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
A11512 A. BUILDING __________
B. WING ______________ 		10/14/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
FAMILY COMFORT HOSPICE, INC 7502 FOOTHILL BLVD, SUITE 203, TUJUNGA, CA, 91042
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)
L0519      
25046 Based on interview and record review, the hospice agency failed to provide the information of scope and limitations of services to four of seven sampled patients (Patient 1, Patient 2, Patient 3 and Patient 5) before providing hospice services to them. This deficient practice resulted in the patient's right not being safeguarded and has a potential to affect the care that would provide to the patients that meet their needs. Findings: a. A review of Patient 1's "Patient Intake" form indicated Patient 1 was admitted to the hospice agency on 6/3/2021, with diagnoses of hypertensive heart disease with heart failure (heart conditions caused by high blood pressure, includes heart failure), and constipation. The referring physician was Physician 2. A review of the Plan of Care (POC), dated 6/3/2021, indicated the Skilled Nurse (SN) visits were four times per month, the chaplain and the Medical Social Worker visits were once a month. A review of the Discharge/Transfer Summary, dated 8/24/2021, indicated Patient 1 and Patient 1's family revoked hospice services due to seeking aggressive treatment. During a telephone interview with Patient 1 on 10/16/2021, at 10:55 a.m., Patient 1 stated somebody knocked on his door and offered hospice services, telling him the benefit in the Medicare program that provides nursing care and medication coverage. The hospice agency's representative did not tell him the program was for the dying people and did not inform him of the limitations of current benefits he was receiving. Patient 1 stated he had signed the papers that were provided by the hospice agency, but he did not realize that his benefits would be limited until he visited his primary physician's office couple of weeks ago. After his primary doctor informed him of the limitations of benefits, Patient 1 called the hospice agency and told them he wanted be out of the program. Patient 1 stated he was fine living by himself without a caregiver, and he did not think he would die soon. b. A review of Patient 2's "Patient Intake" form indicated the patient was admitted to the hospice agency on 4/22/2021, with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). The referring physician was Physician 2. The Plan of Care (POC), dated 4/22/2021, indicated the SN visits was four visits per month, the chaplain and the Medical Social Worker visits were once a month. There were no visits frequency scheduled for the Hospice Aide and Volunteer. A review of the Discharge/Transfer Summary, dated 8/17/2021, indicated Patient 2 and Patient 2's family revoked hospice services due to seeking aggressive treatment. The Department conducted a complaint investigation under the state process on 8/12/2021 at the hospice agency. During a telephone interview with Patient 2's family member (Family Member 3) on 9/20/2021, at 4:40 p.m., Family Member 3 stated she did not think Patient 2 was dying, and the hospice agency's staff did not explain that hospice was for the person whom life expectancy was less than six months. Family Member 3 stated the hospice agency did not explain that Patient 2 has to pay out of pocket for care besides the hospice care. During the survey, an attempt to contact Family Member 3 was unsuccessful. c. A review of Patient 3's "Patient Intake" indicated Patient 3 was admitted to the hospice on 3/18/2021, with diagnoses of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure and diabetes mellitus (DM - A chronic condition that affects the way the body processes blood sugar) without complication. A review of Patient 3's Plan of Care (POC), dated 3/18/2021, indicated the SN visits was once a week, and the Medical Social Worker and the chaplain visits were once a month. During a telephone interview with Patient 3 on 10/13/2021, at 9:35 a.m., Patient 3 stated he was in the hospital and the hospice agency's staff explained that the hospice would provide services and care to him. Patient 3 stated he did not know that he might have to pay money out of his pocket for some services besides hospice service because nobody had told him. 43979 d. A review of Patient 5's "Patient Intake" form indicated Patient 5 had a start of care (SOC) date of 8/29/2021, with diagnosis of Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions). The referring physician was Physician 2. The caregiver/contact was Family Member 2. A review of Patient 5's "Plan of Care (POC)" form, dated 8/29/2021, indicated the SN visits was once a week for three months, the Chaplain visit was to evaluate, and the Medical Social Worker visit was once per month. The Hospice Aide and Volunteer visit were declined. A review of Patient's 5 "Election of Hospice Medicare Benefit and Patient Authorization," dated 8/29/2021, signed by the patient's caregiver, indicated it was left blank under the "Financial Responsibility" section. During a telephone interview with Family Member 2 on 10/13/2021, at 1:14 p.m., Family Member 2 stated neither Patient 5 nor she were not being informed of what services the hospice agency would be offered, did not offer, or any out-of-pocket expenses for services received outside of hospice care. A review of the agency's policy and procedure titled, "Hospice Patient Rights and Responsibilities," revised February 2011, indicated the patient has the right to receive information about the scope of services that the hospice will provide and specific limitations on those services. A review of the facility's policy and procedure titled, "Clinical Records," dated February 2011, indicated, "If eligibility criteria is met the patient and family/caregiver will be provided with a hospice brochure and various educational materials providing sufficient information on: ... Cost to be borne by the patient, if any, for care."
L0520      
25046 Based on observation, interview and record review, the hospice agency failed to meet the Condition of Participation for Initial and Comprehensive Assessment of the Patient by failing to: - Conduct a comprehensive assessment that matched the patients' condition and determined a patient's eligibility for hospice care and services by identifying a terminal illness that meet the criteria for hospice care and services, for six of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5 and Patient 7). (Refer to L 521) The cumulative effect of these systemic practices resulted in the hospice agency's inability to ensure that all seven sampled patients, who were enrolled under hospice services, met the eligibility to receive hospice care and services. The hospice agency also failed to provide quality of care to these patients.
L0521      
25046 Based on observation, interview, and record review, the hospice agency failed to conduct a comprehensive assessment that matched the patients' condition and determined a patient's eligibility for hospice care and services by identifying a terminal illness that meet the criteria for hospice care and services, for six of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5 and Patient 7). This deficient practice resulted in the hospice agency's inability to ensure that all seven sampled patients, who were enrolled under hospice services, met the eligibility to receive hospice care and services. All seven sampled patients received hospice care and services despite these patients were not qualified for the services. Findings: a. A review of Patient 1's "Patient Intake" form indicated Patient 1 was admitted to the hospice agency on 6/3/2021, with diagnoses of hypertensive heart disease with heart failure (heart conditions caused by high blood pressure, includes heart failure), and constipation. The referring physician was Physician 2. There was no caregiver listed on the form. A review of the Plan of Care (POC), dated 6/3/2021, indicated the Skilled Nurse (SN) visits were four times per month, the chaplain and the Medical Social Worker visits were once a month. The Plan of care (POC) dated 6/3/2021 indicated SN was to make 4 visits in a month, the chaplain was to visit once a month and a Medical Social Worker was to visit once a month. The space for hospice aide (HA) visit and volunteer visit were blank. 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 6/3/2021, 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 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 occur at rest). A review of the Comprehensive Assessment, dated 6/3/2021, indicated Patient 1's mental status was alert/oriented to person, place, and date/time, but forgetful. Patient 1 was assessed as independent in the areas of bathing, dressing, toileting, transferring, continence and feeding. It indicated Patient 1 was assessed as "NYHA Class IV." The assessment also indicated that Patient 1 had dyspnea (SOB - shortness of breath) with moderate exertion. A review of the "Face to Face Encounter" form, dated 6/3/2021, signed by Nurse Practitioner 1 (NP 1) and Physician 2, indicated Patient 1 was diagnosed with hypotensive (low blood pressure) episodes, hyperlipidemia (high levels of fat particles in the blood), degenerative joint disease (it occurs when flexible tissue at the ends of bones wears down), arthritis (inflammation of one or more joints) /osteoporosis (a condition in which bones become weak and brittle), and congestive heart disease (a chronic condition in which the heart does not pump blood as well as it should). It indicated Patient 1 denied SOB, but SOB occurs with activity. There was no documented evidence in the form 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 6/3/2021, indicated Patient 1 was alert and oriented with intermittent confusion, had SOB with moderate exertion, had a fair appetite, and had unintentional weight loss of about 11 pounds within past seven months. The form indicated the Medical Director was the attending physician. 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 Discharge/Transfer Summary, dated 8/24/2021, indicated Patient 1 and Patient 1's family revoked hospice services due to seeking aggressive treatment. During an interview and a concurrent record review with the Director of Patient Care Services (DPCS) on 10/13/2021, at 4:15 p.m., the DPCS stated she was not able to find any documentation in the record that indicated Patient 1 had symptoms at rest, had a terminal illness, and would die within six months. The DPCS stated that the "LCD Hospice Eligibility Determination" form, dated 6/3/2021, was incorrect. The DPCS stated she could not find any documented evidence that Patient 1 was eligible to receive the hospice care. During a telephone interview with Patient 1 on 10/16/2021, at 10:55 a.m., Patient 1 stated somebody knocked on his door and offered hospice services, telling him the benefit in the Medicare program that provides nursing care and medication coverage. The hospice agency's representative did not tell him the program was for the dying people and did not inform him of the limitations of current benefits he was receiving. Patient 1 stated he had signed the papers that were provided by the hospice agency, but he did not realize that his benefits would be limited until he visited his primary physician's office couple of weeks ago. After his primary doctor informed him of the limitations of benefits, Patient 1 called the hospice agency and told them he wanted be out of the program. Patient 1 stated he was fine living by himself without a caregiver, and he did not think he would die soon. b. A review of Patient 2's "Patient Intake" form indicated the patient was admitted to the hospice agency on 4/22/2021, with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). The referring physician was Physician 2. The Plan of Care POC, dated 4/22/2021, indicated the SN visits was four visits per month, the chaplain and the Medical Social Worker visits were once a month. There were no visits frequency scheduled for the Hospice Aide and Volunteer. A review of the form titled, "LCD Hospice Eligibility Determination" of "Dementia due to Alzheimer's" dated 4/22/2021, indicated Patient 2 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 - unit of measurement)/deciliter (dl - unit of measurement)" that determined Patient 2 was eligible for hospice services. A review of the Comprehensive Assessment, dated 4/22/2021, indicated Patient 2 had intermittent confusion and episodes of depression and osteoarthritis (it occurs when flexible tissue at the ends of bones wears down). The Comprehensive Assessment indicated that Patient 2 ambulated with use of walker and caregiver helps. Patient 2 was assessed as independent in the areas of bathing, dressing, toileting, transferring, continence and feeding. In addition, Patient 2 was on a regular consistency diet (diet based on tolerance); however, the spaces for the data of height and weight were left blank in the form. A review of the "Face to Face Encounter" form, dated 4/21/2021, signed by NP 2 and Physician 2, indicated Patient 2 had diagnoses of Alzheimer's disease and dementia without behavioral disturbance. It indicated Patient 2's daughter stated Patient 2 was unstable when walking and had multiple falls in the past. Patient 2's daughter asked to get assistance from her home health agency to file for disability. A review of the form titled, "Certificate of Terminal Illness," dated 4/22/2021, indicated Patient 2 was alert and oriented, disoriented to time, forgetful, depressed, and needed close supervision. Patient 2 had fair appetite, consumed about 40 to 50 percent meals, had shortness of breath with moderate exertion, and had unintentional weight loss within past six months. The form indicated the Medical Director was the attending physician. It indicated the Medical Director had certified Patient 2 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. However, the form was not signed and dated by the Medical Director. A review of the Discharge/Transfer Summary, dated 8/17/2021, indicated Patient 2 and Patient 2's family revoked hospice services due to seeking aggressive treatment. The Department conducted a complaint investigation under the state process on 8/12/2021 at the hospice agency. During a telephone interview with Patient 2's family member (Family Member 3) on 9/20/2021, at 4:40 p.m., Family Member 3 stated she did not think Patient 2 was dying, and the hospice agency's staff did not explain that hospice was for the person whom life expectancy was less than six months. During the survey, an attempt to contact Family Member 3 was unsuccessful. During an interview and a concurrent record review with the DPCS on 10/14/2021, at 10:40 a.m., the DPCS stated she was not able to find any documentation that Patient 2 had unintentional weight loss within past six months or had serum albumin less than 2.5 gram (gm)/deciliter (dl) (The normal range of serum albumin is 3.4 to 5.4 g/dL) as indicated in the LCD, dated 4/22/2021. The DPCS stated she was not able to find any documented evidence that Patient 2 had a terminal illness that Patient 2 was going to die within six months if the terminal illness runs its normal course. The DPCS stated she could not find any documented evidence that Patient 2 was eligible to receive the hospice care. c. A review of Patient 3's "Patient Intake" indicated Patient 3 was admitted to the hospice on 3/18/2021, with diagnoses of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure and diabetes mellitus (DM - A chronic condition that affects the way the body processes blood sugar) without complication. A review of Patient 3's POC, dated 3/18/2021, indicated the SN visits was once a week, and the Medical Social Worker and the chaplain visits were once a month. A review of the Comprehensive Assessment, dated 3/18/2021, indicated Patient 3 was oriented, required considerable assistance, and had no sign of distress. Patient 3 was assessed as independent in the areas of bathing, dressing, toileting, transferring, continence and feeding. 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 3/8/2021, 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" with congestive heart failure (CHF - a chronic condition in which the heart does not pump blood as well as it should) or angina (a type of chest pain caused by reduced blood flow to the heart) 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). During an interview and a concurrent record review with the DPCS on 10/13/2021, at 4:15 p.m., the DPCS stated she was not able to find the documentation that Patient 3 had either CHF or angina The DPCS stated that the "LCD Hospice Eligibility Determination" form, dated 3/18/2021, was incorrect. The DPCS stated she was not able to find any documented evidence that Patient 3 had a terminal illness and would die within six months. The DPCS stated she could not find any documented evidence that Patient 3 was eligible to receive the hospice care. d. A review of Patient 4's "Patient Intake" form indicated Patient 4 was admitted to the hospice agency on 4/15/2021, with diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure. The referring physician was Physician 2. A review of Patient 4's POC, dated 4/15/2021, indicated the SN visits was once a week, the chaplain evaluation would start on 10/12/2021, and the Medical Social Worker visit was once a month. The Hospice Aide and volunteer visit were declined. A review of the form titled, "LCD Hospice Eligibility Determination" of "Dementia due to Alzheimer's" dated 4/15/2021, 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 % weight loss during the previous six months or serum albumin was less than 2.5 gram (gm)/deciliter (dl)" that determined Patient 4 was eligible for hospice services. A review of the Comprehensive Assessment, dated 4/15/2021, indicated Patient 4 had intermittent confusion and episodes of depression and osteoarthritis. Patient 4 ambulated with use of walker and caregiver helps. Patient 4 was assessed as independent in the areas of bathing, dressing, toileting, transferring, continence and feeding. In addition, it indicated that Patient 4's height was 64 inches and weight was 157 pounds. A review of the form titled, "Certificate of Terminal Illness," dated 4/15/2021, indicated Patient 4 ate 60 percent of her meals, used walker for ambulation, and was dependent on maximum assistance on two or more activities of daily living. The form indicated the Medical Director was the attending physician. It indicated the Medical Director had certified Patient 4 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. However, the form was not signed and dated by the Medical Director. During a joint home visit at Patient 4's residence with Licensed Vocational Nurse 1 (LVN 1) on 10/13/2021 at 10:50 a.m., Patient 4 was observed sitting in a chair in the living room. Patient 4's family member (Family Member 1) was next to Patient 4. During a concurrent interview with Family Member 1, she stated Patient 4 did not lose weight. Family Member 1 stated Patient 4 ate fine, but she had to feed Patient 4. Family Member 1 stated her friend told her about this hospice agency. Family Member 1 recalled a female doctor came to her house once and she did not remember the doctor's name. Family Member 1 stated she did not know the referring physician, Physician 2. Family Member 1 stated Patient 4's Primary Care Physician (PCP) was Physician 1. During a telephone interview with Physician 1 on 10/13/2021, at 1:25 p.m., Physician 1 stated he has been Patient 4's PCP since 2/22/2019. Physician 1 stated he did not refer Patient 4 to the hospice agency and Patient 4 was not a candidate for hospice care. Physician 1 stated he was frustrated that he did not know Patient 4 was receiving hospice services. Physician 1 stated this was the first time that he was informed Patient 4 was receiving hospice care. Physician 1 stated he did not know the hospice agency's Medical Director or Physician 2, and nobody has contacted him regarding Patient 4's hospice care. Physician 1 stated he did not know why Patient 4 was under hospice care. During an interview and a concurrent record review with the DPCS on 10/14/2021, at 10:40 a.m., the DPCS stated she was not able to find any documentation that Patient 4 had unintentional weight loss within past six months or had serum albumin less than 2.5 gram (gm)/deciliter (dl) (The normal range of serum albumin is 3.4 to 5.4 g/dL) as indicated in the LCD, dated 4/22/2021. The DPCS stated she was not able to find any documented evidence that Patient 4 had a terminal illness that Patient 4 was going to die within six months if the terminal illness runs its normal course. The DPCS stated she could not find any documented evidence that Patient 4 was eligible to receive the hospice care. During a telephone interview with the nurse who was working at Physician 2's office (Registered Nurse 1 [RN 1]) on 10/14/2021, at 2:30 p.m., RN 1 stated Physician 2 was the doctor who referred the patients (Patient 1, Patient 2, Patient 3 and Patient 4) to the hospice agency. RN 1 stated the referred patients or their families would be contacted and the nurse practitioner (NP) would conduct a visit to see these patient one time. RN 1 stated Physician 2 reviewed the NP's notes, signed, and referred the patients to the hospice agency based on the NP's assessment. RN 1 stated those referred patients were not Physician 2's patients. RN 1 stated Physician 2's office did not contact the PCPs of the patients, who were referred by Physician 2 to the hospice agency, for consultation regarding the eligibility of hospice services. An attempt to interview Physician 2 was unsuccessful during the survey because Physician 2 was not available for the interview. 43979 e. A review of Patient 5's "Patient Intake" form indicated Patient 5 had a start of care (SOC) date of 8/29/2021, with diagnosis of Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions). The referring physician was Physician 2. The caregiver/contact was Family Member 2. A review of Patient 5's "Plan of Care (POC)" form, dated 8/29/2021, indicated the SN visits was once a week for three months, the Chaplain visit was to evaluate, and the Medical Social Worker visit was once per month. The Hospice Aide and Volunteer visit were declined. A review of Patient 5's "Face to Face Encounter" form, dated 8/28/2021, signed by Nurse Practitioner 3 (NP 3) and Physician 2, indicted Patient 5 was diagnosed with Alzheimer's Disease, general muscle weakness, protein calorie malnutrition, and frequent falls. The form also indicated the reason for hospice was due to needed support and management of chronic conditions. A review of the form titled, "Certificate of Terminal Illness" (CTI) form for hospice benefits, dated 8/29/2021, indicated Patient 5 was demented (affected with dementia - a group of thinking and social symptoms that interferes with daily functioning), with hard of hearing, bed to chair, resident of assisted living, with bowel and bladder incontinence, dependent on maximum assistance on three or more activities of daily living. The form indicated the hospice agency's Medical Director was the attending physician. It indicated the hospice agency's Medical Director had certified that Patient 5 was terminally ill and has 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 8/29/2021, 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 % weight loss during the previous six months or serum albumin was less than 2.5 gram (gm)/deciliter (dl)" that determined Patient 5 was eligible for hospice services. A review of Patient 5's "Comprehensive Nursing Assessment," dated 8/29/2021, indicated Patient 5's communication was within normal limits and was total dependence with limited range of motion (ROM). Patient 5 was oriented to person, place, forgetful, and was able to understand and participate in care. Patient 5 was able to transfer from bed to chair and used wheelchair. During an observation and a concurrent interview on 10/13/2021, at 11 a.m., at Patient 5's residence with Patient 5's caregiver, Patient 5 was observed sitting on the couch, with a walker parked in front of her while Patient 5's caregiver wassitting on a chair in the kitchen. Patient 5's caregiver stated that Patient 5 is able to ambulate with a walker and goes to restroom by herself. Patient 5's caregiver stated that Patient 5 has improved and has been doing much better than a couple of months ago. During a telephone interview on 10/13/2021, at 1:14 p.m., with Patient 5's family member (Family Member 2), Family Member 2 stated that initially she refused hospice care for her mother. However, after speaking with the hospice agency's staff, she agreed to have hospice care for her mother. Family Member 2 stated, "The doctor didn't say anything about her (Patient 5) dying soon. When I spoke with the hospice office, they explained that hospice doesn't necessarily mean for patients who are dying. Nobody told me that she (Patient 5) had a specific time to live." Family Member 2 stated she did not know if her mother's primary physician was aware that her mother was receiving hospice care. An attempt to interview the hospice agency's Medical Director was made during the survey. During an interview with the hospice agency's Administrator on 10/14/2021, at 1 p.m., the Administrator stated the agency's Medical Director was out of town and was not available for an interview. During an interview with the DPCS on 10/14/2021, at 1:10 p.m., the DPCS was asked to explain the agency's admission process. The DPCS stated in general, the agency receives a referral from a doctor and the patient will be visited and assessed by the Registered Nurse (RN), as well as all other disciplines. The DPCS stated that the CTI form is provided by the agency's Medical Director. The DPCS stated the patient's attending doctoris supposed to sign under the "referring physician" on the CTI form, and the Medical Director fills out the LCD form. The DPCS stated the RN and she completes the LCD form. When asked how she determined the "Yes" answers on the LCD form, the DPCS stated, "We check our chart, The RN suppose to go by their assessment and interview, patient or care giver statement, history and physical, and labs from the previous doctor." When asked if Physician 2 was the primary care physician for Patient 5, the DPCS stated, "I'm not sure. I don't know if she is the patient's attending physician." During a telephone interview with Registered Nurse 1 (RN) 1 on 10/14/2021, at 2:35 p.m., RN 1 stated that their agency sends out a Nurse Practitioner (NP) when either a patient or their family calls to request for an evaluation. RN 1 stated, "We send out our NP when patients or family members call and request our services. The patient then be requested if they would like to be admitted to a certain hospice agency." RN 1 stated that once the NP completes the patient's assessment, they relay their findings to their doctor. In this case, Physician 2 for Patient 5. RN 1 stated that the doctor reviews the RN's assessment and any pertinent information to decide if the patient needs hospice. RN 1 was asked if Physician 2 communicates with the patient's primary doctor, RN 1 stated, "If the doctor does not communicate with the primary doctor is due to not needing any information. We only contact them if needed." During a review of Physician 3's email about Patient 5, received on 10/14/2021, at 4:21 p.m., Physician 3 wrote, "One of my colleagues placed the patient in hospice care. He is on leave and I did not know his rationale. I have known the patient for a long time and though she has gone downhill and needs to be under supervised care she is not, in my opinion, near death within 6 months". 22303 f. A review of Patient 7's "Patient Intake" form indicated a start of care (SOC) date of 9/14/2020, with diagnosis that included Alzheimer's Disease. A review of Patient 7's POC, from 9/14/2020 to 12/12/2021, included an order for the skilled nurse to visit of four visits a month, the chaplain and the Medical Social Worker to visit once a month. The space for Hospice Aide visit and volunteer visits were left blank. It was indicated that Physician 2, a mobile physician who represents a certain random medical group, was the referring physician for Patient 7. A review of the form titled, "LCD Hospice Eligibility Determination" of "Dementia due to Alzheimer's" dated 9/14/2021, indicated Patient 7 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 greater than 2.5 gm/dl." A review of the Comprehensive Hospice Assessment, dated 9/14/2021, indicated Patient 7 had intermittent confusion and episodes of depression and osteoarthritis. Patient 7 ambulated with walker and caregiver helps. Patient 7 was assessed as independent in the areas of bathing, dressing, toileting, transferring, continence and feeding. A review of Patient 7's CTI (certificate of terminal illness) form, dated 9/14/2021, indicated the hospice agency's Medical Director had certified that Patient 7 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. However, the agency's Medical Director also signed under the physician signature space indicating he was the referring physician of Patient 7 for the hospice services. On 10/13/2021, at 11 a.m., a home visit was conducted at Patient 7's residence. Patient 7 was observed sitting in a couch and was talking to herself. At 11:15 a.m., during an interview with Patient 7's caregiver, when asked why Patient 7 needed hospice services, Patient 7's caregiver stated she wanted to have a hospice nurse to visit every week to check on Patient 7's health status due to having dementia (a group of thinking and social symptoms that interferes with daily functioning). Patient 7's caregiver stated she called Physician 2's clinic to help admit Patient 2 in the hospice services. Patient 7's caregiver further stated that the hospice agency's Medical Director was not Patient 7's attending physician. During an interview with the DPCS on 10/14/2021, at 12 p.m., when asked if she could provide clinical documentation for the LCD criteria that were checked and were met by the Patient 7, DPCS stated the hospice did not have one to provide. The DPCS also stated she was not able to find the documented evidence that Patient 7 had a terminal illness and would die within six months. On 10/14/21, at 1 p.m., the Medical Director was called over the phone but was not available. The office manager of the medical clinic stated the hospice agency's Medical Director was out of town and could not get a return call from him. On 10/14/21, at 2:45 p.m., during an interview with RN 1 (Physician 2's registered nurse at his medical clinic), she stated that Physician 2 was the referring doctor for Patient 7. RN 1 also stated that Patient 7's caregiver called the clinic for referral to hospice services. RN 1 also stated that Physician 2 sent a nurse practitioner to Patient 7's residence for a face to face encounter. She further stated that Physician 2 referred Patient 7 to hospice services based on the face to face encounter visit done by the nurse practitioner. A review of the agency's policy and procedure titled, "Admission Criteria and Process," revised February 2011, indicated the patient must have a life limiting illness with a life expectance of six months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by LCD. A review of the agency's policy and procedure titled, "Certification of Terminal Illness," revised March 2012, indicated, "Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) moths or less life expectancy if the disease runs its normal course, by the attending physician and the hospice medical director ..."
L0536      
25046 Based on interview and record review, the hospice agency failed to meet the Condition of Participation regarding interdisciplinary group, care planning and coordination of services, for four of seven sampled patients (Patient 1, Patient 3, Patient 4 and Patient 7). The hospice agency failed to: 1. Ensure an interdisciplinary group meetings were conducted no less than every 15 days, for two of seven sampled patients (Patient 1 and Patient 3). (Refer to L541) 2. Ensure the plan of care was revised to reflect a patient's refusal of skilled nurse (SN) visit for one of seven sampled patients (Patient 1). (Refer to L553) 3. Ensure that the nutritional status, for one of seven sampled patients (Patient 1), was assessed and nutritional needs were addressed. (Refer to L555) 4. Ensure the primary physicians for two of seven sampled patients (Patient 1 and Patient 4) were consulted for hospice eligibility criteria. (Refer to L558) The cumulative effect of these systemic practices resulted in the hospice agency's inability to provide the services that met the patient's needs and the agency failed to ensure the provision of quality and safe health care to the patients.
L0541      
25046 Based on interview and record review, the hospice failed to ensure the interdisciplinary group team (IDG, individual who are qualified and competent to practice in the professional roles) meetings were held no less than every 15 days to identify and discuss the patients ongoing assessments and care planning, for two of seven sampled patients (Patient 1 and Patient 3). This deficient practice had the potential for care needs that were not being identified and assessed by the IDG that could result in inapproriate care and services provided to the hospice patients. Findings: a. A review of Patient 1's "Patient Intake" form indicated Patient 1 was admitted to the hospice agency on 6/3/2021, with diagnoses of hypertensive heart disease with heart failure (heart conditions caused by high blood pressure, includes heart failure), and constipation. The referring physician was Physician 2. There was no caregiver listed on the form. A review of the Discharge/Transfer Summary, dated 8/24/2021, indicated Patient 1 and Patient 1's family revoked hospice services due to seeking aggressive treatment. A review of the Plan of Care (POC), dated 6/3/2021, indicated the Skilled Nurse (SN) visits were four times per month, the chaplain and the Medical Social Worker visits were once a month. The spaces for Hospice Aide and volunteer visits were left blank. A further review of Patient 1's record indicated there was no documented evidence that IDG meeting was conducted after 6/3/2021 until the patient's discharge on 8/24/2021. There was no documented evidence the physician, the registered nurse, and the social worker had participated in the IDG meetings. The spaces for the signatures of the IDG members were blank. During an interview and a concurrent record review with the Director of Patient Care Services (DPCS) on 10/14/2021, at 1:30 p.m., the DPCS stated she was not able to find the documented evidence the physician, the registered nurse, and the social worker had participated in the IDG meeting on 6/3/2021. The DPCS stated she was not able to find any documented evidence that IDG meeting was conducted for Patient 1 until Patient 1's discharged from the hospice service on 8/24/2021. b. A review of Patient 3's "Patient Intake" indicated Patient 3 was admitted to the hospice on 3/18/2021, with diagnoses of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure and diabetes mellitus (DM - A chronic condition that affects the way the body processes blood sugar) without complication. A review of Patient 3's POC, dated 3/18/2021, and the IDG/conference note/Update to Plan of Care, dated 6/17/2021, indicated the SN visits was once a week, and the Medical Social Worker and the chaplain visits were once a month. The spaces for the signatures of the IDT members were blank. There was no documented evidence that the physician, the registered nurse, and the social worker had participated/conducted the IDG meetings for Patient 3. During an interview and a concurrent record review with the Director of Patient Care Services (DPCS) on 10/13/2021, at 4:15 p.m., the DPCS stated she was not able to find the documented evidence the physician, the registered nurse, and the social worker had participated/conducted the IDG meeting on 3/18/2021 and 6/17/2021. During an interview with the chaplain on 10/14/2021, at 11:20 a.m., he stated whenever he participated in the IDG meeting, he had signed his signature. He stated if there was no signature of his, he did not remember whether he had participated or not for Patient 3. A review of the agency's policy and procedure titled, "Interdisciplinary Team Meeting," revised March 2021, indicated "the interdisciplinary team will meet on a regular basis to discuss patient and family/caregiver changes and progress and to update the plan of care, death and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. The patient's plan of care will be updated at a frequency no less than every 15 days or more frequently if the patient's condition requires; social, cultural, and physical environments presenting obstacles to effective intervention; integration of alternative therapies into medical regime to assist in effectiveness; and any special needs of the patient." The members at the interdisciplinary team meeting will sign and attendance form that will be kept by the hospice clinical supervisor.
L0553      
25046 Based on interview and record review, the hospice agency failed to ensure the plan of care was revised to reflect a patient's refusal of skilled nurse (SN) visit for one of seven sampled patients (Patient 1). This deficient practice had the potential for not providing appropriate patient care services to maintain the patient's highest practicable well-being. Findings: A review of Patient 1's record titled, "Patient Intake" indicated that patient was admitted to the hospice agency on 6/3/2021, with diagnoses of hypertensive heart disease with heart failure (heart problem that occur because of high blood pressure present over a long time) and constipation (difficulty with bowel elimination). The plan of care (POC), dated 6/3/2021, indicated the SN was was to visit four times a month. A review of Patient 1's Nursing Clinical Note performed by a Licensed Vocational Nurse 2 (LVN 2), dated 6/7/2021, 6/13/2021, 6/20/2021, 6/27/2021, 7/4/2021, 7/11/2021, 7/18/2021, 7/25/2021, 8/1/2021, 8/10/2021, 8/15/2021, 8/24/2021 indicated "telehealth (a doctor provides care without an in-person office visit). Telehealth is done ... visits were conducted." A review of Patient 1's Summary (Terminal Condition/Intervention) section indicated the same narrative Nursing Clinical Notes, from 6/7/2021 to 8/24/2021 that indicated, "SN called patient at home. Per CMS (Centers for Medicare and Medicaid) patients visits are being conducted via telehealth to help prevent the spread of Covid-19 (an infectious disease caused by severe acute respiratory syndrome coronavirus 2). Patient 1 is awake, alert and oriented x 2/ Vital signs taken by the caregiver. Vital signs with normal limits. Afebrile. No changes in patients condition. No complaint of pain. SN instructed caregiver/patient regarding guidelines for safety taking medications at the right time and right dose as prescribed by medical doctor. Caregiver/patient verbalized understanding. Encouraged caregiver/patient to call the agency or SN with any concerns, questions and any change in patient condition. Caregiver/patient verbalized understanding. Patient was stable and comfortable during phone visit." On 10/13/2021, at 4:50 p.m., during a telephone interview, Licensed Vocational Nurse 2 (LVN 2) stated she did not visit Patient 1 from 6/7/2021 to 8/24/2021 because Patient 1 had refused SN visit, instead, telehealth visit was conducted. When asked if she saw the caregiver took Patient 1's vital signs, she stated she did not. LVN 2 stated she just documented the vital signs that Patient 1 told her. LVN 2 also stated she did not notify the Director of Patient Care Services (DPCS) about Patient 1's refusal of the SN visit but had mentioned the refusal to the receptionist. During an interview on 10/12/2021 at 4:55 p.m., the receptionist stated Patient 1 had refused all discipline's visit from the beginning but had not reported to the DPCS or the Administrator. During an interview on 10/13/2021, at 4:56 p.m., the DPCS stated that the agency staff should have notified IDG member, and the IDG should have revised the plan of care or should have discharged Patient 1 when Patient 1 had refused SN visits. On 10/16/2021, at 10:55 a.m., during a telephone interview with Patient 1, he stated he called the agency and told them he wanted to be out of the hospice program after he was informed of the limitations of benefits from his primary doctor's office weeks after he had enrolled with the hospice agency. Patient 1 stated he lived by himself and did not have a caregiver. Patient 1 stated he had not been taking his vital signs at home. A review of the agency's policy and procedure titled, "Interdisciplinary Team Coordination of Care", revised on March 2012, indicated visiting nurse and hospice care personnel will communicate changes in a timely manner via e mail, telephone, one- to one meeting, interdisciplinary team meetings, and home visits. A review of the agency's policy and procedure titled, "Interdisciplinary Team Meeting", revised March 2021, indicated the interdisciplinary team will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates the plan of care, death and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. The patient's plan of care will be updated at a frequency no less than every 15 days or more frequently if the patient's condition required. Patients requesting or requiring a transfer due to a change in the level of care necessary to meet his/her needs or a wish to utilize the services of another hospice will be reviewed and planning initiated for the transfer.
L0555      
25046 Based on interview and record review, the hospice agency failed to ensure that the nutritional status, for one of seven sampled patients (Patient 1), was assessed and nutritional needs were addressed. This deficient practice placed Patient 1 at risk for complications such as malnutrition (lack of sufficient nutrients in the body) when progressive weight loss were not provided with appropriate interventions. Findings: A review of Patient 1's record titled, "Patient Intake" form indicated the patient was admitted to the hospice agency on 6/3/2021, with diagnoses of hypertensive heart disease with heart failure (heart problem that occur because of high blood pressure present over a long time) and constipation (difficulty with bowel elimination). The plan of care (POC) for Patient 1 indicated the potential for altered nutritional status related to disease process, lack of appetite, and the unintentional progressive weight loss of more than 10 percent over last 6 months. The interventions indicated to assess and report signs and symptoms of malnutrition, monitor percentage of meals and snacks the patient consumes, to report a pattern of inadequate intake, assess and report signs and symptoms of fluid volume deficit (a state or condition where the fluid output exceeds the fluid intake), and to assess/monitor nutritional needs every visit. A review of Patient 1's Nursing Clinical Notes, dated 6/7/2021, 6/13/2021, 6/20/2021, 6/27/2021, 7/4/2021, 7/11/2021, 7/18/2021, 7/25/2021, 8/1/2021, 8/10/2021, 8/15/2021, 8/24/2021 during the telehealth visits conducted by Licensed Vocational Nurse 2 (LVN 2), indicated appetite was good. However, the notes did not indicate that Patient 1's weights were monitored. A review of Patient 1's summary section (Terminal Condition/Intervention) of the Nursing Clinical Notes indicated the same narrative statements from 6/7/2021 to 8/24/2021, and did not indicate Patient 1's nutrional status were monitored. On 10/13/2021 at 4:50 p.m., during a telephone interview, Licensed Vocational Nurse 2 (LVN 2) stated she did not visit Patient 1 from 6/7/2021 to 8/24/2021 because Patient 1 had refused SN visits. When asked, LVN 2 stated she had never measured or asked Patient 1's weight. On 10/16/2021 at 10:55 a.m., during a telephone interview with Patient 1, he stated he lives by himself and did not have a caregiver. He stated he never took his weight at home, only when he visits his primary physician. A review of the agency's policy and procedure titled, "Interdisciplinary team coordination of Care", undated, indicated the type and scope of services provided by the interdisciplinary team would be based upon comprehensive and ongoing assessment regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions.
L0558      
25046 Based on interview and record review, the hospice agency failed to ensure the primary physicians for two of seven sampled patients (Patient 1 and Patient 4) were consulted for hospice eligibility criteria. This failure resulted in the patients admitted to the hospice services when the they did not meet the criteria for receiving hospice care. Findings: a. A review of Patient 1's "Patient Intake" form indicated Patient 1 was admitted to the hospice agency on 6/3/2021, with diagnoses of hypertensive heart disease with heart failure (heart conditions caused by high blood pressure, includes heart failure), and constipation. The referring physician was Physician 2. There was no caregiver listed on the form. 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 6/3/2021, 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 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 occur at rest). A review of the "Face to Face Encounter" form, dated 6/3/2021, signed by Nurse Practitioner 1 (NP 1) and Physician 2, indicated Patient 1 was diagnosed with hypotensive (low blood pressure) episodes, hyperlipidemia (high levels of fat particles in the blood), degenerative joint disease (it occurs when flexible tissue at the ends of bones wears down), arthritis (inflammation of one or more joints) /osteoporosis (a condition in which bones become weak and brittle), and congestive heart disease (a chronic condition in which the heart does not pump blood as well as it should). It indicated Patient 1 denied SOB, but SOB occurs with activity. There was no documented evidence in the form 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 physician's certification for Patient 1's hospice benefit dated 6/3/2021, performed by the hospice agency's Medical Director, indicated Patient 1 was alert and oriented with intermittent confusion, had SOB with moderate exertion. During an interview on 10/13/2021, at 4:15 p.m., the DPCS stated the certification did not indicate that Patient 1 had symptoms at rest. During an interview and a concurrent record review on 10/14/2021, at 10:40 a.m., the DPCS stated she could not find documentations that the hospice agency had communicated or consulted Patient 1's primary care physician (PCP) for hospice eligibility. b. A review of Patient 4's "Patient Intake" form indicated Patient 4 was admitted to the hospice agency on 4/15/2021, with diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure. The referring physician was Physician 2. A review of the form titled, "LCD Hospice Eligibility Determination" of "Dementia due to Alzheimer's" dated 4/15/2021, 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 % weight loss during the previous six months or serum albumin was less than 2.5 gram (gm)/deciliter (dl)" that determined Patient 4 was eligible for hospice services. A review of the Comprehensive Assessment, dated 4/15/2021, indicated Patient 4 had intermittent confusion and episodes of depression and osteoarthritis. Patient 4 ambulated with use of walker and caregiver helps. Patient 4 was assessed as independent in the areas of bathing, dressing, toileting, transferring, continence and feeding. In addition, it indicated that Patient 4's height was 64 inches and weight was 157 pounds. A review of the form titled, "Certificate of Terminal Illness," dated 4/15/2021, indicated Patient 4 ate 60 percent of her meals, used walker for ambulation, and was dependent on maximum assistance on two or more activities of daily living. The form indicated the Medical Director was the attending physician. It indicated the Medical Director had certified Patient 4 was terminally ill and had a life expectancy of six months or less if the terminal illness runs its normal course. However, the form was not signed and dated by the Medical Director. On 10/13/2021 at 10:50 a.m., during a joint home visit with Licensed Vocational Nurse 1 (LVN 1) at Patient 4's residence, Patient 4 was observed sitting on a chair in the living room with Family member 1 next to Patient 4. During the interview, Family member 1 stated Patient 4 had not lost weight. On 10/13/2021, at 1:25 p.m., during a telephone interview, Physician 1 stated he did not refer Patient 4 to the hospice agency because Patient 4 was not a candidate for hospice care. Physician 1 stated he was not aware Patient 4 was receiving hospice services. Physician 1 also stated the Medical Director had not contacted him regarding Patient 4's hospice care. During an interview on 10/14/2021, at 10:40 a.m., the DPCS stated she was not able to find supporting evidence that Patient 4 was eligible to receive the hospice care and documentations that the agency had communicated or consulted with Patient 1's PCP for hospice eligibility. On 10/14/2021, at 2:30 p.m., during a telephone interview, Registered Nurse 1 (RN 1), who worked from Physician 2's office, stated Physician 2 did not consult Patient 4's PCP for hospice eligibility after the nurse practitioner's (NP) assessments were reviewed, and prior to referring Patient 4 to the the hospice agency. A review of the agency's policy and procedure titled, "Admission Criteria and Process", revised February 2011, indicated the patient must have a life limiting illness with a life expectance of six months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by LCD. A review of the agency's policy and procedure titled, "Certification of Terminal illness", revised on March 2012, indicated when certifying the patient as terminally ill, the hospice Medical Director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis.
L0584      
43979 Based on interview and record review, the facility failed to follow their Registered Nurse position qualifications for one of three Registered Nurses (Registered Nurse 2 [RN 2]). This failure had the potential to result in the patients were assessed and evaluated by an unqualified RN that could affect the quality of care the patients received. Findings: On 10/14/2021, at 12:40 p.m., during an interview and concurrent record review with the Administrator, RN 2's employee file was reviewed. The employee file indicated RN 2 graduated from a nursing school on March 19, 2021. The employment application form did not indicate dates of employment and work history. The Administrator stated he did not know when RN 2 was hired. As of the moment, RN 2 had been taking patient assignments. During a review of agency's document titled, "Registered Nurse Job Description Summary," dated 1/1/2021, the Registered Nurse Job Description Summary indicated, "Position qualifications should be a minimum of two years experience, at least one of which is in the area of public health, home care, or hospice nursing is preferred.
L0587      
25046 Based on interview and record review, the hospice agency failed to meet the Condition of Participation regarding core services by failing to: Ensure the supervisory visits were conducted by a Registered Nurse (RN) at least every 14 days as indicated in the agency's policy for four of seven patients (Patients 1, 2, 3 and 4). (Refer to L 591) The cumulative effect of these systemic practices resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment.
L0591      
25046 Based on interview and record review, the hospice agency failed to ensure the supervisory visits by a Registered Nurse (RN) were conducted every 14 days as indicated in the agency's policy for four of seven patients, (Patient 1, 2, 3 and 4). a. For Patient 1, there was no documentation of supervisory visits conducted by the RN from 6/13/2019 to 8/24/2021, a total of 10 visits. b. For Patient 2, there was no documentation of supervisory visits conducted by the RN from from 4/22/2021 to 8/17/2021, a total of 16 visits. c. For Patient 3, there was no documentation of supervisory visits conducted by the RN from 3/18/2021 to 10/11/2021, a total of 29 visits. d. For Patient 4, there was no documentation of supervisory visits conducted by the RN from 4/15/2021 to 10/14/2021, a total of 26 visits. This deficient practice had the potential for inadequate assessment of patient's needs resulting to inapproriate care and services provided to the hospice patients. Findings: a. A review of Patient 1's record titled, "Patient Intake" form indicated the patient was admitted to the hospice agency on 6/3/2021, with diagnoses of hypertensive heart disease with heart failure (heart problem that occur because of high blood pressure present over a long time) and constipation (difficulty with bowel elimination). A review of the plan of care (POC) for Patient 1 dated 6/3/2021 indicated skilled nurse (SN) to visit 4 times a month. A review of the Patient 1's record, dated 6/13/2019 to 8/24/2021, did not indicate the RN supervisory visits were conducted. b. A review of Patient 2's record titled, "Patient Intake" form indicated the patient was admitted to the hospice agency on 4/22/2021, with diagnoses of Alzheimer's disease (progressive decrease in memory) and major depressive disorder (a common but serious mood disorder). A review of the POC for Patient 2 dated 4/22/2021 indicated SN to visit 4 times a month. A review of the Patient 2's record, dated from 4/22/2021 to 8/17/2021, did not indicate RN supervisory visits were conducted. c. A review of Patient 3's record titled, "Patient Intake" indicated the patient was admitted to the hospice agency on 3/18/2021, with diagnoses of hypertensive heart disease without heart failure and diabetes mellitus (high blood sugar). A review of Patient 3's POC dated 3/18/2021, indicated the SN to visit once a week. A review of Patient 3's record dated 3/18/2021 to 10/11/2021 did not indicate the RN supervisory visits were conducted except on 6/30/2021, 7/14/2021, and 7/28/2021. d. A review of Patient 4's record titled, "Patient Intake" form indicated the patient was admitted to the hospice agency on 4/15/2021, with diagnoses of Alzheimer's disease and hypertensive heart disease without heart failure. The POC for Patient 4 dated 4/15/2021 indicated SN to visit once a week. A review of the Patient 4's record dated 4/15/2021 to 10/14/2021 did not indicate the RN supervisory visits were conducted. On 10/14/2021 at 12:40 p.m., during an interview, when asked for RN supervisory visits for the patients, the Director of Patient Care Services, stated the supervisory visits should have been conducted every 14 days. DPCS was unable to provide documentation of RN supervisory visits. A review of the agency's policy and procedure titled, "Supervisory Visits" revised on February 2011, indicated the supervisory visit must be conducted no less frequently than every 14 days. The visit must assess quality of care and services provided by the hospice aide and whther the interdisciplinary team services ordered meet the patient needs and to whether the aide is following the patient's plan of care.
L0642      
22303 Based on interview and record review, the hospice agency failed to hire a qualified volunteer coordinator to ensure services were provided according to its policy on volunteer services. This deficient practice had the potential for volunteers for the agency not to receive guidance in the provision of care for the patients during home visits. Findings: On 10/12/2021 at 12 p.m., during an interview, the Director of Patient Care Services stated that the agency did not have a volunteer coordinator since May 2021. A review of the agency's undated policy and procedure for "Volunteer Services" indicated the hospice would provide volunteer services under the direction of a volunteer coordinator or staff member responsible for planning, organizing and directing a comprehensive volunteer services program and with the assistance of trained hospice volunteers.
L0648      
25046 Based on interview and record review, the hospice agency failed to meet the Condition of Participation regarding Organizational Environment by failing to: 1. Ensure the Director of Patient Care Services (DPCS) and an Administrator Designee were available for the the day to day operation and management of the hospice agency (Refer to L 651). 2. Ensure a qualified person to function as an administrator who had the education and experience required to run the daily operation of the hospice agency. (Refer to L 651) 3. Ensure the education and in-service trainings were provided to all staff involved in hospice patient care, and maintain the records of in-service trainings provided for the previous 12 months. (Refer to L 663) The cumulative effect of these systemic practices resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment.
L0651      
25046 Based on observation, interview, and record review, the hospice agency's governing body failed to assume full legal authority and responsiblity for the provision of all hospice services and continuous quality assessment and performance improvement (QAPI) by failing to: a. Ensure the Director of Patient Care Services (DPCS) and an Administrator Designee were available for the the day to day operation and management of the hospice agency. b. Ensure a qualified person to function as an administrator who had the education and experience required to run the daily operation of the hospice agency. This failure potentially caused the hospice agency to lack direction and guidance for effective operation of the agency which could affect the hospice ability to effectively coordinate care and services of the patients under hospice services. Findings: a. During a complaint investigation under the state process, on 8/12/2021 at 10:10 a.m., the surveyor arrived at the hospice agency, the door was closed and nobody answered when the door was knocked. On 8/12/2021 at 10:10 a.m., the surveyor called the agency's phone number and a receptionist answered. During a concurrent telephone interview, the receptionist stated she could not come to the agency, but she would call the Administrator and the DPCS to inform them that the surveyors are onsite. At 10:20 a.m., during a follow-up telephone call to the hospice agency, the receptionist stated she had called the Administrator and the DPCS, however, they told her that they could not come to the agency. The receptionist stated the Administrator was sick and the DPCS was working in another agency in Los Angeles area. On 8/12/2021 at 10:40 a.m. a telephone interview with the DPCS was conducted. DPCS stated she could not come to the office because she was working with another agency and was seeing patients. DPCS also stated she is working for six other agencies. When asked, what if the hospice patients needs a registered nurse (RN) in case of an emergency, DPCS stated the receptionist would call the RNs on the schedule and would arrange the visits. DPCS also stated the agency has an additional three RNs. On 8/12/2021 at 12:05 p.m., a telephone call was made to a DPCS designee. DPCS designee stated she could not come to the hospice agency on 8/13/2021 and 8/14/2021 tomorrow because she has a full schedule and works with other home health agencies. She also stated the agency had two RNs besides the DPCS and the designee. On 8/12/2021 at 2:14 p.m., a telephone call was made to RN 3. RN 3 stated he is not available for this hospice agency today because he is working for another agency. RN 3 also stated he works with other several home health agencies and hospice agencies. On 8/12/2021 at 2:30 p.m. a telephone call was made to RN 2. RN 2 stated he could not come to this agency and is working with other agency's patients. RN 2 also stated he works with four to five other agencies. On 8/12/2021 at 7:20 p.m., a telephone interview was conducted with the Administrator. The Administrator stated the agency could not provide the requested documents until next week because he is sick and the DPCS is not available. The agency does not have an office staff who can work on the requested documents. On 8/17/2021 at 5:20 p.m., a telephone call was made to the hospice agency. A staff answered and stated, she is not aware when the DPCS would be available. On 8/18/2021 at 10:20 a.m., during a phone interview with the DPCS, when asked if there were other RNs to take care of this agency's patients when needed, DPCS stated "No." b. On 10/12/2021 at 10 a.m., the survey team arrived at the agency to conduct the complaint validation survey. The Administrator and the DPCS were not in the office. The receptionist stated that she would call them. On 10/12/2021 at 11:30 a.m., a telephone call was made to the DPCS and informed the DPCS the reason for the onsite visit. The DPCS stated it would be hard for her come to the office today because she is working for another agency. DPCS stated, "I am available tomorrow from 8 a.m. to -11 a.m." and stated, "I'll try to come today." During a concurrent interview, the DPCS was informed that she and the Administrator were also not available to the agency on 8/12/2021, 8/13/2021, 8/17/2021, and 8/18/2021. On 10/12/2021 at 12:30 p.m., the DPCS came to the agency at 12:30 p.m., and left the agency at 1:30 p.m. On 10/12/2021 at 2:30 p.m., the receptionist stated the internet is down and could not print the documents requested. On 10/13/2021, the administrator was not present at the agency. The DPCS arrived at 4:15 p.m. On 10/14/2021 at 12:55 p.m., the governing body and quality assurance performance improvement (QAPI) minutes were requested. The administrator and the DPCS provided the QAPI minutes dated 4/16/2021, 7/9/2021, 10/10/2021 that were not signed by the QAPI committee members. On 10/14/2021 at 1:35 p.m., the DPCS stated she had to leave the office to work for another agency. The DPCS also stated the designee and the two other RNs are not available to come to the agency. On 10/14/2021, at 3 p.m., the administrator and the DPCS were not available for the exit conference, and a telephone exit conference was conducted with the Administrator. 43979 c. During an interview on 10/14/2021, at 12:40 p.m., the Administrator stated his experience consist of volunteering at an agency by assisting the Administrator last year. Administrator stated, "Last year I worked for a facility, I forgot what type. I think it was a home health agency. I forgot the name. I was helping the administrator out." During a concurrent interview and record review, on 10/14/2021, at 12:45 p.m. with the administrator, the Administrator's employee file was reviewed. The Administrator's employee application indicated, his name and phone number only. Administrator stated, "I know, all HR files need to be looked over and completed. Administrator stated, "Can you tell me what should be in the employee files, so that I may know? What should my next step be? What do you suggest I should do?"
L0663      
25046 Based on interview and record review, the hospice agency failed to: 1. Ensure that education program and in-service trainings were provided to all staff involved with hospice patient care. 2. Maintain the records of in-service trainings provided for the previous 12 months. These deficient practices had the potential to affect the quality of care provided by the staff to the hospice patients. Findings: During an interview on 10/14/2021 at 1:05 p.m., the Director of Patient Care Services stated, the training and in-services were not done last year. When asked for the agency's training records, the DPCS could not provide records and proofs that in-services and trainings were provided to the agency staff.
L0680      
22303 Based on observation, interview and record review, the hospice agency failed to store patient's medical records in a locked location. This failure had the potential that all patient's clinical records would be accessed by unauthorized users. Findings: On 10/12/2021 at 11 a.m., during an initial tour of the agency, the cabinet that contained patients' clinical records were not locked. A review of the patient census indicated the agency had a total of 23 patients under their care. On 10/12/2021 at 12 p.m., during an interview, the Director for Patient Care Services (DPCS)stated the cabinets that are storing the patient clinical records should have been locked. DPCS also stated she could not find a padlock with a key to lock them. A review of agency's undated policy and procedure titled, "Protection of Records" indicated the medical records should be stored in locked cabinets if not in use.