Every finding on record at Creekway Healthcare LLC

It is required that written patient care instructions for a hospice aide are prepared by a registered nurse (RN) who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 9 (33%) clinical records reviewed in which aide services were accepted revealed that the agency did not ensure specific written patient care instructions were provided for the hospice aide. Clinical Record 1: The patient elected hospice benefit was dated 6/3/2023 for a diagnosis of senile degeneration of the brain. The recertification nursing assessment and aide care plan dated 11/29/2023 identified the patient as being on oxygen continuously at 2 liters per minute (LPM). The aide care plan had the relevant tasks of a bedbath and dressing the patient every visit. The aide care plan did not provide specific instructions for the aide to leave the oxygen or remove it during these tasks. Clinical Record 3: The patient elected hospice benefit was dated 10/14/2023 for a diagnosis of Atherosclerosis. The initial nursing assessment dated 10/14/2023 identified the patient as being on oxygen continuously at 2 liters per minute (LPM). The aide care plan dated 12/16/2023 had the relevant tasks of a shower chair and dressing the patient every visit. The aide care plan did not provide specific instructions for the aide to leave the oxygen or remove it during these tasks. Clinical Record 8: The patient elected hospice benefit was dated 8/19/2023 for a diagnosis of chronic obstructive pulmonary disease (COPD). The initial nursing assessment dated 8/19/2023 identified the patient as being on oxygen continuously at 3 liters per minute (LPM). The aide care plan dated 8/19/2023 had the relevant tasks of shower chair and dressing the patient every visit. The aide care plan did not provide specific instructions for the aide to leave the oxygen or remove it during these tasks. A joint clinical record review and interview was conducted with the Alternative Director of Nursing (ADON) on 1/4/2024 during which she confirmed specific instructions for the oxygen had not been included in the aide care plans.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 6 of 9 (67%) clinical records reviewed in which aide services were accepted revealed that the agency did not ensure the services were provided per the plan of care (POC). Clinical Record 1: The patient elected hospice benefit was dated 6/3/2023 for a diagnosis of senile degeneration of the brain. The aide care plan dated 11/29/2023 assigned the aide frequency of visits two times a week and the tasks of "shampoo 1x weekly and shave 1x weekly." A review of the aide visit notes for visits provided twice weekly dated 12/4/2023, 12/8/2023, 12/11/2023, and 12/15/2023 revealed the aide documented “shampoo and shaving" completed at each visit indicating shampooing and shaving were completed twice a week instead of weekly as assigned. Clinical Record 2: The patient elected hospice benefit was dated 10/14/2023 for a diagnosis of Atherosclerosis. The aide care plan dated 12/2/2023 assigned the aide frequency of visits three times a week and the tasks of "shampoo 1x weekly and shower 1x weekly, preferably Friday mornings." A review of the aide visit notes for visits provided three times weekly dated 12/5/2023, 12/8/2023, 12/9/2023, 12/12/2023, 12/14/2023, and 12/15/2023 revealed the aide documented "shampoo and shower" completed at each visit indicating shampoo and shower were completed three times weekly instead of weekly as assigned. Clinical Record 3: The patient elected hospice benefit was dated 12/16/2023 for a diagnosis of chronic obstructive pulmonary disease (COPD). The aide care plan dated 12/16/2023 assigned the aide frequency as two times a week and the task of "shampoo 1x weekly". A review of the aide visit notes provided twice weekly on 12/19/2023 and 12/22/2023 revealed the aide documented "shampoo" completed at each visit indicating shampoo was completed twice weekly instead of weekly as assigned. The aide care plan assigns the following tasks every visit: "comb hair, brush teeth, apply deodorant, apply lotion, and provide peri care. " The aide visit on 12/26/2023 revealed these tasks were not marked as completed. Clinical Record 6: The patient elected hospice benefit was dated 7/10/2023 for a diagnosis of atherosclerotic heart disease. The aide care plan dated 7/10/2023 assigned the aide frequency as two times a week and the tasks of "shampoo and shave 1x weekly'. A review of the aide visit notes provided twice weekly on 9/11/2023, 9/15/2023, 9/18/2023 and 9/22/2023 revealed the aide documented "shampoo and shave" completed at each visit indicated shampoo and shave was completed twice weekly instead of weekly as assigned. Clinical Record 7: The patient elected hospice benefit was dated 8/24/2023 for a diagnosis of cerebrovascular disease. The aide care plan dated 8/24/2023 assigned the aide frequency as three times a week and the task of "shampoo 1x weekly." A review of the aide visit notes provided three times weekly on 9/5/2023, 9/7/2023, and 9/9/2023 revealed the aide documented "shampoo" completed at each visit indicated shampoo was completed three times weekly instead of weekly as assigned. Clinical Record 8: The patient elected hospice benefit was dated 8/19/2023 for a diagnosis of chronic obstructive pulmonary disease (COPD). The aide care plan dated 8/19/2023 assigned the aide frequency as two times a week and the tasks of "shampoo 1x weekly'. A review of the aide visit notes provided twice weekly on 8/29/2023 and 9/2/2023 revealed the aide documented "shampoo" completed at each visit indicated shampoo was completed twice weekly instead of weekly as assigned. A joint record review and interview was conducted with the Director of Nursing (DON) on 1/5/2024 in which DON confirmed the aide did mark "completed" during more than one visit throughout the week. The DON stated, “they were supposed to put a note on the bottom on the days they did not complete the tasks.”

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview, and personnel record review. In 2 of 8 (25%) of personnel records reviewed revealed the agency did not ensure the skills and competencies of individuals providing care were assessed. Agency Policy: HR.CR 10 Competency Assessment dated 2021 stated in relevant part "Policy: A hospice must assess the skills and competence of all individuals providing care. 8. Any skill which is technical must be observed. These should be assessed immediately upon hire and annually." Personnel Record 3: The Director of Nursing (DON) with a hire date of 9/9/2022 had an initial orientation competency skills checklist dated 9/14/2022 and an annual competency checklist dated 9/12/2023. The checklist was blank under every competency where the employee was to be evaluated as "competent? (yes, no, n/a) for the initial and annual competency. Personnel Record 7: The hospice aide who has direct patient contact who was hired on 9/16/2022 had an Initial orientation competency skills checklist dated 9/17/2022 which stated, "boxes with * must be with patient" These technical skills were checked off as verbal instead of observation. There was no documented evidence that the aide’s technical skills were observed. A joint personnel record review was completed with the Director of Nursing (DON) on 1/5/2024. The DON confirmed the skills competency checklists had not been completed per agency policy.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which the patient was eligible for recertification, revealed that the agency did not ensure the recertification of the terminal illness was completed in the required time frame. Clinical Record 1: The patient elected hospice benefit was dated 6/3/2023 for a diagnosis of senile degeneration of the brain. A clinical record review on 1/4/2024 revealed there was no documented evidence of the signed recertification of terminal illness (CTI) for the benefit period beginning 11/30/2023 and no verbal order was present. Clinical Record 2: The patient elected hospice benefit was dated 10/14/2023 for a diagnosis of Atherosclerosis. A clinical record review on 1/4/2024 revealed that there was no documented evidence of the signed recertification of terminal illness (CTI) for the benefit period beginning on 12/13/2023 and no verbal order was present. A joint clinical record review and interview was conducted with the Director of Nursing (DON) on 1/5/2024. DON confirmed the CTIs did not contain the hospice medical director's signature.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 3 (100%) clinical records reviewed for hospice patients that revoked the hospice benefit or were discharged for extended prognosis, revealed that the agency did not forward the attending physician a copy of the discharge summary. Agency Policy: Discharge from hospice policy PC. D 20 dated 2021 states in relevant part "when a patient is discharged from hospice the hospice provides a copy of the patient's clinical record (if requested) and a copy of the discharge summary to the patient's attending physician and any new agency providing care. Clinical Record 5: The patient elected hospice benefit was dated 9/13/2023 for senile degeneration of the brain. The patient was discharged by the hospice agency for extended prognosis on 9/30/2023. There was no documented evidence in the clinical record that a discharge summary was provided to the attending physician. Clinical Record 6: The patient elected hospice benefit was dated 7/10/2023 for a diagnosis of atherosclerotic heart disease. The patient was discharged by the hospice agency on 9/23/2023 for extended prognosis. There was no documented evidence in the clinical record that a discharge summary was provided to the attending physician. Clinical Record 9: The patient elected hospice benefit was dated 6/9/2023 for a diagnosis of atherosclerotic heart disease. The patient revoked the hospice services on 8/23/2023 There was no documented evidence in the clinical record that a discharge summary was provided to the attending physician. A joint record review and interview with the Administrator was conducted on 1/4/2024. The Administrator confirmed the discharged summaries had not been provided to the attending physician(s).

It is required that each patient’s individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 6 (67%) clinical records reviewed revealed the plan of care (POC) lacked patient and family goals and planned interventions based on problems identified in the initial and updated comprehensive assessments. Document 12: Policy #PC.P55, "Plan of Care - Content (Dated: 2021)," stated in part "The plan of care must reflect patient and family goals and interventions based on the problems identified." Clinical Record 1: The patient elected the hospice benefit on 09/13/23. The frequency for both the Chaplain and Master of Social Work (MSW) per the POC dated 09/13/2023 was once per month plus one PRN visit. The record lacked goals and interventions for both spiritual and psychosocial needs. The patient had urinary incontinence per the certification of terminal illness (CTI) dated 09/13/2023. The record lacked a goal and intervention(s) for urinary incontinence. Clinical Record 2: The patient elected the hospice benefit on 06/3/23. The frequency for both the Chaplain and MSW per the POC dated 06/03/23 is once per month plus one PRN visit. The record lacked goals and interventions for both spiritual and psychosocial needs. Clinical Record 3: The patient elected the hospice benefit on 07/10/2023. The frequency for the Chaplain per the POC dated 07/10/2023 was once per month plus one PRN visit. The record lacked goals and interventions for spiritual needs. Clinical Record 5: The patient elected the hospice benefit on 8/19/23. The volunteer frequency was one per month as per the POC dated 8/19/23. The POC dated 8/19/23 lacked a goal and intervention(s) for the volunteer. Upon interview on 09/19/2023, the Administrator, the Alternate Director of Clinical Services, and the Alternate Administrator reviewed and agreed the agency did not ensure goals and interventions were included on the POC based on problems identified in the initial and updated comprehensive assessments.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 2 of 3 (67%) home visits it was observed that the clinicians failed to follow standards of practice during hand washing with soap and water, as per the agency, "Infection Control - Hand Hygiene and Bag Technique" policy. Document 2: Policy PC.I20, "Infection Control - Hand Hygiene and Bag Technique (Date: 2021)," stated in part, "Paper towels should be used to dry hands after soap and water washing, then used to turn off faucet..." Home Visit 1: During Home Visit 1 with the registered nurse (RN) on 09/19/23, it was observed that the RN turned off the faucet without use of a paper towel and prior to drying hands. Home Visit 3: During Home Visit 3 with the chaplain on 09/19/23, it was observed that the chaplain turned off the faucet without use of a paper towel and prior to drying hands. During an interview on 9/20/23, the Administrator, the Alternate Director of Clinical Services, and the Alternate Administrator reviewed and agreed the clinicians failed to follow standards of practice during hand washing with soap and water, as per the agency, "Infection Control - Hand Hygiene and Bag Technique" policy.

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) clinical records reviewed for patients that had nursing care provided by a licensed vocation nurse (LVN), and the patient had been on service for at least 30 days since the first LVN visit revealed the agency did not ensure that the licensed vocational nurse (LVN) was supervised by a registered nurse (RN) as per the Nursing Services Policy. Document 4: Policy PC.N15, "Nursing Services (Dated: 2021)," stated in part, "Procedure: 8. The RN makes a minimum every 30 days supervisory home visit and documents that the LPN is routinely providing nursing services in accordance with the patient's plan of care and the LPN's scope of practice." Clinical Record 2: The patient elected the hospice benefit on 6/3/23. There were LVN visit notes dated 7/31/23 and 8/12/23. The record lacked evidence of a LVN supervisory visit at minimum every 30 days. The record had evidence of a LVN supervisory visit by an RN that was dated 9/2/23, which was 33 days after the initial LVN visit. Upon interview on 9/19/23, the Administrator, the Alternate Director of Clinical Services, and the Alternate Administrator reviewed and agreed the agency did not ensure that the LVN was supervised by a RN at minimum every 30 days.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; Permitted to be performed under state law and regulation; and consistent with the hospice aide training. This CONDITION was not met as evidenced by clinical and personnel records reviews and interview. The agency failed to ensure the following: that hospice aide services were provided only after hospice aides had successfully completed a competency evaluation program [HSRM.9.I/L615]; that the hospice aide provided services that were included in the plan of care [HCDT.16.I/L626] and that the hospice aide reported changes in the patient’s medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes related to the plan of care and quality assessment and improvement activities. Further, that the hospice aide completed appropriate records in compliance with the hospice’s policies and procedures HCDT.18.I/L628]. The cumulative effect of these deficiencies has resulted in the hospice agency's inability to ensure the provision of quality care for the Condition of Participation CFR 418.76.

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below. A training program that addresses each of the following subject areas: a) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; b) Observation, reporting, and documentation of patient status and the care or service provided; c) Reading and recording temperature, pulse, and respiration; d) Basic infection control procedures; e) Basic elements of body function and changes in body function that must be reported to an aide’s supervisor; f) Maintenance of a clean, healthy, and safe environment; g) Recognizing emergencies and the knowledge of emergency procedures and their application; h) The physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; i) Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: i. Bed bath; ii. Sponge, tub, and shower bath; iii. Hair shampoo (sink, tub, and bed); iv. Nail and skin care; v. Oral hygiene; vi. Toileting and elimination; j) Safe transfer techniques and ambulation; k) Normal range of motion and positioning; l) Adequate nutrition and fluid intake; m) Any other task that the hospice may choose to have an aide perform not addressed item 2.i (a-f) above, the basic checklist. AND 3) The competency evaluation addresses each of the following subject areas from item 2, above; they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including: a) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; b) Reading and recording temperature, pulse, and respiration; c) Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: i. Bed bath; ii. Sponge, tub, and shower bath; iii. Hair shampoo (sink, tub, and bed); iv. Nail and skin care; v. Oral hygiene; vi. Toileting and elimination; d) Safe transfer techniques and ambulation; e) Normal range of motion and positioning. 4) The remaining subject areas in item 2 above may be evaluated through written examination, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation. This standard was not met as evidenced by document review, interview and personnel record review. In 2 of 2 (100%) hospice aide personnel records reviewed revealed the agency did not ensure the initial aide skills competency evaluation was completed by direct observation with a patient or a pseudo patient. Personnel Record 2: The hospice aide was hired on 9/16/22. The hospice aide skills checklist was dated 9/16/22. The record lacked evidence that the hospice aide was evaluated by observing the aide's performance of the (*) task with a patient or a pseudo patient. The record had evidence of verbal evaluation method documented for the (*) tasks that require observation with a patient or in a lab (i.e. bed bath, sponge bath, tub bath, shower, shampoo hair (sink), shampoo hair (tub), shampoo hair (bed), nail care, skin care, oral hygiene, toileting (toilet), toileting (bedpan/urinal), toileting (briefs), catheter care, safe transfer techniques, safe ambulation, normal range of motion, positioning (body alignment and pressure relief). Personnel Record 10: The hospice aide was hired on 7/11/23. The hospice aide skills checklist was dated 8/3/23. The record lacked evidence that the hospice aide was evaluated by observing the aide's performance of the (*) task with a patient or a pseudo patient. The record had evidence of verbal evaluation method documented for the (*) tasks that required observation with patient or in a lab (i.e. bed bath, sponge bath, tub bath, shower, shampoo hair (sink), shampoo hair (tub), shampoo hair (bed), nail care, skin care, oral hygiene, toileting (toilet), toileting (bedpan/urinal), toileting (briefs), catheter care, safe transfer techniques, safe ambulation, normal range of motion, positioning (body alignment and pressure relief)). Document 14: Policy PC.H35, "Hospice Aide Qualifications (Dated: 2021)," stated in part, "Competency evaluation. 1. An individual may furnish hospice aide services on behalf of a hospice only after that individual has successfully completed a competency evaluation program as described in this section. Hospice Aide skills and competencies are assessed prior to delivery of services . . . 2. A hospice aide competency must address each of the following subject areas: a. The following must be evaluated by observing an aide's performance of the task with a patient: i. Communication skills, including the ability to read, write, and verbally report clinical information to patients, care givers, and other hospice staff ii. Reading and recording temperature, pulse, and respiration; iii. Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: 1) Bed bath; 2) Sponge, tub, and shower bath; 3) Hair shampoo (sink, tub, and bed); 4) Nail and skin care; 5) Oral Hygiene; and 6) Toileting and elimination. iv. Safe transfer v. Normal range of motion and positioning." Document 7: The Hospice Aide Competency Skills Checklist has Skills that are, "(*) - Must be observed with a patient. The skills included were: Communication skills (including the ability to read, write and verbally report clinical information to patients, caregivers and other hospice staff); reading and recording temperature, pulse and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks, including: bed bath, sponge bath, tub bath, shower, shampoo hair (sink), shampoo hair (tub), Shampoo hair (bed), nail care, skin care, oral hygiene, toileting (toilet), toileting (bedpan/urinal), Toileting (briefs), catheter care. Safe transfer techniques, Safe ambulation, Normal range of motion, and positioning (body alignment and pressure relief). Per this document last page, "(*) - Must be observed with a patient. Items that are not observed cannot be performed independently until an RN is able to observe the aide performing the tasks. If an aide is not competent in one area, he or she can complete patient visits independently, but they cannot perform the task they were incompetent with until they show competence in the task with an RN present. If an aide is not competent in 2 or more areas, the aide cannot perform patient visits independently." Upon interview on 9/20/23, the Administrator, the Alternate Director of Clinical Services, and the Alternate Administrator reviewed and agreed the agency did not ensure that the initial hospice aide competency included the evaluation method of direct observation on a patient or pseudo patient for the required (*) skills prior to the aide delivering services.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 6 (17%) clinical records reviewed for patients that elected hospice aide services revealed the agency did not ensure that the hospice aide had provided services included in the plan of care (POC). Document 6: Policy #PC.H25, "Hospice Aide Assignments and Duties (Dated: 2021)," stated in part, "Procedure: Hospice aides will provide services included in the aide plan of care." Clinical Record 2: The patient elected the hospice benefit on 6/3/23. The hospice aide plan of care dated 8/3/23 ordered a shower every visit. The aide visit notes dated 9/6/23, 9/9/23, 9/12/23, 9/13/23, and 9/15/23 stated that the aide completed a shower. Upon interview during the patient observation visit on 9/19/23, the aide reported that she started completing a bed bath on all her visits since 9/6/23 but checked off that she was completing a shower. Home Visit 2: Upon interview during the observation visit for this patient that elected the hospice benefit on 6/3/23, the aide reported she started performing a bed bath on this patient since 9/6/23. When probed, the aide did notify the Alternate Director of Clinical Services prior to performing a bed bath at today's visit. She confirmed during that call that she had performed bed baths starting 9/6/23. Upon interview on 9/19/23, the Administrator, the Alternate Director of Clinical Services, and the Alternate Administrator reviewed and agreed the agency did not ensure that the aide provided services included in the aide POC.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 6 (17%) clinical records reviewed for patients that elected hospice aide services revealed the agency did not ensure that the aide reported changes in the patient's medical, nursing, rehabilitative, and/or social needs to a registered nurse (RN) as the changes related to the plan of care (POC) and any quality assessment and improvement activities. Document 6: Policy #PC.H25, "Hospice Aide Assignments and Duties (Dated: 2021)," stated in part, "Procedure: 7. Hospice aides must report changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities." Clinical Record 2: The patient elected hospice benefit on 6/3/23. The hospice aide POC dated 8/17/23 ordered a shower. The hospice aide completed visits on 9/6/23, 9/9/23, 9/12/23, 9/13/23, and 9/15/23. During an interview the aid reported she checked off that a shower was completed even though she actually performed a bed bath. The record lacked evidence that the aide notified the nurse of the change in the patient's medical status as the changes related to the POC. Upon interview on 9/19/23 with the Alternate Director of Clinical Services, the hospice aide for the patient (record 2) reported when asked how long ago she started performing a bed bath instead of the shower on the patient, she reported, "Probably about a week and a half ago." The aide stated, "I checked off I did the shower, but actually completed a bed bath because the patient is no longer getting out of bed." Upon interview on 9/19/23, the Administrator, Alternate Director of Patient Care Services, the Alternate Administrator reviewed and agreed that the agency did not ensure the hospice aide reported changes in the patient medical status as the changes related to the POC.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The agency did not ensure the volunteer recruitment and retention ongoing efforts were being documented. Document 9: Policy #HR.V30, "Volunteers - Recruitment (Dated: 2021)," stated in part, "Procedure: 6. All efforts to recruit hospice volunteers are documented and maintained by the Volunteer Coordinator." Document 10: Policy #HR.V35, "Volunteers - Retention, Support and Education (Dated: 2021)," stated in part, "Policy: In order to retain qualified, competent volunteers the agency provides on-going support and continuing education opportunities. Procedure: 3. Documentation of in-service/continuing education is retained in the volunteer personnel file." Upon interview on 9/20/23, the Volunteer Coordinator (VC) reported that recruitment of volunteers has been done internally by word of mouth. She also reported, to this point, no retention efforts have been completed, as it hasn't been very long. The VC stated there was no documentation of recruitment or retention efforts since inception of the program. Upon interview on 9/20/23, the Administrator, the Alternate Director of Clinical Services, and the Alternate Administrator reviewed and agreed the agency did not ensure documentation of the volunteer recruitment and retention efforts. The agency did not ensure the volunteer recruitment and retention ongoing efforts were being documented.

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: Related diagnosis(es), if any. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 6 (50%) clinical records reviewed revealed that the agency did not ensure the physician narrative on the certification of terminal illness (CTI) included related diagnoses(es) that supported the prognostication of the patient's terminal illness. Document 13: Policy #PC.C10, "Certification of Terminal Illness (Date: 2021)," stated in part, "The physician must consider ...related diagnosis(es), if any... when writing the content of the certification." Clinical Record 2: The patient elected the hospice benefit on 6/3/23. The certification of terminal illness (CTI) dated 9/1/23, benefit period 9/1/2023 to 11/29/2023, lacked evidence of related diagnosis(es). There was evidence of a primary diagnosis of, "Dementia". Clinical Record 4: The patient elected the hospice benefit on 8/24/23. The Initial CTI dated 8/24/23, benefit period 8/24/23 to 11/21/23, lacked evidence of related diagnosis(es). There was evidence of a primary diagnosis of, "CVA". Clinical Record 5: The patient elected the hospice benefit on 8/19/23. The CTI dated 8/19/23, benefit period from 08/19/2023 to 11/16/2023, lacked evidence of related diagnosis(es). There was evidence of a primary diagnosis of, "COPD". Upon interview on 09/19/2023, the Administrator, Alternate Administrator and Alternate Director of Clinical Services reviewed and agreed that the physician narrative on the CTI lacked evidence for consideration of related diagnosis(es) that support the prognostication of the patient's terminal illness.