Every finding on record at Amalfi Hospice Care, Inc

Based on observation, interview, and record review, the agency failed to provide the Hospice Election Statement (an explanation of hospice services, a life expectancy of six months or less to live, and an abandoning of curative treatments and acceptance of palliative care) Consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of the suggested medical care) and Notice of Rights and Responsibilities (Bill of Rights- a document that provides patients with information on how they can reasonably expect to be treated during their hospice care) in a language and manner the patients understood for one of four sampled patients (Patient 3) when Patient 3’s wife was a Spanish speaker, could not speak and/or read English and had signed Patient 3’s Hospice Election Statement, Consents and Notice of Rights and Responsibilities on Patient 3’s behalf.This failure had the potential to cause Patient 3’s wife not to understand the meaning of hospice, a life expectancy of six months or less to live, an abandoning of curative treatments and acceptance of palliative care (to make the effects of a disease less severe) and Patient 3’s Bill of Rights. --- 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 March 21, 2025, with a benefit period of March 21, 2025, to June 18, 2025 (Benefit Period One). Patient 3 had diagnoses that included Hemiplegia following cerebral infarction affecting right dominant side (Right sided paralysis[the loss of muscle function, resulting in an inability to move or feel certain parts of the body] following a stroke [a medical emergency that occurs when blood flow to the brain is disrupted, leading to damage of brain tissue]) and Patient 3’s primary language was Spanish. A review of Patient 3’s “Election of Medicare [a federal health insurance program for individuals aged 65 and older] /Medi-Cal [a joint federal and state program that helps cover medical costs for some people with limited income and resources] Hospice Benefit,” dated March 21, 2025, written in the English language and signed by Patient 3’s wife, indicated, “I understand that: … 2. By electing hospice care under the Medicare Hospice Benefit, I waive all other Medicare Part A services, except, a) my right to treatment or therapy for any condition other than my terminal illness under Medicare Part A and B, and b) I do not waive the right to continue seeing my attending physician and I will be responsible for any bills from my attending physician under Medicare Part B, when appropriate. … I understand that hospice care provides: … 2. Care by the hospice physician, professional nurses and others as is appropriate will be provided as often as necessary to permit control of pain, discomfort, anxiety, and other disturbing symptoms of illness. I understand hospice care is not intended to be curative, rather it is to provide comfort and intended to alleviate, to the extent possible, symptoms connected with illness.” A review of Patient 3’s “Release of Information and Consent for Treatment,” dated March 21, 2025, written in the English language and signed by Patient 3’s wife, indicated, “1. PATIENT SELF-DETERMINATION ACT AND BILL OF RIGHTS: I have received a written statement of my rights as a patient of [Name of agency] I understand my rights because they have been explained to me and my questions have been answered. I have received written and verbal information about advance directives, [Name of agency] policy, applicable state law, the state hotline number and other information necessary to make decisions about advance directives and my care in accordance with the Patient Self Determination Act of 1990. 2. RELEASE OF INFORMATION: I consent to the release of my personal information by my Physician, Licensed health care professionals, or Facility, and to allow the disclosure of medical records kept by the above-named patient to [Name of agency]. I consent to the release of information by [Name of agency] or their representatives to any Regulatory or Accrediting agencies, other health care providers involved in my care and to third party payers, in order to assure my continued care, proper communication of information to my physician(s) referral source, and proper reimbursement of services. 3. CONSENT TO RECEIVE TREATMENT/CARE: I voluntarily consent to receive care/treatment from [Name of agency] consistent with a medical care/treatment plan established by physician and [Name of agency] Interdisciplinary group. I understand that if I am in a condition requiring services not provided by [Name of agency] my legal representative, or I, or my physician must arrange for such services, [Name of agency] shall assist in locating such services, but shall in no way be responsible for failure to provide the same, and is hereby released from any and all liability arising from fact that I am not provided with such additional care. In the event a health care worker sustains exposure to my blood or bloody fluids, I give permission for my blood to be tested for infectious diseases such as HIV [human immunodeficiency virus-a virus that attacks the body's immune system] and hepatitis [inflammation of the liver]. I understand that the exposed employee will be informed of the results of the test. I understand that I will not be billed for any laboratory fees incurred in relation to the above circumstance.” During a home visit and interview with a Registered Nurse 1 (RN 1), Patient 3’s wife and daughter and Patient 3, on April 22, 2025, from 9:47 AM to 11:26 AM, RN 1 stated she had conducted Patient 3’s initial admission assessment and spoke and read the Spanish language. RN 1 stated she had given the Explanation of Benefits (EOB) in the Spanish language for Patient 3’s wife but had provided the consents in the English language because Patient 3’s daughter spoke English. RN 1 confirmed Patient 3’s wife had signed the consents and could speak and read the Spanish language, RN 1 stated, “I should have provided the consents in Spanish.” Patient 3’s wife stated RN 1 had explained about hospice in the Spanish language, but it would have been easier for her to understand if she could have read the consents for herself. Patient 3’s wife stated if the information the hospice provided had been in the Spanish language she could have referred back to it if she needed to remember what was discussed.  During an interview with the Administrator/Owner (Admin/Owner) on April 23, 2025, at 10 AM, the Admin/Owner stated the agency had consents and a home notebook in the Spanish language for their Spanish speaking patients. The Admin/Owner confirmed Patient 3 had not received the consents and home notebook in the Spanish language and should have.  A review of the agency’s policy and procedure (P&P) titled, “Rights/Responsibilities,” dated April 2020, it indicated, “PURPOSE: To encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. POLICY: Each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights and responsibilities as described. A patient may designate someone to act as his/her representative in accordance with state law. This representative, on behalf of the patient, may exercise any of the rights provided by the policies and procedures established by the organization. … PROCEDURE: … 4. The Patient Rights and Responsibilities statement will be explained and distributed to the patient prior to the initiation of organization services. This explanation will be in a language or communication method that the patient can reasonably be expected to understand. … C. Written information will be provided to patients in English and the predominant non-English languages of the patient population served.”

The agency failed to ensure the Condition of Participation: L 648 §418.100 Organization and administration of services was in compliance when: Based on observation, interview, and record review, the Governing Body (GB) failed to operate and manage the agency from September 7, 2024, to April 24, 2025, for four of four samples patients (Patients 2, 3, 4, and 5), when: 1. The agency failed to provide the Hospice Election Statement (an explanation of hospice services, a life expectancy of six months or less to live, and an abandoning of curative treatments and acceptance of palliative care) Consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of the suggested medical care) and Notice of Rights and Responsibilities (Bill of Rights- a document that provides patients with information on how they can reasonably expect to be treated during their hospice care) in a language and manner the patients understood for one of four sampled patients (Patient 3) when Patient 3’s wife was a Spanish speaker, could not speak and/or read English and had signed Patient 3’s Hospice Election Statement, Consents and Notice of Rights and Responsibilities on Patient 3’s behalf. (Refer to L 651) 2. The agency failed to ensure the Medical Director (MD) 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 2, 3, 4, and 5) when: 2a. For Patient 5: The MD conducted the face to face encounter and certified the patient as terminally ill. (Refer to L 651) 2b-d. For Patients 2, 3, and 4: the CTI for the first and second 90-day benefit period was not signed by two physicians. (Refer to L 651) 3a-d. The MD failed his responsibility for the medical component of the hospice program for four of four sampled patients (Patients: 2, 3, 4, and 5) when an attending physician's confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. The MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. (Refer to L 651) The cumulative effect of these systemic practices resulted in the potential to cause Patient 3’s wife not to understand the meaning of hospice, a life expectancy of six months or less to live, an abandoning of curative treatments and acceptance of palliative care and Patient 3’s Bill of Rights, and Patients 2, 3, 4 and 5 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 not correctly evaluating Patients 2, 3, 4 and 5’s terminal diagnosis and prognosis of six months or less to live.

Based on observation, interview, and record review, the Governing Body (GB) failed to operate and manage the agency from September 7, 2024, to April 24, 2025, for four of four samples patients (Patients 2, 3, 4, and 5), when:1. The agency failed to provide the Hospice Election Statement (an explanation of hospice services, a life expectancy of six months or less to live, and an abandoning of curative treatments and acceptance of palliative care) Consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of the suggested medical care) and Notice of Rights and Responsibilities (Bill of Rights- a document that provides patients with information on how they can reasonably expect to be treated during their hospice care [a specialized form of medical care provided to individuals with terminal illnesses who have a life expectancy of six months or less]) in a language and manner the patients understood for one of four sampled patients (Patient 3) when Patient 3’s wife was a Spanish speaker, could not speak and/or read English and had signed Patient 3’s Hospice Election Statement, Consents and Notice of Rights and Responsibilities on Patient 3’s behalf. This failure had the potential to cause Patient 3’s wife not to understand the meaning of hospice, a life expectancy of six months or less to live, an abandoning of curative treatments and acceptance of palliative care (to make the effects of a disease less severe) and Patient 3’s Bill of Rights.2. The agency failed to ensure the Medical Director (MD) 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 2, 3, 4, and 5) when:2a. For Patient 5: The MD conducted the face to face encounter and certified the patient as terminally ill.2b-d. For Patients 2, 3, and 4: the CTI for the first and second 90-day benefit period was not signed by two physicians.These failures had the potential to cause Patients 2, 3, 4 and 5, not be given the opportunity to try curative treatments and opt for palliative care, too soon, due to the MD not correctly evaluating Patients 2, 3, 4 and 5’s terminal diagnosis and prognosis of six months or less to live.3a-d. The MD failed his responsibility for the medical component of the hospice program for four of four sampled patients (Patients: 2, 3, 4, and 5) when an attending physician's confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. The MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. This failure had the potential to cause Patients 2, 3, 4 and 5 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 not correctly evaluating Patients 2, 3, 4 and 5’s terminal diagnosis and prognosis of six months or less to live. --- 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 March 21, 2025, with a benefit period of March 21, 2025, to June 18, 2025 (Benefit Period One). Patient 3 had diagnoses that included Hemiplegia following cerebral infarction affecting right dominant side (Right sided paralysis[the loss of muscle function, resulting in an inability to move or feel certain parts of the body] following a stroke [a medical emergency that occurs when blood flow to the brain is disrupted, leading to damage of brain tissue]) and Patient 3’s primary language was Spanish.A review of Patient 3’s “Election of Medicare [a federal health insurance program for individuals aged 65 and older]/Medi-Cal [a joint federal and state program that helps cover medical costs for some people with limited income and resources] Hospice Benefit,” dated March 21, 2025, written in the English language and signed by Patient 3’s wife, indicated, “I understand that: … 2. By electing hospice care under the Medicare Hospice Benefit, I waive all other Medicare Part A services, except, a) my right to treatment or therapy for any condition other than my terminal illness under Medicare Part A and B, and b) I do not waive the right to continue seeing my attending physician and I will be responsible for any bills from my attending physician under Medicare Part B, when appropriate. … I understand that hospice care provides: … 2. Care by the hospice physician, professional nurses and others as is appropriate will be provided as often as necessary to permit control of pain, discomfort, anxiety, and other disturbing symptoms of illness. I understand hospice care is not intended to be curative, rather it is to provide comfort and intended to alleviate, to the extent possible, symptoms connected with illness.”A review of Patient 3’s “Release of Information and Consent for Treatment,” dated March 21, 2025, written in the English language and signed by Patient 3’s wife, indicated, “1. PATIENT SELF-DETERMINATION ACT AND BILL OF RIGHTS: I have received a written statement of my rights as a patient of [Name of agency] I understand my rights because they have been explained to me and my questions have been answered. I have received written and verbal information about advance directives, [Name of agency] policy, applicable state law, the state hotline number and other information necessary to make decisions about advance directives and my care in accordance with the Patient Self Determination Act of 1990. 2. RELEASE OF INFORMATION: I consent to the release of my personal information by my Physician, Licensed health care professionals, or Facility, and to allow the disclosure of medical records kept by the above-named patient to [Name of agency]. I consent to the release of information by [Name of agency] or their representatives to any Regulatory or Accrediting agencies, other health care providers involved in my care and to third party payers, in order to assure my continued care, proper communication of information to my physician(s) referral source, and proper reimbursement of services. 3. CONSENT TO RECEIVE TREATMENT/CARE: I voluntarily consent to receive care/treatment from [Name of agency] consistent with a medical care/treatment plan established by physician and [Name of agency] Interdisciplinary group. I understand that if I am in a condition requiring services not provided by [Name of agency] my legal representative, or I, or my physician must arrange for such services, [Name of agency] shall assist in locating such services, but shall in no way be responsible for failure to provide the same, and is hereby released from any and all liability arising from fact that I am not provided with such additional care. In the event a health care worker sustains exposure to my blood or bloody fluids, I give permission for my blood to be tested for infectious diseases such as HIV [human immunodeficiency virus-a virus that attacks the body's immune system] and hepatitis [inflammation of the liver]. I understand that the exposed employee will be informed of the results of the test. I understand that I will not be billed for any laboratory fees incurred in relation to the above circumstance.”During a home visit and interview with a Registered Nurse (RN 1), Patient 3’s wife and daughter and Patient 3, on April 22, 2025, from 9:47 AM to 11:26 AM, RN 1 stated she had conducted Patient 3’s initial admission assessment and spoke and read the Spanish language. RN 1 stated she had given the Explanation of Benefits (EOB) in the Spanish language for Patient 3’s wife but had provided the consents in the English language because Patient 3’s daughter spoke English. RN 1 confirmed Patient 3’s wife had signed the consents and could speak and read the Spanish language, RN 1 stated, “I should have provided the consents in Spanish.” Patient 3’s wife stated RN 1 had explained about hospice in the Spanish language, but it would have been easier for her to understand if she could have read the consents for herself. Patient 3’s wife stated if the information the hospice provided had been in the Spanish language she could have referred back to it if she needed to remember what was discussed. During an interview with the Administrator/Owner (Admin/Owner) on April 23, 2025, at 10 AM, the Admin/Owner stated the agency had consents and a home notebook in the Spanish language for their Spanish speaking patients. The Admin/Owner confirmed Patient 3 had not received the consents and home notebook in the Spanish language and should have. A review of the agency’s policy and procedure titled, “Rights/Responsibilities,” dated April 2020, indicated, “PURPOSE: To encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. POLICY: Each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights and responsibilities as described. A patient may designate someone to act as his/her representative in accordance with state law. This representative, on behalf of the patient, may exercise any of the rights provided by the policies and procedures established by the organization. … PROCEDURE: … 4. The Patient Rights and Responsibilities statement will be explained and distributed to the patient prior to the initiation of organization services. This explanation will be in a language or communication method that the patient can reasonably be expected to understand. … C. Written information will be provided to patients in English and the predominant non-English languages of the patient population served.”2a. A review of Patient 5’s face sheet, undated, indicated a start of care date of September 7, 2024, with a benefit period of March 6, 2025, to May 4, 2025 (Benefit Period three). Patient 5 had diagnoses that included age-related cognitive decline (the gradual decline in cognitive abilities, such as memory, attention, and processing speed, that can occur as people age).A review of Patient 5’s CTI dated March 6, 2025, to May 4, 2025 (Benefit Period three), indicated certification of Patient 5’s prognosis of six months or less life expectancy by the MD. A review of Patient 5’s face-to-face encounter for the third benefit period dated February 16, 2025, indicated the face-to-face encounter had been conducted by the MD.A review of Patient 5’s claims for payment, indicated a claim for payment was submitted for March 1, 2025, to March 29, 2025.During an interview with the MD on April 23, 2025, at 11:53 PM, the MD stated he had certified Patient 5’s terminal illness and performed the face-to-face encounter. The MD stated he did not know the certifying doctor could not conduct the face-to-face encounter. 2b. A review of Patient 2’s face sheet, undated, indicated a start of care date of December 5, 2024, with a benefit period of December 5, 2024, to March 4, 2025 (First 90-day benefit period). Patient 2 had diagnoses that included age-related cognitive decline. A review of Patient 2’s hospice referral order dated December 4, 2024, by Patient 2’s Attending Physician (AP 1), indicated, “Associated Dx [diagnosis]: [blank], Additional Details: Reason: Hospice.”A review of Patient 2’s “Physician’s Certification for Hospice Benefit,” dated December 5, 2024, to March 4, 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 December 5, 2024.A review of Patient 2’s “Physician’s Certification for Hospice Benefit,” dated December 5, 2024, to March 4, 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,” signed by the MD on December 5, 2024.There was no documented evidence to show AP 1 had been contacted and supporting documentation obtained. There was no documented evidence to show AP 1 had confirmed Patient 2’s hospice service needs or 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 March 1, 2025.During an interview with the MD on April 23, 2025, at 11 AM, the MD stated he had not known Patient 2’s referral order had not indicated a terminal diagnosis, and he had not reached out to AP 1 to consult about Patient 2’s terminal diagnosis. The MD stated he did not know a patient’s first and second benefit periods required two physician’s signatures certifying the patients as terminally ill.2c. A review of Patient 3’s face sheet indicated a start of care date of March 21, 2025, with a benefit period of March 21, 2025, to June 18, 2025 (Benefit Period One). Patient 3 had diagnoses that included Hemiplegia following cerebral infarction affecting right dominant side (Right sided paralysis following a stroke).A review of Patient 3’s hospice referral order dated February 21, 2025, by Patient 3’s Attending Physician (AP 2), indicated, “Associated Dx: [blank], Additional Details: Reason: Hospice.”A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated March 21, 2025, to June 18, 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 March 21, 2025.A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated March 21, 2025, to June 18, 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,” signed by the MD on March 21, 2025.There was no documented evidence to show AP 2 had been contacted and supporting documentation obtained. There was no documented evidence to show AP 2 had confirmed Patient 3’s hospice service needs or 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 for service dates from March 21, 2025, to March 29, 2025.During an interview with the MD on April 23, 2025, at 11:37 AM, the MD stated he had not known Patient 3’s referral order had not indicated a terminal diagnosis, and he had not reached out to AP 2 to consult about Patient 3’s terminal diagnosis. The MD stated he did not know a patient’s first and second benefit periods required two physician’s signatures certifying the patients as terminally ill.2d. A review of Patient 4’s face sheet indicated a start of care date of April 10, 2025, with a benefit period of April 10, 2025, to July 8, 2025 (Benefit Period One). Patient 4 had diagnoses that included age-related cognitive decline.A review of Patient 4’s hospice referral order dated April 9, 2025, by Patient 4’s Attending Physician (AP 3), indicated, “Associated Dx: [blank], Additional Details: Reason: Hospice.”A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated April 10, 2025, to July 8, 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 April 10, 2025. A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated April 10, 2025, to July 8, 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,” signed by the MD on April 10, 2025. There was no documented evidence to show AP 3 had been contacted and supporting documentation obtained. There was no documented evidence to show AP 3 had confirmed Patient 4’s hospice service needs or 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 pending for April 2025.During an interview with the MD on April 23, 2025, at 11:52 AM, the MD stated he had not known Patient 4’s referral order had not indicated a terminal diagnosis, and he had not reached out to AP 3 to consult about Patient 4’s terminal diagnosis. The MD stated he did not know a patient’s first and second benefit periods required two physician’s signatures certifying the patients as terminally ill.A review of the agency’s policy and procedure titled, “Face-to-Face Encounter,” dated April 2020, 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. … 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 the agency’s policy and procedure titled “Certification of Terminal Illness,” dated April 2020, 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: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient’s attending physician, if any, will certify the patient’s terminal illness. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. 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 and the hospice Medical Director. … PROCEDURE: 1. At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient’s individual circumstances based on: his/her review of the patient’s medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient’s attending physician will sign the certification of terminal illness and authorization for hospice services forms.) …”3a. A review of Patient 2’s face sheet, undated, indicated a start of care date of December 5, 2024, with a benefit period of December 5, 2024, to March 4, 2025 (First 90-day benefit period). Patient 2 had diagnoses that included age-related cognitive decline.A review of Patient 2’s hospice referral order dated December 4, 2024, by AP 1, indicated, “Associated Dx [diagnosis]: [blank], Additional Details: Reason: Hospice.”A review of Patient 2’s 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), contained within Patient 2’s clinical record indicated an Emergency Room (ER) visit dated December 2, 2024. The ER visit indicated a right forehead hematoma (a closed wound where blood collects and fills a space inside the body) and right eye bruising after a fall. There were no fractures (breaks), and Patient 2 was discharged in stable condition. There was no documented evidence to show a discussion of hospice with Patient 2 or a responsible party. There was no documented evidence to show a terminal diagnosis had been determined. There was no documented evidence to show additional H&P in Patient 2’s clinical record.During an interview with Patient 2’s son on April 22, 2025, at 12:09 PM, Patient 2’s son stated there was no discussion about hospice services from a physician at Patient 2’s ER visit. Patient 2’s son stated hospice services were to monitor his dad’s health and Patient 2’s son was unaware his dad needed to give up curative treatments, “I would still take him to the hospital.”A review of Patient 2’s “Physician’s Certification for Hospice Benefit,” dated December 5, 2024, to March 4, 2025, signed by the MD on December 5, 2024, indicated:a. Functional Status (a patient’s ability to perform activities of daily living (ADLs) and other tasks that are necessary for independence and well-being).KPS (Karnofsky Performance Status-A scale from 0 to 100 that assesses a patient's ability to perform daily activities and their level of independence): (Blank-no scale value indicated).PPS (Palliative Performance Scale-A comprehensive scale that includes factors like ambulation (the ability to walk), disease burden, intake, and mental status. It is often used in hospice and palliative care settings to assess functional decline and determine hospice eligibility). (Blank-no scale value indicated).FAST (Functional Assessment Staging-Specifically designed for patients with Alzheimer's disease [a progressive brain disorder that primarily affects memory, thinking, and reasoning skills, ultimately leading to dementia- a general term for a decline in mental ability severe enough to interfere with daily life] and other dementias [other diseases that cause dementia]. It assesses functional decline in areas like cognition, independence, continence, and speech). (Blank-no stage value indicated). NYHA (New York Heart Association Functional Classification-A system for classifying heart failure based on the severity of symptoms and limitations in physical activity. It helps clinicians understand the impact of heart failure on a patient's daily life and choose appropriate treatments). (Blank-no functional classification indicated).b. LCD Determination Status ((Local Coverage Determination is a document developed by Medicare Administrative Contractors (MACs) to guide in the determination of a patient’s terminal diagnosis. The document contains information about the patient's clinical status, symptoms, and signs, as well as relevant laboratory findings, to help determine if they meet the criteria for a six-month prognosis. The physician's Certification of Terminal Illness (CTI) must address the relevant LCDs to document the patient's eligibility for hospice benefits). Patient 2’s LCD indicated “Patient does not qualify per LCD Guidelines, PART III - Disease specific guidelines, DISEASE NOT FOUND.”c. Certifying Physician Narrative (explains the clinical findings supporting a patient's life expectancy of six months or less): "[Patient 2] admitted to Hospice with a diagnosis of Age related cognitive decline. He is awake alert but confused. His Vital signs (Clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicates the state of a patient's essential body functions) are stable, and pain is 0/10 [a numerical tool used to assess and track pain levels, where 0 represents no pain and 10 represents the worst pain imaginable]. His heart is regular in rhythm and with [mild swelling in lower extremities]. His lungs sounds are clear but diminished [less air is moving through the lungs]. His [belly] is soft and non-distended. He requires maximum assistance with all [his] ADL’s. He is high risk for fall. His skin is warm and dry. … Because of [his] advanced age and he is DNR [Do not Resuscitate-a legal document that instructs medical personnel not to perform cardiopulmonary resuscitation (CPR) if a person's heart stops or they stop breathing] and comfort measures only and no further aggressive treatment. His life expectancy is expected to be 6 months or less if the disease is allowed to run its natural course."During an interview with the MD on April 23, 2025, at 11 AM, the MD stated he had not known Patient 2’s referral order had not indicated a terminal diagnosis, and he did not reach out to AP 1 to consult about Patient 2’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. After review of Patient 2’s H&P information available in Patient 2’s clinical record, the MD stated the information from the H&P was insufficient to make a judgment for a terminal illness with a prognosis of six months or less to live. The MD confirmed the “Functional Status,” section of the CTI was blank and should have indicated the appropriate assessed values. The MD confirmed Patient 2 had been admitted with the terminal diagnosis of “age-related cognitive decline,” and the LCD guidelines determined this diagnosis did not qualify Patient 2 for hospice services. The MD reviewed his physician’s summary and stated the summary did not support Patient 2’s life expectancy of six months or less. The MD reviewed the definition of a terminal diagnosis (Old age itself is not considered a terminal condition. Terminal conditions are defined as illnesses that are expected to lead to death due to the illness itself, rather than from the natural progression of aging. While old age can increase the likelihood of developing terminal illnesses or experiencing age-related decline, it is not the illness itself that causes death). The MD stated Patient 2’s admitting terminal diagnosis of “age-related cognitive decline,” did not meet the definition of a terminal condition.3b. A review of Patient 3’s face sheet indicated a start of care date of March 21, 2025, with a benefit period of March 21, 2025, to June 18, 2025 (Benefit Period One). Patient 3 had diagnoses that included Hemiplegia following cerebral infarction affecting right dominant side.A review of Patient 3’s hospice referral order dated February 21, 2025, by AP 2, indicated, “Associated Dx: [blank], Additional Details: Reason: Hospice.”A review of Patient 3’s H&P, contained within Patient 3’s clinical record indicated an ER visit to Acute Care Hospital A, dated February 14, 2025. The ER visit indicated Patient 3 admitted to ER for “activated stroke” (a specific protocol within a hospital or medical system to rapidly respond to a suspected stroke). The ER physician’s assessment indicated, “I independently reviewed the above diagnostics as noted in the above [Emergency Department] Course. This patient presents with symptoms concerning for acute [sudden] CVA [Cerebrovascular Accident-also known as a stroke] versus TIA [Transient Ischemic Attack-a temporary blockage of blood flow to the brain. The blockage lasts for a short period, usually minutes to hours, and symptoms disappear completely within 24 hours. A TIA does not cause permanent brain damage or lasting neurological deficits]. Patient presented with initial NIH 6 [The National Institutes of Health Stroke Scale-NIHSS- a score of 6 or less generally indicates a milder stroke with a good recovery prognosis] and with resolving [getting better] aphasia [difficulty speaking]. Reportedly with [right] arm weakness at [the initial assessment]. CXR [chest X-ray] with demonstrated concerns for multifocal [multiple areas] pneumonia [lung infection] with reported history of recent treatment. Demonstrated afib RVR [atrial fibrillation with rapid ventricular response, a heart rhythm problem where the heart's upper chambers (atria) beat irregularly and chaotically, and the lower chambers (ventricles) beat too quickly in response] with improvement … CTA head [Computed tomography angiography- a medical imaging procedure that uses a CT scan to visualize the blood vessels in the head and neck] /neg negative for LVO [A negative finding for Large Vessel Occlusion (LVO) in stroke assessment means that the initial assessment indicates that a large artery in the brain is not blocked]. CT head negative for ICH [Intracerebral Hemorrhage, a "negative" finding typically refers to a lack of visible bleeding or other stroke-related abnormalities] with concerns for age-indeterminate infarcts [strokes, where the exact time the damage occurred is not clearly defined] … However, presentation most concerning for a TIA. EKG [electrocardiogram-a medical test that measures the electrical activity of the heart] without evidence of STEMI [Myocardial Infarction-a severe type of heart attack] or ischemia [a condition where the heart muscle does not get enough oxygen-rich blood due to reduced blood flow], fingerstick BS [blood sugar] not hypoglycemic [low blood sugar]. … with plans for transfer to [Acute Care Hospital B]. … Impression: 1. TIA (transient ischemic attack) 2. Aphasia …” There was no documented evidence to show a discussion of hospice with Patient 3 or a responsible party. There was no documented evidence to show a terminal diagnosis had been determined.A review of Patient 3’s H&P, contained within Patient 3’s clinical record, did not indicate H&P from Acute Care Hospital B. There was no documented evidence to show Patient 3’s had any additional H&P. During a concurrent observation and interview at Patient 3’s home visit on April 22, 2025, from 9:47 AM, to 11:26 AM, with Patient 3, Patient 3’s wife, Patient 3’s daughter and a Hospice Aide (HA 1), Patient 3 was in his room laying in a hospital bed, Patient 3 demonstrated how his right arm was weak, but he could lift the right arm off his bed a few inches and wiggle his fingers. Patient 3 stated his legs were too weak to walk but he could move both his legs and feet, Patient 3 demonstrated moving both legs and feet. Patient 3 stated he wanted to get stronger so he could get out of bed and spend time with his grandson. Patient 3 stated he did not know he was receiving hospice services and did not know what hospice was. Patient 3 stated no one talked to him about hospice services and he did not believe he had only 6 months to live. Patient 3’s daughter stated Acute Care Hospital A transferred Patient 3 to Acute Care Hospital B and Acute Care Hospital B told the family Patient 3 did not have a stroke and the right arm weakness was due to his previous pneumonia infection and discharged Patient 3 home with home health services. Patient 3’s daughter stated the home health services were very poor and as long as Patient 3 could wiggle his toe that was good enough and discharged Patient 3. Patient 3’s wife stated she knew hospice was for end of life care and she knew Patient 3 was not at the end of his life and would not die in 6 months, but when the hospice called an offered the services, she was desperate, so she said “Yes,” because “I needed help with his care.” Patient 3’s wife stated she knew her husband needed additional services to help him recover and get stronger, so she talked to the Hospice Aide (HA 1) and asked about more services for Patient 3. HA 1 stated Patient 3’s wife had spoken to him about different services for Patient 3 because he was not a good fit for hospice, and I reported to the office asking them to speak with Patient 3’s wife about options for home health services.A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated March 21, 2025, to June 18, 2025, signed by the MD on March 21, 2025, indicated:a. Functional Status:KPS: (Blank-no scale value indicated).PPS: (Blank-no scale value indicated).FAST: (Blank-no stage value indicated). NYHA: (Blank-no functional classification indicated).b. LCD Determination Status: (Blank-LCD determination for stroke was not completed)c. Certifying Physician Narrative: "[Patient 3] admitted to Hospice with a diagnosis of Hemiplegia [paralysis] following CVA [stroke]. His co-morbidities (the simultaneous presence of two or more diseases or medical conditions in a patient) are AF [atrial fibrillation- an irregular and often rapid heart rhythm that affects the heart's upper chambers)], DM [diabetes mellitus- A group of diseases that result in too much sugar in the blood], Hypertension [high blood pressure] and malignant neoplasm [unspecified cancer]. He is alert and oriented x3 [a patient is awake and aware of three key things: their identity (person), their location (place), and the approximate time (time)] with episodes of SOB [shortness of breath]. He is on Oxygen …. His vital signs are stable and Oxygen saturation [amount of oxygen in the blood] of 98% [percent]. His heart [has a regular rate and rhythm] and lower extremities are without edema [swelling]. His lung sounds are clear to auscultation [upon listening]. His [belly] is soft and non-distended. He has [an indwelling urinary catheter] attached to a bag draining clear yellow urine. He has [right] sided weakness. He is bedbound [cannot get out of bed by himself] and requires maximum assistance with all his ADL’s. He is DNR and comfort measures only and no further aggressive treatment or therapy. His life expectancy is expected to be 6 months or less if the disease is allowed to run its natural course."During an interview with the MD on April 23, 2025, at 11:37 AM, the MD stated he had not known Patient 3’s referral order had not indicated a terminal diagnosis, and he did not reach out to AP 2 to consult about Patient 3’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. After review of Patient 3’s H&P information available in Patient 3’s clinical record, the MD confirmed Acute Care Hospital A’s ER physician’s impression was Patient 3 had a TIA, not an acute CVA [stroke]. The MD stated he did not know about Patient 3’s transfer to Acute Care Hospital B with a discharge on home health services. The MD stated he had not reached out to Acute Care Hospital B to consult with Patient 3’s physician or obtain additional H&P. The MD stated he was unaware of Patient 3’s family’s assertion that Acute Care Hospital B had told them Patient 3 did not have a stroke. The MD confirmed the “Functional Status,” section of the CTI was blank and should have indicated the appropriate assessed values. The MD confirmed Patient 3 had been admitted with the terminal diagnosis of “Hemiplegia following cerebral infarction affecting right dominant side [stroke],” and the LCD guidelines for “stroke” were blank. The MD reviewed his physician’s summary and stated the summary did not support Patient 3’s life expectancy of six months or less.3c. A review of Patient 4’s face sheet indicated a start of care date of April 10, 2025, with a benefit period of April 10, 2025, to July 8, 2025 (Benefit Period One). Patient 4 had diagnoses that included age-related cognitive decline.A review of Patient 4’s hospice referral order dated April 9, 2025, by Patient 4’s Attending Physician (AP 3), indicated, “Associated Dx: [blank], Additional Details: Reason: Hospice.”A review of Patient 4’s H&P, contained within Patient 4’s clinical record indicated an ER visit, dated January 12, 2025. The ER visit indicated “Left lower lobe pneumonia, Influenza A infection [the flu].” There was no documented evidence to show a discussion of hospice with Patient 4 or a responsible party. There was no documented evidence to show a terminal diagnosis had been determined.A review of Patient 4’s H&P, contained within Patient 4’s clinical record indicated an ER visit, dated March 30, 2025. The ER visit indicated, “[Patient 4] with past medical history significant for sick sinus syndrome [a heart rhythm disorder where the heart's natural pacemaker (sinus node) does not function properly, leading to irregular or slow heartbeats] [after] pacemaker brought in by ambulance to [ER] with concern for left sided chest pain this evening. Patient described the pain as a burning sensation underneath the Pacemaker site. … [Chest X-Ray] Findings: Negative for infiltrate [no fluid in lings], negative for pneumothorax [collapsed lung], negative for effusion [a buildup of fluid between the layers of tissue that line the lungs and chest cavity]. Impression: Normal. … Discussed case with family to include goals of care. Granddaughter …  and grandson-in-law state they do not wish for patient to have invasive procedures or surgery as she has a DNR code status. Should cardiac interrogation [Pacemaker interrogation results provide data about a patient's pacemaker's status and performance. This includes information like battery life, lead functionality, and any recorded arrhythmias or other events. The data helps doctors ensure the device is working properly and adjust settings if needed] show no significant changes they wish for patient to be discharged. Discussed indications for admission, risks/benefits of various care plan options - shared decision to likely discharge was agreed upon.” There was no documented evidence to show a discussion of hospice with Patient 4 or a responsible party. There was no documented evidence to show a terminal diagnosis had been determined.During Patient 4’s home visit and interview on April 22, 2025, from 12:43 PM, to 1:10 PM, with a Licensed Vocational Nurse (LVN 1), Patient 4’s granddaughter, and Patient 4’s grandson-in-law, Patient 4’s granddaughter stated the physician at the hospital had not discussed hospice with her. Patient 4’s granddaughter stated, “Hospice, it [doesn’t] really mean to die, it’s to keep her [Patient 4] comfortable with no pain. The nurses said it doesn’t mean they [patients] are going to die quickly.” Patient 4’s granddaughter stated she did not know curative treatment stopped after admission to hospice.A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated April 10, 2025, to July 8, 2025, signed by the MD on April 10, 2025, indicated:a. Functional Status:KPS: 40, Disabled; requires special care and assistance.PPS: 30, Totally bed-bound, unable to do any work, extensive evidence of disease, total dependence for care, reduced intake and fully conscious or confused or drowsy.FAST: 7-C, Ambulatory ability is lost (cannot walk without personal assistance).NYHA: III, Patients with marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes palpitation, dyspnea or anginal painb. LCD Determination Status: Patient 4’s LCD indicated “Patient does not qualify per LCD Guidelines, PART III - Disease specific guidelines, DISEASE NOT FOUND.”c. Certifying Physician Narrative: [Patient 4] admitted to Hospice with a diagnosis of Age related cognitive decline. Her co-morbidities are GERD [gastroesophageal reflux disease-a digestive disorder where stomach acid frequently flows back up into the tube that carries food from your mouth to your stomach], Constipation [difficulty emptying bowels], Insomnia [difficulty sleeping], presence of Pacemaker, Sick sinus syndrome and Dementia. She was seen at her home with stable vital signs and Oxygen saturation of 97% [on room air]. She is awake, alert and hard of hearing. Her heart is regular and contracted [both lower extremities- a medical condition where both legs are stiff and limited in their range of motion, often due to permanent tightening of muscles, tendons, ligaments, or other tissues around the joints]. Her [belly] is soft and nondistended.  Her lung sounds are coarse, bilateral [both sides]. Her skin is warm, dry and intact. She is DNR and comfort measures only. She is KPS 40. PPS 30. FAST 7C. And NYHA III. She requires maximum assistance with all her ADL’s. Because of her Advanced age, her life expectancy is expected to be 6 months or less if the disease process is allowed to run its natural course."During an interview with the MD on April 23, 2025, at 11:52 AM, the MD stated he had not known Patient 4’s referral order had not indicated a terminal diagnosis, and he did not reach out to AP 3 to consult about Patient 4’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. After review of Patient 4’s H&P information available in Patient 4’s clinical record, the MD stated the information from the H&P was insufficient to make a judgment for a terminal illness with a prognosis of six months or less to live. The MD confirmed Patient 4 had been admitted with the terminal diagnosis of “age-related cognitive decline,” and the LCD guidelines determined this diagnosis did not qualify Patient 4 for hospice services. The MD reviewed his physician’s summary and stated the summary did not support Patient 4’s life expectancy of six months or less. After the MD reviewed the definition of a terminal diagnosis, the MD stated Patient 4’s admitting terminal diagnosis of “age-related cognitive decline,” did not meet the definition of a terminal condition.3d. A review of Patient 5’s face sheet, undated, indicated a start of care date of September 7, 2024, with a benefit period of March 6, 2025, to May 4, 2025 (Benefit Period three). Patient 5 had diagnoses that included age-related cognitive decline. A review of Patient 5’s hospice referral order dated September 5, 2024, by Patient 5’s Attending Physician (AP 4), indicated, “Ambulatory referral (a medical recommendation from a primary care provider to a specialist for further evaluation, diagnosis, or treatment) to Hospice. Associated Dx: Moderate dementia with other behavioral disturbance, unspecified dementia type … Referred to Specialty: Hospice Services Reason for Referral: … Dementia of uncertain etiology, rapidly progressive with rapid functional decline. Life expectancy less than 6 months. …”A review of Patient 5’s H&P contained within Patient ’s 5 clinical record indicated an Emergency Room (ER) visit dated September 1, 2024. The ER visit indicated, “[Patient 5] who presents to the Emergency Department with concern for altered mental status since fall 3-4 weeks ago. Differential diagnoses including stroke, UTI [urinary tract infection], electrolyte derangements [a disruption or imbalance in the normal levels of electrolytes within the body], hypoglycemia [low blood sugar], hepatic encephalopathy [a serious condition where brain function deteriorates due to the buildup of toxins in the blood, which is caused by a damaged liver's inability to filter them out]. CBC [complete blood count] unremarkable, no WBC [white blood cell] elevation and no anemia [low number of red blood cells]. LFTs [liver function tests] WNL [within normal limits]. Electrolytes WNL. No acute AKI [acute kidney injury]. Urine positive for WBCs and leuks [leukocytes are white blood cells], but negative nitrites [Nitrites are a different form of nitrogen, and they are usually not found in healthy urine]. Will start [an antibiotic] while awaiting CT head and abdomen. Patient signed out to oncoming provider pending imaging studies.” There was no documented evidence to show a discussion of hospice with Patient 5 or a responsible party. There was no documented evidence to show a terminal diagnosis had been determined.A review of Patient 5’s “Physician’s Certification for Hospice Benefit,” dated March 6, 2025, to May 4, 2025, signed by the MD on March 6, 2025, indicated:a. Functional Status:KPS: 40, Disabled; requires special care and assistance.PPS: 40, Mainly in bed, unable to do any work, extensive evidence of disease, considerable dependence for care, normal or reduced intake and fully conscious …FAST: 7-A, Ability to speak limited to approximately a half dozen intelligible different words or fewer, in the course of an average day or in the course of intensive interview.NYHA: IV, Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or of the anginal syndrome even at rest. If any physical activity is undertaken, discomfort is increased.b. LCD Determination Status: Patient 5’s LCD indicated “Patient does not qualify per LCD Guidelines, PART III - Disease specific guidelines, DISEASE NOT FOUND.”c. Certifying Physician Narrative: “[Patient 5] admitted to Hospice with a diagnosis of Age related cognitive decline. She was seen at her home for recertification. Her vital signs … are stable with Oxygen saturation of 100% at RA. Her pain is 0/10 at time of visit. She is alert, calm, cooperative but confused. Her lung sounds clear and diminished bilateral. Her heart is RRR, and lower extremities are without edema. Her [belly] is soft with [normal] active bowel sounds. She is on soft mechanical soft diet [ground food] and has decreased oral intake with …. [a] daily supplement. Her skin is warm dry and intact. She requires maximum assistance with all her ADL’s. She is high risk for fall and on Fall precaution. She is DNR and comfort measures only. Because of her Advanced age, her life expectancy is expected to be 6 months or less if the disease is allowed to run its natural course.”During an interview with the MD on April 23, 2025, at 12:08 PM, the MD stated he had not known Patient 5’s referral order had indicated dementia as a terminal diagnosis, and he did not reach out to AP 4 to consult about Patient 5’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. After review of Patient 5’s H&P information available in Patient 5’s clinical record, the MD stated the information from the H&P was insufficient to make a judgment for a terminal illness with a prognosis of six months or less to live. The MD confirmed Patient 5 had been admitted with the terminal diagnosis of “age-related cognitive decline,” and the LCD guidelines determined this diagnosis did not qualify Patient 5 for hospice services. The MD reviewed his physician’s summary and stated the summary did not support Patient 5’s life expectancy of six months or less. After the MD reviewed the definition of a terminal diagnosis, the MD stated Patient 5’s admitting terminal diagnosis of “age-related cognitive decline,” did not meet the definition of a terminal condition.A review of the agency’s policy and procedure (P&P) titled, “Physician Services-Medical Director,” dated April 2020, indicated, “POLICY: … 3. 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. … 7. Providing written certification of the terminal illness including a short clinical narrative for all subsequent benefit periods and provide a face-to-face encounter visit with patient prior to third hospice benefit period and subsequent benefit periods. … 12. Documenting care provided in the patient’s clinical record, providing evidence of progression of the end-stage disease process. …”A review of the agency’s P&P titled, “Certification of Terminal Illness,” dated April 2020, 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: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient’s attending physician, if any, will certify the patient’s terminal illness. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. 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 and the hospice Medical Director. … PROCEDURE: 1. At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient’s individual circumstances based on: his/her review of the patient’s medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient’s attending physician will sign the certification of terminal illness and authorization for hospice services forms.) …”During an interview with the Admin/Owner on April 24, 2025, at 11:23 AM, the Admin/Owner stated she was a member of the Governing Body (GB) and assumed full legal authority and responsibility for the operation of the agency, and for the quality of care and services provided. The Admin/Owner stated the GB had not identified:1. The agency did not provide the Hospice Election Statement, Consents, and Notice of Rights and Responsibilities in a language and manner the patients understood for Patient 3 when Patient 3’s wife was a Spanish speaker, could not speak and/or read English and had signed Patient 3’s Hospice Election Statement, Consents and Notice of Rights and Responsibilities on Patient 3’s behalf. 2. The agency did not ensure the MD certified the patients' terminal illnesses before the agency submitted a claim for payment, for Patients 2, 3, 4, and 5 when:2a. For Patient 5: The MD conducted the face to face encounter and certified the patient as terminally ill.2b-d. For Patients 2, 3, and 4: the CTI for the first and second 90-day benefit period was not signed by two physicians.3a-d. The MD failed his responsibility for the medical component of the hospice program for Patients: 2, 3, 4, and 5 when an attending physician's confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. The MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services.A review of the agency’s P&P titled, “Governing Body,” dated April 2020, 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 [name of the agency]. The Governing Body of [name of agency] will serve as the governing authority for the hospice program, which will function according to [name of agency] bylaws.”

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) 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 2, 3, 4, and 5) when:a. For Patient 5: The MD conducted the face to face encounter and certified the patient as terminally ill. (Refer to L 667)b. For Patients 2, 3, and 4: the CTI for the first and second 90-day benefit period was not signed by two physicians. (Refer to L 667)2. Based on observation, interview, and record review, the MD failed his responsibility for the medical component of the hospice program for four of four sampled patients (Patients: 2, 3, 4, and 5) when an attending physician's confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. The MD failed to review data from a referral source 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 2, 3, 4 and 5 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 not correctly evaluating Patients 2, 3, 4 and 5’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) 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 ( a disbursement of money related to insurance), for four of four sampled patients (Patients 2, 3, 4, and 5) when:1. For Patient 5: The Medical Director (MD) conducted the face to face encounter and certified the patient as terminally ill.2. For Patients 2, 3, and 4: the CTI for the first and second 90-day benefit period was not signed by two physicians.These failures had the potential to cause Patients 2, 3, 4 and 5, not 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 not correctly evaluating Patients 2, 3, 4 and 5’s terminal diagnosis and prognosis of six months or less to live. --- 1. A review of Patient 5’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of September 7, 2024, with a benefit period of March 6, 2025, to May 4, 2025 (Benefit Period three). Patient 5 had diagnoses that included age-related cognitive decline (the gradual decline in cognitive abilities, such as memory, attention, and processing speed, that can occur as people age).A review of Patient 5’s CTI dated March 6, 2025, to May 4, 2025 (Benefit Period three), indicated certification of Patient 5’s prognosis of six months or less life expectancy by the MD. A review of Patient 5’s face-to-face encounter for the third benefit period dated February 16, 2025, indicated the face-to-face encounter had been conducted by the MD.A review of Patient 5’s claims for payment, indicated a claim for payment was submitted for March 1, 2025, to March 29, 2025.During an interview with the MD on April 23, 2025, at 11:53 PM, the MD stated he had certified Patient 5’s terminal illness and performed the face-to-face encounter. The MD stated he did not know the certifying doctor could not conduct the face-to-face encounter. 2a. A review of Patient 2’s face sheet, undated, indicated a start of care date of December 5, 2024, with a benefit period of December 5, 2024, to March 4, 2025 (First 90-day benefit period). Patient 2 had diagnoses that included age-related cognitive (mental processes related to knowing, understanding, learning, and thinking) decline. A review of Patient 2’s hospice (a specialized form of medical care provided to individuals with terminal illnesses who have a life expectancy of six months or less) referral order dated December 4, 2024, by Patient 2’s Attending Physician (AP 1), indicated, “Associated Dx [diagnosis]: [blank], Additional Details: Reason: Hospice.”A review of Patient 2’s “Physician’s Certification for Hospice Benefit,” dated December 5, 2024, to March 4, 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 December 5, 2024.A review of Patient 2’s “Physician’s Certification for Hospice Benefit,” dated December 5, 2024, to March 4, 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 team composed of professionals from various disciplines who collaborate to develop and review the patient's plan of care)  Meetings and Plan of Care if I choose to follow the Patient,” signed by the MD on December 5, 2024.There was no documented evidence to show that AP 1 had been contacted and supporting documentation obtained. There was no documented evidence to show AP 1 confirmed Patient 2’s hospice service needs or 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 March 1, 2025.During an interview with the MD on April 23, 2025, at 11 AM, the MD stated he had not known Patient 2’s referral order had not indicated a terminal diagnosis, and he had not reached out to AP 1 to consult about Patient 2’s terminal diagnosis. The MD stated he did not know a patient’s first and second benefit periods required two physician’s signatures certifying the patients as terminally ill.2b. A review of Patient 3’s face sheet indicated a start of care date of March 21, 2025, with a benefit period of March 21, 2025, to June 18, 2025 (Benefit Period One). Patient 3 had diagnoses that included Hemiplegia following cerebral infarction affecting right dominant side (Right side paralysis [the complete or partial loss of muscle function] following a stroke- a medical emergency that occurs when blood flow to the brain is disrupted, leading to damage of brain tissue]).A review of Patient 3’s hospice referral order dated February 21, 2025, by Patient 3’s Attending Physician (AP 2), indicated, “Associated Dx: [blank], Additional Details: Reason: Hospice.”A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated March 21, 2025, to June 18, 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 March 21, 2025.A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated March 21, 2025, to June 18, 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,” signed by the MD on March 21, 2025.There was no documented evidence to show that AP 2 had been contacted and supporting documentation obtained. There was no documented evidence to show AP 2 had confirmed Patient 3’s hospice service needs or 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 for service dates from March 21, 2025, to March 29, 2025.During an interview with the MD on April 23, 2025, at 11:37 AM, the MD stated he had not known Patient 3’s referral order had not indicated a terminal diagnosis, and he had not reached out to AP 2 to consult about Patient 3’s terminal diagnosis. The MD stated he did not know a patient’s first and second benefit periods required two physician’s signatures certifying the patients as terminally ill.2c. A review of Patient 4’s face sheet indicated a start of care date of April 10, 2025, with a benefit period of April 10, 2025, to July 8, 2025 (Benefit Period One). Patient 4 had diagnoses that included age-related cognitive decline.A review of Patient 4’s hospice referral order dated April 9, 2025, by Patient 4’s Attending Physician (AP 3), indicated, “Associated Dx: [blank], Additional Details: Reason: Hospice.”A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated April 10, 2025, to July 8, 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 April 10, 2025. A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated April 10, 2025, to July 8, 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,” signed by the MD on April 10, 2025. There was no documented evidence to show that AP 3 had been contacted and supporting documentation obtained. There was no documented evidence to show AP 3 had confirmed Patient 4’s hospice service needs or 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 pending for April 2025.During an interview with the MD on April 23, 2025, at 11:52 AM, the MD stated he had not known Patient 4’s referral order had not indicated a terminal diagnosis, and he had not reached out to AP 3 to consult about Patient 4’s terminal diagnosis. The MD stated he did not know a patient’s first and second benefit periods required two physician’s signatures certifying the patients as terminally ill.A review of the agency’s policy and procedure titled, “Face-to-Face Encounter,” dated April 2020, 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. … 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 the agency’s policy and procedure titled “Certification of Terminal Illness,” dated April 2020, 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: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient’s attending physician, if any, will certify the patient’s terminal illness. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. 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 and the hospice Medical Director. … PROCEDURE: 1. At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient’s individual circumstances based on: his/her review of the patient’s medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient’s attending physician will sign the certification of terminal illness and authorization for hospice services forms.) …”

Based on observation, interview, and record review, the Medical Director (MD) failed his responsibility for the medical component of the hospice program for four of four sampled patients (Patients: 2, 3, 4, and 5) when an attending physician's confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. The MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. This failure had the potential to cause Patients 2, 3, 4 and 5 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 Medical Director not correctly evaluating Patients 2, 3, 4 and 5’s terminal diagnosis and prognosis of six months or less to live. --- 1. A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of December 5, 2024, with a benefit period of December 5, 2024, to March 4, 2025 (First 90-day benefit period). Patient 2 had diagnoses that included age-related cognitive decline (the gradual decline in cognitive abilities, such as memory, attention, and processing speed, that can occur as people age). A review of Patient 2’s hospice referral order dated December 4, 2024, by Patient 2’s Attending Physician (AP 1), indicated, “Associated Dx [diagnosis]: [blank], Additional Details: Reason: Hospice.” A review of Patient 2’s 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), contained within Patient 2’s clinical record indicated an Emergency Room (ER) visit dated December 2, 2024. The ER visit indicated a right forehead hematoma (a closed wound where blood collects and fills a space inside the body) and right eye bruising after a fall. There were no fractures (breaks), and Patient 2 was discharged in stable condition. There was no documented evidence to show a discussion of hospice with Patient 2 or a responsible party. There was no documented evidence to show a terminal diagnosis had been determined.  There was no documented evidence to show additional H&P in Patient 2’s clinical record. During an interview with Patient 2’s son on April 22, 2025, at 12:09 PM, Patient 2’s son stated there was no discussion about hospice services from a physician at Patient 2’s ER visit. Patient 2’s son stated hospice services were to monitor his dad’s health and Patient 2’s son was unaware his dad needed to give up curative treatments, “I would still take him to the hospital.” A review of Patient 2’s “Physician’s Certification for Hospice Benefit,” dated December 5, 2024, to March 4, 2025, signed by the MD on December 5, 2024, indicated: a. Functional Status (a patient’s ability to perform activities of daily living (ADLs) and other tasks that are necessary for independence and well-being). KPS (Karnofsky Performance Status-A scale from 0 to 100 that assesses a patient's ability to perform daily activities and their level of independence): (Blank-no scale value indicated). PPS (Palliative Performance Scale-A comprehensive scale that includes factors like ambulation, disease burden, intake, and mental status. It is often used in hospice and palliative care settings to assess functional decline and determine hospice eligibility). (Blank-no scale value indicated). FAST (Functional Assessment Staging-Specifically designed for patients with Alzheimer's disease [a progressive brain disorder that primarily affects memory, thinking, and reasoning skills, ultimately leading to dementia- a general term for a decline in mental ability severe enough to interfere with daily life] and other dementias [other diseases that cause dementia]. It assesses functional decline in areas like cognition, independence, continence, and speech). (Blank-no stage value indicated).  NYHA (New York Heart Association Functional Classification-A system for classifying heart failure based on the severity of symptoms and limitations in physical activity. It helps clinicians understand the impact of heart failure on a patient's daily life and choose appropriate treatments). (Blank-no functional classification indicated). b. LCD Determination Status ((Local Coverage Determination is a document developed by Medicare Administrative Contractors (MACs) to guide in the determination of a patient’s terminal diagnosis. The document contains information about the patient's clinical status, symptoms, and signs, as well as relevant laboratory findings, to help determine if they meet the criteria for a six-month prognosis. The physician's Certification of Terminal Illness (CTI) must address the relevant LCDs to document the patient's eligibility for hospice benefits). Patient 2’s LCD indicated “Patient does not qualify per LCD Guidelines, PART III - Disease specific guidelines, DISEASE NOT FOUND.” c. Certifying Physician Narrative (explains the clinical findings supporting a patient's life expectancy of six months or less): "[Patient 2] admitted to Hospice with a diagnosis of Age related cognitive decline. He is awake alert but confused. His Vital signs are stable, and pain is 0/10 [a numerical tool used to assess and track pain levels, where 0 represents no pain and 10 represents the worst pain imaginable]. His heart is regular in rhythm and with [mild swelling in lower extremities]. His lungs sounds are clear but diminished [less air is moving through the lungs]. His [belly] is soft and non-distended. He requires maximum assistance with all [his] ADL’s. He is high risk for fall. His skin is warm and dry. … Because of [his] advanced age and he is DNR [Do not Resuscitate-a legal document that instructs medical personnel not to perform cardiopulmonary resuscitation (CPR) if a person's heart stops or they stop breathing] and comfort measures only and no further aggressive treatment. His life expectancy is expected to be 6 months or less if the disease is allowed to run its natural course." During an interview with the MD on April 23, 2025, at 11 AM, the MD stated he had not known Patient 2’s referral order had not indicated a terminal diagnosis, and he did not reach out to AP 1 to consult about Patient 2’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. After review of Patient 2’s H&P information available in Patient 2’s clinical record, the MD stated the information from the H&P was insufficient to make a judgment for a terminal illness with a prognosis of six months or less to live. The MD confirmed the “Functional Status,” section of the CTI was blank and should have indicated the appropriate assessed values. The MD confirmed Patient 2 had been admitted with the terminal diagnosis of “age-related cognitive decline,” and the LCD guidelines determined this diagnosis did not qualify Patient 2 for hospice services. The MD reviewed his physician’s summary and stated the summary did not support Patient 2’s life expectancy of six months or less. The MD reviewed the definition of a terminal diagnosis (Old age itself is not considered a terminal condition. Terminal conditions are defined as illnesses that are expected to lead to death due to the illness itself, rather than from the natural progression of aging. While old age can increase the likelihood of developing terminal illnesses or experiencing age-related decline, it is not the illness itself that causes death). The MD stated Patient 2’s admitting terminal diagnosis of “age-related cognitive decline,” did not meet the definition of a terminal condition. 2. A review of Patient 3’s face sheet indicated a start of care date of March 21, 2025, with a benefit period of March 21, 2025, to June 18, 2025 (Benefit Period One). Patient 3 had diagnoses that included Hemiplegia following cerebral infarction affecting right dominant side (Right sided paralysis following a stroke). A review of Patient 3’s hospice referral order dated February 21, 2025, by Patient 3’s Attending Physician (AP 2), indicated, “Associated Dx: [blank], Additional Details: Reason: Hospice.” A review of Patient 3’s H&P, contained within Patient 3’s clinical record indicated an ER visit to Acute Care Hospital A, dated February 14, 2025. The ER visit indicated Patient 3 admitted to ER for “activated stroke” (a specific protocol within a hospital or medical system to rapidly respond to a suspected stroke). The ER physician’s assessment indicated, “I independently reviewed the above diagnostics as noted in the above [Emergency Department] Course. This patient presents with symptoms concerning for acute [sudden] CVA [Cerebrovascular Accident-also known as a stroke] versus TIA [Transient Ischemic Attack-a temporary blockage of blood flow to the brain. The blockage lasts for a short period, usually minutes to hours, and symptoms disappear completely within 24 hours. A TIA does not cause permanent brain damage or lasting neurological deficits]. Patient presented with initial NIH 6 [The National Institutes of Health Stroke Scale-NIHSS- a score of 6 or less generally indicates a milder stroke with a good recovery prognosis] and with resolving [getting better] aphasia [difficulty speaking]. Reportedly with [right] arm weakness at [the initial assessment]. CXR [chest X-ray] with demonstrated concerns for multifocal [multiple areas] pneumonia [lung infection] with reported history of recent treatment. Demonstrated afib RVR [atrial fibrillation with rapid ventricular response, a heart rhythm problem where the heart's upper chambers (atria) beat irregularly and chaotically, and the lower chambers (ventricles) beat too quickly in response] with improvement … CTA head [Computed tomography angiography- a medical imaging procedure that uses a CT scan to visualize the blood vessels in the head and neck] /neg negative for LVO [A negative finding for Large Vessel Occlusion (LVO) in stroke assessment means that the initial assessment indicates that a large artery in the brain is not blocked]. CT head negative for ICH [Intracerebral Hemorrhage, a "negative" finding typically refers to a lack of visible bleeding or other stroke-related abnormalities] with concerns for age-indeterminate infarcts [strokes, where the exact time the damage occurred is not clearly defined] … However, presentation most concerning for a TIA. EKG [electrocardiogram-a medical test that measures the electrical activity of the heart] without evidence of STEMI [Myocardial Infarction-a severe type of heart attack] or ischemia [a condition where the heart muscle does not get enough oxygen-rich blood due to reduced blood flow], fingerstick BS [blood sugar] not hypoglycemic [low blood sugar]. … with plans for transfer to [Acute Care Hospital B]. … Impression: 1. TIA (transient ischemic attack) 2. Aphasia …” There was no documented evidence to show a discussion of hospice with Patient 3 or a responsible party. There was no documented evidence to show a terminal diagnosis had been determined. A review of Patient 3’s H&P, contained within Patient 3’s clinical record, did not indicate H&P from Acute Care Hospital B. There was no documented evidence to show Patient 3 had any additional H&P.  During Patient 3’s home visit on April 22, 2025, from 9:47 AM, to 11:26 AM, with Patient 3, Patient 3’s wife, Patient 3’s daughter and a Hospice Aide (HA 1), Patient 3 was in his room laying in a hospital bed, Patient 3 demonstrated how his right arm was weak, but he could lift the right arm off his bed a few inches and wiggle his fingers. Patient 3 stated his legs were too weak to walk but he could move both his legs and feet, Patient 3 demonstrated moving both legs and feet. Patient 3 stated he wanted to get stronger so he could get out of bed and spend time with his grandson. Patient 3 stated he did not know he was receiving hospice services and did not know what hospice was. Patient 3 stated no one talked to him about hospice services and he did not believe he had only 6 months to live. Patient 3’s daughter stated Acute Care Hospital A transferred Patient 3 to Acute Care Hospital B and Acute Care Hospital B told the family Patient 3 did not have a stroke and the right arm weakness was due to his previous pneumonia infection and discharged Patient 3 home with home health services. Patient 3’s daughter stated the home health services were very poor and as long as Patient 3 could wiggle his toe that was good enough and discharged Patient 3. Patient 3’s wife stated she knew hospice was for end of life care and she knew Patient 3 was not at the end of his life and would not die in 6 months, but when the hospice called and offered the services, she was desperate, so she said “Yes,” because “I needed help with his care.” Patient 3’s wife stated she knew her husband needed additional services to help him recover and get stronger, so she talked to the Hospice Aide (HA 1) and asked about more services for Patient 3. HA 1 stated Patient 3’s wife had spoken to him about different services for Patient 3 because he was not a good fit for hospice, and I reported to the office asking them to speak with Patient 3’s wife about options for home health services. A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated March 21, 2025, to June 18, 2025, signed by the MD on March 21, 2025, indicated: a. Functional Status: KPS: (Blank-no scale value indicated). PPS: (Blank-no scale value indicated). FAST: (Blank-no stage value indicated).  NYHA: (Blank-no functional classification indicated). b. LCD Determination Status: (Blank-LCD determination for stroke was not completed) c. Certifying Physician Narrative: "[Patient 3] admitted to Hospice with a diagnosis of Hemiplegia [paralysis] following CVA [stroke]. His co-morbidities are AF [atrial fibrillation], DM [diabetes mellitus- A group of diseases that result in too much sugar in the blood], Hypertension [high blood pressure] and malignant neoplasm [unspecified cancer]. He is alert and oriented x 3 [a patient is awake and aware of three key things: their identity (person), their location (place), and the approximate time (time)] with episodes of SOB [shortness of breath]. He is on Oxygen …. His vital signs are stable and Oxygen saturation [amount of oxygen in the blood] of 98% [percent]. His heart [has a regular rate and rhythm] and lower extremities are without edema [swelling]. His lung sounds are clear to auscultation [upon listening]. His [belly] is soft and non-distended. He has [an indwelling urinary catheter] attached to a bag draining clear yellow urine. He has [right] sided weakness. He is bedbound [cannot get out of bed by himself] and requires maximum assistance with all his ADL’s. He is DNR and comfort measures only and no further aggressive treatment or therapy. His life expectancy is expected to be 6 months or less if the disease is allowed to run its natural course." During an interview with the MD on April 23, 2025, at 11:37 AM, the MD stated he had not known Patient 3’s referral order had not indicated a terminal diagnosis, and he did not reach out to AP 2 to consult about Patient 3’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. After review of Patient 3’s H&P information available in Patient 3’s clinical record, the MD confirmed Acute Care Hospital A’s ER physician’s impression was Patient 3 had a TIA, not an acute CVA [stroke]. The MD stated he did not know about Patient 3’s transfer to Acute Care Hospital B with a discharge on home health services. The MD stated he had not reached out to Acute Care Hospital B to consult with Patient 3’s physician or obtain additional H&P. The MD stated he was unaware of Patient 3’s family’s assertion that Acute Care Hospital B had told them Patient 3 did not have a stroke. The MD confirmed the “Functional Status,” section of the CTI was blank and should have indicated the appropriate assessed values. The MD confirmed Patient 3 had been admitted with the terminal diagnosis of “Hemiplegia following cerebral infarction affecting right dominant side [stroke],” and the LCD guidelines for “stroke” were blank. The MD reviewed his physician’s summary and stated the summary did not support Patient 3’s life expectancy of six months or less.  3. A review of Patient 4’s face sheet indicated a start of care date of April 10, 2025, with a benefit period of April 10, 2025, to July 8, 2025 (Benefit Period One). Patient 4 had diagnoses that included age-related cognitive decline. A review of Patient 4’s hospice referral order dated April 9, 2025, by Patient 4’s Attending Physician (AP 3), indicated, “Associated Dx: [blank], Additional Details: Reason: Hospice.” A review of Patient 4’s H&P, contained within Patient 4’s clinical record indicated an ER visit, dated January 12, 2025. The ER visit indicated “Left lower lobe pneumonia, Influenza A infection [the flu].” There was no documented evidence to show a discussion of hospice with Patient 4 or a responsible party. There was no documented evidence to show a terminal diagnosis had been determined. A review of Patient 4’s H&P, contained within Patient 4’s clinical record indicated an ER visit, dated March 30, 2025. The ER visit indicated, “[Patient 4] with past medical history significant for sick sinus syndrome [a heart rhythm disorder where the heart's natural pacemaker (stimulating the heart muscle and regulating its contractions) does not function properly, leading to irregular or slow heartbeats] [after] pacemaker brought in by ambulance to [ER] with concern for left sided chest pain this evening. Patient described the pain as a burning sensation underneath the Pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions) site. … [Chest X-Ray] Findings: Negative for infiltrate [no fluid in lings], negative for pneumothorax [collapsed lung], negative for effusion [a buildup of fluid between the layers of tissue that line the lungs and chest cavity]. Impression: Normal. … Discussed case with family to include goals of care. Granddaughter …  and grandson-in-law state they do not wish for patient to have invasive procedures or surgery as she has a DNR code status. Should cardiac interrogation [Pacemaker interrogation results provide data about a patient's pacemaker's status and performance. This includes information like battery life, lead functionality, and any recorded arrhythmias or other events. The data helps doctors ensure the device is working properly and adjust settings if needed] show no significant changes they wish for patient to be discharged. Discussed indications for admission, risks/benefits of various care plan options - shared decision to likely discharge was agreed upon.” There was no documented evidence to show a discussion of hospice with Patient 4 or a responsible party. There was no documented evidence to show a terminal diagnosis had been determined. During Patient 4’s home visit on April 22, 2025, from 12:43 PM, to 1:10 PM, with a Licensed Vocational Nurse (LVN 1), Patient 4’s granddaughter, and Patient 4’s grandson-in-law, Patient 4’s granddaughter stated the physician at the hospital had not discussed hospice with her. Patient 4’s granddaughter stated, “Hospice, it [doesn’t] really mean to die, it’s to keep her [Patient 4] comfortable with no pain. The nurses said it doesn’t mean they [patients] are going to die quickly.” Patient 4’s granddaughter stated she did not know curative treatment stopped after admission to hospice. A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated April 10, 2025, to July 8, 2025, signed by the MD on April 10, 2025, indicated: a. Functional Status: KPS: 40, Disabled; requires special care and assistance. PPS: 30, Totally bed-bound, unable to do any work, extensive evidence of disease, total dependence for care, reduced intake and fully conscious or confused or drowsy. FAST: 7-C, Ambulatory ability is lost (cannot walk without personal assistance). NYHA: III, Patients with marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes palpitation, dyspnea or anginal pain b. LCD Determination Status: Patient 4’s LCD indicated “Patient does not qualify per LCD Guidelines, PART III - Disease specific guidelines, DISEASE NOT FOUND.” c. Certifying Physician Narrative: [Patient 4] admitted to Hospice with a diagnosis of Age related cognitive decline. Her co-morbidities are GERD [gastroesophageal reflux disease-a digestive disorder where stomach acid frequently flows back up into the tube that carries food from your mouth to your stomach], Constipation [difficulty emptying bowels], Insomnia [difficulty sleeping], presence of Pacemaker, Sick sinus syndrome and Dementia. She was seen at her home with stable vital signs and Oxygen saturation of 97% [on room air]. She is awake, alert and hard of hearing. Her heart is regular and contracted [both lower extremities- a medical condition where both legs are stiff and limited in their range of motion, often due to permanent tightening of muscles, tendons, ligaments, or other tissues around the joints]. Her [belly] is soft and nondistended.  Her lung sounds are coarse, bilateral [both sides]. Her skin is warm, dry and intact. She is DNR and comfort measures only. She is KPS 40. PPS 30. FAST 7C. And NYHA III. She requires maximum assistance with all her ADL’s. Because of her Advanced age, her life expectancy is expected to be 6 months or less if the disease process is allowed to run its natural course." During an interview with the MD on April 23, 2025, at 11:52 AM, the MD stated he had not known Patient 4’s referral order had not indicated a terminal diagnosis, and he did not reach out to AP 3 to consult about Patient 4’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. After review of Patient 4’s H&P information available in Patient 4’s clinical record, the MD stated the information from the H&P was insufficient to make a judgment for a terminal illness with a prognosis of six months or less to live. The MD confirmed Patient 4 had been admitted with the terminal diagnosis of “age-related cognitive decline,” and the LCD guidelines determined this diagnosis did not qualify Patient 4 for hospice services. The MD reviewed his physician’s summary and stated the summary did not support Patient 4’s life expectancy of six months or less. After the MD reviewed the definition of a terminal diagnosis, the MD stated Patient 4’s admitting terminal diagnosis of “age-rel ated cognitive decline,” did not meet the definition of a terminal condition. 4. A review of Patient 5’s face sheet, undated, indicated a start of care date of September 7, 2024, with a benefit period of March 6, 2025, to May 4, 2025 (Benefit Period three). Patient 5 had diagnoses that included age-related cognitive decline.  A review of Patient 5’s hospice referral order dated September 5, 2024, by Patient 5’s Attending Physician (AP 4), indicated, “Ambulatory referral to Hospice. Associated Dx: Moderate dementia with other behavioral disturbance, unspecified dementia type … Referred to Specialty: Hospice Services Reason for Referral: … Dementia of uncertain etiology, rapidly progressive with rapid functional decline. Life expectancy less than 6 months. …” A review of Patient 5’s H&P contained within Patient 5's clinical record indicated an Emergency Room (ER) visit dated September 1, 2024. The ER visit indicated, “[Patient 5] who presents to the Emergency Department with concern for altered mental status since fall 3-4 weeks ago. Differential diagnoses including stroke, UTI [urinary tract infection], electrolyte derangements [a disruption or imbalance in the normal levels of electrolytes within the body], hypoglycemia [low blood sugar], hepatic encephalopathy [a serious condition where brain function deteriorates due to the buildup of toxins in the blood, which is caused by a damaged liver's inability to filter them out]. CBC [complete blood count-a common blood test that measures the number and characteristics of red blood cells, white blood cells, and platelets in the blood] unremarkable, no WBC [white blood cell] elevation and no anemia [low number of red blood cells]. LFTs [liver function tests] WNL [within normal limits]. Electrolytes WNL. No acute AKI [acute kidney injury]. Urine positive for WBCs and leuks [leukocytes are white blood cells], but negative nitrites [Nitrites are a different form of nitrogen, and they are usually not found in healthy urine]. Will start [an antibiotic] while awaiting CT head and abdomen. Patient signed out to oncoming provider pending imaging studies.” There was no documented evidence to show a discussion of hospice with Patient 5 or a responsible party. There was no documented evidence to show a terminal diagnosis had been determined.  A review of Patient 5’s “Physician’s Certification for Hospice Benefit,” dated March 6, 2025, to May 4, 2025, signed by the MD on March 6, 2025, indicated: a. Functional Status: KPS: 40, Disabled; requires special care and assistance. PPS: 40, Mainly in bed, unable to do any work, extensive evidence of disease, considerable dependence for care, normal or reduced intake and fully conscious … FAST: 7-A, Ability to speak limited to approximately a half dozen intelligible different words or fewer, in the course of an average day or in the course of intensive interview. NYHA: IV, Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or of the anginal syndrome even at rest. If any physical activity is undertaken, discomfort is increased. b. LCD Determination Status: Patient 5’s LCD indicated “Patient does not qualify per LCD Guidelines, PART III - Disease specific guidelines, DISEASE NOT FOUND.” c. Certifying Physician Narrative: “[Patient 5] admitted to Hospice with a diagnosis of Age related cognitive decline. She was seen at her home for recertification. Her vital signs … are stable with Oxygen saturation of 100% at RA. Her pain is 0/10 at time of visit. She is alert, calm, cooperative but confused. Her lung sounds clear and diminished bilateral. Her heart is RRR (regular rate and rhythm), and lower extremities are without edema. Her [belly] is soft with [normal] active bowel sounds. She is on soft mechanical soft diet [ground food] and has decreased oral intake with …. [a] daily supplement. Her skin is warm dry and intact. She requires maximum assistance with all her ADL’s. She is high risk for fall and on Fall precaution. She is DNR and comfort measures only. Because of her Advanced age, her life expectancy is expected to be 6 months or less if the disease is allowed to run its natural course.” During an interview with the MD on April 23, 2025, at 12:08 PM, the MD stated he had not known Patient 5’s referral order had indicated dementia as a terminal diagnosis, and he did not reach out to AP 4 to consult about Patient 5’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. After review of Patient 5’s H&P information available in Patient 5’s clinical record, the MD stated the information from the H&P was insufficient to make a judgment for a terminal illness with a prognosis of six months or less to live. The MD confirmed Patient 5 had been admitted with the terminal diagnosis of “age-related cognitive decline,” and the LCD guidelines determined this diagnosis did not qualify Patient 5 for hospice services. The MD reviewed his physician’s summary and stated the summary did not support Patient 5’s life expectancy of six months or less. After the MD reviewed the definition of a terminal diagnosis, the MD stated Patient 5’s admitting terminal diagnosis of “age-related cognitive decline,” did not meet the definition of a terminal condition. A review of the agency’s policy and procedure titled, “Physician Services-Medical Director,” dated April 2020, indicated, “POLICY: … 3. 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. … 7. Providing written certification of the terminal illness including a short clinical narrative for all subsequent benefit periods and provide a face-to-face encounter visit with patient prior to third hospice benefit period and subsequent benefit periods. … 12. Documenting care provided in the patient’s clinical record, providing evidence of progression of the end-stage disease process. …” A review of the agency’s policy and procedure titled “Certification of Terminal Illness,” dated April 2020, 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: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient’s attending physician, if any, will certify the patient’s terminal illness. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. 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 and the hospice Medical Director. … PROCEDURE: 1. At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient’s individual circumstances based on: his/her review of the patient’s medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient’s attending physician will sign the certification of terminal illness and authorization for hospice services forms) …”

Observed in Emergency Management Session. During the Emergency Management Session, it was noted that the Emergency Operations Plan did not include a contact list of individuals and entities to be notified in response to an emergency or disaster incident. For example, the Emergency Operations plan did not include a contact list of: 1) Staff - Physicians and other licensed practitioners, 2) Volunteers, 3) Other health care organizations, 4) Entities providing services under arrangement, including suppliers of essential services, equipment, and supplies, 5) Relevant community partners (such as fire, police, local incident command, public health departments), 6) Relevant authorities (such as federal, state, tribal, regional, and local emergency preparedness staff) and 7) Other sources of assistance (such as health care coalitions). This observation was reviewed with the Administrator.

Observed in Record Review. Example #2: During a review of the medical record for RRNHV#4, the plan of care included an order for Hospice Aide visits 2 times per week. There was no documented evidence that Hospice Aide visits were completed during week 1 through week 9 of services. This observation was reviewed with the Administrator and the Director of Patient Care Services. Observed in Record Review. In 2 of 8 patient records reviewed, for patients receiving Hospice Aide services, it was noted that the organization did not ensure Hospice Aide visits were completed in accordance with the plan of care. For example, during a review of the medical record for RRNHV#2, the plan of care included an order for Hospice Aide visits 2 times per week. There was no documented evidence that Hospice Aide visits were completed during week 2 and week 3 of services. This observation was reviewed with the Administrator and the Director of Patient Care Services.

Observed in Record Review. In 1 of 5 patient records reviewed, the initial bereavement assessment was not completed. In RR #3, the surveyor noted that the bereavement risk assessment was not completed as part of the comprehensive assessment. This was confirmed with the Administrator/DPCS.

Observed in Record Review. In 1 of 5 patient records reviewed, Patient record was inaccurate or contains errors (i.e. conflicts with other documentation). For example, in HV#1/RR#1, the surveyor noted there was conflicting timeframes for goals. For example, the new pain goal was as follows: New pain or pain out of control as determined by the patient as a level of greater than 6 will be controlled within 24-48 hours with medication adjustments and interventions; however, the record also indicated a target date of 3 months. This was confirmed by the Administrator/DPCS. Observed in Record Review. In 1 of 5 patient records reviewed, documentation in the patient record was not entered in a timely manner. In RR#2, the surveyor observed missing aide visit notes. The last entry was 15 days ago. According to the organization's Timely Submission of Patient Documentation Policy No. 11.6.1, all visit reports must be submitted the next scheduled work day, not exceeding seven (7) business days. This was confirmed by the Administrator/DPCS.

Observed in Patient Home. In 1 of 1 home visits conducted, the clinician did not conduct a comprehensive reassessment of the patient’s condition. During HV#1, the nurse was observed obtaining the patient’s oxygen level and indicated the patient’s oxygen saturation was 87%; however, the nurse did not further assess the patient’s respiratory condition and required prompting later in the visit to re-evaluate the patient’s oxygen saturation. The patient is taking Senna and Docusate daily and the caregiver reported the patient has 3-4 bowel movements a day and “always seems to have to go”; however, the nurse did not further assess the patient’s bowel status or further evaluate the medications the patient is taking for a bowel regimen. The caregiver reported the patient sometimes has leg pain and they will give him ibuprofen; however, there was no further pain assessment completed related to the patient’s leg pain nor the use of ibuprofen, which was not on the patient’s medication profile. The patient stated he had a fall earlier that morning and the caregiver stated he “slid out of bed” and the fire department was called to assist him back to bed; however, the nurse did not conduct an assessment related to the fall. This was discussed with the Administrator/Director of Patient Care Services following the visit.

Observed in Record Review. In 1 of 1 patient records reviewed, the interdisciplinary Group (IDG) did not include participation/collaboration from the spiritual counselor. Upon review of HV#1 and IDG update documentation, the spiritual counselor section was left blank, and there was no documentation to validate the spiritual counselor attended the IDG meeting nor documentation to validate coordination occurred with the team regarding the patient’s status and/or condition. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 1 patient records reviewed, patient/family education was not documented as provided. Upon review of HV#1, it was noted the patient had a co-morbid diagnosis of diabetes and during the home visit, the caregiver stated they perform blood glucose checks every morning to monitor his blood sugar. Upon review of nursing notes, there was no documentation to validate education had been provided regarding performing blood glucose checks nor documentation to validate the caregiver's competency with the procedure was assessed. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 1 patient records reviewed, the plan of care did not include all goals based on the patient’s needs. Upon review of HV#1, it was noted the patient had a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD) with oxygen and albuterol ordered; however, on review of the plan of care, there were no goals established related to the patient’s respiratory needs identified on the comprehensive assessment. On review of the comprehensive assessment, it was noted the patient was identified as a fall risk; however, on review of the plan of care, there were no goals established related to safety. On review of the plan of care, goals were not measurable, specific, or included a time frame. Examples included the following: Optimal blood sugar management for patient's comfort; To breathe easily without increased effort or discomfort; Patient will maintain optimum peripheral circulation. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 1 patient records reviewed, the plan of care did not include all interventions based on the patient’s needs. Upon review of HV#1, it was noted the patient had a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD) with oxygen and albuterol ordered; however, on review of the plan of care, there were no interventions established related to the patient’s respiratory needs identified on the comprehensive assessment. On review of the comprehensive assessment, it was noted the patient was identified as a fall risk; however, on review of the plan of care, there were no interventions established related to fall prevention education. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 1 patient records reviewed, collaboration with the hospice physician did not occur. During HV#1, the patient stated he fell earlier in the morning and the caregiver reported he slid out of bed to the floor. The nurse did not contact the physician prior to the end of the visit and on review of the nurses' visit note documentation completed following the visit, there was no documentation to validate the physician had been notified of the patient's fall. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Patient Home. In 1 of 1 home visits conducted in which reusable equipment was utilized, standard precautions were not used to reduced the risk of infection related to disinfection of equipment. During HV#1, the clinician was observed cleaning their vital sign equipment with a Clorox disinfecting wipe and placing the equipment immediately back into their bag without observing the manufacturer's guidelines of a 4-minute wet time. This was discussed with the Administrator/Director of Patient Care Services following the visit.

Observed in Record Review. In 1 of 1 patient records reviewed with aide services, the hospice aide did not provide care as ordered. Upon review of HV#1 and all 6 aide visit notes, it was noted the following task was not documented as completed as ordered on the aide plan of care: recording bowel movements. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 1 patient records reviewed with aide services, supervision was not completed every 14 days as required. Upon review of HV#1, it was noted aide services were initiated 17 days ago and to date, no supervisory visits have been completed. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.54, §418.56, §418.104, and §418.116.

Observed in Record Review. In 1 of 1 patient records reviewed, clinical documentation was not present. Upon review of HV#1, it was noted place holders were present in the record for nursing notes that indicated the date and time of the visits; however, the clinical documentation for those visits was not completed. This was reviewed and validated with the Administrator/Director of Patient Care Services. Observed in Patient Home. In 1 of 1 home visits conducted in which medication reconciliation was conducted, the medication profile was inaccurate. During HV#1 in discussion with the caregiver, she stated they occasionally give the patient Ibuprofen for leg pain; however, on review of the medication profile in the record, Ibuprofen was not listed. Albuterol was listed on the medication profile; however, per the caregiver, the medication had not been delivered and was not in the home. This was discussed with the Administrator/Director of Patient Care Services following the visit.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization did not amend the record according to policy. According to organizational policy Entries Into The Clinical Record No. 5-006, amendments, corrections, or late entries within the electronic medication record must identify any amendment, correction, or late entry and provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each record modification. Upon review of HV#1, it was noted the plan of care did not include a respiratory or safety care plan; however, on review of the record later in the day, these care plans were included. On review of Interdisciplinary Group (IDG) documentation, there was no documentation from the spiritual counselor nor a signature to validate they had attended IDG; however, on review of the record later in the day, the documentation was present with a signature of attendance. In discussion with the Administrator/Director of Patient Care Services, these changes were made during the survey; however, there was no documentation to validate these changes were made as amendments to the record. This was validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 1 patient records reviewed, the record contained inaccurate information. Upon review of HV#1, it was noted the spiritual counselor's assessment indicated a completion date of 11/22/22; however, on review of the patient's folder and staff sign-in sheet in the home, the spiritual counselor dated his visit 11/28/22. On clarification from the spiritual counselor, the visit was completed on 11/28 due to patient request. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Patient Home. In 1 of 1 home visits conducted, medications were not disposed of according to law and regulation. According to Public Law 115-271, medications may be disposed of upon patient death, when the medication is expired, or when the patient no longer needs it due to a change in the plan of care. During HV#1, the nurse removed 3 pills from the patient's pillbox, verified them against the bubble pack of Norco, and placed the 3 pills in an unlabeled container stating they were not labeled and would need to be destroyed. Upon interview with the nurse, she stated she was going to take them back to the office to dispose of them. On review of the record, Norco was an active medication with no changes noted in the plan of care. In discussion with the Administrator/Director of Patient Care Services, the medication should not have been removed from the home and if disposal was warranted, the medication should have been disposed of in the home.