Hope Hospice Care Inc.

“Upon patient record review, 1 of 14 (Patient #3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #3 Wound care being provided by contracted agency, no evidence in POC of this being addressed to identify pt/family goals and interventions based on comprehensive assessments and documentation from The Wound Pros.”

“Based on observation, interview, record review and document review, the agency failed to maintain compliance with conditions of participation regarding a patient’s capacity to provide informed consent for hospice care without appropriate support, and for not administering a cardiac medication for chest pain as prescribed. Findings include: During the onsite survey on 01/28/2025 through 01/31/2025, the agency failed to ensure patients rights were honored by the following: A patient with impaired decision-making ability related to mental disability, signed a consent for hospice services and election for hospice care (L507). A patient having chest pain did not receive prescribed medication to treat the condition (L512). The cumulative effect of these systemic practices resulted in the failure of the agency to ensure statutorily mandated care to honor the patients rights to receive adequate health care.”

“Based on interview and document review, the agency failed to maintain condition level compliance with the quality assessment and performance improvement (QAPI) program. Findings include: During the onsite survey on 01/28/2025 through 01/31/2025, the agency failed to ensure its QAPI program demonstrated the following: - The data collection for its QAPI program was not limited to the data collected during patient assessments (L563). - The agency conducted and documented any performance improvement projects, reasons for conducting these projects, and the measurable progress achieved on these projects (L573). - The Governing Body (Chief Executive Officer) ) actively participated in ensuring an ongoing QAPI program was implemented and maintained (L574). The cumulative effect of these systemic practices resulted in the failure of the agency to ensure statutorily mandated care to its patients and a failure to monitor and improve its care to the patients receiving services.”

“Based on observation, record review, interview and document review, the agency failed to maintain condition level compliance with the condition of participation by admitting patients for hospice care with false diagnoses, and not completing face-to-face physician notes. Findings include: On 01/28/2025 through 01/31/2025, the agency failed to ensure the Medical Director accurately evaluated and admitted hospice patients following standards of practice as follows: False medical diagnoses were used to guarantee the admission of patients to hospice care for two of 14 sampled patients and physicians face-to-face visit notes were not completed (L667). Incomplete physicians face-to-face visit notes (P7,P8). Patients were admitted with appropriate hospice diagnosis for terminal illness The cumulative effect of these systemic practices resulted in the failure of the agency to ensure statutorily mandated care to its patients by inappropriately admitting patients to hospice care and inaccurately completing face-to-face visits notes.”

“Based on interview, record review and document review, the agency failed to maintain compliance with conditions of participation for complete and accurate clinical records regarding skilled visits and conformance with the physicians orders and plans of care. Findings include: Review of clinical records and interview revealed the agency failed to ensure the clinical record contained the comprehensive assessment for a patients current recertification period (L672); failed to ensure the clinical record contained the physicians order for the wound care treatment (L678); failed to ensure the clinical notes and visit notes were complete, accurate, and were appropriately authenticated and dated (G679); and failed to ensure the clinical record and discharge documents were forwarded to a receiving facility in a timely manner (L682). The cumulative effect of these systemic practices resulted in the failure of the agency to ensure statutorily mandated care to its patients and failure to maintain correct clinical information.”

“Based on observation, record review, interview, and document review, the facility failed to ensure a patient with impaired decision making related to mental disability did not sign a consent for hospice services and election for hospice care for 1 of 14 sampled patients (Patient 2). The deficient practice had the potential to deprive the patient for the right to seek curative medical care to treat medical conditions. Findings include: Patient 2 (P2) P2 was admitted on 01/09/2025 with unspecified heart disease as the primary hospice diagnoses. History and physical examination performed in a hospital prior to be admitted to hospice care dated 12/29/2024, documented P2 diagnoses included schizophrenia and mental disability. An initial comprehensive nursing assessment dated 01/09/2025, documented P2 was alert, awake, oriented in person and time, with slurred speech to less than six intelligible words. The initial comprehensive assessment revealed P2 was unable to understand and participate in own care. The medical record revealed P2 signed the admission consent dated 01/09/2025 and cosigned by a Registered Nurse, that included patient rights and responsibilities, consent for treatment, release of information, authorization for payments/election for hospice care, and consent to film or record. The documented revealed P2 had not initiated a living will or a durable power of attorney for health care decisions. On 01/28/2025 at 1:30 PM, a home visit was conducted at the group home where P2 resided. P2 was alert with imprecise articulation of words, slow and slurred speech, and difficult to understand. A hospice Registered Nurse assessed the patient and asked yes or no questions that were unintelligibly answered. The RN confirmed had been the admission nurse for P2 and the questions asked during the initial assessment were made with a P2s family member on the phone since the patient was unable to make decisions. The RN was not sure if the family member had a power of attorney over P2 to make decisions related to healthcare. The review of P2s medical record lacked documented evidence P2 had designated a person to act as a power of attorney to make decisions related to healthcare for hospice or life-sustaining treatment. On 01/29/2025 at 2:30 PM, a phone interview was conducted with P2’s family member listed in the medical record as emergency contact. The family member indicated P2 was not able to sign documents due to the mental disability condition. The family member denied having a power of attorney rights to consent for hospice care or signed consent for primary care giver. The family member was not aware the services provided by the facility were end of life care since the philosophy of hospice care was not explained. On 01/30/2025 at 1:30 PM, the Director of Patient Care Services (DPCS) explained the patients were admitted based on the assessment performed by the admitting nurse. The diagnosis for hospice were based on the documentation reviewed by the admitting nurse, past medical history and referral. DPCS indicated the nurse would notify the hospice physician who would review the information and certify the patient for hospice care. DPCS acknowledged P2 should not have signed the consent for treatment due to cognitive impairment and should have had a designated legal representative to exercise a durable power of attorney for decision-making process related to health care. On 01/31/2025 at 5:00 PM, the Medical Director who also was P2s attending hospice physician, confirmed a physicians face to face assessment that generally was performed by a hospice nurse practitioner, had not been completed and the criteria for admission used for the certification of terminal illness was based on the information collected by the RN during the initial assessment, including information of P2s mental status. The facility policy titled Provision of Care and Record Management dated November 2020, documented the patient must desire hospice services and be aware of the diagnosis and prognosis to be admitted.”

“Based on record review, interview, and document review, the facility failed ensure a patient having chest pain received prescribed medication to treat the condition, for 1 of 14 sampled patients (Patient 2). The deficient practice had the potential to place the patient at risk for complications related including a cardiac attack. Findings include: Patient 2 (P2) P2 was admitted on 01/09/2025 with unspecified heart disease as the primary hospice diagnoses. A physician order for life-sustaining treatment dated 01/09/2025, documented P2 would receive full treatment to prolong life by all medically effective means including transferring to a hospital and advanced life support. A physicians order dated 01/09/2025, indicated nitroglycerin (drug used primarily to provide relief from anginal chest pain) 0.4 milligrams (mg) buccal (under the tongue) every 5 minutes for three doses for chest pain. A nursing visit note dated 01/10/2025, revealed P2 had been having episodes of chest pain even at rest. A nursing visit note dated 01/13/2025, 01/20/2025, and 01/27/2025, documented P2 was complaining of chest pain with a pain level of 4-6 in the scale 1 to 10. The nursing visit note lacked documented evidence the prescribed nitroglycerine was administered by the nurse as ordered. The medication administration record (MAR) for the month of January 2025, revealed the medication nitroglycerin for chest pain had not been administered as per physicians order. On 01/31/2025 at 10:08 AM, P2s attending Registered Nurse (RN) explained in the event a patient who was a full code (full cardiopulmonary resuscitation) presented signs and symptoms of cardiac attack, the care giver would call 911 and simultaneously the attending hospice physician and the hospice nurse. If the nurse was assessing a patient who complained of cardiac symptoms such as chest pain, a medication like nitroglycerine would be administered as ordered and the physician would be notified. The RN confirmed P2 complained of chest pain on the above-mentioned dates while the RN was visiting but the medication nitroglycerin was not administered, and the physician was not notified since the chest pain was P2s baseline pain. After reviewing the previous nursing visits notes, the RN could not define the baseline chest pain since the medical record lacked documented evidence of previous episodes of chest pain. The RN acknowledged that by not administering the prescribed nitroglycerine for chest pain, P2 was placed at risk for complications related to cardiac attack. The facility policy titled Patient Bill of Rights dated November 2020, documented the patients had the right to receive effective pain and symptom management for conditions related to the terminal illness.”

“Based on observation, interview, record review and document review, the agency failed to ensure the comprehensive assessment included an accurate and complete patient medication record for 1 of 14 sampled patients (Patient 1). The deficient practice had the potential for failing to provide an effective medication management for the patient. Findings include: Patient 1 (P1) P1 was admitted on 01/08/2025, with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, generalized anxiety disorder, and insomnia. The Plan of Care (POC)/Interdisciplinary Group (IDG) Review of P1s comprehensive assessment dated 01/22/2025, documented the following medications for the patient and the dates the medications were ordered: - 01/11/2025 Docusate Sodium 250 milligram (mg) one capsule by mouth daily - 01/11/2025 Suprax 400 mg one tablet by mouth once a day for seven days. Start date was 01/11/2025. - 01/08/2025 Albuterol Sulfate HFA 90 microgram (mcg)/actuation Inhalation Aerosol two puffs twice daily - 01/08/2025 Atorvastatin Calcium 20 mg one tablet by mouth daily - 01/08/2025 Bupropion Hydrochloride 100 mg Extended-Release one tablet by mouth daily - 01/08/2025 Buspirone Hydrochloride 15 take one-half tablet (7.5 mg) by mouth twice daily - 01/08/2025 Escitalopram 20 mg one tablet by mouth daily - 01/08/2025 Melatonin 5 mg one tablet by mouth daily at bedtime - 01/08/2025 Quetiapine Fumarate 50 mg one tablet by mouth daily at bedtime - 01/08/2025 Stimulant Laxative Plus Stool Softener 50 mg-8.6 mg one tablet by mouth twice daily - 01/08/2025 Tramadol Hydrochloride 100 mg Extended-Release one tablet daily as needed every six hours The same medications were listed in the POC Summary as of 01/28/2025 and the Current Treatment / Medication / DME (durable medical equipment) List (Patient Medication Profile) the agency had provided prior to the home visit with P1. On 01/28/2025 at 1:30 PM, during a home visit with P1, a reconciliation of the patients home medications with the Patient Medication Profile was conducted with P1s caregiver. P1 was residing in a group home. The caregiver provided P1s Medication Administration Record (MAR) for January 2025 maintained at the group home which documented the patients list of medications and record of administration. The following were the discrepancies identified during the medication reconciliation: - Vitamin D3 1,000 units were included in the medication supply. The MAR documented Vitamin D3 5,000 units one capsule daily was administered to the patient daily. The medication was not included in the Patient Medication Profile and POC Summary maintained at the agency. - Albuterol Sulfate Inhalation Aerosol HFA inhale two puffs by mouth every six hours as needed for shortness of breath was documented in the MAR. The medication was not included in the patients medication supply or home medications. There was no documentation in the MAR the patient had received the medication. The agencys Patient Medication Profile and POC Summary documented the medication was ordered to be given twice daily. - Tramadol 50 mg two tablets as needed every six hours for pain were included in the medication supply. The medication was not included in the MAR. - Trazodone 50 mg one tablet by mouth at bedtime was included in the MAR and documented as administered daily. The medication was not included in the Patient Medication Profile and POC Summary maintained at the agency. - There were PRN medications listed in the MAR such as Loperamide 2 mg, Hydrocodone APAP 5-325 mg, Naproxen 250 mg, Acetaminophen 500 mg, Hydroxyzine HCL 25 mg, Cyclobenzaprine 5 mg, Diclofenac Gel 1%, Ammonium Lactate 12%, and Nystatin Powder. The medications were not included in the Patient Medication Profile and POC Summary maintained at the agency. P1s caregiver confirmed the findings and explained the group home was not provided with a hospice binder which included the Patient Medication Profile and POC Summary. The caregiver revealed the agencys registered nurse (RN) had not reconciled P1s home medications and MAR with the Patient Medication Profile and POC Summary maintained at the agency. On 01/28/2025 at 2:18 PM, an RN indicated checking a patients medications every home visit to determine which medications needed a refill. The RN acknowledged not checking the MAR maintained at the group home and reconciling the medications. On 01/31/2025 at 11:47 AM, the Director of Patient Care Services (DPCS) revealed the nurses were expected to reconcile the medications with the patient/caregiver every visit. The DPCS explained sometimes the patients would go to a clinic or their primary care physician and new medications would be ordered. The Patient Medication Profile and POC Summary maintained at the agency should have been updated and reconciled with the patients medication supply or home medications, and the MAR maintained at the group home. The agencys policy titled Medication Profile dated November 2020, documented the medication profile would be updated for each change to reflect current medications, and new and/or discontinued medications. A drug regimen review would be performed by a registered nurse at the time of initial and comprehensive assessment, when updates to the comprehensive assessments were performed, when care was resumed after a patient had been placed on hold, and with the addition of a new medication. During subsequent home visits, the medication profile would be used as a care planning and teaching guide to ensure the patient and family/caregiver, as well as other clinicians, understood the medication regimen.”

“Based on interview, record review and document review, the agency failed to ensure the comprehensive assessment was updated to reflect the current and accurate wound care treatment for 1 of 14 sampled patients (P7). The deficient practice had the potential for failure to make accurate care planning decisions and inadequate monitoring of the patients wound progression or healing. Findings include: Patient 7 (P7) P7 was admitted on 07/18/2024, with a diagnosis of displaced intertrochanteric fracture of right femur. The physicians order dated 07/18/2024, documented the following: - Adhesive foam dressing with gentle border 6x6 inches every visit - Medi honey gel wound dressing every visit. The site of the wound was not documented in the physicians order. P7 was recertified for the period 10/16/2024 through 01/13/2025, and from 01/14/2025 through 03/14/2025. The Communication Note dated 10/17/2024, documented the wound care specialist discontinued wound care treatment. The agencys RN would continue to do wound care treatment and management for the patient. The Narrative section of the RN Visit Notes dated 10/22/2024, 10/28/2024, 11/07/2024, 11/13/2024, 11/19/2024, 11/27/2024, 12/04/2024, 12/11/2024, 12/16/2024, 12/24/2024, 12/30/2024, 01/06/2025, 01/11/2025, 01/16/2025, 01/21/2025, and 01/29/2025, documented a stage 2 decubitus on lower back, treated with antibiotic cream and foam dressing, will have wound care specialist consulted. P7s POC (Plan of Care) Summary as of 01/29/2025, documented a stage 2 decubitus on lower back, treated with antibiotic cream and foam dressing, will have wound care specialist consulted. P7s medical record lacked documented evidence a physicians order was obtained for the antibiotic cream and a wound care specialist was consulted per the documentation in the above-mentioned RN Visit Notes and POC Summary. On 01/31/2025 at 3:24 PM, the Director of Patient Care Services (DPCS) confirmed the findings and indicated the nurses should have followed the physicians order dated 07/18/2024 for P7s wound care treatment. The DPCS explained the wound care specialist had discontinued the wound care treatment per the Communication Note dated 10/17/2024, and the agencys RN would continue to do the wound care treatment and management for the patient. The DPCS acknowledged the documentation in the RN Visit Notes and POC Summary as of 01/29/2025, regarding the use of the antibiotic cream in P7s wound care treatment and wound care specialist would be consulted were inaccurate. The DPCS indicated the current and ordered wound treatment for P7 was Medi honey gel and foam dressing. The DPCS revealed the patient had cancelled the service of the wound care specialist. The DPCS confirmed P7s comprehensive assessment was not updated during the interdisciplinary group meetings to include the patients current and ordered wound treatment and the agencys RN would continue to do the wound care treatment and management for the patient. The agencys policy titled Comprehensive Assessment dated November 2020, documented the comprehensive assessment would be updated by the interdisciplinary group as frequently as the patients condition would require but at a minimum of every 15 days. If there had been a change in the patients condition/status, then the comprehensive assessment must be updated. The agencys policy titled Interdisciplinary Group Meeting dated November 2020, documented the interdisciplinary group would meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. The changes or updates would include changes in treatments or procedures.”

“Based on interview, record review and document review, the agency failed to ensure the registered nurse (RN) and hospice aide (HA) visits were provided in accordance with the plan of care for 1 of 14 sampled patients (Patient 5). The deficient practice had the potential for patients adverse events or decline for not receiving the care and services per the plan of care. Findings include: Patient 5 (P5) P5 was admitted on 10/31/2024, with a diagnosis of cerebral infarction. P5s initial certification period (benefit period) was from 10/31/2024 through 01/28/2025. P5s plan of care documented the following frequency of visits for the RN and HA: - RN (skilled nursing visits) one time per week plus three PRN (as needed) visits - HA three times a week P5s medical record lacked documented evidence RN visits were conducted for the week of 11/03/2024 to 11/09/2024, and the week of 01/12/2025 to 01/18/2025, per the patients plan of care. P5s medical record lacked documented evidence HA visits were completed for the week of 01/12/2025 to 01/18/2025, and the week of 01/19/2025 to 01/25/2025, per the patients plan of care. For the week of 01/12/2025, an HA visit was conducted on 01/13/2025 and 01/15/2025 but a third HA visit was not performed for the said week. There was no documented HA visit for the week of 01/19/2025. On 01/31/2025 at 12:08 PM, the Director of Patient Care Services (DPCS) confirmed the findings and explained the clinicians were expected to follow the patients plan of care including the frequency of visits. The DPCS acknowledged there was no documented missed visits or communication from the RN and HA regarding the reason why the visits were not conducted. The DPCS revealed the last HA visit was on 01/15/2025 and there was no physicians order to discontinue the HA visit. The agencys policy titled The Plan of Care dated November 2020, documented the care provided to the patient must be in accordance with the plan of care.”

“Based on observation, record review, interview, and document review, the facility failed ensure: 1) a physician was notified about a patient having chest pain, for 1 of 14 sampled patients (Patient 2); 2) phone calls made through the phone line used for patients and care givers to communicate with the agency was answered; and 3) a hospice folder containing the POC, calendar of visits, medication profile, communication notes, and other hospice documents was provided to the patient/caregiver for 1 of 14 sampled patients (Patient 1). The deficient practice could have caused a delay of pertinent treatment, by preventing the effective communication among the interdisciplinary team and caregivers. Findings include: Patient 1 (P1) P1 was admitted on 01/08/2025, with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, generalized anxiety disorder, and insomnia. On 01/28/2025 at 1:30 PM, during a home visit with P1, a reconciliation of the patients home medications with the Patient Medication Profile was conducted with P1s caregiver. P1 was residing in a group home. There were discrepancies identified during the medication reconciliation. P1s caregiver confirmed the discrepancies and explained the group home was not provided with a hospice binder which included the Patient Medication Profile, POC (Plan of Care) Summary, and admission documents. On 01/28/2025 at 2:00 PM, the Spiritual Counselor, who was conducting a home visit with P1, confirmed the patient had no hospice binder maintained in the group home. The Spiritual Counselor indicated a hospice binder should have contained the patients plan of care, medication profile, and visit calendar. On 01/28/2025 at 2:18 PM, a Registered Nurse (RN) explained the admitting nurse would have prepared and provided the hospice binder to the patient/caregiver during the initial visit. The hospice binder should have contained copies of the consents, patient rights, emergency telephone numbers, plan of care, medication profile, admission packet and documents, and visit calendar. The RN revealed the agency staff conducting home visits would have referred to the hospice binder for updates and communication with other disciplines involved with the patient care. On 01/31/2025 at 11:33 AM, the Director of Patient Care Services (DPCS) indicated every patient should have been provided with a hospice binder upon admission. The hospice binder should have contained copies of the patient consents, calendar of visits, plan of care, medication list, and admission packet and documents. The DPCS revealed the hospice binder served as a guide to all clinicians and patient/caregiver regarding the hospice care and services being provided to the patient. The DPCS confirmed all clinicians involved in the patient care were expected to check the hospice binder every visit. The agencys policy titled Admission Documents dated November 2020, documented the agency would provide written admission documents prior to or at the initiation of home care services. The appropriate documents would be included in an admission folder bearing the name of the agency. The admission information would be reviewed with the patient and/or family at the start of care visit. The admission information would be left in the patients home. 1) Patient 2 (P2) P2 was admitted on 01/09/2025 with unspecified heart disease as the primary hospice diagnoses. A physicians order dated 01/09/2025, indicated nitroglycerin (drug used primarily to provide relief from anginal chest pain) 0.4 milligrams (mg) buccal (under the tongue) every 5 minutes for three doses for chest pain. A nursing visit note dated 01/10/2025, revealed P2 had been having episodes of chest pain even at rest. A nursing visit note dated 01/13/2025, 01/20/2025, and 01/27/2025, documented P2 was complaining of chest paint with a pain level of 4-6 in the scale 1 to 10. The nursing visit note lacked documented evidence the attending physician was notified about P2 having chest pain. The medication administration record (MAR) for the month of January 2025, revealed the medication nitroglycerin for chest pain had not been administered as per physicians order. On 01/31/2025 at 10:08 AM, P2s attending Registered Nurse (RN) explained in the event a patient who was full code (full cardiopulmonary resuscitation) presented signs and symptoms of cardiac attack, the care giver would call 911 and simultaneously the attending hospice physician and the hospice nurse. If the nurse was assessing a patient who complained of cardiac symptoms such as chest pain, the physician would be notified. The RN confirmed P2 complained of chest pain on the above-mentioned dates while the RN was visiting but the physician was not notified since the RN considered the chest pain as P2s baseline pain. After reviewing the previous nursing visits notes, the RN could not define the baseline chest pain since the medical record lacked documented evidence of previous episodes of chest pain. The RN acknowledged that not notifying the attending physician could lead to delay of treatment, worsening the patients condition, increasing the risk of complications such as heart failure, cardiac attack, or even death. On 01/31/2025 at 11:30 AM, the Director of Patient Care Services (DPCS) explained changes in patient conditions should be notified to the attending physician by the nurse to ensure the pertinent intervention to treat the condition. The DPCS acknowledged the physician should have been notified about P2s chest pain. The facility policy titled Care/Service Coordination dated November 202, documented timely and ongoing communication was the responsibility of each team member and the clinician/technician would be responsible for facilitating communications about changes in the patient’s status. 2) On 01/28/2025 at 10:00 AM, a visit was performed to the facilitys previous location as the facility’s address had not been updated in the State database. The inspectors performed three phone calls using the 24/7 phone number of record, to verify the new location but the call was not answered. A message was left to confirm the new location, but a phone call was never returned. On 01/28/2025 at 10:30 AM, an entrance conference was conducted with the hospice administrator who was asked about the operation of the 24/7 phone line that was not answered. The administrator called the number and confirmed the calls were not answered. The administrator indicated the phone number was used for patient/family/caregiver communication with hospice nurse on call. On 01/30/2025 at 2:00 PM, the Administrator explained the person responsible to answer the phone was not carrying the phone at the time calls were made on 01/28/2025. The Administrator acknowledged the calls should have been answered in a timely manner to ensure the communication with the patients and caregivers was optimal to honor any request related to patients care.”

“Based on interview and document review, the agency failed to provide documented evidence the data collection for its quality assessment and performance improvement (QAPI) program was not limited to the data collected during patient assessments. The deficient practice had resulted in the agency failing to examine all aspects of its operation and failure to evaluate all patient services and all activities which could impact the patient/family care. Findings include: On 01/31/2025 at 1:25 PM, the agencys QAPI program was reviewed with the Administrator. The Administrator provided the QAPI binder and indicated everything about QAPI was contained within the binder. The Administrator provided the copies of the minutes of the QAPI meetings dated 03/30/2024, 06/30/2024, 09/30/2024, and 12/30/2024. The Administrator explained the quality indicators documented in the minutes of the meeting were the QAPI studies conducted and the data was collected from the electronic health record or during patient assessments. Review of the QAPI minutes of the meeting for the four quarters mentioned above and the QAPI binder revealed the following: - The quality indicators were the same for the four quarters such as infection control, falls, discharge/transfer to other agencies, wound, timely documentation, and medication errors. The recommendations (corrective actions) were also the same for each quality indicator throughout the four quarters. - There was no documented evidence the data collection or quality indicators included other hospice services such as physician services, clinical records, patient rights, and coordination of care. - There was no documented evidence of the monitoring and results of the actions taken. - The members present were the Administrator and the Director of Patient Care Services (DPCS) designee. - The Administrator attended and approved the minutes of the meetings. There was no documented evidence of attendees from other disciplines such as physician services, nursing services, medical social services, counseling services, contract services like the therapists, and volunteers. The Administrator confirmed the findings and explained being the concurrent DPCS, Clinical Director, QAPI Coordinator, and Chairperson of the Governing Body. The agencys policy titled Responsibilities of the QAPI Committee dated November 2020, documented the QAPI Committee was responsible for evaluating and prioritizing QAPI activities based on the aggregation of analysis of data collected. Under the direction of the QAPI Coordinator, the committee would issue a quarterly report summarizing the QAPI activities and results of actions taken. The report would be submitted to the Governing Body and appropriate manager and staff. QAPI Committee members were appointed for staggered one-year term and renewable for a second term. The committee would include representatives from the following areas: - Administration - Clinical management - Business office/billing - Medical records - Pharmacy - Nursing - Medical Director or designee - Spiritual care services - Bereavement services - Volunteer services - Support services - Contracted services - Medical social services”

“Based on interview and document review, the agency failed to ensure it conducted and documented any performance improvement projects, reasons for conducting these projects, and the measurable progress achieved on these projects. The deficient practice had the potential for the facility failing to maintain an active, integrated, and organized continuous quality improvement program to patients receiving services. Findings include: On 01/31/2025 at 1:25 PM, the agencys quality assessment and performance improvement (QAPI) program was reviewed with the Administrator. The Administrator provided the QAPI binder and indicated everything about QAPI was contained within the binder. The Administrator provided the copies of the minutes of the QAPE meetings dated 03/30/2024, 06/30/2024, 09/30/2024, and 12/30/2024. The Administrator explained the quality indicators documented in the minutes of the meeting were the QAPI studies conducted and the data was collected from the electronic health record or during patient assessments. Review of the QAPI minutes of the meeting for the four quarters mentioned above and the QAPI binder revealed the following: - The quality indicators were the same for the four quarters such as infection control, falls, discharge/transfer to other agencies, wound, timely documentation, and medication errors. The recommendations (corrective actions) were also the same for each quality indicator throughout the four quarters. - There was no documented evidence of the monitoring and results of the actions taken. - There was no documented evidence the agency conducted any performance improvement projects, reasons for conducting these projects, and the measurable progress achieved on these projects. The Administrator reiterated the quality indicators documented in the QAPI minutes of the meeting, were the focus of the QAPI program and were not classified as distinct improvement projects.”

“Based on interview and document review, the agency failed to provide documented evidence the Governing Body (Chief Executive Officer) actively participated in ensuring an ongoing quality assessment and performance improvement (QAPI) program was implemented and maintained. The deficient practice led to lack of oversight and accountability for the overall management and operation of the agency. Findings include: The agencys organization chart documented the name of the Chief Executive Officer (CEO) as the Governing Body. There were no other names listed as members of the Governing Body. On 01/31/2025 at 1:25 PM, the agencys QAPI program was reviewed with the Administrator. The Administrator provided the QAPI binder and indicated everything about QAPI was contained within the binder. The Administrator provided the copies of the minutes of the QAPI meetings dated 03/30/2024, 06/30/2024, 09/30/2024, and 12/30/2024. Review of the QAPI minutes of the meeting for the four quarters mentioned above and the QAPI binder revealed the following: - The quality indicators were the same for the four quarters such as infection control, falls, discharge/transfer to other agencies, wound, timely documentation, and medication errors. The recommendations (corrective actions) were also the same for each quality indicator throughout the four quarters. - There was no documented evidence the data collection or quality indicators included other hospice services such as physician services, clinical records, patient rights, and coordination of care. - There was no documented evidence of the monitoring and results of the actions taken. - The members present were the Administrator and the Director of Patient Care Services (DPCS) designee. - The Administrator attended and approved the minutes of the meetings. There was no documented evidence of attendees from other disciplines such as physician services, nursing services, medical social services, counseling services, contract services like the therapists, and volunteers. - There was no documented evidence the CEO as the agencys Governing Body participated in the implementation, maintenance, and evaluation of the QAPI program. On 01/31/2025 at 1:41 PM, the Administrator provided copies of the minutes of the meeting of the Governing Body dated 08/07/2024, 12/04/2024, 12/30/2024, 01/02/2025, 01/06/2025, and 01/07/2025. The regular attendees to the meeting were the Administrator as the Chairperson and the DPCS Designee. There was no documented evidence the CEO attended the said meetings to ensure the discussion and evaluation of the agencys QAPI program. The Administrator confirmed the findings and explained being the concurrent DPCS, Clinical Director, QAPI Coordinator, and Chairperson of the Governing Body. The Administrator revealed the CEO was the owner of the agency. The Administrator was asked several times during the survey to facilitate an interview with the DPCS Designee. The Administrator failed to secure the interview with the DPCS Designee. The agencys policy titled Governing Body dated November 2020, documented the Governing Body would assume full legal authority, responsibility, decision-making and accountability for the overall management and operations, the provision of services, fiscal operations, human resource management, review of the organizations budget and operational plans, and its quality assessment and performance improvement (QAPI) program.”

“Based on interview and record review, the agency failed to ensure a supervisory visit for the hospice aides (HA) was performed every 14 days for 3 of 14 sampled patients (Patient 5, 6, and 7). The deficient practice had the potential for failing to assess the competence and the quality of services provided by the HA in a timely manner. Findings include: Patient 5 (P5) P5 was admitted on 10/31/2024, with a diagnosis of cerebral infarction. The HA Visit Notes dated 11/25/2024, 11/27/2024, 11/29/2024, 12/02/2024, 12/04/2024, 12/06/2024, 12/09/2024, 12/11/2024, 12/13/2024, 12/16/2024, 12/18/2024, 12/20/2024, 12/23/2024, 12/26/2024, 12/27/2024, 12/30/2024, 01/01/2025, 01/03/2025, 01/06/2025, 01/08/2025, 01/10/2025, 01/13/2025, 01/15/2025, documented HA2 performed the visits and signed the HA Visit Notes. The Supervisory Note section of the RN (registered nurse) Visit Notes dated 11/26/2024, 12/03/2024, 12/09/2024, 12/16/2024, 12/22/2024, 01/04/2025, 01/06/2025, 01/24/2025, and 01/27/2025, documented a supervisory visit was conducted for HA1. P5s medical record lacked documented evidence HA1 performed HA visits or was assigned to P5 from 11/25/2024 to 01/15/2025. On 01/31/2025 at 11:52 AM, the Director of Patient Care Services (DPCS) explained a supervisory visit for HA was conducted every 14 days. An RN would perform a supervisory visit for the HA providing care or was assigned to the patient. The supervisory visit was documented in the RN Visit Notes. The DPCS revealed the HA did not have to be present during this visit. Referring to the Supervisory Note section of the RN Visit Notes, the DPCS indicated the nurse would answer either Yes or No for the following: - If the HA had demonstrated competence with assigned tasks. - If the HA had good communication with the patient and family. - If the aide services met the patients needs. - If the aide had complied with infection control policies and procedures. The DPCS confirmed HA1 was not assigned to P5 from 11/25/2024 to 01/15/2025. The supervisory visits documented in the RN Visit Notes from 11/26/2024 to 01/27/2025 were incorrect because the name of HA1 was entered instead of HA2 who performed the visits to P5 starting 11/25/2024. The DPCS revealed HA1 was previously assigned to P5 and HA1s last visit to P5 was on 11/22/2024. The DPCS acknowledged there were no supervisory visits conducted for HA2. Patient 6 (P6) P6 was admitted on 08/07/2024, with diagnoses including essential primary hypertension and cerebral infarction. P6 was recertified for the period 11/05/2024 through 02/02/2025. P6s POC (Plan of Care) Summary for the current recertification period documented the following frequency of visits for RN and HA: - RN (skilled nursing visits) one time per week plus three PRN (as needed) visits - HA three times a week P6s medical record lacked documented evidence supervisory visits were conducted for the HA assigned or performed the visits to P6 for the current recertification period. On 01/31/2025 at 12:16 PM, the DPCS confirmed the findings and acknowledged the Supervisory Note section of the RN Visit Notes from 11/07/2024 to 01/29/2025 were left blank. Patient 7 (P7) P7 was admitted on 07/18/2024, with a diagnosis of displaced intertrochanteric fracture of right femur. P7 was recertified for the period 10/16/2024 through 01/13/2025, and from 01/14/2025 through 03/14/2025. P7s POC Summary for the current recertification period (01/14/2025 through 03/14/2025) documented the following frequency of visits for RN and HA: - RN (skilled nursing visits) one time per week plus three PRN visits - HA three times a week P7s medical record lacked documented evidence supervisory visits were conducted for the HA assigned or performed the visits to P7 for the current recertification period. On 01/31/2025 at 12:20 PM, the DPCS confirmed the findings and revealed the last supervisory visit conducted for the HA assigned to P7 was on 11/27/2024, during the previous recertification period. The DPCS explained the next supervisory visit should have been completed on 12/11/2024, 12/24/2024, 01/06/2025, and 01/21/2025. The DPCS indicated for P7s current recertification period, the RN performed a home visit on 01/16/2025, 01/21/2025, and 01/29/2025 and there was no supervisory visit documented in the RN Visit Notes for the said dates.”

“Based on observation, record review, interview, and document review, the facility failed to 1) ensure false medical diagnoses were not used to guarantee the admission of patients to hospice care for two of 14 sampled patients (Patient 2 and 3), and 2) physicians face-to-face visit notes were completed for 2 of 14 sampled patients (Patient 7 and 8). The deficiency practice placed the patients at risk for inappropriate treatment plans, causing inaccurate end-of-life care, potentially affecting patients’ overall health. Patient 7 (P7) P7 was admitted on 07/18/2024, with a diagnosis of displaced intertrochanteric fracture of right femur. P7s current recertification period (benefit period) was for the period 01/14/2025 through 03/14/2025. A review of the Face-to-Face Visit Note for P7 revealed the following: - Visit date was 01/09/2025. Time In: 3:30 PM. Time Out: 4:30 PM. - Place of Service; Home - Patient/Patient Caregiver chief complaint was left blank. - The Subjective section and Clinical Findings Summary section had identical documentation, word for word. The documentation included the patients diagnosis, allergies, and age. Documentation included the following: Patient alert but had dementia, very pleasant. Daughter next-of-kin and patient was living with lots of family members in a two-story house with dogs as pets. Patient caregiver informed of hospice care and agreed with treatment plans. Stage 2 decubitus on lower back, treated with antibiotic cream and foam dressing, wound care specialist to be consulted, patient caregiver agreeable. Patient caregiver educated on importance of repositioning while patient on bed and encouraged to have patient up most of the day to relieve pressure on back. - The Objective section which should have included information about the assessment or findings on patients HEENT (Head, Eyes, Ears, Nose, and Throat), Cardiac, Lung, Abdomen, and Extremities was left blank. - The Medical Director electronically signed the Face-to-Face Visit Note for P7 on 01/09/2025. P7s Physicians Certification For Hospice Benefit documented the following: - The effective date of certification was from 01/14/2025 to 03/14/2025. - The certification was based on a Face-to-Face Encounter. (The visit date was left blank.) - The RN (Registered Nurse) Prognosis Summary and the Certifying Physician Narrative had identical documentation, word for word, and similar to the Subjective section and Clinical Findings Summary section of the above-mentioned Face-to-Face Visit Note. - The Physician Narrative section for Face-to-Face Narrative was left blank. - The Medical Director Attestation/Certification indicated attesting/confirming that the Medical Director composed this narrative based on the review of patients medical record, team assessment and/or examination of the patient. - The Medical Director reviewed and electronically signed P7s Physicians Certification For Hospice Benefit on 01/14/2025. On 01/30/2025 at 3:46 PM, the Administrator confirmed the findings and acknowledged the Medical Director should have completed P7s Face-to-Face Visit Note including the Objective section of the form within five days from the visit date, or by 01/14/2025. The Administrator indicated the Medical Director should have also completed the Face-to-Face Narrative of P7s Physicians Certification For Hospice Benefit. The Administrator explained a face-to-face visit was conducted by a physician or nurse practitioner before the start of the third benefit period to certify if the patient was terminally ill. P7s current recertification period was the patients third benefit period and a face-to-face visit was required. The Administrator indicated the Face-to-Face Visit Note should have been completed and contain accurate information. Patient 8 (P8) P8 was admitted on 07/17/2024, with a diagnosis of atherosclerosis heart disease. P8s current recertification period was for the period 01/13/2025 through 03/13/2025. This was the patients third benefit period. A review of the Face-to-Face Visit Note for P8 revealed the following: - Visit date was 01/08/2025. Time In: 1:30 PM. Time Out: 2:30 PM. - Place of Service; Home - Patient/Patient Caregiver chief complaint was left blank. - The Subjective section and Clinical Findings Summary section had identical documentation, word for word. The documentation included the patients diagnosis, allergies, and age. The documentation included the following: Patient was living with roommates in a single level home. Next-of-kin lived in town. Patient used to be walking without assistive device. Now dependent on a cane. Fall episode last month. Patient felt cognitive and physical decline and had been mostly homebound due to activity intolerance. Only able to manage to walk 15 to 20 feet at a time without having shortness of breath. - The Objective section which should have included information about the assessment or findings on patients HEENT, Cardiac, Lung, Abdomen, and Extremities was left blank. - The Medical Director electronically signed the Face-to-Face Visit Note for P8 on 01/08/2025. P8s Physicians Certification For Hospice Benefit documented the following: - The effective date of certification was from 01/13/2025 to 03/13/2025. - The certification was based on a Face-to-Face Encounter. (The visit date was left blank.) - The Physician Narrative section for Face-to-Face Narrative was left blank. - The Certifying Physician Narrative had identical documentation, word for word, and similar to the Subjective section and Clinical Findings Summary section of the above-mentioned Face-to-Face Visit Note. - The Medical Director Attestation/Certification indicated attesting/confirming that the Medical Director composed this narrative based on the review of patients medical record, team assessment and/or examination of the patient. - The Medical Director reviewed and electronically signed P8s Physicians Certification For Hospice Benefit on 01/13/2025. On 01/31/2025 at 12:35 PM, the Administrator confirmed the findings and explained the Medical Director should have completed P8s Face-to-Face Visit Note including the Objective section of the form within five days from the visit date, or by 01/13/2025. The Administrator indicated the Medical Director should have also completed the Face-to-Face Narrative of P8s Physicians Certification For Hospice Benefit. On 01/31/2025 at 5:15 PM, the Medical Director revealed a face-to-face visit was conducted by the Medical Director or a nurse practitioner. The Medical Director confirmed all sections of the Face-to-Face Visit Note and Physicians Certification For Hospice Benefit should have been completed. The Professional Services Agreement Medical Director was signed and executed by the agency and the Medical Director. The duties and responsibilities of the Medical Director enumerated in the agreement included the following: - Submission to the agency of the documentation of services provided as appropriate. - Perform face to face encounters as necessary. The Job Description Summary for the Medical Director documented the Medical Director would have overall responsibility for the medical component of the hospice program. The duties and responsibilities of the Medical Director included, but not limited to the following: - Reviewing patients medical eligibility for hospice services, in accordance with hospice policies and procedures, and establishing the plan of care in conjunction with the attending physician and interdisciplinary group prior to providing care written certification of terminal illness. - Providing written certification of the terminal illness for all subsequent benefit periods. - Perform face-to-face encounters within 30 days of the third and subsequent hospice benefit certification periods and attest to the encounter. (A nurse practitioner may complete the encounter and report findings to the hospice physician.) - Documenting care provided in the patients medical record, providing evidence of progression of the end-stage disease process. The Medical Director signed the Job Description Summary on 10/21/2021. Findings include: Two patients were admitted without an appropriate hospice diagnosis for terminal illness (Patient 2 and 3). Patient 2 (P2) P2 was admitted on 01/09/2025 with unspecified heart disease as the primary hospice diagnoses. A certification of terminal illness was signed by the Medical Director on 01/09/2025, attesting P2 was terminally ill with a life expectancy of six (6) months or less if the terminal illness run its normal course. Hospice medical record revealed a referral for hospice from a medical office dated 01/08/2025. The referral directed to see attached history and physical for the referral diagnoses. The referring physician was listed as a physician employed by the hospice agency. It was not clear when the physician assessed P2 and if there was a clinical indication and a rational to refer P2 to hospice care. The attached documents to the hospice referral included an acute care record for a hospitalization that occurred prior to the admission to hospice care. The hospital record revealed P2 arrived at the hospital on 12/29/2024 via emergency medical services (EMS) for homelessness. The record documented diagnoses including homelessness, hungry, weakness, inability to walk. The past medical history included mental disability, schizophrenia, and traumatic brain injury. The physical assessment including vital signs performed on 12/29/2024, 01/04/2025, and 01/05/2025, and the laboratory analysis performed on 12/29/2024 were unremarkable for a cardiac event or disease. The record did not have documented evidence of cardiology evaluation, diagnoses or treatment related to a heart disease. The discharge planning documented P2 to return to residential facility/group home. A hospice referral was not included in the discharge planning. The hospital medical record lacked documented evidence P3 had a cardiac disease or a cardiac terminal condition such as ischemic heart disease, congestive heart failure The review of the hospice comprehensive nursing assessment dated 01/09/2025, revealed the following: The assessment documented unspecified heart disease as the primary hospice diagnosis. The assessment indicated the illness trajectory and reason for hospice admission was based on the information reported by the medical history, documenting ischemic heart disease as a comorbidity. The Local Coverage Determinations (LCD, a general guideline for hospice eligibility for patients with non-cancerous conditions, created by Medicare Administrative Contractors to determine whether a service was covered) used the diagnosis of heart disease as the determination for hospice coverage. The LCD indicated P2 had an untreatable condition since the patient was ruled out as a candidate for surgical procedure. The assessment revealed the RN used the New York Heart Association (NYHA) Functional Classification as part of the criteria for hospice eligibility. NYHA Functional Classification is a tool that categorizes heart failure patients into four groups based on their physical activity limitations, including normal breathing, shortness of breath, and angina pain. The NYHA Functional Classification assessment documented a class IV level, indicating P2 was mostly bedbound, had a severe limitation, and was experiencing cardiac symptoms even while at rest. The assessment revealed a cardiovascular examination conducted by a Registered Nurse (RN). The exam indicated P2 did not have blood pressure symptoms since the systolic blood pressure was within normal limits. The examination documented regular pulse, unspecified cardiac-related pain and edema. The assessments narrative written by the RN documented P2 was discharged from a hospital after falling. The narrative indicated P2 was cognitively impaired and physically wheelchair bound, with limited mobility and increased episodes of chest pain. The narrative documented a next of kin (NOK) family member contacted via phone call indicated P2 had abused drugs in the past, leading to heart disease, brain damage, seizures and mental disorder. The narrative revealed the RN explained to the NOK that P2 had been admitted to hospice care and NOK agreed with the plan. The assessment final statement for the admission order revealed the RN discussed P2’s status with the Physician who issued an order to admit the patient to hospice based on the information provided to the Physician by the RN, and the Physician’s review of the patient’s medical history. The medical record revealed an LCD hospice eligibility determination assessment dated 01/09/2025, documented P2 was a congestive heart failure or angina patient that met the criteria for NYHA class IV level. The hospice eligibility assessment documented P2 had an untreatable heart disease condition, and the patient had been ruled out as a candidate for surgical treatment. On 01/28/2025 at 1:30 PM, a home visit was conducted at a group home where P2 resided. P2 was found sitting in a wheelchair, alert with imprecise articulation of words, slow and slurred speech, and difficult to understand. A hospice RN assessed the patient and asked yes or no questions that were unintelligibly answered. The RN confirmed had been the admission nurse for P2 and the questions asked during the initial assessment were made with P2s family member on the phone since the patient was unable to make decisions. The RN confirmed P2’s condition was stable and was not in distress. On 01/28/2025 at 1:40 PM, a group home caregiver (CG) explained P2 complained of agitation but did not complain about chest pain. Medical records from the group home revealed P2 did not have pain medication and nitroglycerin which was ordered for chest pain, was never administered. On 01/31/2025 at 10:08 AM, the RN who performed the admission comprehensive assessment, explained after a referral was obtained by the facility, the hospice nurse performed the admission assessment at the patient’s location to determine the eligibility for hospice care, using tools including the NYHA Functional Classification. The assessment also used clinical records and family/patient interviews. The RN indicated the information collected during the assessment was transmitted and discussed with the hospice physician who used the information to certify the patient for hospice care. The RN confirmed had admitted P2 on 01/09/2025 with primary diagnosis of heart disease as terminal illness based on the information provided by the NOK who said P2 was admitted several times to hospitals for cardiac problems. The RN acknowledged had not reviewed P2’s history and physical to verify the information about cardiac diseases. Patient #3 (P3) P3 was admitted on 12/06/2024, with unspecified heart disease as the primary hospice diagnoses. A certification of terminal illness was signed by the Medical Director on 12/06/24, attesting P3 was terminally ill with a unspecified heart diseases, and with a life expectancy of six (6) months or less if the terminal illness run its normal course. Hospice medical record revealed a referral for hospice from a medical office dated 12/05/2024. The referral documented P3 had a unspecific heart disease as the diagnosis to be admitted to hospice care. The medical records from an acute care and from a skilled nursing facility where P3 resided prior to being transferred to a group home and admitted to hospice care, revealed the following diagnoses: Infection of amputation stump left lower extremity. Acquired absence of left leg above knee. Type 2 diabetes with diabetic polyneuropathy. Unspecified primary hypertension. Unspecified hyperlipidemia. Benign prostatic hyperplasia with lower urinary tract symptoms. Unspecified urine retention. Unspecified muscle wasting and atrophy. Unspecified muscle weakness without atrophy. Other abnormalities related to mobility and lack of coordination. The medical records lacked documented evidence P3 had a cardiovascular disease in terminal stage or condition. The review of the P3s comprehensive nursing assessment dated 12/06/2024, revealed the following: The assessment documented unspecified heart disease as the primary hospice diagnosis. The assessment indicated the illness trajectory and reason for hospice admission was based on the information reported by P3 and the medical history. The LCD indicated P3 had an untreatable condition since the patient was ruled out as a candidate for surgical procedure related to the hospice diagnosis. The assessment revealed the RN used the New York Heart Association (NYHA) Functional Classification as part of the criteria for hospice eligibility. The NYHA Functional Classification assessment documented a class III level, indicating P3 had marked limitation in activity due to symptoms, even during less-than-ordinary activity, and was comfortable only at rest. The assessment revealed a cardiovascular examination conducted by a RN. The exam indicated P3 had regular pulse, pitting edema but did not have a cardiac-related pain. The assessment final statement for the admission order revealed the RN discussed P3’s status with the Physician who issued an order to admit the patient to hospice based on the information provided to the Physician by the RN, and the Physician’s review of the patient’s medical history. The medical record revealed an LCD hospice eligibility determination assessment dated 12/06/2024, documented P3 was a congestive heart failure or angina patient that met the criteria for NYHA class IV level. The hospice eligibility assessment documented P3 had an untreatable heart disease condition and the patient had been ruled out as a candidate for surgical treatment. On 01/29/2025 at 9:30 AM, a home visit was conducted at a group home were P2 resided. P2 was found sitting in a wheelchair, alert and oriented in person, place, time, and situation. P3 was assessed by a Registered Nurse who obtained the following vital signs: Blood pressure 109/68; heart rate 65 beats per minute; oxygen saturation 100 % at room air. The patient did not display signs of distress. On 01/29/2025 at 10:20 AM, P3 explained having a surgery for left knee replacement that eventually became infected leading to the amputation. P3 was discharged to a skilled nursing facility for rehabilitation and then transferred to the group home. The patient verbalized had never suffered from cardiovascular disease or chest pain. On 01/31/2025 at 1:30 PM, the RN who performed the admission comprehensive assessment, explained P3 was transferred from a skilled nursing facility to a group home and when the assessment occurred, P3 was found in bed very weak and lethargic. The RN indicated the criteria used to admit P3 to hospice care was based on the information collected from the medical record provided by the skilled nursing, and from the information provided by P3. The RN acknowledged P3 did not have history of terminal untreatable cardiovascular disease and the determination for the diagnosis of heart disease was based on the fact that P3 had history of high blood pressure, hyperlipidemia (high level of fats in blood) and pedal edema (feet swelling). On 01/31/2025 at 5:00 PM, the Medical Director confirmed the admission of the two patients, and the certifications of terminal illness were performed based on the data collected by nurses and correlated with patients medical records. Regarding P2, the Medical Director explained the determination to admit P2 to hospice care were based on P2’s medical history and by the assessment performed by the RN. When the surveyor informed the physician there was no evidence in the medical record P2 had history or a diagnosis of cardiovascular diseases that lead to a terminal condition, the Medical Director could not provide an explanation about the origin of P2s heart disease diagnosis. The Medical Director was not aware the RN who performed the initial assessment for P2 had used the NYHA Functional Classification based on the subjective information provided by a family member. The Medical Director confirmed a face-to-face evaluation of P2 and P3 had not been performed yet and acknowledged P2 should have been discharged from hospice care for lack of criteria. The facility policy titled Admission Criteria and Process dated November 2020, documented a patient must have a life-limiting illness with a life expectancy of six month or less, as determined by the attending physician and hospice Medical Director, using the LCD clinical prognosis criteria.”

“Based on interview, record review and document review, the agency failed to ensure a patients clinical (medical) record contained the comprehensive assessment for the current recertification period for 1 of 14 sampled patients (P7). The deficient practice had the potential for failure to develop the patients individualized plan of care in a timely manner and delay the provision of the required care and services for the patient based on the comprehensive assessment. Findings include: Patient 7 (P7) P7 was admitted on 07/18/2024, with a diagnosis of displaced intertrochanteric fracture of right femur. P7 was certified and recertified for the following benefit period: - 07/18/2024 to 10/15/2024 (initial certification) - 10/16/2024 to 01/13/2025 - 01/14/2025 to 03/14/2025 (current recertification period) On 01/30/2025 at 3:50 PM, a review of P7s electronic health record (EHR) revealed there was no comprehensive assessment completed for the current recertification period. A screenshot of the History of Nursing Assessment contained the comprehensive assessments completed for P7 which were dated 07/18/2024 and 10/15/2024. The Director of Patient Care Services (DPCS) who was present during the patients EHR review confirmed the findings and explained the registered nurse (RN) assigned to P7 should have completed the comprehensive assessment by 01/12/2025, for the current recertification period. The DPCS indicated the comprehensive assessments contained in P7s medical record dated 07/18/2024 and 10/15/2024 were completed for the patients initial certification and subsequent recertification (10/16/2024 to 01/13/2025), respectively. On 01/31/2025 in the morning, during the continuation of medical record review, a comprehensive assessment for P7 was now contained in the EHR. The visit date was 01/11/2025 and the RN electronically signed the assessment on 01/11/2025. The DPCS confirmed the comprehensive assessment was added or entered into P7s medical record (EHR) after the findings were brought up and discussed with the DPCS. The DPCS acknowledged the comprehensive assessment dated 01/11/2025 was not in P7s medical record during the record review on 01/30/2025. The agencys policy titled Contents of Clinical Record dated November 2020, documented the clinical record should contain patient and family/caregiver initial, comprehensive and ongoing comprehensive assessments.”

“Based on interview, record review and document review, the agency failed to provide documented evidence a physicians order was obtained for the wound care treatment for 1 of 14 sampled patients (P7). The deficient practice had the potential for failing to provide an effective medication management for the patient and risk for medication error. Findings include: Patient 7 (P7) P7 was admitted on 07/18/2024, with a diagnosis of displaced intertrochanteric fracture of right femur. P7 was certified and recertified for the following benefit period: - 07/18/2024 to 10/15/2024 (initial certification) - 10/16/2024 to 01/13/2025 - 01/14/2025 to 03/14/2025 (current recertification period) The physicians order dated 07/18/2024, documented the following: - Adhesive foam dressing with gentle border 6x6 inches every visit - Medi honey gel wound dressing every visit. The Communication Note dated 10/17/2024, documented the wound care specialist discontinued wound care treatment. The agencys RN would continue to do wound care treatment and management for the patient. The Narrative section of the RN Visit Notes dated 10/22/2024, 10/28/2024, 11/07/2024, 11/13/2024, 11/19/2024, 11/27/2024, 12/04/2024, 12/11/2024, 12/16/2024, 12/24/2024, 12/30/2024, 01/06/2025, 01/11/2025, 01/16/2025, 01/21/2025, and 01/29/2025, documented stage 2 decubitus on lower back, treated with antibiotic cream and foam dressing. P7s POC (Plan of Care) Summary as of 01/29/2025, documented stage 2 decubitus on lower back, treated with antibiotic cream and foam dressing. P7s medical record lacked documented evidence a physicians order was obtained for the antibiotic cream used to treat the patients wound, per the documentation in the above-mentioned RN Visit Notes and POC Summary. On 01/31/2025 at 3:24 PM, the Director of Patient Care Services (DPCS) confirmed the findings and indicated the current and ordered wound treatment for P7 was Medi honey gel and foam dressing. The DPCS explained the wound care specialist had discontinued the wound care treatment per the Communication Note dated 10/17/2024, and the agencys RN would continue to do the wound care treatment and management for the patient. The DPCS indicated the nurses should have called the physician, clarified the order or obtained new order for the wound care treatment. The DPCS acknowledged the nurses should have obtained a physicians order for the antibiotic cream prior to providing the treatment to P7. The agencys policy titled Administration and Documentation of Medications dated November 2020, documented licensed nursing personnel would administer and document only those medications which have been ordered by the physician, as a part of the plan of care and have been approved for safe administration and monitoring during a hospice visit.”

“Based on interview, record review and document review, the agency failed to ensure the clinical notes and visit notes were complete, accurate, and were appropriately authenticated and dated for 4 of 14 sampled patients (Patient 1, 5, 7 and 8). The deficient practice had the potential for failing to ensure the care and services were provided to the patients in a timely manner and documented accurately. Findings include: Patient 1 (P1) P1 was admitted on 01/08/2025, with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, generalized anxiety disorder, and insomnia. P1s initial certification period (benefit period) was from 01/08/2025 through 04/07/2025. Inaccurate Visit Note P1s medical record contained a Registered Nurse (RN) Visit Note dated 01/06/2025 which documented the following: - Visit Date: 01/06/2025. Type: In-Person. In: 7:15 PM. Out: 7:45 PM. - Narrative: Full body observation and assessment done by skilled nursing. Vital signs checked and recorded. - The RN electronically signed the visit note on 01/06/2025. On 01/30/2025 at 10:54 AM, the Director of Patient Care Services (DPCS) confirmed the RN Visit Note dated 01/06/2025 was inaccurate because the visit date was prior to P1s admission on 01/08/2025. The DPCS revealed the entered date could not have been a typographical error because the RN visits following the admission date were all done in accordance with the physicians order and plan of care. There were no missed visits for P1s RN required services. POC (Plan of Care) / IDG (Interdisciplinary Group) Review notes not authenticated and dated P1s POC / IDG Review notes dated 01/08/2025 and 01/22/2025 were not authenticated and dated by the RN who was the member of the patients IDG. On 01/30/2025 at 10:27 AM, the DPCS confirmed the findings and acknowledged the RN should have signed and dated the POC / IDG Review notes after the meeting or within five days from the date of the meeting. Patient 5 (P5) P5 was admitted on 10/31/2024, with a diagnosis of cerebral infarction. P5s initial certification period was from 10/31/2024 through 01/28/2025. P5s plan of care documented the frequency of visit for the Spiritual Counselor (SC) which was one time monthly plus three PRN (as needed) visits. On 01/30/2025, a review of P5s medical record revealed SC visits were completed on 11/04/2024 and 12/14/2024. There was no documented evidence of SC visit for the month of January 2025. On 01/31/2025, during the continuation of medical record review, an SC visit note was entered into P5s electronic health record (medical record) for the January 2025 SC visit which documented the following: - Visit Date: 01/27/2025. Time In: 5:30 PM. Time Out: 6:00 PM. - The SC electronically signed the visit note on 01/09/2025. On 01/31/2025 at 11:52 AM, the DPCS confirmed the findings and indicated the SC visit note for January 2025 was inaccurate. The DPCS explained the SC visit was done on 01/09/2025 and not 01/27/2025. Patient 7 (P7) P7 was admitted on 07/18/2024, with a diagnosis of displaced intertrochanteric fracture of right femur. P7 was certified and recertified for the following benefit period: - 07/18/2024 to 10/15/2024 (initial certification) - 10/16/2024 to 01/13/2025 - 01/14/2025 to 03/14/2025 (current recertification period) Altered RN Visit Notes The physicians order dated 07/18/2024, documented the following: - Adhesive foam dressing with gentle border 6x6 inches every visit - Medi honey gel wound dressing every visit. The site of the wound was not documented in the physicians order. The Communication Note dated 10/17/2024, documented the wound care specialist discontinued wound care treatment. The agencys RN would continue to do wound care treatment and management for the patient. The Narrative section of the RN Visit Notes dated 10/22/2024, 10/28/2024, 11/07/2024, 11/13/2024, 11/19/2024, 11/27/2024, 12/04/2024, 12/11/2024, 12/16/2024, 12/24/2024, 12/30/2024, 01/06/2025, 01/11/2025, 01/16/2025, 01/21/2025, and 01/29/2025, documented stage 2 decubitus on lower back, treated with antibiotic cream and foam dressing, will have wound care specialist consulted. P7s POC (Plan of Care) Summary as of 01/29/2025, documented stage 2 decubitus on lower back, treated with antibiotic cream and foam dressing, will have wound care specialist consulted. P7s medical record lacked documented evidence a physicians order was obtained for the antibiotic cream, and a wound care specialist was consulted per the documentation in the above-mentioned RN Visit Notes and POC Summary. On 01/31/2025 at 3:24 PM, the DPCS confirmed the findings and acknowledged the documentation in the RN Visit Notes and POC Summary as of 01/29/2025, regarding the use of the antibiotic cream in P7s wound care treatment, and wound care specialist would be consulted were inaccurate. The DPCS indicated the current and ordered wound treatment for P7 was Medi honey gel and foam dressing. The DPCS revealed the patient had cancelled the service of the wound care specialist. After the interview with the DPCS, the copies of the RN Visit Notes were requested. On 01/31/2025 at 4:15 PM, the DPCS provided the RN Visit Notes for P7 dated 10/22/2024, 10/28/2024, 11/07/2024, 11/13/2024, 11/19/2024, 11/27/2024, 12/04/2024, 12/11/2024, 12/16/2024, 12/24/2024, 01/06/2025, and 01/11/2025. The Narrative Section of the RN Visit Notes documented the hospice RN would continue to do wound care treatment and management for the patient. Stage 2 decubitus on lower back treated with Medi honey and foam dressing. The said new version of the RN Visit Notes documented the same name of the visiting RN (not the DPCS) and the date the visiting RN electronically signed the visit notes which corresponded to the visit dates. On 01/31/2025 at 4:15 PM, the DPCS confirmed changing the RN Visit Notes to reflect the physician ordered wound care treatment such as Medi honey and foam dressing and adding the verbiage, “;Hospice RN will continue to do wound care treatment and management for the patient.” The DPCS acknowledged the RN Visit Notes were altered. Incomplete Physician Notes P7s current recertification period was for the period 01/14/2025 through 03/14/2025. A review of the physician Face-to-Face Visit Note for P7 revealed the following: - Visit date was 01/09/2025. Time In: 3:30 PM. Time Out: 4:30 PM. - Place of Service; Home - Patient/Patient Caregiver chief complaint was left blank. - The Subjective section and Clinical Findings Summary section had identical documentation, word for word. The documentation included the patients diagnosis, allergies, and age. Patient alert but had dementia, very pleasant. Daughter next-of-kin and patient was living with lots of family members in a two-story house with dogs as pets. Patient caregiver informed of hospice care and agreed with treatment plans. Stage 2 decubitus on lower back, treated with antibiotic cream and foam dressing, wound care specialist to be consulted, patient caregiver agreeable. Patient caregiver educated on importance of repositioning while patient on bed and encouraged to have patient up most of the day to relieve pressure on back. - The Objective section which should have included information about the assessment or findings on patients HEENT (Head, Eyes, Ears, Nose, and Throat), Cardiac, Lung, Abdomen, and Extremities was left blank. - The Medical Director electronically signed the Face-to-Face Visit Note for P7 on 01/09/2025. P7s Physicians Certification For Hospice Benefit documented the following: - The effective date of certification was from 01/14/2025 to 03/14/2025. - The certification was based on a Face-to-Face Encounter. (The visit date was left blank.) - The RN (Registered Nurse) Prognosis Summary and the Certifying Physician Narrative had identical documentation, word for word, and similar to the Subjective section and Clinical Findings Summary section of the above-mentioned Face-to-Face Visit Note. - The Physician Narrative section for Face-to-Face Narrative was left blank. - The Medical Director Attestation/Certification indicated attesting/confirming that the Medical Director composed this narrative based on the review of patients medical record, team assessment and/or examination of the patient. - The Medical Director reviewed and electronically signed P7s Physicians Certification For Hospice Benefit on 01/14/2025. On 01/30/2025 at 3:46 PM, the Administrator confirmed the findings and acknowledged the Medical Director should have completed P7s Face-to-Face Visit Note including the Objective section of the form within five days from the visit date, or by 01/14/2025. The Administrator indicated the Medical Director should have also completed the Face-to-Face Narrative of P7s Physicians Certification For Hospice Benefit. The Administrator explained a face-to-face visit was conducted by a physician or nurse practitioner before the start of the third benefit period to certify if the patient was terminally ill. P7s current recertification period was the patients third benefit period and a face-to-face visit was required. The Administrator indicated the Face-to-Face Visit Note should have been completed and contained accurate information. Patient 8 (P8) P8 was admitted on 07/17/2024, with a diagnosis of atherosclerosis heart disease. P8s current recertification period was for the period 01/13/2025 through 03/13/2025. This was the patients third benefit period. A review of the Face-to-Face Visit Note for P8 revealed the following: - Visit date was 01/08/2025. Time In: 1:30 PM. Time Out: 2:30 PM. - Place of Service; Home - Patient/Patient Caregiver chief complaint was left blank. - The Subjective section and Clinical Findings Summary section had identical documentation, word for word. The documentation included the patients diagnosis, allergies, and age. Patient was living with roommates in a single level home. Next-of-kin lived in town. Patient used to be walking without assistive device. Now dependent on a cane. Fall episode last month. Patient felt cognitive and physical decline and had been mostly homebound due to activity intolerance. Only able to manage to walk 15 to 20 feet at a time without having shortness of breath. - The Objective section which should have included information about the assessment or findings on patients HEENT, Cardiac, Lung, Abdomen, and Extremities was left blank. - The Medical Director electronically signed the Face-to-Face Visit Note for P8 on 01/08/2025. P8s Physicians Certification For Hospice Benefit documented the following: - The effective date of certification was from 01/13/2025 to 03/13/2025. - The certification was based on a Face-to-Face Encounter. (The visit date was left blank.) - The Physician Narrative section for Face-to-Face Narrative was left blank. - The Certifying Physician Narrative had identical documentation, word for word, and similar to the Subjective section and Clinical Findings Summary section of the above-mentioned Face-to-Face Visit Note. - The Medical Director Attestation/Certification indicated attesting/confirming that the Medical Director composed this narrative based on the review of patients medical record, team assessment and/or examination of the patient. - The Medical Director reviewed and electronically signed P8s Physicians Certification For Hospice Benefit on 01/13/2025. On 01/31/2025 at 12:35 PM, the Administrator confirmed the findings and explained the Medical Director should have completed P8s Face-to-Face Visit Note including the Objective section of the form within five days from the visit date, or by 01/13/2025. The Administrator indicated the Medical Director should have also completed the Face-to-Face Narrative of P8s Physicians Certification For Hospice Benefit. On 01/31/2025 at 5:15 PM, the Medical Director revealed a face-to-face visit was conducted by the Medical Director or a nurse practitioner. The Medical Director confirmed all sections of the Face-to-Face Visit Note and Physicians Certification For Hospice Benefit should have been completed. On 01/31/2025 at 10:30 AM, a Registered Nurse (RN) indicated the IDG meeting was conducted every two weeks to discuss and update a patients plan of care. The RN, SC, social worker, and physician assigned to the patient attended the IDG meetings. The RN explained the attendees should have completed and signed the IDG notes at the end of the meeting or within the day. The RN revealed the clinicians could enter the visit dates, complete the visit notes, and electronically sign the notes few days after the actual visit date. The RN explained the agencys electronic health record system allowed the staff to affix their electronic signature on prior dates or antedate their signatures. On 01/31/2025 at 4:05 PM, the DPCS explained the staff were expected to enter and complete the clinical notes accurately and in a timely manner and sign the notes on the actual date their electronic signatures were entered. The DPCS indicated a quarterly review of the clinical record was done by a third party or outside vendor but the DPCS could not provide the name of the vendor or the contract with the vendor. There was no documented evidence of an ongoing clinical record review. The DPCS confirmed being the concurrent Administrator, Clinical Director, Quality Assessment and Performance Improvement (QAPI) Coordinator, and Chairperson of the Governing Body. The DPCS revealed doing the clinical record review if the DPCS had time. The agencys policy titled Contents of Clinical Record dated November 2020, documented a clinical record would be maintained for each patient receiving care. The clinical record would contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. Each entry would be dated and signed, including title and credentials, by the person providing the care/service. The agencys policy titled Clinical Record Review dated November 2020, documented each clinical record would be reviewed on an ongoing basis by the Clinical Supervisor, QAPI Coordinator, Clinical Director, or designees for the timeliness of entries into the clinical record, compliance with organizational policy and established plan of care, completeness and accuracy of clinical records, appropriateness of services rendered, and the need for continued care. All record reviews would be documented and the data collated and analyzed.”

“Based on record review, interview and document review, the facility failed to complete a discharge process in a timely manner for a patient who transferred to another hospice agency (Patient 14). The deficient practice had the potential to interrupt the continuation of care, delaying the provision of quality hospice services for a patient. Findings include: Patient 14 (P14) P14 was admitted on 05/15/2023, with unspecific cerebral infarction as the primary hospice diagnosis. A discharge summary dated 06/01/2023, P14 was discharged from the hospice agency services because the patient transferred to another hospice agency. According to the discharge summary, P14’s plan of care and advanced directives were sent to the receiving agency. On 01/30/2024 at 2:00 PM, was advised by a third party P14 wanted to be transferred to another hospice agency because was not satisfied with the service received. Advised by the third party the patient could not be admitted to the receiving hospice agency because the discharge documents were not transmitted to Medicare timely. Calls were placed to the discharging hospice agency to request the finalization of the process to ensure the continuation of care, but the sending agency never responded. A Medicare submission report revealed the hospice agency transmitted the discharge documents to Medicare on 12/19/2023, six month after P14 was discharged. The report documented the submission of the discharge documents was late and should have been transmitted less than or equal to 30 days. On 01/31/2024 at 3:30 PM, the facilitys Administrator explained if a patient decided to transfer to another hospice agency, the discharge documents, including the discharge summary should be transmitted to Medicare in a reasonable period of time. The Administrator indicated failing to transmit the documents timely could affect the patient’s benefits for hospice care. The Administrator could not find documentation with the rationale for delaying the transmission of the discharge documents and acknowledged the documents were transmitted late. The facility policy titled Interdisciplinary Group Meeting dated November 2020, documented the case of a patient requesting transfer to another hospice would be reviewed to determine any assistance the patient may need to complete the process.”

“Nevada Revised Statutes (NRS) 449.123 Initial and periodic investigations of employee, employee of temporary employment service or independent contractor of facility, hospital, agency, program or home; penalty. 1.  Except as otherwise provided in subsections 2 and 3, within 10 days after hiring an employee, accepting an employee of a temporary employment service or entering into a contract with an independent contractor, the administrator of, or the person licensed to operate a facility, hospital, agency, program or home shall: (a) Obtain a written statement from the employee, employee of the temporary employment service or independent contractor stating whether he or she has been convicted of any crime listed in NRS 449.174; (b) Obtain an oral and written confirmation of the information contained in the written statement obtained pursuant to paragraph (a); (c) Obtain proof that the employee, employee of the temporary employment service or independent contractor holds any required license, permit or certificate; (d) Obtain from the employee, employee of the temporary employment service or independent contractor one set of fingerprints and a written authorization to forward the fingerprints to the Central Repository for Nevada Records of Criminal History for submission to the Federal Bureau of Investigation for its report; (e) Submit to the Central Repository for Nevada Records of Criminal History the fingerprints obtained pursuant to paragraph (d) to obtain information on the background and personal history of each employee, employee of a temporary employment service or independent contractor to determine whether the person has been convicted of any crime listed in NRS 449.174; and (f) If an Internet website has been established pursuant to NRS 439.942: (1) Screen the employee, employee of the temporary employment service or independent contractor using the Internet website. Upon request of the Division, proof that the employee, temporary employee or independent contractor was screened pursuant to this subparagraph must be provided to the Division. (2) Enter on the Internet website information to be maintained on the website concerning the employee, employee of the temporary employment service or independent contractor. Based on interview, record review and document review, the agency failed to provide documented evidence a current Nevada Automated Background Checks System (NABS) Clearance was obtained for 2 of 14 sampled employees (Employee 6 and 10); and the current NABS Clearance was issued under the name of the agency for 2 of 3 contractual employees (Employee 11 and 12). The deficient practice had the potential for the agency to miss the opportunity to complete a thorough and updated background check of its employees. Findings include: Current NABS Clearance Review of the personnel records revealed Employee 6 and 10 had no current NABS Clearance. Employee 6 was the Social Worker and hired on 04/01/2022. Employee 10 was hired on 01/18/2023 as a Volunteer. NABS Clearance under the name of the agency Review of the personnel records revealed Employee 11 and 12 had no current NABS Clearance under the name of the agency. The NABS Surveyor Report for the agency generated on 01/22/2025, did not include the names of Employee 6, 10, 11, and 12. On 01/31/2025 at 1:16 PM, the Administrator confirmed the findings and acknowledged a current NABS Clearance under the name of the agency should have been obtained for regular and contractual employees to comply with the State requirements for criminal background checks. A previous inquiry was made with the person in-charge of the State Background Check Program. Per email-response of the person in-charge dated 04/02/2024, NABS fingerprint clearance letters were specific to the facility/license they were issued to, and are non-transferrable between facilities (agencies). NABS background clearances were valid for five years of continuous employment with a given facility. They were also valid for up to six months (180 days) between facilities. If the applicant (employee) had received a NABS determination of “Eligible for Employment” within the preceding 180 days, the system would give the option to add the new application with fingerprints NOT required. A clearance letter for that specific facility would be generated by NABS within few minutes of the new application being submitted. Every employee, contractor, or temporary worker of a facility required to use NABS must have an application entered in order to be included on that facility’s employee roster for periodic employment verification, as well as the background clearance requirement.”

“Upon patient record review 4 of 14 (Patient #1,3,7,14) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, 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. Patient #1,7,14, No evidence of MSW and SC initial assess completed. No RN initial assessment of psych social or spiritual completed. Patient #3, No evidence of MSW initial assessment completed. No RN initial assessment of psych social completed.”

“Upon patient record review, 1 of 14 (Patient #3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1, Upon home visit, no evidence of folic acid, levothyroxine, Voltaren, ibuprofen, Senna, vitamin c, probiotic, vascepa, b-complex, on the medication profile. Patient #2, Upon home visit, no evidence of metoprolol, terazosin, vascepa, vitamin k-2, on the medication profile. Patient has cipro and acyclovir that both patient and nurse state he is no longer taking these medications. Both bottles still have medications, no evidence patient completed prescriptions. Patient #3, Upon home visit, no evidence of metformin, flexeril, Morphine ER 15mg bid, on the medication profile. In addition, no evidence oxygen was documented on medication sheet. O2 2-4l/nasal cannula as needed for shortness of breath was documented on treatment sheet.”

“Upon patient record review, 1 of 14 (Patient #7) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #7, No evidence of bereavement assessment completed, bereavement note on 1/30/24, states no family or friends to list. Consents document primary caregiver as Brooke.”

“Upon patient record review, 13 of 14 (Patient #1,2,3,4,6,7,8,9,10,11,12,13,14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1, Pain care plan states to give pain medication. No evidence of pain medication on medication profile. Patient #2, No evidence of psych social or spiritual care plans for funeral planning and spiritual support needed. Patient #3, Patient terminal diagnosis is CKD. No evidence of care plan related to terminal diagnosis. Patient #4, No evidence of psych social care plan on 1/24/24. No evidence of care plan identifying no mortuary per MSW assessment. No spiritual care plans. Patient #6, MSW visit declined, RN documented in MSW note on 2/19/24. MSW made visit on 5/4/24. No evidence of initial psych social care plan. IDG note on 5/1/24 only has respiratory care plan. Patient #7, No evidence of any care plans on 1/26/24. On 3/6/24 only care plan was respiratory. Patient terminal diagnosis is Heart disease. No evidence of cardiac care plan. Patient #8, MSW and SC both completed initial assessment on 1/22/24. No evidence of initial psych social or spiritual care plans. Patient #9, MSW completed visit on 1/13/24. No evidence of psych social care plan. Patient #10, MSW initial visit completed on 11/5/23. No evidence of psych social initial care plan. No evidence of patient full code status addressed on care plans. SC assessment on 11/2/23. No evidence of spiritual care plan. Patient #11,12, MSW initial assessment documented patient is full code and no mortuary. No evidence of of code status or mortuary addressed in care plan. Patient #13, No evidence of initial care plans completed on 12/13/23. No psych social and spiritual cares plan noted on IDG note on 1/24/24. Patient #14, Patient has morphine liquid 100mg/5ml every 4 hours. No evidence of pain care plan”

“Upon client record review, 8 of 14 (Patient #1,3,4,5,6,7,9,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, SC frequency order reads eval and 1 + 3 PRN and recertify. No evidence of identifying the 1 as monthly, weekly or additional PRN. Patient #3, SC made visits on 12/22/23, 3/19/24, 6/17/24. No evidence of any orders for SC visits. Patient #4, SC frequency eval within 5 days, 3 PRN and every recert. SC note on 1/29/24 (patient’s admit date) and 4/25/24 completed as routine visit and in narrative documents patient declined service. No evidence of order to discontinue frequency. Patient #5, MSW and SC services declined. On 4/5/24 noted completed with documentation in narrative stating patient declined services. Patient #6, MSW note on 2/19/24 narrative documents service offered and declined. MSW made visit on 5/4/24 without order for visit. Patient #7, MSW frequency eval, 3 PRN and every recert. No evidence of visits completed. MSW notes on 1/26/24 (patient admitted 1/21) and 4/23/24 documents in narrative, service declined. Patient #9, No evidence of frequency order for SC. Patient was seen on 5/28/24 by SC without order. On 1/8/24 and 4/5/24 RN documented SC offered but declined. MSW frequency eval, 3 PRN and recert. Visit completed 1/13/24 (patient admitted 1/8), recert visit on 4/5/24 was completed by RN stating RN offered and instructed patient importance of MSW service patient declined and verbalized understanding. No dc order. Patient #10, MSW visit made on 1/29/24, 4/28/24 and 6/27/24 document RN offered but declined. SC visits on 4/28/24 and 6/27/24 documented in narrative, offered but declined. No dc order.”

“Upon patient record review, 4 of 14 (Patient #9,11,12,14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #9,11,12, No evidence of parameters for vital signs documented on aide care plan. Patient #14, Aide care plan states, report to RN if any abnormal findings. No evidence of specific findings.”

“Upon patient record review 4 of 14 (Patient #2,8,13,14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2, HHA frequency 3x/week, no evidence of 3 visits the first week. Patient #8, HHA frequency 3x/week, no evidence of 3rd visit completed each week. Patient #13, HHA frequency 5x/week, no evidence of 3rd, 4th and 5th visit for the first week. Patient #14, HHA has order on 11/13/23 for daughter requests HHA effective today, no evidence of frequency order.”

“Upon patient record review 4 of 14 (Patient #8,11,12,14) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #8, No evidence of aide supervisory visits, no sup visits were completed on 3/26, 4/3, 4/9, 4/23, 5/1. Patient #11, No evidence of aide supervisory visits on 12/12, 12/19, 12/24. Patient #12, No evidence of aide supervisory visits on 12/12, 12/18, 12/24, 1/4, 1/11. Patient #14, No evidence of aide supervisory visits on 11/13, 11/21, 11/30, 12/4.”

“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. During survey it was noted there was no oversight of governing body/administrator regarding QAPI as there was no program or activities related. In addition, during survey the administrator admitted to ACHC surveyor and DoV surveyor present, that he had deleted an identified IDG note that was documented on patient #1 that was dated prior to patient SOC date and billed for visits not ordered or requested by patients.”

“Upon patient client record review, 5 of 14 (Patient #1,2,6,10,13) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1, RN note on 6/28/24 narrative documentation of scoliosis, patient does not have scoliosis. Patient #2, IDG note on 6/4/24 missing RN and MSW signature Patient #6,10,13, No evidence of RN signature in initial nursing assessment.”