Survey Report for 551642

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	551642	A. BUILDING __________ B. WING ______________	01/18/2022
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
MGA HOSPICE, INC	121 W. LEXINGTON DR. SUITE 216, GLENDALE, CA, 91203
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0520
L0520	25046 Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Initial and Comprehensive Assessment was met as evidenced by: The hospice agency failed to conduct and document in writing a patient-specific comprehensive assessment that identified the patient's need for hospice care and services, and the patient's need for physical, psychosocial, emotional, and spiritual care for six of six sampled patients (Patient 1, 2, 3, 4, 5, and 6). This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions (L521). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with the Initial and Comprehensive Assessment of Patient to ensure highest quality of care are provided to the patients assessed for eligibility to receive hospice care and services.
L0521	Initial & Comprehensive Assessment Of Patient 418.54 Corrected On: 04/07/2022
	43979 Based on observation, interview, and record review, the hospice failed to conduct a an accurate comprehensive assessment that reflect the patients current health status and identify patients needs for hospice care and services related to hospice eligibility and management of the terminal illness for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6). This deficient practice has the potential for the patients not receiving appropriate healthcare services that could affect their quality of care and quality of life. Findings a. A complaint validation survey was conducted on 1/13/2022, regarding Patient 1 receiving hospice care and had no knowledge as to why the patient was provided hospice care and services. A review of Patient 1's "Face Sheet" form, indicated Patient 1 was admitted to the hospice on 8/20/2020, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (the buildup of plaque inside your arteries) without angina pectoris (chest pain). The end of care date was on 8/11/2021. The referring physician and medical director was Physician 1. The space for authorized representative was left blank. A review of Patient 1's "LCD Hospice Eligibility Determination" (Local Coverage Determination- determining Terminal Status)" of "Heart Disease" dated 8/20/2020 and 6/10/2021, indicated that section 1, "Untreatable Condition" and section 2, "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated Patient 1 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest). A review of Patient 1's clinical record indicated no documented evidence Patient 1 was ruled out as a candidate for surgical procedure related heart disease. Patient 1 declined surgical procedures and Patient 1 was optimally treated for heart disease with diuretics. There was no documented evidence Patient 1 was on complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest. A review of Patient 1's Physician's Certification for Hospice Benefit (CTI - document showed the physician certified a patient's eligibility for hospice benefits), dated 6/16/2021 to 8/14/2021, indicated Patient 1 was awake and oriented x 3 (person, place, and date), on NYHA Class III, and is unable to carry out any physical activity without discomfort. The "Physician Narrative" indicated Patient 1 had a primary diagnosis of heart disease and co-morbidities of hyperlipidemia (high cholesterol), hypertension (high blood pressure), congestive heart failure (weakened heart muscle), diabetes mellitus II (high blood sugar), seizures (stiffness, twitching or limpness), and generalize body weakness. It indicated Patient 1 was assessed to be in status of NYHA III. It indicated Patient 1 was eligible for hospice services and met LCD guidelines. Physician 1 had certified Patient 1 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 1's "Plan of Care (POC/IDG)" form, dated 7/15/2021, indicated License Vocational Nurse (LVN) and Hospice Aide (HA) were declined. Medical Social Worker (MSW) and Spiritual Counselor (SC) was to visit once a month and the Registered Nurse (RN) was to visit every 14 days. A review of Patient 1's Comprehensive Nursing Assessment dated 8/20/2020 indicated Patient 1 was awake, alert, and oriented x 3 (time, place, person), and had normal speech. Patient 1 was ambulatory with the use of walker and needed moderate assistance. Cardiac rate was regular, at 75 beats per minute, no edema observed. Patient 1's NYHA class III (New York Heart Association class - Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea). Patient 1's mobility was completely immobile, and activity was bedfast. Patient 1 was unable to perform physical activity without dyspnea (difficulty or labored breathing). The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None". A review of Patient 1's Licensed Vocational Nurse (LVN) clinical notes dated 7/27/2021 & 8/10/2021 indicated Patient 1 was placed on NYHA class III (New York Heart Association class - Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea). A review of Patient 1's Registered Nurse (RN) clinical notes dated 7/22/2021 & 8/5/2021 indicated Patient 1 was placed on NYHA class III (New York Heart Association class - Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea). A review of Patient 1's Discharge/Transfer Summary dated 8/11/2021, indicated Patient 1 revoked hospice services due to wanting to visit her cardiologist regarding continuing care. During a complaint validation survey on 1/14/2022 at 3:36 p.m., Patient 1's Care Giver (CG 1) was contacted by telephone and was unsuccesful. During a complant investigation using the State process, a telephone interview on 11/29/2021, at 11:45 a.m., with Patient 1's CG 1, CG 1 stated Patient 1 lived at Assisted Living Facility (ALF 2) for over a year. CG 1 stated Patient 1 always goes out for walks and currently out walking. During a complaint validation survey on 1/14/2022 at 3:36 p.m., Patient 1 was contacted by telephone and was unsuccesful. During a complaint investigation using the State process, a telephone interview on 11/29/2021, at 12:45 p.m., Patient 1 stated, "I have been here for about a year and that's how long I've been in hospice. My granddaughter brought me here to this facility (ALF 2), she found this hospice house. When asked if she knew what hospice services meant, Patient 1 stated, "Yes, they explained to me that a nurse would come check on me once a week and take my temperature and check my blood pressure". When asked if she was terminally ill, Patient 1 stated, "No, I have heart issues, but I am fine. No one ever told me I'm terminally ill". When asked if she knew hospice is palliative care, not preventative or curative, Patient 1 stated, "No. I never knew that. I just thought I'm in a hospice house, but I wanted to go to my regular doctor who I've been going to for over 10 years and they told me I can't, so I didn't want to have it anymore. My primary doctor was Physician 5. I want to be seen by her and went back to her." During a complaint investigation using the State process, a telephone interview on 12/2/2021, at 2:22 p.m., with Patient 1's physician (Physician 5), Physician 5 stated, "Patient 1, has been my patient since March 30, 2017, her last visit was on October 18, 2021. I had another visit from her on January 8, 2020 post hospitalization, follow up on ER (Emergency Room) for cough and weakness 2020 visit. Her medical conditions were, hypertension, diabetes type II, hyperlipidemia, chronic kidney disease stage 3, seizure disorder, osteoporosis". When asked if she referred Patient 1 to hospice, Physician 5 stated, "No, I never referred Patient 1 to hospice and was not aware she received hospice services. No one from hospice called to ask me anything". When asked if Patient 1 was a hospice candidate, Physician 5 stated, "No, it was my medical opinion she was not a hospice candidate." During a concurrent interview and record review on 1/18/2022 at 11:30 a.m., of Patient 1's medical records, with License Vocational Nurse 1 (LVN 1), LVN 1 was unable to find who Patient 1's primary doctor (before hospice services). LVN 1 was unable to verify or find any documented evidence Patient 1 was ruled out as a candidate for surgical procedure related heart disease, Patient 1 declined surgical procedures or that Patient 1 was optimally treated for heart disease with diuretics. There was no documented evidence that indicated Patient 1 was at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest, that determined Patient 1 met the criteria for "NYHA Class IV". LVN 1 could not provide the documented evidence that Patient 1 was eligible to receive hospice care. b. A review of Patient 2's "Face Sheet" from, indicated Patient 2 was admitted to the hospice on 5/15/2021, with a primary diagnosis of heart disease, unspecified. The referring physician and medical director was Physician 1. The end of care date of 12/2/2021. A review of Patient 2's "LCD Hospice Eligibility Determination" (Local Coverage Determination- determining Terminal Status)" of "Heart Disease" dated 5/15/2021 and 11/6//2021, indicated that section 1, "Untreatable Condition" and section 2, "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated that Patient 2 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest). A review of Patient 2's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified the patient's eligibility for hospice benefits), dated 5/15/2021 to 8/12/2021 and another CTI dated 8/13/2021 to 11/10/2021, indicated that Patient 2 was awake and oriented x 3 (person, place, and date), on NYHA Class IV, and is unable to carry out any physical activity without discomfort. In the space "Physician Narrative" indicated Patient 2 had a primary diagnosis of heart failure and has no co-morbidities listed. It indicated Patient 2 was ambulatory on moderate to maximum assistance. It indicated Patient 2 was assessed to be in status of NYHA IV. It indicated Patient 2 was eligible for hospice services and met LCD guidelines. It indicated Physician 1 certified Patient 2 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 2's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 11/11/2021 to 1/9/2022 indicated Patient 2 was currently homebound since leaving home requires taking effort. The space "Physician Narrative" is blank. A review of Patient 2's "Plan of Care (POC/IDG)" form, dated 5/20/2021 & 11/18/2021, indicated License Vocational Nurse (LVN) was to visit twice a week and 1 as needed (PRN) and Medical Social Worker (MSW) was to visit once a month and 1 PRN. There were no visit for other disciplines (Hospice aid, Chaplain, Volunteer, or Registered Nurse). A review of Patient 2's Comprehensive Nursing Assessment dated 5/15/2020 indicated Patient 2 was awake, alert, and oriented x 3 (time, place, person), and had limited speech. Patient 2 was ambulatory by using walker and wheelchair. Cardiac rate was regular, at 77 beats per minute, no edema observed. Patient 2's NYHA class IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest). Patient 2's mobility was very limited, and activity was chairfast. Patient 2 was unable to perform physical activity without dyspnea (difficulty or labored breathing). The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None". A review of Patient 2's Discharge/Transfer Summary dated 12/2/2021, indicated Patient 2 revoked hospice services due to contacting his primary care physician and his cardiologist to start to seek treatment for his diagnosis. During a telephone interview on 1/14/2022 at 3:19 p.m., with Patient 2, Patient 2 stated that he was referred to hospice by a friend, (Friend 1) and was told that hospice was a way to get taken care of when he needed help. He was not aware of what hospice was. Patient 2 stated that he has never been told that he has or had a terminal illness. Patient 2 stated, "I do have heart issues, but that is all". When asked, how long he was in hospice, Patient 2 stated, "A very short time. I tried to go back to my own doctor. I told her that I don't want this, and I don't need it. I see my doctor every 3 months; I've been doing it for years. That's why I wanted to get out of hospice because I couldn't see my own doctor". Patient 2 was asked what the hospice staff would do when they visit, Patient 2 stated, "They did a decent job, but it was interfering me from seeing my regular doctor and I did not appreciate that at all. I don't want to get anyone in trouble, but it was not for me. As soon as I realized I was not able to see my doctor when I wanted to, I got out." Patient 2 stated, a nurse just showed up one day and said you're on hospice. They told me they would take my blood pressure and vitals. I let them know I don't have a terminal illness. A nurse practitioner showed up once or twice. I mentioned to them that I want to be able to see my regular doctors. I don't know what this is all about. I used to see Physician 6 at Medical Office 1 but, she was not there anymore, and I'm supposed to see a doctor, Physician 7, and my cardiologist that I go to was Physician 8. I had a heart attack a few years ago and I have CHF. I do little driving, I have a car service that takes me places, but I need to see my doctors". When asked if any of his doctors recommended hospice services or are aware that he has hospice, Patient 2 stated, "No, none of my doctors recommended hospice, I haven't told them they signed me up, I don't even know how I got signed up." Patient 2 stated, "I'm on my way to see my doctor." When asked if he has shortness of breath, Patient 2 stated, "No, I don't have any shortness of breath. I told you, I have had a few heart issues but I'm pretty health for the most part. The next time anyone from that hospice comes, I am going to be very suspicious about it and tell them to leave." During an interview on 1/18/2020 at 11:20 a.m. with ADM. ADM was asked how they get patient referrals, ADM stated, "We get patients through word-of-mouth referrals, we pass out brochures, and if a patient is discharged from the hospital, we also get referrals from the hospital. During a concurrent interview and record review on 1/18/2022 at 11:45 a.m., of Patient 2's medical records, with License Vocational Nurse 1 (LVN 1). LVN 1 was unable to find who Patient 2's primary doctor was (before hospice services). LVN 1 stated, "I don't know, it is not in the patients chart". LVN 1 was unable to verify or find any documented evidence Patient 2 was ruled out as a candidate for surgical procedure related heart disease, or Patient 2 declined surgical procedures. c. During a joint home visit to Patient 6's home at the Assisted Living Facility 2, on 1/14/2022 at 10 a.m., with License Vocational Nurse 3 (LVN 3), Patient 6 was observed fully clothed, resting on bed, and watching television. Patient 6 was awake, alert, and oriented, was able to state name and date of birth. Patient 6 was unable to communicate well, and was unable to answer questions asked. Patient 6 remained quiet when asked questions. A review of Patient 6's "Face Sheet" from, indicated Patient 6 was admitted to the hospice on 2/3/2018, with a primary diagnosis of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills) and comorbidities of anxiety, seizure disorder, osteoarthritis (degeneration of joint cartilage and the underlying bone) and generalize body weakness. The referring physician and medical director was Physician 1. A review of Patient 6's "LCD Hospice Eligibility Determination" (Local Coverage Determination- determining Terminal Status)" of "Dementia due to Alzheimer's" dated 2/3/2018 and 11/12/2021, indicated that section 1, "Activity of Daily Living (ADL)" must be met and at least one in section 2 "Documented History/Progression of at least any One of the following" must be met. LCD section 2f (Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl) has been marked as "Yes." A review of Patient 6's Acute Hospital 2 (AC2) notes dated 2/1/2018, indicated Patient 6 was admitted on 2/1/2018 and had a weight recorded at 163 pounds (lb.) 8 ounces (oz). A review of Patient 6's record indicated there was no documented evidence Patient 6 had a 10% weight loss during the previous six months or a serum albumin <2.5 gm/dl. A review of Patient 6's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 11/14/2021 to 1/12/2022. The "Physician Narrative" indicated Patient 6 had declining appetite with 10% weight loss last 6 months. It indicated Patient 6 continued to meet LCD guidelines for hospice care. A review of Patient 6's "Plan of Care" (POC) form, dated 1/30/2022, indicated Hospice Aid (HA) was to visit twice per week, License Vocational Nurse (LVN) was to visit twice a week and 1 as needed (PRN) and Medical Social Worker (MSW) was to visit once a month and 1 PRN. There were no visit for other disciplines (Chaplain, Volunteer, or Registered Nurse). A review of Patient 6's Comprehensive Nursing Assessment dated 2/3/2018 indicated Patient 6 was confused and disoriented. Patient 6's mobility was very limited, and activity was bedfast. The section for "Personal Care and Support Needs" indicated the need for volunteer, and community support were marked as "None". During a concurrent interview and record review of Patient 6's medical record on 1/18/2022 at 12 p.m., with License Vocational Nurse 1 (LVN 1), LVN 1 was unable to verify or provide any documented evidence Patient 6 had a 10% weight loss as indicated on Patient 6's LCD dated 2/3/2018 or 11/12/2021. LVN 1 could not provide the documented evidence that Patient 6 was eligible to receive hospice care. During a telephone interview on 1/18/2022 at 12:26 p.m., with Physician 1, Physician 1 stated, "I'll have my people call you back later. I'm driving right now. I can't answer any questions before I go over them with my attorney either way." During a telephone interview on 1/18/2022 at 12:31 p.m., with the hospice facility's Nurse Practitioner (NP), NP stated had been working at facility for 3-4 months with Physician 1. NP stated that the admission process consists of them receiving a prescription or referral, then the patient's history and physical was reviewed. NP stated, "then we send an RN to do the hospice evaluation. Then we all meet with the IDT (interdisciplinary team) to initiate a care plan. MD does the initial visit and I do the follow up, usually." NP stated that patients must fit within the LCD guidelines according to their diagnosis and it should have been documented in the clinical records. A review of facility Policy and Procedure titled, "Admission Criteria and Process" undated, indicates, "The patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs) ... The patient must have a life-limiting illness with a life expectancy of six (6) months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determination ...Eligibility criteria will be continually reviewed by the interdisciplinary team to ensure appropriate of hospice care ... If the request for service is not made by the patient's physician, he/she will be consulted prior to the evaluation visit/initiation of services." A review of facility's Policy and Procedure titled, "Comprehensive Assessment", undated, indicates. "During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least the following information, as relevant: C. Nature and condition causing admission (including the presence or lack of objective data and subjective complaints). A review of facility's Policy and Procedure titled, "Certification of Terminal Illness", undated, indicates, clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. 25046 d. A review of Patient 3's Patient Intake form indicated patient was admitted to the hospice facility on 4/1/2021, with diagnosis of unspecified heart disease. The referring physician was Physician 1, who was also the Medical Director of the hospice facility. A review of Patient 3's Comprehensive Assessment, dated 4/1/2021, indicated Patient 3 was awake, alert and oriented x 3, and had normal speech. Patient 3 was ambulatory with the use of a cane and walker and needed moderate assistance. Cardiac rate was regular, no edema observed, and no pain or chest discomfort noticed. Patient 3 had episodes of moderate dyspnea (difficult or labored breathing) on exertion. The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None". The Plan of care (POC) dated 10/7/2021 indicated LVN was to visit Patient 3 once a week. There were no visits indicated for other disciplines ( Hospice aid, Medical Social Worker, Chaplain, or volunteer) indicated in the POC. A review of Patient 3's form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine patient's eligibility for hospice services) of "Heart Disease," dated 4/21/2021, indicated sections for "untreatable condition" and "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated Patient 3 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of Patient 3's clinical record indicated there was no documented evidence Patient 3 was ruled out as a candidate for surgical procedure related heart disease, Patient 3 declined surgical procedures and was optimally treated for heart disease with diuretics and vasodilators. There was no documented evidence indicated Patient 3 had discomfort and symptom occurred at rest that determined Patient 3 met the criteria for "NYHA Class IV." A review of the form titled, "Certificate of Terminal Illness," (the document that showed a physician certified a patient's eligibility for hospice benefit), dated 4/1/2021, indicated Patient 3 was awake, oriented x 3, had episodes of moderate dyspnea during exertion. The "Physician Narrative" indicated Patient 3 had diagnoses of heart disease and co-morbidities of hypertension, generalized weakness, and constipation. Patient 3 was assessed to be in status of NYHA IV (symptom occurred at rest). It indicated Patient 3 was eligible for hospice service and met LCD guide lines. The Physician 1 had certified Patient 3 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. A review of the Discharge/Transfer Summary, dated 10/21/2021, indicated Patient 3 was discharged from the hospice due to non-compliance with the plan of care. It was indicated Patient 3 had declined SN visit for 2 weeks and was not answering or returning phone calls. During the complaint validation survey on 1/14/2022, an attempt to contact Physician 2 by telephone and was unsuccessful. On 11/30/2021, at 12:15 p.m. during a complaint investigation under the State process, a telephone interview with Physician 2 was conducted. Physician 2 stated Patient 3 had been his patient for a long time, and Patient 3 came to his office every three months. Patient 3 had stopped coming a little while but he was back. Physician 2 stated he was not aware Patient 3 was receiving hospice services and no one contacted him. Physician 2 stated that Patient 3 did not have any terminal illnesses and he was not a hospice candidate in Physician 2's medical opinion. On 1/14/2022, at 3:50 p.m., during a telephone interview with Patient 3, he stated that he smokes and had high blood pressure, but he did not think he would die soon. Patient 3 stated he was referred to the hospice agency by the owner of the house where the patient was residing. Patient 3 stated the hospice staff told him that the nurse would come to take blood pressure and temperature, and would give him medications for high blood pressure. Patient 3 stated two nurses from the hospice visited him, but he did not meet any doctor from the hospice. Patient 3 stated he does not have to take the train or bus to go to the physician's office every three months to get medications. During an interview and a concurrent record review with the Administrator and Licensed Vocational Nurse 1 (LVN 1) on 1/14/2022, at 4:10 p.m., both were not able to find the documented evidence in the record that indicated Patient 3 had symptoms at rest, and the supportive evidence of LCD assessment dated 4/21/2021. Both Administrator and LVN 1 could not provide the documented evidence that Patient 1 was eligible to receive the hospice care. On 1/18/2022, at 12:25 p.m., during a telephone interview with Physician 1, stated he could not answer the questions before he went over the questions with his attorney. On 1/18/2022, at 12:30 p.m., during a telephone interview with Nurse Practitioner 1 (NP 1), who had worked with Physician 1, NP stated the patients at the hospice facility became Physician 1's patients upon admission to the hospice. NP 1 stated the patients must meet the LCD guideline according to the diagnoses and it should have been documented in the clinical record. e. During Patient 4's joint home visit at assisted living facility with Licensed Vocational Nurse 2 (LVN 2) on 1/14/2022 at 11 a.m., Patient 4 was observed lying in a bed. Patient 4 was awake and alert, denied pain, and not able to communicate well. A review of Patient 4's Patient Intake form indicated Patient 4 was admitted to the hospice agency on 7/26/2021, with diagnosis of senile degeneration of brain. The referring physician was Physician 1. A review of the Comprehensive Assessment, dated 7/29/2021, indicated Patient 4 was awake and alert, able to verbalize pain, but confused and disoriented. Patient 4 was ambulatory by using walker and needed maximum assist. The space for the height, weight, and mac (mid-arm circumference -used for monitoring the nutritional status of patients in emergency situations and recommended for the assessment of acute malnutrition in adults) were blank. A review of the form titled, "Certificate of Terminal Illness," dated 7/26/2021, in the physician narrative indicated Patient 4 had increased weakness and confusion, consuming 65-70 percent of meals daily. It indicated Patient 4 was appropriate for LCD eligibility. Physician 1 certified Patient 1 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. A review of the form titled, "LCD Hospice Eligibility Determination" of "Dementia due to Alzheimer's" dated 7/26/2021, indicated Patient 4 met the criteria for the sections for "ADL" (Activities of Daily Living) and "History/Progression" of "inability to maintain sufficient fluid and calorie intake with 10 % (percent) weight loss during the previous six months or serum albumin (albumin is a protein in the blood) was less than 2.5 gram (gm)/deciliter (dl)" (The normal range of serum albumin is 3.4 to 5.4 g/dl) that determined Patient 4 was eligible for hospice services. A review of the acute hospital notes dated 7/24/2021, indicated Patient 4's estimated weight was 81 kilogram and albumin level was 3.3. gram (gm)/deciliter (dl). A review of Patient 4's record indicated no documented evidence the patient had 10 percent weight loss during the previous six months or serum albumin level was less than 2.5 gm/dl. During an interview and a concurrent record review with the Licensed Vocational Nurse 1 (LVN 1) on 1/18/2022, at 10:45 a.m., LVN 1 was not able to find the documented evidence in the record to indicate Patient 4 had 10 percent weight loss or serum albumin level was less than 2.5 gm/dl, as indicated in the LCD, dated 7/26/2021. LVN 1 was not able to provide the documented evidence Patient 4 was eligible to receive hospice care. On 1/18/2022, at 12:25 p.m., during a telephone interview with Physician 1, stated he could not answer the questions before he went over the questions with his attorney. On 1/18/2022, at 12:30 p.m., during a telephone interview with Nurse Practitioner 1 (NP 1), who had worked with Physician 1, stated the patients at the hospice agency became Physician 1's patients upon admission to the hospice. NP 1 stated the patients must meet the LCD guideline according to the diagnoses and it should have been documented in the clinical record. f. During Patient 5'
	s joint home visit at assisted living facility with Licensed Vocational Nurse 2 (LVN 2) on 1/14/2022 at 11:25 a.m., Patient 5 was observed lying in a bed. Patient 5 was awake and alert, denied pain. Patient 5 was able to answer to the simple question by saying "yes" or "no". A review of Patient 5's Patient Intake form indicated Patient 5 was admitted to the hospice agency on 10/7/2021, with diagnosis of Alzheimer's disease. The referring physician was Physician 1. A review of the Comprehensive Assessment, dated 7/29/2021, indicated Patient 5 was awake and alert and oriented, able to verbalize pain. Patient 5 was ambulatory with the use of a walker and needed moderate assist. The space for the height, weight, and mac (Mid-arm circumference -used for monitoring the nutritional status of patients in emergency situations and recommended for the assessment of acute malnutrition in adults) were blank. A review of the form titled, "Certificate of Terminal Illness," dated 10/6/2021, indicated the space for physician narrative was blank. It was indicated in the space for "Certifying Physician Summary as follows: "It is my clinical judgement that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to the hospice agency. I have been encouraged to participate in the IDG meeting and Plan of care" "I attest/confirm that I composed the narrative based on my review of Patient 5's medical record, team assessment and/or examination of the patient" A review of the form titled, "LCD Hospice Eligibility Determination" of "Dementia due to Alzheimer's" dated 10/7/2021, indicated Patient 5 met the criteria for the sections for "ADL" (Activities of Daily Living) and "History/Progression" of "inability to maintain sufficient fluid and calorie intake with 10 % (percent) weight loss during the previous six months or serum albumin (albumin is a protein in the blood) was less than 2.5 gram (gm)/deciliter (dl)" (The normal range of serum albumin is 3.4 to 5.4 g/dl) that determined Patient 5 was eligible for hospice services. A review of Patient 5's record indicated there was no documented evidence Patient 5 had 10 percent weight loss during the previous six months or serum albumin level was less than 2.5 gm/dl. During an interview and a concurrent record review with the Licensed Vocational Nurse 1 (LVN 1) on 1/18/2022, at 10:45 a.m., LVN 1 was not able to provide the documented evidence in the record to indicate Patient 5 had 10 percent weight loss or serum albumin level was less than 2.5 gm/dl, as indicated in the LCD, dated 10/7/2021. LVN 1 was not able to find the documented evidence Patient 5 was eligible to receive the hospice care. During a telephone interview with Family Member (FM) 1, on 1/18/2022, at 11:15 a.m., FM1 stated Patient 5 had been under Physician 1's care for years, and did not think Patient 5 will die within 6 months. On 1/18/2022, at 12:25 p.m., during a telephone interview, Physician 1 stated he could not answer the questions before he goes over the question with his attorney. On 1/18/2022, at 12:30 p.m., during a telephone interview with Nurse Practitioner 1 (NP 1), who had worked with Physician 1, the NP stated the patients at the agency became Physician 1's patients upon admission to the agency. NP 1 stated the patients must meet the LCD guideline according to the diagnoses and it should have been documented in the clinical record. On 1/20/2022, at 4 p.m., during a telephone interview, Physician 4 stated she had been Patient 5's doctor since August 2018 and did not refer the patient for hospice care. Physician 4 stated she was not contacted by anybody for consultation regarding Patient 5's hospice enrollment. Physician 4 stated Patient 5 was not eligible to receive hospice care. A review of the agency's undated policy titled "Admission Criteria and Process" indicated the hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patient's attending physician, if any. The patient's life-limiting illness and prognosis of six months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). It indicated that during the initial visit, the admitting clinician will review the patient's eligibility for hospice services, according to the admission criteria and standard prognosis criteria to determine/confirm further.
L0536
L0536	25046 Based on observation, interview, and record review, the hospice facility failed to ensure the Condition of Participation for IDG, Care Planning, Coordiantion of Services was met as evidenced by: 1. The hospice agency failed to ensure that one of six sampled patients and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care for one of six sampled patients (Patient 4). (Refer to L544) 2. The hospice agency failed to develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures to: Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions for five of six patients (Patients 1, 2, 3, 5, and 6). (Refer to L558) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with IDG, Care Planning, and Coordination of Services to ensure highest quality of care are provided to the patients accurately assessed to receive hospice care and services.
L0544
L0544	25046 Based on observation, interview and record review, the hospice staff failed to ensure primary care giver(s) received instructions and training to monitor and document one of six sampled patients (Patient 4) blood pressure related to hypotention (low BP) as identified in the plan of care. Patient 4's plan of care identified the patient has the potential for altered cardiac status related to hypotension (low blood pressure {BP}) and was receiving Midodrine medication as needed to treat systolic BP less than 100 millimeter mercury (mmHg). There was no evidence the hospice staff gave instructions or training to the primary caregiver(s) to monitor and document the patient's BP in the clinical record. This deficient practice has the potential for the patient's low BP will not be identified and not treated promptly that could lead to complications such as severe dizziness and fainting. Findings: A review of Patient 4's Patient Intake form indicated Patient 4 was admitted to the hospice on 7/26/2021, with diagnosis of senile degeneration (loss of intellectual ability) of brain. A review of Patient 4's plan of care (POC) dated 12/16/2021, indicated the Registered Nurse (RN) visit was two times per month, Licensed Vocational Nurse (LVN) visit was two times per week and one as needed, hospice aide (HA) visit was two times per week, Medical Social Worker (MSW) and spiritual counselor visits were one time per month and one time as needed. The POC included the physician's order dated 9/3/2021, for Midodrine 2.5 milligram (mg) one tablet three times a day as needed if systolic blood pressure was less than 100 millimeter mercury (mmHg). A review of Patient 4's POC (target date:1/13/2022) indicated the patient had potential for altered cardiac status related to hypotension and Midodrine will be administered as prescribed by the hospice doctor. On 1/14/2022, at 11 a.m., during a joint home visit with licensed vocational nurse (LVN 2) at the assisted living facility, where Patient 4 resided, the patient was observed lying in a bed. Patient 4 was awake, alert, denied pain, and had difficulty to communicate. On 1/14/2022, at 12:15 p.m., all medications Patient 4's was currently taking were reviewed. One of the medications listed included Midodrine HCL 2.5 mg. to treat low BP. It indicated to administer Midodrine HCL 2.5 mg. as needed to treat systolic BP less than 100 millimeter mercury (mmHg). On 1/14/2022, at 12:30 p.m., during an interview with the owner (Owner 1), at the assisted living facility, he stated caregivers at the facility had been checking Patient 4's blood pressure everyday when the hospice nurse does not visit Patient 4. The BP monitoring documentation was requested, however, Owner 1 was not able to provide the documented evidence Patient 4's blood pressure was monitored after October 2021. During a concurrent interview with LVN 2, he stated the caregivers at the assisted living facility should have checked Patient 4's blood pressure on non- SN visit days. On 1/18/2022, at 1:35 p.m., during an interview with LVN 1, stated she was not able to find the documented evidence that caregivers were instructed to check Patient 4's blood pressure everyday on non-SN visit day for possible administration of Midodrine HCL 2.5 mg. A review of the agency's undated policy titled, "Medication Profile" indicated each patient and/or family/caregiver will receive appropriate written teaching materials for specific medications he/she is receiving. The material should contain information on actions of the medication, potential side effects, contraindications, and any special instructions when taking the specific medication.
L0558
L0558	43979 Based on interview and record review, the hospice agency failed to facilitate the exchange of information and coordination between the hospice staff and the patients' primary/attending physicians to provide hospice services to five of six patients (Patients 1, 2, 3, 5, and 6). This failure had the potential to result in the lack of coordination by the healthcare personnel to accurately assess the general health condition and eligibility of the patients to be provided hospice care and services that could affect their quality of care and quality of life. Findings: a. A complaint validation survey was conducted 1/13/2022, regarding Patient 1 receiving hospice care and had no knowledge as to why the patient was provided hospice care and services. A review of Patient 1's "Face Sheet" form, indicated Patient 1 was admitted to the hospice agency on 8/20/2020 and an end of care date of 8/11/2021, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (the buildup of plaque inside your arteries) without angina pectoris (chest pain). The referring physician and medical director was Physician 1. The space for authorized representative was left blank. A review of Patient 1's "LCD Hospice Eligibility Determination" (Local Coverage Determination- determining Terminal Status)" of "Heart Disease" dated 8/20/2020 and 6/10/2021, indicated that section 1, "Untreatable Condition" and section 2, "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated that Patient 1 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest). A review of Patient 1's record indicated there was no documented evidence Patient 1 was ruled out as a candidate for surgical procedure related heart disease, Patient 1 declined surgical procedures and Patient 1 was optimally treated for heart disease with diuretics. There was no documented evidence that indicated Patient 1 was at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest, that determined Patient 1 met the criteria for "NYHA Class IV." A review of Patient 1's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 6/16/2021 to 8/14/2021, indicated that Patient 1 was awake and oriented x3 (person, place, and date), on NYHA Class III, and is unable to carry out any physical activity without discomfort. The "Physician Narrative" indicated Patient 1 had a primary diagnosis of heart disease and co-morbidities of hyperlipidemia (high cholesterol), hypertension (high blood pressure), congestive heart failure (weakened heart muscle), diabetes mellitus II (high blood sugar), seizures (stiffness, twitching or limpness), and generalize body weakness. It indicated Patient 1 was assessed to be in status of NYHA III. It indicated Patient 1 was eligible for hospice services and met LCD guidelines. It indicated the Physician 1 had certified that Patient 1 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 1's "Plan of Care (POC/IDG)" form, dated 7/15/2021, indicated License Vocational Nurse (SN) and Hospice Aide (HA) were declined. Medical Social Worker (MSW) and Spiritual Counselor (SC) was to visit once a month and the Registered Nurse (RN) was to visit every 14 days. A review of Patient 1's Comprehensive Nursing Assessment dated 8/20/2020 indicated Patient 1 was awake, alert, and oriented x3 (time, place, person), and had normal speech. Patient 1 was ambulatory by using walker and needed moderate assistance. Cardiac rate was regular, at 75 beats per minute, no edema observed. Patient 1's NYHA class III (New York Heart Association class - Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea). Patient 1's mobility was completely immobile, and activity was bedfast. Patient 1 was unable to perform physical activity without dyspnea (difficulty or labored breathing). The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." A review of Patient 1's Licensed Vocational Nurse (LVN) clinical notes dated 7/27/2021 & 8/10/2021 indicated Patient 1 was placed on NYHA class III (New York Heart Association class - Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea). A review of Patient 1's Registered Nurse (RN) clinical notes dated 7/22/2021 & 8/5/2021 indicated Patient 1 was placed on NYHA class III (New York Heart Association class - Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea). A review of Patient 1's Discharge/Transfer Summary dated 8/11/2021, indicated Patient 1 revoked hospice services due to wanting to visit her cardiologist regarding continuing care. During a complaint validation survey on 1/14/2022 at 3:36 p.m., Patient 1's Care Giver (CG 1) was contacted by telephone and was unsuccesful. During a complaint investigation using the State process, a telephone interview on 11/29/2021, at 11:45 a.m., with Patient 1's CG 1, CG 1 stated Patient 1 lived at Assisted Living Facility (ALF 2) for over a year. CG 1 stated Patient 1 always goes out for walks and currently out walking. During a complaint validation survey on 1/14/2022 at 3:36 p.m., Patient 1 was contacted by telephone and was unsuccesful. During a complaint investigation using the State process, a telephone interview on 11/29/2021, at 12:45 p.m., with Patient 1, Patient 1 stated, "I have been here for about a year and that's how long I've been in hospice. My granddaughter brought me here to this facility (ALF 2), she found this hospice house. When asked if she knew what hospice services meant, Patient 1 stated, "Yes, they explained to me that a nurse would come check on me once a week and take my temperature and check my blood pressure". When asked if she was terminally ill, Patient 1 stated, "No, I have heart issues, but I am fine. No one ever told me I'm terminally ill". When asked if she knew hospice was palliative care, not preventative or curative, Patient 1 stated, "No. I never knew that. I just thought I'm in a hospice house, but I wanted to go to my regular doctor who I've been going to for over 10 years and they told me I can't, so I didn't want to have it anymore. My primary doctor is Physician 5. I want to be seen by her and had went back to her." During a complaint investigation using a State process, a telephone interview on 12/2/2021, at 2:22 p.m., with Patient 1's physician (Physician 5), Physician 5 stated, "Patient 1, has been my patient since March 30, 2017, her last visit was on October18, 2021. I had another visit from her on January 8, 2020 post hospitalization, follow up on ER (Emergency Room) for cough and weakness 2020 visit. Her medical conditions are, hypertension, diabetes type II, hyperlipidemia, chronic kidney disease stage 3, seizure disorder, osteoporosis". When asked if she referred Patient 1 to hospice, Physician 5 stated, "No, I never referred Patient 1 to hospice and was not aware she received hospice services. No one from hospice called to ask me anything". When asked if Patient 1 was a hospice candidate, Physician 5 stated, "No, it was my medical opinion that she was not a hospice candidate." During a concurrent interview and record review on 1/18/2022 at 11:30 a.m., of Patient 1's medical records, with Licensed Vocational Nurse 1 (LVN 1). LVN 1 was unable to find who Patient 1's primary doctor (before hospice services). LVN 1 was unable to verify or find any documented evidence Patient 1 was ruled out as a candidate for surgical procedure related heart disease, Patient 1 declined surgical procedures or that Patient 1 was optimally treated for heart disease with diuretics. Also, there was no documented evidence that indicated Patient 1 was at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest, that determined Patient 1 met the criteria for "NYHA Class IV". LVN 1 could not provide the documented evidence that Patient 1 was eligible to receive hospice care. b. A review of Patient 2's "Face Sheet" from, indicated Patient 2 was admitted to the hospice agency on 5/15/2021 and an end of care date of 12/2/2021, with a primary diagnosis of Heart Disease, unspecified. The referring physician and medical director was Physician 1. A review of Patient 2's "LCD Hospice Eligibility Determination" (Local Coverage Determination- determining Terminal Status)" of "Heart Disease" dated 5/15/2021 and 11/6//2021, indicated that section 1, "Untreatable Condition" and section 2, "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated that Patient 2 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest). A review of Patient 2's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 5/15/2021 to 8/12/2021 and another CTI dated 8/13/2021 to 11/10/2021, indicated that Patient 2 was awake and oriented x3 (person, place, and date), on NYHA Class IV, and is unable to carry out any physical activity without discomfort. In the space "Physician Narrative" indicated Patient 2 had a primary diagnosis of heart failure and has no co-morbidities listed. It also indicated; Patient 2 is ambulatory on moderate to maximum assistance. It indicated Patient 2 was assessed to be in status of NYHA IV. It indicated Patient 2 was eligible for hospice services and met LCD guidelines. It indicated Physician 1 certified Patient 2 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 2's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 11/11/2021 to 1/9/2022 indicated Patient 2 was currently homebound since leaving home requires taking effort. The space "Physician Narrative" is blank. A review of Patient 2's "Plan of Care (POC/IDG)" form, dated 5/20/2021 & 11/18/2021, indicated License Vocational Nurse (LVN) was to visit twice a week and 1 as needed (PRN) and Medical Social Worker (MSW) was to visit once a month and 1 PRN. There were no visit for other disciplines (Hospice aid, Chaplain, Volunteer, or Registered Nurse). A review of Patient 2's Comprehensive Nursing Assessment dated 5/15/2020 indicated Patient 2 was awake, alert, and oriented x3 (time, place, person), and had limited speech. Patient 2 was ambulatory by using walker and wheelchair. Cardiac rate was regular, at 77 beats per minute, no edema observed. Patient 2's NYHA class IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest). Patient 2's mobility was very limited, and activity was chairfast. Patient 2 was unable to perform physical activity without dyspnea (difficulty or labored breathing). The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None". A review of Patient 2's Discharge/Transfer Summary dated 12/2/2021, indicated Patient 2 revoked hospice services due to contacting his primary care physician and his cardiologist to start to seek treatment for his diagnosis. During a telephone interview on 1/14/2022 at 3:19 p.m., with Patient 2, Patient 2 stated, a nurse just showed up one day and said you're on hospice. They told me they would take my blood pressure and vitals. I let them know I don't have a terminal illness. A nurse practitioner showed up once or twice. I mentioned to them that I want to be able to see my regular doctors. I don't know what this is all about. I used to see ... (Physician 6) at ... (Medical Office 1) but, she is not there anymore, and I'm supposed to see a doctor ... (Physician 7), and my cardiologist that I go to is ... (Physician 8). I had a heart attack a few years ago and I have CHF. I do little driving, I have a car service that takes me places, but I need to see my doctors". When asked if any of his doctors recommended hospice services or are aware that he has hospice, Patient 2 stated, "No, none of my doctors recommended hospice, I haven't told them they signed me up, I don't even know how I got signed up." Patient 2 stated that he was referred to hospice by a friend, (Friend 1) and was told that hospice was a way to get taken care of when he needed help. He was not aware of what hospice was. Patient 2 stated that he has never been told that he has or had a terminal illness. Patient 2 stated, "No, I thank God that I don't have one. I do have heart issues, but that is all." When asked, how long were you in hospice? Patient 2 stated, "A very short time. I tried to go back to my own doctor. I told her that I don't want this, and I don't need it. I see my doctor every 3 months; I've been doing it for years. That's why I wanted to get out of hospice because I couldn't see my own doctor". When asked, what hospice staff would do when they do a visit? Patient 2 stated, "They did a decent job, but it was interfering from me seeing my regular doctor and I did not appreciate that at all. I don't want to get anyone in trouble, but it was not for me. As soon as I realized I was not able to see my doctor when I wanted to, I got out." Patient 2 stated, "I'm on my way to see my doctor." When asked if he has shortness of breath, Patient 2 stated, "No, I don't have any shortness of breath. I told you, I have had a few heart issues but I'm pretty health for the most part. The next time anyone from that hospice comes, I am going to be very suspicious about it and tell them to leave." During an interview on 1/18/2022 at 11:20 a.m., with ADM, ADM was asked how they get patient referrals, ADM stated, "We get patients through word-of-mouth referrals, we pass out brochures, and if a patient is discharged from the hospital, we also get referrals from the hospital." During a concurrent interview and record review on 1/18/2022 at 11:45 a.m., of Patient 2's medical records, with License Vocational Nurse 1 (LVN 1). LVN 1 was unable to find who Patient 2's primary doctor (before hospice services). LVN 1 stated, "I don't know, it is not in the patients chart." LVN 1 was unable to verify or find any documented evidence Patient 2 was ruled out as a candidate for surgical procedure related heart disease, or Patient 2 declined surgical procedures. c. During a joint home visit to Patient 6's home Assisted Living Facility 2, on 1/14/2022 at 10 a.m., with Licensed Vocational Nurse 3 (LVN 3), Patient 6 was observed fully clothed, resting on bed, watching television. Patient 6 was awake, alert, and oriented, was able to state name and date of birth. Patient 6 was unable to communicated well, was unable to answer questions asked. Patient 6 remained quiet when asked questions. A review of Patient 6's "Face Sheet" from, indicated Patient 6 was admitted to the hospice agency on 2/3/2018, with a primary diagnosis of Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills) and comorbidities of anxiety, seizure disorder, osteoarthritis (degeneration of joint cartilage and the underlying bone) and generalize body weakness. The referring physician and medical director was Physician 1. A review of Patient 6's "LCD Hospice Eligibility Determination" (Local Coverage Determination- determining Terminal Status)" of "Dementia due to Alzheimer's" dated 2/3/2018 and 11/12/2021, indicated that section 1, "Activity of Daily Living (ADL)" must be met and at least one in section 2 "Documented History/Progression of at least any One of the following" must be met. LCD section 2f (Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl) has been marked as "Yes". A review of Patient 6's Acute Hospital 2 (AC2) notes dated 2/1/2018, indicated Patient 6 was admitted on 2/1/2018 and had a weight recorded at 163 pounds (lb.) 8 ounces (oz). A review of Patient 6's record indicated there was no documented evidence Patient 6 had a 10% weight loss during the previous six months or a serum albumin <2.5 gm/dl. A review of Patient 6's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 11/14/2021 to 1/12/2022, indicated in the space "Physician Narrative" that Patient 6 had declining appetite with 10% weight loss last 6 months. It indicated Patient 6 continued to meet LCD guidelines for hospice care. A review of Patient 6's "Plan of Care" (POC) form, dated 1/30/2022, indicated Hospice Aid (HA) was to visit twice per week, License Vocational Nurse (LVN) was to visit twice a week and 1 as needed (PRN) and Medical Social Worker (MSW) was to visit once a month and 1 PRN. There were no visit for other disciplines (Chaplain, Volunteer, or Registered Nurse). A review of Patient 6's Comprehensive Nursing Assessment dated 2/3/2018 indicated Patient 6 was confused and disoriented. Patient 6's mobility was very limited, and activity was bedfast. The section for "Personal Care and Support Needs" indicated the need for volunteer, and community support were marked as "None". During a concurrent interview and record review on 1/18/2022 at 12 p.m., of Patient 6's medical records, with License Vocational Nurse 1 (LVN 1). LVN 1 was unable to verify or find any documented evidence Patient 6 had a 10% weight loss as indicated on Patient 6's LCD dated 2/3/2018 or 11/12/2021. LVN 1 could not provide the documented evidence that Patient 6 was eligible to receive hospice care. During a telephone interview on 1/18/2022 at 12:26 p.m., with Physician 1, Physician 1 stated, "I'll have my people call you back later. I'm driving right now. I can't answer any questions before I go over them with my attorney either way". During a telephone interview on 1/18/2022 at 12:31 p.m., with the hospice facility Nurse Practitioner (NP), NP stated had been working at facility for 3-4 months with Physician 1. NP stated that the admission process consists of them receiving a prescription or referral, then the patient's history and physical was reviewed. NP stated, "then we send an RN to do the hospice evaluation. Then we all meet with the IDT (interdisciplinary team) to initiate a care plan. MD does the initial visit and I do the follow up, usually." NP stated that patients must fit within the lcd guidelines according to their diagnosis and it should have been documented in the clinical records. A review of facility Policy and Procedure titled, "Admission Criteria and Process" undated, indicates, ...hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patient's attending physician, if any ... If the request for service is not made by the patient's physician, he/she will be consulted prior to the evaluation visit/initiation of services." A review of facility's Policy and Procedure titled, "Comprehensive Assessment", undated, indicates. "During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least the following information, as relevant: C. Nature and condition causing admission (including the presence or lack of objective data and subjective complaints). A review of facility's Policy and Procedure titled, "Certification of Terminal Illness", undated, indicates, the hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorize for hospice services forms ...Both the attending physicians and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. 25046 d. A review of Patient 3's Patient Intake form indicated Patient 3 was admitted to the hospice agency on 4/1/2021, with diagnosis of unspecified heart disease. The referring physician was Physician 1 who was also the Medical Director of the hospice facility. A review of the Comprehensive Assessment, dated 4/1/2021, indicated Patient 3 was awake, alert and oriented x 3, and had normal speech. Patient 3 was ambulatory by using cane and walker and needed moderate assist. Cardiac rate was regular, no edema observed, and no pain or chest discomfort noticed. Patient 3 had episodes of moderate dyspnea on exertion. The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." A review of Patient 3's Plan of care (POC) dated 10/7/2021 indicated LVN was to visit the patient once a week. There were no visits indicated for other discipline (Hospice aid, Medical Social Worker, Chaplain, or volunteer) indicated in the POC. A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine patient's eligibility for hospice services) of "Heart Disease," dated 4/21/2021, indicated that the sections for "untreatable condition" and "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated that Patient 3 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of Patient 3's clinical record indicated there was no documented evidence Patient 3 was ruled out as a candidate for surgical procedure related heart disease, Patient 3 declined surgical procedures and patient 3 was optimally treated for heart disease with diuretics and vasodilators. Also, there was no documented evidence that indicated Patient 3 had discomfort and symptoms occuring at rest that determined Patient 1 met the criteria for "NYHA Class IV." A review of the form titled, "Certificate of Terminal Illness," (the document that showed a physician certified a patient's eligibility for hospice benefit), dated 4/1/2021, indicated Patient 3 was awake, oriented x 3, had episodes of moderate dyspnea during exertion. The "Physician Narrative" indicated Patient 3 had diagnoses of heart disease and co-morbidities of hypertension, generalized weakness, and constipation. it indicated Patient 3 was assessed to be in status of NYHA IV (symptom occurred at rest). It indicated Patient 3 was eligible for hospice service and met LCD guide lines. Physician 1 had certified Patient 3 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. During the complaint validation survey on 1/14/2022, an attempt to contact Physician 2 by telephone and was unsuccessful. On 11/30/2021, at 12:15 p.m. during a complaint investigation under the State process, a telephone interview with Physician 2 was conducted. Physician 2 stated Patient 3On 11/30/2021, at 12:15 p.m. during a telephone interview with Physician 2, stated Patient 3 had been his patient for a long time, and Patient 3 came to his office every three months. Physician 2 stated he was not aware Patient 3 was receiving hospice services and no one contacted him regarding hospice care for Patient 3. Physician 2 stated that Patient 3 did not have any terminal illnesses and he was not a hospice candidate in Physician 2's medical opinion. On 1/14/2022, at 3:50 p.m., during a telephone interview with Patient 3, he stated that he smokes and had high blood pressure, but he did not think he would die soon. Patient 3 stated the patient was referred to the hospice by the owner of the house where the patient resided. Patient 3 stated before, he had to take a train and a bus to go to Physician 2's office every three months to get medication. When asked whether Physician 2 knew about Patient 3's enrollment to the hospice service, he stated "No." During an interview and a concurrent record review with the Administrator and Licensed Vocational Nurse 1 (LVN 1) on 1/18/2022, at 10:15 a.m., both of them were not able to find the documented evidence in the record that indicated the agency /Physician 1 had contacted Physician 2 for recommendation/consultation /input to check eligibility to receive the hospice care. e. On 1/14/2022 at 11:25 a.m., during Patient 5's joint home visit with Licensed Vocational Nurse 2 (LVN 2) at the assisted living facility, Patient 5 was observed lying in a bed. Patient 5 was awake and alert, denied pain. Patient 5 was able to answer to the simple question by saying "yes" or "no." A review of Patient 5's Intake form indicated Patient 5 was admitted to the hospice agency on 10/7/2021, with diagnosis of Alzheimer's disease. The referring physician was Physician 1 who was the Medical Director of the agency. A review of the form titled, "LCD Hospice Eligibility Determination" of "Dementia due to Alzheimer's" dated 7/26/2021, indicated Patient 4 met the criteria for the sections for "ADL" (Activities of Daily Living) and "History/Progression" of "inability to maintain sufficient fluid and calorie intake with 10 % (percent) weight loss during the previous six months or serum albumin (albumin is a protein in the blood) was less than 2.5 gram (gm)/deciliter (dl)" (The normal range of serum albumin is 3.4 to 5.4 g/dl) that determined Patient 4 was eligible for hospice services. A review of Patient 5's record indicated there was no documented evidence Patient 5 had 10 percent weight loss during the previous six months or serum albumin level was less than 2.5 gm/dl. A review of the form titled, "Certificate of Terminal Illness," dated 10/6/2021, indicated the space for physician narrative was blank. Instead it was indicated in the space for "certifying Physician Summary as follows: "It is my clinical judgement that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to the hospice agency. I have been encouraged to participate in the IDG meeting and Plan of care" "I attest/confirm that I composed the narrative based on my review of Patient's medical record, team assessment and/or examination of the patient." During an interview and a concurrent record review with the Licensed Vocational Nurse 1 (LVN 1) on 1/18/2022, at 11 a.m., she was not able to find the documented evidence in the record that indicated the agency /Physician 1 had contacted Physician 4 for recommendation/consultation /input to check eligibility to receive the hospice care. During a telephone interview with Family member 1, on 1/18/2022, at 11:15 a.m., she stated Patient 5 had been under Physician 5's care for years, and she did not think Patient 5 was going to die within 6 months. On 1/18/2022, at 12:25 p.m., during a telephone interview with Physician 1 (Medical Director), he stated he could not answer the questions before he went over the questions with his attorney. On 1/18/2022, at 12:30 p.m., during a telephone interview with Nurse Practitioner 1 (NP 1), who had worked with Physician 1, the NP stated the patients at the agency became Physician 1's patients upon admission to the agency, not from before. NP 1 stated the patients must fit within the LCD guideline according to the diagnoses. NP 1 stated they should look other information such as cormobility, patient's condition, and other diagnoses that will contribute admission to hospice, and it should have been documented in the clinical record. On 1/20/2022, at 4 p.m., during a telephone interview with Physician 4, she stated she had been Patient 5's doctor since August 2018 and did not refer the patient to the hospice agency. She stated she did not know Patient 5 was under hospice care, and she did not think Patient 5 was eligible for hospice care. Physician 4 stated she was not contacted by anybody for consultation regarding Patient 5's hospice enrollment. A review of the agency's undated policy titled "Certification of Terminal Illness" indicated the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. The hospice Medical Director must consider at least the diagnosis of the terminal condition of the patient and current relevant information supporting the diagnosis. A review of the agency's undated policy titled "Admission Criteria and Process" indicated the hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patient's attending physician, if any.
L0664
L0664	25046 Based on observation, interview, and record review, the hospice facility failed to ensure the Condition of Participation for Medical Director was met as evidenced by: The hospice agency failed to ensure the medical director or physician designee (who is a hospice employee or under contract with the hospice) had the responsibility for the medical component of the hospice's patient care program, including initial certifications and recertifications of terminal illness six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6). (Refer to L667) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.
L0667	Initial Certification Of Terminal Illness 418.102(b) Corrected On: 04/07/2022
	43979 Based on interview, and record review, the hospice medical director failed to review clinical information for each hospice patient necessary to initially certify or recertify patients to receive hospice services for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6). This deficient practice resulted in the provision of hospice services to patients who were not clinically eligible to receive hospice services. Findings: a. A complaint validation survey was conducted 1/13/2022, regarding Patient 1 receiving hospice care and had no knowledge as to why the patient was provided hospice care and services. A review of Patient 1's "Face Sheet" form, indicated Patient 1 was admitted to the hospice facility on 8/20/2020 and an end of care date of 8/11/2021, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (the buildup of plaque inside your arteries) without angina pectoris (chest pain). The referring physician and medical director was Physician 1. The space for authorized representative was left blank. A review of Patient 1's "LCD Hospice Eligibility Determination" (Local Coverage Determination- determining Terminal Status)" of "Heart Disease" dated 8/20/2020 and 6/10/2021, indicated that section 1, "Untreatable Condition" and section 2, "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated Patient 1 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest). A review of Patient 1's record indicated no documented evidence Patient 1 was ruled out as a candidate for surgical procedure related heart disease, Patient 1 declined surgical procedures and Patient 1 was optimally treated for heart disease with diuretics. There was no documented evidence Patient 1 was on complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest, that determined Patient 1 met the criteria for "NYHA Class IV." A review of Patient 1's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 6/16/2021 to 8/14/2021, indicated that Patient 1 was awake and oriented x3 (person, place, and date), on NYHA Class III, and was unable to carry out any physical activity without discomfort. The "Physician Narrative" indicated Patient 1 had a primary diagnosis of heart disease and co-morbidities of hyperlipidemia (high cholesterol), hypertension (high blood pressure), congestive heart failure (weakened heart muscle), diabetes mellitus II (high blood sugar), seizures (stiffness, twitching or limpness), and generalize body weakness. It indicated Patient 1 was assessed to be in status of NYHA III. It indicated Patient 1 was eligible for hospice services and met LCD guidelines. It indicated the Physician 1 had certified Patient 1 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 1's "Plan of Care (POC/IDG)" form, dated 7/15/2021, indicated License Vocational Nurse (SN) and Hospice Aide (HA) were declined. medical social worker (MSW) and spiritual counselor (SC) was to visit once a month and the registered nurse (RN) was to visit every 14 days. A review of Patient 1's Comprehensive Nursing Assessment dated 8/20/2020 indicated Patient 1 was awake, alert, and oriented x3 (time, place, person), and had normal speech. Patient 1 was ambulatory by using walker and needed moderate assistance. Cardiac rate was regular, at 75 beats per minute, no edema observed. Patient 1's NYHA class III (New York Heart Association class - Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea). Patient 1's mobility was completely immobile, and activity was bedfast. Patient 1 was unable to perform physical activity without dyspnea (difficulty or labored breathing). The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." A review of Patient 1's licensed vocational nurse (LVN) clinical notes dated 7/27/2021 & 8/10/2021 indicated Patient 1 was placed on NYHA class III (New York Heart Association class - Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea). A review of Patient 1's Registered Nurse (RN) clinical notes dated 7/22/2021 & 8/5/2021 indicated Patient 1 was placed on NYHA class III (New York Heart Association class - Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea). A review of Patient 1's Discharge/Transfer Summary dated 8/11/2021, indicated Patient 1 revoked hospice services due to wanting to visit her cardiologist (heart doctor) regarding continuing care. During a complaint validation survey on 1/14/2022 at 3:36 p.m., Patient 1's Care Giver (CG 1) was contacted by telephone and was unsuccesful. During a complaint investigation using the State process, a telephone interview on 11/29/2021, at 11:45 a.m., with Patient 1's CG 1, CG 1 stated Patient 1 resided at the Assisted Living Facility (ALF 2) for over a year. CG 1 stated Patient 1 always goes out for walks and currently was out walking. During a complaint validation survey on 1/14/2022 at 3:36 p.m., Patient 1 was contacted by telephone and was unsuccesful. During a complaint investigation using the State process, a telephone interview on 11/29/2021, at 12:45 p.m., with Patient 1, Patient 1 stated, "I have been here for about a year and that's how long I have had hospice. My granddaughter brought me here to this facility (ALF 2), she found this hospice house. When asked if she knew hospice services, Patient 1 stated, "Yes, they explained to me that a nurse would come, check on me once a week and take my temperature and check my blood pressure". When asked if she was terminally ill, Patient 1 stated, "No, I have heart issues, but I am fine. No one ever told me I'm terminally ill". When asked if she knew hospice was palliative care, not preventative or curative, Patient 1 stated, "No. I never knew that. I just thought I'm in a hospice house, but I wanted to go to my regular doctor who I've been going to for over 10 years and they told me I can't, so I didn't want to have it anymore. My primary doctor was Physician 5. I want to be seen by her and have went back to her." During a complaint investigation using the State process a telephone interview on 12/2/2021, at 2:22 p.m., with Patient 1's physician, Physician 5, Physician 5 stated, "Patient 1 has been my patient since March 30, 2017, her last visit was on October18, 2021. I had another visit from her on January 8, 2020 post hospitalization, follow up on ER (Emergency Room) for cough and weakness. Her medical conditions are, hypertension, diabetes type II, hyperlipidemia, chronic kidney disease Stage 3, seizure disorder, osteoporosis". When asked if she referred Patient 1 to hospice, Physician 5 stated, "No, I never referred Patient 1 to hospice and was not aware she received hospice services. No one from hospice called to ask me anything." When asked if she thought Patient 1 was a hospice candidate, Physician 5 stated, "No, it is my medical opinion that she is not a hospice candidate." During a concurrent interview and record review on 1/18/2022 at 11:30 a.m., of Patient 1's medical records, with license vocational nurse 1 (LVN 1). LVN 1 was unable to find who Patient 1's primary doctor (before hospice services). LVN 1 was unable to verify or find any documented evidence Patient 1 was ruled out as a candidate for surgical procedure related heart disease, Patient 1 declined surgical procedures or that Patient 1 was optimally treated for heart disease with diuretics. There was no documented evidence that indicated Patient 1 was at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest, that determined Patient 1 met the criteria for "NYHA Class IV". LVN 1 could not provide the documented evidence that Patient 1 was eligible to receive hospice care. b. A review of Patient 2's "Face Sheet" indicated Patient 2 was admitted to the hospice facility on 5/15/2021, and an end of care date of 12/2/2021, with a primary diagnosis of heart disease, unspecified. The referring physician and medical director was Physician 1. A review of Patient 2's "LCD Hospice Eligibility Determination" (Local Coverage Determination- determining Terminal Status)" of "Heart Disease" dated 5/15/2021 and 11/6//2021, indicated that section 1, "Untreatable Condition" and section 2, "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated that Patient 2 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest). A review of Patient 2's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 5/15/2021 to 8/12/2021 and another CTI dated 8/13/2021 to 11/10/2021, indicated that Patient 2 was awake and oriented x3 (person, place, and date), on NYHA Class IV, and is unable to carry out any physical activity without discomfort. In the space "Physician Narrative" indicated Patient 2 had a primary diagnosis of heart failure and has no co-morbidities listed. It also indicated; Patient 2 was ambulatory on moderate to maximum assistance. It indicated Patient 2 was assessed to be in status of NYHA IV. It indicated Patient 2 was eligible for hospice services and met LCD guidelines. It indicated the Physician 1 had certified that Patient 2 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 2's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 11/11/2021 to 1/9/2022 indicated Patient 2 was currently homebound since leaving home requires taking effort. The space "Physician Narrative" is blank. A review of Patient 2's "Plan of Care (POC/IDG)" form, dated 5/20/2021 & 11/18/2021, indicated license vocational nurse (LVN) was to visit twice a week and as needed (PRN) and medical social worker (MSW) was to visit once a month and 1 PRN. There were no visit for other disciplines (hospice aid, chaplain, volunteer, or registered Nurse). A review of Patient 2's Comprehensive Nursing Assessment dated 5/15/2020 indicated Patient 2 was awake, alert, and oriented x3 (time, place, person), and had limited speech. Patient 2 was ambulatory by using walker and wheelchair. Cardiac rate was regular, at 77 beats per minute, no edema observed. Patient 2's NYHA class IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest). Patient 2's mobility was very limited, and activity was chairfast. Patient 2 was unable to perform physical activity without dyspnea (difficulty or labored breathing). The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." A review of Patient 2's Discharge/Transfer Summary dated 12/2/2021, indicated Patient 2 revoked hospice services due to contacting his primary care physician and his cardiologist to start to seek treatment for his diagnosis. During a telephone interview on 1/14/2022, at 3:19 p.m., with Patient 2, Patient 2 stated that he was referred to hospice by a friend, (Friend 1) and was told that hospice was a way to get taken care of when he needed help. Patient 2 stated that he has never been told that he has or had a terminal illness. Patient 2 stated, " I do have heart issues, but that is all". When asked, how long Patient 2 was in hospice, stated "A very short time. I tried to go back to my own doctor. I told her that I don't want this, and I don't need it. I see my doctor every 3 months; I've been doing it for years. That's why I wanted to get out of hospice because I couldn't see my own doctor." When asked, what hospice staff would do when they do a visit, Patient 2 stated, "They did a decent job, but it was interfering from me seeing my regular doctor and I did not appreciate that at all. I don't want to get anyone in trouble, but it was not for me. As soon as I realized I was not able to see my doctor when I wanted to, I got out." Patient 2 stated, a nurse just showed up one day and said you're on hospice. They told me they would take my blood pressure and vitals. I let them know I don't have a terminal illness. A nurse practitioner showed up once or twice. I mentioned to them that I want to be able to see my regular doctors. I don't know what this is all about. I used to see Physician 6 at the Medical Office 1 but, she was not there anymore, and I'm supposed to see a doctor Physician 7, and my cardiologist that I go to was Physician 8. I had a heart attack a few years ago and I had CHF. I do little driving, I have a car service that takes me places, but I need to see my doctors". When asked if any of his doctors recommended hospice services or were aware that he has provided hospice care, Patient 2 stated, "No, none of my doctors recommended hospice, I haven't told them they signed me up, I don't even know how I got signed up." Patient 2 stated, "I'm on my way to see my doctor". When asked if he has shortness of breath, Patient 2 stated, "No, I don't have any shortness of breath. I told you, I have had a few heart issues but I'm pretty health for the most part. The next time anyone from that hospice comes, I am going to be very suspicious about it and tell them to leave." During an interview on 1/18/2022 at 11:20 a.m., with ADM. ADM was asked how they get patient referrals, ADM stated, "We get patients through word-of-mouth referrals, we pass out brochures, and if a patient is discharged from the hospital, we also get referrals from the hospital." During a concurrent interview and record review on 1/18/2022 at 11:45 a.m., of Patient 2's medical records, with LVN 1, LVN 1 was unable to find who Patient 2's primary doctor (before hospice services). LVN 1 stated, "I don't know, it is not in the patients chart." LVN 1 was unable to verify or find any documented evidence Patient 2 was ruled out as a candidate for surgical procedure related heart disease, or Patient 2 declined surgical procedures. c. During a joint home visit to Patient 6's home Assisted Living Facility 2, on 1/14/2022 at 10 a.m., with license vocational nurse (LVN 3), Patient 6 was observed fully clothed, resting on bed, watching television. Patient 6 was awake, alert, and oriented, was able to state name and date of birth. Patient 6 was unable to communicated well, was unable to answer questions asked. Patient 6 remained quiet when asked questions. A review of Patient 6's "Face Sheet" from, indicated Patient 6 was admitted to the hospice facility on 2/3/2018, with a primary diagnosis of Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills) and comorbidities of anxiety, seizure disorder, osteoarthritis (degeneration of joint cartilage and the underlying bone) and generalize body weakness. The referring physician and medical director was Physician 1. A review of Patient 6's "LCD Hospice Eligibility Determination" (Local Coverage Determination- determining Terminal Status)" of "Dementia due to Alzheimer's" dated 2/3/2018 and 11/12/2021, indicated that section 1, "Activity of Daily Living (ADL)" must be met and at least one in section 2 "Documented History/Progression of at least any One of the following" must be met. LCD section 2f (Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl) has been marked as "Yes." A review of Patient 6's Acute Hospital 2 (AC2) dated 2/1/2018, indicated Patient 6 was admitted on 2/1/2018 and had a weight recorded at 163 pounds (lb.) 8 ounces (oz). A review of Patient 6's record indicated there was no documented evidence Patient 6 had a 10% weight loss during the previous six months or a serum albumin <2.5 gm/dl. A review of Patient 6's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 11/14/2021 to 1/12/2022, indicated in the space "Physician Narrative" that Patient 6 had declining appetite with 10% weight loss last 6 months. It indicated Patient 6 continued to meet LCD guidelines for hospice care. A review of Patient 6's "Plan of Care" (POC) form, dated 1/30/2022, indicated hospice aid (HA) was to visit twice per week, license vocational nurse (LVN) was to visit twice a week and 1 as needed (PRN) and medical social worker (MSW) was to visit once a month and 1 PRN. There were no visit for other disciplines (Chaplain, Volunteer, or Registered Nurse). A review of Patient 6's Comprehensive Nursing Assessment dated 2/3/2018 indicated Patient 6 was confused and disoriented. Patient 6's mobility was very limited, and activity was bedfast. The section for "Personal Care and Support Needs" indicated the need for volunteer, and community support were marked as "None." During a concurrent interview and record review on 1/18/2022 at 12 p.m., of Patient 6's medical records, with LVN 1, LVN 1 was unable to verify or find any documented evidence Patient 6 had a 10% weight loss as indicated on Patient 6's LCD dated 2/3/2018 or 11/12/2021. LVN 1 could not provide the documented evidence that Patient 6 was eligible to receive hospice care. During a telephone interview on 1/18/2022 at 12:26 p.m., with Physician 1, Physician 1 stated, "I'll have my people call you back later. I'm driving right now. I can't answer any questions before I go over them with my attorney either way." During a telephone interview on 1/18/2022 at 12:31 p.m., with the hospice agency Nurse Practitioner (NP), NP stated had been working at facility for 3-4 months with Physician 1. NP stated that the admission process consists of them receiving a prescription or referral, then the patient's history and physical was reviewed. NP stated, "then we send an RN to do the hospice evaluation. Then we all meet with the IDT (interdisciplinary team) to initiate a care plan. MD does the initial visit and I do the follow up, usually." NP stated that patients must fit within the LCD guidelines according to their diagnosis and it should have been documented in the clinical records. A review of facility Policy and Procedure titled, "Admission Criteria and Process" undated, indicates, "The patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs) ... The patient must have a life-limiting illness with a life expectancy of six (6) months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria in the organization's intermediary Local Coverage Determination ...Eligibility criteria will be continually reviewed by the interdisciplinary team to ensure appropriate of hospice care ... If the request for service is not made by the patient's physician, he/she will be consulted prior to the evaluation visit/initiation of services." A review of facility's Policy and Procedure titled, "Comprehensive Assessment", undated, indicates. "During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least the following information, as relevant: C. Nature and condition causing admission (including the presence or lack of objective data and subjective complaints). A review of facility's Policy and Procedure titled, "Certification of Terminal Illness", undated, indicates, clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification ... 25046 d. A review of Patient 3's Patient Intake form indicated Patient 3 was admitted to the hospice agency on 4/1/2021, with diagnosis of unspecified heart disease. The referring physician was Physician 1 who was the Medical Director of the agency. A review of the Comprehensive Assessment, dated 4/1/2021, indicated Patient 3 was awake, alert and oriented x 3, and had normal speech. Patient 3 was ambulatory by using cane and walker and needed moderate assist. Cardiac rate was regular, no edema observed, and no pain or chest discomfort noticed. Patient 3 had episodes of moderate dyspnea on exertion. The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None". The Plan of care (POC) dated 10/7/2021 indicated LVN was to visit the patient once a week. There were no visit for other discipline ( Hospice aid, Medical Social Worker, Chaplain, or volunteer) indicated in the POC. A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine patient's eligibility for hospice services) of "Heart Disease," dated 4/21/2021, indicated that the sections for "untreatable condition" and "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated that Patient 3 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of Patient 3's record indicated there was no documented evidence Patient 3 was ruled out as a candidate for surgical procedure related heart disease, Patient 3 declined surgical procedures and patient 3 was optimally treated for heart disease with diuretics and vasodilators. Also, there was no documented evidence that indicated Patient 1 had discomfort and symptom occurred at rest that determined Patient 1 met the criteria for "NYHA Class IV." A review of the form titled, "Certificate of Terminal Illness," (the document that showed a physician certified a patient's eligibility for hospice benefit), dated 4/1/2021, indicated Patient 3 was awake, oriented x 3, had episodes of moderate dyspnea during exertion. In the space of "Physician Narrative" indicated Patient 3 had diagnosis of heart disease and co-morbidities of hypertension, generalized weakness, and constipation. it indicated Patient 3 was assessed to be in status of NYHA IV (symptom occurred at rest). It indicated Patient 3 was eligible for hospice service and met LCD guide lines. It indicated the Medical Director had certified that Patient 1 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. On 1/14/2022, at 3:50 p.m., during a telephone interview with Patient 3, he stated that he smokes and had high blood pressure, but he did not think he would die soon. Patient 3 stated the patient was referred to the hospice agency by the owner of the house where the patient was staying. Patient 3 stated before, he had to take a train and a bus to go to Physician 2's office every three months to get medication. When asked whether Physician 2 knew about Patient 3's enrollment to the hospice service, Patient 3 stated "No." During the complaint validation survey on 1/14/2022, an attempt to contact Physician 2 by telephone and was unsuccessful. On 11/30/2021, at 12:15 p.m. during a complaint investigation under the State process, a telephone interview with Physician 2 was conducted. Physician 2 stated Patient 3 had been his patient for a long time, and stated he was not aware Patient 3 was receiving hospice services and no one contacted him. Physician 2 stated that Patient 3 did not have any terminal illnesses and he was not a hospice candidate in Physician 2's medical opinion. During an interview and a concurrent record review with the Administrator and Licensed Vocational Nurse 1 (LVN 1) on 1/18/2022, at 10:15 a.m., both of them were not able to find the documented evidence in the record that indicated the agency /Physician 1 had reviewed Patient 3's clinical information (including current history and physicals, laboratory and imaging data, biopsy results, etc.) supporting diagnoses of terminal illnesses. On 1/18/2022, at 12:25 p.m., during a telephone interview with Physician 1 (Medical Director), he stated he could not answer the questions before he went over the questions with his attorney. On 1/18/2022, at 12:30 p.m., during a telephone interview with Nurse Practitioner 1 (NP 1), who had worked with Physician 1, the NP stated the patients at the agency became Physician 1's patients upon admission to the agency, not from before. NP 1 stated the patients must fit within the LCD guideline according to the diagnoses. NP 1 stated they should look other information such as cormobility, patient's condition, and other diagnoses that will contribute admission to hospice, and it should have been documented in the clinical record. e. During Patient 4's joint home visit at assisted living facility with Licensed Vocational Nurse 2 (LVN 2) on 1/14/2022 at 11 a.m., Patient 4 was observed lying in a bed. Patient 4 was awake and alert, denied pain, but was not able to communicate well because Patient 4 was not able to answer, but kept on telling his own stories. A review of Patient 4's Patient Intake form indicated Patient 4 was admitted to the hospice agency on 7/26/2021, with diagnosis of senile degeneration of brain. The referring physician was Physician 1 who was the Medical Director of the agency. A review of the Comprehensive Assessment, dated 7/29/2021, indicated Patient 4 was awake and alert, able to verbalize pain, but confused and disoriented. Patient 4 was ambulatory by using walker and needed maximum assist. The space for the height, weight, and mac (Mid-arm circumference -used for monitoring the nutritional status of patients in emergency situations and recommended for the assessment of acute malnutrition in adults) were blank. A review of the form titled, "Certificate of Terminal Illness," dated 7/26/2021, in the physician narrative indicated Patient 4 had increase in weakness and confusion, consuming 65-70 percent of meals daily. It indicated Patient 4 was appropriate for LCD eligibility. It indicated the Medical Director had certified that Patient 1 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. A review of the form titled, "LCD Hospice Eligibility Determination" of "Dementia due to Alzheimer's" dated 7/26/2021, indicated Patient 4 met the criteria for the sections for "ADL" (Activities of Daily Living) and "History/Progression" of "inability to maintain sufficient fluid and calorie intake with 10 % (percent) weight loss during the previous six months or serum albumin (albumin is a protein in the blood) was less than 2.5 gram (gm)/deciliter (dl)" (The normal range of serum albumin is 3.4 to 5.4 g/dl) that determined Patient 4 was eligible for hospice services. A review of Acute hospital note dated 7/24/2021 indicated Patient 4's estimated weight was 81 kilogram and albumin level was 3.3. gram (gm)/deciliter (dl). A review of Patient 4's record indicated there was no documented evidence Patient 4 had 10 percent weight loss during the previous six months or serum albumin level was less than 2.5 gm/dl. During an interview and a concurrent record review with the Licensed Vocational Nurse 1 (LVN 1) on 1/18/2022, at 11:10 a.m., she was not able to find the documented evidence the agency /Physician 1 had reviewed Patient 3's clinical information (including current history and physicals, laboratory and imaging data, biopsy results, etc.) to support diagnoses of terminal illnesses. On 1/18/2022, at 12:25 p.m., during a telephone interview with Physician 1 (Medical Director), he stated he could not answer the questions before he go over the question with his attorney. On 1/18/2022, at 12:30 p.m., during a telephone interview with Nurse Practitioner 1 (NP 1), who had worked with Physician 1, the NP stated the patients at the agency became Physician 1's patients upon admission to the agency, not from before. NP 1 stated the patients must fit within the LCD guideline according to the diagnoses. NP1 stated they should look other information such as cormobility, patient's condition, and other diagnoses that will contribute admission to hospice, and it should have been documented in the clinical record. f. During Patient 5's joint home visit at assisted living facility with Licensed Vocational Nurse 2 (LVN 2) on 1/14/2022 at 11:25 a.m., Patient 5 was observ
	ed lying in a bed. Patient 5 was awake and alert, denied pain. Patient 5 was able to answer to the simple question by saying "yes" or "no". A review of Patient 5's Patient Intake form indicated Patient 5 was admitted to the hospice agency on 10/7/2021, with diagnosis of Alzheimer's disease. The referring physician was Physician 1 who was the Medical Director of the agency. A review of the Comprehensive Assessment, dated 7/29/2021, indicated Patient 5 was awake and alert and oriented, able to verbalize pain. Patient 5 was ambulatory by using walker and needed moderate assist. The space for the height, weight, and mac (Mid-arm circumference -used for monitoring the nutritional status of patients in emergency situations and recommended for the assessment of acute malnutrition in adults) were blank. A review of the form titled, "Certificate of Terminal Illness," dated 10/6/2021, indicated the space for physician narrative was blank. Instead it was indicated in the space for "certifying Physician Summary as follows: "It is my clinical judgement that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to the hospice agency. I have been encouraged to participate in the IDG meeting and Plan of care" "I attest/confirm that I composed the narrative based on my review of Patient's medical record, team assessment and/or examination of the patient" A review of the form titled, "LCD Hospice Eligibility Determination" of "Dementia due to Alzheimer's" dated 10/7/2021, indicated Patient 5 met the criteria for the sections for "ADL" (Activities of Daily Living) and "History/Progression" of "inability to maintain sufficient fluid and calorie intake with 10 % (percent) weight loss during the previous six months or serum albumin (albumin is a protein in the blood) was less than 2.5 gram (gm)/deciliter (dl)" (The normal range of serum albumin is 3.4 to 5.4 g/dl) that determined Patient 4 was eligible for hospice services. A review of Patient 5's record indicated there was no documented evidence Patient 5 had 10 percent weight loss during the previous six months or serum albumin level was less than 2.5 gm/dl. During an interview and a concurrent record review with the Licensed Vocational Nurse 1 (LVN 1) on 1/18/2022, at 11 a.m., she was not able to find the documented evidence in the record the agency /Physician 1 had reviewed Patient 5's clinical information (including current history and physicals, laboratory and imaging data, biopsy results, etc.) supporting diagnoses of terminal illnesses. During a telephone interview with Family member 1, on 1/18/2022, at 11:15 a.m., she stated Patient 5 had been under Physician 5's care for years, and she did not think Patient 5 was going to die within 6 months. On 1/18/2022, at 12:25 p.m., during a telephone interview with Physician 1 (Medical Director), he stated he could not answer the questions before he went over the questions with his attorney. On 1/18/2022, at 12:30 p.m., during a telephone interview with Nurse Practitioner 1 (NP 1), who had worked with Physician 1, the NP stated the patients at the agency became Physician 1's patients upon admission to the agency, not from before. NP 1 stated the patients must fit within the LCD guideline according to the diagnoses. Also, they should look other information such as cormobility, patient's condition, and other diagnoses that will contribute admission to hospice, and it should have been documented in the clinical record. On 1/20/2022, at 4 p.m., during a telephone interview with Physician 4, she stated she had been Patient 5's doctor since August 2018 and did not refer the patient to the hospice agency. She stated she did not know Patient 5 was under hospice care, and she did not think Patient 5 was eligible for hospice care. Physician 4 stated she was not contacted by anybody for consultation regarding Patient 5's hospice enrollment. A review of the agency's undated policy titled "Admission Criteria and Process" indicated the hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patient's attending physician, if any. The patient's life-limiting illness and prognosis of six months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). A review of the agency's undated :Job Description Summary" indicated the duties and responsibilities of the Medical Director will include reviewing patients' medical eligibility for hospice services, in accordance with hospice program policies and procedures.