Every finding on record at Caring Angels Group Inc

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination, the primary terminal condition, elated diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 10 (20%) clinical records of patients who received hospice services revealed that the hospice agency did not ensure that the medical director or physician designee completed the written certification of terminal illness after the patient had been admitted. Document 1: Agency Policy 2003, CHAP Hospice Operations/Revised December 2018, stated in part, that at the time of admission to hospice, the medical director or the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on his/her review of the patient's medical record or examination of the patient. Clinical Record 6: The patient elected their hospice benefit on 06/05/2023 and was admitted on 06/05/2023. The benefit period was from 06/05/2023-09/01/2023. There was no documented evidence that the hospice medical director had completed the written certification of terminal illness. Clinical Record 7: The patient elected their hospice benefit on 06/21/2023 and was admitted on 06/21/2023. The benefit period was from 06/21/2023-09/17/2023. There was no documented evidence that the hospice medical director had completed the written certification of terminal illness. During an interview on 06/20/2023, the Director of Nursing agreed that the clinical records did not have a written certification of terminal illness documented by the hospice medical director or physician designee. The Director of Nursing stated that the medical director always completes the written certifications and emails a copy to the hospice agency. The Director of Nursing called the hospice medical director during the discussion to ask the medical director if the written certifications could be faxed or emailed as soon as possible. The hospice medical director informed the Director of Nursing that she was not in her office then.