Every finding on record at Brio Hospice

Based on interview, and record review, the agency failed to ensure patients could exercise their rights for one of the 14 sampled patients (Patient 11) when Patient 11 was not provided with an "Advance Beneficiary Notice of Noncoverage" (ABN—a notice that explains the patient's right to appeal discharge from hospice services) two days prior to discharge, which would have allowed sufficient time for Patient 11 to appeal the discharge. This failure caused Patient 11 to lose the hospice services necessary for maintaining health and safety, without the chance to appeal. --- A review of Patient 11’s face sheet undated indicated a start of care date of October 31, 2024, with a benefit period of February 28, 2025, to April 28, 2025 (Benefit Period seven). Patient 11 had diagnoses that included atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow).A review of Patient 11’s physician’s order dated April 28, 2025, indicated, “Discharge patient from [name of agency] effective 4/28/2025 due to extended prognosis. Patient no longer meets criteria for hospice re-certification.”A review of Patient 11’s ABN, undated, indicated, “The Effective Date Coverage of Your Current Hospice Services Will End: 04/28/[25].” Patient 11 signed the ABN on April 28, 2025.During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on July 7, 2025, at 10:07 AM, the AD/DPCSD stated she could not show documented evidence Patient 11 had been provided with the ABN two days prior to his discharge on April 28, 2025. The AD/DPCSD stated she was aware of the requirement to provide the ABN two days prior to discharge to allow Patient 11 time to appeal. A review of the agency’s policy and procedure titled “Expedited Determination Policy,” dated March 2013, indicated, “POLICY: Each Medicare beneficiary will be notified in writing using the … "Generic Notice of Medicare Provider Non-Coverage," no later than [two] days before covered Hospice services(s) will end. PURPOSE: To define Hospice responsibility for implementation  of … (Benefits Improvement and Protection Act).”

Based on observation, interview, and record review, the agency failed to ensure a review of all the medications the patients were taking was conducted for two of 14 sampled patients (Patients 1 and 3) when: For Patient 1: the Medication Profile (MP-a current list of all medications prescribed for a specific patient), indicated the wrong dose for two medications (Milk of Magnesia-a medication to relieve constipation and acetaminophen-a pain medication) and one medication (atorvastatin- a medication to lower cholesterol and triglyceride levels in the blood) was not indicated on the MP.  For Patient 3: the MP indicated escitalopram (a medication to treat depression) and Patient 3's wife stated she had not been administering the medication to Patient 3 for six months. This failure had the potential to cause Patients 1 and 3 to suffer ineffective drug therapy, significant side effects and noncompliance with drug therapy. --- 1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 26, 2025, with a benefit period of May 25, 2025, to July 23, 2025 (Benefit Period five). Patient 1 had diagnoses that included Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions). During a home visit on July 8, 2025, with a Hospice Aide (HA 1) and Patient 1’s Caregiver (CG), an observation of Patient 1’s actual medication bottles available in the home were compared with Patient 1’s most current MP.   During a concurrent observation and interview on July 8, 2025, from 10:08 AM, to 10:47 AM with Patient 1’s CG: a. The MP indicated, Milk of Magnesia (magnesium hydroxide) 1200 mg (milligrams-a unit of measurement) in 5 (five) ml (milliliters-a unit of measurement), give 30 ml by mouth every 24 hours as needed if no BM (bowel movement) in 3 (three) days. Patient 1’s medication bottle’s pharmacy label indicated give once a day as needed if no bowel movement for 24 hours. b. The MP indicated, acetaminophen 500 mg Oral Tablet, give 1 (one) Tablet equaling 500 mg for mild pain and 2 (two) Tablets equaling 1000 mg for moderate pain every 6 (six) hours as needed. Patient 1’s medication bottle’s pharmacy label indicated acetaminophen 325 mg Oral Tablet, take two tablets by mouth every six hours as needed for mild pain. c. The CG provided a medication bottle whose pharmacy label indicated atorvastatin 40 mg tablets, take one tablet by mouth at bedtime. The CG stated Patient 1’s daughter told her to start administering the medication a month ago. Patient 1’s MP did not indicate the atorvastatin medication.  2. A review of Patient 3’s face sheet undated indicated a start of care date of November 16, 2024, with a benefit period of May 15, 2025, to July 13, 2025 (Benefit Period three). Patient 3 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). During a home visit on July 8, 2025, with a Licensed Vocational Nurse (LVN 1) and Patient 3’s Wife, an observation of Patient 3’s actual medication bottles available in the home were compared with Patient 3’s most current MP.   During a concurrent observation and interview on July 8, 2025, from 11:56 AM, to 12:48 PM with LVN 1 and Patient 3’s Wife: a. The MP indicated escitalopram (escitalopram oxalate) 10 mg Oral Tablet, give one tablet daily. Patient 3's wife stated she had not been administering the medication to Patient 3 for six months. LVN 1 stated she was supposed to check all the medications at each visit, “I guess I missed that one.” During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on July 9, 2025, from 9 AM to 9:20 AM, the AD/DPCSD stated it was her expectation that the Skilled Nurse (SN) would conduct a medication reconciliation at each visit and if there were any changes the MP would be updated. The AD/DPCSD stated Patients 1 and 3 should have had accurate MPs in their clinical records and did not.  A review of the agency’s policy and procedure titled “Medication Reconciliation/Medication Profile,” dated June 2018, indicated, “POLICY: Hospice will reconcile patient’s medications at time of admission and on an ongoing basis. PURPOSE: To define the medication reconciliation process. PROCEDURE: … 2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. …”

Based on observation, interview, and record review, the agency failed to develop an individualized plan of care (a nursing care plan is a written document that outlines the individualized care a patient will receive, which includes: a patient’s needs, the problem, the goal and interventions to meet the goal) for one of 14 sampled patients (Patient 3) when Patient 3’s care plan did not indicate vital sign (vital sign readings routinely monitored by medical professionals included the following: temperature, heart rate, blood pressure, respiratory rate and pain level) reporting parameters (indicate what vital sign readings to report to the physician) or interventions to address Patient 3’s low heart rate.  This failure had the potential to cause the Skilled Nurse (SN) not to know when to notify the physician of abnormal vital signs readings and for Patient 3 to suffer dizziness, fatigue, shortness of breath, and fainting, leading to falls and potential injury. --- A review of Patient 3’s face sheet undated indicated a start of care date of November 16, 2024, with a benefit period of May 15, 2025, to July 13, 2025 (Benefit Period three). Patient 3 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age).During Patient 3’s home visit on July 8, 2025, from 11:56 AM to 12:48 PM, a concurrent observation and interview with a Licensed Vocational Nurse (LVN 1) was conducted. LVN 1 was observed taking Patient 3’s heart rate reading and LVN 1 stated Patient 3’s heart rate was 43 beats per minute (a normal adult male’s heart rate was between 60 and 100 beats per minute). LVN 1 stated Patient 3’s care plan did not contain vital sign reporting parameters, and she had not been provided with vital sign reporting parameters for Patient 3. LVN 1 stated a low heart rate was normal for Patient 3 and she had seen Patient 3’s heart rate go as low as 37 beats per minute. LVN 1 stated she had reported Patient 3’s low heart rate to the physician but had not received instructions. A review of Patient 3’s care plans from May 15, 2025, to July 9, 2025, was conducted. There was no documented evidence to show vital sign reporting parameters or interventions to address Patient 3’s low heart rate.A review of Patient 3’s Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) meetings from May 15, 2025, to July 9, 2025, was conducted. There was no documented evidence to show Patient 3’s low heart rate had been discussed and care planned. During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on July 9, 2025, at 11:37 AM, the AD/DPCSD confirmed Patient 3’s care plan did not indicate vital sign reporting parameters, and it should have. The AD/DPCSD stated she was unable to show documented evidence Patient 3’s low heart rate had been discussed with the physician during the IDG meetings. The AD/DPCSD confirmed Patient 3’s care plan did not address Patient 3’s low heart rate and it should have.A review of the agency’s policy and procedure titled “IDG Care Planning Process,” dated June 2018, indicated, “POLICY: In order to assure that care provided is appropriately planned to meet each patient's specific needs and problems, Hospice will utilize data/information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessments, in the care planning process to provide care that is consistent with the patient and family needs, with patient's needs and goals as a priority. PURPOSE: To define the IDG care planning process and documentation of care planning. PROCEDURE: 1. Hospice has designated an interdisciplinary group which, in consultation with the patient's attending physician, prepares a written plan of care for each patient. The group consists of: A physician member who is the Hospice Medical Director or another Hospice physician who is employed by or under contract with Hospice (the physician must be a Doctor of Medicine or osteopathy), Registered nurse. … 2. The care of plan specifies the care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions. 3. The IDG works together to meet the physical, medical, psychosocial, emotional and spiritual needs of Hospice patients and families facing terminal illness and bereavement. IDG members provide the care and services offered by Hospice: IDG supervises the care and services. … Supervision of care by the IDG members is accomplished by face-to-face or telephone conferences, evaluations, discussions and general oversight, as well as by direct observations. A registered nurse that is a member of the IDG is designated to provide coordination of care and to ensure continuous assessment of each patient's and family's needs and implementation of the IDG plan of care. … 8. An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, … 9. The IDG (in collaboration with the patient's attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. The revised plan of care includes information from the patient's updated comprehensive assessment and notes the patient's progress toward outcomes and goals specified in the plan of care, advance directives, effectiveness of pain and symptom management, and spiritual and psychosocial needs.”

Based on interview and record review, the agency failed to provide nursing services in accordance with the nurse practice act (Licensed Vocational Nurse-LVN- Scope of Practice for the State of California Board of Vocational Nursing 2518.5 (a) [Chapter 5, Section II: Assessment/ Implementation]) for one (1) of 14 sampled patients (Patient 11) when LVN 2 independently conducted Patient 11’s discharge assessment (a comprehensive evaluation to determine a patient's readiness for discharge, ensuring they can safely transition to the next phase of care or life without hospice services. It involves assessing various factors to ensure a safe and successful discharge, minimizing the risk of readmission or adverse events), discharge teaching (the process of educating a patient and their family about the patient's medical condition, care plan, and necessary follow-up instructions before their hospice services end) and completed Patient 11's discharge summary (a comprehensive report summarizing a patient's hospice stay, including their condition, treatment, and follow-up instructions). This failure had the potential to result in critical aspects of post-discharge care for Patient 11 being overlooked or inaccurately evaluated. Consequently, Patient 11 may be discharged without a comprehensive understanding of their medication regimen, follow-up appointments, instructions to promote circulation and reduce leg swelling, or potential complications. The absence of proper discharge instructions and support increases the risk of medication errors, falls, infections, hospital re-admissions, or other adverse outcomes that could affect Patient 11’s recovery and overall well-being. --- A review of Patient 11’s face sheet undated indicated a start of care date of October 31, 2024, with a benefit period of February 28, 2025, to April 28, 2025 (Benefit Period seven). Patient 11 had diagnoses that included atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). Patient 11 was discharged April 28, 2025.A review of Patient 11’s “Hospice Live Discharge/Transfer Summary,” dated April 28, 2025, by LVN 2, indicated, “Received [Patient 11] alert and oriented to person only. [Patient 11] is non-verbal and unable to make needs known. [Patient 11] can answer simple yes and no questions with head nods. Vital signs were taken, and assessment was performed. [Patient 11] continues to have a fair appetite. [Patient 11] remains stable and [there are no] significant changes during visit. Left [Patient 11] comfortable.”During an interview with LVN 2 on July 8, 2025, at 1:56 PM, LVN 2 stated she had conducted Patient 11’s discharge assessment, discharge teaching and completed the discharge summary. LVN 2 stated she did not normally complete these tasks, but the Registered Nurse (RN) had already visited Patient 11 that week and she was at her visit with Patient 11, so the office asked her to conduct the discharge. During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on July 10, 2025, at 1:13 PM, it was confirmed that LVN 2 had been instructed by the office to conduct Patient 11's discharge. The AD/DPCSD acknowledged that LVN 2 should not have been directed to perform duties beyond her scope of practice and that LVN 2 should not have carried out tasks outside her authorized practice boundaries.A review of the agency’s policy and procedure titled “Professional Standards of Practice,” dated March 2013, indicated, “POLICY: Hospice and staff will comply with accepted standards of practice, physician orders and IDG plans of care. PURPOSE: To assure appropriate care provision. PROCEDURE: 1. Hospice and staff will comply with accepted professional standards and principles that apply to the professionals who are furnishing care, e.g., state practice acts. Patient care and services will be provided for each patient according to applicable law and regulation and accepted standards of practice. Hospice maintains copies of all applicable standards of practice from state licensing authority. 2. Hospice staff will provide care, treatment and services to each patient according to the IDG plan of care and physician orders. 3. Staff will be educated about state and federal regulations and laws, including Medicare Conditions of Participation (CoPs) and state licensure requirements.”

Based on interview, and record review, the agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses before the agency submitted a claim for payment, for six of 14 sampled patients (Patients 1, 3, 7, 10, 11, and 13) when the Medical Director (MD) conducted the face to face encounter and certified the patients as terminally ill.  This failure had the potential to cause Patients 1, 3, 7, 10, 11, and 13, 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 1, 3, 7, 10, 11, and 13’s terminal diagnosis and prognosis of six months or less to live. --- 1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 26, 2025, with a benefit period of May 25, 2025, to July 23, 2025 (Benefit Period five). Patient 1 had diagnoses that included Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions).A review of Patient 1’s Certification of Terminal Illness (CTI-a document that certifies a patient as having a life-limiting illness with a prognosis of six months or less if the illness runs its natural course),  dated May 25, 2025, to July 23, 2025 (Benefit Period five), indicated certification of Patient 1’s prognosis of six months or less life expectancy by the MD. A review of Patient 1’s face-to-face encounter for the fifth benefit period dated May 20, 2025, was incorporated into Patient 1’s CTI and indicated the face-to-face encounter had been conducted by the MD.A review of Patient 1’s claims for payment indicated a claim for payment was submitted June 2, 2025.2. A review of Patient 3’s face sheet undated indicated a start of care date of November 16, 2024, with a benefit period of May 15, 2025, to July 13, 2025 (Benefit Period three). Patient 3 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age).A review of Patient 3’s CTI dated May 15, 2025, to July 13, 2025 (Benefit Period three), indicated certification of Patient 3’s prognosis of six months or less life expectancy by the MD. A review of Patient 3’s face-to-face encounter for the third benefit period dated May 6, 2025, was incorporated into Patient 3’s CTI and indicated the face-to-face encounter had been conducted by the MD.A review of Patient 3’s claims for payment indicated a claim for payment was submitted June 2, 2025.3. A review of Patient 7’s face sheet undated indicated a start of care date of March 14, 2025, with a benefit period of May 13, 2025, to July 11, 2025 (Benefit Period seven). Patient 7 had diagnoses that included senile degeneration of the brain.A review of Patient 7’s CTI dated May 13, 2025, to July 11, 2025 (Benefit Period seven), indicated certification of Patient 7’s prognosis of six months or less life expectancy by the MD. A review of Patient 7’s face-to-face encounter for the seventh benefit period dated May 5, 2025, was incorporated into Patient 7’s CTI and indicated the face-to-face encounter had been conducted by the MD.A review of Patient 7’s claims for payment indicated a claim for payment was submitted June 2, 2025.4. A review of Patient 10’s face sheet undated indicated a start of care date of December 12, 2024, with a benefit period of June 10, 2025, to August 8, 2025 (Benefit Period third). Patient 10 had diagnoses that included senile degeneration of the brain.A review of Patient 10’s CTI dated June 10, 2025, to August 8, 2025 (Benefit Period three), indicated certification of Patient 10’s prognosis of six months or less life expectancy by the MD. A review of Patient 10’s face-to-face encounter for the third benefit period dated June 5, 2025, was incorporated into Patient 10’s CTI and indicated the face-to-face encounter had been conducted by the MD.A review of Patient 10’s claims for payment indicated a claim for payment was submitted July 2, 2025.5. A review of Patient 11’s face sheet undated indicated a start of care date of October 31, 2024, with a benefit period of February 28, 2025, to April 28, 2025 (Benefit Period seven). Patient 11 had diagnoses that included atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow).A review of Patient 11’s CTI dated February 28, 2025, to April 28, 2025 (Benefit Period seven), indicated certification of Patient 11’s prognosis of six months or less life expectancy by the MD. A review of Patient 11’s face-to-face encounter for the seventh benefit period dated February 13, 2025, was incorporated into Patient 11’s CTI and indicated the face-to-face encounter had been conducted by the MD.A review of Patient 11’s claims for payment indicated a claim for payment was submitted April 2, 2025.6. A review of Patient 13’s face sheet undated indicated a start of care date of May 21, 2025, with a benefit period of May 21, 2025, to July 19, 2025 (Benefit Period three). Patient 13 had diagnoses that included Alzheimer’s disease.A review of Patient 13’s CTI dated May 21, 2025, to July 19, 2025 (Benefit Period three), indicated certification of Patient 13’s prognosis of six months or less life expectancy by the MD. A review of Patient 13’s face-to-face encounter for the third benefit period dated May 21, 2025, was incorporated into Patient 13’s CTI and indicated the face-to-face encounter had been conducted by the MD.A review of Patient 13’s claims for payment indicated a claim for payment was submitted June 2, 2025.During an interview with the MD on July 10, 2025, from 9:56 AM to 10:31 AM, the MD confirmed that he certified the terminal illnesses for Patients 1, 3, 7, 10, 11, and 13 and conducted face-to-face encounters for Patients 1, 3, 7, 10, 11, and 13. The MD stated he was not aware of the regulatory requirement prohibiting the certifying physician from also conducting the face-to-face encounter. During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on July 10, 2025, at 10:43 AM, the AD/DPCSD stated she was not aware of the regulatory requirement prohibiting the certifying physician from also conducting the face-to-face encounter.A review of the agency’s policy and procedure titled “Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face Evaluations,” dated March 2019, indicated, “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. … A hospice physician or hospice Nurse Practitioner who performs the encounter must attest in writing that he or she had a face-to-face encounter with the patient, including the date of the encounter. 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 agency failed to measure and analyze quality indicators (a measurable element of the agency's practice that can be used to assess the quality of care provided) in order to assess the agency's processes of care, services, and operations, from January 1, 2021, to June 14, 2022, in a universe of nine (9) patients. This failure had the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized and unaddressed. Findings: A review of the agency's "Quality Assessment and Performance Improvement (QAPI)" binder, dated 2021 to 2022, with a QAPI Coordinator (QAPI Coord), was conducted from January 1, 2021, to June 14, 2022. The QAPI binder contained data collection on the following quality indicators: a. Chart Audit/Records review b. Discharge by reason c. Discharged by length of stay d. Emergency preparedness e. Patient Falls The QAPI binder did not contain documented evidence to show the agency had analyzed the data they had collected or developed mechanisms such as thresholds (a value), setting upper and lower control limits (identifies what value is acceptable), percentages (numbers that summarize data), ratios (the relationship in quantity, amount, or size between two or more things) or performance goals in order to identify levels, patterns or trends in the agency's provision of care from January 1, 2021, to June 14, 2022. During an interview with a QAPI Coordinator (QAPI Coord) on June 14, 2022, at 2:47 PM, the QAPI Coord stated she was responsible for the QAPI Program. The QAPI Coord stated she had not developed performance measures such as thresholds and benchmarks to measure and determine outcomes and performance expectations for quality indicators: chart audit/records review, discharge by reason, discharged by length of stay, emergency preparedness and patient falls. The QAPI Coord stated she had not followed the agency's policy and procedure titled "Quality Assurance/Performance Improvement," dated 2017. A review of the agency's policy and procedure titled "Quality Assurance/Performance Improvement," dated 2017, indicated the following: "Program scope: a. The program will at least be capable of showing measurable improvement in indicators related to improved palliative outcomes and hospice services. b. [Name of agency] will measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable [name of agency] to assess processes of care, hospice services, and operations. Program data: a. The program will use quality indicator data, including patient care, and other relevant data, in the design of its program. b. [Name of agency] will use the data collected to do the following: c. Monitor the effectiveness and safety of services and quality of care. d. Identify opportunities and priorities for improvement. ... Principles of Quality Assurance/Performance Improvement: 1. Plans of Correction: A written plan of correction is developed in response to any QAPI activity that does not meet an acceptable threshold. ... 3. QAPI Program Framework: Within the QAPI program, [name of agency] identifies the performance expectations, attributes or dimensions which describe expected performance of a function, process or service provided by [name of agency]. Performance measures (benchmarks/statistical measures) are developed and/or are chosen from external systems, by [name of agency] to measure and determine outcomes and performance expectations of these organizational processes, functions, and services. Within the QAPI program, the criteria used to ensure that the data collected are appropriate for monitoring, [name of agency] performance include: a. The measure can identify the events it was intended to identify b. The measure has a documented numerator statement and a denominator statement or description of the population to which the measure is applicable c. The measure has defined data elements and allowable values d. The measure can detect changes in performance over time e. The measure allows for comparison over time within the organization or between the organization and other entities f. The data intended for collection are available; and g. Results can be reported in a way that is useful to the organization."

The agency failed to ensure that the Condition of Participation: L 664 418.102 Medical director was in compliance as follows: Based on interview, and record review, the agency failed to ensure the Medical Director certified the patients' terminal illnesses (a prognosis of six months or less life expectancy if the disease runs its normal course) for the first 90-day benefit period (hospice services are provided in two 90-day periods and an unlimited number of 60-day periods) with two physician signatures before the agency submitted a claim for payment, for seven (7) of 11 sampled patients (Patients 4, 5, 6, 8, 9, 10 and 11). (Refer to L 667) The cumulative effect of these systemic practices resulted in the potential to cause Patients 4, 5, 6, 8, 9, 10 and 11 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon.

Based on interview, and record review, the agency failed to ensure the Medical Director certified the patients' terminal illnesses (a prognosis of six months or less life expectancy if the disease runs its normal course) for the first 90-day benefit period (hospice services are provided in two 90-day periods and an unlimited number of 60-day periods) with two physician signatures before the agency submitted a claim for payment, for seven (7) of 11 sampled patients (Patients 4, 5, 6, 8, 9, 10 and 11). This failure had the potential to cause Patients 4, 5, 6, 8, 9, 10 and 11 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon. Findings: 1. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of February 25, 2022, with a benefit period of February 25, 2022, to May 25, 2022 (First 90-day benefit period). Patient 4 had diagnoses that included atherosclerotic heart disease (heart disease due to a buildup of plaques on artery walls). A review of Patient 4's physician's order (by Attending Physician-AP 1) dated February 25, 2022, indicated a hospice referral to the agency. A review of Patient 4's "Physician Certification of Terminal Illness," dated February 26, 2022, indicated Patient 4 was in his "First (90 Day) Benefit Period." Patient 4's "Physician Certification of Terminal Illness," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. Patient 4's "Physician Certification of Terminal Illness," indicated the Hospice Medical Director's signature on both lines. There was no documented evidence to show AP 1 had signed Patient 4's "Physician Certification of Terminal Illness." A review of Patient 4's claims for payment from February 25, 2022, to June 16, 2022, indicated Patient 4's first claim for payment was submitted on March 18, 2022. 2. 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 April 19, 2022, with a benefit period of April 19, 2022, to July 17, 2022 (First 90-day benefit period). Patient 5 had diagnoses that included senile degeneration of brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 5's physician's order (by Attending Physician-AP 2) dated April 18, 2022, indicated a hospice referral to the agency. A review of Patient 5's "Physician Certification of Terminal Illness," dated April 20, 2022, indicated Patient 5 was in her "First (90 Day) Benefit Period." Patient 5's "Physician Certification of Terminal Illness," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. Patient 5's "Physician Certification of Terminal Illness," indicated the Hospice Medical Director's signature on both lines. There was no documented evidence to show AP 2 had signed Patient 5's "Physician Certification of Terminal Illness." A review of Patient 5's claims for payment from April 19, 2022, to June 16, 2022, indicated Patient 5's first claim for payment was submitted on May 18, 2022. 3. A review of Patient 6's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of April 4, 2022, with a benefit period of April 4, 2022, to July 2, 2022 (First 90-day benefit period). Patient 6 had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 6's physician's order (by a Physician's Assistant (PA 1) under Attending Physician-AP 3) dated March 21, 2022, indicated a hospice referral to the agency. A review of Patient 6's "Physician Certification of Terminal Illness," dated April 4, 2022, indicated Patient 6 was in her "First (90 Day) Benefit Period." Patient 6's "Physician Certification of Terminal Illness," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. Patient 6's "Physician Certification of Terminal Illness," indicated the Hospice Medical Director's signature on both lines. There was no documented evidence to show AP 3 had signed Patient 6's "Physician Certification of Terminal Illness." A review of Patient 6's claims for payment from April 4, 2022, to June 16, 2022, indicated Patient 6's first claim for payment was submitted on March 18, 2022. 4. A review of Patient 8's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of February 1, 2021, with a benefit period of February 1, 2021, to May 1, 2021 (First 90-day benefit period). Patient 8 had diagnoses that included senile degeneration of brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 8's physician's hospice referral order (by Attending Physician-AP 4) dated January 22, 2021, indicated a hospice referral to the agency. A review of Patient 8's "Physician Certification of Terminal Illness," dated February 4, 2021, indicated Patient 8 was in her "First (90 Day) Benefit Period." Patient 8's "Physician Certification of Terminal Illness," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. Patient 8's "Physician Certification of Terminal Illness," indicated the Hospice Medical Director's signature on both lines. There was no documented evidence to show AP 4 had signed Patient 8's "Physician Certification of Terminal Illness." A review of Patient 8's claims for payment from February 1, 2021, to June 16, 2022, indicated Patient 8's first claim for payment was submitted on March 17, 2021. 5. A review of Patient 9's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of March 1, 2022, with a benefit period of March 1, 2022, to May 29, 2022 (First 90-day benefit period). Patient 9 had diagnoses that included senile degeneration of brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 9's physician's hospice referral order (by Attending Physician-AP 5) dated February 19, 2022, indicated a hospice referral to the agency. A review of Patient 9's "Physician Certification of Terminal Illness," dated March 3, 2022, indicated Patient 9 was in his "First (90 Day) Benefit Period." Patient 9's "Physician Certification of Terminal Illness," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. Patient 9's "Physician Certification of Terminal Illness," indicated the Hospice Medical Director's signature on both lines. There was no documented evidence to show AP 5 had signed Patient 9's "Physician Certification of Terminal Illness." A review of Patient 9's claims for payment from March 1, 2022, to June 16, 2022, indicated Patient 9's first claim for payment was submitted on April 12, 2022. 6. A review of Patient 10's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of May 20, 2020, with a benefit period of May 20, 2020, to August 17, 2020 (First 90-day benefit period). Patient 10 had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 10's physician's hospice referral order (by Attending Physician-AP 6) dated May 19, 2020, indicated a hospice referral to the agency. A review of Patient 10's "Physician Certification of Terminal Illness," dated May 21, 2020, indicated Patient 10 was in her "First (90 Day) Benefit Period." Patient 10's "Physician Certification of Terminal Illness," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. Patient 10's "Physician Certification of Terminal Illness," indicated the Hospice Medical Director's signature on both lines. There was no documented evidence to show AP 6 had signed Patient 10's "Physician Certification of Terminal Illness." A review of Patient 10's claims for payment from May 20, 2020, to June 16, 2022, indicated Patient 10's first claim for payment was submitted on June 16, 2020. 7. A review of Patient 11's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of April 5, 2022, with a benefit period of April 5, 2022, to July 3, 2022 (First 90-day benefit period). Patient 11 had diagnoses that included heart disease. A review of Patient 11's physician's hospice referral order (by Attending Physician-AP 7) dated April 5, 2022, indicated a hospice referral to the agency. A review of Patient 11's "Physician Certification of Terminal Illness," dated April 6, 2022, indicated Patient 11 was in her "First (90 Day) Benefit Period." Patient 11's "Physician Certification of Terminal Illness," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. Patient 11's "Physician Certification of Terminal Illness," indicated the Hospice Medical Director's signature on both lines. There was no documented evidence to show AP 7 had signed Patient 11's "Physician Certification of Terminal Illness." A review of Patient 11's claims for payment from April 5, 2022, to June 16, 2022, indicated Patient 11's first claim for payment was submitted on May 18, 2022. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on June 16, 2022, at 4:30 PM, the Admin/DPCS verified the Medical Director (MD) signed as both Medical Director and Attending Physician on Patients 4, 5, 6, 8, 9, 10 and 11's "Physician Certification of Terminal Illness." The Admin/DPCS verified the Attending Physician (AP) should have signed on the Attending Physician signature line for the "Physician Certification of Terminal Illness," as follows: a. For Patient 4, AP 1 should have signed the "Physician Certification of Terminal Illness." b. For Patient 5, AP 2 should have signed the "Physician Certification of Terminal Illness." c. For Patient 6, AP 3 should have signed the "Physician Certification of Terminal Illness." d. For Patient 8, AP 4 should have signed the "Physician Certification of Terminal Illness." e. For Patient 9, AP 5 should have signed the "Physician Certification of Terminal Illness." f. For Patient 10, AP 6 should have signed the "Physician Certification of Terminal Illness." g. For Patient 11, AP 7 should have signed the "Physician Certification of Terminal Illness." The Admin/DPCS verified the agency had submitted claims for payment for Patients 4, 5, 6, 8, 9, 10 and 11 before obtaining two physician signatures on the "Physician Certification of Terminal Illness." In a continued interview with the Admin/DPCS on June 16, 2022, at 4:30 PM, the Admin/DPCS stated the agency had not obtained a signature from Patients 4, 5, 6, 8, 9, 10 and 11's Attending Physicians certifying their terminal illness before billing for services. The Admin/DPCS stated she had been confused between the physician signature for certification of terminal illness and which physician would follow the patients while receiving hospice services. The Admin/DPCS stated since the Medical Director was following Patients 4, 5, 6, 8, 9, 10 and 11 during their hospice care she had the Medical Director sign as the Attending Physician on the "Physician Certification of Terminal Illness." A review of the agency's policy and procedure titled "Eligibility-Notice of Election-Certification of Terminal Illness-Attestation-Medicare," dated 2016, indicated the following: "Policy: The Hospice will adhere to the requirements for Hospice Coverage under the Medicare benefit. ... Procedure: 1. Eligibility: In order to be eligible to elect hospice care under Medicare, a patient must be ... b. Certified as being terminally ill. An individual is considered to be terminally ill if the medical prognosis is that the individual's life expectancy is 6 months or less if the illness runs its normal course. ... 2. Duration of hospice care coverage-Election periods. a. A patient may elect to receive hospice care during one or more of the following election periods: i. An initial 90-day period; ... 3. Certification of terminal illness ... a. Timing of certification: ... ii. The hospice must obtain the written certification before it submits a claim for payment. ... c. Certification will be based on the clinical judgment of the medical director of the hospice, or the physician member of the hospice IDG [Interdisciplinary Group], and the individual's attending physician if the individual has an attending physician regarding the normal course of the patient's illness. ... f. Sources of certification. i. Initial certifications may be completed up to 15 days before hospice care is elected. For the initial 90-day period, the hospice must obtain written certification statements ... from: The medical director of the hospice or the physician member of the hospice interdisciplinary group; and The patient's attending physician if the patient has an attending physician. ..."

Based on interview, and record review the agency failed to ensure COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) un-vaccinated staff followed additional transmission-based precautions (precautions used to help stop the spread of germs from one person to another) when a Spiritual Counselor (SC 1) did not wear a NIOSH (National Institute for Occupational Safety and Health)-approved N95 mask (a particulate-filtering facepiece respirator that filters at least 95 percent of airborne particles) or received a weekly COVID-19 test when visiting the agency's patients, in a universe of 9 patients. This failure had the potential to cause the spread of the COVID-19 virus to the agency's patients. Findings: During an interview with a Spiritual Counselor (SC 1), in the presence of the Administrator/Director of Patient Care Services (Admin/DPCS) on June 15, 2022, at 1:43 PM, SC 1 stated he had requested and received a non-medical exemption to the COVID-19 vaccination from the agency. SC 1 stated he did not test once per week before seeing the agency's patients. SC 1 stated the agency had not asked him to test once per week. SC 1 stated he purchased his own N95 masks and wore those N95 masks when seeing the agency's patients. SC 1 stated he would send a picture of the N95 masks he wore to the agency. The Admin/DPCS stated SC 1 was required to test weekly. The Admin/DPCS stated SC 1 was required to wear a NIOSH approved N95 mask. The Admin/DPCS stated she did not know whether SC 1 was wearing a NIOSH approved N95 mask. A review of the pictures SC 1 forwarded to the agency of the masks he wore during patient visits indicated the following: 1. Picture one was of a mask that indicated "NIOSH N95." 2. Picture two was of a package of masks that indicated "KN95 Foldable Protective Mask Non-Medical." 3. Picture three was of a mask that indicated "KN95" During an interview with SC 1, in the presence of the Admin/DPCS on June 15, 2022, at 3:18 PM, SC 1 stated he wore all three masks randomly when he visited the agency's patients. SC 1 stated, "I wear whatever mask is in my car at the time of my visit." SC 1 stated his church gave him the NIOSH N95 and he had about 4 (four) of them. SC 1 stated he bought the KN95 masks himself. The Admin/DPCS stated SC 1 must wear a NIOSH N95 mask every time he visited their patients. The Admin/DPCS stated SC 1 cannot wear KN95 masks when he visited the agency's patients. Record review indicated SC 1 last saw the agency's patient on May 18, 2022. A review of the agency's policy and procedure titled "COVID-19 Vaccination," dated January 2022, indicated the following: "Accommodations for Unvaccinated Staff with a Qualifying Exemption/Contingency Plan: Staff who are not yet fully vaccinated, or who have been granted an exemption or accommodation as authorized by law, or who have a temporary delay, must adhere to additional precautions. The actions or job modifications that may be implemented to support risk reduction of COVID-19 transmission include, but are not limited to: ... Requiring at least weekly testing for exempted staff... Requiring staff who have not completed their primary vaccination series to use a NIOSH [National Institute for Occupational Safety and Health]-approved N95 or equivalent or higher-level respirator for source control, regardless of whether they are providing direct care to or otherwise interacting with patients."