week and three as needed visits. Patient 1 also had an order for Registered Nurse (RN) visit once every two weeks and three as needed visits. A review of Patient 1’s POC/IDG Review dated 5/6/2024, indicated the nursing staff would be responsible to continue scheduled visits, reinforce education on caregiver for pain regimen, breathing treatment regimen, skin care regimen, diet regimen, and to report any changes in patients condition. A review of Patient 1s “;Current Treatment/Medication/DME (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living)” indicated that Patient 1 was on the following medications: - Metformin (a medication used to treat high blood sugar levels/diabetes) 500 mg tablet, one tablet, once a day, for diabetes (a chronic disease characterized by elevated levels of blood glucose in the blood). - Oxycodone Hydrochloride (a prescription medication to treat moderate to severe pain) 5 mg tablet, one tablet every 6 hours as needed for moderate to severe pain. - Acetaminophen (an over-the-counter medication to treat mild pain or fever) 500 mg tablet, one tablet every 6 hours as needed for mild pain or fever over 100.4 F. During a joint home visit on 5/14/2024 at 1 p.m., with the Licensed Vocational Nurse 1 (LVN 1), observed Patient 1 sitting in a wheelchair, awake, alert, and oriented. During medication review with LVN 1 on 5/14/2024 at 1:55 p.m., it was noted the Metformin 500 mg bottle was empty. The filled date on the label was 3/29/24 and the quantity was 30. Oxycodone Hydrochloride 5 mg and Acetaminophen 500 mg were not available at the facility where Patient 1 was residing. During an interview with LVN 1 on 5/14/2024 at 2:15 p.m., LVN 1 stated that she had never visited Patient 1 before, so she did not know if another nurse had ordered a refill for the Metformin. LVN 1 stated she also did not know if Patient 1 had run out of the Oxycodone and Acetaminophen. LVN 1 stated it was very important that Patient 1 did not run out of Metformin since she was diabetic. LVN 1 stated that pain medications should be available to the patient because the emphasis of hospice was comfort care. During a telephone interview on 5/14/2024 at 4:14 p.m. with LVN 2, who had been visiting Patient 1 weekly, LVN 2 stated she last checked Patient 1s Metformin on 5/2/2024. According to LVN 2, the Metformin bottle was not empty at that time. LVN 2 stated she did not recall ordering a Metformin refill for Patient 1. LVN 2 stated she did not pay attention to the pain medication. According to LVN 2, she only paid attention to Furosemide because Patient 1 had severe swelling on both of her legs. According to LVN 2, she only requested refill for Furosemide on 5/2/2024. During a telephone interview with the DPCSD on 5/15/2024 at 2:55 p.m., the DPCSD stated the visiting nurse was responsible to check patients medications with each visit to find out if patient needed refill, or if there were any changes. The DPCSD stated pain management was very important in hospice care to provide patient with comfort. A review of the HAs policy titled “;Patient Bill of Rights/Responsibilities,” revised November 2021, indicated that the patient has the right to receive effective pain and symptom management for conditions related to the terminal illness. A policy on Plan of Care was not provided by the HA as requested by the survey team.”

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group/IDG (consists of nurses, physicians, social workers, and counselors) maintains responsibility for directing, coordinating, and supervising the care and services provided for one of fourteen sampled patients (Patient 1). This deficient practice resulted in the HAs failure to deliver care and services to Patient 1 as specified in the plan of care. A review of Patient 1s admission record indicated Patient 1 was admitted on 12/30/2023 with a primary diagnosis of heart failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). A review of Patient 1’s Plan of Care/Interdisciplinary Group Review (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated , and 12/30/2023, 1/1/2024, 1/15/2024, 1/29/2024, 2/12/2024, 2/26/2024, 3/25/2024, 4/8/2024, 4/22/2024, and 5/6/2024 indicated that patients blood sugar level would be controlled with current medications and symptoms of hypoglycemia (low blood sugar level) and hyperglycemia (high blood sugar level) would be detected early for timely intervention. The POC/IDG Review with the dates above also indicated that Patient 1s caregiver was to report blood sugar below 60 mg/dl or above 350 mg/dl. A review of “;Visit Note RN” for Patient 1, dated 4/6/2024 and 4/20/2024, completed by the DPCSD, indicated the “;diabetes-blood sugar” section was marked “;none.” There was no documented evidence on both notes the DPCSD inquired about the blood sugar monitoring from Patient 1s caregiver or provided education regarding blood sugar monitoring. A review of “;Visit Note LVN” for Patient 1, dated 4/18/2024, 4/25/2024, and 5/2/2024, completed by LVN 2, indicated the “;diabetes-blood sugar” section was marked “;none.” There was no documented evidence on the notes dated 4/18/2024 and 4/25/2024 that LVN 2 inquired about the blood sugar monitoring from Patient 1s caregiver. On the visit note dated 5/2/2024, LVN 2 documented that Patient 1s caregiver reported that Patient 1s blood sugar levels were well-controlled; however, there was no documentation of the blood sugar range. A review of Patient 1’s POC/IDG Review, dated 5/6/2024, indicated Patient 1 had regular blood sugar monitoring and that blood sugar levels were well-controlled. The POC/IDG Review indicated the Licensed Vocational Nurse (LVN) visit frequency for Patient 1 was once per week and three as needed visits. Patient 1 also had an order for Registered Nurse (RN) visit once every two weeks and three as needed visits. During a joint home visit with LVN 1 on 5/14/2024 at 1 p.m., observed Patient 1 sitting in a wheelchair, awake, alert, and oriented. During an interview with Patient 1 on 5/14/24 at 2:10 p.m., when Patient 1 was asked if a staff or caregiver at the facility had been checking her blood sugar, Patient 1 said no. Patient 1 stated that her physician was probably the one checking her blood sugar. There was no glucometer (a device to check blood sugar levels) observed in the basket where Patient 1s medications were stored. There was no blood sugar log for Patient 1 observed. During a telephone interview with the Director of Patient Care Services Designee (DPCSD) on 5/15/2024 at 2:55 p.m., the DPCSD stated she carried a glucometer with her, and she would always check Patient 1s blood sugar during her visits. The DPCSD stated she asked Patient 1s caregiver about her blood sugar and was told that Patient 1s blood sugar was “;good.” The DPCSD stated the caregiver was not able to provide her with a blood sugar log. The DPCSD also stated she had never seen a glucometer for Patient 1 at the facility. During a telephone interview with LVN 2 on 5/15/2024 at 3:07 p.m., LVN 2 stated there used to be a female caregiver for Patient 1 at the facility. LVN 2 stated she would ask the caregiver regarding Patient 1s blood sugar during her visits, and she was always told that Patient 1s blood sugar was “;okay.” LVN 2 stated the caregiver was never able to inform her regarding Patient 1s blood sugar numbers. LVN 2 also stated when she asked for documentation of Patient 1s blood sugar, the caregiver was not able to provide any. LVN 2 stated she had never observed a glucometer during her visits. LVN 2 stated she had never checked Patient 1s blood sugar. A review of the HAs policy titled “;Interdisciplinary Group Membership and Responsibilities,” revised November 2021, indicated the interdisciplinary group responsibilities include provision and/or supervision and coordination of hospice care and services.”

“Based on interview and record review, the skilled nurse (SN) failed to follow nursing visit frequency as ordered and as indicated in the plan of care (POC), for one of 14 sampled patients (Patient 14). This deficient practice had the potential for Patient 14 not to received care and services to meet the care goals need that could affect their overall health status. Findings: A review of Patient 14s admission record indicated a start of care (SOC) date of 12/28/2023 with a primary diagnosis of Senile Degeneration of Brain, not elsewhere classified (a decrease in the ability to think, concentrate or remember). A review of Patient 14’s Plan of Care (POC)/Interdisciplinary Group (IDG) Review dated from 1/15/2024 to 2/12/2024, included an order for a Skilled Nurse (SN) to visit once a week for 90 days to assess all systems, evaluate patients care needs and to provide pain management and comfort measures. On 5/17/2024, at 1:45 p.m., a concurrent review of Patient 14’s “;Monthly Schedule, February 2024” with the Administrator Designee (ADMD) from dates through 12/29/2022, indicated there was no nurses home visit conducted on the week from 2/11/2024 to 2/18/2024. A further review of the Patient 14’s clinical records indicated no documentation or communication notes found to justify reason for the missed SN visits. During an interview with the Skilled Nurse/Licensed Vocational Nurse (LVN3) on 5/15/2024, at 2:45 p.m., LVN3 stated that she was aware of missed visit on week of 2/11/24 to 2/18/24, LVN3 stated that she did not want to see the patient anymore due to personal reasons and she spoke with the ADMD regarding it. LVN 3 stated that the agencys office and the ADMD should have been documented it in the communication log and looked for a nurse to conduct visit. During an interview with Registered Nurse (RN3) on 5/15/2024, at 1:40 p.m., RN3 stated that if skilled nurse (SN) is not going to make visit to patient, SN should communicate with the agency and the patient/patients caregiver to reschedule visit and communicate with the agencys office to reschedule for a sooner visit with another nurse. RN3 stated that missed visits should be documented to communication log and should be used to communicate with staff about visits. RN3 stated that negative outcome would be patients change of condition might be missed and agency would not be able to intervene with appropriate interventions to prevent the change of condition from progressing. During an interview with the ADMD on 5/17/2024, at 2:00 p.m., he stated that the skilled nurse was not available to conduct a visit to Patient 14 and he was not able to provide another nurse to conduct a visit to the patient. ADMD stated he did not document the situation and it needs to be documented in communication note indicating the reason. A review of the hospice agencys policy and procedure titled “;Missed Visits”, revised November 2021, indicated that to ensure that missed visits are documented and does not affect the quality of patient care, missed visits will be communicated to the Interdisciplinary Group at the IDG meeting, a missed visit will be rescheduled the same week if possible, missed visits will be documented in the clinical record and if a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit.”

“Based on interview and record review the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure contents and information in the patients medical records were safeguarded from unauthorized access by HA staff and/or contracted staff to make any alterations or modifications for ten of fourteen sampled selected patients (Patient 1, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 13, and Patient 14). This deficient practice had the potential to result in an unauthorized and inaccurate patient information or assessment and could affect the patients’ quality of care and well-being. a. A review of Patient 6s admission record indicated a start of care (SOC) date of 2/13/2024 with a primary diagnosis of Hypertensive Heart Disease with Heart Failure (is a long-term condition that develops over many years in people who have high blood pressure, it is a group of medical problems including heart failure and irregular heartbeat that can happen when an individuals high blood pressure (hypertension) is unmanaged). A review of form “;Audit Log” dated from 4/9/2024 to 4/30/2024 , the log was printed for Patient 6, which included “;Spiritual Chaplain (SC)/All Modules”, indicated that SC made twenty six (26) document modifications with IP addresses (Internet Protocol, which is the set of rules governing the format of data sent via the internet or local network and IP addresses are the identifier that allows information to be sent between devices on a network, it contain location information and make devices accessible for communication) of 83.139.27.24, 46.36.115.226 and 178.219.56.90. When the IP addresses were searched, it indicated an IP location of City: Argavand/Region: Ararat/Country: Armenia (83.139.27.24), City: Ashtarak/Region: Aragacotn/Country: Armenia (46.36.115.226) and City/Region: Ararat/Country: Armenia (178.219.56.90). b. A review of Patient 7s admission record indicated a start of care (SOC) date of 12/30/2023 with a primary diagnosis of Cerebral Infarction, unspecified (refers to damage to tissues in the brain due to the loss of oxygen in the area). A review of form “;Audit Log” dated from 4/5/2024 to 5/13/2024 , the log was printed for Patient 7, which included “;Spiritual Chaplain (SC)/All Modules”, indicated that SC made fifty five (55) document modifications with IP addresses (Internet Protocol, which is the set of rules governing the format of data sent via the internet or local network and IP addresses are the identifier that allows information to be sent between devices on a network, it contain location information and make devices accessible for communication) of 109.172.234.147, 46.36.115.226 and 178.219.56.90. When the IP addresses were searched, it indicated an IP location of City/Region: Tbilisi/Country: Georgia (109.172.234.147), City: Ashtarak/Region: Aragacotn/Country: Armenia (46.36.115.226) and City/Region: Ararat/Country: Armenia (178.219.56.90). c. A review of Patient 8s admission record indicated a start of care (SOC) date of 1/13/2024 with a primary diagnosis of Heart Failure, unspecified (is a condition that develops when the heart does not pump enough blood for the body’s needs and can happen if the heart is unable to fill up with enough blood.). A review of form “;Audit Log” dated from 4/8/2024 to 5/13/2024 , the log was printed for Patient 8, which included “;Spiritual Chaplain (SC)/All Modules”, indicated that SC made sixty four (64) document modifications with IP addresses (Internet Protocol, which is the set of rules governing the format of data sent via the internet or local network and IP addresses are the identifier that allows information to be sent between devices on a network, it contain location information and make devices accessible for communication) of 212.73.91.35 and 46.36.115.226. When the IP addresses were searched, it indicated an IP location of City/Region: Yerevan/Country: Armenia (212.73.91.35), and City: Ashtarak/Region: Aragacotn/Country: Armenia (46.36.115.226). d. A review of Patient 9s admission record indicated a start of care (SOC) date of 1/22/2024 with a primary diagnosis of End Stage Heart Failure (is a final and most severe stage of heart failure which a person experiences symptoms of heart failure (condition that develops when the heart does not pump enough blood for the body’s needs and can happen if the heart is unable to fill up with enough blood) which include shortness of breath, fatigue and irregular heartbeat even at rest). A review of form “;Audit Log” dated from 4/9/2024 to 5/13/2024 , the log was printed for Patient 9, which included “;Spiritual Chaplain (SC)/All Modules”, indicated that SC made sixty six (66) document modifications with IP addresses (Internet Protocol, which is the set of rules governing the format of data sent via the internet or local network and IP addresses are the identifier that allows information to be sent between devices on a network, it contain location information and make devices accessible for communication) of 212.73.91.35, 46.36.115.226 and 178.219.56.90. When the IP addresses were searched, it indicated an IP location of City/Region: Yerevan/Country: Armenia (212.73.91.35), City: Ashtarak/Region: Aragacotn/Country: Armenia (46.36.115.226) and City/Region: Ararat/Country: Armenia (178.219.56.90). e. A review of Patient 10s admission record indicated a start of care (SOC) date of 12/29/2023 with a primary diagnosis of Chronic Obstructive Pulmonary Disease, unspecified (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing). A review of form “;Audit Log” dated from 4/23/2024 to 5/13/2024 , the log was printed for Patient 10, which included “;Spiritual Chaplain (SC)/All Modules”, indicated that SC made twelve (12) document modifications with IP address (Internet Protocol, which is the set of rules governing the format of data sent via the internet or local network and IP addresses are the identifier that allows information to be sent between devices on a network, it contain location information and make devices accessible for communication) of 46.36.115.226. When the IP address was searched, it indicated an IP location of City: Ashtarak/Region: Aragacotn/Country: Armenia (46.36.115.226). f. A review of Patient 13s admission record indicated a start of care (SOC) date of 12/2/2023 with a primary diagnosis of Hypertensive Heart Disease with Heart Failure (is a long-term condition that develops over many years in people who have high blood pressure, it is a group of medical problems including heart failure and irregular heartbeat that can happen when an individuals high blood pressure (hypertension) is unmanaged). A review of form “;Audit Log” dated from 4/4/2024 to 5/13/2024 , the log was printed for Patient 13, which included “;Spiritual Chaplain (SC)/All Modules”, indicated that SC made seventy four (74) document modifications with IP addresses (Internet Protocol, which is the set of rules governing the format of data sent via the internet or local network and IP addresses are the identifier that allows information to be sent between devices on a network, it contain location information and make devices accessible for communication) of 78.109.77.128, 212.73.91.35, 46.36.115.226 and 178.219.56.90. When the IP addresses were searched, it indicated an IP location of City: Yerevan/Country: Armenia (78.109.77.128), City/Region: Yerevan/Country: Armenia (212.73.91.35), City: Ashtarak/Region: Aragacotn/Country: Armenia (46.36.115.226) and City/Region: Ararat/Country: Armenia (178.219.56.90). g. A review of Patient 14s admission record indicated a start of care (SOC) date of 12/28/2023 with a primary diagnosis of Senile Degeneration of Brain, not elsewhere classified (a decrease in the ability to think, concentrate or remember). A review of form “;Audit Log” dated from 4/23/2024 to 5/13/2024 , the log was printed for Patient 14, which included “;Spiritual Chaplain (SC)/All Modules”, indicated that SC made ten (10) document modifications with IP address (Internet Protocol, which is the set of rules governing the format of data sent via the internet or local network and IP addresses are the identifier that allows information to be sent between devices on a network, it contain location information and make devices accessible for communication) of 46.36.115.226. When the IP address was searched, it indicated an IP location of City: Ashtarak/Region: Aragacotn/Country: Armenia (46.36.115.226). During a telephone interview on 5/17/2024 at 11:43 a.m. with the Spiritual Chaplain (SC), SC stated that he lives locally in Los Angeles, California. SC stated that he is involved in patient admissions around the local area that hospice agency is servicing, and he logs into Electronic Medical Record (EMR) system to document when needed. The audit log was explained to SC. SC stated he did not go on vacation since he started working for the agency on 11/2023. SC stated he was unsure why his computer to use for documentation has an IP address outside of the country, he stated he did not share his log in credentials to anyone. SC stated that he uses a VPN (or Virtual Private Network, establishes a digital connection between your computer and a remote server owned by a VPN provider, creating a point-to-point tunnel that encrypts personal data, masks the IP address, and lets the sidestep website blocks and firewalls on the internet.) attached to the same computer he uses to watch foreign Armenian movies. During an interview with the Administrator Designee (ADMD) on 5/18/2024 at 12:10 p.m., The ADMD stated that all staff should safeguard their credentials and not permitted other to log in and to document and sign in, on behalf of them. ADMD stated that according to office records, SC did not go on vacation since start of his employment with the hospice agency. A review of the hospice agencys policy and procedure titled “;Provision of Care and Record Management”, revised November 2021, indicated that no person involved in the care of a patient may participate in the review of that patients record, all records reviewed will be secure for confidentiality and all records will be reviewed in the designated area. A review of the hospice agencys policy and procedure titled “;Clinical Service Data Collection”, revised April 2019, indicated that entries to the clinical/service record will be made only by organization personnel and/or by contract personnel who have a written agreement with the organization. A review of the hospice agencys policy and procedure titled “;Computer Access to Information”, revised November 2021, indicated that authorized personnel will be assigned passwords and/or access codes and complete a signed statement that no one else will be allowed to use his/her computer key, data will be protected by safeguards that prevent unauthorized access to information and/or modification of existing data. h. A review of Patient 1s admission record indicated Patient 1 was admitted on 12/30/2023 with a primary diagnosis of heart failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). A review of form “;Audit Log,” dated from 1/2/2024 to 5/16/2024 , the log was printed for Patient 1, which included “;Spiritual Chaplain (SC)/All Modules”, indicated that SC made sixty seven (67) document modifications with IP addresses 46.36.115.226, 178.219.56.90, and 109.172.234.147. When the IP addresses were searched, it indicated an IP location of Armenia (178.219.56.90 and 46.36.115.226) and Georgia (109.172.234.147). i. A review of Patient 3s admission record indicated Patient 3 was admitted on 3/26/2024 with a primary diagnosis of benign(not harmful/not malignant) neoplasm (abnormal growth of tissues that may or may not be cancerous) of meninges (membrane of the brain). A review of form “;Audit Log,” dated from 3/26/2024 to 5/16/2024 , the log was printed for Patient 3, which included “;Spiritual Chaplain (SC)/All Modules”, indicated that SC made twenty four (24) document modifications with IP addresses 46.36.118.88 and 212.73.91.35. When the IP addresses were searched, it indicated an IP location of Armenia (212.73.91.35) and Spain (46.36.118.88). j. A review of Patient 4s admission record indicated Patient 3 was admitted on 1/13/2024 with a primary diagnosis of senile degeneration of brain (refers to the mental deterioration associated with aging; it is characterized by a decline in cognitive abilities, including concentration, memory recall, and judgment). A review of form “;Audit Log,” dated from 1/17/2024 to 5/16/2024 , the log was printed for Patient 4, which included “;Spiritual Chaplain (SC)/All Modules”, indicated that SC made fifty six (56) document modifications with IP addresses 46.36.115.226 and 212.73.91.35. When the IP addresses were searched, it indicated an IP location of Armenia for both IP addresses. a. During a review of Patient 1s admission record indicated the agency admitted Patient 1 on 12/30/2023 with a primary diagnosis of heart failure (a condition that occurs when the heart muscle does not pump blood as well as it should; when this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath). During a review of the HA’s “;Audit Log,” dated from 1/2/2024 to 5/16/2024, for Patient 1, the Audit Log which included “;Spiritual Chaplain (SC)/All Modules,” indicated the SC made sixty-seven document modifications with the Internet Protocol (IP, a unique string of characters that identifies each computer using the Internet Protocol to communicate over a network) addresses 46.36.115.226, 178.219.56.90, and 109.172.234.147. When the IP addresses were searched, it indicated an IP location in Armenia (178.219.56.90 and 46.36.115.226) and in Georgia (109.172.234.147). b. During a review of Patient 3s admission record indicated Patient 3 was admitted on 3/26/2024 with a primary diagnosis of benign (not harmful/not malignant) neoplasm (abnormal growth of tissues that may or may not be cancerous) of meninges (membrane of the brain). During a review of the HA’s “;Audit Log,” dated from 3/26/2024 to 5/16/2024, for Patient 3, the Audit Log which included “;Spiritual Chaplain (SC)/All Modules,” indicated the SC made twenty-four document modifications with IP addresses 46.36.118.88 and 212.73.91.35. When the IP addresses were searched, it indicated an IP location of Armenia (212.73.91.35) and Spain (46.36.118.88). c. During a review of Patient 4s admission record indicated Patient 4 was admitted on 1/13/2024 with a primary diagnosis of senile degeneration of the brain (refers to the mental deterioration associated with aging). During a review of the HA’s form “;Audit Log,” dated from 1/17/2024 to 5/16/2024, for Patient 4, the Audit Log which included “;Spiritual Chaplain (SC)/All Modules,” indicated the SC made fifty-six document modifications with IP addresses 46.36.115.226 and 212.73.91.35. When the IP addresses were searched, it indicated an IP location of Armenia for both IP addresses. d. During a review of Patient 6s admission record indicated a start of care (SOC) date of 2/13/2024 with a primary diagnosis of Hypertensive Heart Disease with Heart Failure (is a long-term condition that develops over many years in people who have high blood pressure, it is a group of medical problems including heart failure and irregular heartbeat). During a review of the HAs “;Audit Log,” dated from 4/9/2024 to 4/30/2024, indicated the Audit Log for Patient 6, which included “;Spiritual Chaplain (SC)/All Modules”, indicated the SC made twenty-six document modifications with IP addresses of 83.139.27.24, 46.36.115.226, and 178.219.56.90. When the IP addresses were searched, it indicated an IP location of City: Argavand/Region: Ararat/Country: Armenia (83.139.27.24), City: Ashtarak/Region: Aragacotn/Country: Armenia (46.36.115.226) and City/Region: Ararat/Country: Armenia (178.219.56.90). e. During a review of Patient 7s admission record indicated a start of care (SOC) date of 12/30/2023 with a primary diagnosis of Cerebral Infarction, unspecified (refers to damage to tissues in the brain due to the loss of oxygen in the area). During a review of the HAs “;Audit Log,” dated from 4/5/2024 to 5/13/2024, for Patient 6, the Audit Log the log, which included “;Spiritual Chaplain (SC)/All Modules,” indicated the SC made fifty five document modifications with IP addresses of 109.172.234.147, 46.36.115.226 and 178.219.56.90. When the IP addresses were searched, it indicated an IP location of City/Region: Tbilisi/Country: Georgia (109.172.234.147), City: Ashtarak/Region: Aragacotn/Country: Armenia (46.36.115.226) and City/Region: Ararat/Country: Armenia (178.219.56.90). f. During a review of Patient 8s admission record indicated a start of care (SOC) date of 1/13/2024 with a primary diagnosis of Heart Failure, unspecified (is a condition that develops when the heart does not pump enough blood for the body’s needs and can happen if the heart is unable to fill up with enough blood.). During a review of the HAs “;Audit Log” dated from 4/8/2024 to 5/13/2024, for Patient 8, which included “;Spiritual Chaplain (SC)/All Modules,” indicated the SC made sixty four document modifications with IP addresses of 212.73.91.35 and 46.36.115.226. When the IP addresses were searched, it indicated an IP location of City/Region: Yerevan/Country: Armenia (212.73.91.35), and City: Ashtarak/Region: Aragacotn/Country: Armenia (46.36.115.226). g. During a review of Patient 9s admission record indicated a start of care (SOC) date of 1/22/2024 with a primary diagnosis of End Stage Heart Failure (is a final and most severe stage of heart failure which a person experiences symptoms of heart failure (condition that develops when the heart does not pump enough blood for the body’s needs and can happen if the heart is unable to fill up with enough blood) which include shortness of breath, fatigue and irregular heartbeat even at rest). During a review of the HAs “;Audit Log” dated from 4/9/2024 to 5/13/2024, for Patient 9 which included “;Spiritual Chaplain (SC)/All Modules,” indicated the SC made sixty six document modifications with IP addresses of 212.73.91.35, 46.36.115.226 and 178.219.56.90. When the IP addresses were searched, it indicated an IP location of City/Region: Yerevan/Country: Armenia (212.73.91.35), City: Ashtarak/Region: Aragacotn/Country: Armenia (46.36.115.226) and City/Region: Ararat/Country: Armenia (178.219.56.90). h. During a review of Patient 10s admission record indicated a start of care (SOC) date of 12/29/2023 with a primary diagnosis of Chronic Obstructive Pulmonary Disease, unspecified (COPD, is a disease that damages the lungs in ways that make it hard to breathe). During a review of form “;Audit Log” dated from 4/23/2024 to 5/13/2024, for Patient 10 which included “;Spiritual Chaplain (SC)/All Modules,” indicated the SC made twelve document modifications with IP address of 46.36.115.226. When the IP address was searched, it indicated an IP location of City: Ashtarak/Region: Aragacotn/Country: Armenia (46.36.115.226). i. During a review of Patient 13s admission record indicated a start of care (SOC) date of 12/2/2023 with a primary diagnosis of Hypertensive Heart Disease with Heart Failure (is a long-term condition that develops over many years in people who have high blood pressure, it is a group of medical problems including heart failure and irregular heartbeat that can happen when an individuals high blood pressure [hypertension] is unmanaged). During a review of form “;Audit Log” dated from 4/4/2024 to 5/13/2024, for Patient 13, which included “;Spiritual Chaplain (SC)/All Modules,” indicated that SC made seventy four document modifications with IP addresses of 78.109.77.128, 212.73.91.35, 46.36.115.226 and 178.219.56.90. When the IP addresses were searched, it indicated an IP location of City: Yerevan/Country: Armenia (78.109.77.128), City/Region: Yerevan/Country: Armenia (212.73.91.35), City: Ashtarak/Region: Aragacotn/Country: Armenia (46.36.115.226) and City/Region: Ararat/Country: Armenia (178.219.56.90). j. A review of Patient 14s admission record indicated a start of care (SOC) date of 12/28/2023 with a primary diagnosis of Senile Degeneration of Brain, not elsewhere classified (a decrease in the ability to think, concentrate or remember). During a review of the HAs “;Audit Log” dated from 4/23/2024 to 5/13/2024, for Patient 14, which included “;Spiritual Chaplain (SC)/All Modules,” indicated the SC made ten document modifications with IP address of 46.36.115.226. When the IP address was searched, it indicated an IP location of City: Ashtarak/Region: Aragacotn/Country: Armenia (46.36.115.226). During a telephone interview on 5/17/2024, at 11:43 a.m., with the Spiritual Chaplain (SC), the SC stated that he lived locally in Los Angeles, California. The SC stated he was involved in patient admissions around the local area that hospice agency was servicing, and he logs into Electronic Medical Record (EMR) system to document when needed. The audit log was explained to SC. SC stated he did not go on vacation since he started working for the agency on 11/2023. The SC stated he was unsure why his computer to use for documentation has an IP address outside of the country, he stated he did not share his log in credentials to anyone. The SC stated he used a VPN (or Virtual Private Network, establishes a digital connection between your computer and a remote server owned by a VPN provider, creating a point-to-point tunnel that encrypts personal data, masks the IP address, and lets the sidestep website blocks and firewalls on the internet) attached to the same computer he uses to watch foreign Armenian movies. During an interview with the Administrator Designee (ADMD) on 5/18/2024, at 12:10 p.m., the ADMD stated that all staff should safeguard their credentials and not permitted other to log in and to document and sign in, on behalf of them. The ADMD stated that according to office records, the SC did not go on vacation since start of his employment with the hospice agency. A review of the hospice agencys policy and procedure titled “;Provision of Care and Record Management”, revised November 2021, indicated that no person involved in the care of a patient may participate in the review of that patients record, all records reviewed will be secure for confidentiality and all records will be reviewed in the designated area. A review of the hospice agencys policy and procedure titled “;Clinical Service Data Collection”, revised April 2019, indicated that entries to the clinical/service record will be made only by organization personnel and/or by contract personnel who have a written agreement with the organization. A review of the hospice agencys policy and procedure titled “;Computer Access to Information”, revised November 2021, indicated that authorized personnel will be assigned passwords and/or access codes and complete a signed statement that no one else will be allowed to use his/her computer key, data will be protected by safeguards that prevent unauthorized access to information and/or modification of existing data.”