Every finding on record at Ezra Healthcare, LLC

Based on interview and record review, it was determined the hospice agency failed to meet the Condition of Participation for Organizational Environment. Specifically, the agency was operating two branches that were not approved by Medicare or the State Agency. Findings include: The hospice agency failed to ensure multiple hospice locations were approved by Medicare and the State Agency prior to providing services. (Refer to tag L656)

Based on interview and record review, it was determined the hospice agency did not ensure multiple hospice locations were approved by Medicare and the State Agency prior to providing services. Findings include: On 6/13/22 at approximately 8:30 AM, an entrance conference was conducted. When asked about multiple locations, the surveyor was informed the agency had two branches, one located in Kaysville and the other located in Murray. On 6/13/22 at 10:36 AM, an interview was conducted with the administrator (ADM). The ADM stated they had submitted a CMS form 855A application for the Kaysville branch but it had not been approved yet. The ADM further stated they had not submitted a CMS form 855A for the Murray branch. The ADM confirmed that the Kaysville location had been open and functioning for five to six months and the Murray location had been open and functioning for two to three months. On 6/13/22 at 11:40 AM, the ADM provided a document titled IN PROGRESS MEDICARE APPLICATION as evidence of the CMS form 855A for the agency's Kaysville branch. The document did not identify that it was an application for a branch and did not include a Kaysville address or location of a requested branch. According to the Federal Code of Regulations 420.206. All hospice locations must be approved by Medicare prior to providing Medicare reimbursed services.