Every finding on record at Compassionate Touch Hospice Care, Inc.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to take appropriate corrective actions regarding an active employee who was convicted (found guilty) of elder abuse on 7/31/2023 according to the Los Angeles Times online newspaper article dated 8/2/2023, for one of 14 active employees (Employee 1). This deficient practice placed 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) at risk for being abused or mistreated by Employee 1. --- Findings: On 8/30/2023, at 3:45 p.m., a complaint validation survey was conducted at the HA regarding a complaint allegation concerning Employee 1, who was the current Administrator (ADM) and the Director of Patient Care Services (DPCS) for the HA. The complaint indicated the ADM/DPS was convicted of elderly abuse of six disabled patients living in a boarding care facility (assisted living facility that offers personal assistance with basic daily tasks) from a previous hospice agency employer. The article indicated ";The victims in this case suffered horrific neglect and lack of care at the hands of those who were trusted with their well-being." A review of Employee 1's California Board of Nursing Registered Nurse Licensing details indicated Employee 1 had several administrative disciplinary actions (a management action taken to correct improper or inappropriate behavior or conduct and intended to be corrective in nature) filed against her (ADM/DPCS) on 8/5/2009, 6/21/2010, 10/3/2013, and on 5/22/2014. A review of the HAs Personnel Files indicated the HA hired Employee 1 on 9/1/2015 as the DPCS of the HA. A review of the HA's updated version dated 1/17/2023, "Organizational Chart," indicated Employee 1 was the active ADM and DPCS of the HA. A review of Employee 1s Comprehensive Criminal (background check) record with a completion date of 5/26/2023, the Comprehensive Criminal record indicated there was no criminal record found for Employee 1. The Comprehensive Criminal record indicated the report did not guarantee the accuracy or truthfulness of the information as to the subject of the investigation. A review of Los Angeles Times online article, dated 8/2/2023, indicated Employee 1 was convicted of elder and dependent adult abuse at a boarding care facility on 7/31/2023. The article indicated Employee 1 was one of three people who left six residents emaciated (abnormally thin or weak) and dehydrated (a condition in which you lose so much body fluid that your body can not function normally) and did not provide the care the patients needed at the board and care facility. Retrieved from: https://www.latimes.com/california/story/2023-08-02/dehydration-emaciation-4-convicted-of-elder-dependent-abuse-at-riverside-facility During an interview on 9/2/2023, at 11 am, with Employee 1, Employee 1stated she was looking for someone to relieve her from her DPCS and she (DPCS/Employee 1) would remain working and providing patient care services as a Registered Nurse. During an interview on 9/3/2023, at 1 p.m., with Employee 1, Employee 1 stated she (DPCS/Employee 1) conducted field work (would go inside patients homes), and she would perform the initial, recertification, and conduct supervisory visits for the HAs LVNs (license vocational nurses) and Hospice aides. Employee 1 stated she would take the patients (in general) vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure), that would indicate the state of a patient's essential body functions for the patients (in general) and would perform skilled nursing interventions as ordered for the patients during her visits. When Employee 1 was asked what the HA would do if the HA would find out one of their active skilled nurses was convicted of abuse and was seeing patients. Employee 1 stated the HA would do an investigation, remove the alleged nurse from visiting and taking care of all assigned patients and will allow to work in the HA as office or staffing clerks until the investigation was done. Employee 1 stated she would not suspend or terminate their employment for being convicted, but she would do so once they were sentenced. When Employee 1 was asked if she knew any of her active employees had a current verified abuse violation, she stated she was not aware of any employee who was convicted of abuse. Employee 1 stated the HA did not have a complete policy and procedure for abuse screening and prevention and the HA including herself did not provide abuse training yearly for her active employees for the last three years. When Employee 1 was asked if the HAs Standard of Conduct (includes policies and rules for employees and employers to follow in the workplace) for all employees were annually reviewed, she stated no, and stated she could not show any documented evidence it was reviewed annually. A review of the agencys undated policy and procedure titled, ";Assessment of Possible Abuse/Neglect," indicated the HA will report all suspected cases of abuses neglect, or exploitation (means taking advantage of a resident for personal gain using manipulation, intimidation, threats, in compliance with appropriate state statutes to appropriate protection organizations) in compliance with appropriate state statutes to appropriate protection organizations. A review of the HA's undated policy and procedure entitled, "Standards of Conduct/Ethical Behavior", indicated the organization and its employees must, at all times, comply with all applicable laws and regulations. The organization will not condone the activities of personnel who achieves results through violation of the law, unethical business or patient care practices. The Standards of Conduct will be reviewed at new employee orientation and annually thereafter. The Standard of Conduct will be a part of the Employee Handbook and the employee will sign an acknowledgement of receipt and understanding of its contents at hire.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation for Initial And Comprehensive Assessment Of Patient was met as follows: 1. Based on observation, interview and record review, the hospice agency failed to update the comprehensive assessment of one of 14 sampled patients (Patient I), who was observed lying in bed in supine (lying horizontally with the face and torso facing up) position with cloth restraint belt applied around the patient's waist and tied on each side of the bed rail with a locked device on both ends to lock and unlock the restraint. (Refer to L545) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients accurately assessed to receive hospice care and services. Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of the Patient was met as follows: 1. The hospice agency failed to conduct an accurate comprehensive reassessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patients current health status and identified the patients need for hospice care and services related to eligibility and management of the terminal illness, for two of 14 sampled patients (Patient 8 and Patient 9). (Refer to L524) 2. The hospice agency staff failed to review all medications the patients were taking and update the medication profile with the currently used medications for one of 14 sampled patients (Patient 9). The patient was at risk for medication errors and adverse drug reactions. (Refer to L 530). 3. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated Federal regulations for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on observation, interview, and record review, the hospice agency (HA) failed to conduct an accurate comprehensive reassessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patients current health status and identified the patients need for hospice care and services related to eligibility and management of the terminal illness, for two of 14 sampled patients (Patient 8 and Patient 9). This deficient practice resulted in the provision of hospice services to patients who were not clinically eligible to receive hospice care and services. --- Findings: a. A review of Patient 8's admission record indicated the patient was admitted to the HA on 3/25/2022, with terminal diagnosis of hypertensive heart disease (long-term condition that develops over many years in people who have high blood pressure) without heart failure (a condition in which the heart doesn't pump blood as well as it should). A review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 6/29/23, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus 2 prn (pro re nata, which means ";as needed") visits, the spiritual counselor (SC) and Master of Social Work (MSW) to visit 1 per Month plus 1 prn visit. A review of Patient 8s Re-cert Assessment, dated 7/11/23, indicated Patient 8 needed moderate assistance with ambulation using a cane or a walker. It also indicated Patient 8 needed moderate assistance with toileting, transfer, dressing, feeding, and bathing, and had generalized muscle weakness. The Re-cert assessment form indicated, Patient 8 denies any chest pain, has no edema, has normal respiration, has clear lung sounds and mild dyspnea (shortness of breath). The assessment further indicated Patient 8 meets criteria for hospice care and remained eligible for hospice services showing slow, steady decline. A review of Patient 8s "Local Coverage Determination" (LCD, determining Terminal Status)" Hospice Eligibility Determination form for Heart Disease, dated 7/11/23, indicated Patient 8 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 8 has been ruled out as a candidate for surgical procedures or has declined surgical procedures. Section 2 was marked "yes" that Patient 8s heart disease met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest), and with an ejection fraction less than 20% (Measures the amount of blood the left ventricle of the heart pumps out to your body with each heartbeat. A reading of 20% or below is very severe heart failure). During a joint home visit, on 8/31/23 at 11:00 a.m. with the Licensed Vocational Nurse (LVN 1) at Patient 8s residence, Patient 8 was observed walking out of the house, picked up a box on the ground and walked back inside the house. Patient 8 was alert and oriented x 3 (to person, place, and time), ambulated without using an assistive device, was not on oxygen, and was not having any shortness of breath or complaining of any chest pain. During an interview, Patient 8 stated he prepares meal every day for him and his wife (Patient 9). Patient 8 stated he drove his car regularly for years for doctors appointment and to buy grocery. Patient 8 further stated, he never had shortness of breath, had not been ruled out as a candidate nor declined any surgical procedures, and nobody told him that he has a life expectancy of 6 months or less. A review of Patient 8's clinical record indicated there was no documentation of Patient 8 had been ruled out as a candidate or refused any surgical procedures, had been optimally treated for heart disease with diuretics and vasodilator, unable to be on vasodilator due to a medical condition, had ejection fraction of less than 20%, met the criteria for NYHA Class IV level for heart disease or Patient 8s condition had been declining. b. A review of Patient 9's admission record indicated the patient was admitted to the HA on 6/21/22, with terminal diagnosis of atherosclerotic heart disease of native coronary artery (refers to the accumulation of plaque on the inner walls of blood vessels, and this plaque consists of substances found in the bloodstream, such as fat, cholesterol, and calcium) without angina pectoris (medical term for chest pain or discomfort due to coronary heart disease). A review of Patient 9's POC/IDG form, dated 6/29/23, indicated the frequency of visits of skilled nurse to one visit per week plus 2 prn visits, the spiritual counselor (SC) and medical social worker (MSW) to visit 1 per Month plus 1 prn visit. Hospice aide service was declined. A review of Patient 9s Re-cert Assessment, dated 7/11/23, indicated Patient 9 is awake, alert, oriented x 2 (to place and person), and needed moderate assistance with ambulation using a cane or a walker. It also indicated Patient 9 needed moderate assistance with toileting, transfer and feeding, and maximum assistance with bathing and dressing. The Re-cert assessment also indicated Patient 9 denies any chest pain, has no edema, has normal respiration, and had mild shortness of breath when ambulating several feet but resolves after a couple of minutes with rest. The assessment further indicated Patient 9 meets criteria for hospice care and remained eligible for hospice services. A review of Patient 9s "LCD Hospice Eligibility Determination)" form for Heart Disease, dated 7/11/23, indicated Patient 9 does not qualify per LCD guidelines. During a joint home visit, on 8/31/23 at 11:20 a.m. with the Licensed Vocational Nurse (LVN 1) at Patient 9s residence, Patient 9 was observed walking out of her bedroom to the living room without using an assistive device with a steady gait. Patient 9 was alert and oriented x 3, has no shortness of breath and no chest pain. During an interview, Patient 9 stated she had not been ruled out as a candidate nor declined any surgical procedures and had never used supplemental oxygen for the past year. Patient 9 stated she does her ADLs (activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating) independently, goes to church every Sunday for years and prepares a big meal when her prayer group comes into her house every few months. During a telephone interview with Patient 9s attending physician (PA 1), on 8/31/23 at 3:35 p.m., PA 1 stated he did not refer Patient 9 to hospice care nor had any conversation or discussion with the hospice agencys Medical Director or physician designee about Patient 9s medical history and diagnoses. A review of Patient 9's clinical record indicated there was no documented evidence Patient 9 had been ruled out as a candidate or refused any surgical procedures, had been optimally treated for heart disease with diuretics and vasodilator, unable to be on vasodilator due to a medical condition, had ejection fraction of less than 20% or met the criteria for NYHA Class IV level for heart disease. On 9/1/23 at 3:40 p.m., during a phone interview with the Medical Director Designee (MD 2), he stated he certified patients had terminal illness and admitted to hospice care by reviewing patients medical history, prior medical record, and reviewed registered nurse initial assessment. When asked if he was the attending physician of Patient 8 and Patient 9, MD 2 stated he was not. When asked if he contacted or had conversation with Patient 8 and Patient 9s attending physician regarding patients diagnosis and/or eligibility for hospice service, MD 2 stated he did not. On 9/1/23, at 6:20 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find the documented evidence Patient 8 and Patient 9 had been ruled out as a candidate or has declined surgical procedures, nor has an ejection fraction less than 20%. DPCS stated the agency was planning to discharge Patient 8 and Patient 9 for the current benefit period, but the patients requested to continue with the service. A review of the agency's policy and procedure titled, ";"Admission Criteria and Process", revised November 2020, indicated Compassionate Touch Hospice Care Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of six months or less will be determine by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Compassionate Touch Hospice Care Inc will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. A review of the hospice agencys policy and procedure titled, ";Ongoing Assessments", revised April 2021, indicated the scope and intensity of ongoing hospice patient assessments will be determined by the patients prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. The nurse will assess each patient on each visit, for progress towards hospice goals and patient needs and problems, and the need for an alternative setting or level of care.

Based on observation, interview and record review, the hospice agency (HA) staff failed to review all medication the patient was taking and update the medication profile with the currently used medications for one of 14 sampled patients (Patient 9). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions. --- Findings: A review of Patient 9's admission record indicated the patient was admitted to the HA on 6/21/22, with terminal diagnosis of atherosclerotic heart disease of native coronary artery (refers to the accumulation of plaque on the inner walls of blood vessels, and this plaque consists of substances found in the bloodstream, such as fat, cholesterol, and calcium) without angina pectoris (medical term for chest pain or discomfort due to coronary heart disease). A review of Patient 9's Plan of Care(POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 6/29/23, indicated the frequency of visits of skilled nurse to one visit per week plus 2 prn (pro re nata, which means ";as needed") visits, to assess and monitor effectiveness of the current and new medications or treatments, and to instruct the patient and/or patient caregiver (pcg) regarding new medication or treatment orders and side effects. On 8/31/23, at 11:20 a.m., a joint home visit was conducted at Patient 9's residence, with a Licensed Vocational nurse (LVN 1). Patient 9 was observed alert, oriented x 3 (to person, place, and time) and ambulatory with a steady gait. On 8/31/23, at 11:42 a.m., during a review of Patient 9s current medication with LVN 1, there was a bottle of Meclizine (used to prevent and treat nausea, vomiting, and dizziness caused by motion sickness) 25 milligram (mg) one tablet by mouth daily filled date 10/26/22, found together with the rest of Patient 9s medication. However, the patients current medication list provided by the HA indicated patient was not taking the medication. Patient 9s current medication list provided by the HA also indicated Patient 9 was on Simvastatin (treat high cholesterol and triglyceride [fat] levels in the blood) 20 mg 1 tablet by mouth once a day at bedtime. However, the medication bottle was not found. On 8/31/23, at 11:45 a.m., during an interview with Patient 9, she stated she stopped taking Simvastatin 3 weeks prior per physicians instruction and has been taking Meclizine tablet since October 2022. On 9/1/23 at 6:20 p.m., during an interview with the DPCS, the DPCS stated, nursing staff need to review patients current medication on every visit and update the medication profile in the patients clinical record. A review of the hospice agencys policy and procedure titled, ";Medication Profile", revised April 2021, indicated patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to update the comprehensive assessment of one of 14 sampled patients (Patient I), who was observed lying in bed in supine (lying horizontally with the face and torso facing up) position with cloth restraint (a device that limits the patient's movement) belt applied around the patient's waist and tied on each side of the bed rail with a locked device on both ends to lock and unlock the restraint. The HA failed to : 1. Assess Patient I of the need and justification for the use of restraints.2. Assess for least restrictive measures prior to the use of restraint.3. Assess changes in patient's condition and response to care that led to the use of restraint.4. Ensure a physician order for the use of restraint.5. Ensure care plan was developed for use of restraint.6. Ensure Medical Director or physician designee was notified for use of restraint.7. Ensure hospice staff was trained for restraint management. As a result, the non-compliance placed Patient I at risk for dehydration, choking, aspiration, asphyxia ( deprived of oxygen), or injury that could lead to hospitalization or death associated with restraint use. On 9/1/2023, at 1:40 p.m., an Immediate Jeopardy (IJ- a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was called in the presence of the agencys Administrator (ADM)/Director of Patient Care Services (DPCS) related to the hospice agency failed to update the comprehensive assessment of one of 14 sampled patients (Patient I), who was observed lying in bed in supine (lying horizontally with the face and torso facing up) position with cloth restraint belt applied around the patient's waist and tied on each side of the bed rail with a locked device on both ends to lock and unlock the restraint. The agency failed to assess Patient I for the need and justification for the use of restraints, failed to assess for least restrictive measures prior to the use of restraint. failed to assess changes in patient condition and response to care that led to the use of restraint, failed to obtain a physician order for the use of restraint, failed to develop care plan for use of restraint, failed to notify notify the Medical Director or physician designee for use of restraint and failed to provide training for hospice staff regarding restraint management. As a result, the non-compliance placed Patient I at risk for dehydration, choking, aspiration, asphyxia ( deprived of oxygen), or injury that could lead to hospitalization or death associated with restraint use. On 9/2/23, at 5:50 p.m., the survey team removed the IJ in the presence of the DPCS/Administrator, after verifying and confirming onsite that the agency implemented the IJ removal plan related to failure to Initial and Comprehensive Assessment Of The Patient (update of the comprehensive assessment). --- A review of Patient 1's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated, the patient was admitted to the hospice agency on 1/20/2023, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys the memory and other important mental functions). A review of Patient 1s Plan of Care(POC)/interdisciplinary group(IDG) Review, indicated an order dated 1/20/2023, for routine level of care (routine visits from a home provided by licensed medical professionals under the direct supervision of a physician) by a SN (skilled nurse) once a week, Social Worker (MSW) to evaluate and assess for needs within 5 days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within five days of admission to identify spiritual needs. On 8/31/2023, at 11 a.m., a joint home visit with the DPCS (director of patient care services) was conducted at a boarding care facility where Patient 1 was residing. Patient 1 was observed lying in bed in supine (lying horizontally with the face and torso facing up) position with cloth restraint (device that limits the client's freedom to and ability to move) belt applied around the patient's waist and tied on each side of the bed rail (are adjustable metal or rigid plastic bars that attach to the bed) with a locked device on both ends to lock and unlock the restraint. Patient 1 was awake, confused, lethargic (general state of fatigue that involves a lack of energy and motivation for physical and mental tasks), looked calm and was quiet. Patient 1's family members were present in the room standing next to the bedside. On 8/31/2023, at 11:15 a.m., during an interview with Family Member 1, stated he was aware that the boarding care facility staff were applying a belt restraint to the patient for safety issues. On 8/31/2023 at 12 p.m., during an interview with Caregiver 1, stated he applied the soft cloth belt restraint to Patient 1 daily while patient lying in bed from the time the patient wakes up in the morning and when he sleeps at night. Caregiver 1 stated, the patient tends to get agitated and tries to get out of the bed so the soft belt restraint prevents him to fall out from bed when unattended. A review of Patient 1s POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) meeting record, dated 1/26/23, 2/9/23, 2/23/23, 3/9/23, 3/23/23, 4/6/23, 4/20/23, 5/4/23, 5/18/23, 6/1/23, 6/29/23, 7/13/23, 7/27/23, 8/10/23 and 8/24/23, indicated there was no documentation of a discussion pertaining to Patient 1's plan of care for the need and usage of restraint and it's management. A review of Patient 1s clinical record indicated there was no documentation of an assessment for the need and justification for the use of restraints, changes in patient condition and response to care that led to the use of restraint. There was no care plan developed for use of restraint. There was no documentation of a signed informed consent for the use of restraints. There was no documentation that the license staff notified the Medical Director or physician designee for use of restraint and no physician's order for restraint was obtained. There was no documentation the hospice agency provided license nurses training for restraint management. On 9/1/2023, at 1:15 p.m., during an interview with the DPCS, she stated the patient should not be restrained at all. DPCS stated, there was no informed consent obtained for use of restraint, there was no documented evidence of an assessment for the need and justification for the use of restraints, no care plan developed for use of restraint, no documented evidence that less restrictive measure were attempted as alternative for use of restraint, no documentation that the license staff notified the Medical Director or physician designee for use of restraint, no documentation the hospice agency provided license nurses training for restraint management and there was no physician's order for the use of the restraint. A review of the agency's undated policy and procedure titled, "Interdisciplinary Group Meeting," , indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor. A review of the agency's undated policy and procedure entitled" Appropriate Use Of Restraints And Supplies", indicated that the patients and family/caregivers will receive information regarding the appropriate, safe and effective use of restraints, alternatives to use of restraints and attention to the needs of the patient in restraint. Every effort will be used to avoid restraining patients. A physician's order is required for the application of any restraint.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met as follows: 1. The HA failed to ensure patient care plan was developed and completed that included problems, interventions, and goals, for two of 14 sampled patients (Patients 1 and 7). (Refer to L545) 2. The HA failed to manage and monitor the use of psychotropic medications (any drug that affects mental function, behavior and mood for two of 14 sampled patients (Patients 1 and 7) (Refer to L549) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients accurately assessed to receive hospice care and services.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has 6 months or less to live) failed to ensure patient care plan was developed and completed that included problems, interventions, and goals, for two of 14 sampled patients (Patients 1 and 7). This deficient practice had the potential to affect the necessary care and services needed to maintain the highest practicable physical, mental, and psychosocial well-being of Patients 1 and 7 receiving hospice care services. --- a. A review of Patient 1's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated he was admitted to the hospice agency on 1/23/2023, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys the memory and other important mental functions). A review of Patient 1s POC (Plan of Care)/IDG (interdisciplinary group) Review, indicated an order dated 1/23/2023, for routine level of care (routine visits from a home provided by licensed medical professionals under the direct supervision of a physician) by a SN (skilled nurse) once a week, Social Worker (MSW) to evaluate and assess for needs within 5 days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within 5 days of admission to identify spiritual needs. A review of Patient 1's Physician's order dated 2/25/2023, indicated to administer Seroquel (psychotropic medication [any drug that affects mental function, behavior, and mood]) 100 mg (milligrams, a unit of measurement) one tablet daily in the morning, Seroquel 200 mg one tablet daily from 3 p.m., to 4 p.m., Seroquel 200 mg one tablet daily from 8 p.m., to 9 p.m. for anxiety and agitation. There was also a Physician's order dated 8/24/2023, to administer Haldol (psychotropic) 5 mg one tablet daily at bedtime to take with Seroquel medication for insomnia (lack of sleep). On 8/31/2023, at 11 a.m., a home visit with the DPCS (director of patient care services) was conducted at a boarding care facility where Patient 1 was residing. Patient 1 who was observed lying in bed in supine (lying horizontally with the face and torso facing up) position with cloth restraint belt applied around the patient's waist and tied on each side of the bed rail (are adjustable metal or rigid plastic bars that attach to the bed) with a locked device on both ends to lock and unlock the restraint. Patient 1 was awake, confused, lethargic (general state of fatigue that involves a lack of energy and motivation for physical and mental tasks), looked calm and was quiet. Patient 1's family members were present in the room standing next to the bedside. On 8/31/2023 at 11:30 a.m., during a home visit, a review of Patient 1's medications indicated there was a medication container of Seroquel 100 mg one tab daily in the morning, a medication container of Seroquel 200 mg one tab daily from 3 to 4 p.m., a medication container of Seroquel 200 mg one tab daily from 8 to 9 p.m. and a medication container of bottle of Haldol 5 mg one tab daily at bedtime. On 8/31/2023 at 11:50 a.m., during an interview with Caregiver 1, he stated he administered Seroquel 100 mg (milligrams) one tab daily in the morning, Seroquel 200 mg one tab at 3 p.m., Seroquel 200 mg one tab with Haldol 5 mg one tab at 9 p.m. daily. On 9/1/2023, at 1 p.m., during an interview with the DPCS, she stated when she visits Patient 1, the patient did not show any behavior of being agitated or restless at all. When DPCS was asked if the Seroquel and Haldol medication dosages was safe to give to the patient, she stated yes, that it was safe to help control his agitated behavior and having a hard time sleeping at night. On 9/1/2023, at 1:30 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), who was assigned for Patient 1, she stated there were days during her visits that she saw the patient was being agitated and restless and moves from side to side of the bed while lying down, but majority of her visits, the patient was observed being calmed with no behaviors of agitation or restlessness. On 9/2/2023, at 2 p.m., during an interview with the Medical Director, he stated that he was aware that the patient was taking Seroquel and Haldol medications daily. He also stated a 500 mg dose of Seroquel with Haldol 5 mg daily were not high dosages and it is safe for the patient to take to control his moods as long it does not exceed the maximum dose of 800 mg a day. He further stated that he was not aware if this patient had a psychiatric consult and if the patient has a diagnosis history of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality). A further review of Patient 1s clinical record did not indicate a Plan of Care (POC) was developed and/or completed for psychotropic medication management (Seroquel and Haldol) for Patient 1. b. A review of Patient 7's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated he was admitted to the hospice agency on 12/29/2022, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys the memory and other important mental functions). A review of Patient 7s POC (Plan of Care)/IDG (interdisciplinary group) Review, indicated an order dated 12/29/2022, for routine level of care (routine visits from a home provided by licensed medical professionals under the direct supervision of a physician) by a SN (skilled nurse) once a week, Social Worker (MSW) to evaluate and assess for needs within 5 days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within 5 days of admission to identify spiritual needs. A review of Patient 7's Physician's order dated 12/29/2023, indicated to administer Seroquel 50 mg (milligrams) one tab daily in the morning and Seroquel 200 mg one tab daily at bedtime for Alzheimer's disease. On 9/2/2023, at 2 p.m., during an interview with the Medical Director, he stated that he was aware Patient 7 was taking Seroquel 50 mg in a.m. and 200 mg in p.m. daily and the dosages were not high and safe for the patient to take as long it did not exceed the maximum dose of 800 mg a day. He further stated that he was not aware if Patient 7 had a psychiatric consult and if the patient has a diagnosis history of psychosis. The Medical Director stated he did not know if Patient 1 had diagnosis of mental illness such as schizophrenia (mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships). On 9/2/2023, at 3 p.m., during an interview with the DPCS, when she was asked if the Seroquel medication dosages were safe to give to Patient 7, she stated yes, that it was safe to help control Patient 7s disease process. A further review of Patient 7s clinical record did not indicate a Plan of Care (POC) was developed and/or completed for psychotropic medication management (Seroquel) for Patient 7. On 9/3/2023, at 12 p.m., during an interview with the DPCS, she stated that there was no plan of care developed for psychotropic medication management for Patients 1 and 7. A review of the agency's undated policy and procedure titled, "Plan of Care", indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on observation, interview, and record review, the Hospice Agency (agency providing care to terminally ill patients who has six months or less to live) failed to manage and monitor the use of psychotropic medications (any drug that affects mental function, behavior, and mood) for two of 14 sampled patients (Patients 1 and 7). The hospice agency failed to: 1. Ensure to have the indications for the use of psychotropic medications. 2. Ensure to have a signed informed consent (permission granted in the knowledge of the possible consequences) for the use of psychotropic medications. 3. Monitor for specific target behaviors for the use of psychotropic medications. 4. Monitor for potential side effects (undesirable effect) of psychotropics medications. 5. Ensure to have a Psychiatric (is a medical doctor who specializes in the mental health field) consult for a mental status examination before prescribing psychotropic medications. As a result, Patients 1 and 7 received high doses of psychotropic medications and placed Patients 1 and 7 at risk of receiving unnecessary medications. Patients 1 and 7 were also placed at risk for unrecognized adverse reactions (unexpected negative reaction) such as death associated with the use of psychotropic drugs. On 9/1/2023, at 3 p.m., an Immediate Jeopardy (IJ- a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was called in the presence of the agencys Administrator (ADM)/Director of Patient Care Services (DPCS) related to the hospice agency failed to manage and monitor the use of psychotropic medications for two of 14 sampled patients (Patients 1 and 7). During the skilled nurse visits, the nursing staff failed (in general) to assess prescribed psychotropic drugs within established specific parameters, failed to have a signed informed consent for the use of psychotropic medications, failed to have a psychiatric consult for mental status examination before prescribing psychotropic medications and failed to monitor for specific target behaviors for the use of psychotropic medications. As a result, Patients 1 and 7 received high doses of psychotropic medications and placed Patients 1 and 7 at risk of receiving unnecessary medication. Patients 1 and Patient 7 were also placed at risk for unrecognized adverse reactions such as death associated with the use of psychotropic drugs. On 9/2/2023 at 12:06 p.m. the agency sent the IJ Removal Plan by email, and the survey team notified the DPCS the IJ Removal Plan was not accepted at 1:30 pm. On 9/2/2023, at 5:26 p.m., the agency sent a revised IJ Removal Plan by email, and the survey team notified the DPCS the IJ Removal Plan was not accepted on 9/3/2023 at 6:30 p.m. On 9/3/2023, at 12:21 p.m., the agency sent a revised IJ Removal Plan by email, and the survey team notified the DPCS the IJ Removal Plan was not accepted on 9/3/2023 at 4 p.m. On 9/3/2023, at 3 p.m., the DPCS submitted a revised IJ Removal Plan and it was not acceptable. The IJ was not removed. On 9/3/2023 at 4:10 p.m., the survey team completed the survey tasks, and exited with the Immediate Jeopardy not removed, related to failure to Interdisciplinary Group Care Planning and Coordination of Services (manage and monitor the use of psychotropic medications- any drug that affect mental function, behavior, and mood). --- Findings: a. A review of Patient 1's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated he was admitted to the hospice agency on 1/20/2023, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys the memory and other important mental functions). A review of Patient 1s POC (Plan of Care)/IDG (interdisciplinary group) Review, indicated an order dated 1/20/2023, for routine level of care (routine visits from a home provided by licensed medical professionals under the direct supervision of a physician) by a SN (skilled nurse) once a week, Social Worker (MSW) to evaluate and assess for needs within 5 days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within five days of admission to identify spiritual needs. A review of Patient 1's Physician's order dated 2/25/2023, indicated to administer Seroquel (psychotropic medication) 100 mg (milligrams, a unit of measurement) one tablet daily in the morning, Seroquel 200 mg one tablet daily from 3 p.m., to 4 p.m., Seroquel 200 mg one tablet daily from 8 p.m., to 9 p.m. for anxiety and agitation. There was also a Physician's order dated 8/24/2023, to administer Haldol (psychotropic) 5 mg one tablet daily at bedtime to take with Seroquel medication for insomnia (lack of sleep). A review of Patient 1s clinical record indicated there was no documentation for the indication for the use of Seroquel and Haldol medications. There was no documentation the monitoring and tracking of specific behaviors that Patient 1 exhibited. There was no documentation that Patient 1 was monitored for the potential side effects of Seroquel and Haldol. There was no documentation that an informed consent for the psychotropic drugs was completed for Patient 1. There was no documentation a psychiatric evaluation was completed for Patient 1. On 8/31/2023, at 11 a.m., a home visit with the DPCS (director of patient care services) was conducted at a boarding care facility where Patient 1 was residing. Patient 1 who was observed lying in bed in supine (lying horizontally with the face and torso facing up) position with cloth restraint belt applied around the patient's waist and tied on each side of the bed rail (are adjustable metal or rigid plastic bars that attach to the bed) with a locked device on both ends to lock and unlock the restraint. Patient 1 was awake, confused, lethargic (general state of fatigue that involves a lack of energy and motivation for physical and mental tasks), looked calm and was quiet. Patient 1's family members were present in the room standing next to the bedside. On 8/31/2023 at 11:30 a.m., during a home visit, a review of Patient 1's medications indicated there was a medication container of Seroquel 100 mg one tab daily in the morning, a medication container of Seroquel 200 mg one tab daily from 3 to 4 p.m., a medication container of Seroquel 200 mg one tab daily from 8 to 9 p.m. and a medication container of bottle of Haldol 5 mg one tab daily at bedtime. On 8/31/2023 at 11:50 a.m., during an interview with Caregiver 1, he stated he administered Seroquel 100 mg (milligrams) one tab daily in the morning, Seroquel 200 mg one tab at 3 p.m., Seroquel 200 mg one tab with Haldol 5 mg one tab at 9 p.m. daily. A review of Patient 1s Communication/Progress Log dated 9/1/2023, timed at 5:33 a.m., indicated patient care giver called the hospice agency and reported that Patient 1 was lethargic and started Patient 1 on oxygen Patient 1 had a decline in status within the past two weeks. The Registered Nurse on call gave Patient 1s family member an update on Patient 1s condition. On 9/1/2023, at 1 p.m., during an interview with the DPCS, she stated when she visits Patient 1, the patient did not show any behavior of being agitated or restless at all. When DPCS was asked if the Seroquel and Haldol medication dosages was safe to give to the patient, she stated yes, that it was safe to help control with the patient's agitated behavior and having a hard time sleeping at night. On 9/1/2023, at 1:30 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), who was assigned for Patient 1, she stated there were days during her visits that she saw the patient was being agitated and restless and moves from side to side of the bed while lying down, but majority of her visits, the patient was observed being calmed with no behaviors of agitation or restlessness. On 9/2/2023, at 12 p.m., during an interview with the DPCS, she stated there was no informed consent for the use of psychotropic medications for Patient 1. The DPCS stated Patient 1s family members were aware Patient 1 was on Seroquel and Haldol medications. The DPCS stated the visiting nurse (unidentified) had documented in her nursing notes Patient 1 was agitated and restless on some visits, but failed to document the monitoring, tracking of specific behaviors and the side effects of the Seroquel and Haldol medications. She further stated that she would call the hospice Medical Director to ask an order to get the patient a psychiatric consult right away. On 9/2/2023, at 2 p.m., during an interview with the Medical Director, he stated that he was aware that the patient was taking Seroquel and Haldol medications daily. He also stated a 500 mg dose of Seroquel with Haldol 5 mg daily were not high dosages and safe for the patient to take to control his moods as long it does not exceed the maximum dose of 800 mg a day. He further stated that he was not aware if this patient had a psychiatric consult and if the patient has a diagnosis history of psychosis. During an interview with the DPCS on 9/3/2023 at 1 p.m., when asked for a policy and procedure for psychotropic medication, the DPCS stated the agency did not have any existing policy on hand for psychotropic medication management. b. A review of Patient 7's demographics indicated he was admitted to the hospice agency on 12/29/2022, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys the memory and other important mental functions). A review of Patient 7s POC (Plan of Care)/IDG (interdisciplinary group) Review, indicated an order dated 12/29/2022, for routine level of care (routine visits from a home provided by licensed medical professionals under the direct supervision of a physician) by a SN (skilled nurse) once a week, Social Worker (MSW) to evaluate and assess for needs within 5 days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within 5 days of admission to identify spiritual needs. A review of Patient 7's Physician's order dated 12/29/2023, indicated to administer Seroquel 50 mg (milligrams) one tab daily in the morning and Seroquel 200 mg one tab daily at bedtime for Alzheimer's disease. A review of Patient 7s clinical record indicated there was no documentation for the indication for the use of Seroquel medication. There was no documentation the monitoring and tracking of specific behaviors that Patient 7 exhibited. There was no documentation that Patient 7 was monitored for the potential side effects of Seroquel and Haldol. There was no documentation that an informed consent for the psychotropic drugs was completed for Patient 7. There was no documentation a psychiatric evaluation was completed for Patient 7. On 9/2/2023, at 12 p.m., during an interview with the DPCS, she stated there was no informed consent for the use of psychotropic medications for Patient 7. The DPCS stated there was no documented evidence for the monitoring, tracking of specific behaviors and the side effects of the Seroquel. On 9/2/2023, at 2 p.m., during an interview with the Medical Director, he stated that he was aware Patient 7 was taking Seroquel 50 mg in a.m. and 200 mg in p.m. daily and the dosages were not high and safe for the patient to take as long it did not exceed the maximum dose of 800 mg a day. He further stated that he was not aware if Patient 7 had a psychiatric consult and if the patient has a diagnosis history of psychosis. The Medical Director stated he did not know if Patient 7 had diagnosis of mental illness such as schizophrenia (mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships). On 9/2/2023, at 3 p.m., during an interview with the DPCS, when she was asked if the Seroquel medication dosages were safe to give to Patient 7, she stated yes, that it was safe to help control Patient 7's disease process. During an interview with the DPCS on 9/3/2023 at 1 p.m., when asked for a policy and procedure for psychotropic medication, the DPCS stated the agency did not have any existing policy on hand for psychotropic medication management. Reference According to the U.S. Food and Drug Administration (FDA) indicated elderly patients with dementia-(loss of memory and other mental abilities severe enough to interfere with daily life), related psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality) treated with antipsychotic drugs are at an increased risk of death. The FDA indicated consideration should be given to a slower rate of dose titration (changes to medication doses to achieve the best clinical response and a lower target dose) in the elderly. The FDA indicated Seroquel was for the treatment of schizophrenia (mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships) and bipolar disease (a mental condition marked by alternating periods of elation and depression[sadness). For elderly use to consider a lower starting dose (50 mg/day), slower titration and careful monitoring during the initial dosing period in the elderly. https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020639s061lbl.pdf According to the FDA indicated debilitated or geriatric (elderly) patients, as well as those with a history of adverse reactions to antipsychotic drugs, may require less Haldol. The FDA indicated the optimal response in such patients is usually obtained with more gradual dosage adjustments and at lower dosage levels. The FDA indicated the side effects were tardive dyskinesia (a disorder that results in involuntary repetitive body movements, which may include grimacing, sticking out the tongue or smacking the lips) and sudden death. The FDA indicated Haldol was for the use in the treatment of schizophrenia.https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/015923s082,018701s057lbl.pdf

Based on observation, interview, and record review, the hospice agency (agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation for Medical Director was met as evidenced by: - The hospice agency failed to ensure the medical director and/or physician designee conducted a review and verify the patients clinical information to determine patients need of recertification (a critical piece of documentation necessary to ensure Medicare payment for the hospice services) of terminal illness (illness with a prognosis of having 6 months of life or less to live) for continued hospice care and services for two of 14 sampled patients (Patients 8 and 9). (Refer to L668) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily mandated (state law) compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification (a critical piece of documentation necessary to ensure Medicare payment for the hospice services) of terminal illness (illness with a prognosis of having six months of life or less to live) for continued hospice care and services for two of 14 sampled patients (Patients 8 and 9). This deficient practice resulted for the HA to claim reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential for Patients 8 and 9 to not receive appropriate healthcare services that could affect their quality of life. --- Findings: a. A review of Patient 8's admission record indicated the patient was admitted to the HA on 3/25/2022, with terminal diagnosis of hypertensive heart disease (long-term condition that develops over many years in people who have high blood pressure) without heart failure (a condition in which the heart doesn't pump blood as well as it should). A review of Patient 8s "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" form for Heart Disease, dated 7/11/2023, indicated Patient 8 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 8 had been ruled out as a candidate for surgical procedures or had declined surgical procedures. Section 2 was marked "yes" that Patient 8s heart disease met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest), and with an ejection fraction less than 20% (Measures the amount of blood the left ventricle of the heart pumps out to your body with each heartbeat. A reading of 20% or below is very severe heart failure). A record review of Patient 8s record titled, ";Physicians Certification for Hospice Benefit," for certification period 7/18/2023 to 9/15/2023, indicated this was Patient 8s eighth recertification. The record indicated the Medical Director (MD 1) attested/confirmed he had composed the narrative based on his review of Patient 8s medical record, team assessment, and/or examination of the patient. The physicians Face-to face and narrative summary were blank. A review of Patient 8's clinical record indicated there was no documented evidence Patient 8 had been ruled out as a candidate or refused any surgical procedures, had been optimally treated for heart disease with diuretics (medication that helps reduce fluid buildup in the body) and vasodilator (medication that open the blood vessels) unable to be on vasodilator due to a medical condition, had ejection fraction of less than 20% or met the criteria for NYHA Class IV level for heart disease. During a joint home visit observation n 8/31/2023 at 11 a.m., with the Licensed Vocational Nurse 1(LVN 1) at Patient 8s residence, Patient 8 was observed walking out of the house, picked up a box on the ground and walked back inside the house. Patient 8 was alert and oriented to person, place, and time, ambulatory (walking) without the use of an assisted device, was not on oxygen, and was not having any shortness of breath or complaining of any chest pain. During an interview, Patient 8 stated he prepared meals every day for him and his wife (Patient 9). Patient 8 stated he would drive his car regularly for doctors appointments and to buy groceries. Patient 8 stated he had not been ruled out as a candidate nor declined any surgical procedures, and nobody told him that he had a life expectancy of six months or less. b. A review of Patient 9's admission record indicated the patient was admitted to the HA on 6/21/2022, with terminal diagnosis of atherosclerotic heart disease of native coronary artery (refers to the accumulation of plaque on the inner walls of blood vessels, and this plaque consists of substances found in the bloodstream, such as fat, cholesterol, and calcium) without angina pectoris (medical term for chest pain or discomfort due to coronary heart disease). A record review of Patient 9s record titled, ";Physicians Certification for Hospice Benefit", for certification period 7/16/2023 to 9/13/2023, indicated this was Patient 9s 8th recertification. The record also indicated MD 1 attested/confirmed he had composed the narrative based on his review of patients medical record, team assessment and/or examination of the patient. The physicians Face-to face and narrative summary were blank. A review of Patient 9s "LCD Hospice Eligibility Determination)" form for Heart Disease, dated 7/11/2023, indicated Patient 9 did not qualify per LCD guidelines. A review of Patient 9's clinical record indicated there was no documented evidence Patient 9 had been ruled out as a candidate or refused any surgical procedures, had been optimally treated for heart disease with diuretics and vasodilator, unable to be on vasodilator due to a medical condition, had ejection fraction of less than 20% or met the criteria for NYHA Class IV level for heart disease. During a joint home visit observation, on 8/31/2023 at 11:20 a.m. with the Licensed Vocational Nurse 1 (LVN 1) at Patient 9s residence, Patient 9 was observed walking out of her bedroom to the living room without using an assistive device with a steady gait. Patient 9 was alert and oriented x 3, had no shortness of breath and no chest pain. During an interview Patient 9 stated she had not been ruled out as a candidate nor declined any surgical procedures and had never used supplemental oxygen for the past year. Patient 9 stated she did her ADLs (activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating) independently, goes to church every Sunday for years and prepared a big meal when her prayer group who would go to her house. During a telephone interview with Patient 9s attending physician (PA 1), on 8/31/2023 at 3:35 p.m., PA 1 stated he did not refer Patient 9 to hospice care nor had any conversation or discussion with the hospice agencys Medical Director or physician designee about Patient 9s medical history and diagnosis. During a phone interview on 9/1/2023 at 3:40 p.m., with the Medical Director Designee (MD 2), he stated he certified patients who had terminal illness by following LCD criteria and admitted to hospice care by reviewing patients (in general) medical history, prior medical record, and reviewed registered nurse initial assessment. When asked if he was the attending physician of Patient 8 and Patient 9, MD 2 stated he was not. When asked if he contacted or had conversation with Patient 8 and Patient 9s attending physician regarding patients diagnosis and/or eligibility for hospice service, MD 2 stated he did not. During a concurrent interview and record review on 9/1/23, at 6:20 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find the documented evidence Patient 8 and Patient 9 had been ruled out as a candidate or has declined surgical procedures, nor has an ejection fraction less than 20%. DPCS stated the agency was planning to discharge Patient 8 and Patient 9 for the current benefit period, but the patients requested to continue with the service. A review of the hospice agencys policy and procedure titled, ";Certification of Terminal Illness", revised November 2020, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. The policy indicated that subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient's medical record or, if applicable, examination of the patient. A review of the hospice agencys policy and procedure titled, ";Physician Services – Medical Director", revised November 2020, indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The duties and responsibilities of the Medical Director will include, but not be limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, providing written certification and narrative of the terminal illness for all subsequent benefit periods, and consulting with attending physicians regarding pain and symptoms management for hospice patients.