Crest Home Health and Hospice, LLC

“Based on ALF medical record review, hospice medical record review, and staff interview, it was determined the agency failed to ensure the plan of care contained current and accurate medications the patient was taking for 1 of 3 patients (Patient #4) whose care in the home was observed and whose records were reviewed. Failure to ensure the plan of care contained all current and accurate medications caused potential for duplicate drug therapy and medication side effects. Findings include: Patient #4 was an 83 year old female admitted to the agency on 7/03/24 with a terminal diagnosis of senile degeneration of the brain. Additional diagnoses included dementia and anxiety. She received SN, volunteer, social work, chaplain, and aide services. Her record for the certification period 12/30/24 to 2/27/25 was reviewed. A visit to Patient #4 at her residence, an ALF, was conducted with the chaplain on 2/04/25 beginning at 2:15 PM. When the visit was complete, a medication list was obtained from ALF staff. Patient #4s ALF medication list was compared with her hospice medication list and the following discrepancies were identified: - - Ondansetron 4 mg tablet every 4 hours as needed was on the ALF medication list but not the hospice medication list - - Acetaminophen 650 mg suppository and 500 mg tablet every 4 hours as needed was on the hospice medication list but not the ALF medication list - - Euthrox 100 mcg daily and levothyroxine 100 mcg daily were both on the hospice medication list. Euthrox is the brand name for levothyroxine. The medications were duplicates. - - Memantine 10 mg tablet twice daily was listed on the medication list 3 times. All 3 were listed as active medications. The DCS was interviewed on 2/05/25 beginning at 2:10 PM and Patient #4s medication lists were reviewed with her. She confirmed the hospice and ALF medication lists did not match. She confirmed the levothyroxine and memantine were duplicates. The agency failed to ensure the plan of care contained accurate medication lists.”

“Based on review of Quality Assessment Performance Improvement records and staff interview, it was determined the hospice failed to implement and maintain documentation of performance improvement projects currently being conducted, goals for the selected performance improvement projects, and any measurable progress achieved on these projects. This prevented the agency from examining its patient care processes and had the potential to affect all patients who were currently receiving hospice services. The Agencys quality assurance and performance improvement plan was reviewed. It included under the objectives section: “;To collect and analyze data to improve identified processes and outcomes of care.” Additionally, under the section titled “;Data Collection,” it included. “;Data collection will be ongoing, and frequency will be determined by the process improvement activity and approved by the Governing body. Data collected will be used to monitor the effectiveness and safety of services and the quality of care.” Thes processes were not followed, examples included The Agencys quality program and performance improvement projects were reviewed. The listed problem of the agencys performance improvement project was “;5 falls 3rd quarter.” In the section titled “;Interventions to correct the problem:” included, “;Root cause Analysis.” The performance improvement project included that there were 2 falls in 11/2024 and 3 falls in 12/24. The performance improvement project did not include a goal for the problem identified, an overall analysis of data collected, and did not include the root cause analysis of the falls identified. The Agency Administrator was interviewed on 2/05/24 beginning at 2:15 PM and the performance improvement project was reviewed in his presence. When asked for a documented analysis of the data collected, he was able to verbalize the investigation into the falls but confirmed he did not have documentation of his investigations and analysis. He stated there was no specific documented goal for the performance improvement project. The agency failed to ensure PIP’s included data analysis, goals, and measurable improvements were documented. mm”

“Based on review of organizational charts, review of physician contracts, and staff interview, it was determined the hospice failed to designate a single hospice physician to serve as Medical Director of the agency. This had the potential to result in a lack of clear lines of authority, a lack of accountability, and a lack of sufficient oversight and supervision of patient care. Findings include: The Medical Director and additional physician contracts were requested. The agency provided an “Associate Medical Director Agreement” contract. The contract identified 2 physicians (Physician #1 and Physician #2) as the agencys associate medical directors. The Agencys organizational chart included Physician #2 as the agencys medical director. The organizational chart did not list Physician #1. Additionally, a document titled “;Associate Medical Director Agreement,” which outlines and defines the qualifications, responsibilities, compensation, billing, termination, etc., listed only Physician #1. The Agencys administrator was interviewed on 2/5/25 at 9:45 AM and the Physician contracts were reviewed in his presence. He confirmed that Physician #1 and Physician #2 were listed as associate medical directors on the contract and amendment. The amendment did not clearly define that there was to be a change in medical directors. It was unclear through contract review which physician was the agencys medical director. The Agency administrator stated that Physician #2 was the medical director and Physician 1 no longer had a role at the agency. Additionally, a document titled “;Associate Medical Director Agreement,” which outlines and defines the qualifications, responsibilities, compensation, billing, termination, etc., listed only Physician #1. The agency failed to ensure physician contracts clearly identified Physician #2 as the agencys Medical Director. lkj”

“Based on Medicare Benefit Policy Manual review, medical record review, and staff interview, it was determined the medical director failed to ensure hospice patients had a terminal illness for 1 of 2 patients (Patient #1) who were live discharges and whose records were reviewed. Failure to ensure hospice patients who did not have a terminal illness were promptly discharged caused improper level of service to be provided to the patient. Additionally, it created the potential for improper billing of hospice level services. Findings include: According to the Medicare Benefit Policy Manual chapter 9, “Hospice care is a benefit under the hospital insurance program. To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill.” Patient #1 was a 91 year old male admitted to hospice services on 8/30/24 with an initial terminal diagnosis of unspecified protein calorie malnutrition. Additional diagnoses included pneumonitis and hemiplegia. He received SN, volunteer, social work, chaplain, and aide services. His record for the certification period 10/29/24 to 12/27/24 was reviewed. Patient #1 was discharged off hospice services on 12/27/24 because he was no longer terminally ill. Patient #1s medical record included an SN note dated 11/26/24 which stated, “;Discussed that patient will most likely graduate off of hospice at the end of this recertification. Plan for patient to Discharge off of hospice services at end of certification, pending any changes in health, patient will continue on home health services for catheter management after discharge.” Patient #1s medical record included an SN note dated 12/07/24 which stated, “;Plan for discharge at end of certification.” Patient #1s medical record included an SN note dated 12/13/24 which stated, “;planning for discharge at end of cert [certification] period.” Patient #1s IDG meeting notes were reviewed. The IDG meeting on 12/02/24 included the nursing documentation from 11/26/24 which stated Patient #1 would most likely discharge off hospice services. The IDG meeting was signed off by the Medical Director. The IDG meeting on 12/16/24 included the nursing documentation from 11/26/24 which stated Patient #1 would most likely discharge off hospice services. It also included the nursing documentation from 12/07/24 and 12/13/24 which stated the agency planned to discharge Patient #1 at the end of the certification period. The IDG note was signed off by the nurse practitioner. It was unclear why the agency waited until the end of the certification period to discharge Patient #1 who was no longer terminally ill, when it was initially noted by the nurse on 11/26/24, a month prior to being discharged. The administrator was interviewed on 2/05/25 beginning at 12:49 PM and Patient #1s record was reviewed with him. He stated there was confusion regarding Patient #1s face to face assessment, but he should have been discharged within 2 weeks of the nurse noting he was no longer terminally ill. The medical director failed to ensure Patient #1 had a terminal diagnosis.”