Angels of Valley Hospice Care, Inc.

“Upon patient record review, 2 of 14 (Patient #4, #5) 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. #4-In SN note dated 05/07/25, the SN documented pain in the pain section as 1/10. In the Narrative Note documented patient had no pain. #5-In SN notes dated 01/29/25, 02/05/25, 02/12/25, and 02/19/25, the SN documented pain in the pain section as 1/10, 4/10, 4/10, and 2/10. In the narrative notes documented patient had no pain.”

“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] patients) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding the Patients Rights were met as follows: 1. The hospice agency failed to ensure the patient or representative, was provided with verbal and written notices regarding the patient’s rights and responsibilities, in a language and manner that the patient would understand for four of fourteen sampled patients. (Patient 1, Patient 8, Patient 9, and Patient 11). (Refer to L502). 2. The hospice agency failed to ensure a completed copy of written information regarding advance directive (a legal document that outlines person’s wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions was provided for one of fourteen sampled patients (Patient 3). (Refer to L503). 3. The hospice agency failed to inform about the scope of services the hospice agency will provide and the limitations of the services for four of fourteen sampled patients (Patient 1, Patient 2, Patient 8, and Patient 9). (Refer to L519). The cumulative effect of this systemic practice resulted in the failure of the hospice agency to deliver statutorily mandated compliance with Federal regulation for Patients Rights to ensure their rights as certified patients receiving hospice care are not violated and provided the highest quality of 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] patients) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding the Initial and Comprehensive Assessment (an assessment to identify the physical, psychosocial [relating social conditions to mental health], emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process) of patients was met as follows: 1. The hospice agency failed to complete the physical components in the comprehensive nursing assessment for one of fourteen sampled patients (Patient 6). (Refer to L524) 2. The hospice agency failed to include the objective data that demonstrated that the patients had weight loss of more than ten percent (%-unit of measure) in six months for five of 14 sampled patients (Patient 1, Patient 2, Patient 5, Patient 6, and Patient 7). (Refer to L525). 3. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse [RN], Medical Social Worker [MSW], Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for two of fourteen sample patients (Patient 1 and Patient 2). (Refer to L 533). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care were being provided to patients certified to receive the Medicare (a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities) hospice benefits.”

“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 meet the Condition of Participation (conditions that healthcare organizations must meet to begin and continue participating in the Medicare and Medicaid programs) for Interdisciplinary group, care planning, and coordination of services as follows: 1. The hospice agency failed to follow the plan of care regarding the monitoring of blood pressure for one of fourteen sampled patients (Patient 5). (Refer to L543). 2. The hospice agency failed to develop an individualized plan of care that included the frequency of nursing visits for two of fourteen sampled patients (Patient 1 and Patient 2). (Refer to L545). 3. The hospice agencys IDG (The Interdisciplinary Group [IDG – meeting where the Registered Nurse (RN), Medical Social Worker (MSW), Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) members failed to meet to review the IDG/POC for three of fourteen sampled patients (Patient 1, Patient 2, and Patient 5). (Refer to L552). The cumulative effect of this systemic practice resulted in the failure of the hospice agency to deliver statutorily mandated compliance with Federal regulation for Interdisciplinary group, care planning, and coordination of services to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.”

“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 meet the Condition of Participation (conditions that healthcare organizations must meet to begin and continue participating in the Medicare and Medicaid programs) for Core Services as follows: 1. The hospice agency failed to ensure nursing care and services were met and provided for two of fourteen sampled patients (Patient 1 and Patient 2). (Refer to L591). The cumulative effect of this systemic practice resulted in the failure of the hospice agency to deliver statutorily mandated compliance with Federal regulation for Core Services to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.”

“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 (condition that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Medical Director was met as follow: 1. The HA failed to ensure that the Medical Director conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial certifications for three of fourteen sampled patients (Patient 1, Patient 2 and Patient 10) to support the diagnosis of the patients’ terminal illnesses (a health condition that cannot be cured) and to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The HA failed to ensure there were documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice care and services. (Refer to L667). This deficient practice resulted in patient being enrolled in hospice and receiving care without a proper verification of patient eligibility and had the potential for Patient 1, Patient 2, and Patient 10, not receiving necessary care and healthcare resources to meet their care goals. (Refer to L667). 2. The HA failed to ensure, the medical director to assume responsibility for the medical component of the hospices patient care program for three of fourteen sampled patients (Patient 1, Patient 2 and Patient 10). This deficient practice resulted in patients being enrolled to the HA without oversight of the implementation of the hospice services to ensure the patients and patients familys needs were being met. (Refer to L 669). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory (written law) mandated compliance with Federal regulation for Medical Director services to ensure quality of patient care are provided to the patients certified to receive hospice services.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (condition that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Clinical Records was met as follows: 1. 1. The HA failed to complete clinical notes that included nursing visit notes and weight log records for five of fourteen sampled patients (Patient 1, Patient 2, Patient 5, Patient 6, and Patient 7). (Refer to L672). This deficient practice resulted in Patient 1, Patient 2, Patient 5, Patient 6, and Patient 7 did not have completed clinical records that could potentially not identify a change in patients conditions and affect the care and services received by the patients. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated (written law) compliance with Federal regulations for Clinical Records to maintain accurate and updated clinical records for all patients.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide four of fourteen sampled patients (Patient 1, Patient 8, patient 9, and Patient 11) information regarding their rights and responsibilities as a hospice patient in a language that would be understood and preferred by these patients. This deficient practice resulted in the patient not informed and lack of understanding of the HAs care and services, available for the patients and their family, and patients not able to exercise their right to decline the hospice services. b. During a review of Patient 8s Personal Information, the Personal Information indicated that Patient 8 was admitted to the HA on 10/11/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (a condition that occurs when plaque builds up in the coronary arteries, narrowing them and reducing blood flow to the heart; this can lead to chest pain, or angina, and is the most common cause of unstable angina). The Personal Information indicated that Patient 8s primary language was Spanish. During a review of Patient 8s Release of Information and Consent for Treatment, and Election of Medicare Hospice Benefit, both forms dated 11/1/2023, it was noted the forms were written in English. On 4/11/2024, at 3:19 p.m., during a phone interview with the surveyor in her native language (Spanish), Patient 8 stated she had never heard of the HA. Patient 8 stated that there were nurses who came to see her and her husband (Patient 9) at their home, and took her blood pressure, blood sugar, and listened to her heart. Patient 8 stated she did not know what hospice care meant, or who it was meant for. Patient 8 stated she did not have a primary physician. Patient 8 stated she did not know Patient 9’s (husband) physicians name. c. During a review of Patient 9s Personal Information, the Personal Information indicated that Patient 9 was admitted to the HA on 11/1/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a chronic condition that occurs when plaque builds up in the coronary arteries, narrowing them and limiting blood flow to the heart). The Personal Information indicated that Patient 9s primary language was Spanish. During a review of Patient 9s Release of Information and Consent for Treatment, and Election of Medicare Hospice Benefit, both forms dated 11/1/2023, it was noted the forms were written in English. During a concurrent interview and record review with the Director of Patient Care Services (DPCSD) on 12/20/2024 at 1:25 p.m., the DPCSD reviewed both Patient 8’s and Patient 9s Release of Information and Consent for Treatment and Election of Medicare Hospice Benefit. The DPCSD confirmed the forms were signed by Patient 8 and Patient 9. The DPCSD also confirmed he was the one signing as the hospice representative. The DPCSD stated he did not speak Spanish, and Patient 8 and Patient 9 only spoke Spanish. When asked how he explained regarding the hospice services and benefits to Patient 8 and Patient 9, the DPCSD stated usually when the patient did not speak English, he would have a family member who spoke English and also spoke the patients native language present during the form signing. However, there was no documentation that the explanation regarding Release of Information and Consent for Treatment, and Election of Medicare Hospice Benefit were done with a family member who spoke English and Spanish present. During a review of the HAs policy and procedure, titled “;Rights/Responsibilities,” revised November 2023, the policy and procedure indicated that the patient rights and responsibilities statement will be explained and distributed to the patient prior to the initiation of organization services. This explanation will be in a language or communication method that the patient can reasonably be expected to understand. a. During a review of Patient 1s “;Personal Information”, indicated a start of care (SOC) date of 4/17/2023 and an end of care date of 8/1/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood without a chest pain). During an interview on 12/17/2024, at 12:01 p.m., with the Patient 1s Caregiver/Family Member/Stepdaughter (FM1), FM1 stated that her stepfather (Patient 1) cannot sign any consent for himself, stated Patient1 was illiterate, only went to school up to 3rd or 4th grade, spoke Spanish language only. FM1 stated that her stepfather (Patient 1) did not understand the hospice program and services. FM1 stated that the HA put some of her mothers diagnosis to his stepfathers records. FM1 stated they sent medical equipment and medical supplies to her parents home but were not needed. FM1 stated that Patient 1 (stepfather) can still drive short distances, still cooks, does some house chores but forgetful sometimes, stated that the HA representative promised them for free nursing visits, free medications supply and equipment, but unaware of what hospice was about and services it can provide. FM1 stated Patient 1 has no heart disease but only memory problems and goes to see his primary doctors regularly. During a concurrent interview and record review on 12/20/2024 at 11:15 a.m., with the Director of Patient Care Services Designee (DPCSD) of Patient 1s clinical records, titled “;Rights and Responsibilities/Release of Information and Consent for Treatment”, dated 4/17/2023, indicated the content is in English text language. DPCSD confirmed and stated that Patient1 only spoke Spanish, stated he used the assistance of the HAs Spanish speaking staff. During further review of Patient 1s clinical records with the DPCSD, there were no clinical documentations that DPCSD used a language translation service to explain to Patient 1 of the HAs philosophy, limitations of services and the documents that he signed. DPCSD stated that he should have documented regarding the language interpretation services provided to Patient 1 during admission process to validate that it was done. DPCSD stated that it is important that instructions and explanation regarding hospice should be explained in patients preferred language for better understanding. d. During a review of Patient 11s “;admission record it indicated a start of care (SOC) date of 4/30/24 with a terminal diagnoses of heart disease (variety of issues that can affect your heart). During a review of Patient 11s “;plan of care/IDG review dated 12/6/24 it indicated the frequency of visits of skilled nurses (SN) is 1 per week; RN1 per 2 weeks; Spiritual counselor 1/month. During an interview on 12/19/23 at 1:10 pm, with Patient 11s wife it was determined that an interpreter was needed in order to further our conversation. Both Patient 11 and wife spoke mainly Spanish and, no one was available to translate. During an interview on 12/20/24 at 10:40 am, with the DPCS designee he was asked how communications with patients or family members who require language translation are handled by the hospice agency. DPCS stated that either family members assist with all communications between the patient and the agency or an agency staff member would be used to do the same thing. When asked if this was done for Patient 11, DPCS designee stated yes. When asked if he could provide any documentation to support it, the DPCS designee failed to provide the documented evidence.”

“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 a completed copy of written information regarding advance directive (a legal document that outlines person’s wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions for one of fourteen sampled patients (Patient 3). This failure had the potential to result in the patients family and/or caregivers not knowing the patient’s wishes and or medical decisions which can result in psychological distress to the patient/patients family/caregiver. During a review of Patient 3s “;Personal Information”, indicated a start of care (SOC) date of 12/5/2024, with a primary diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) with late onset. During a review of Patient 3s POC (Plan of Care, consists of different patient goals, nursing and allied health assessment and interventions to help attain those goals, and expected outcomes aligned with the patient’s needs)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 12/5/2024, indicated the frequency of visits for skilled nurse (SN) to two visit per week plus one PRN (pro re nata, which means “;as needed”) visits for pain and symptom management, the Master of Social Work (MSW) to visit one time then on every recertification for psychosocial issues, needs and concerns, Spiritual Counselor (SC) to visit one time then on every recertification for spiritual issues and concerns and Hospice Aide (HA) to visit twice a week as needed for assistance in activities of daily living (ADLs). During a home visit observation on 12/18/2024, at 10 a.m., at Patient 3s residence, with Licensed Vocational Nurse (LVN 1), Patient 3 was observed resting comfortably on his bed. Patient 3 was alert, awake and oriented to his name and place but confused at times. During a concurrent review of Patient 3s hospice folder with LVN 1, the folder had the name of the agency, inside of the folder was a copy of Patient 3s plan of care, active medication list signed notice of patients rights and a POLST (Physician Orders for Life-Sustaining Treatment), dated 12/5/2024, indicated no selection mark on section: A. Cardiopulmonary Resuscitation (CPR, a method that can help save a life during cardiac arrest, when the heart stops beating or beats too ineffectively to circulate blood to the brain and other vital organs) , no selection mark on section B. Medical Interventions, and has no Patient 3 and/or Patient 3s Legal Representatives signature. During interview with LVN 1, stated she was unaware that Patient 3s Legal Representative, stated that POLST was not valid unless it was completed and signed by the patient or legal representative. LVN1 stated it should have been checked and processed by the social worker. LVN 1 stated that if Patient 3s heartbeat stops, then a CPR must perform since the POLST was not completed yet and the code status of the patient was FULL code and not DNR (Do Not Resuscitate). During a concurrent record review and interview on 12/20/24, at 10:30 a.m., with the Registered Nurse Supervisor (RNS), indicated Patient 3s POLST was incomplete and unsigned by Patient 3 and/or his legal representative. RNS confirmed that Patient 3s POLST, dated 12/5/2024, is incomplete and unsigned, RNS stated that a completed copy should have been provided to Patient 3s hospice agencys home folder for future reference to define the code status of the patient. During a telephone interview on 12/20/2024, at 12:11 p.m., with the Master of Social Work (MSW), MSW stated that she keeps on following up with Patient 3s legal representative to explain and sign the POLST. MSW stated that an incomplete POLST should have not been placed in Patient 3s hospice folder as it could create a confusion of Patient 3s code status. MSW stated that a completed POLST was very important for the healthcare providers future reference when Patient 3s medical condition decline or if his heartbeat stops. During a review of the HAs policy and procedure entitled, “;Do Not Resuscitate/Do Not Intubate Orders”, revised November 2023, the policy and procedure indicated that a written Do Not Resuscitate (DNR) order signed by the patients physician (or authorized independent practitioner) must be on file in the patients clinical record and admission folder in the patients home.”

“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 inform the patient about the scope of services the hospice agency will provide and the limitations of the services for four of fourteen sampled patients (Patient 1, Patient 2, Patient 8, and Patient 9). This deficient practice resulted in the patients not being aware of the care and services the HA provided and had the potential for misinformation, misunderstanding and miscommunication of hospice care and services provided. b. During a review of Patient 8s Personal Information, the Personal Information indicated that Patient 8 was admitted to the HA on 10/11/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (a condition that occurs when plaque builds up in the coronary arteries, narrowing them and reducing blood flow to the heart; this can lead to chest pain, or angina, and is the most common cause of unstable angina). The Personal Information indicated that Patient 8s primary language was Spanish. During a review of Patient 8s Release of Information and Consent for Treatment, and Election of Medicare Hospice Benefit, both forms dated 11/1/2023, it was noted the forms were written in English. On 4/11/2024, at 3:19 p.m., during a phone interview with the surveyor in her native language (Spanish), Patient 8 stated she had never heard of the HA. Patient 8 stated that there were nurses who came to see her and her husband (Patient 9) at their home, and took her blood pressure, blood sugar, and listened to her heart. Patient 8 stated she did not know what hospice care meant, or who it was meant for. Patient 8 stated she did not have a primary physician. Patient 8 stated she did not know her husbands (Patient 9) physicians name. Patient 8 stated no physician had told her that neither she nor her husband had a terminal illness and had 6 months or less to live. c. During a review of Patient 9s Personal Information, the Personal Information indicated that Patient 9 was admitted to the HA on 11/1/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a chronic condition that occurs when plaque builds up in the coronary arteries, narrowing them and limiting blood flow to the heart). The Personal Information indicated that Patient 9s primary language was Spanish. During a review of Patient 9s Release of Information and Consent for Treatment, and Election of Medicare Hospice Benefit, both forms dated 11/1/2023, it was noted the forms were written in English. During a concurrent interview and record review with the Director of Patient Care Services (DPCSD) on 12/20/2024 at 1:25 p.m., the DPCSD reviewed Patient 8 and patient 9s Release of Information and Consent for Treatment and Election of Medicare Hospice Benefit. The DPCSD confirmed the forms were signed by Patient 8 and Patient 9. The DPCSD also confirmed he was the one signing as the hospice representative. The DPCSD stated he did not speak Spanish, and Patient 8 and Patient 9 only spoke Spanish. When asked how he explained regarding the hospice services and benefits to Patient 8 and Patient 9, the DPCSD stated usually when the patient did not speak English, he would have a family member who spoke English and also spoke the patients native language present during the form signing. However, there was no documentation that the explanation regarding Release of Information and Consent for Treatment, and Election of Medicare Hospice Benefit were done with a family member who spoke English and Spanish present. During a review of the HAs policy and procedure, titled “;Rights/Responsibilities,” revised November 2023, the policy and procedure indicated that the patients rights included the following: - The right to be informed of his/her condition, to participate in all aspects of care including development on their plan of care, and the right to refuse all or part of his/her care to the extent permitted by law. - The right to have communication needs met. The policy and procedure also indicated that the patient rights and responsibilities statement will be explained and distributed to the patient prior to the initiation of organization services. This explanation will be in a language or communication method that the patient can reasonably be expected to understand. a. During a review of Patient 1s “;Personal Information”, indicated a start of care (SOC) date of 4/17/2023 and an end of care date of 8/1/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood without a chest pain). The Personal Information indicated that Patient 1s primary language was English. During a review of Patient 1s Release of Information and Consent for Treatment, and Election of Medicare Hospice Benefit, both forms dated 4/17/2023, it was noted the forms were written in English. b. During a review of Patient 2s “;Personal Information”, indicated a start of care (SOC) date of 4/11/2023 and an end of care date of 6/26/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood with unstable chest pain). The Personal Information indicated that Patient 1s primary language was left blank. During an interview on 12/17/2024, at 12:01 p.m., with the Patient 1s and Patient 2 s Caregiver/Family Member/daughter (FM1), FM1 stated that her stepfather (Patient 1) cannot sign any consent for himself, stated Patient 1 was illiterate (unable to read or write), only went to school up to 3rd or 4th grade, speaks Spanish language only. FM1 stated that her stepfather (Patient 1) did not understand the hospice program and services and the HA or the nurse that admitted them did not explain what hospice program was about. FM1 stated that the HA put some of her mothers diagnosis to his stepfathers records. FM1 stated they sent medical equipment and medical supplies to her parents home but were not needed. FM1 stated that his stepfather (Patient 1) can still drive short distances, still cooks, does some house chores but forgetful sometimes, stated according to her mother (Patient 2), the HA representative promised her stepfather (Patient 1) and her mother (Patient 2) for free nursing visits, free medications supply and equipment, but were not explained of what hospice is all about and services it can provide. FM1 stated her parents (Patient 1 and Patient 2) has no heart disease and terminal illnesses, stated she brought them to see their primary and specialty doctors regularly. During a concurrent interview and record review with the Director of Patient Care Services (DPCSD) on 12/20/2024 at 11:30 p.m., the DPCSD reviewed Patient 1 and Patient 2s Release of Information and Consent for Treatment and Election of Medicare Hospice Benefit. The DPCSD confirmed the forms were signed by Patient 1 and Patient 2. The DPCSD also confirmed he was the one signing as the hospice representative. The DPCSD stated he does not speak Spanish, and Patient 1 only speaks Spanish, but Patient 2 does speak English as her primary language. DPCSD stated usually when the patient does not speak English, he would have a family member who spoke English and spoke the patients native language present during the form signing. However, there was no documentation that the explanation regarding Release of Information and Consent for Treatment, and Election of Medicare Hospice Benefit were done with a family member who spoke English and Spanish present. a. During a review of Patient 1s “;Personal Information”, indicated a start of care (SOC) date of 4/17/2023 and an end of care date of 8/1/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood without a chest pain). The Personal Information indicated that Patient 1s primary language was English. During a review of Patient 1s Release of Information and Consent for Treatment, and Election of Medicare Hospice Benefit, both forms dated 4/17/2023, it was noted the forms were written in English. b. During a review of Patient 2s “;Personal Information”, indicated a start of care (SOC) date of 4/11/2023 and an end of care date of 6/26/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood with unstable chest pain). The Personal Information indicated that Patient 1s primary language was left blank. During an interview on 12/17/2024, at 12:01 p.m., with the Patient 1s and Patient 2 s Caregiver/Family Member/daughter (FM1), FM1 stated that her stepfather (Patient 1) cannot sign any consent for himself, stated Patient 1 was illiterate (unable to read or write), only went to school up to 3rd or 4th grade, speaks Spanish language only. FM1 stated that her stepfather (Patient 1) did not understand the hospice program and services and the HA or the nurse that admitted them did not explain what hospice program was about. FM1 stated that the HA put some of her mothers diagnosis to his stepfathers records. FM1 stated they sent medical equipment and medical supplies to her parents home but were not needed. FM1 stated that his stepfather (Patient 1) can still drive short distances, still cooks, does some house chores but forgetful sometimes, stated according to her mother (Patient 2), the HA representative promised her stepfather (Patient 1) and her mother (Patient 2) for free nursing visits, free medications supply and equipment, but were not explained of what hospice is all about and services it can provide. FM1 stated her parents (Patient 1 and Patient 2) has no heart disease and terminal illnesses, stated she brought them to see their primary and specialty doctors regularly. During a concurrent interview and record review with the Director of Patient Care Services (DPCSD) on 12/20/2024 at 11:30 p.m., the DPCSD reviewed Patient 1 and Patient 2s Release of Information and Consent for Treatment and Election of Medicare Hospice Benefit. The DPCSD confirmed the forms were signed by Patient 1 and Patient 2. The DPCSD also confirmed he was the one signing as the hospice representative. The DPCSD stated he does not speak Spanish, and Patient 1 only speaks Spanish, but Patient 2 does speak English as her primary language. DPCSD stated usually when the patient does not speak English, he would have a family member who spoke English and spoke the patients native language present during the form signing. However, there was no documentation that the explanation regarding Release of Information and Consent for Treatment, and Election of Medicare Hospice Benefit were done with a family member who spoke English and Spanish present. b. During a review of Patient 8s Personal Information, the Personal Information indicated that Patient 8 was admitted to the HA on 10/11/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (a condition that occurs when plaque builds up in the coronary arteries, narrowing them and reducing blood flow to the heart; this can lead to chest pain, or angina, and is the most common cause of unstable angina). The Personal Information indicated that Patient 8s primary language was Spanish. During a review of Patient 8s Release of Information and Consent for Treatment, and Election of Medicare Hospice Benefit, both forms dated 11/1/2023, it was noted the forms were written in English. On 4/11/2024, at 3:19 p.m., during a phone interview with the surveyor in her native language (Spanish), Patient 8 stated she had never heard of the HA. Patient 8 stated that there were nurses who came to see her and her husband (Patient 9) at their home, and took her blood pressure, blood sugar, and listened to her heart. Patient 8 stated she did not know what hospice care meant, or who it was meant for. Patient 8 stated she did not have a primary physician. Patient 8 stated she did not know her husbands (Patient 9) physicians name. Patient 8 stated no physician had told her that neither she nor her husband had a terminal illness and had 6 months or less to live. c. During a review of Patient 9s Personal Information, the Personal Information indicated that Patient 9 was admitted to the HA on 11/1/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a chronic condition that occurs when plaque builds up in the coronary arteries, narrowing them and limiting blood flow to the heart). The Personal Information indicated that Patient 9s primary language was Spanish. During a review of Patient 9s Release of Information and Consent for Treatment, and Election of Medicare Hospice Benefit, both forms dated 11/1/2023, it was noted the forms were written in English. During a concurrent interview and record review with the Director of Patient Care Services (DPCSD) on 12/20/2024 at 1:25 p.m., the DPCSD reviewed Patient 8 and patient 9s Release of Information and Consent for Treatment and Election of Medicare Hospice Benefit. The DPCSD confirmed the forms were signed by Patient 8 and Patient 9. The DPCSD also confirmed he was the one signing as the hospice representative. The DPCSD stated he did not speak Spanish, and Patient 8 and Patient 9 only spoke Spanish. When asked how he explained regarding the hospice services and benefits to Patient 8 and Patient 9, the DPCSD stated usually when the patient did not speak English, he would have a family member who spoke English and also spoke the patients native language present during the form signing. However, there was no documentation that the explanation regarding Release of Information and Consent for Treatment, and Election of Medicare Hospice Benefit were done with a family member who spoke English and Spanish present. During a review of the HAs policy and procedure, titled “;Rights/Responsibilities,” revised November 2023, the policy and procedure indicated that the patients rights included the following: - The right to be informed of his/her condition, to participate in all aspects of care including development on their plan of care, and the right to refuse all or part of his/her care to the extent permitted by law. - The right to have communication needs met. The policy and procedure also indicated that the patient rights and responsibilities statement will be explained and distributed to the patient prior to the initiation of organization services. This explanation will be in a language or communication method that the patient can reasonably be expected to understand.”

“Based on interview and record review, the Hospice Agency (HA- agency providing care to terminally ill patients who have six months or less to live) failed to conduct the physical assessment including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patients terminal illness for one of fourteen sampled patients (Patient 6). This deficient practice has the potential to result in the failure to identify the physical needs related to the terminal illness that must be addressed in order to promote the hospice patients well-being, comfort, and dignity throughout the dying process. During a review of Patient 6s Personal Information, the Personal Information indicated that Patient 6 was admitted to the HA on 12/11/2024 with a primary diagnosis of hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure) with heart failure (a chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 6s Comprehensive Nursing Assessment dated 12/11/2024, the height, weight, body mass index (BMI, a tool that healthcare providers use to estimate the amount of body fat by using height and weight measurements; it can help assess risk factors for certain health conditions), oxygen saturation (the percentage of oxygen in a person’s blood, and a measure of how well the lungs are working), and mid-arm circumference (MAC, measurement of the arm circumference in centimeters, used as an indicator of nutritional status) sections were blank. The nutrition section of the Comprehensive Nursing Assessment indicated that Patient 6 had poor appetite, poor skin turgor, and dry membranes. Per National Library of Medicine, poor skin turgor and dry membranes are symptoms of dehydration. (https://medlineplus.gov/ency/article/003281.htm). During a concurrent interview and record review with the Registered Nurse Supervisor (RNS) on 12/20/2024 at 12:10 p.m., the Comprehensive Nursing Assessment for Patient 6 was considered incomplete due to the vitals and measurement section was left blank. The RNS stated that it was very important to assess the patients weight, BMI, oxygen saturation, and MAC to obtain a complete picture of the patients health status. The RNS stated if the patients weight was not obtained upon admission, it would be hard to determine later on if patient had lost weight or not, or if patient needed supplemental nutrition or consult. During a review of the HAs policy and procedure, titled “;Comprehensive Assessment,” revised November 2023, the policy and procedure indicated that during a comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant: H. a physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patients terminal illness. The “;Comprehensive Assessment” Policy and Procedure also indicated the agency must assure that the data elements allow for measurement of outcomes.”

“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 include the objective data that demonstrated that the patients had weight loss of more than 10% in six months for four of fourteen sampled patients (Patient 1, Patient 5, Patient 6, and Patient 7). This deficient practice had the potential to cause inaccurate assessment and that could result to the patients needs not addressed appropriately. c. During a review of Patient 5s Personal Information, the Personal Information indicated that Patient 5 was admitted to the HA on 3/28/2024 with a primary diagnosis of senile degeneration of brain (a term for a group of neurological disorders that cause a gradual decline in cognitive abilities; this can include memory loss, difficulty reasoning, and an inability to perform everyday tasks). During a review of Patient 5s Comprehensive Nursing Assessment, dated 3/28/2024, the Comprehensive Nursing Assessment indicated Patient 5 weighted 140 pounds and had a body mass index (BMI, a tool that healthcare providers use to estimate the amount of body fat by using height and weight measurements; it can help assess risk factors for certain health conditions) of 25.6. According to the Centers for Disease Control and Prevention (CDC, the national public health agency in the U.S.), an adult with a BMI of 25 to less than 30 is considered overweight (https://www.cdc.gov/bmi/adult-calculator/bmi-categories.html). The Comprehensive Nursing Assessment indicated that Patient 5 had a weight loss of more than ten percent in six months. The narrative section of the Comprehensive Nursing Assessment did not specify what Patient 5s weight was six months prior to admission or how many pounds Patient 5 had lost in six months prior to admission to the HA. d. During a review of Patient 6s Personal Information, the Personal Information indicated that Patient 6 was admitted to the HA on 12/11/2024 with a primary diagnosis of hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure) with heart failure (a chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 6s Comprehensive Nursing Assessment, dated 12/11/2024, the Comprehensive Nursing Assessment did not indicate Patient 6s weight and BMI upon admission. The Comprehensive Nursing Assessment indicated that Patient 6 had had a weight loss of more than ten percent in six months. The narrative section of the Comprehensive Nursing Assessment did not specify what Patient 6s weight was six months prior to admission or how many pounds Patient 6 had lost in six months prior to admission to the HA. e. During a review of Patient 7s Personal Information, the Personal Information indicated that Patient 7 was admitted to the HA on 4/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a chronic condition that occurs when plaque builds up in the coronary arteries, narrowing them and limiting blood flow to the heart). During a review of Patient 7s Comprehensive Nursing Assessment, dated 4/25/2024, the Comprehensive Nursing Assessment indicated Patient 7 weighted 150 pounds and had a BMI of 22.1. According to CDC, an adult with a BMI of 18.5 to less than 25 is considered as having a healthy weight (https://www.cdc.gov/bmi/adult-calculator/bmi-categories.html). The Comprehensive Nursing Assessment indicated that Patient 7 had had a weight loss of more than ten percent in six months. The narrative section of the Comprehensive Nursing Assessment did not specify what Patient 7s weight was six months prior to admission or how many pounds Patient 7 had lost in six months prior to admission to the HA. During a concurrent record review and interview with the Registered Nurse Supervisor (RNS) on 12/20/2024 at 11:25 a.m., the RNS reviewed the Comprehensive Nursing Assessment for Patient 5, Patient 6, and Patient 7. The RNS verified there was no weight loss amount documented and no patients weight six month prior to admission was documented for the three patients. The RNS also reviewed the electronic health record for Patient 5, Patient 6, and Patient 7. The RNS stated there was also no documentation in the electronic health record regarding how many pounds of weight Patient 5, Patient 6, and Patient 7 had lost in the past 6 months prior to hospice admission, or how much the three patients weighed 6 months before hospice admission. The RNS stated that to be able to determine that Patient 5, Patient 6, and Patient 7 had loss more than ten percent of body weight in six months, there had to be a baseline weight. The RNS stated there was no documentation to support the over ten percent weight loss in six months. The RNS stated the patients weight should have been part of the comprehensive assessment and had to be supported by objective data in order for the assessment to be accurate. Per RNS, accurate assessment was important so that patients needs could be identified and addressed. During a review of the HAs policy and procedure, titled “;Comprehensive Assessment,” revised November 2023, the policy and procedure indicated that during a comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant: H. a physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patients terminal illness. The “;Comprehensive Assessment” Policy and Procedure also indicated the agency must assure that the data elements allow for measurement of outcomes. a. During a review of Patient 1s “;Personal Information”, indicated a start of care (SOC) date of 4/17/2023 and an end of care date of 8/1/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood without a chest pain). During a review of Patient 1s Comprehensive Nursing Assessment, dated 4/17/2023, the Comprehensive Nursing Assessment indicated Patient 1 weighed 167 pounds and had a body mass index (BMI, a tool that healthcare providers use to estimate the amount of body fat by using height and weight measurements; it can help assess risk factors for certain health conditions) of 25.4. According to the Centers for Disease Control and Prevention (CDC, the national public health agency in the U.S.), an adult with a BMI of 25 to less than 30 is considered overweight (https://www.cdc.gov/bmi/adult-calculator/bmi-categories.html). The Comprehensive Nursing Assessment indicated that Patient 1 had had a weight loss of more than ten percent in six months. The narrative section of the Comprehensive Nursing Assessment did not specify what Patient 1s weight was six months prior to admission or how many pounds Patient 5 had lost in six months prior to admission to the HA. During a concurrent record review and interview with the Registered Nurse Supervisor (RNS) on 12/20/2024 at 12:20 p.m., the RNS reviewed the Comprehensive Nursing Assessment for Patient 1. The RNS verified there was no weight loss amount documented and no patients weight six month prior to admission was documented for Patient 1. The RNS also reviewed the electronic health record for Patient 1. The RNS stated there was also no documentation in the electronic health record regarding how many pounds of weight Patient 1 had lost in the past 6 months prior to hospice admission, or how much Patient 1 weighed 6 months before hospice admission. The RNS stated that to be able to determine that Patient 1 had loss more than ten percent of body weight in six months, there had to be a baseline weight. The RNS stated there was no documentation to support the over ten percent weight loss in six months. The RNS stated the patients weight should have been part of the comprehensive assessment and had to be supported by objective data for the assessment to be accurate. Per RNS, accurate assessment was important so that patients needs could be identified and addressed.”

“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 interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for three of nineteen sample selected patients (Patient 1, Patient 2, and Patient 5). This failure had potential for harm if patients are prevented from reaching their goals, due to IDG not addressing changes in the patient’s condition. a. During a review of Patient 1s “;Personal Information”, indicated a start of care (SOC) date of 4/17/2023 and an end of care date of 8/1/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood without a chest pain). During a concurrent record review and interview on 12/20/2024 at 12:15 p.m., with the Registered Nurse Supervisor (RNS) of Patient 1 s clinical record titled “;Plan of Care/Interdisciplinary Group Review” (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), indicated the following: - 4/28/2023, no signatures of IDG members (Medical Director (MD), Master of Social Work (MSW), and Spiritual Chaplain (SC). - 5/12/2023, no signatures of IDG members (MD, MSW, SC and Registered Nurse (RN)). - 5/26/2023, no signatures of IDG members (MD, MSW, SC and RN). - 6/9/2023, no signatures of IDG members (MD, MSW, SC and RN). - 6/23/2023, no signatures of IDG members (MD, MSW, SC and RN). - 7/7/2023, no signatures of IDG members (MD, MSW, and SC). - 7/21/2023, no signatures of IDG members (MD, MSW, SC and RN). - 8/1/2023, no signatures of IDG members (MD, MSW, and SC). b. During a review of Patient 2s “;Personal Information”, indicated a start of care (SOC) date of 4/11/2023 and an end of care date of 6/26/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood with unstable chest pain). During a concurrent record review and interview on 12/20/2024 at 12:30 p.m., with the Registered Nurse Supervisor (RNS) of Patient 2 s clinical record titled “;POC/IDG Review”, indicated the following: - 4/11/2023, no signatures of IDG members (MD, MSW, and SC). - 4/14/2023, no signatures of IDG members (MD, MSW, and SC). - 4/28/2023, no signatures of IDG members (MD, MSW, and SC). - 5/12/2023, no signatures of IDG members (MD, MSW, and SC). - 5/26/2023, no signatures of IDG members (MD, MSW, and SC). - 6/9/2023, no signatures of IDG members (MD, MSW, and SC). The RNS confirmed the reviewed POC/IDG Review of Patient 1 and Patient 2 were missing the IDG members signatures. There was no documented evidence of coordination of care between the IDG members. RNS stated that there is no separate sign-in sheet for IDG members during meeting. The RNS stated the IDG members would only sign electronically when they attended the IDG meetings, there was no separate sign-in sheet. The RNS stated if the POC/IDG Review was not signed by a particular IDG member, it would mean that IDG member was not present during the meeting to review the patients individualized plan of care. RNS stated patients assessments need to be documented timely to inform involved staff of the patients status. RNS stated the nursing assessment dictates what goes on the patients individualized plan of care, and without a documented assessment the patients plan of care does get updated. RNS stated when a patient plan of care is not updated the patient does not receive the care and treatment the physician ordered. RNS stated that the interdisciplinary team (IDT) which consist of the MD, MSW, SC, and DPCS meet every 14 days to update patients condition and make changes to their plan of care if needed. The RNS stated each individual discipline documents their findings and sign the day of the meeting. During a telephone interview on 12/20/2024, at 12:11 p.m., with the MSW, MSW stated she attended the IDG meeting which is every 14 days with the other IDG members consist of the MD, RN, and SC. MSW stated they do not have any sign in sheet, they sign electronically to validate their attendance. MSW stated she does not remember what happened when her signatures were missing on Patient 1 and Patient 2s IDG/POC review. MSW stated she does not remember anymore since the patients were discharged long time ago. During a telephone interview on 12/20/2024, at 12:17 p.m., with the SC, SC stated that he started to work for the HA since the first quarter of this year (2024). SC stated he attends the IDG meeting every 14 days. SC stated he sign his attendance digitally and there is no other sign in sheet to validate the attendance. c. During a review of Patient 5s Personal Information, the Personal Information indicated that Patient 5 was admitted to the HA on 3/28/2024 with a primary diagnosis of senile degeneration of brain (a term for a group of neurological disorders that cause a gradual decline in cognitive abilities; this can include memory loss, difficulty reasoning, and an inability to perform everyday tasks). During a concurrent record review and interview with the Registered Nurse Supervisor (RNS) on 12/20/2024 at 1:10 p.m., the RNS reviewed Patient ss “;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 12/6/2024. The RNS verified the POC/IDG Review was missing the RN, Physician, and Chaplain signatures. There was no documented evidence of coordination of care between the IDG members. When the RNS was asked if there was a separate sign-in sheet for IDG members, the RNS stated the IDG members would only sign online when they attended the IDG meetings, there was no separate sign-in sheet. The RNS stated if the POC/IDG Review was not signed by a particular IDG member, it would mean that IDG member was not present during the meeting to review the patients individualized plan of care. During a review of the HAs policy and procedure, titled “;The Plan of Care,” revised November 2023, the policy and procedure indicated that the plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, but the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver.”

“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 follow the individualized written plan of care for one of fourteen sampled patients (Patient 5). This deficient practice has the potential to result in Patient 5s condition unmonitored and delay provision of the necessary interventions and treatment. During a review of Patient 5s Personal Information, the Personal Information indicated that Patient 5 was admitted to the HA on 3/28/2024 with a primary diagnosis of senile degeneration of brain (a term for a group of neurological disorders that cause a gradual decline in cognitive abilities; this can include memory loss, difficulty reasoning, and an inability to perform everyday tasks). During a review of Patient 5’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 was reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 12/6/2024, the POC/IDG Review indicated that the HA would monitor patients vital signs, especially blood pressure and heart rate. The POC/IDG Review indicated that patients blood pressure would be maintained within 90 mmHg (a measurement unit) and 160 mmHg with use of current medications. Per POC/IDG Review on 12/6/2024, the frequency of Licensed Vocational Nurse (LVN, a licensed nurse) visit was twice per week, and the frequency of Registered Nurse (RN) visit was once every two weeks. During a review of Patient 5s Current Treatment/Medication/DME (Durable Medical Equipment, any medical equipment used in the home to aid in a better quality of living) List, the Current Treatment/Medication/DME List indicated that Patient 5 was on Metoprolol Tartrate (a medication to manage high blood pressure [a chronic condition where the force of the blood pushing against the walls of the blood vessels is too high; high blood pressure can lead to other serious problems such as heart attack and stroke]) 25 mg (a measurement unit) tablet, one tablet twice daily, and Nifedipine (a medication to manage high blood pressure) 30 mg extended release tablet, one tablet daily. Both medications had the following parameter: check blood pressure before delivering, hold if systolic blood pressure (the first number, it measures the pressure the blood is pushing against the artery walls when the heart beats) is more than 110 mmHg. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 12/18/2024 at 11 a.m., observed Patient 5 sitting in a wheelchair, awake, and alert. A facility staff, the medication technician (MT), was also present during the joint visit. The MT stated that all of Patient 5s medications were administered by the MTs, such as himself. During the home visit, a medication review was performed with LVN 1 at 11:50 a.m. When LVN 1 was asked for a blood pressure monitoring log for Patient 5, LVN 1 stated the facility should have it since Patient 5 lives there. During an interview with the MT on 12/18/2024 at 12 p.m., the MT stated the medication technician checked Patient 5s blood pressure before giving the blood pressure medication, but it was never recorded or documented. According to the MT, if the blood pressure was below the parameter, the blood pressure medications would be held. During an interview with LVN 1 on 12/18/2024 at 12:05 p.m., LVN 1 stated that she had never seen Patient 5 before. LVN 1 stated she was not the regular nurse for Patient 5. LVN 1 was asked how the HA monitored Patient 5s blood pressure to ensure it was within the 90 mmHg to 160 mmHg as written in the patients care plan, LVN 1 stated a blood pressure log was required to monitor his blood pressure. LVN 1 stated that even though Patient 5s blood pressure was okay at that time, it needed to be monitored. During a phone interview with LVN 2 on 12/19/2024 at 10:33 a.m., LVN 2 stated she was the regular nurse for Patient 5. Per LVN 2, she saw Patient 5 twice a week. LVN 2 stated she was aware that Patient 5 was taking blood pressure medications and required blood pressure monitoring. LVN 2 stated that every time she checked Patient 5s blood pressure during her visits, it was within range. When LVN 2 was asked if checking the patients blood pressure twice a week was considered adequate monitoring, LVN 2 stated, “;No. Its not checked just twice a week but every day, the staff checks every day.” When LVN 2 was asked to provide the range for Patient 5s blood pressure, LVN 2 stated that per facility staff, “;Its good.” LVN 2 stated the facility staff never gave her the numbers for the blood pressure, but instead they told her that it was good. LVN 2 stated she instructed the facility staff to check the patients blood pressure before administering Metoprolol Tartrate and Nifedipine. LVN 2 stated she told the facility staff to write it down. When LVN 2 was asked if she had asked the facility staff to provide her with the documentation of Patient 5s blood pressure, since she asked them to document it, she stated she had never done that. LVN 2 stated she had never seen a blood pressure log or records for Patient 5. LVN 2 stated she had never followed-up with the facility staff to see if they write down the blood pressure as instructed. During a concurrent interview and record review with the Registered Nurse Supervisor (RNS) on 12/20/2024 at 10:45 a.m., the RNS reviewed Patient 5s POC/IDR Review, dated 12/6/2024, and Current Treatment/Medication/DME List. The RNS confirmed that Patient 5 required blood pressure monitoring due to being on blood pressure medications. The RNS acknowledged there was no blood pressure log maintained by the facility or by the HA. The RNS stated that HAs LVN should have followed-up regarding her instruction to the staff during her visits, and the RN should have checked for the blood pressure log during the supervisory visits. The RNS stated documenting the patients blood pressure twice a week during the LVN visits was not adequate monitoring. During a review of the HAs policy and procedure, titled “;The Plan of Care,” revised November 2023, the policy and procedure indicated that a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.”

“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 develop an individualized plan of care that included the frequency of nursing visits for two of fourteen sampled patients (Patient 1 and Patient 2). This failure had resulted in not meeting the patients care needs. a. During a review of Patient 1s “;Personal Information”, the “;Personal Information” indicated a start of care (SOC) date of 4/17/2023 and an end of care date of 8/1/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (a condition which affects the arteries [blood vessels that distribute oxygen-rich blood to your entire body] that supply the heart with blood without a chest pain). During an interview and concurrent record review on 12/20/2024, at 12:40 p.m., with the Director of Patient Care Services Designee (DPCSD) of Patient 1s clinical record, titled “;Current Treatment/Medication/DME (Durable Medical Equipment) List”, order date of 4/17/2023, the “;Current Treatment/Medication/DME List” indicated no physicians order for the frequency of nursing visits. During an interview and concurrent record review on 12/20/2024, at 12:40 p.m., with the DPCSD of Patient 1s clinical record, titled “;Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors)”, dated 4/28/2023, 5/12/2023, 5/26/2023, 6/9/2023 and 6/23/2023, the “;POC/IDG Review indicated no frequency of nursing visits. The DPCSD confirmed that no orders were obtained for the frequency of nursing visits for Patient 1. The DPCSD stated he did not know what happened and why it was missed. The DPCSD stated that it was his mistake and the agencys mistake on why there was no order and why it was not caught. The DPCSD stated that it is important that nursing services and visits were provided to patients to ensure the quality of patients care. b. During a review of Patient 2s “;Personal Information”, the “;Personal Information” indicated a start of care (SOC) date of 4/11/2023 and an end of care date of 6/26/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (a condition which affects the arteries [blood vessels that distribute oxygen-rich blood to your entire body] that supply the heart with blood with unstable chest pain). During an interview and concurrent record review on 12/20/2024, at 12:55 p.m., with the DPCSD of Patient 2s clinical record, titled “;Current Treatment/Medication/DME (Durable Medical Equipment) List”, order date of 4/11/2023, the “;Current Treatment/Medication/DME List” indicated no physicians order for frequency of nursing visits. During an interview and concurrent record review on 12/20/2024, at 12:55 p.m., with the DPCSD of Patient 2s clinical record, titled “;POC/IDG Review”, dated 4/11/2023, 4/14/2023, 4/28/2023, 5/12/2023 and 5/26/2023, the “;POC/IDG Review indicated no frequency of nursing visits. The DPCSD confirmed that no orders were obtained for frequency of nursing visits for Patient 2 and stated he did not know what happened and why it was missed. The DPCSD stated that it was his mistake and the agencys mistake on why there was no order and why it was not caught. The DPCSD stated that it is important that nursing services and visits were provided to patients to ensure the quality of patients care. During a review of the HAs policy and procedure, titled “;The Plan Of Care”, revised November 2023, the policy and procedure indicated that orders for the start of care will be verbally received by the Case Manager (or Hospice Registered Nurse) from the attending physician (or authorized independent practitioner) and documented on the plan of care/physician order form.”

“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 IDG (Interdisciplinary Group, IDG – meeting where the Registered Nurse [RN], Medical Social Worker [MSW], Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) members met to review the IDG/POC for three of fourteen sampled patients (Patient 1, Patient 2, and Patient 5). This deficient practice had the potential to result in patients’ progress or decline will not be coordinated with the members of the IDG to update information on the POC for further intervention and palliation (medical care that relieves symptoms). c. During a review of Patient 5s Personal Information, the Personal Information indicated that Patient 5 was admitted to the HA on 3/28/2024 with a primary diagnosis of senile degeneration of brain (a term for a group of neurological disorders that cause a gradual decline in cognitive abilities; this can include memory loss, difficulty reasoning, and an inability to perform everyday tasks). During a concurrent record review and interview with the Registered Nurse Supervisor (RNS) on 12/20/2024 at 1:10 p.m., the RNS reviewed Patient ss “;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 12/6/2024. The RNS verified the POC/IDG Review was missing the RN, Physician, and Chaplain signatures. There was no documented evidence of coordination of care between the IDG members. When the RNS was asked if there was a separate sign-in sheet for IDG members, the RNS stated the IDG members would only sign online when they attended the IDG meetings, there was no separate sign-in sheet. The RNS stated if the POC/IDG Review was not signed by a particular IDG member, it would mean that IDG member was not present during the meeting to review the patients individualized plan of care. During a review of the HAs policy and procedure, titled “;The Plan of Care,” revised November 2023, the policy and procedure indicated that the plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, but the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. a. During a review of Patient 1s “;Personal Information”, indicated a start of care (SOC) date of 4/17/2023 and an end of care date of 8/1/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood without a chest pain). During a concurrent record review and interview on 12/20/2024 at 12:15 p.m., with the Registered Nurse Supervisor (RNS) of Patient 1 s clinical record titled “;Plan of Care/Interdisciplinary Group Review” (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), indicated the following: - 4/28/2023, no signatures of IDG members (Medical Director (MD), Master of Social Work (MSW), and Spiritual Chaplain (SC). - 5/12/2023, no signatures of IDG members (MD, MSW, SC and Registered Nurse (RN)). - 5/26/2023, no signatures of IDG members (MD, MSW, SC and RN). - 6/9/2023, no signatures of IDG members (MD, MSW, SC and RN). - 6/23/2023, no signatures of IDG members (MD, MSW, SC and RN). - 7/7/2023, no signatures of IDG members (MD, MSW, and SC). - 7/21/2023, no signatures of IDG members (MD, MSW, SC and RN). - 8/1/2023, no signatures of IDG members (MD, MSW, and SC). b. During a review of Patient 2s “;Personal Information”, indicated a start of care (SOC) date of 4/11/2023 and an end of care date of 6/26/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood with unstable chest pain). During a concurrent record review and interview on 12/20/2024 at 12:30 p.m., with the Registered Nurse Supervisor (RNS) of Patient 2 s clinical record titled “;POC/IDG Review”, indicated the following: - 4/11/2023, no signatures of IDG members (MD, MSW, and SC). - 4/14/2023, no signatures of IDG members (MD, MSW, and SC). - 4/28/2023, no signatures of IDG members (MD, MSW, and SC). - 5/12/2023, no signatures of IDG members (MD, MSW, and SC). - 5/26/2023, no signatures of IDG members (MD, MSW, and SC). - 6/9/2023, no signatures of IDG members (MD, MSW, and SC). The RNS confirmed the reviewed POC/IDG Review of Patient 1 and Patient 2 were missing the IDG members signatures. There was no documented evidence of coordination of care between the IDG members. RNS stated that there is no separate sign-in sheet for IDG members during meeting. The RNS stated the IDG members would only sign electronically when they attended the IDG meetings, there was no separate sign-in sheet. The RNS stated if the POC/IDG Review was not signed by a particular IDG member, it would mean that IDG member was not present during the meeting to review the patients individualized plan of care. During a telephone interview on 12/20/2024, at 12:11 p.m., with the MSW, MSW stated she attended the IDG meeting which is every 14 days with the other IDG members consist of the MD, RN, and SC. MSW stated they do not have any sign in sheet, they sign electronically to validate their attendance. MSW stated she does not remember what happened when her signatures were missing on Patient 1 and Patient 2s IDG/POC review. MSW stated she does not remember anymore since the patients were discharged long time ago. During a telephone interview on 12/20/2024, at 12:17 p.m., with the SC, SC stated that he started to work for the HA since the first quarter of this year (2024). SC stated he attends the IDG meeting every 14 days. SC stated he sign his attendance digitally and there is no other sign in sheet to validate the attendance.”

“Based on observation and interview, the Hospice Agency (HA; agency providing care to terminally ill patients who have six months or less to live) failed to follow accepted standards of practice related to prevent the transmission of infections related to the use of nasal cannula (a medical device that provides supplemental oxygen to patients through two prongs that sit inside the nostrils) and humidifier bottle (a sealed bottle of water inserted into a breathing circuit to add moisture to the breathing gases for administration to a patient) for one of fourteen sampled patients (Patient 5). This deficient practice had the potential to expose patient to pathogens that could result in infections. During a review of Patient 5s Personal Information, the Personal Information indicated that Patient 5 was admitted to the HA on 3/28/2024 with a primary diagnosis of senile degeneration of brain (a term for a group of neurological disorders that cause a gradual decline in cognitive abilities; this can include memory loss, difficulty reasoning, and an inability to perform everyday tasks). During a review of Patient 5s Current Treatment/Medication/DME (Durable Medical Equipment, any medical equipment used in the home to aid in a better quality of living) List, the Current Treatment/Medication/DME List indicated that Patient 5 could have oxygen inhalation at 2 liters (a measurement unit) per minute via nasal canula as needed for mild dyspnea (shortness of breath) with respiratory rate of 21-22 count per minute. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 12/18/2024 at 11 a.m., observed an oxygen tank (a large metal cylinder that stores compressed oxygen) and an oxygen concentrator (a medical device that separates nitrogen from the air) in Patient 5s room. Observed a humidifier bottle with clear liquid inside connected to the oxygen concentrator. The humidifier bottle was undated. Also observed a nasal cannula attached to the oxygen concentrator, with part of the nasal cannula, including the prongs that go inside the nostril, lying on the floor. On 12/18/2024, at 11:30 a.m., during an interview with the Medication Technician (MT) at the facility where Patient 5 was residing, the MT stated the facility staff did not handle the humidifier bottle, the hospice nurse did. The MT stated, “;I dont know whats inside the bottle or when it was changed.” During an interview with LVN 1 on 12/18/2024 at 11:35 a.m., LVN 1 stated the humidifier bottle looked dusty. LVN 1 stated, “;The humidifier bottle should have sterile water inside and it should be dated, so we know when it was changed or if it needs to be changed. Its to prevent infection.” LVN 1 stated the nasal cannula was contaminated since it was lying on the floor. LVN 1 stated the facility staff needed to be educated to make sure nasal cannula was not on the floor. Per LVN 1, if the patient used the contaminated nasal cannula, it could cause infection. During an interview with the Registered Nurse Supervisor (RNS) on 12/20/2024 at 12:50 p.m., the RNS stated the facility staff needed to be accountable as well because the patient lived in the facility. The RNS stated the humidifier needed to be washed regularly and the sterile water changed. The RNS stated the nasal cannula should have been disposed when the staff or the nurse noticed that it was on the floor. During a review of the HAs policy and procedure, titled “;Standard Precautions,” revised November 2023, the policy and procedure indicated that humidifiers and air conditioners can harbor infectious organisms, and they should be cleaned and serviced regularly.”

“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 nursing care and services were provided during certification period for two of fourteen sampled patients (Patient 1 and Patient 2). This failure had resulted in not meeting the patients care needs. a. During a review of Patient 1s “;Personal Information”, indicated a start of care (SOC) date of 4/17/2023 and an end of care date of 8/1/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood without a chest pain). During a concurrent record review and interview on 12/20/2024 at 1:45 p.m., with the Director of Patient Care Services Designee (DPCSD) of Patient 1 s electronic medical record titled “;History of Visit Notes”, the DPCSD confirmed and stated that the history of visit notes page was blank and indicated no previous documentations of visit notes. b. During a review of Patient 2s “;Personal Information”, indicated a start of care (SOC) date of 4/11/2023 and an end of care date of 6/26/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood with unstable chest pain). During a concurrent record review and interview on 12/20/2024 at 1:55 p.m., with the Director of Patient Care Services Designee (DPCSD) of Patient 2 s electronic medical record titled “;History of Visit Notes”, the DPCSD confirmed and stated that the history of visit notes page was blank and indicated no previous documentations of visit notes. During an interview on 12/20/2024, at 2:00 p.m., the DPCSD stated that the history of visit notes will show all the previous and most recent nurse visits documentations. DPCSD stated that if there were no visit notes, there was no visit conducted. DPCSD stated he oversees the clinical operation of the HA, however, stated he does not know why Patient 1 and Patient 2s history of visit notes was missing and what happened to it. DPCSD stated that he and the HA admitted their mistake. DPCSD stated the assigned nurse to visit Patient 1 and 2 was no longer working with the HA. DPCSD stated that it is important to have a visit note to validate that a nurse visit was conducted. DPCSD stated that nursing services is important to ensure that patients health condition is improving or not and to provide care and needs of patients while they are on hospice care. DCPSD stated that if nursing services were not provided to patients, there will be a lack of coordination between the healthcare team and patients condition can get worse if not continuously monitored. During a review of the agencys policy entitled “;Hospice Nursing Care” dated November 2023, it indicated the nursing services will be provided in accordance with accepted standards of practice by or under the supervision of a registered nurse, a hospice registered nurse will be assigned as the case manager for each patient and family/caregiver, and his/her duties will be enumerated in a job description, duties will include coordination of care and fostering communication between the patient and the interdisciplinary group.”

“The Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that the Medical Director conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial certifications for three of fourteen sampled patients (Patient 1, Patient 2, and Patient 10) to support the diagnosis of the patients’ terminal illnesses and to qualify for hospice care. The HA failed to ensure there were documentation of clinical information that included patients history and physical, laboratory and imaging data, biopsy [a medical procedure that involves removing a small sample of tissue or fluid from the body for examination] results, et cetera (etc- and other things), necessary for initial certification of hospice care and services. This deficient practice resulted in patients being enrolled in hospice and receiving care without a proper verification of patient eligibility, and had the potential for Patient 1, Patient 2, and Patient 10 not receiving necessary care and healthcare resources to meet their care goals. a. During a review of Patient 1s “;Personal Information”, indicated a start of care (SOC) date of 4/17/2023 and an end of care date of 8/1/2023; with a primary diagnosis of atherosclerosis heart disease (thickening or hardening of the arteries [blood vessels] caused by a buildup of plaque in the inner lining of an artery) of native coronary artery (the blood vessels that supply the heart with oxygen and nutrients. ) without angina pectoris (chest pain) During a review of Patient 1s clinical record titled “;Comprehensive Assessment”, dated 4/17/2023, indicated in the Activities of Daily Living (ADL, activities related to personal care which include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) Assessment the total number of activities with complete dependence (0-6) was two out six, to which Patient 1 was dependent to bathing and transfer. Patient 1’s Comprehensive Assessment indicated that Patient 1 required a cane for movement, has moderate dyspnea (difficulty in breathing) with mild exertion, diminished lung sounds, labored respirations, and pitting edema (characterized by an excess of watery fluid collecting in the cavities or tissues of the body) in bilateral (both) lower extremities (legs). A review of Patient 1s clinical record titled “;Physicians Certification for Hospice Benefit”, with date of certification of 4/17/2023 to 7/15/2023, indicated Patient 1 has increased generalized body weakness, mild to moderate shortness of breath (SOB) with activities and the ability to carry out daily activities prognosis (predication), scores (range from 0 to 100, a higher score means the patient is better able to carry out daily activities). Patient 1s score was determined as 50 percent. During a concurrent record review and interview on 12/20/2024, at 1:30 p.m., with the Director of Patient Care Services Designee (DPCSD), reviewed Patient 1s clinical record titled “;Local Coverage Determination (LCD) Hospice Eligibility Determination” (a determination for hospice eligibility used by national government services used to determine guidelines for terminally ill patients and if they have a life expectancy of six months or less), dated 7/10/2023. Indicated in section for “;New York Heart Association (NYHA) Class 4 (classification of heart failure, with class 4 being the most severe stage of heart failure) was marked as “;Yes” and indicated in section b. Is Ejection fraction less than 20 (if available) marked as “;No”. DPCSD stated he (DPCSD) was unsure why the date of Patient 1s LCD is 7/10/2023. DPCSD stated that Patient 1s LCD should be completed on or before Patient 1s start of care which is 4/17/2023. b. During a review of Patient 2s “;Personal Information”, indicated a start of care (SOC) date of 4/11/2023 and an end of care date of 6/26/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris. During a review of Patient 2s clinical record titled “;Comprehensive Assessment”, dated 4/11/2023, indicated in the Activities of Daily Living Assessment the total number of activities with complete dependence was four out of six, to which Patient 2 was dependent to ambulation, toileting, bathing and transfer. Patient 2’s Comprehensive Assessment indicated that Patient 2 required a cane for movement, has mild dyspnea (difficulty in breathing) with mild exertion, diminished (lesser) lung sounds, labored (struggle) respirations, and pitting edema in bilateral lower extremities. A review of Patient 2s clinical record titled “;Physicians Certification for Hospice Benefit”, with date of certification of 4/11/2023 to 7/9/2023, indicated Patient 2 is confused, has mild SOB on mild exertion and is relieved with rest, mainly on bed rest, with activities and the ability to carry out daily activities prognosis, scores (range from 0 to 100, a higher score means the patient is better able to carry out daily activities). Patient 1s score was determined as 50 percent. A review of Patient 2s “;Local Coverage Determination (LCD) Hospice Eligibility Determination”, dated 7/10/2023, indicated in section for “;New York Heart Association (NYHA Class 4) classification of heart failure, (with class 4 being the most severe stage of heart failure) was marked as “;Yes”. During an interview on 12/17/2024, at 12:01 p.m., with the Patient 1s and Patient 2s Caregiver/Family Member/Stepdaughter (FM1), FM1 stated that her stepfather (Patient 1) cannot sign any consent for himself, stated Patient 1 is illiterate, only went to school up to 3rd or 4th grade, speaks Spanish language only. FM1 stated that her stepfather (Patient 1) did not understand the hospice program and services and the HA or the nurse that admitted them did not explain what hospice program all is about. FM1 stated that the HA put some of her mothers diagnosis to his stepfathers records. FM1 stated they sent medical equipment and medical supplies to her parents home but were not needed. FM1 stated that his stepfather (P1) can still drive short distances, still cooks, does some house chores but forgetful sometimes, stated according to her mother (Patient 2), the HA representative promised her stepfather (Patient 1) and her mother (Patient 2) for free nursing visits, free medications supply and equipment, but were not explained of what hospice is all about and services it can provide. FM1 stated her parents (Patient 1 and Patient 2) has no heart disease and terminal illnesses, stated she brought them to see their primary and specialty doctors regularly. FM1 stated that her parents do some house chores and not bed ridden. FM1 stated that she would know if the HA requested her parents clinical records from their primary doctors as they will notify her because she is the legal representative for both of her parents. During an interview on 12/20/2024 at 1:27 p.m., with the Medical Director (MD), MD stated that HA did not provide patients previous clinical records to him (MD) for review. MD stated that patients previous clinical records were supposed to be in the electronic medical records. MD stated he (MD) signed the Certification of Terminal illness (CTI) and nurses assist him (MD) in the assessments. MD stated he (MD) had not done any LCD and was unfamiliar with LCD. MD stated that the nurses might completed the patients LCD for him. MD stated that he sees patients through in person and video visits with the HA nurse. MD stated his diagnosis for a patient is through subjective symptoms and functional status like their breathing, mild exertion (use of energy) with SOB. MD stated that verifying the patients eligibility, including ensuring that patient had clinical documentation that supported the terminal diagnosis prior to enrolling the patient to hospice was the HAs responsibility, not his. The MD stated that he did not review patients clinical information because it should have been done by the HA. The MD stated he would write his narrative for the “;Physicians Certification for Hospice Benefit” and sign it himself. The MD also stated that if he had had a face-to-face encounter with a patient, he would have documented his assessment and signed it. During an interview on 12/20/2024 at 2:00 p.m., with the DPCSD, the DPCSD stated that Patient 1 and Patient 2 were eligible per LCD Guidelines. DPCSD stated that to be able for a patient to meet the condition of NYHA Class 4, the patient should be unable to carry on physical activity without discomfort and symptoms of shortness of breath or diminished lung sounds must be present even at rest. DCPSD stated that clinical documentations should support the patients terminal diagnosis to accurately formulate an individualized care plan. DPCSD stated that the Medical Director (MD) completes the patients LCD and CTI. MD stated that nurses provided assessments and assistance such as preparing patients previous clinical records for MD. DPCSD was not able to provide the clinical documentation to support Patient 1 and Patient 2s terminal diagnosis as requested by the survey team. c. During a review of patient 10s “;admission record”, the admission record indicated a start of care (SOC) date of 11/4/24 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD- a condition involving constriction of the airways or difficulty/discomfort in breathing). During a review of patient 10s “;plan of care/ IDG Review” dated 11/22/24, the “;plan of care/ IDG Review” indicated the frequency of visits of skilled nursing (SN) is one visit per week, and Registered Nurse visits at 1 per 2 weeks. During a phone interview conducted on 12/20/24 at 1:30pm with MD, MD stated that the LCD for patient 10 was not completed and remained blank. MD stated that he (MD)did not routinely complete an LCD for patients. When asked how does MD check if the patient meets hospice criteria, MD stated that he (MD) does a video call with the nurse doing the initial assessment of the patient in addition to checking the patients history, physical, laboratory test results, and other “;relevant” documents. During a review of the HA policy’s “;Certification of Terminal Illness” and “Professional Services agreement Medical Director” both dated November 2023, the policy indicated each patient who elects 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, physician member of the interdisciplinary team and/or the hospice Medical Director. Hospice services will be provided in two (2) 90-day periods and an unlimited number of 60-day periods if the patient is recertified at the beginning of each benefit period. Tools such as the fiscal intermediary’s Local Coverage Determinations, along with other supporting documentation, can be used to provide guidance in determining and documenting terminal prognosis. LCD is completed in the EMR for each terminal illness. Duties and Responsibilities of Medical Director: (a) Medical Director is responsible for the submission to hospice of documentation of services provided as appropriate. (b) Medical Director will be a participating member of the hospice interdisciplinary group of the organization and participate in the annual evaluation. (c) Medical Director will advise and/or assist in the resolution of concerns/conflicts involving physicians utilizing the services of hospice. (f) Medical Director will review and sign initial hospice certification of terminal illness and recertification as indicated.. (Medical Director will review medical data from the referral source in order to validate the diagnosis and the life limiting prognosis established by the attending physician. (g) Medical Director will review the clinical records and/or performing a medical examination to continue the appropriateness of services. a. During a review of Patient 1s “;Personal Information”, indicated a start of care (SOC) date of 4/17/2023 and an end of care date of 8/1/2023; with a primary diagnosis of atherosclerosis heart disease (thickening or hardening of the arteries [blood vessels] caused by a buildup of plaque in the inner lining of an artery) of native coronary artery (the blood vessels that supply the heart with oxygen and nutrients. ) without angina pectoris (chest pain) During a review of Patient 1s clinical record titled “;Comprehensive Assessment”, dated 4/17/2023, indicated in the Activities of Daily Living (ADL, activities related to personal care which include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) Assessment the total number of activities with complete dependence (0-6) was two out six, to which Patient 1 was dependent to bathing and transfer. Patient 1’s Comprehensive Assessment indicated that Patient 1 required a cane for movement, has moderate dyspnea (difficulty in breathing) with mild exertion, diminished lung sounds, labored respirations, and pitting edema (characterized by an excess of watery fluid collecting in the cavities or tissues of the body) in bilateral (both) lower extremities (legs). A review of Patient 1s clinical record titled “;Physicians Certification for Hospice Benefit”, with date of certification of 4/17/2023 to 7/15/2023, indicated Patient 1 has increased generalized body weakness, mild to moderate shortness of breath (SOB) with activities and the ability to carry out daily activities prognosis (predication), scores (range from 0 to 100, a higher score means the patient is better able to carry out daily activities). Patient 1s score was determined as 50 percent. During a concurrent record review and interview on 12/20/2024, at 1:30 p.m., with the Director of Patient Care Services Designee (DPCSD), reviewed Patient 1s clinical record titled “;Local Coverage Determination (LCD) Hospice Eligibility Determination” (a determination for hospice eligibility used by national government services used to determine guidelines for terminally ill patients and if they have a life expectancy of six months or less), dated 7/10/2023. Indicated in section for “;New York Heart Association (NYHA) Class 4 (classification of heart failure, with class 4 being the most severe stage of heart failure) was marked as “;Yes” and indicated in section b. Is Ejection fraction less than 20 (if available) marked as “;No”. DPCSD stated he (DPCSD) was unsure why the date of Patient 1s LCD is 7/10/2023. DPCSD stated that Patient 1s LCD should be completed on or before Patient 1s start of care which is 4/17/2023. b. During a review of Patient 2s “;Personal Information”, indicated a start of care (SOC) date of 4/11/2023 and an end of care date of 6/26/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris. During a review of Patient 2s clinical record titled “;Comprehensive Assessment”, dated 4/11/2023, indicated in the Activities of Daily Living Assessment the total number of activities with complete dependence was four out of six, to which Patient 2 was dependent to ambulation, toileting, bathing and transfer. Patient 2’s Comprehensive Assessment indicated that Patient 2 required a cane for movement, has mild dyspnea (difficulty in breathing) with mild exertion, diminished (lesser) lung sounds, labored (struggle) respirations, and pitting edema in bilateral lower extremities. A review of Patient 2s clinical record titled “;Physicians Certification for Hospice Benefit”, with date of certification of 4/11/2023 to 7/9/2023, indicated Patient 2 is confused, has mild SOB on mild exertion and is relieved with rest, mainly on bed rest, with activities and the ability to carry out daily activities prognosis, scores (range from 0 to 100, a higher score means the patient is better able to carry out daily activities). Patient 1s score was determined as 50 percent. A review of Patient 2s “;Local Coverage Determination (LCD) Hospice Eligibility Determination”, dated 7/10/2023, indicated in section for “;New York Heart Association (NYHA Class 4) classification of heart failure, (with class 4 being the most severe stage of heart failure) was marked as “;Yes”. During an interview on 12/17/2024, at 12:01 p.m., with the Patient 1s and Patient 2s Caregiver/Family Member/Stepdaughter (FM1), FM1 stated that her stepfather (Patient 1) cannot sign any consent for himself, stated Patient 1 is illiterate, only went to school up to 3rd or 4th grade, speaks Spanish language only. FM1 stated that her stepfather (Patient 1) did not understand the hospice program and services and the HA or the nurse that admitted them did not explain what hospice program all is about. FM1 stated that the HA put some of her mothers diagnosis to his stepfathers records. FM1 stated they sent medical equipment and medical supplies to her parents home but were not needed. FM1 stated that his stepfather (P1) can still drive short distances, still cooks, does some house chores but forgetful sometimes, stated according to her mother (Patient 2), the HA representative promised her stepfather (Patient 1) and her mother (Patient 2) for free nursing visits, free medications supply and equipment, but were not explained of what hospice is all about and services it can provide. FM1 stated her parents (Patient 1 and Patient 2) has no heart disease and terminal illnesses, stated she brought them to see their primary and specialty doctors regularly. FM1 stated that her parents do some house chores and not bed ridden. FM1 stated that she would know if the HA requested her parents clinical records from their primary doctors as they will notify her because she is the legal representative for both of her parents. During an interview on 12/20/2024 at 1:27 p.m., with the Medical Director (MD), MD stated that HA did not provide patients previous clinical records to him (MD) for review. MD stated that patients previous clinical records were supposed to be in the electronic medical records. MD stated he (MD) signed the Certification of Terminal illness (CTI) and nurses assist him (MD) in the assessments. MD stated he (MD) had not done any LCD and was unfamiliar with LCD. MD stated that the nurses might completed the patients LCD for him. MD stated that he sees patients through in person and video visits with the HA nurse. MD stated his diagnosis for a patient is through subjective symptoms and functional status like their breathing, mild exertion (use of energy) with SOB. MD stated that verifying the patients eligibility, including ensuring that patient had clinical documentation that supported the terminal diagnosis prior to enrolling the patient to hospice was the HAs responsibility, not his. The MD stated that he did not review patients clinical information because it should have been done by the HA. The MD stated he would write his narrative for the “;Physicians Certification for Hospice Benefit” and sign it himself. The MD also stated that if he had had a face-to-face encounter with a patient, he would have documented his assessment and signed it. During an interview on 12/20/2024 at 2:00 p.m., with the DPCSD, the DPCSD stated that Patient 1 and Patient 2 were eligible per LCD Guidelines. DPCSD stated that to be able for a patient to meet the condition of NYHA Class 4, the patient should be unable to carry on physical activity without discomfort and symptoms of shortness of breath or diminished lung sounds must be present even at rest. DCPSD stated that clinical documentations should support the patients terminal diagnosis to accurately formulate an individualized care plan. DPCSD stated that the Medical Director (MD) completes the patients LCD and CTI. MD stated that nurses provided assessments and assistance such as preparing patients previous clinical records for MD. DPCSD was not able to provide the clinical documentation to support Patient 1 and Patient 2s terminal diagnosis as requested by the survey team. c. During a review of patient 10s “;admission record”, the admission record indicated a start of care (SOC) date of 11/4/24 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD- a condition involving constriction of the airways or difficulty/discomfort in breathing). During a review of patient 10s “;plan of care/ IDG Review” dated 11/22/24, the “;plan of care/ IDG Review” indicated the frequency of visits of skilled nursing (SN) is one visit per week, and Registered Nurse visits at 1 per 2 weeks. During a phone interview conducted on 12/20/24 at 1:30pm with MD, MD stated that the LCD for patient 10 was not completed and remained blank. MD stated that he (MD)did not routinely complete an LCD for patients. When asked how does MD check if the patient meets hospice criteria, MD stated that he (MD) does a video call with the nurse doing the initial assessment of the patient in addition to checking the patients history, physical, laboratory test results, and other “;relevant” documents. During a review of the HA policy’s “;Certification of Terminal Illness” and “Professional Services agreement Medical Director” both dated November 2023, the policy indicated each patient who elects 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, physician member of the interdisciplinary team and/or the hospice Medical Director. Hospice services will be provided in two (2) 90-day periods and an unlimited number of 60-day periods if the patient is recertified at the beginning of each benefit period. Tools such as the fiscal intermediary’s Local Coverage Determinations, along with other supporting documentation, can be used to provide guidance in determining and documenting terminal prognosis. LCD is completed in the EMR for each terminal illness. Duties and Responsibilities of Medical Director: (a) Medical Director is responsible for the submission to hospice of documentation of services provided as appropriate. (b) Medical Director will be a participating member of the hospice interdisciplinary group of the organization and participate in the annual evaluation. (c) Medical Director will advise and/or assist in the resolution of concerns/conflicts involving physicians utilizing the services of hospice. (f) Medical Director will review and sign initial hospice certification of terminal illness and recertification as indicated.. (Medical Director will review medical data from the referral source in order to validate the diagnosis and the life limiting prognosis established by the attending physician. (g) Medical Director will review the clinical records and/or performing a medical examination to continue the appropriateness of services.”

“The Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the HAs Medical Director oversaw the hospices patient care program for three of fourteen sampled patients (Patient 1, Patient 2, and Patient 10) This deficient practice resulted in Patient 1, Patient 2, and Patient 10 being enrolled to the HA without oversight and had the potential to affect the patients care. c. During a review of patient 10s “;admission record” it indicated a start of care (SOC) date of 11/4/24 with a terminal diagnoses of Chronic Obstructive Pulmonary Disease (COPD) a condition involving constriction of the airways or difficulty/discomfort in breathing. During a review of patient 10s “;plan of care/ IDG Review” dated 11/22/24 it indicated the frequency of visits of skilled nursing (SN) is 1 per week, RN 1 per 2 weeks. During a phone interview conducted on 12/20/24 at 1:30pm with the Medical Director he stated that the LCD for patient 10 was not completed and remained blank. He stated I dont routinely do that. When asked how does he check if the patient is hospice criteria he stated he does a facetime video with the nurse doing the initial assessment of the patient in addition to checking the patients history, physical, labs, and other relevant documents. During a review of the agency policy’s “;Certification of Terminal Illness” and “Professional Services agreement Medical Director” both dated November 2023 indicated each patient who elects 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, physician member of the interdisciplinary team and/or the hospice Medical Director. Hospice services will be provided in two (2) 90-day periods and an unlimited number of 60-day periods if the patient is recertified at the beginning of each benefit period. Tools such as the fiscal intermediary’s Local Coverage Determinations, along with other supporting documentation, can be used to provide guidance in determining anddocumenting terminal prognosis. LCD is completed in the EMR for each terminal illness. Duties and Responsibilities of Medical Director: (a) Medical Director is responsible for the submission to hospice of documentation of services provided as appropriate. (b) Medical Director will be a participating member of the hospice interdisciplinary group of the organization and participate in the annual evaluation. (c) Medical Director will advise and/or assist in the resolution of concerns/conflicts involving physicians utilizing the services of hospice. (f) Medical Director will review and sign initial hospice certification of terminal illness and recertification as indicated.. (Medical Director will review medical data from the referral source in order to validate the diagnosis and the life limiting prognosis established by the attending physician. (g) Medical Director will review the clinical records and/or performing a medical examination to continue the appropriateness of services. a. During a review of Patient 1s “;Personal Information”, indicated a start of care (SOC) date of 4/17/2023 and an end of care date of 8/1/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood without a chest pain). During a review of Patient 1s clinical record titled “;Comprehensive Assessment”, dated 4/17/2023, indicated in the Activities of Daily Living (ADL, activities related to personal care which include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) Assessment the total number of activities with complete dependence (0-6) was 2 out 6, to which Patient 1 was dependent to bathing and transfer. Patient 1’s Comprehensive Assessment indicated that Patient 1 required a cane for movement, has moderate dyspnea (difficulty in breathing) with mild exertion, diminished lung sounds, labored respirations, and pitting edema (characterized by an excess of watery fluid collecting in the cavities or tissues of the body) in bilateral lower extremities. A review of Patient 1s clinical record titled “;Physicians Certification for Hospice Benefit”, with date of certification of 4/17/2023 to 7/15/2023, indicated Patient 1 has increased generalized body weakness, mild to moderate shortness of breath (SOB) with activities and the ability to carry out daily activities prognosis, scores (range from 0 to 100, a higher score means the patient is better able to carry out daily activities). Patient 1s score was determined as 50 percent. During a concurrent record review and interview on 12/20/2024, at 1:30 p.m., with the Director of Patient Care Services Designee (DPCSD) of Patient 1s clinical record titled “;Local Coverage Determination (LCD) Hospice Eligibility Determination” (a determination for hospice eligibility used by national government services used to determine guidelines for terminally ill patients and if they have a life expectancy of six months or less), dated 7/10/2023, indicated in section for “;New York Heart Association (NYHA Class 4) classification of heart failure, (with class 4 being the most severe stage of heart failure) was marked as “;Yes” and indicated in section b. Is Ejection fraction <20 (if available) marked as “;No”. DPCSD stated he was unsure why the date of Patient 1s LCD is 7/10/2023 and it should be completed on or before Patient 1s start of care which is 4/17/2023. b. During a review of Patient 2s “;Personal Information”, indicated a start of care (SOC) date of 4/11/2023 and an end of care date of 6/26/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood with unstable chest pain). During a review of Patient 2s clinical record titled “;Comprehensive Assessment”, dated 4/11/2023, indicated in the Activities of Daily Living (ADL, activities related to personal care which include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) Assessment the total number of activities with complete dependence (0-6) was 4 out 6, to which Patient 2 was dependent to ambulation, toileting, bathing and transfer. Patient 2’s Comprehensive Assessment indicated that Patient 2 required a cane for movement, has mild dyspnea (difficulty in breathing) with mild exertion, diminished lung sounds, labored respirations, and pitting edema (characterized by an excess of watery fluid collecting in the cavities or tissues of the body) in bilateral lower extremities. A review of Patient 2s clinical record titled “;Physicians Certification for Hospice Benefit”, with date of certification of 4/11/2023 to 7/9/2023, indicated Patient 2 is confused, has mild SOB on mild exertion and is relieved with rest, mainly on bed rest, with activities and the ability to carry out daily activities prognosis, scores (range from 0 to 100, a higher score means the patient is better able to carry out daily activities). Patient 1s score was determined as 50 percent. A review of Patient 2s “;Local Coverage Determination (LCD) Hospice Eligibility Determination” (a determination for hospice eligibility used by national government services used to determine guidelines for terminally ill patients and if they have a life expectancy of six months or less), dated 7/10/2023, indicated in section for “;New York Heart Association (NYHA Class 4) classification of heart failure, (with class 4 being the most severe stage of heart failure) was marked as “;Yes”. During an interview on 12/17/2024, at 12:01 p.m., with the Patient 1s and Patient 2s Caregiver/Family Member/Stepdaughter (FM1), FM1 stated that her stepfather (Patient 1) cannot sign any consent for himself, stated Patient 1 is illiterate, only went to school up to 3rd or 4th grade, speaks Spanish language only. FM1 stated that her stepfather (Patient 1) did not understand the hospice program and services and the HA or the nurse that admitted them did not explain what hospice program all is about. FM1 stated that the HA put some of her mothers diagnosis to his stepfathers records. FM1 stated they sent medical equipment and medical supplies to her parents home but were not needed. FM1 stated that his stepfather (P1) can still drive short distances, still cooks, does some house chores but forgetful sometimes, stated according to her mother (Patient 2), the HA representative promised her stepfather (Patient 1) and her mother (Patient 2) for free nursing visits, free medications supply and equipment, but were not explained of what hospice is all about and services it can provide. FM1 stated her parents (Patient 1 and Patient 2) has no heart disease and terminal illnesses, stated she brought them to see their primary and specialty doctors regularly. FM1 stated that her parents do some house chores and not bed ridden. FM1 stated that she would know if the HA requested her parents clinical records from their primary doctors as they will notify her because she is the legal representative for both of her parents. During an interview on 12/20/2024 at 1:27 p.m., with the MD, MD stated that HA did not provide patients previous clinical records to him for review. MD stated that patients previous clinical records supposed to be in the electronic medical records. MD stated he signed the CTI and nurses assist him in assessments. MD stated he had not done any LCD and unfamiliar with it. MD stated that the nurses might completed the patients LCD for him. MD stated that he sees patients through in person and video visit with the HA nurse. MD stated his diagnosis for a patient is through subjective symptoms and functional status like their breathing, mild exertion with SOB. MD stated that verifying the patients eligibility, including ensuring that patient had clinical documentation that supported the terminal diagnosis prior to enrolling the patient to hospice was the HAs responsibility, not his. The MD stated that he did not review patients clinical information because it should have been done by the HA. The MD stated he would write his narrative for the “;Physicians Certification for Hospice Benefit” and sign it himself. The MD also stated that if he had had a face-to-face encounter with a patient, he would have documented his assessment and signed it. MD stated that he conducted a face-to-face visit with the patients to determine their hospice eligibility, the agency provided him the copies of patients History & Physical and medical records to review hospice eligibility, the registered nurses also help him for patients assessment. MD stated that he certifies the patients base on the nurses assessments, medical records, and H&P.” During an interview on 12/20/2024 at 2:00 p.m., with the DPCSD, the DPCSD stated that Patient 1 and Patient 2 were eligible per LCD Guidelines. DPCSD stated that to be able for a patient to meet the condition of NYHA Class 4, the patient should be unable to carry on physical activity without discomfort and symptoms of shortness of breath or diminished lung sounds must be present even at rest. DPCSD stated that they could not find it and we may not have it. DCPSD stated that clinical documentations should support the patients terminal diagnosis to accurately formulate an individualized care plan. DPCSD stated that the Medical Director (MD) completes the patients LCD and CTI. MD stated that nurses provided assessments and assistance such as preparing patients previous clinical records for MD. DPCSD was not able to provide the clinical documentation to support Patient 1 and Patient 2s terminal diagnosis as requested by the survey team.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to complete clinical notes that included nursing visit notes and weight log records for five of fourteen sampled patients (Patient 1, Patient 2, Patient 5, Patient 6, and Patient 7). This deficient practice resulted in Patient 1, Patient 2, Patient 5, Patient 6, and Patient 7 did not have completed clinical records that could potentially not identify a change in patients conditions and affect the care and services received by the patients. c. During a review of Patient 5s Personal Information, the Personal Information indicated that Patient 5 was admitted to the HA on 3/28/2024 with a primary diagnosis of senile degeneration of brain (a term for a group of neurological disorders that cause a gradual decline in cognitive abilities; this can include memory loss, difficulty reasoning, and an inability to perform everyday tasks). During a review of Patient 5s Comprehensive Nursing Assessment, dated 3/28/2024, the Comprehensive Nursing Assessment indicated Patient 5 weighted 140 pounds and had a body mass index (BMI, a tool that healthcare providers use to estimate the amount of body fat by using height and weight measurements; it can help assess risk factors for certain health conditions) of 25.6. According to the Centers for Disease Control and Prevention (CDC, the national public health agency in the U.S.), an adult with a BMI of 25 to less than 30 is considered overweight (https://www.cdc.gov/bmi/adult-calculator/bmi-categories.html). The Comprehensive Nursing Assessment indicated that Patient 5 had had a weight loss of more than ten percent in six months. The narrative section of the Comprehensive Nursing Assessment did not specify what Patient 5s weight was six months prior to admission or how many pounds Patient 5 had lost in six months prior to admission to the HA. d. During a review of Patient 6s Personal Information, the Personal Information indicated that Patient 6 was admitted to the HA on 12/11/2024 with a primary diagnosis of hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure) with heart failure (a chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 6s Comprehensive Nursing Assessment, dated 12/11/2024, the Comprehensive Nursing Assessment did not indicate Patient 6s weight and BMI upon admission. The Comprehensive Nursing Assessment indicated that Patient 6 had had a weight loss of more than ten percent in six months. The narrative section of the Comprehensive Nursing Assessment did not specify what Patient 6s weight was six months prior to admission or how many pounds Patient 6 had lost in six months prior to admission to the HA. e. During a review of Patient 7s Personal Information, the Personal Information indicated that Patient 7 was admitted to the HA on 4/25/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (a chronic condition that occurs when plaque builds up in the coronary arteries, narrowing them and limiting blood flow to the heart). During a review of Patient 7s Comprehensive Nursing Assessment, dated 4/25/2024, the Comprehensive Nursing Assessment indicated Patient 7 weighted 150 pounds and had a BMI of 22.1. According to CDC, an adult with a BMI of 18.5 to less than 25 is considered as having a healthy weight (https://www.cdc.gov/bmi/adult-calculator/bmi-categories.html). The Comprehensive Nursing Assessment indicated that Patient 7 had had a weight loss of more than ten percent in six months. The narrative section of the Comprehensive Nursing Assessment did not specify what Patient 7s weight was six months prior to admission or how many pounds Patient 7 had lost in six months prior to admission to the HA. During a concurrent record review and interview with the Registered Nurse Supervisor (RNS) on 12/20/2024 at 11:25 a.m., the RNS reviewed the Comprehensive Nursing Assessment for Patient 5, Patient 6, and Patient 7. The RNS verified there was no weight loss amount documented and no patients weight six month prior to admission was documented for the three patients. The RNS also reviewed the electronic health record for Patient 5, Patient 6, and Patient 7. The RNS stated there was also no documentation in the electronic health record regarding how many pounds of weight Patient 5, Patient 6, and Patient 7 had lost in the past 6 months prior to hospice admission, or how much the three patients weighed 6 months before hospice admission. The RNS stated that to be able to determine that Patient 5, Patient 6, and Patient 7 had loss more than ten percent of body weight in six months, there had to be a baseline weight. The RNS stated there was no documentation to support the over ten percent weight loss in six months. During a review of the HAs policy and procedure, titled “;Contents of the Clinical Record,” revised November 2023, the policy and procedure indicated the clinical record will contain sufficient information to identify the patient, describe patient problems/needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. a. During a review of Patient 1s Personal Information, the Personal Information indicated a start of care (SOC) date of 4/17/2023 and an end of care date of 8/1/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood without a chest pain). During a concurrent record review and interview on 12/20/2024, at 1:45 p.m., with the Director of Patient Care Services Designee (DPCSD) of Patient 1s electronic medical record titled “;History of Visit Notes”, the DPCSD stated that the history of visit notes page was blank and indicated no previous documentations of visit notes. b. During a review of Patient 2s Personal Information, the Personal indicated a start of care (SOC) date of 4/11/2023 and an end of care date of 6/26/2023, with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (is a condition which affects the arteries (blood vessels that distribute oxygen-rich blood to your entire body) that supply the heart with blood with unstable chest pain). During a concurrent record review and interview on 12/20/2024, at 1:55 p.m., with the Director of Patient Care Services Designee (DPCSD) of Patient 2 s electronic medical record titled “;History of Visit Notes”, the DPCSD stated that the history of visit notes page was blank and indicated no previous documentations of visit notes. During an interview on 12/20/2024, at 2:00 p.m., the DPCSD stated that the history of visit notes will show all the previous and most recent nurse visits documentations. The DPCSD stated that if there were no visit notes, there was no visit conducted. The DPCSD stated he oversaw the clinical operation of the HA and stated he did not know why Patient 1 and Patient 2s history of visit notes was missing and what happened to it. The DPCSD stated that he and the HA admitted their mistake. The DPCSD stated the assigned nurse to visit Patient 1 and 2 was no longer working with the HA. The DPCSD stated that it is important to have a visit note in order to validate that a nurse visit was conducted.”

“Based on interview and record review, the agency failed to ensure that the nurse visits notes for three of fourteen sampled patients (Patient 10, Patient 11, and Patient 12) were signed by the visiting nurse. This deficient practice had the potential to result in patients’ progress or decline will not be documented accurately to ensure that the care and services were provided in accordance with the plan of care. a. During a review of Patient 10s “;Admission record”, the “;Admission record” indicated a start of care (SOC) date of 11/4/24 with a terminal diagnoses of Chronic Obstructive Pulmonary Disease (COPD, a condition involving constriction of the airways or difficulty/discomfort in breathing). During a review of Patient 10s “;Plan of Care/ IDG Review”, dated 11/22/24, the “;Plan of Care/ IDG Review” indicated the frequency of visits of the skilled nursing (SN) is once per week, for the Registered Nurse (RN) once per two weeks. During an interview on 12/20/2024 at 9:55 am with Director of Patient Care Services Designee (DPCSD), the DPSCD stated that home visits were not signed by the visiting nurse for Patient 10 on the following dates: 11/6/2024 and 11/11/2024. b. During a review of Patient 11s “;Admission record”, the “;Admission record” indicated an SOC date of 4/30/2024 with a terminal diagnoses of heart disease (variety of issues that can affect the heart). During a review of Patient 11s “;Plan of Care/IDG review” dated 12/6/2024, the “;Plan of Care/IDG review” indicated the frequency of visits of the skilled nurses (SN) is once per week, for the RN once per two weeks, and for the Spiritual counselor once a month. During an interview on 12/20/2024 at 9:55 am with the DPCSD, the DPCSD stated that home visits were not signed by the visiting nurse for Patient 11 on the following dates: 11/5/2024, 11/19/2024, 12/3/2024, and 12/17/2024. During an interview on 12/20/2024 at 12:40 pm with Licensed Vocational Nurse (LVN3), the LVN 3 stated she completed all the scheduled visits for Patient 11, however, may not have signed a few of the visit notes. The LVN 3 stated that its important to sign all the documentation regarding patient visits to ensure the visits were made by her and all work was completed by her. c. During a review of Patient 12s “;Admission Record”, the “;Admission Record” indicated an SOC date of 3/6/2024 with a terminal diagnosis of chronic combined systolic and diastolic heart failure (left side of the heart becomes to weak to squeeze normal amount of blood out of the heart when it pumps). During a review of Patient 12s “Plan of Care/ IDG review” dated 12/6/2024, the “Plan of Care/ IDG review” indicated the frequency of visits of the skilled nurses (SN) once per week, for RN once per two weeks, for the Spiritual Counselor once every certification period, and for the MSW once every certification period. During an interview on 12/20/2024 at 9:55 am with DPCSD, the DPCSD stated that home visits were not signed by the visiting nurse for Patient 12 on the following dates: 10/1/2024, 10/15/2024, and 10/29/2024. During an interview on 12/20/2024 at 12:20 pm with LVN 4, the LVN 4 stated that some signatures for home visits made for Patient 12 were missing. The LVN 4 stated that these signatures are important because it signifies that visits were made by her and all orders by the MD were followed. During a review of the agency’s policy and procedure titled “;Entries Into The Clinical Record”, dated November 2023, the policy and procedure indicated the documentation in the clinical record will be timely, detailed, accurate, and reflect the care and services were provided. The policy and procedure indicated, the clinical note will include the signature of clinician and his/her credentials.”