Every finding on record at A to Z Hospice Care, Inc

Based on interview and record review, the agency failed to ensure the comprehensive assessment (a detailed evaluation of a patient's complete health status that includes physical status, mental status, spiritual status and psychosocial status) identified the physical needs of two of four sampled patients (Patient 3 and 4) when: 1. For Patient 3: a Registered Nurse (RN 1) did not perform a wound assessment for Patient 3’s diabetic ulcers (open sores, or wounds, on the skin, most commonly on the feet, that occur in people with diabetes- a chronic condition where blood glucose (sugar) levels are too high because the body either doesn't produce enough insulin or cannot use insulin effectively) on the right foot affecting toes one through four or the surgical site of a left leg below the knee amputation (the surgical removal of all or part of a limb, such as a finger, toe, arm, or leg).  2. For Patient 4: RN 3 did not perform a wound assessment for the surgical site of Patient 4’s left foot toe amputation, which involved the fourth toe. These failures had the potential to cause Patient 3 and 4 to suffer severe complications such as infection, gangrene (the death of body tissue caused by a lack of blood supply or a bacterial infection) and repeat amputations due to Patient 3 and 4’s impaired wound healing from diabetes and the trauma of recent surgery. --- Findings: 1. A review of Patient 3’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of August 18, 2025, with a benefit period of August 18, 2025, to November 15, 2025 (Benefit Period one). Patient 3 had diagnoses that included atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (heart disease affecting the patient's own coronary arteries, a condition characterized by a buildup of plaque that can cause chest pain called angina pectoris, with the specific type of angina being unspecified).” A review of Patient 3’s admission assessment, dated August 19, 2025, by RN 1, indicated “She [Patient 3] has a left leg amputation with sutures [sterile materials used to close wounds or surgical incisions by holding the tissue edges together for healing] in place, a pacemaker [a small, battery-operated electronic device implanted in the chest to help control or regulate a slow or irregular heartbeat], a dialysis port [a surgically created opening in the body that allows blood to flow out to a dialysis machine (a medical device that functions as an artificial kidney to filter waste products and excess fluid from the blood when a person's own kidneys are unable to do so)] to the left abdomen, and a Dexcom sensor [a small, disposable device, part of a continuous glucose monitoring system, that is inserted under the skin to measure glucose levels in the body's fluid] to the left arm. On admission, the patient was alert and oriented x4 [a person who is alert and oriented to person, place, time and event], though intermittently dazed and unable to sustain conversation. She is unable to reposition herself independently and requires full assistance with ADLs [Activities of Daily Living- fundamental self-care tasks like bathing, dressing, eating, toileting, transferring (moving between positions), and maintaining continence]. Skin assessment revealed multiple diabetic ulcers to the right foot digits [toes], scattered bruising to bilateral [both] arms, and oral ulcers [painful, open sores that form on the inside of the mouth, often appearing as a white or yellow center with a red border] noted on the tongue and gums.” A review of Patient 3’s skin assessment, dated August 19, 2025, by RN 1, indicated:1a. Open Date: August 19, 20251b. Location: diabetic ulcers on the right foot affecting toes one through four.1c. Description: no documentation.1d. Size-length, width, depth: no documentation.1e. Color of wound bed or edges: P = Pink (healthy wound edges), R = Red (inflamed wound edges or healthy healing tissue in wound bed), Y = Yellow (slough, a type of tissue incapable of healing due to a lack of blood supply or other injury), E = Eschar Hard Black (hard, dead tissue that requires removal to allow for healing), B = Soft Blue/Black (indicates severe pressure damage to the underlying soft tissue): no documentation.1f. Drainage (the fluid released from the wound): no documentation.1g. Odor (smell indicates bacterial presence, due to infection or tissue breakdown): no documentation.1h. Inflammation (the initial stage of the body's immune response to injury to clear debris and fight infection, characterized by redness, heat, swelling, and pain. Prolonged or excessive inflammation can indicate infection or a need for an intervention to promote healing): no documentation.1i. Undermining /Tunneling (undermining is when the wound edges separate from the underlying tissue, creating a "shelf" or space under the skin's surface, similar to an iceberg. Tunneling is a narrow, deep passageway or tract that extends from the wound into the deeper tissue. Both represent "dead space" and indicate significant tissue damage beneath the surface that can harbor bacteria, impede healing, and make the wound appear smaller than it is): no documentation.2a. Open Date: August 19, 20252b. Location: surgical site of a left leg below the knee amputation.2c. Description: no documentation.2d. Size-length, width, depth: no documentation.2e. Color of wound bed or edges: no documentation.2f. Drainage: no documentation.2g. Odor: no documentation.2h. Inflammation: no documentation.2i. Undermining /Tunneling: no documentation. RN 1 was unavailable for interview. During an interview on September 18, 2025, at 11:53 AM, with the Vice President of Operations (VP/O) and the Director of Patient Care Services (DPCS), the VP/O and DPCS confirmed RN 1 had not conducted a wound assessment during Patient 3’s admission assessment and should have.  2. A review of Patient 4’s face sheet, undated, indicated a start of care date of August 15, 2025, with a benefit period of August 15, 2025, to November 12, 2025 (Benefit Period one). Patient 4 had diagnoses that included hypertensive heart disease with heart failure (a condition where high blood pressure (hypertension) damages the heart over time, leading to its inability to pump blood effectively). A review of Patient 4’s admission assessment, dated August 15, 2025, by RN 3, indicated, “Patient [4] has a left toe surgical amputation.” A review of Patient 4’s skin assessment, dated August 15, 2025, by RN 3, indicated:1a. Open Date: August 15, 20251b. Location: surgical site of Patient 4’s left foot toe amputation, which involved the fourth toe.1c. Description: surgical amputation1d. Size-length, width, depth: no documentation.1e. Color of wound bed or edges: no documentation.1f. Drainage: no documentation.1g. Odor: no documentation.1h. Inflammation: no documentation.1i. Undermining /Tunneling: no documentation. RN 3 was unavailable for interview. During an interview on September 18, 2025, at 12:11 PM, with the VP/O and the DPCS, the VP/O and DPCS confirmed RN 3 had not conducted a wound assessment during Patient 4’s admission assessment and should have.  A review of the agency’s policy and procedure titled “Comprehensive Assessment,” dated May 2022, indicated, “PURPOSE: To provide guidelines for the comprehensive assessment. … PROCEDURE: 1. 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: … a. Comprehensive skin assessment to be completed upon admission and once weekly by a qualified skilled nurse or other licensed provider to include the following elements: i. Measurements of any wounds or other skin impairments, ii. Location and description of wound bed, iii. Drainage, if applicable, to include color, consistency, odor, etc., iv. Tunneling or undermining, if applicable, v. Assessment of surrounding tissues. …”

Based on observation, interview, and record review, the agency failed to develop an individualized plan of care (a nursing care plan is a written document that outlines the individualized care a patient will receive, which includes: a patient’s needs, the problem, the goal and interventions to meet the goal) for two of four sampled patients (Patients 3 and 4) when: 1. For Patient 3, daily peritoneal dialysis treatments (a home-based treatment for kidney failure that uses the lining of the abdomen as a filter to remove waste and excess fluid from the blood) and the presence of a pacemaker (a small, battery-operated electronic device implanted in the chest to help control or regulate a slow or irregular heartbeat), were not included in Patient 3’s care plan.  This failure had the potential to cause Patient 3 to suffer fluid and electrolyte imbalances (the body has either too much or too little water and minerals like sodium, potassium, and calcium to function correctly), infections, and inconsistent peritoneal dialysis treatments due to insufficient monitoring for complications. Additionally, not including the presence of a pacemaker in the care plan may result in insufficient monitoring for complications and potential interference with the natural process of the heart stopping during the dying process.   2. For Patient 4, the presence of a cholecystostomy tube and drainage bag (a small plastic tube inserted into the gallbladder to drain infected bile and relieve pressure) were not included in Patient 4’s care plan.  This failure had the potential to cause Patient 4 to suffer an infection at the drain site, dislodgement of the drain tube, and bleeding due to insufficient monitoring for complications. --- Findings: 1. A review of Patient 3’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of August 18, 2025, with a benefit period of August 18, 2025, to November 15, 2025 (Benefit Period one). Patient 3 had diagnoses that included atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (heart disease affecting the patient's own coronary arteries, a condition characterized by a buildup of plaque that can cause chest pain called angina pectoris, with the specific type of angina being unspecified). During a concurrent observation and interview at the home visit on September 16, 2025, from 11:37 AM, to 1:28 PM, with Patient 3’s Daughter 1 and Daughter 2, Patient 3’s Daughter 1 stated a peritoneal dialysis machine located at Patient 3’s bedside and also stated she administered peritoneal dialysis treatments for Patient 3 nightly for a duration of 11 hours. Patient 3’s Daughter 2 stated Patient 3 had a pacemaker placed during a recent hospital admission in August 2025.  A review of Patient 3’s admission assessment, dated August 19, 2025, by a Registered Nurse (RN 1), indicated Patient 3’s pacemaker and a dialysis port [a surgically created opening in the body that allows blood to flow out to a dialysis machine (a medical device that functions as an artificial kidney to filter waste products and excess fluid from the blood when a person's own kidneys are unable to do so) but no indication of peritoneal dialysis treatments. A review of Patient 3’s care plan dated September 17, 2025, was conducted. There was no documented evidence to show the peritoneal dialysis treatments and presence of the pacemaker had been included in Patient 3’s plan of care. RN 1 was unavailable for interview. During an interview on September 18, 2025, at 11:53 AM, with the Vice President of Operations (VP/O) and Director of Patient Care Services (DPCS), the VP/O and DPCS confirmed RN 1 had not included the peritoneal dialysis treatments and presence of the pacemaker in Patient 3’s plan of care and should have.  2. A review of Patient 4’s face sheet, undated, indicated a start of care date of August 15, 2025, with a benefit period of August 15, 2025, to November 12, 2025 (Benefit Period one). Patient 4 had diagnoses that included hypertensive heart disease with heart failure (a condition where high blood pressure (hypertension) damages the heart over time, leading to its inability to pump blood effectively). During a concurrent observation and interview at home visit on September 16, 2025, from 2:08 PM to 3:06 PM, with Patient 4, Patient 4’s Wife and Son, a cholecystostomy tube was observed on the upper right side of Patient 4's abdomen, connected to a drainage bag that was approximately one-eighth full. Patient 4's wife stated the tube had been placed during Patient 4's recent hospital admission in July 2025. A review of Patient 4’s admission assessment, dated August 15, 2025, by RN 3, indicated, “Patient [4] has a cholecystostomy drain in his [right upper quadrant] draining [approximately] 30 cc [cubic centimeter-a unit of measurement] of green output.” A review of Patient 4’s care plan dated September 17, 2025, was conducted. There was no documented evidence to show the cholecystostomy tube had been included in Patient 4’s plan of care. RN 3 was unavailable for interview. During an interview on September 18, 2025, at 12:11 PM, with the VP/O and DPCS, the VP/O and DPCS confirmed RN 3 had not included the cholecystostomy tube in Patient 4’s plan of care and should have.  A review of the agency’s policy and procedure titled “The Plan of Care,” dated July 2025, indicated, “PURPOSE: To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. POLICY: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. This plan of care must be initiated at the start of care. …”

The agency failed to ensure the Condition of Participation: L 648 §418.100 Organization and administration of services was in compliance when: 1.The agency failed to ensure the comprehensive assessment (a detailed evaluation of a patient's complete health status that includes physical status, mental status, spiritual status and psychosocial status) identified the physical needs of two of four sampled patients (Patient 3 and 4) when: 1a. For Patient 3: a Registered Nurse (RN 1) did not perform a wound assessment for Patient 3’s diabetic ulcers (open sores, or wounds, on the skin, most commonly on the feet, that occur in people with diabetes- a chronic condition where blood glucose (sugar) levels are too high because the body either doesn't produce enough insulin or cannot use insulin effectively) on the right foot affecting toes one through four or the surgical site of a left leg below the knee amputation (the surgical removal of all or part of a limb, such as a finger, toe, arm, or leg). (Refer to L 651) 1b. For Patient 4: RN 3 did not perform a wound assessment for the surgical site of Patient 4’s left foot toe amputation, which involved the fourth toe. (Refer to L 651) 2. The agency failed to develop an individualized plan of care (a nursing care plan is a written document that outlines the individualized care a patient will receive, which includes: a patient’s needs, the problem, the goal and interventions to meet the goal) for two of four sampled patients (Patients 3 and 4) when: 2a. For Patient 3, daily peritoneal dialysis treatments (a home-based treatment for kidney failure that uses the lining of the abdomen as a filter to remove waste and excess fluid from the blood) and the presence of a pacemaker (a small, battery-operated electronic device implanted in the chest to help control or regulate a slow or irregular heartbeat), were not included in Patient 3’s care plan. (Refer to L 651) 2b. For Patient 4, the presence of a cholecystostomy tube and drainage bag (a small plastic tube inserted into the gallbladder to drain infected bile and relieve pressure) were not included in Patient 4’s care plan. (Refer to L 651) 3. The agency failed to ensure the Medical Director (MD) or Associate Medical Director (AMD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for four of four sampled patients (Patients 1, 2, 3, and 4) when: 3a. For Patient 1: The AMD 1 performed the face-to-face encounter (F2F-an in-person non-certifying physician’s or nurse practitioners’ clinical assessment of the patient) and certified Patient 1 as terminally ill, despite the regulatory requirement for two separate clinicians to conduct these clinical assessments. (Refer to L 651) 3b-d. For Patients 2, 3 and 4: the CTI for the first and second 90-day benefit periods were not signed by the MD and Patient 2, 3, and 4’s Attending Physicians (APs), as mandated by the regulatory requirements. (Refer to L 651) 4. The MD and AMD failed their responsibility for the medical component of the hospice program for four of four sampled patients (Patients: 1, 2, 3, and 4) when an attending physician's confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. The MD and AMD failed to review data from a referral source or an attending physician in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. (Refer to L 651) 5. The hospice failed to retain administrative and financial management, over a contracted wound care company for two of four sampled patients (Patients 1 and 2) when the contracted wound care company billed wound care services outside of the hospice benefit. (Refer to L 655) The cumulative effect of these systemic practices resulted in the potential to cause Patient 3 and 4 to suffer severe complications such as infection, gangrene (the death of body tissue caused by a lack of blood supply or a bacterial infection) and repeat amputations due to Patient 3 and 4’s impaired wound healing from diabetes and the trauma of recent surgery; Patient 3 to suffer fluid and electrolyte imbalances (the body has either too much or too little water and minerals like sodium, potassium, and calcium to function correctly), infections, and inconsistent peritoneal dialysis treatments due to insufficient monitoring for complications. Additionally, not including the presence of a pacemaker in Patient 3’s care plan may result in insufficient monitoring for complications and potential interference with the natural process of the heart stopping during the dying process; Patient 4 to suffer an infection at the drain site, dislodgement of the drain tube, and bleeding due to insufficient monitoring for complications. In addition, Patients 1, 2, 3, and 4 not to be given the opportunity to try curative treatments and opt for palliative care, too soon due to their attending physicians not identifying them as terminally ill and the MD or AMD not evaluating, in the approved manner, Patients 1, 2, 3, and 4’s terminal diagnosis and prognosis of six months or less to live. Furthermore, Patients 1 and 2 had the potential to suffer financial harm through unexpected bills, as well as distress from inappropriate medical procedures, such as aggressive or unnecessary wound treatments, that may be contrary to the comfort-focused goals of hospice care.

Based on observation, interview, and record review, the Governing Body (GB) failed to operate and manage the agency from October 2, 2024, to September 18, 2025, for four of four sampled patients (Patients 1, 2, 3, and 4), when: 1. The agency failed to ensure the comprehensive assessment (a detailed evaluation of a patient's complete health status that includes physical status, mental status, spiritual status and psychosocial status) identified the physical needs of two of four sampled patients (Patient 3 and 4) when: 1a. For Patient 3: a Registered Nurse (RN 1) did not perform a wound assessment for Patient 3’s diabetic ulcers (open sores, or wounds, on the skin, most commonly on the feet, that occur in people with diabetes- a chronic condition where blood glucose (sugar) levels are too high because the body either doesn't produce enough insulin or cannot use insulin effectively) on the right foot affecting toes one through four or the surgical site of a left leg below the knee amputation (the surgical removal of all or part of a limb, such as a finger, toe, arm, or leg).  1b. For Patient 4: RN 3 did not perform a wound assessment for the surgical site of Patient 4’s left foot toe amputation, which involved the fourth toe. These failures had the potential to cause Patient 3 and 4 to suffer severe complications such as infection, gangrene (the death of body tissue caused by a lack of blood supply or a bacterial infection) and repeat amputations due to Patient 3 and 4’s impaired wound healing from diabetes and the trauma of recent surgery. 2. The agency failed to develop an individualized plan of care (a nursing care plan is a written document that outlines the individualized care a patient will receive, which includes: a patient’s needs, the problem, the goal and interventions to meet the goal) for two of four sampled patients (Patients 3 and 4) when: 2a. For Patient 3, daily peritoneal dialysis treatments (a home-based treatment for kidney failure that uses the lining of the abdomen as a filter to remove waste and excess fluid from the blood) and the presence of a pacemaker (a small, battery-operated electronic device implanted in the chest to help control or regulate a slow or irregular heartbeat), were not included in Patient 3’s care plan. This failure had the potential to cause Patient 3 to suffer fluid and electrolyte imbalances (the body has either too much or too little water and minerals like sodium, potassium, and calcium to function correctly), infections, and inconsistent peritoneal dialysis treatments due to insufficient monitoring for complications. Additionally, not including the presence of a pacemaker in the care plan may result in insufficient monitoring for complications and potential interference with the natural process of the heart stopping during the dying process.   2b. For Patient 4, the presence of a cholecystostomy tube and drainage bag (a small plastic tube inserted into the gallbladder to drain infected bile and relieve pressure) were not included in Patient 4’s care plan. This failure had the potential to cause Patient 4 to suffer an infection at the drain site, dislodgement of the drain tube, and bleeding due to insufficient monitoring for complications. 3. The agency failed to ensure the Medical Director (MD), or Associate Medical Director (AMD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for four of four sampled patients (Patients 1, 2, 3, and 4) when: 3a. For Patient 1: The AMD 1 performed the face-to-face encounter (F2F-an in-person non-certifying physician’s or nurse practitioners’ clinical assessment of the patient) and certified Patient 1 as terminally ill, despite the regulatory requirement for two separate clinicians to conduct these clinical assessments.  3b-d. For Patients 2, 3 and 4: the CTI for the first and second 90-day benefit periods were not signed by the MD and Patient 2, 3, and 4’s Attending Physicians (APs), as mandated by the regulatory requirements. These failures had the potential to cause Patients 1, 2, 3, and 4 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to the MD and AMD not evaluating, in the approved manner, Patients 1, 2, 3, and 4’s terminal diagnosis and prognosis of six months or less to live. 4. The MD and the AMD failed their responsibility for the medical component of the hospice program for four of four sampled patients (Patients: 1, 2, 3, and 4) when an AP’s confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. The MD and AMD failed to review data from a referral source or an attending physician in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. This failure had the potential to cause Patients 1, 2, 3, and 4 not to be given the opportunity to try curative treatments and opt for palliative care, too soon due to their APs not identifying them as terminally ill and the MD or AMD not evaluating, in the approved manner, Patients 1, 2, 3, and 4’s terminal diagnosis and prognosis of six months or less to live. --- Findings: 1a. A review of Patient 3’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of August 18, 2025, with a benefit period of August 18, 2025, to November 15, 2025 (Benefit Period one). Patient 3 had diagnoses that included atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (heart disease affecting the patient's own coronary arteries, a condition characterized by a buildup of plaque that can cause chest pain called angina pectoris, with the specific type of angina being unspecified).” A review of Patient 3’s admission assessment, dated August 19, 2025, by RN 1, indicated “She [Patient 3] has a left leg amputation with sutures [sterile materials used to close wounds or surgical incisions by holding the tissue edges together for healing] in place, a pacemaker a dialysis port [a surgically created opening in the body that allows blood to flow out to a dialysis machine (a medical device that functions as an artificial kidney to filter waste products and excess fluid from the blood when a person's own kidneys are unable to do so)] to the left abdomen, and a Dexcom sensor [a small, disposable device, part of a continuous glucose monitoring system, that is inserted under the skin to measure glucose levels in the body's fluid] to the left arm. On admission, the patient was alert and oriented x4 [a person who is alert and oriented to person, place, time and event], though intermittently dazed and unable to sustain conversation. She is unable to reposition herself independently and requires full assistance with ADLs [Activities of Daily Living- fundamental self-care tasks like bathing, dressing, eating, toileting, transferring (moving between positions), and maintaining continence]. Skin assessment revealed multiple diabetic ulcers to the right foot digits [toes], scattered bruising to bilateral [both] arms, and oral ulcers [painful, open sores that form on the inside of the mouth, often appearing as a white or yellow center with a red border] noted on the tongue and gums.” A review of Patient 3’s skin assessment, dated August 19, 2025, by RN 1, indicated:1a. Open Date: August 19, 20251b. Location: diabetic ulcers on the right foot affecting toes one through four.1c. Description: no documentation.1d. Size-length, width, depth: no documentation.1e. Color of wound bed or edges: P = Pink (healthy wound edges), R = Red (inflamed wound edges or healthy healing tissue in wound bed), Y = Yellow (slough, a type of tissue incapable of healing due to a lack of blood supply or other injury), E = Eschar Hard Black (hard, dead tissue that requires removal to allow for healing), B = Soft Blue/Black (indicates severe pressure damage to the underlying soft tissue): no documentation.1f. Drainage (the fluid released from the wound): no documentation.1g. Odor (smell indicates bacterial presence, due to infection or tissue breakdown): no documentation.1h. Inflammation (the initial stage of the body's immune response to injury to clear debris and fight infection, characterized by redness, heat, swelling, and pain. Prolonged or excessive inflammation can indicate infection or a need for an intervention to promote healing): no documentation.1i. Undermining /Tunneling (undermining is when the wound edges separate from the underlying tissue, creating a "shelf" or space under the skin's surface, similar to an iceberg. Tunneling is a narrow, deep passageway or tract that extends from the wound into the deeper tissue. Both represent "dead space" and indicate significant tissue damage beneath the surface that can harbor bacteria, impede healing, and make the wound appear smaller than it is): no documentation.2a. Open Date: August 19, 20252b. Location: surgical site of a left leg below the knee amputation.2c. Description: no documentation.2d. Size-length, width, depth: no documentation.2e. Color of wound bed or edges: no documentation.2f. Drainage: no documentation.2g. Odor: no documentation.2h. Inflammation: no documentation.2i. Undermining /Tunneling: no documentation. RN 1 was unavailable for interview. During an interview on September 18, 2025, at 11:53 AM, with the Vice President of Operations (VP/O) and Director of Patient Care Services (DPCS), the VP/O and DPCS confirmed RN 1 had not conducted a wound assessment during Patient 3’s admission assessment and should have.  1b. A review of Patient 4’s face sheet, undated, indicated a start of care date of August 15, 2025, with a benefit period of August 15, 2025, to November 12, 2025 (Benefit Period one). Patient 4 had diagnoses that included hypertensive heart disease with heart failure (a condition where high blood pressure (hypertension) damages the heart over time, leading to its inability to pump blood effectively). A review of Patient 4’s admission assessment, dated August 15, 2025, by RN 3, indicated, “Patient [4] has a left toe surgical amputation.” A review of Patient 4’s skin assessment, dated August 15, 2025, by RN 3, indicated:1a. Open Date: August 15, 20251b. Location: surgical site of Patient 4’s left foot toe amputation, which involved the fourth toe.1c. Description: surgical amputation1d. Size-length, width, depth: no documentation.1e. Color of wound bed or edges: no documentation.1f. Drainage: no documentation.1g. Odor: no documentation.1h. Inflammation: no documentation.1i. Undermining /Tunneling: no documentation. RN 3 was unavailable for interview. During an interview on September 18, 2025, at 12:11 PM, with the VP/O and DPCS, the VP/O and DPCS confirmed RN 3 had not conducted a wound assessment during Patient 4’s admission assessment and should have.  A review of the agency’s policy and procedure (P&P) titled, “Comprehensive Assessment,” dated May 2022, indicated, “PURPOSE: To provide guidelines for the comprehensive assessment. … PROCEDURE: 1. 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: … a. Comprehensive skin assessment to be completed upon admission and once weekly by a qualified skilled nurse or other licensed provider to include the following elements: i. Measurements of any wounds or other skin impairments, ii. Location and description of wound bed, iii. Drainage, if applicable, to include color, consistency, odor, etc., iv. Tunneling or undermining, if applicable, v. Assessment of surrounding tissues. …” 2a. A review of Patient 3’s face sheet, undated, indicated a start of care date of August 18, 2025, with a benefit period of August 18, 2025, to November 15, 2025 (Benefit Period one). Patient 3 had diagnoses that included atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. During a concurrent observation and interview at the home visit on September 16, 2025, from 11:37 AM, to 1:28 PM, with Patient 3’s Daughter 1 and Daughter 2, Patient 3’s Daughter 1 stated a peritoneal dialysis machine located at Patient 3’s bedside and also stated she administered peritoneal dialysis treatments for Patient 3 nightly for a duration of 11 hours. Patient 3’s Daughter 2 stated Patient 3 had a pacemaker placed during a recent hospital admission in August 2025.  A review of Patient 3’s admission assessment, dated August 19, 2025, by RN 1, indicated Patient 3’s pacemaker and a dialysis port [a surgically created opening in the body that allows blood to flow out to a dialysis machine (a medical device that functions as an artificial kidney to filter waste products and excess fluid from the blood when a person's own kidneys are unable to do so) but no indication of peritoneal dialysis treatments. A review of Patient 3’s care plan, dated September 17, 2025, was conducted. There was no documented evidence to show the peritoneal dialysis treatments and presence of the pacemaker had been included in Patient 3’s plan of care. RN 1 was unavailable for interview. During an interview on September 18, 2025, at 11:53 AM, with the VP/O and DPCS, the VP/O and DPCS confirmed RN 1 had not included the peritoneal dialysis treatments and presence of the pacemaker in Patient 3’s plan of care and should have.  2b. A review of Patient 4’s face sheet, undated, indicated a start of care date of August 15, 2025, with a benefit period of August 15, 2025, to November 12, 2025 (Benefit Period one). Patient 4 had diagnoses that included hypertensive heart disease with heart failure. During a concurrent observation and interview at the home visit on September 16, 2025, from 2:08 PM to 3:06 PM, with Patient 4, Patient 4’s Wife and Son, a cholecystostomy tube was observed on the upper right side of Patient 4's abdomen, connected to a drainage bag that was approximately one-eighth full. Patient 4's wife stated the tube had been placed during Patient 4's recent hospital admission in July 2025. A review of Patient 4’s admission assessment, dated August 15, 2025, by RN 3, indicated, “Patient [4] has a cholecystostomy drain in his [right upper quadrant] draining [approximately] 30 cc [cubic centimeter-a unit of measurement] of green output.” A review of Patient 4’s care plan, dated September 17, 2025, was conducted. There was no documented evidence to show the cholecystostomy tube had been included in Patient 4’s plan of care. RN 3 was unavailable for interview. During an interview on September 18, 2025, at 12:11 PM, with the VP/O and DPCS, the VP/O and DPCS confirmed RN 3 had not included the cholecystostomy tube in Patient 4’s plan of care and should have.  A review of the agency’s P&P titled “The Plan of Care,” dated July 2025, indicated, “PURPOSE: To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. POLICY: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. This plan of care must be initiated at the start of care. …” 3. A review of “42 CFR [Code of Federal Regulation] § 418.22 - Certification of terminal illness, (4) Face-to-face encounter,” updated June 3, 2025, indicated, “(4) The physician or nurse practitioner who performs the face-to-face encounter with the patient described in paragraph (a)(4) of this section must attest in writing that he or she had a face-to-face encounter with the patient, including the date of that visit. The attestation of the nurse practitioner or a non-certifying hospice physician shall state that the clinical findings of that visit were provided to the certifying physician for use in determining continued eligibility for hospice care.” 3a. A review of Patient 1’s face sheet, undated, indicated a start of care date of October 2, 2024, with a benefit period of May 30, 2025, to July 28, 2025 (Benefit Period eight). Patient 1 had diagnoses that included cirrhosis of liver (a chronic liver disease characterized by the formation of scar tissue that replaces healthy liver cells). A review of Patient 1’s CTI, dated May 30, 2025, to July 28, 2025 (Benefit Period eight) indicated certification of Patient 1’s prognosis of six months or less life expectancy by the AMD 1.  A review of Patient 1’s F2F, dated May 9, 2025, indicated the AMD 1 had conducted the F2F encounter for benefit period 8. A review of Patient 1’s claims for payment, indicated claims for payment were submitted on June 6, 2025, July 7, 2025, and August 6, 2025.  During an interview on September 18, 2025, at 1:06 PM, with the AMD 1, the AMD 1 stated he had certified Patient 1’s terminal illness in the eighth benefit period and conducted the F2F encounter. The AMD 1 stated he was not aware of the regulatory requirement for two separate clinicians to conduct these clinical assessments.  A review of the agency’s P&P titled, “Face-To-Face Encounter,” dated July 2025, indicated, “PURPOSE: To establish a process to comply with the Face-to-Face Encounter requirement. POLICY: A face-to-face encounter will be performed for patients entering the third and all subsequent benefit periods. PROCEDURE: 1. The hospice director (employed, volunteer, or under contract) or a hospice employed nurse practitioner (NP) will perform a face-to-face encounter within 30 days prior to the hospice recertification for the third and all subsequent benefit periods. 2. During the Face-to-Face encounter, the hospice medical director or NP must gather and document clinical findings to determine the patient's continued hospice eligibility. 3. The physician/NP who performs the face-to-face encounter will attest in writing that he/she had the face-to-face encounter, including the date of the visit. The NP must also attest that the clinical findings were provided to the certifying physician.” A review of “42 CFR § 418.22 - Certification of terminal illness, (c) Sources of certification,” updated June 3, 2025, indicated, “(1) For the initial 90-day period, the hospice must obtain written certification statements (and oral certification statements if required under paragraph (a)(3) of this section) from - (i) The medical director of the hospice or the physician member of the hospice interdisciplinary group; and (ii) The individual's attending physician, if the individual has an attending physician. …” A review of “42 CFR § 418.3(2) - Definition of Attending Physician-Hospice,” updated June 3, 2025, indicated, “… (2) Is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual's medical care.”  3b. A review of Patient 2’s face sheet, undated, indicated a start of care date of April 8, 2025, with a benefit period of April 8, 2025, to July 6, 2025 (Benefit Period one). Patient 2 had diagnoses that included hypertensive heart disease without heart failure (a condition where prolonged high blood pressure (hypertension) damages the heart without causing the heart to pump inefficiently (heart failure).” A review of Patient 2’s physician’s referral order, dated April 7, 2025, by the AMD 1, indicated to evaluate for hospice services.  During an interview on September 17, 2025, at 9:54 AM, with Patient 2’s grandson, Patient 2’s grandson identified Patient 2’s attending physician as Attending Physician (AP 2).  A review of Patient 2’s face sheet from the Assisted Living Facility (ALF-a living arrangement in which people with special needs, especially seniors, live in a facility that provides help with everyday tasks such as bathing, dressing, and taking medication) where Patient 2 lived, indicated Patient 2’s attending physician was AP 2. A review of Patient 2’s “Physician’s Certification for Hospice Benefit,” dated April 8, 2025, to July 6, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the AMD 2 on April 14, 2025.  A review of Patient 2’s “Physician’s Certification for Hospice Benefit,” dated April 8, 2025, to July 6, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment 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 Hospice. I have been encouraged to participate in the IDG [Interdisciplinary group - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient] Meetings and Plan of Care if I choose to follow the Patient.” The document indicated for the MD to sign, but it remained unsigned. There was no documented evidence to show AP 2 provided a signature verifying Patient 2’s prognosis of six months or less life expectancy.  A review of Patient 2’s claims for payment, indicated a claim for payment was submitted on September 5, 2025. During an interview on September 18, 2025, at 1:31 PM, with the AMD 2 and the MD, the AMD 2 confirmed the MD, nor the AP 2 had signed Patient 2’s CTI for benefit period one. The AMD 2 stated he did not know about the requirement for the MD and attending physician to sign the patients’ CTIs in the first and second benefit periods. The MD stated he had not signed Patient 2’s CTI for benefit period one and he did not know about the requirement for the MD and attending physician to sign the patients’ CTIs in the first and second benefit periods. 3c. A review of Patient 3’s face sheet, undated, indicated a start of care date of August 18, 2025, with a benefit period of August 18, 2025, to November 15, 2025 (Benefit Period one). Patient 3 had diagnoses that included atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (heart disease affecting the patient's own coronary arteries, a condition characterized by a buildup of plaque that can cause chest pain called angina pectoris, with the specific type of angina being unspecified).” A review of Patient 3’s physician’s referral order, dated August 18, 2025, by the MD, indicated to evaluate for hospice services.  During an interview at the home visit on September 16, 2025, from 11:37 AM, to 1:28 PM, with Patient 3’s Daughter 1 and Daughter 2, Patient 3’s Daughter 1 and Daughter 2 identified Patient 3’s attending physician as Attending Physician (AP 3). A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated August 18, 2025, to November 15, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MD on August 25, 2025.   A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated August 18, 2025, to November 15, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment 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 Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient.” The document indicated for the MD to sign, but it remained unsigned. There was no documented evidence to show the AP 3 provided a signature verifying Patient 3’s prognosis of six months or less life expectancy.   A review of Patient 3’s claims for payment, indicated a claim for payment was submitted on September 5, 2025. During an interview with the MD on September 18, 2025, at 1:56 PM, the MD confirmed the AP 3 had not signed Patient 3’s CTI for benefit period one. The MD stated he did not know about the requirement for the MD and attending physician to sign the patients’ CTIs in the first and second benefit periods.  3d. A review of Patient 4’s face sheet, undated, indicated a start of care date of August 15, 2025, with a benefit period of August 15, 2025, to November 12, 2025 (Benefit Period one). Patient 4 had diagnoses that included hypertensive heart disease with heart failure (a condition where high blood pressure (hypertension) damages the heart over time, leading to its inability to pump blood effectively). A review of Patient 4’s physician’s referral order, dated August 12, 2025, by Patient 4’s Referring Physician (RP), indicated to evaluate for hospice services.  During an interview at the home visit on September 16, 2025, from 2:08 PM, to 3:06 PM, with Patient 4’s Wife and Son, Patient 4’s Wife and Son identified Patient 4’s attending physician as Attending Physician (AP 4).  A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated August 15, 2025, to November 12, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MD on August 18, 2025.    A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated August 15, 2025, to November 12, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment 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 Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient.” The document indicated for the RP to sign, but it remained unsigned. There was no documented evidence to show the RP or AP 4 provided a signature verifying Patient 4’s prognosis of six months or less life expectancy. A review of Patient 4’s claims for payment, indicated a claim for payment was submitted on September 5, 2025. During an interview on September 18, 2025, at 2:12 PM, with the MD, the MD confirmed the RP, nor the AP 4 had signed Patient 4’s CTI for benefit period one. The MD stated he did not know about the requirement for the MD and attending physician to sign the patients’ CTIs in the first and second benefit periods.  A review of the agency’s P&P titled, “Certification of Terminal Illness,” dated July 2025, indicated, “PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: … Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, physician member of the interdisciplinary team and/or the hospice Medical Director (or physician designee).” 4. A review of “42 CFR [Code of Federal Regulation] § 418.25 – Admission to hospice care,” updated June 3, 2025, indicated, “(a) The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient's attending physician (if any).” 4a. A review of Patient 1’s face sheet, undated, indicated a start of care date of October 2, 2024, with a benefit period of October 2, 2024, to November 30, 2025 (Benefit Period four) Patient 1 had diagnoses that included cirrhosis of liver. Discharged July 28, 2025. A review of Patient 1’s physician’s referral order, dated October 2, 2024, by AMD 1, indicated to evaluate for hospice services.  During an interview on September 18, 2025, at 11:00 AM, with the VP/O and DPCS, the VP/O and DPCS confirmed the AMD 1 had referred Patient 1 to his own hospice agency. The VP/O and the DPCS stated Patient 1’s Attending Physician (AP) had not been identified and therefore was not provided to the AMD 1 for consultation. During the interview, the VP/O accessed Patient 1’s medical group's portal and identified AP 1 as Patient 1’s AP. The VP/O further confirmed the H&P (History and Physical-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), that the AMD 1 would use to determine Patient 1’s terminal diagnosis and medical prognosis was missing from Patient 1’s clinical record.  AP 1 was unavailable for interview. A review of Patient 1’s CTI, dated October 2, 2024, to November 30, 2025 (Benefit Period four), indicated certification of Patient 1’s prognosis of six months or less life expectancy by the AMD 1.  During an interview on September 18, 2025, at 1:06 PM, with the AMD 1, the AMD 1 confirmed he had referred Patient 1 to his own hospice and did not reach out to AP 1 to consult about Patient 1’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. 4b. A review of Patient 2’s face sheet, undated, indicated a start of care date of April 8, 2025, with a benefit period of April 8, 2025, to July 6, 2025 (Benefit Period one). Patient 2 had diagnoses that included hypertensive heart disease without heart failure. A review of Patient 2’s physician’s referral order, dated April 7, 2025, by AMD 1, indicated to evaluate for hospice services.  During an interview on September 17, 2025, at 9:54 AM, with Patient 2’s grandson, Patient 2’s grandson stated that the ALF told the family to switch Patient 2 to hospice because Patient 2 was having frequent hospitalizations. Patient 2’s grandson stated the ALF did not provide a list of hospices to choose from and the ALF stated they would set the hospice up for Patient 2. Patient 2’s grandson identified AP 2 as Patient 2’s AP.  AP 2 declined an interview but provided a written statement dated September 17, 2025, and signed by AP 2. The statement indicated that AP 2 had seen Patient 2 on March 2, 2023, at the request of the ALF for a PPD test (purified protein derivative, also known as a Mantoux test, is a skin test used to detect a tuberculosis (TB) infection) and that AP 2 had no knowledge of Patient 2 being on hospice services. During an interview on September 18, 2025, at 11:43 AM, with the VP/O and the DPCS, the VP/O and DPCS confirmed that the AMD 1 had referred Patient 2 to his own hospice agency. The VP/O and the DPCS stated Patient 2’s AP had not been identified and therefore was not provided to the AMD 2 for consultation. The VP/O further confirmed the H&P that the AMD 2 would use to determine Patient 2’s terminal diagnosis and medical prognosis was missing from Patient 2’s clinical record.  A review of Patient 2’s CTI, dated April 8, 2025, to July 6, 2025, (Benefit Period one), indicated certification of Patient 2’s prognosis of six months or less life expectancy by the AMD 2.  During an interview on September 18, 2025, at 1:31 PM, with the AMD 2, the AMD 2 stated he did not reach out to AP 2 to consult about Patient 2’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. 4c. A review of Patient 3’s face sheet, undated, indicated a start of care date of August 18, 2025, with a benefit period of August 18, 2025, to November 15, 2025 (Benefit Period one). Patient 3 had diagnoses that included atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. A review of Patient 3’s physician’s referral order, dated August 18, 2025, by the MD, indicated to evaluate for hospice services.  During an interview at the home visit on September 16, 2025, from 11:37 AM, to 1:28 PM, with Patient 3, Patient 3’s Daughter 1 and Daughter 2, Patient 3’s Daughter 1 and Daughter 2 stated they had not asked about hospice services and a physician had not discussed hospice with them. Patient 3’s Daughter 1 and Daughter 2 stated the hospice staff just showed up to the critical care unit in the acute care hospital where Patient 3 was admitted and told them about what hospice could do for Patient 3. Daughter 1 stated she needed help caring for Patient 3 at home, so she decided “why not?” Patient 3’s Daughter 2 stated the nurses and doctors at the acute care hospital were confused and asked them why hospice staff were visiting Patient 3. Patient 3’s Daughter 1 and Daughter 2 stated the hospice staff never asked who Patient 3’s AP was and identified Patient 3’s AP as AP 3. Patient 3’s Daughter 1 and Daughter 2 stated the hospice staff did not tell them what Patient 3’s terminal diagnosis was and if they had known it was heart disease they would have taken Patient 3 to a cardiologist (a medical specialist who diagnoses and treats diseases and conditions of the heart and blood vessels), Patient 3’s Daughter 2 stated “My mom [Patient 3] wants everything done to save her life.” Patient 3 stated she knew she was receiving hospice services, but she did not know what hospice was.  During an interview on September 17, 2025, at 10:48 AM, with AP 3, AP 3 stated he saw Patient 3 on June 19, 2025, for an annual visit. AP 3 learned in early August 2025 that Patient 3 had been admitted to hospice, informed by the daughter during a call to arrange a post-hospital follow-up visit. AP 3 stated the hospice did not call him to consult over a terminal diagnosis or request a referral order. AP 3 stated he would have declined to sign the CTI with a terminal diagnosis of atherosclerotic heart disease because Patient 3's ejection fraction (EF- measures the heart's ability to pump oxygen-rich blood out to the body) was 55% (percent) to 60% (indicates the heart is pumping blood efficiently, as this range is considered normal) while in the hospital, and the echocardiogram (a medical imaging test that uses ultrasound waves to create detailed images of the heart. It provides information about the heart's structure, function, and blood flow) demonstrated normal functioning as of June 2025. AP 3 stated that there was no discussion with the patient or family about hospice services, as it was not deemed necessary at that point in Patient 3's life. During an interview on September 18, 2025, at 11:53 AM, with the VP/O and DPCS, the VP/O and DPCS confirmed the MD had referred Patient 3 to his own hospice agency. The VP/O and the DPCS stated Patient 3’s AP had not been identified and therefore was not provided to the MD for consultation.  A review of Patient 3’s CTIb dated August 18, 2025, to November 15, 2025 (Benefit Period one), indicated certification of Patient 3’s prognosis of six months or less life expectancy by the MD.  During an interview on September 18, 2025, at 1:56 PM, with the MD, the MD confirmed he had referred Patient 3 to his own hospice agency. The MD stated he did not reach out to AP 3 to consult about Patient 3’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. 4d. A review of Patient 4’s face sheet, undated, indicated a start of care date of August 15, 2025, with a benefit period of August 15, 2025, to November 12, 2025 (Benefit Period one). Patient 4 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 4’s physician’s referral order, dated August 12, 2025, by Patient 4’s Referring Physician (RP), indicated to evaluate for hospice services.  During an interview at the home visit on September 16, 2025, from 2:08 PM, to 3:06 PM, with Patient 4, Patient 4’s Wife and Son, Patient 4’s wife stated she received a phone call from the hospice staff after Patient 4’s discharge from the acute care hospital. Patient 4’s wife stated the hospice staff told her Patient 4’s medical group r eferred him to hospice. Patient 4’s wife stated she had not asked for hospice services and no physician in the hospital had discussed hospice services with her or Patient 4. Patient 4's son stated the hospice staff, during their visit to discuss services, communicated the impression that the hospice would aid in Patient 4's recovery, rather than preparing for end-of-life care within six months. Patient 4’s son stated he was hoping to take Patient 4 on two planned trips this year. Patient 4’s wife stated she took Patient 4 to his gastroenterologist (a medical doctor who specializes in the diagnosis and treatment of conditions affecting the digestive system) follow-up appointment for Patient 4’s newly placed cholecystostomy tube and the gastroenterologist told her he could not treat Patient 4 because he was on hospice, Patient 4’s wife stated, “I was shocked!” Patient 4’s Wife and Son stated the hospice staff never asked about Patient 4's AP, who they identified as AP 4. Patient 4 stated he did not know he was receiving hospice services and did not know what hospice was.  AP 4 was unavailable for interview. During an interview on September 18, 2025, at 12:11 PM, with the VP/O and DPCS, the VP/O and DPCS stated Patient 4’s AP had not been identified and therefore was not provided to the MD for consultation.  A review of Patient 4’s CTI, dated August 15, 2025, to November 12, 2025, (Benefit Period one) indicated certification of Patient 4’s prognosis of six months or less life expectancy by the MD.  During an interview on September 18, 2025, at 2:12 PM, with the MD, the MD stated he did not reach out to AP 4 or the RP to consult about Patient 4’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. A review of the agency’s P&P titled, “Certification of Terminal Illness,” dated July 2025, indicated, “PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: … When certifying the patient as terminally ill, the hospice Medical Director (or physician designee), physician member of the interdisciplinary team and/or physician designee 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. Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, physician member of the interdisciplinary team and/or the hospice Medical Director (or physician designee). … PROCEDURE: … Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. …” A review of the agency’s P&P titled, “Physician Services-Medical Director,” dated July 2025, indicated, “PURPOSE: To ensure qualified medical direction and consultation for the delivery of hospice services and programs. To demonstrate that the Medical Director/hospice team physician (physician designee) has overall responsibility for patient care through documentation that demonstrates interaction/ communication with the attending physician as necessary for appropriate medical care. … POLICY … Reviewing patients' medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness.” During an interview on September 18, 2025, at 3:24 PM, with the VP/O and Chief Financial Officer (CFO), the VP/O and CFO stated they were members of the GB and assumed full legal authority and responsibility for the operation of the agency, and for the quality of care and services provided.  The VP/O and CFO stated the GB had not identified: 1a-b. that the comprehensive assessment did not identify the physical needs of  Patients 3 and 4 when: for Patient 3: RN 1 did not perform a wound assessment for Patient 3’s diabetic ulcers on the right foot affecting toes one through four or the surgical site of a left leg below the knee amputation, and for Patient 4: RN 3 did not perform a wound assessment for the surgical site of Patient 4’s left foot toe amputation, which involved the fourth toe. 2a-b. that an individualized plan of care was not developed for Patients 3 and 4) when: for Patient 3, daily peritoneal dialysis treatments and the presence of a pacemaker were not included in Patient 3’s care plan, and for Patient 4, the presence of a cholecystostomy tube and drainage bag were not included in Patient 4’s care plan. 3a-d. that the MD or AMD did not certify the patients' terminal illnesses as mandated by the regulatory requirements for Patients 1, 2, 3, and 4 when: for Patient 1: the AMD 1 performed the F2F and certified Patient 1 as terminally ill, despite the regulatory requirement for two separate clinicians to conduct these clinical assessments, and for Patients 2, 3 and 4: the CTI for the first and second 90-day benefit periods were not signed by the MD and Patient 2, 3, and 4’s APs. 4a-d. that the MD and AMD 1 and 2 were not fulfilling their responsibility for the medical component of the hospice program for Patients 1, 2, 3, and 4 when an attending physician's confirmation of service needs, verification of the patients' medical prognosis and supporting documentation were not obtained. In addition, the MD and AMD 1 and 2 had not reviewed data from a referral source or APs in order to validate the Patients’ diagnoses, life-limiting prognoses or appropriateness of hospice services. A review of the agency’s P&P titled, “Governing Body,” dated July 2025, indicated, “PURPOSE: To outline the roles and responsibilities of the Governing Body. POLICY: The Governing Body will assume full legal authority and responsibility for the operation of Organization's Name. The Governing Body of Organization's Name will serve as the governing authority for the hospice program, which will function according to Organization's Name's bylaws.”

Based on interview and record review, the hospice failed to retain administrative and financial management, over a contracted wound care company for two of four sampled patients (Patients 1 and 2) when the contracted wound care company billed wound care services outside of the hospice benefit. This failure had the potential to cause Patients 1 and 2 to suffer financial harm through unexpected bills, as well as distress from inappropriate medical procedures, such as aggressive or unnecessary wound treatments, that may be contrary to the comfort-focused goals of hospice care. --- Findings: A review of “42 CFR [Code of Federal Regulation] § 418.24 - Election of hospice care,” updated September 22, 2025, “(g) Waiver of other benefits. For the duration of an election of hospice care, an individual waives all rights to Medicare payments for the following services: (2) Any Medicare services that are related to the treatment of the terminal condition for which hospice care was elected or a related condition or that are equivalent to hospice care…”  1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of October 2, 2024, with a benefit period of October 2, 2024, to November 30, 2025 (Benefit Period four) Patient 1 had diagnoses that included cirrhosis of liver (a chronic liver disease characterized by the formation of scar tissue that replaces healthy liver cells). Discharged July 28, 2025. A review of Patient 1’s Hospice Benefit Election, dated October 2, 2024, signed by Patient 1’s wife, indicated, “As a Medicare Part A [a federal health insurance program], Medi-Cal [is California's Medicaid program-a federal and state health insurance program], or Private Insurance beneficiary, I hereby elect [name of hospice agency] as my sole provider of hospice care Effective (date) [October 2, 2024]. I understand that while this election is in force, Medicare/Medi-Cal/Private Insurance will make payments for care related to this illness to the physician designated below and to [name of hospice agency], and that the services related to this illness provided by hospitals, Home health agencies, nursing homes, and any other company or agency will not be reimbursed by Medicare/MediCal/Private Insurance unless specifically ordered and authorized by [name of hospice agency] I understand that the services not related to this illness will continue to be covered by Medicare/Medi-Cal/Private Insurance along with hospice benefits.” A review of Patient 1’s Certification of Terminal Illness (CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) dated October 2, 2024, to November 30, 2025 (Benefit Period four) indicated, “RN [Registered Nurse] Prognosis Summary: … Comorbidities [two or more medical conditions existing alongside a patient's primary terminal illness and contribute to a patient's terminality and overall prognosis]: … PVD [peripheral vascular disease-any disorder of the blood vessels (arteries or veins), most commonly affecting the legs and feet. PVD restricts blood flow to the limbs causing non-healing sores, tissue death or amputation in severe cases), DM [diabetes mellites- high blood sugar levels which contribute to diabetic ulcers through peripheral arterial disease, which impairs blood flow. This combination leads to poor wound healing, an increased risk of infection, and potentially progressing to a bone infection and lower limb amputation-surgical removal of a limb] … Patient has a history of being on hospice services …Patient is bedbound [unable to get out of bed] and dependent for all ADLs [activities of daily living] … He has a wound on his [right] hip. He has a wound on his bilateral [both] feet. He has peripheral vascular disease which causes wound healing complications. … Certifying Physician Narrative: … [Patient 1’s] other comorbid conditions include … peripheral vascular disease, diabetes, … Due to the patient`s advanced cirrhosis recent decline with worsening pain, poor functional status, patient has life expectancy of less than [six] months and is hospice appropriate…” A review of Patient 1’s contracted wound care company’s initial wound evaluation and treatment, dated July 3, 2025, indicated, “[body] Location: Left [Middle] …, Ankle, Etiology [cause of the wound]: Venous Ulcer [an open, often painful sore on the lower leg or ankle caused by poor blood circulation] with fat layer exposed … Treatment Plan Goal: Treatment plan is palliative [to make the effects of the wound less severe], preventing infection.” A review of Patient 1’s contracted wound care company’s visit, dated July 18, 2025, indicated, “[body] Location: Left [Middle] …, Ankle, Etiology: Venous Ulcer with fat layer exposed … Wound Description: Left [middle ankle] Diabetic Ulcer [an open sore that develops on the foot due to poor blood circulation and nerve damage caused by high blood sugar levels] … Treatment Plan Goal: Treatment plan is palliative, preventing infection. ; Removal Of Slough [dead tissue]; Weekly Debridement [the medical removal of dead or damaged tissue] To Promote Healing Is Initiated; Wound care to support healing and protect surrounding skin.” A review of Patient 1’s contracted wound care company’s visit, dated July 22, 2025, indicated, “[body] Location: Left [Middle] …, Ankle, Etiology: Venous Ulcer with fat layer exposed … Wound Description: Left [middle ankle] Diabetic Ulcer … Treatment Plan Goal: Treatment plan is palliative, preventing infection. ; Removal Of Slough; Weekly Debridement To Promote Healing Is Initiated; Wound care to support healing and protect surrounding skin.” During an interview on September 18, 2025, at 10:40 AM, with the Contracted Wound Care Company’s Administrator (CWCC/Admin), the CWCC/Admin stated Patient 1’s wound care visits dated July 3, 18, and 22, 2025 were billed outside the hospice benefit due to the severity if the wound. The CWCC/Admin stated after Patient 1’s July 22, 2025, visit there was a discussion to proceed with a skin graft (a surgical procedure to move a patch of healthy skin from one part of the body (the donor site) to cover a damaged or missing area of skin on another part of the body (the recipient site)), but Patient 1 was discharged from hospice and the skin graft was not done.  2. A review of Patient 2’s face sheet, undated, indicated a start of care date of April 8, 2025, with a benefit period of April 8, 2025, to July 6, 2025 (Benefit Period one). Patient 2 had diagnoses that included hypertensive heart disease without heart failure (a condition where prolonged high blood pressure (hypertension) damages the heart WITHOUT causing the heart to pump inefficiently (heart failure). A review of Patient 2’s Hospice Benefit Election, dated April 8, 2025, signed by Patient 2’s grandson, indicated, “As a Medicare Part A, Medi-Cal, or Private Insurance beneficiary, I hereby elect [name of hospice agency] as my sole provider of hospice care Effective (date) [April 8, 2025] I understand that while this election is in force, Medicare/Medi-Cal/Private Insurance will make payments for care related to this illness to the physician designated below and to [name of hospice agency], and that the services related to this illness provided by hospitals, Home health agencies, nursing homes, and any other company or agency will not be reimbursed by Medicare/MediCal/Private Insurance unless specifically ordered and authorized by [name of hospice agency] I understand that the services not related to this illness will continue to be covered by Medicare/Medi-Cal/Private Insurance along with hospice benefits.” A review of Patient 2’s CTI, dated April 8, 2025, to July 6, 2025 (Benefit Period one), indicated, “RN Prognosis Summary: … Comorbidities include … ulceration [open sore, or ulcer, on the surface of the skin] to the [right lower leg] [secondary-resulting from] to vascular insufficiency [medical term for any condition that prevents the blood vessels from working correctly, resulting in poor blood flow] … [Patient 2] was just [discharged] from [an acute care hospital] last evening for treatment of [right lower leg] cellulitis [bacterial infection of the deeper layers of the skin and the tissue underneath] … [right lower leg] noted with an infected [right lower leg] vascular [a network of vessels or tubes that transport fluids] wound … Certifying Physician Narrative: … Her comorbidities include … ulceration to the right lower extremity … secondary to vascular insufficiency, … [Patient 2] was recently discharged from [an acute care hospital] for treatment of [right lower leg] cellulitis … Given her advanced condition, she is appropriate for hospice care with a life expectancy of 6 months or less if the disease continues its expected course.” A review of Patient 2’s contracted wound care company’s initial wound evaluation and treatment, dated May 1, 2025, indicated, “[Body] Location: Right Lower Leg, … Etiology: Venous Ulcer with fat layer exposed … Patient Assessment: Patient Is Tolerating Gentle Sharp Debridement(s); Weekly Debridement To Promote Healing Is Initiated; Wounds Are Showing Healthy Progress…” A review of Patient 2’s contracted wound care company’s visit, dated May 8, 2025, indicated, “Patient Assessment: Wounds Are Showing Healthy Progress; The wound is resolved; Discharged from wound specialist.” During an interview on September 18, 2025, at 10:50 AM, with the CWCC/Admin, the CWCC/Admin stated Patient 2’s wound care visits dated May 1, and 8, 2025 were billed outside the hospice benefit due to the wound debridement.  During an interview on September 18, 2025, at 3:31 PM, with the Chief Financial Officer (CFO) and the Vice President of Operations (VP/O), the CFO stated he owned 50% (percent) of the hospice agency and 50% of the contracted wound care company. The CFO stated he did not know the contracted wound care company was billing outside the hospice benefit. The VP/O stated the contracted wound care company should not have billed Patient 1 and 2’s wound care visits outside the hospice benefit and the hospice should have been billed. The VP/O stated she did not know the contracted wound care company was billing outside the hospice benefit. A review of the agency’s policy and procedure (P&P) titled, “Medicare Hospice Benefit,” dated July 2025, indicated, “POLICY: … Hospice programs participating in the Medicare hospice benefit will be reimbursed for each patient day in the program according to the level of care: routine home care, continuous care in times of crisis, inpatient respite care, and general inpatient care. Out of these daily rates, the hospice program must provide all of the hospice services required by the patient …” A review of the agency’s P&P titled, “Written Agreements for Contracted Services,” dated July 2025, indicated, “PURPOSE: To specify the contents of a written agreement by defining the nature and scope of services provided by clinicians and others not directly employed by hospice. … PROCEDURE: … G. The procedure for determining charges and reimbursement … 3. The organization will retain responsibility for evaluating services, maintaining professional, administrative and financial management responsibility, and ensuring continuity of care through its performance improvement program and/or corporate compliance program. If during the annual vendor evaluation of services, it is found that services are not being provided per the written agreement, those services will not be billed to avoid improper billing. … 6. As part of the organization's annual evaluation process, the Executive Director/Administrator with the assistance of other hospice personnel, will monitor, evaluate, and audit the contracted services to ensure that they are being provided according to the contract, Medicare Conditions of Participation, and [accrediting organization] standards. …”

The agency failed to ensure that the Condition of Participation: L 664 §418.102 Medical director was in compliance as follows: 1. Based on interview and record review, the agency failed to ensure the Medical Director (MD) or Associate Medical Director (AMD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for four of four sampled patients (Patients 1, 2, 3, and 4) when: 1a. For Patient 1: The AMD 1 performed the face-to-face encounter (F2F-an in-person non-certifying physician’s or nurse practitioners’ clinical assessment of the patient) and certified Patient 1 as terminally ill, despite the regulatory requirement for two separate clinicians to conduct these clinical assessments. (Refer to L 667) 1b. For Patients 2, 3 and 4: the CTI for the first and second 90-day benefit periods were not signed by the MD and Patient 2, 3, and 4’s Attending Physicians (APs), as mandated by the regulatory requirements. (Refer to L 667) 2. Based on interview and record review, the MD and the AMD failed their responsibility for the medical component of the hospice program for four of four sampled patients (Patients: 1, 2, 3, and 4) when an attending physician's confirmation of service needs, verification of the patients' medical prognosis and supporting documentation were not obtained. The MD and AMD failed to review data from a referral source or an attending physician in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. (Refer to L 669) The cumulative effect of these systemic practices resulted in the potential to cause Patients 1, 2, 3, and 4 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and the MD or AMD not evaluating, in the approved manner, Patients 1, 2, 3, and 4’s terminal diagnosis and prognosis of six months or less to live.

Based on interview and record review, the agency failed to ensure the Medical Director (MD) or Associate Medical Director (AMD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for four of four sampled patients (Patients 1, 2, 3, and 4) when: 1. For Patient 1: The AMD 1 performed the face-to-face encounter (F2F-an in-person non-certifying physician’s or nurse practitioners’ clinical assessment of the patient) and certified Patient 1 as terminally ill, despite the regulatory requirement for two separate clinicians to conduct these clinical assessments.  2. For Patients 2, 3 and 4: the CTI for the first and second 90-day benefit periods were not signed by the MD and Patient 2, 3, and 4’s Attending Physicians (APs), as mandated by the regulatory requirements. These failures had the potential to cause Patients 1, 2, 3, and 4 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to the MD and AMD not evaluating, in the approved manner, Patients 1, 2, 3, and 4’s terminal diagnosis and prognosis of six months or less to live. --- Findings: A review of “42 CFR [Code of Federal Regulation] § 418.22 - Certification of terminal illness, (4) Face-to-face encounter,” updated June 3, 2025, indicated, “(4) The physician or nurse practitioner who performs the face-to-face encounter with the patient described in paragraph (a)(4) of this section must attest in writing that he or she had a face-to-face encounter with the patient, including the date of that visit. The attestation of the nurse practitioner or a non-certifying hospice physician shall state that the clinical findings of that visit were provided to the certifying physician for use in determining continued eligibility for hospice care.” 1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of October 2, 2024, with a benefit period of May 30, 2025, to July 28, 2025 (Benefit Period eight). Patient 1 had diagnoses that included cirrhosis of liver (a chronic liver disease characterized by the formation of scar tissue that replaces healthy liver cells). A review of Patient 1’s CTI, dated May 30, 2025, to July 28, 2025 (Benefit Period eight) indicated certification of Patient 1’s prognosis of six months or less life expectancy by the AMD 1.  A review of Patient 1’s F2F, dated May 9, 2025, indicated the AMD 1 had conducted the F2F encounter for benefit period 8. A review of Patient 1’s claims for payment indicated claims for payment were submitted on June 6, 2025, July 7, 2025, and August 6, 2025.  During an interview on September 18, 2025, at 1:06 PM, with the AMD 1, the AMD 1 stated he had certified Patient 1’s terminal illness in the eighth benefit period and conducted the F2F encounter. The AMD 1 stated he was not aware of the regulatory requirement for two separate clinicians to conduct these clinical assessments.  A review of the agency’s policy and procedure (P&P) titled, “Face-To-Face Encounter,” dated July 2025, indicated, “PURPOSE: To establish a process to comply with the Face-to-Face Encounter requirement. POLICY: A face-to-face encounter will be performed for patients entering the third and all subsequent benefit periods. PROCEDURE: 1. The hospice director (employed, volunteer, or under contract) or a hospice employed nurse practitioner (NP) will perform a face-to-face encounter within 30 days prior to the hospice recertification for the third and all subsequent benefit periods. 2. During the Face-to-Face encounter, the hospice medical director or NP must gather and document clinical findings to determine the patient's continued hospice eligibility. 3. The physician/NP who performs the face-to-face encounter will attest in writing that he/she had the face-to-face encounter, including the date of the visit. The NP must also attest that the clinical findings were provided to the certifying physician.” A review of “42 CFR § 418.22 - Certification of terminal illness, (c) Sources of certification,” updated June 3, 2025, indicated, “(1) For the initial 90-day period, the hospice must obtain written certification statements (and oral certification statements if required under paragraph (a)(3) of this section) from - (i) The medical director of the hospice or the physician member of the hospice interdisciplinary group; and (ii) The individual's attending physician, if the individual has an attending physician. …” A review of “42 CFR § 418.3(2) - Definition of Attending Physician-Hospice,” updated June 3, 2025, indicated, “… (2) Is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual's medical care.”  2a. A review of Patient 2’s face sheet, undated, indicated a start of care date of April 8, 2025, with a benefit period of April 8, 2025, to July 6, 2025 (Benefit Period one). Patient 2 had diagnoses that included hypertensive heart disease without heart failure (a condition where prolonged high blood pressure (hypertension) damages the heart without causing the heart to pump inefficiently (heart failure).” A review of Patient 2’s physician’s referral order, dated April 7, 2025, by the AMD 1, indicated to evaluate for hospice services.  During an interview on September 17, 2025, at 9:54 AM, with Patient 2’s grandson, Patient 2’s grandson identified Patient 2’s attending physician as Attending Physician (AP 2).  A review of Patient 2’s face sheet from the Assisted Living Facility (ALF-a living arrangement in which people with special needs, especially seniors, live in a facility that provides help with everyday tasks such as bathing, dressing, and taking medication) where Patient 2 lived, indicated Patient 2’s attending physician was AP 2. A review of Patient 2’s “Physician’s Certification for Hospice Benefit,” dated April 8, 2025, to July 6, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the AMD 2 on April 14, 2025.  A review of Patient 2’s “Physician’s Certification for Hospice Benefit,” dated April 8, 2025, to July 6, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment 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 Hospice. I have been encouraged to participate in the IDG [Interdisciplinary group - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient] Meetings and Plan of Care if I choose to follow the Patient,” the document indicated for the MD to sign, but it remained unsigned. There was no documented evidence to show AP 2 provided a signature verifying Patient 2’s prognosis of six months or less life expectancy.  A review of Patient 2’s claims for payment, indicated a claim for payment was submitted on September 5, 2025. During an interview on September 18, 2025, at 1:31 PM, with the AMD 2 and the MD, the AMD 2 confirmed the MD nor the AP 2 had signed Patient 2’s CTI for benefit period one. The AMD 2 stated he did not know about the requirement for the medical director and attending physician to sign the patients’ CTIs in the first and second benefit periods. The MD stated he had not signed Patient 2’s CTI for benefit period one and he did not know about the requirement for the medical director and attending physician to sign the patients’ CTIs in the first and second benefit periods. 2b. A review of Patient 3’s face sheet, undated, indicated a start of care date of August 18, 2025, with a benefit period of August 18, 2025, to November 15, 2025 (Benefit Period one). Patient 3 had diagnoses that included atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (heart disease affecting the patient's own coronary arteries, a condition characterized by a buildup of plaque that can cause chest pain called angina pectoris, with the specific type of angina being unspecified).” A review of Patient 3’s physician’s referral order, dated August 18, 2025, by the MD, indicated to evaluate for hospice services.  During an interview at the home visit on September 16, 2025, from 11:37 AM, to 1:28 PM, with Patient 3’s Daughter 1 and Daughter 2, Patient 3’s Daughter 1 and Daughter 2 identified Patient 3’s attending physician as Attending Physician (AP 3).  A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated August 18, 2025, to November 15, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MD on August 25, 2025.   A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated August 18, 2025, to November 15, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment 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 Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient,” the document indicated for the MD to sign, but it remained unsigned. There was no documented evidence to show AP 3 provided a signature verifying Patient 3’s prognosis of six months or less life expectancy.   A review of Patient 3’s claims for payment, indicated a claim for payment was submitted on September 5, 2025. During an interview on September 18, 2025, at 1:56 PM, with the MD, the MD confirmed the AP 3 had not signed Patient 3’s CTI for benefit period one. The MD stated he did not know about the requirement for the medical director and attending physician to sign the patients’ CTIs in the first and second benefit periods.  2c. A review of Patient 4’s face sheet, undated, indicated a start of care date of August 15, 2025, with a benefit period of August 15, 2025, to November 12, 2025 (Benefit Period one). Patient 4 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 4’s physician’s referral order, dated August 12, 2025, by Patient 4’s Referring Physician (RP), indicated to evaluate for hospice services.  During an interview at the home visit on September 16, 2025, from 2:08 PM, to 3:06 PM, with Patient 4’s Wife and Son, Patient 4’s Wife and Son identified Patient 4’s attending physician as Attending Physician (AP 4).  A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated August 15, 2025, to November 12, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MD on August 18, 2025.    A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated August 15, 2025, to November 12, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment 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 Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient,” the document indicated for the RP to sign, but it remained unsigned. There was no documented evidence to show the RP or AP 4 provided a signature verifying Patient 4’s prognosis of six months or less life expectancy. A review of Patient 4’s claims for payment, indicated a claim for payment was submitted on September 5, 2025. During an interview on September 18, 2025, at 2:12 PM, with the MD, the MD confirmed the RP, nor the AP 4 had signed Patient 4’s CTI for benefit period one. The MD stated he did not know about the requirement for the medical director and attending physician to sign the patients’ CTIs in the first and second benefit periods.  A review of the agency’s P&P titled, “Certification of Terminal Illness,” dated July 2025, indicated, “PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: … Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, physician member of the interdisciplinary team and/or the hospice Medical Director (or physician designee).”

Based on interview and record review, the Medical Director (MD) and the Associate Medical Director (AMD) failed their responsibility for the medical component of the hospice program for four of four sampled patients (Patients: 1, 2, 3, and 4) when an attending physician's confirmation of service needs, verification of the patients' medical prognosis, and supporting documentation were not obtained. The MD and AMD failed to review data from a referral source or an attending physician in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. This failure had the potential to cause Patients 1, 2, 3, and 4 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and the MD or AMD not evaluating, in the approved manner, Patients 1, 2, 3, and 4’s terminal diagnosis and prognosis of six months or less to live. --- Findings: A review of “42 CFR [Code of Federal Regulation] § 418.25 – Admission to hospice care,” updated June 3, 2025, indicated, “(a) The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient's attending physician (if any).” A review of “42 CFR § 418.3(2) - Definition of Attending Physician-Hospice,” updated June 3, 2025, indicated, “… (2) Is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual's medical care.”  1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of October 2, 2024, with a benefit period of October 2, 2024, to November 30, 2025 (Benefit Period four) Patient 1 had diagnoses that included cirrhosis of liver (a chronic liver disease characterized by the formation of scar tissue that replaces healthy liver cells). Patient 1 discharged on July 28, 2025. A review of Patient 1’s physician’s referral order, dated October 2, 2024, by the AMD 1, indicated to evaluate for hospice services.  During an interview on September 18, 2025, at 11:00 AM, with the Vice President of Operations (VP/O) and Director of Patient Care Services (DPCS), the VP/O and DPCS confirmed the AMD 1 had referred Patient 1 to his own hospice agency. The VP/O and DPCS stated Patient 1’s Attending Physician (AP) had not been identified and therefore was not provided to the AMD 1 for consultation. During the interview, the VP/O accessed Patient 1’s medical group's portal and identified AP 1 as Patient 1’s AP. The VP/O further confirmed the H&P (History and Physical-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), that the AMD 1 would use to determine Patient 1’s terminal diagnosis and medical prognosis was missing from Patient 1’s clinical record.  AP 1 was unavailable for interview. A review of Patient 1’s CTI, dated October 2, 2024, to November 30, 2025 (Benefit Period four) indicated certification of Patient 1’s prognosis of six months or less life expectancy by the AMD 1.  During an interview on September 18, 2025, at 1:06 PM, with the AMD 1, the AMD 1 confirmed he had referred Patient 1 to his own hospice and did not reach out to AP 1 to consult about Patient 1’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. 2. A review of Patient 2’s face sheet, undated, indicated a start of care date of April 8, 2025, with a benefit period of April 8, 2025, to July 6, 2025 (Benefit Period one). Patient 2 had diagnoses that included hypertensive heart disease without heart failure (a condition where prolonged high blood pressure (hypertension) damages the heart without causing the heart to pump inefficiently (heart failure). A review of Patient 2’s physician’s referral order, dated April 7, 2025, by the AMD 1, indicated to evaluate for hospice services.  During an interview on September 17, 2025, at 9:54 AM, with Patient 2’s grandson, Patient 2’s grandson stated the Assisted Living Facility (ALF-a living arrangement in which people with special needs, especially seniors, live in a facility that provides help with everyday tasks such as bathing, dressing, and taking medication) told the family to switch Patient 2 to hospice because Patient 2 was having frequent hospitalizations. Patient 2’s grandson stated the ALF did not provide a list of hospices to choose from and the ALF stated they would set the hospice up for Patient 2. Patient 2’s grandson identified AP 2 as Patient 2’s AP.  AP 2 declined an interview but provided a written statement dated September 17, 2025, and signed by AP 2. The statement indicated that AP 2 had seen Patient 2 on March 2, 2023, at the request of the ALF for a PPD test (purified protein derivative, also known as a Mantoux test, is a skin test used to detect a tuberculosis (TB) infection) and that AP 2 had no knowledge of Patient 2 being on hospice services. During an interview on September 18, 2025, at 11:43 AM, with the VP/O and DPCS, the VP/O and DPCS confirmed the AMD 1 had referred Patient 2 to his own hospice agency. The VP/O and DPCS stated Patient 2’s AP had not been identified and therefore was not provided to the AMD 2 for consultation. The VP/O further confirmed the H&P that the AMD 2 would use to determine Patient 2’s terminal diagnosis and medical prognosis was missing from Patient 2’s clinical record.  A review of Patient 2’s CTI, dated April 8, 2025, to July 6, 2025, (Benefit Period one) indicated certification of Patient 2’s prognosis of six months or less life expectancy by the AMD 2.  During an interview on September 18, 2025, at 1:31 PM, with the AMD 2, the AMD 2 stated he did not reach out to AP 2 to consult about Patient 2’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. 3. A review of Patient 3’s face sheet, undated, indicated a start of care date of August 18, 2025, with a benefit period of August 18, 2025, to November 15, 2025 (Benefit Period one). Patient 3 had diagnoses that included atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (heart disease affecting the patient's own coronary arteries, a condition characterized by a buildup of plaque that can cause chest pain called angina pectoris, with the specific type of angina being unspecified). A review of Patient 3’s physician’s referral order, dated August 18, 2025, by the MD, indicated to evaluate for hospice services.  During an interview at the home visit on September 16, 2025, from 11:37 AM, to 1:28 PM, with Patient 3, Patient 3’s Daughter 1 and Daughter 2, Patient 3’s Daughter 1 and Daughter 2 stated they had not asked about hospice services and a physician had not discussed hospice with them. Patient 3’s Daughter 1 and Daughter 2 stated the hospice staff just showed up to the critical care unit in the acute care hospital where Patient 3 was admitted and told them about what hospice could do for Patient 3. Daughter 1 stated she needed help caring for Patient 3 at home, so she decided “why not?” Patient 3’s Daughter 2 stated the nurses and doctors at the acute care hospital were confused and asked them why hospice staff were visiting Patient 3. Patient 3’s Daughter 1 and Daughter 2 stated the hospice staff never asked who Patient 3’s AP was and identified Patient 3’s AP as AP 3. Patient 3’s Daughter 1 and Daughter 2 stated the hospice staff did not tell them what Patient 3’s terminal diagnosis was and if they had known it was heart disease they would have taken Patient 3 to a cardiologist (a medical specialist who diagnoses and treats diseases and conditions of the heart and blood vessels), Patient 3’s Daughter 2 stated “My mom [Patient 3] wants everything done to save her life.” Patient 3 stated she knew she was receiving hospice services, but she did not know what hospice was.  During an interview on September 17, 2025, at 10:48 AM, with AP 3, AP 3 stated he saw Patient 3 on June 19, 2025, for an annual visit. AP 3 learned in early August 2025 that Patient 3 had been admitted to hospice, informed by the daughter during a call to arrange a post-hospital follow-up visit. AP 3 stated the hospice did not call him to consult over a terminal diagnosis or request a referral order. AP 3 stated he would have declined to sign the CTI with a terminal diagnosis of atherosclerotic heart disease because Patient 3's ejection fraction (EF- measures the heart's ability to pump oxygen-rich blood out to the body) was 55% (percent) to 60% (indicates the heart is pumping blood efficiently, as this range is considered normal) while in the hospital, and the echocardiogram (a medical imaging test that uses ultrasound waves to create detailed images of the heart. It provides information about the heart's structure, function, and blood flow) demonstrated normal functioning as of June 2025. AP 3 stated that there was no discussion with the patient or family about hospice services, as it was not deemed necessary at that point in Patient 3's life. During an interview on September 18, 2025, at 11:53 AM, with the VP/O and DPCS, the VP/O and DPCS confirmed the MD had referred Patient 3 to his own hospice agency. The VP/O and DPCS stated Patient 3’s AP had not been identified and therefore was not provided to the MD for consultation.  A review of Patient 3’s CTI, dated August 18, 2025, to November 15, 2025, (Benefit Period one) indicated certification of Patient 3’s prognosis of six months or less life expectancy by the MD.  During an interview on September 18, 2025, at 1:56 PM, with the MD, the MD confirmed he had referred Patient 3 to his own hospice agency. The MD stated he did not reach out to AP 3 to consult about Patient 3’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. 4. A review of Patient 4’s face sheet, undated, indicated a start of care date of August 15, 2025, with a benefit period of August 15, 2025, to November 12, 2025 (Benefit Period one). Patient 4 had diagnoses that included hypertensive heart disease with heart failure. A review of Patient 4’s physician’s referral order, dated August 12, 2025, by Patient 4’s Referring Physician (RP), indicated to evaluate for hospice services.  During an interview at the home visit on September 16, 2025, from 2:08 PM, to 3:06 PM, with Patient 4, Patient 4’s Wife and Son, Patient 4’s wife stated she received a phone call from the hospice staff after Patient 4’s discharge from the acute care hospital. Patient 4’s wife stated the hospice staff told her Patient 4’s medical group referred him to hospice. Patient 4’s wife stated she had not asked for hospice services and no physician in the hospital had discussed hospice services with her or Patient 4. Patient 4's son stated the hospice staff, during their visit to discuss services, communicated the impression that the hospice would aid in Patient 4's recovery, rather than preparing for end-of-life care within six months. Patient 4’s son stated he was hoping to take Patient 4 on two planned trips this year. Patient 4’s wife stated she took Patient 4 to his gastroenterologist (a medical doctor who specializes in the diagnosis and treatment of conditions affecting the digestive system) follow-up appointment for Patient 4’s newly placed cholecystostomy tube (is a thin, plastic tube placed into the gallbladder to drain pus or bile when surgery to remove the gallbladder (cholecystectomy) is not possible or is delayed) and the gastroenterologist told her he could not treat Patient 4 because he was on hospice, Patient 4’s wife stated, “I was shocked!” Patient 4’s Wife and Son stated the hospice staff never asked about Patient 4's AP, who they identified as AP 4. Patient 4 stated he did not know he was receiving hospice services and did not know what hospice was.  AP 4 was unavailable for interview. During an interview on September 18, 2025, at 12:11 PM, with the VP/O and DPCS, the VP/O and DPCS stated Patient 4’s AP had not been identified and therefore was not provided to the MD for consultation.  A review of Patient 4’s CTI, dated August 15, 2025, to November 12, 2025, (Benefit Period one) indicated certification of Patient 4’s prognosis of six months or less life expectancy by the MD.  During an interview on September 18, 2025, at 2:12 PM, with the MD, the MD stated he did not reach out to AP 4 or the RP to consult about Patient 4’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. A review of the agency’s policy and procedure (P&P) titled, “Certification of Terminal Illness,” dated July 2025, indicated, “PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: … When certifying the patient as terminally ill, the hospice Medical Director (or physician designee), physician member of the interdisciplinary team and/or physician designee 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. Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, physician member of the interdisciplinary team and/or the hospice Medical Director (or physician designee). … PROCEDURE: … Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. …” A review of the agency’s P&P titled, “Physician Services-Medical Director,” dated July 2025, indicated, “PURPOSE: To ensure qualified medical direction and consultation for the delivery of hospice services and programs. To demonstrate that the Medical Director/hospice team physician (physician designee) has overall responsibility for patient care through documentation that demonstrates interaction/ communication with the attending physician as necessary for appropriate medical care. … POLICY … Reviewing patients' medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness.”

Observed in Tracer Activities. In 3 out of 12 records, the organization did not provide ongoing education and training to all staff, individuals providing services under arrangement, and volunteers that are consistent with their roles and responsibilities in an emergency at least every two years. Examples: In the volunteer records HR#10; HR#11, and HR#12, the volunteers were not included int he Emergency Management training for 2024 and 2025. This was confirmed by the Senior VP and VP of Clinical Operations.

Observed in Tracer Visit. In 3 out of 4 records the hospice did not develop an individualized plan of care with measurable goals and time frames. Examples: RRHV#1 examples included the following: Pain will be managed at a comfortable level. Patient will have needs met on a day to day basis. Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects x30 days. RRHV#2 examples included the following: Pain will remain in comfortable level during care. Will maintain optimum peripheral circulation. RRHV#3 examples included the following: Pt will achieve and maintain peripheral circulation for pt comfort x 30 days. Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects x 30 days. Pt Blood sugar will be managed for comfort x 30 days. Pt/Family/PCG demonstrates understanding of catheter use x 30 days. Pain will remain in comfortable level during care x 30 days. Pt will promote rest status for Pt/Family/PCG x 30 days. This was confirmed by the VP of Clinical Operations.

Observed in Tracer Visit. In 2 out of 3 records, range orders for oxygen did not have defined parameters and indications for adjusting and/or changing the settings. Examples: In RRHV#2, the PRN oxygen order was for a range of 2-5 LPM without defined parameters or indications for adjusting. In RRHV#3, the PRN oxygen order was for 2-6 LPM without defined parameters or indications for adjusting. This was confirmed with the VP of Clinical Operations.

Observed in Tracer Visit. In 3 out of 4 records, the organization did not provide a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Examples: In RRHV#2, the plan of care included prn nursing visits without an indication as to when the PRN visit would be initiated. In RRHV#3, the plan of care included PRN nursing and spiritual care visits without an indication as to when the PRN visit would be initiated. In RRHV#4, the plan of care included prn nursing visits without an indication as to when the PRN visit would be initiated. This was confirmed with the VP of Clinical Operations.

Observed in Tracer Visit. In 3 out of 4 records, the organization did not provide the patient with services according to the patient's individualized plan of care. Examples: In RRHV#1, 2 aide visits were missed in week 1 of benefit period 19. In RRHV#3, 1 nursing visit was missed in week 4 of benefit period 1 and 1 aide visit was missed in weeks 10 -13 of benefit period 1. In RRHV#4, 2 aide visits were missed during week 1 of benefit period 2. This was confirmed by the VP of Clinical Operations and the Senior Vice President.

Observed in Tracer Activities. In 5 out of 12 HR records, the organization did not provide infection control education to all staff. Examples: There is no documentation of completion for the annual IC training provided per policy for HR#6 (Bereavement Coordinator); HR#8 (MSW) and Volunteers (HR#10. HR#11, and HR#12). This was confirmed by the Senior VP and the VP of Clinical Operations.

Observed in Tracer Visit. In 2 out 3 home visit records, the medication profile within the medical record was inaccurate. Examples: In RRHV#1, BIOFREEZE ointment and a generic OTC arthritic cream was being used by the patient but was not on the medication profile within the medical record. In RRHV#2, Ibuprofen and prescribed Tussin DM where present in the home but not on the medication profile within the medical record. In RRHV#2, Biscolax Suppositories were on the medication profile but were not present in the home. In RRHV#4, the Humalog strength was inaccurate at 20 mg vs the pen strength of 100 units/ml. Aspirin was listed as chewable but was in the form of an EC tablet. This was confirmed by the Clinical RNs being observed by the Surveyor during the visits.

Observed in Record Review. In 1 of 2 discharge records, the hospice did not provide the patient’s attending physician with a copy of the hospice discharge summary. Example: In RRDC#2, a discharge summary was not sent to the Attending Physician after the patient revoked hospice services. This was confirmed by the Senior Vice President.

Observed in Record Review. In 3 of 5 patient records reviewed, the surveyor noted that the plan of care did not specify the reason for PRN visits. For example in review of RR 1 the MSW frequency was list as MSW _ per month + 3 prn visits with no indicator/reason for the prn visits. This was also observed in RR 2 where the frequency was documented as MSW one time then prn, with no indicator/reason for prn visits. Finally, in RR 3 the MSW frequency was documented as; MSW 1 as needed and recert with no indicator/reason for prn visits. This was validated with the Administrator.

Observed in Data Session. During the Data session, the surveyor noted although the organization was collecting data, the frequency was not approved by the governing body. This was validated in a discussion with and observation by the Senior Vice President and the Operations Manager.

Observed in Data Session. During the Data session, the surveyor noted that the organization leadership had not: - Set priorities for data collection, performance improvement activities, and patient health outcomes - Give priority to high-volume, high-risk, or problem-prone processes for performance improvement activities (Note: Examples of areas of risk include blood-borne infections, wound care, undetected urinary tract infections, oxygen-related fires, and patient handoff to or from the home care organization.) - Identify the frequency of data collection for performance improvement activities - Reprioritize performance improvement activities in response to changes in the internal or external environment and the organization’s governing body is ultimately accountable for making sure that the priorities that are selected address improvements to the safety and quality of patient care. This was validated in a discussion with and observation by the Senior Vice President and the Operations Manager.

Observed in Individual Tracer. In 1 of 3 home visits conducted, During the Tracer 3, the surveyor noted that while the aide showered the patient only one washcloth was used and after the perineal area was cleansed the same washcloth was used to finish the legs. In addition the aide did not change his gloves during the bathing process. This was validated in a discussion wit the Senior VP and Operations Manager.

Observed in Data Session. During the data session, the surveyor noted that the organization did not have a written infection control plan that included limiting the spread of infections associated with the use of medical equipment and supplies. This was validated in a discussion with and observation by the Senior Vice President and the Operations Manager. Observed in Data Session. During the data session, the surveyor noted that the organization did not have a written infection control plan that included limiting the spread of infections associated with procedures. This was validated in a discussion with and observation by the Senior Vice President and the Operations Manager. Observed in Data Session. During the data session, the surveyor noted that the organization did not have a written plan that included limiting exposure to pathogens. This was validated in a discussion with and observation by the Senior Vice President and the Operations Manager. Observed in Data Tracer. During the data session, the surveyor noted that the organization had not documented a plan for implementing appropriate actions to improve disease prevention. This was validated in a discussion with and observation by the Senior Vice President and the Operations Manager.

Observed in Record Review. In 3 of 11 patient records reviewed, During the record review of Tracer 2, the surveyor noted that the plan of care did not specify the reason for PRN visits. The frequency was listed as SN 1 x wk and 3 PRN without an indicator. During Tracer 3 the MSW frequency was listed as 1 x per month and 3 PRN with no indicator. In RR 2 the MSW frequency was 1 x per month and 3 PRN with no indicator. This was validated in a discussion with and observation by the Senior VP and Operations Manager.

Observed in Leadership Session. The surveyor noted that the governing body/leadership did not ensure that the following conditions of participation were met as determined through observations, documentation and staff interviews at 418.60. This was confirmed with the Senior Vice President.