Every finding on record at Amazing Grace Hospice, Inc

The agency failed to ensure that the Condition of Participation: L 587 §418.64 Core services was in compliance as follows: Based on interview, and record review, the agency failed to ensure a Director of Patient Care Services (DPCS) or Director of Patient Care Services Designee (DPCSD) provided direction and oversight to assure quality of care and supervision of staff, in a universe of 25 patients, when: 1. The agency failed to follow State Law [Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(A) Director of Patient Care Services] when the DPCS was unable to full fill the DPCS role due to working 12-hour shifts, four days a week as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse, in an acute care hospital. (Refer to L 591) 2. The agency failed to follow State Law [Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(B) Director of Patient Care Services] when a DPCS Designee (DPCSD) was unable to full fill the DPCS role due to health issues and leave of absences. (Refer to L 591) 3. The agency failed to follow State Law [Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(D)(1) Director of Patient Care Services] when there was no documented evidence to show the DPCS had three years experience within the last five years in a hospice, home health agency, primary care clinic or health facility, at least one year of which was in a supervisory or administrative capacity. (Refer to L 591) The cumulative effect of these systemic practices resulted in the potential for patients to suffer poor quality and safety of patient care when there was no DPCS monitoring care plans, staff competency, adherence to regulations, or promptly addressing any potential issues that could impact patient well-being.

Based on interview, and record review, the agency failed to ensure a Director of Patient Care Services (DPCS) or Director of Patient Care Services Designee (DPCSD) provided direction and oversight to assure quality of care and supervision of staff, in a universe of 25 patients, when: 1. The agency failed to follow State Law [Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(A) Director of Patient Care Services] when the DPCS was unable to full fill the DPCS role due to working 12-hour shifts, four days a week as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse, in an acute care hospital. 2. The agency failed to follow State Law [Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(B) Director of Patient Care Services] when a DPCS Designee (DPCSD) was unable to full fill the DPCS role due to health issues and leave of absences. 3. The agency failed to follow State Law [Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(D)(1) Director of Patient Care Services] when there was no documented evidence to show the DPCS had three years experience within the last five years in a hospice, home health agency, primary care clinic or health facility, at least one year of which was in a supervisory or administrative capacity. This failure had the potential for patients to suffer poor quality and safety of patient care when there was no DPCS monitoring care plans, staff competency, adherence to regulations, or promptly addressing any potential issues that could impact patient well-being. --- An unannounced visit was made to the agency on August 26, 2024, at 11:24 AM, to investigate a complaint for improperly evaluated hospice admissions and no DPCS oversight. 1. During an interview with the Administrator (Admin) on August 26, 2024, at 11:33 AM, the Admin stated the Director of Patient Care Services was (DPCS 1) and she had verbally accepted the position on July 6, 2024. The Admin stated DPCS 1 had another fulltime job and could not full fill the DPCS role at this time. During an interview with DPCS 1 on August 26, 2024, at 1:32 PM, DPCS 1 stated she had verbally accepted the DPCS position on July 6, 2024. DPCS 1 stated she worked 12-hour shifts, four days a week as an ICU nurse, in an acute care hospital and would not be able to full fill the DPCS position until September 30, 2024. DPCS 1 confirmed she would not be able to full fill the DPCS position for 86 days. An unannounced return visit was made to the agency on October 28, 2024, at 9:34 AM, to continue the investigation for improperly evaluated hospice admissions and no DPCS oversight. During a home visit with a Licensed Vocational Nurse (LVN 1) on October 29, 2024, at 11:10 AM, LVN 1 stated she had been working at the agency for two years and did not know DPCS 1 had accepted the DPCS role, ";I thought she just did nursing visits." LVN 1 stated she was not aware of a DPCS Designee (DPCSD). LVN 1 stated the agency provided ongoing monthly in-service training but there had not been an in-service for a while. During a review of the in-service binder, undated, indicated no in-services had been conducted in March 2024, June 2024, July 2024, August 2024, or September 2024. During an interview with the Admin on October 30, 2024, at 9:54 AM, the Admin stated the agency usually provided in-services at least once per month and it was unusual to have five months without an in-service. The Admin stated the in-services had ";dropped off," due to the difficulties full filling the DPCS position. A review of the ";Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(A) Director of Patient Care Services," undated, indicated, ";The Director of Patient Care Services or his/her designee shall be available on the premises or accessible by telecommunications during operating hours. The Director of Patient Care Services shall devote a sufficient number of hours to assure the quality and adequacy of services provided and supervision of staff." A review of the agencys policy and procedure titled, ";Job Description Director," dated February 2022, indicated, ";JOB SUMMARY: To provide Hospice care to the terminally ill hospice patient twenty-four hours/day, seven days/week. To work as a member of the Hospice team in providing Hospice care. Oversees and supervises all Hospice care to patients and families in all settings. ... Essential Functions: 1. Participates in developing standards which ensure safe and therapeutically effective service to patients and families. ... 5. Is responsible for recruiting, hiring, evaluating and terminating service personnel. 6. Participates in planning for the orientation of new employees. Conducts selected orientation classes. ... 9. Participates in establishing the functions and qualifications for each service position; coordinates interdisciplinary team services: Assures ongoing assessment of patient/family needs and implementation of interdisciplinary group plan of care. Assures physician approval of plans for continuity of medical care. Provides individual or group support concerning job related stress or issues. ... 22. Oversees Hospice's ongoing Quality Assurance/Performance Improvement (QAPI) program. 23. Provides 24 hour/day, seven (7) days/week on-call coverage. 24. Plans and supervises the Hospice. 25. Ensures that patients' plans of care are developed, implemented and evaluated. 26. Conducts patient case conferences, in-services, staff meetings and maintains documentation; participates in community education projects. 27. Ensures that all necessary supplies and equipment are available. 28. Is normally available at all times during and after operating hours; may designate a qualified temporary replacement if he/she will not be available. 29. Ensures compliance with federal, state, and local rules, accreditation standards and Hospice policies in all patient care aspects of the Hospice. ..." 2. During an interview with the Administrator (Admin) on August 26, 2024, at 11:33 AM, the Admin stated the DPCSD was unable to cover the DPCS position due to health issues and DPCS 1 had not appointed a new DPCSD. The Admin stated the DPCSD was unavailable for an interview due to her health issues. During a return visit interview with the Admin on October 30, 2024, at 2:16 PM, the Admin stated the DPCSD had been unable to cover the DPCS position from August 26, 2024, to October 30, 2024, due to health issues (a total of 65 days) and the agency had not appointed a new DPCSD. The Admin stated the DPCSD was unavailable for an interview due to her health issues. A review of the ";Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(B) Director of Patient Care Services," undated, indicated, ";In the temporary absence (in excess of twenty [20] consecutive working days) of the Director of Patient Care Services, a Registered Nurse shall be designated in writing as responsible for fulfilling the duties of Director of Patient Care Services." 3. A review of DPCS 1s personnel file indicated the following: a. ";State of California Board of Registered Nursing," certificate, dated August 21, 2021, indicated DPCS 1 was issued her RN license on August 21, 2021. b. DPCS 1 was hired as a visiting nurse on September 1, 2021. During an interview with the Admin on October 30, 2024, at 1:53 PM, the Admin stated DPCS 1 had been working at the agency as a visiting nurse for two years, 10 months and 4 days before being offered the DPCS position. The Admin stated DPCS 1 did not make the State requirement of three years of experience within the last five years in a hospice or home health agency, primary care clinic or health facility, at least one year of which was in a supervisory or administrative capacity. A review of the ";Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(D)(1) Director of Patient Care Services," undated, indicated, ";The Director of Patient Care Services shall qualify for the position by fulfilling the requirements under one of the following categories: 1. A Registered Nurse with a baccalaureate or higher degree in nursing or another health-related field with three years of experience within the last five years in a hospice or home health agency, primary care clinic or health facility, at least one year of which was in a supervisory or administrative capacity. ..."

The agency failed to ensure the Condition of Participation: L 648 §418.100 Organization and administration of services was in compliance when: Based on interview, and record review, the Governing Body (GB) failed to operate and manage the agency from November 7, 2023, to October 30, 2024, in a universe of 25 patients when: 1. The agency failed to ensure a Director of Patient Care Services (DPCS) or Director of Patient Care Services Designee (DPCSD) provided direction and oversight to assure quality of care and supervision of staff, in a universe of 25 patients, when: a. The agency failed to follow State Law [Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(A) Director of Patient Care Services] when the DPCS was unable to full fill the DPCS role due to working 12-hour shifts, four days a week as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse, in an acute care hospital. (Refer to L 651) b. The agency failed to follow State Law [Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(B) Director of Patient Care Services] when a DPCS Designee (DPCSD) was unable to full fill the DPCS role due to health issues and leave of absences. (Refer to L 651) c. The agency failed to follow State Law [Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(D)(1) Director of Patient Care Services] when there was no documented evidence to show the DPCS had three years experience within the last five years in a hospice, home health agency, primary care clinic or health facility, at least one year of which was in a supervisory or administrative capacity. (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 six sampled patients (Patients 1, 2, 3, and 4) when: a. For Patient 4 the Medical Director (MD) failed to provide a written certification of the patients' terminal illness (A signed document from a physician that confirms a patient's terminal illness diagnosis. It must be on file in the patient's medical record before a claim is submitted for payment. The written certification includes a narrative explanation of the patient's clinical findings and a life expectancy of six months or less). (Refer to L 651) b. For Patient 4, the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. (Refer to L 651) c. For Patient 1, 2, 3, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. (Refer to L 651) 3. The Medical Director (MD) failed his responsibility for the medical component of the hospice program when a physician's referral order for hospice services, a confirmation of service needs, a verification of the patients' medical prognosis and supporting documentation was not obtained for three of six sampled patients (Patients 2, 3, and 4). (Refer to L 651) The cumulative effect of these systemic practices resulted in the potential for patients to suffer poor quality and safety of patient care when there was no DPCS monitoring care plans, staff competency, adherence to regulations, or promptly addressing any potential issues that could impact patient well-being. In addition, Patients 1, 2, 3, and 4 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and referring to hospice care.

Based on interview, and record review, the Governing Body (GB) failed to operate and manage the agency from November 7, 2023, to October 30, 2024, in a universe of 25 patients when: 1. The agency failed to ensure a Director of Patient Care Services (DPCS) or Director of Patient Care Services Designee (DPCSD) provided direction and oversight to assure quality of care and supervision of staff, in a universe of 25 patients, when: a. The agency failed to follow State Law [Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(A) Director of Patient Care Services] when the DPCS was unable to full fill the DPCS role due to working 12-hour shifts, four days a week as an Intensive Care Unit (ICU- a department of a hospital in which patients who are dangerously ill are kept under constant observation) nurse, in an acute care hospital. b. The agency failed to follow State Law [Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(B) Director of Patient Care Services] when a DPCS Designee (DPCSD) was unable to full fill the DPCS role due to health issues and leave of absences. c. The agency failed to follow State Law [Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(D)(1) Director of Patient Care Services] when there was no documented evidence to show the DPCS had three years experience within the last five years in a hospice, home health agency, primary care clinic or health facility, at least one year of which was in a supervisory or administrative capacity. This failure had the potential for patients to suffer poor quality and safety of patient care when there was no DPCS monitoring care plans, staff competency, adherence to regulations, or promptly addressing any potential issues that could impact patient well-being. 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 six sampled patients (Patients 1, 2, 3, and 4) when: a. For Patient 4 the Medical Director (MD) failed to provide a written certification of the patients' terminal illness (A signed document from a physician that confirms a patient's terminal illness diagnosis. It must be on file in the patient's medical record before a claim is submitted for payment. The written certification includes a narrative explanation of the patient's clinical findings and a life expectancy of six months or less). b. For Patient 4, the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. c. For Patient 1, 2, 3, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. These failures had the potential to cause Patients 1, 2, 3, and 4, 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 not being properly evaluated as terminally ill. 3. The Medical Director (MD) failed his responsibility for the medical component of the hospice program when a physician's referral order for hospice services, a confirmation of service needs, a verification of the patients' medical prognosis and supporting documentation was not obtained for three of six sampled patients (Patients 2, 3, and 4). This failure had the potential to cause Patients 2, 3, 4 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and referring to hospice care. --- 1. An unannounced visit was made to the agency on August 26, 2024, at 11:24 AM, to investigate a complaint for improperly evaluated hospice admissions and no DPCS oversight. a. During an interview with the Administrator (Admin) on August 26, 2024, at 11:33 AM, the Admin stated the Director of Patient Care Services was (DPCS 1) and she had verbally accepted the position on July 6, 2024. The Admin stated DPCS 1 had another fulltime job and could not full fill the DPCS role at this time. During an interview with DPCS 1 on August 26, 2024, at 1:32 PM, DPCS 1 stated she had verbally accepted the DPCS position on July 6, 2024. DPCS 1 stated she worked 12-hour shifts, four days a week as an ICU nurse, in an acute care hospital and would not be able to full fill the DPCS position until September 30, 2024. DPCS 1 confirmed she would not be able to full fill the DPCS position for 86 days. An unannounced return visit was made to the agency on October 28, 2024, at 9:34 AM, to continue the investigation for improperly evaluated hospice admissions and no DPCS oversight. During a home visit with a Licensed Vocational Nurse (LVN 1) on October 29, 2024, at 11:10 AM, LVN 1 stated she had been working at the agency for two years and did not know DPCS 1 had accepted the DPCS role, ";I thought she just did nursing visits." LVN 1 stated she was not aware of a DPCS Designee (DPCSD). LVN 1 stated the agency provided ongoing monthly in-service training but there had not been an in-service for a while. During a review of the in-service binder, undated, indicated no in-services had been conducted March 2024, June 2024, July 2024, August 2024, or September 2024. During an interview with the Admin on October 30, 2024, at 9:54 AM, the Admin stated the agency usually provided in-services at least once per month and it was unusual to have five months without an in-service. The Admin stated the in-services had ";dropped off," due to the difficulties full filling the DPCS position. A review of the ";Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(A) Director of Patient Care Services," undated, indicated, ";The Director of Patient Care Services or his/her designee shall be available on the premises or accessible by telecommunications during operating hours. The Director of Patient Care Services shall devote a sufficient number of hours to assure the quality and adequacy of services provided and supervision of staff." A review of the agencys policy and procedure titled, ";Job Description Director," dated February 2022, indicated, ";JOB SUMMARY: To provide Hospice care to the terminally ill hospice patient twenty-four hours/day, seven days/week. To work as a member of the Hospice team in providing Hospice care. Oversees and supervises all Hospice care to patients and families in all settings. ... Essential Functions: 1. Participates in developing standards which ensure safe and therapeutically effective service to patients and families. ... 5. Is responsible for recruiting, hiring, evaluating and terminating service personnel. 6. Participates in planning for the orientation of new employees. Conducts selected orientation classes. ... 9. Participates in establishing the functions and qualifications for each service position; coordinates interdisciplinary team services: Assures ongoing assessment of patient/family needs and implementation of interdisciplinary group plan of care. Assures physician approval of plans for continuity of medical care. Provides individual or group support concerning job related stress or issues. ... 22. Oversees Hospice's ongoing Quality Assurance/Performance Improvement (QAPI) program. 23. Provides 24 hour/day, seven (7) days/week on-call coverage. 24. Plans and supervises the Hospice. 25. Ensures that patients' plans of care are developed, implemented and evaluated. 26. Conducts patient case conferences, in-services, staff meetings and maintains documentation; participates in community education projects. 27. Ensures that all necessary supplies and equipment are available. 28. Is normally available at all times during and after operating hours; may designate a qualified temporary replacement if he/she will not be available. 29. Ensures compliance with federal, state, and local rules, accreditation standards and Hospice policies in all patient care aspects of the Hospice. ..." b. During an interview with the Administrator (Admin) on August 26, 2024, at 11:33 AM, the Admin stated the DPCSD was unable to cover the DPCS position due to health issues and DPCS 1 had not appointed a new DPCSD. The Admin stated the DPCSD was unavailable for an interview due to her health issues. During a return visit interview with the Admin on October 30, 2024, at 2:16 PM, the Admin stated the DPCSD had been unable to cover the DPCS position from August 26, 2024, to October 30, 2024, due to health issues (a total of 65 days) and the agency had not appointed a new DPCSD. The Admin stated the DPCSD was unavailable for an interview due to her health issues. A review of the ";Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(B) Director of Patient Care Services," undated, indicated, ";In the temporary absence (in excess of twenty [20] consecutive working days) of the Director of Patient Care Services, a Registered Nurse shall be designated in writing as responsible for fulfilling the duties of Director of Patient Care Services." c. A review of DPCS 1s personnel file indicated the following: a. ";State of California Board of Registered Nursing," certificate, dated August 21, 2021, indicated DPCS 1 was issued her RN license on August 21, 2021. b. DPCS 1 was hired as a visiting nurse on September 1, 2021. During an interview with the Admin on October 30, 2024, at 1:53 PM, the Admin stated DPCS 1 had been working at the agency as a visiting nurse for two years, 10 months and 4 days before being offered the DPCS position. The Admin stated DPCS 1 did not make the State requirement of three years of experience within the last five years in a hospice or home health agency, primary care clinic or health facility, at least one year of which was in a supervisory or administrative capacity. A review of the ";Standards of Quality Hospice Care, Article (ART) 5 Staffing-5.3(D)(1) Director of Patient Care Services," undated, indicated, ";The Director of Patient Care Services shall qualify for the position by fulfilling the requirements under one of the following categories: 1. A Registered Nurse with a baccalaureate or higher degree in nursing or another health-related field with three years of experience within the last five years in a hospice or home health agency, primary care clinic or health facility, at least one year of which was in a supervisory or administrative capacity. ..." 2a. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of November 7, 2023, with a benefit period of July 4, 2024, to September 1, 2024 (Benefit Period Four). Patient 4 had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and makes it difficult to breathe). A review of Patient 4s CTIs from November 7, 2023, to September 1, 2024, was conducted. There was no documented evidence to show a written CTI for benefit period four (July 4, 2024, to September 1, 2024). A review of Patient 4s claims for payment, indicated a claim for payment was submitted on October 1, 2024. During an interview with the Medical Director (MD) on October 30, 2024, from 1:13 PM to 1:20 PM, the MD stated he was aware of the requirement for a written CTI. The MD stated he did not know why Patient 4s clinical record did not contain a written CTI for benefit period four. 2b. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of November 7, 2023, with a benefit period of July 4, 2024, to September 1, 2024 (Benefit Period Four). Patient 4 had diagnoses that included Chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 4s Verbal CTI dated July 4, 2024, to September 1, 2024 (Benefit Period Four), indicated verbal certification of Patient 4s prognosis of six months or less life expectancy by the Medical Director (MD). A review of Patient 4s face-to-face encounter for the fourth benefit period dated July 4, 2024, to September 1, 2024, indicated the face-to-face encounter had been conducted by the MD. A review of Patient 4s claims for payment, indicated a claim for payment was submitted on October 1, 2024. During an interview with the MD on October 30, 2024, from 1:13 PM to 1:20 PM, the MD stated he had verbally certified Patient 4s 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. 2c. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 26, 2024, with a benefit period of June 26, 2024, to September 23, 2024 (First 90-day benefit period). Patient 1 had diagnoses that included brain cancer. A review of Patient 1s ";Written Certification [CTI]," dated June 26, 2024, to September 23, 2024, indicated the Medical Directors signature. There was no documented evidence to show an Attending Physician (AP) for Patient 1 had been identified, contacted, or supporting documentation obtained. There was no documented evidence to show an AP had confirmed Patient 1s hospice service needs or provided a signature verifying Patient 1s prognosis of six months or less life expectancy. A review of Patient 1s claims for payment, indicated a claim for payment was submitted on July 11, 2024. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 14, 2024, with a benefit period of June 14, 2024, to September 11, 2024 (First 90-day benefit period). Patient 2 had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and makes it difficult to breathe). A review of Patient 2s ";Written Certification [CTI]," dated June 14, 2024, to September 11, 2024, indicated the Medical Directors signature. There was no documented evidence to show an Attending Physician (AP) for Patient 2 had been identified, contacted, or supporting documentation obtained. There was no documented evidence to show an AP had confirmed Patient 2s hospice service needs or provided a signature verifying Patient 2s prognosis of six months or less life expectancy. A review of Patient 2s claims for payment, indicated a claim for payment was submitted on August 21, 2024. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 17, 2024, with a benefit period of June 17, 2024, to September 14, 2024 (First 90-day benefit period). Patient 3 had diagnoses that included Parkinsons disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 3s ";Written Certification [CTI]," dated June 17, 2024, to September 14, 2024, indicated the Medical Directors signature. There was no documented evidence to show an Attending Physician (AP) for Patient 3 had been identified, contacted, or supporting documentation obtained. There was no documented evidence to show an AP had confirmed Patient 3s hospice service needs or provided a signature verifying Patient 3s prognosis of six months or less life expectancy. A review of Patient 3s claims for payment, indicated a claim for payment was submitted on August 21, 2024. During an interview with the Medical Director (MD) on October 30, 2024, from 1:13 PM to 1:20 PM, the MD stated he had certified Patient 1, 2 and 3s terminal illnesses. The MD stated he had not identified, contacted, or obtained supporting documentation from Patient 1, 2, or 3s attending physicians. The MD stated Patients 1, 2, and 3s attending physicians had not confirmed Patients 1, 2, or 3s hospice service needs or provided a signature verifying Patients 1, 2, or 3s prognosis of six months or less life expectancy. The MD stated he had been unaware of this requirement. A review of the agencys policy and procedure titled ";Certification/Recertification of Terminal Illness, Brief Narrative, Statement and Face-to-Face Evaluations," dated May 2023, indicated, ";POLICY: Hospice will obtain appropriate certification and recertification of terminal illness. PURPOSE: To define certification/recertification of terminal illness process. PROCEDURE: 1. In order to be eligible to elect Hospice care under Medicare, a patient must be certified as being terminally ill. 2. A patient may elect to receive Hospice care during one or more of the following election periods: An initial 90-day period. A subsequent 90-day period. A subsequent 60-day period. A subsequent extension period of unlimited duration during the patient's lifetime. The periods of care are available in the order listed and may be elected separately at different times. 3. Hospice will obtain written certification of terminal illness for each of the periods listed, even if a single election continues in effect for two, three or four periods. Hospice will obtain the written certification no later than two (2) calendar days after the period begins. If Hospice cannot obtain the written certification within two (2) calendar days, it will obtain oral certification within two (2) calendar days, and written certification prior to submitting a claim for payment. The initial certification may be completed up to 15 days before Hospice care is elected. 4. The Medical Director, physician member of the IDG or physician designee reviews the clinical information and other documentation that supports the medical prognosis for each Hospice patient. This Brief Narrative Statement must accompany the certification and be filed in the patient record. Such information may be provided verbally and will be documented in the patient record. 5. Such information will be included as a part of Hospice's eligibility assessment. The written certification must specify that it is anticipated that the patient's life expectancy is 6 months or less, if the illness runs its normal course. The physician must consider the following when making this determination: The primary terminal condition. Related diagnosis(es), if any. Current subjective and objective medical findings. Current medication and treatment orders. Information about the medical management of any of the patient's conditions unrelated to the terminal illness. 6. The certification must specify that the patient's prognosis is for a life expectancy of 6 months or less, if the terminal illness runs its normal course. For the initial 90-day period, Hospice must obtain written certification statements (and oral certification statements if required) from: The Medical Director of Hospice or the physician member of the Hospice IDG; and the patient's attending physician, if the patient has an attending physician. 7. For subsequent periods, the only requirement is recertification by either the Medical Director, physician member of the IDG or physician designee's review of patient's clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. 8. Before the recertification period for each patient, the Medical Director, physician member of the IDG or physician designee must review the patient's clinical information (as described in #4) and develop a Brief Narrative Statement. The Physician Brief Narrative Statement must be completed no more than 15 days prior to recertification. 9. Hospice staff must: Make an appropriate entry in the patient's record as soon as they receive an oral certification; and File written certifications in the patient record. 9. In the event that the patient's attending physician is a nurse practitioner, the Hospice Medical Director and/or physician designee must certify or recertify the terminal illness. Nurse practitioners cannot certify or recertify a terminal diagnosis or prognosis. 10. A Hospice physician or nurse practitioner (NP) must have a face-to-face encounter with every Hospice patient prior to the patient's third recertification and each subsequent recertification. ... Where a nurse practitioner or non-certifying hospice physician performed the encounter, the attestation must state that the clinical findings of that visit were provided to the certifying physician. ..." 3a. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 14, 2024, with a benefit period of June 14, 2024, to September 11, 2024 (First 90-day benefit period). Patient 2 had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and makes it difficult to breathe). A review of Patient 2s physicians orders from June 14, 2024, to September 11, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 30, 2024, from 1:13 PM to 1:20 PM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 2s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 3b. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 17, 2024, with a benefit period of June 17, 2024, to September 14, 2024 (First 90-day benefit period). Patient 3 had diagnoses that included Parkinsons disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 3s physicians orders from June 17, 2024, to September 14, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 30, 2024, from 1:13 PM to 1:20 PM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 3s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 3c. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of November 7, 2023, with a benefit period of November 7, 2023, to February 4, 2024 (First 90-day benefit period). Patient 4 had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and makes it difficult to breathe). A review of Patient 4s physicians orders from November 7, 2023, to February 4, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 30, 2024, from 1:13 PM to 1:20 PM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 4s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. A review of the agencys policy and procedure titled ";Patient Admission Criteria," dated June 2019, indicated, ";PURPOSE: To establish criteria for the admission of patients to Hospice. ... Hospice admits a patient only on the recommendation of the Medical Director in consultation with, or input from the patient's attending physician (if any). ... When a telephone or verbal referral is received by Hospice, a referral form is completed by a RN. Referrals may also be received by fax, in person or in the mail. The referral form includes at least the following information from the attending physician: ... Physician's name, address and telephone number and alternative physician to contact is attending is not available. Referral source. Primary admitting terminal diagnosis and other diagnosis(es). Medications and treatments required, including orders for treatments and symptom management. Date of hospital discharge, if applicable. Care or treatments to be provided, including frequency and duration. Dietary restrictions. Any other information reported, e.g., medical management of conditions unrelated to the terminal illness. Current medical findings. ..." A review of the agencys policy and procedure titled ";Physician Orders," dated June 2019, indicated, ";POLICY: Nursing and other services that require a physician's order will be provided in accordance with a physician's order. PURPOSE: To describe the requirements for physician orders. ... 4. Care and services provided will be provided according to physician orders. Orders are current and updated. ... 6. Oral orders are: Put in writing, signed and dated with the date of receipt by a RN (or therapist) responsible for furnishing or supervising ordered services. 7. Orders are verified when: There are questions or discrepancies with orders. A person taking a verbal order is not qualified to review the order for appropriateness." During an interview with the Admin on October 30, 2024, at 2:57 PM, The Admin 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 stated the GB had not identified that: a. a Director of Patient Care Services (DPCS) or Director of Patient Care Services Designee (DPCSD) were not providing direction and oversight to assure quality of care and supervision of staff. b. the Medical Director (MD) had not provided a written certification of Patient 4s terminal illness and Patient 4s CTI did not contain a face-to-face encounter conducted by a non-certifying physician or nurse practitioner. c. Patients 1, 2, and 3s CTIs for the first 90-day benefit period were not signed by two physicians. d. the Medical Director (MD) had not provided for the medical component of the hospice program when a physician's referral order for hospice services, a confirmation of service needs, a verification of the patients' medical prognosis and supporting documentation was not obtained for Patients 2, 3, and 4. A review of the agencys policy and procedure titled, ";Governing Body," dated June 2019, indicated, ";POLICY: The Governing Body assumes full legal authority and responsibility for the management of Hospice, the provision of all Hospice services, its fiscal operations and assumes responsibility for the safety and quality of care provided ... PURPOSE: To ensure lines of authority are established and to ensure appropriate quality services are provided to patients. ..."

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 six sampled patients (Patients 1, 2, 3, and 4) when: a. For Patient 4 the Medical Director (MD) failed to provide a written certification of the patients' terminal illness (A signed document from a physician that confirms a patient's terminal illness diagnosis. It must be on file in the patient's medical record before a claim is submitted for payment. The written certification includes a narrative explanation of the patient's clinical findings and a life expectancy of six months or less). (Refer to L 667) b. For Patient 4, the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. (Refer to L 667) c. For Patient 1, 2, 3, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. (Refer to L 667) 2. Based on interview and record review, the Medical Director (MD) failed his responsibility for the medical component of the hospice program when a physician's referral order for hospice services, a confirmation of service needs, a verification of the patients' medical prognosis and supporting documentation was not obtained for three of six sampled patients (Patients 2, 3, and 4). (Refer to L 669) The cumulative effect of these systemic practices resulted in the potential to cause Patients 1, 2, 3, and 4, not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon. In addition, their attending physicians did not provide a referral order for hospice care or identify Patients 2, 3, and 4 as terminally ill.

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 six sampled patients (Patients 1, 2, 3, and 4) when: 1. For Patient 4 the Medical Director (MD) failed to provide a written certification of the patients' terminal illness (A signed document from a physician that confirms a patient's terminal illness diagnosis. It must be on file in the patient's medical record before a claim is submitted for payment. The written certification includes a narrative explanation of the patient's clinical findings and a life expectancy of six months or less). 2. For Patient 4, the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. 3. For Patient 1, 2, 3, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. These failures had the potential to cause Patients 1, 2, 3, and 4, 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 not being properly evaluated as terminally ill. --- 1. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of November 7, 2023, with a benefit period of July 4, 2024, to September 1, 2024 (Benefit Period Four). Patient 4 had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and makes it difficult to breathe). A review of Patient 4s CTIs from November 7, 2023, to September 1, 2024, was conducted. There was no documented evidence to show a written CTI for benefit period four (July 4, 2024, to September 1, 2024). A review of Patient 4s claims for payment, indicated a claim for payment was submitted on October 1, 2024. During an interview with the Medical Director (MD) on October 30, 2024, from 1:13 PM to 1:20 PM, the MD stated he was aware of the requirement for a written CTI. The MD stated he did not know why Patient 4s clinical record did not contain a written CTI for benefit period four. 2. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of November 7, 2023, with a benefit period of July 4, 2024, to September 1, 2024 (Benefit Period Four). Patient 4 had diagnoses that included Chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 4s Verbal CTI dated July 4, 2024, to September 1, 2024 (Benefit Period Four), indicated verbal certification of Patient 4s prognosis of six months or less life expectancy by the Medical Director (MD). A review of Patient 4s face-to-face encounter for the fourth benefit period dated July 4, 2024, to September 1, 2024, indicated the face-to-face encounter had been conducted by the MD. A review of Patient 4s claims for payment, indicated a claim for payment was submitted on October 1, 2024. During an interview with the MD on October 30, 2024, from 1:13 PM to 1:20 PM, the MD stated he had verbally certified Patient 4s 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. 3a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 26, 2024, with a benefit period of June 26, 2024, to September 23, 2024 (First 90-day benefit period). Patient 1 had diagnoses that included brain cancer. A review of Patient 1s ";Written Certification [CTI]," dated June 26, 2024, to September 23, 2024, indicated the Medical Directors signature. There was no documented evidence to show an Attending Physician (AP) for Patient 1 had been identified, contacted, or supporting documentation obtained. There was no documented evidence to show an AP had confirmed Patient 1s hospice service needs or provided a signature verifying Patient 1s prognosis of six months or less life expectancy. A review of Patient 1s claims for payment, indicated a claim for payment was submitted on July 11, 2024. 3b. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 14, 2024, with a benefit period of June 14, 2024, to September 11, 2024 (First 90-day benefit period). Patient 2 had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and makes it difficult to breathe). A review of Patient 2s ";Written Certification [CTI]," dated June 14, 2024, to September 11, 2024, indicated the Medical Directors signature. There was no documented evidence to show an Attending Physician (AP) for Patient 2 had been identified, contacted, or supporting documentation obtained. There was no documented evidence to show an AP had confirmed Patient 2s hospice service needs or provided a signature verifying Patient 2s prognosis of six months or less life expectancy. A review of Patient 2s claims for payment, indicated a claim for payment was submitted on August 21, 2024. 3c. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 17, 2024, with a benefit period of June 17, 2024, to September 14, 2024 (First 90-day benefit period). Patient 3 had diagnoses that included Parkinsons disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 3s ";Written Certification [CTI]," dated June 17, 2024, to September 14, 2024, indicated the Medical Directors signature. There was no documented evidence to show an Attending Physician (AP) for Patient 3 had been identified, contacted, or supporting documentation obtained. There was no documented evidence to show an AP had confirmed Patient 3s hospice service needs or provided a signature verifying Patient 3s prognosis of six months or less life expectancy. A review of Patient 3s claims for payment, indicated a claim for payment was submitted on August 21, 2024. During an interview with the Medical Director (MD) on October 30, 2024, from 1:13 PM to 1:20 PM, the MD stated he had certified Patient 1, 2 and 3s terminal illnesses. The MD stated he had not identified, contacted, or obtained supporting documentation from Patient 1, 2, or 3s attending physicians. The MD stated Patients 1, 2, and 3s attending physicians had not confirmed Patients 1, 2, or 3s hospice service needs or provided a signature verifying Patients 1, 2, or 3s prognosis of six months or less life expectancy. The MD stated he had been unaware of this requirement. A review of the agencys policy and procedure titled ";Certification/Recertification of Terminal Illness, Brief Narrative, Statement and Face-to-Face Evaluations," dated May 2023, indicated, ";POLICY: Hospice will obtain appropriate certification and recertification of terminal illness. PURPOSE: To define certification/recertification of terminal illness process. PROCEDURE: 1. In order to be eligible to elect Hospice care under Medicare, a patient must be certified as being terminally ill. 2. A patient may elect to receive Hospice care during one or more of the following election periods: An initial 90-day period. A subsequent 90-day period. A subsequent 60-day period. A subsequent extension period of unlimited duration during the patient's lifetime. The periods of care are available in the order listed and may be elected separately at different times. 3. Hospice will obtain written certification of terminal illness for each of the periods listed, even if a single election continues in effect for two, three or four periods. Hospice will obtain the written certification no later than two (2) calendar days after the period begins. If Hospice cannot obtain the written certification within two (2) calendar days, it will obtain oral certification within two (2) calendar days, and written certification prior to submitting a claim for payment. The initial certification may be completed up to 15 days before Hospice care is elected. 4. The Medical Director, physician member of the IDG or physician designee reviews the clinical information and other documentation that supports the medical prognosis for each Hospice patient. This Brief Narrative Statement must accompany the certification and be filed in the patient record. Such information may be provided verbally and will be documented in the patient record. 5. Such information will be included as a part of Hospice's eligibility assessment. The written certification must specify that it is anticipated that the patient's life expectancy is 6 months or less, if the illness runs its normal course. The physician must consider the following when making this determination: The primary terminal condition. Related diagnosis(es), if any. Current subjective and objective medical findings. Current medication and treatment orders. Information about the medical management of any of the patient's conditions unrelated to the terminal illness. 6. The certification must specify that the patient's prognosis is for a life expectancy of 6 months or less, if the terminal illness runs its normal course. For the initial 90-day period, Hospice must obtain written certification statements (and oral certification statements if required) from: The Medical Director of Hospice or the physician member of the Hospice IDG; and the patient's attending physician, if the patient has an attending physician. 7. For subsequent periods, the only requirement is recertification by either the Medical Director, physician member of the IDG or physician designee's review of patient's clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. 8. Before the recertification period for each patient, the Medical Director, physician member of the IDG or physician designee must review the patient's clinical information (as described in #4) and develop a Brief Narrative Statement. The Physician Brief Narrative Statement must be completed no more than 15 days prior to recertification. 9. Hospice staff must: Make an appropriate entry in the patient's record as soon as they receive an oral certification; and File written certifications in the patient record. 9. In the event that the patient's attending physician is a nurse practitioner, the Hospice Medical Director and/or physician designee must certify or recertify the terminal illness. Nurse practitioners cannot certify or recertify a terminal diagnosis or prognosis. 10. A Hospice physician or nurse practitioner (NP) must have a face-to-face encounter with every Hospice patient prior to the patient's third recertification and each subsequent recertification. ... Where a nurse practitioner or non-certifying hospice physician performed the encounter, the attestation must state that the clinical findings of that visit were provided to the certifying physician. ..."

Based on interview and record review, the Medical Director (MD) failed his responsibility for the medical component of the hospice program when a physician's referral order for hospice services, a confirmation of service needs, a verification of the patients' medical prognosis and supporting documentation was not obtained for three of six sampled patients (Patients 2, 3, and 4). This failure had the potential to cause Patients 2, 3, 4 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and referring to hospice care. --- 1. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 14, 2024, with a benefit period of June 14, 2024, to September 11, 2024 (First 90-day benefit period). Patient 2 had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and makes it difficult to breathe). A review of Patient 2s physicians orders from June 14, 2024, to September 11, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 30, 2024, from 1:13 PM to 1:20 PM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 2s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 2. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 17, 2024, with a benefit period of June 17, 2024, to September 14, 2024 (First 90-day benefit period). Patient 3 had diagnoses that included Parkinsons disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 3s physicians orders from June 17, 2024, to September 14, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 30, 2024, from 1:13 PM to 1:20 PM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 3s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. 3. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of November 7, 2023, with a benefit period of November 7, 2023, to February 4, 2024 (First 90-day benefit period). Patient 4 had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and makes it difficult to breathe). A review of Patient 4s physicians orders from November 7, 2023, to February 4, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the Medical Director (MD) on October 30, 2024, from 1:13 PM to 1:20 PM, the MD stated a physicians referral order was required before hospice services were offered to a patient. The MD verified he had not contacted Patient 4s AP to request a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. A review of the agencys policy and procedure titled ";Patient Admission Criteria," dated June 2019, indicated, ";PURPOSE: To establish criteria for the admission of patients to Hospice. ... Hospice admits a patient only on the recommendation of the Medical Director in consultation with, or input from the patient's attending physician (if any). ... When a telephone or verbal referral is received by Hospice, a referral form is completed by a RN. Referrals may also be received by fax, in person or in the mail. The referral form includes at least the following information from the attending physician: ... Physician's name, address and telephone number and alternative physician to contact is attending is not available. Referral source. Primary admitting terminal diagnosis and other diagnosis(es). Medications and treatments required, including orders for treatments and symptom management. Date of hospital discharge, if applicable. Care or treatments to be provided, including frequency and duration. Dietary restrictions. Any other information reported, e.g., medical management of conditions unrelated to the terminal illness. Current medical findings. ..." A review of the agencys policy and procedure titled ";Physician Orders," dated June 2019, indicated, ";POLICY: Nursing and other services that require a physician's order will be provided in accordance with a physician's order. PURPOSE: To describe the requirements for physician orders. ... 4. Care and services provided will be provided according to physician orders. Orders are current and updated. ... 6. Oral orders are: Put in writing, signed and dated with the date of receipt by a RN (or therapist) responsible for furnishing or supervising ordered services. 7. Orders are verified when: There are questions or discrepancies with orders. A person taking a verbal order is not qualified to review the order for appropriateness."

Upon patient record review 1 of 11 (Patient #7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #7: Patient SOC and Comprehensive Assessment 5/21/22. MSW/Psychosocial Assessment Date was 5/27/22.

Upon patient record review, 1 of 11 (Patient #10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #10: 5/26/22 Comprehensive assessment documents patient has Foley Catheter. There is no related order regarding catheter care, maintenance or changes and there is no related discussion/problem/goal addressed in IDG POC.

Upon patient record review 3 of 11 (Patient #2, 4, 8) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient # 2, 4, 8: Aide care plan assigned task of shampoo 1xwkly. The aide documented performing shampoo every visit, which was more than 1xweek.

Upon patient record review, 1 of 11 (Patient #6) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #6: Verbal Certification is only related documentation on file. No evidence of written narrative or certification.

Upon patient client record review, 4 of 11 (Patient #1, 2, 6, 7) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patients #1, 2, 6, 7 Election Statements did not include effective date. The space was blank.

Upon patient record review, 1 of 11 (Patient #2) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient #2: Admitted status post hip surgery. 6/3/22 SN Visit included RN documentation that "Staples removed after received order. Cleansed with wound cleanser and left open to air." RN inadvertently failed to document order received.