Every finding on record at Ghc Hospice Inc

The agency failed to ensure that the Condition of Participation: L 520 418.54 Initial and Comprehensive assessment of the patient was in compliance as follows: 1. Based on interview and record review, the agency failed to ensure a patient-specific comprehensive recertification assessment (describes in detail a patient's medical, physical and psychosocial condition and needs) was conducted for three of 11 sampled patients (Patients 2, 4, and 5). (Refer to L 521) 2. Based on interview, and record review, the agency failed to ensure the comprehensive assessment (describes in detail a patient's medical, physical and psychosocial condition and needs) was updated for five of eleven sampled patients (Patients 2, 4, 5, 10 and 11) when: a. For Patient 2, no recertification orders for benefit period seven (April 12, 2022, to June 10, 2022) were written and signed by a physician. (Refer to L 533) b. For Patient 4, no recertification orders for benefit period number three (May 26, 2022, to July 24, 2022) were written and signed by a physician. (Refer to L 533) c. For Patient 5, no recertification orders for benefit period number four (May 27, 2022, to July 25, 2022) were written and signed by a physician. (Refer to L 533) d. For Patient 10, no discharge orders for a discharge date of January 25, 2022, were written or signed by a physician. And a "Revocation of Hospice Benefit Election," (a patient's choice to no longer receive Medicare covered hospice benefits) was not obtained and signed by Patient 10 or Patient 10's responsible party. (Refer to L 533) e. For Patient 11, no discharge orders for a discharge date of January 3, 2022, were written or signed by a physician. (Refer to L 533) The cumulative effect of these systemic practices resulted in the potential to cause: Patients 2, 4 and 5 not to receive care and services for worsening physical symptoms such as pain, fatigue, wounds or the inability or difficulty in eating and drinking, as well as the families of Patients 2, 4, and 5 not to receive care and services for worsening psychosocial or spiritual distress. These systemic practices resulted in the potential to cause Patients 2, 4, 5, 10 and 11 to receive care and services or not to receive care and services, as directed by a physician.

Based on interview and record review, the agency failed to ensure a patient-specific comprehensive recertification assessment (describes in detail a patient's medical, physical and psychosocial condition and needs) was conducted for three of 11 sampled patients (Patients 2, 4, and 5). This failure had the potential to cause Patients 2, 4 and 5 not to receive care and services for worsening physical symptoms such as pain, fatigue, wounds or the inability or difficulty in eating and drinking. This failure had the potential to cause the families of Patients 2, 4, and 5 not to receive care and services for worsening psychosocial or spiritual distress. Findings: 1. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of May 25, 2021, with a certification period of June 11, 2022, to August 9, 2022. Patient 2 had diagnoses that included Alzheimer disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). There was no documented evidence to show a recertification assessment had been conducted for the certification period of June 11, 2022, to August 9, 2022, for Patient 2. A review of the agency's active patients as of June 27, 2022, was conducted, indicated Patient 2 as a current and active patient. A review of the "history of nursing assessments" for Patient 2 revealed the last "Re-Cert" [recertification] assessment completed was a recertification assessment on April 9, 2022. No other recertification assessments had been completed since April 9, 2022 During a concurrent record review and interview on June 30, 2022, at 10:45 AM, with the Director of Patient Care Services 1 (DPCS 1), the DPCS 1 confirmed that no other recertification assessments had been completed since April 9, 2022, for Patient 2. During an interview with the Director of Patient Care Services 1 (DPCS 1) on June 30, 2022, at 10:50 AM, the DPCS 1 stated Patient 2 was a current and active patient at the agency. DPCS 1 verified that Patient 2 had not received a recertification assessment. DPCS stated, Patient 2's recertification assessment should have been conducted prior to certification period of June 11, 2022, to August 9, 2022, care episode started. 2. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of November 27, 2021, with a benefit period of May 26, 2022, to July 24, 2022, (benefit period number three). Patient 4 had diagnoses that included end stage heart failure (the heart cannot pump blood effectively to meet the body's needs). A review of Patient 4's care plan for benefit period number two, dated February 25, 2022, to May 25, 2022, indicated the following concerns: a. Bedbound (confined to bed because of inability to ambulate or transfer to a wheelchair even with assistance, or to sit safely in a chair or wheelchair without personal assistance). b. Patient 4 had a history of falls with the last fall occurring on February 19, 2022. c. As of April 9, 2022, Patient 4 had four open boils (a painful, pus-filled bump under the skin caused by infected, inflamed hair roots) on his back. d. Muscle spasms to Patient 4's back. e. Potential for increasing pain with disease process related to diagnosis of end stage heart failure. f. Potential for altered respiratory status related to diagnosis of end stage heart failure. A review of Patient 4's comprehensive assessments from November 27, 2021, to June 28, 2022, was conducted. There was no documented evidence to show a comprehensive recertification assessment had been conducted for benefit period number three (May 26, 2022, to July 24, 2022). During an interview with the Director of Patient Care Services (DPCS 1) on June 28, 2022, at 2:17 PM, DPCS 1 stated she was responsible for conducting Patient 4's comprehensive recertification assessment for benefit period number three (May 26, 2022, to July 24, 2022). DPCS 1 stated she had not conducted Patient 4's comprehensive recertification assessment because, "I forgot." DPCS 1 stated Patient 4's care plan had not been updated for benefit period number three because she had not conducted the comprehensive recertification assessment. 3. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 29, 2021, with a benefit period of May 27, 2022, to July 25, 2022, (benefit period number four). Patient 5 had diagnoses that included malignant neoplasm of central nervous system (cancer of the central nervous system). A review of Patient 5's care plan for benefit period number three, dated March 28, 2022, to May 26, 2022, indicated the following concerns: a. Feeding: decreased intake b. Potential for altered bladder elimination related to suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) c. Potential for altered skin integrity related to being chair bound (confined-as by illness or incapacity-to sitting in a chair). d. Potential for altered neurological status (level of alertness; presence of seizures; cognition; mood and affect; and thought content) related to diagnosis of cancer of the central nervous system. e. Alteration in comfort symptoms (pain) related to diagnosis of cancer of the central nervous system. A review of Patient 5's comprehensive assessments from September 29, 2021, to June 28, 2022, was conducted. There was no documented evidence to show a comprehensive recertification assessment had been conducted for benefit period number four (May 27, 2022, to July 25, 2022). During an interview with the Director of Patient Care Services (DPCS 1) on June 28, 2022, at 2:44 PM, DPCS 1 stated she was responsible for conducting Patient 5's comprehensive recertification assessment for benefit period number four (May 27, 2022, to July 25, 2022). The DPCS 1 she had not conducted Patient 5's comprehensive recertification assessment because, "I forgot." DPCS 1 stated Patient 5's care plan had not been updated for benefit period number four because she had not conducted the comprehensive recertification assessment. A review of the agency's policy and procedure titled, "Initial Assessment/Comprehensive Assessment," undated, indicated the following: Policy: Each patient admitted by Hospice will have an appropriate initial assessment and comprehensive assessment performed and documented. Procedure: ... Each patient admitted will receive a comprehensive assessment. The comprehensive assessment will identify the patient's need for Hospice care and identify the patient's need for: Physical care. Psychosocial and emotional care. Spiritual care. All areas of Hospice care related to the palliation and management of the terminal illness and related conditions. The comprehensive assessment will take into consideration the following factors: The nature and the condition causing admission, including the presence or lack of objective data and subjective complaints. Complications and risk factors that affect care planning. Functional status, including the patient's ability to understand and participate in his/her own care. Severity of symptoms. Factors that alleviate or exacerbate physical symptoms. Comfort level of a patient who chooses not to take nutrition therapy. Patient/family spiritual orientation, including the desire for involvement of a religious group. Spiritual concerns or needs identified by the patient or family, e.g. [exempli gratia-for example], despair, suffering, guilt and forgiveness. Patient and family involvement in support group, if any. Additional information about the patient's psychosocial status, such as family relationships, social history, the source, and adequacy of environmental and other resources, coping mechanisms and the patient' and family's reactions to illness. The need for volunteer services to offer support or respite to the patient, family, or other caregivers. The need for an alternative setting or level of care. Anticipated discharge needs, including bereavement and funeral needs. Imminence of death. ... Each patient's comprehensive assessment includes a review of all medications the patient is currently taking (prescription, non-prescription, herbs, home remedies, other alternative treatments, etc. [et cetera- used at the end of a list to indicate that further, similar items are included]) to identify: Drug effectiveness. Side effects. Actual or potential drug interactions. Noncompliance with medications. Duplicate therapy. Ineffective therapy. Potential adverse effects. Medication reactions. Drug therapy associated with lab monitoring. ...

Based on interview, and record review, the agency failed to ensure the comprehensive assessment (describes in detail a patient's medical, physical and psychosocial condition and needs) was updated for five of eleven sampled patients (Patients 2, 4, 5, 10 and 11) when: 1a. For Patient 2, no recertification orders for benefit period seven (April 12, 2022, to June 10, 2022) were written and signed by a physician. 1b. For Patient 4, no recertification orders for benefit period number three (May 26, 2022, to July 24, 2022) were written and signed by a physician. 1c. For Patient 5, no recertification orders for benefit period number four (May 27, 2022, to July 25, 2022) were written and signed by a physician. 2a. For Patient 10, no discharge orders for a discharge date of January 25, 2022, were written or signed by a physician. And a "Revocation of Hospice Benefit Election," (a patient's choice to no longer receive Medicare covered hospice benefits) was not obtained and signed by Patient 10 or Patient 10's responsible party. 2b. For Patient 11, no discharge orders for a discharge date of January 3, 2022, were written or signed by a physician. This failure had the potential to cause Patients 2, 4, 5, 10 and 11 to receive care and services or not to receive care and services as directed by a physician. Findings: 1a. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of May 25, 2021, with a certification period of June 11, 2022, to August 9, 2022. Patient 2 had diagnoses that included Alzheimer disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) A review of the agency's active patients list as of June 27, 2022, was conducted, indicated Patient 2 listed as an active patient. During an interview with the Director of Patient Care Services 1 (DPCS 1) on June 27, 2022, at 10:35 AM, the DPCS 1 verified Patient 2 was listed as a current and active patient at the agency. During a concurrent record review and interview on June 28, 2022, at 12:20 PM, with the Director of Patient Care Services 1 (DPCS 1) of Patient 2 "current treatment/medication list/DME [durable medical equipment] list" electronic clinical record the DPCS 1 confirmed that no recertification physician order had been written and signed by the physician for the certification period of June 11, 2022, to August 9, 2022. DPCS 1 stated, Patient 2's recertification physician order should have been written and signed by physician prior to certification period of June 11, 2022, to August 9, 2022, care episode started. 1b. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of November 27, 2021, with a benefit period of May 26, 2022, to July 24, 2022, (benefit period number three). Patient 4 had diagnoses that included end stage heart failure (the heart cannot pump blood effectively to meet the body's needs). A review of Patient 4's care plan for benefit period number two, dated February 25, 2022, to May 25, 2022, indicated the following concerns: a. Bedbound (confined to bed because of inability to ambulate or transfer to a wheelchair even with assistance, or to sit safely in a chair or wheelchair without personal assistance). b. Patient 4 had a history of falls with the last fall occurring on February 19, 2022. c. As of April 9, 2022, Patient 4 had four open boils (a painful, pus-filled bump under the skin caused by infected, inflamed hair roots) on his back. d. Muscle spasms to Patient 4's back. e. Potential for increasing pain with disease process related to diagnosis of end stage heart failure. f. Potential for altered respiratory status related to diagnosis of end stage heart failure. A review of Patient 4's comprehensive assessments from November 27, 2021, to June 28, 2022, was conducted. There was no documented evidence to show a comprehensive recertification assessment had been conducted for benefit period number three (May 26, 2022, to July 24, 2022). A review of Patient 4's physician's orders from November 27, 2021, to June 28, 2022, was conducted. There was no documented evidence to show a physician's order had been created and signed based on Patient 4's needs from the comprehensive recertification assessment for benefit period number three (May 26, 2022, to July 24, 2022). During an interview with the Director of Patient Care Services (DPCS 1) on June 28, 2022, at 2:17 PM, DPCS 1 stated she was responsible for conducting Patient 4's comprehensive recertification assessment for benefit period number three (May 26, 2022, to July 24, 2022). DPCS 1 stated she had not conducted Patient 4's comprehensive recertification assessment because, "I forgot." DPCS 1 stated there were no recertification orders because she forgot to do the recertification assessment. DPCS 1 stated she would generate a verbal order from her recertification assessment and then give it to the physician to review and sign. DPCS 1 stated, "I didn't do the recertification assessment, so the verbal order was never written or sent to the physician." 1c. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 29, 2021, with a benefit period of May 27, 2022, to July 25, 2022, (benefit period number four). Patient 5 had diagnoses that included malignant neoplasm of central nervous system (cancer of the central nervous system). A review of Patient 5's care plan for benefit period number three, dated March 28, 2022, to May 26, 2022, indicated the following concerns: a. Feeding: decreased intake b. Potential for altered bladder elimination related to suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) c. Potential for altered skin integrity related to being chair bound (confined-as by illness or incapacity-to sitting in a chair). d. Potential for altered neurological status (level of alertness; presence of seizures; cognition; mood and affect; and thought content) related to diagnosis of cancer of the central nervous system. e. Alteration in comfort symptoms (pain) related to diagnosis of cancer of the central nervous system. A review of Patient 5's comprehensive assessments from September 29, 2021, to June 28, 2022, was conducted. There was no documented evidence to show a comprehensive recertification assessment had been conducted for benefit period number four (May 27, 2022, to July 25, 2022). A review of Patient 5's physician's orders from September 29, 2021, to June 28, 2022, was conducted. There was no documented evidence to show a physician's order had been created and signed based on Patient 5's needs from the comprehensive recertification assessment for benefit period number four (May 27, 2022, to July 25, 2022). During an interview with the Director of Patient Care Services (DPCS 1) on June 28, 2022, at 2:44 PM, DPCS 1 stated she was responsible for conducting Patient 5's comprehensive recertification assessment for benefit period number four (May 27, 2022, to July 25, 2022). The DPCS 1 she had not conducted Patient 5's comprehensive recertification assessment because, "I forgot." DPCS 1 stated there were no recertification orders because she forgot to do the recertification assessment. DPCS 1 stated she would generate a verbal order from her recertification assessment and then give it to the physician to review and sign. DPCS 1 stated, "I didn't do the recertification assessment, so the verbal order was never written or sent to the physician." 2a. A review of Patient 10's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 12, 2021, with a certification period of January 8, 2022, to March 8, 2022. Patient 10 had diagnoses that included senile degeneration of the brain (older individuals who suffered from cognitive decline, particularly memory loss). A review of the agency's discharged patients list as of June 27, 2022, was conducted, an interview with the Director of Patient Care Services (DPCS 1) verified Patient 10 was listed as discharged patient from the agency. During record review on June 28, 2022, at 12:40 PM of Patient 10's "visit note on call-triage" dated January 25, 2022, indicated "...We discussed patient's current condition and both daughters state that they would like their mom to be transported to the hospital for further evaluation... and daughters state they would like to have further treatment at hospital...contacted DPCS for hospice/Hospice medical director and IDT [interdisciplinary team] made aware... called 911...ambulance arrived and transported patient to [Name of acute care hospital] ER [emergency room] per both Daughter's wishes for further evaluation...patient left the board and care facility at 7:35 PM...hospice DPCS and IDT made aware..." During a concurrent record review and interview on June 28, 2022, at 12:45 PM, with DPCS 1 of Patient 10's "current treatment/medication list/DME [durable medical equipment] list" electronic clinical record DPCS 1 confirmed that no discharge from agency physician order had been written and signed by the physician. DPCS 1 stated, Patient 10's discharge from the agency physician order should have been written and signed by physician after the transfer note and she did not have it. During concurrent record review and interview on June 2, 2022, at 12:48 PM, of agency policy and procedures "discharge from hospice program" revised November 2011 with DPCS 1 indicated, "...3. when a patient is discharged, transferred, or referred to another organization, relevant information may include...A. Reason for transfer or discharge...B. Physical and psychosocial status at time of transfer or discharge, including specific medical, psychosocial, or other problems requiring interventions or follow-up...C. Summary of the care provided and progress toward achieving goals, including both positive and adverse patient responses to treatment or services...D. A copy of the medication profile, including discontinued medications...E. Continuing symptom management needs, e.g., pain, nausea, dyspnea...F. Follow-up to be provided by an interdisciplinary group member from the service transferring the patient...G. All pertinent laboratory data...H. Summary of patient education provided to the patient and family/caregiver and their comprehension of that information. Instruction and referrals provided to the patient...J. Existence of any Advance Directives, if applicable...K. The date of discharge, which is the date of the last visit made...Documentation will be filed in the clinical record. Information will be documented on a discharge/transfer form, which is to be completed within 72 hours...Obtained a written discharge order from the hospice medical record. DPCS 1 stated, Patient 10's discharge from the agency physician order should have been completed, written, and signed by physician per the agency policy. There was no documented evidence to show a revocation of hospice benefit had been obtained and signed by Patient 10 or Patient 10's responsible party. During a concurrent record review and interview on June 28, 2022, at 12:50 PM, of agency policy and procedure "Revocation of Hospice Benefit Election" revised November 2011, with DPCS 1 indicated "PROCEDURE...1. The patient will choose to revoke his/her election of hospice benefit when he/she...A. Elects active treatment, inconsistent with the role of palliative hospice care...". Furthermore DPCS 1 stated Patient 10's revocation of hospice benefits should have been done as the agency policy. 2b. A review of Patient 11's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 11, 2020, with a certification period of November 5, 2021, to January 3, 2022. Patient 11 had diagnoses that included senile degeneration of the brain (older individuals who suffered from cognitive decline, particularly memory loss). A review of the agency's discharged patients list as of June 27, 2022, was conducted, an interview with DPCS 1 verified Patient 11 was listed as discharged patient from the agency. During record review on June 28, 2022 at 1:05 PM of "Discharge Summary" dated January 3, 2022, indicated "...Upon re-assessment with follow-up SN [Skilled Nursing] visits, the patient has demonstrated no signs of decline and was discussed with an IDT meeting on December 22, 2021, with a scheduled discharge date of January 3, 2022, ...Patient and family made aware, medications were refilled for 2 [two] weeks, supplies were sent out for 2 [two] weeks, NOMNOC [Notice of Medicare Noncoverage] was signed by family who understands and accepts day of discharge January 3, 2022, ... IDT [interdisciplinary team] made aware of patient`s discharge for extended prognosis on January 3, 2022 ..." During a concurrent record review and interview on June 28, 2022, at 12:55 PM, with DPCS 1 of Patient 11's "current treatment/medication list/DME [durable medical equipment] list" electronic clinical record DPCS 1 confirmed that no discharge from agency physician order had been written and signed by the physician. DPCS 1 stated, Patient 11's discharge from the agency physician order should have been written and signed by physician along with discharged summary and she did not. A review of the agency's policy and procedure titled, "Ongoing Assessments," dated November 2011, indicated the following: Purpose: To provide guidelines for further assessment of patients during ongoing care. Policy: The scope and intensity of ongoing hospice patient assessments will be determined by the patient's prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. Procedure: During each home visit, the case Manager or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. ... Based on the reassessments, the plan of care-including problems, needs, goals, and outcomes-will be reviewed and revised by the hospice Case Manager in collaboration with all hospice interdisciplinary group members responsible for the case. Based upon the findings of the reassessment, additional orders will be generated and forwarded to the physician (or other authorized licensed independent practitioner) for signature(s). The physician will be notified to verify any changes in medications, including over-the-counter medications, and treatment/interventions that require physician approval." A review of the agency's policy and procedure titled, "Physician Orders," undated, indicated the following: "Policy: Nursing and other services that require a physician's order will be provided in accordance with a physician's order. ... Procedure: ... Care and services provided will be provided according to physician orders. Orders are current and updated. Drugs and treatments are administered by staff only as ordered by a physician. ..."

Based on interview and record review, the agency failed to conduct an on-site Hospice Aide (HA) supervisory visit every 14 days for nine of 11 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9). This failure had the potential to cause substandard HA care practices to go unrecognized and uncorrected. Findings: 1. A review of Patient 1's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 10, 2021, with a certification period of May 8, 2022, to July 6, 2022. Patient 1 had diagnoses that included senile degeneration of the brain (older individuals who suffered from cognitive decline, particularly memory loss). During a record review on June 30, 2022, at 11:05 AM of Patient 1's electronic clinical record titled "Visit notes" indicated: a. Missed visit on June 11, 2022, and June 25, 2022. b. Revealed the last supervisory visit was on May 28, 2022. No other supervisory visit had been completed since May 28, 2022. During a concurrent record review and interview on June 30, 2022, at 11:08 AM of Patient 1's electronic clinical record titled "Visit notes" with the Director of Patient Care Services 1 (DPCS 1) confirmed missed supervisory visit on June 11,2022, missed supervisory visit on June 25,2022 and no other supervisory visit had been completed since May 28, 2022. During a concurrent record review and interview on June 30, 2022, at 11:10 AM of agency policy and procedure "Hospice aid supervisory visit" revised November 2011 with DPCS 1 indicated "Policy...the registered nurse or therapist must conduct supervisory visit...the frequency of supervisory visit...conducted every two (2) weeks at the minimum". DPCS 1 stated that Patient 1's supervisory visit should have been done every two weeks per the agency policy, but agency failed to reschedule visit. 2. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of May 25, 2021, with a certification period of June 11, 2022, to August 9, 2022. Patient 2 had diagnoses that included Alzheimer disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). During a record review on June 30, 2022, at 11:15 AM of Patient 2's electronic clinical record titled "Visit notes" indicated: a. Missed visit on June 11, 2022, and June 25,2022. b. Revealed the last supervisory visit was on May 21, 2022. No other supervisory visit had been completed since May 21, 2022. During a concurrent record review and interview on June 30, 2022, at 11:18 AM of Patient 2's electronic clinical record titled "Visit notes" with the DPCS 1, confirmed missed supervisory visit on June 11, 2022, missed supervisory visit June 25, 2022, and no other supervisory visit had been completed since May 21, 2022. During a record review on June 30, 2022, at 11:20 AM of Patient 2's electronic clinical record titled "visit note missed visit" indicated: Dated June 11, 2022, "...narrative...attempt to contact family however RN unsuccessful x 3 attempts. Missed visit..." Dated June 25, 2022, "...narrative...attempt to contact family however RN unsuccessful x 3 attempts. Missed visit..." During a concurrent record review and interview on June 30, 2022, at 11:25 AM of agency policy and procedure "Hospice aid supervisory visit" revised November 2011 with DPCS 1 indicated "Policy...the registered nurse or therapist must conduct supervisory visit...the frequency of supervisory visit...conducted every two (2) weeks at the minimum". DPCS 1 stated that Patient 2's supervisory visit should have been done every two weeks per the agency policy, but agency failed to reschedule visit. 3. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of November 11, 2021, with a certification period of May 10, 2022, to July 8, 2022. Patient 3 had diagnoses that included sepsis (a bacterial infection that enters the bloodstream as a severe response to an infection). During a record review on June 30, 2022, at 11:30 AM of Patient 3's electronic clinical record titled "Visit notes" indicated missed visit on June 4, 2022, and incomplete phone supervisory visit note without signature on June 17, 2022. DPCS 1 confirmed missed supervisory visit on June 4, 2022, and incomplete phone supervisory visit note without signature on June 17, 2022, and no other supervisory visit had been completed since May 21, 2022. During a record review on June 30, 2022, at 11:32 AM of Patient 3's electronic clinical record indicated: Titled "visit note missed visit" dated June 14,2022, "...narrative...attempt to contact family however RN unsuccessful x 3 attempts. Missed visit..." Titled "visit note admin" dated June 17,2022, "type: telephone...hospice aid present: no...LVN present: no...electronic signature: [empty]...date: [empty]..." During a concurrent record review and interview on June 30, 2022, at 11:35 PM of agency policy and procedure "Hospice aid supervisory visit" revised November 2011 with DPCS 1 indicated "Policy...the registered nurse or therapist must conduct supervisory visit...the frequency of supervisory visit...conducted every two (2) weeks at the minimum". DPCS 1 stated that Patient 3's supervisory visit should have been done every two weeks per the agency policy, but agency failed to reschedule visit. 4. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of November 27, 2021, with a benefit period of May 26, 2022, to July 24, 2022, (benefit period number three). Patient 4 had diagnoses that included end stage heart failure (the heart cannot pump blood effectively to meet the body's needs). A review of Patient 4's physician order dated May 11, 2022, indicated a Hospice Aide (HA) was to visit Patient 4 two times a week from May 26, 2022, to July 24, 2022. A review of Patient 4's HA visits from May 26, 2022, to June 28, 2022, was conducted. The HA visit notes indicated Patient 4 received HA visits on May 31, 2022, and June 7, 10, 13, 16, 20, 24, 27, 2022. A review of Patient 4's Registered Nursing (RN) visits from May 26, 2022, to June 28, 2022, was conducted. An RN visit note dated June 17, 2022, indicated a HA supervisory visit. The supervisory visit was made 22 days after the start of the benefit period (May 26, 2022, to July 24, 2022). During an interview with a Director of Patient Care Services (DPCS 1) on June 28, 2022, at 2:17 PM, DPCS 1 stated the HA Supervisory Note was late because she did not understand in each new benefit period the patient's needs were reassessed, such as the need for HA services. DPCS 1 stated she did not understand to treat each new benefit period on its own. DPCS 1 stated she had scheduled the HA supervisory visits continuously from the start of care resulting in the discrepancy for benefit period three (May 26, 2022, to July 24, 2022). 5. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 29, 2021, with a benefit period of May 27, 2022, to July 25, 2022, (benefit period number four). Patient 5 had diagnoses that included malignant neoplasm of central nervous system (cancer of the central nervous system). A review of Patient 5's physician order dated May 11, 2022, indicated a Hospice Aide (HA) was to visit Patient 5 three times a week from May 27, 2022, to July 25, 2022. A review of Patient 5's HA visits from May 27, 2022, to June 28, 2022, was conducted. The HA visit notes indicated Patient 5 received HA visits on May 27, 30, 2022, and June 1, 3, 6, 8, 10, 13, 15, 17, 20, 22, 24, 27, 2022. A review of Patient 5's Registered Nursing (RN) visits from May 27, 2022, to June 28, 2022, was conducted. An RN visit note dated May 28, 2022, indicated a HA supervisory visit. Based on the 14-day time frame additional HA supervisory visits should have been conducted on June 11 and 25, 2022. The RN visits notes indicated missed visits for June 11 and 25, 2022. There was no documented evidence to show any follow up visits to make up for the missed HA supervisory visits. During an interview with a Director of Patient Care Services (DPCS 1) on June 28, 2022, at 2:44 PM, DPCS 1 stated HA supervisory visits had not been made every 14 days for Patient 5. DPCS 1 stated the RN should have made up the missed HA supervisory visit as soon as it was possible, and she did not. 6. A review of Patient 6's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of August 14, 2021, with a certification period of June 10, 2022, to August 8, 2022. Patient 6 had diagnoses that included Alzheimer disease (= is a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) During a concurrent record review and interview on June 30, 2022, at 12:10 PM with DPCS 1 of Patient 6's electronic clinical record titled "Visit notes" indicated missed visit on June 11,2022 and June 25,2022. DPCS 1 confirmed missed supervisory visit on June 11,2022, missed supervisory visit on June 25,2022. During an interview on June 30, 2022, at 12:13 PM with DPCS 1 stated the last the last supervisory visit was on May 28, 2022. No other supervisory visit had been completed since May 28, 2022. During record review on June 30, 2022, at 12:15 PM of Patient 6's electronic clinical record titled "visit note missed visit" indicated: Dated June 11,2022, "...narrative...attempt to contact family however RN unsuccessful x 3 attempts. Missed visit..." Dated June 25,2022, "...narrative...attempt to contact family however RN unsuccessful x 3 attempts. Missed visit..." During a concurrent record review and interview on June 30, 2022, at 12:20 PM of agency policy and procedure "Hospice aid supervisory visit" revised November 2011 with DPCS 1 indicated "Policy...the registered nurse or therapist must conduct supervisory visit...the frequency of supervisory visit...conducted every two (2) weeks at the minimum". DPCS 1 stated that Patient 6's supervisory visit should have been done every two weeks per the agency policy, but agency failed to reschedule visit. 7. A review of Patient 7's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of May 22, 2022, with a certification period of May 22, 2022, to August 19, 2022. Patient 7 had diagnoses that included heart failure (is a serious condition in which the heart doesn't pump blood as efficiently as it should). During a record review on June 30, 2022, at 12:25 PM of Patient 7's electronic clinical record titled "Visit notes" indicated missed visit on June 5, 2022, and June 18, 2022. During a concurrent record review and interview on June 30, 2022, at 12:28 PM with DPCS 1 stated confirmed missed supervisory visit on June 5,2022, missed supervisory visit on June 18, 2022, and no other supervisory visit had been completed since start of care assessment May 22, 2022. During a record review on June 30, 2022, at 12:30 PM of Patient 7's electronic clinical record titled "visit note missed visit" indicated: Dated June 5,2022, "...narrative...attempt to contact family however RN unsuccessful x 3 attempts. Missed visit..." Dated June 18, 2022, "...narrative...attempt to contact family however RN unsuccessful x 3 attempts. Missed visit..." During a concurrent record review and interview on June 30, 2022, at 12:35 PM of agency policy and procedure "Hospice aid supervisory visit" revised November 2011 with DPCS 1 indicated "Policy...the registered nurse or therapist must conduct supervisory visit...the frequency of supervisory visit...conducted every two (2) weeks at the minimum". DPCS 1 stated that Patient 7's supervisory visit should have been done every two weeks per the agency policy, but agency failed to reschedule visit. 8. A review of Patient 8's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of March 15, 2022, with a certification period of May 17, 2022, to August 14, 2022. Patient 8 had diagnoses that included hypertension with heart failure (is refers to heart problems that occur because of high blood pressure that is present over a long time). During a record review on June 30, 2022, at 1:40 PM of Patient 8's electronic clinical record titled "Visit notes" indicated: a. Missed visit on June 11,2022 and June 25,2022. b. Revealed the last supervisory visit was on May 28, 2022. No other supervisory visit had been completed since May 28, 2022. During a concurrent record review and interview on June 30, 2022, at 1:42 PM of Patient 8's electronic clinical record titled "Visit notes" with DPCS 1 confirmed missed supervisory visit June 11, 2022, missed supervisory visit on June 25, 2022, and no other supervisory visit had been completed since May 28, 2022. During a c record review on June 30, 2022, at 1:45 PM of Patient 8's electronic clinical record titled "visit note missed visit" indicated: Dated June 11,2022, "...narrative...attempt to contact family however RN unsuccessful x 3 attempts. Missed visit..." Dated June 25,2022, "...narrative...attempt to contact family however RN unsuccessful x 3 attempts. Missed visit..." During a concurrent record review and interview on June 30, 2022, at 1:48 PM of agency policy and procedure "Hospice aid supervisory visit" revised November 2011 with DPCS 1 indicated "Policy...the registered nurse or therapist must conduct supervisory visit...the frequency of supervisory visit...conducted every two (2) weeks at the minimum". DPCS 1 stated that Patient 8's supervisory visit should have been done every two weeks per the agency policy, but agency failed to reschedule visit. 9. A review of Patient 9's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of February 2, 2022, with a certification period of April 17, 2022, to July 15, 2022. Patient 9 had diagnoses that included senile degeneration of the brain (older individuals who suffered from cognitive decline, particularly memory loss). During a record review on June 30, 2022, at 1:50 PM of Patient 8's electronic clinical record titled "Visit notes" indicated: a. Missed visit on June 11, 2022, and June 25, 2022. b. Revealed the last supervisory visit was on May 28, 2022. No other supervisory visit had been completed since May 28, 2022. During a concurrent record review and interview on June 30, 2022, at 1:52 PM of Patient 8's electronic clinical record titled "Visit notes" with DPCS 1 confirmed missed supervisory visit June 11,2022, missed supervisory visit on June 25,2022, and no other supervisory visit had been completed since May 28, 2022. During a record review on June 30, 2022, at 1:50 PM of Patient 8's electronic clinical record titled "visit note missed visit" indicated: Dated June 11,2022, "...narrative...attempt to contact family however RN unsuccessful x 3 attempts. Missed visit..." Dated June 25,2022, "...narrative...attempt to contact family however RN unsuccessful x 3 attempts. Missed visit..." During a concurrent record review and interview on June 30, 2022, at 1:55 PM of agency policy and procedure "Hospice aid supervisory visit" revised November 2011 with DPCS 1 indicated "Policy...the registered nurse or therapist must conduct supervisory visit...the frequency of supervisory visit...conducted every two (2) weeks at the minimum". DPCS 1 stated that Patient 8's supervisory visit should have been done every two weeks per the agency policy, but agency failed to reschedule visit. A review of the agency's policy and procedure titled, "Hospice Aide Supervisory Visits," dated November 2011, indicated the following: "Purpose: To establish guidelines for the responsibilities and the frequency of supervisory visits for hospice aides. Procedure: 1. The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established but are conducted every two (2) weeks at a minimum. ... 4. Supervisory visits and overall supervision will be documented in the clinical record. A. Supervisory visits will be documented on a supervisory visit form. B. Ongoing supervision will be documented within the plan of care, Hospice Aide Assignment Sheet and clinical notes."

The agency failed to ensure that the Condition of Participation: L 664 418.102 Medical director was in compliance as follows: Based on interview, and record review, the agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for nine (9) of 11 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 10 and 11) when: a. For Patient 1: The CTI for benefit period number eight (8) (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) did not contain a face-to-face encounter (an in-person non-certifying physician's or nurse practitioners' clinical assessment of the patient) summary (a brief statement of the clinical findings) or a physician's certifying summary (a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less. The narrative must reflect the patient's individual clinical circumstances and cannot contain check boxes or standard language used for all patients). And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. (Refer to L 667) b. For Patient 2: The CTI for benefit period number seven (7) did not contain a face-to-face encounter summary or a physician's certifying summary. And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. (Refer to L 667) c. For Patient 3: The CTI for the first 90-day benefit period was not signed by two physicians and did not contain a physician's certifying summary. The CTI for benefit period number three (3) did not contain a face-to-face encounter summary or a physician's certifying summary. And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. (Refer to L 667) d. For Patient 4: The CTI for the first 90-day benefit period was not signed by two physicians and did not contain a physician's certifying summary. The CTI for benefit period number three (3) did not contain a face-to-face encounter summary or a physician's certifying summary and was not signed by a physician. And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. (Refer to L 667) e. For Patient 5: The CTI for the first 90-day benefit period was not signed by two physicians and did not contain a physician's certifying summary. The CTI for benefit period number (4) did not contain a face-to-face encounter summary or a physician's certifying summary and was not signed by a physician. And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. (Refer to L 667) f. For Patient 6: The CTI for benefit period number four (4) did not contain a face-to-face encounter summary or a physician's certifying summary. And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. (Refer to L 667) g. For Patient 7: The CTI for the first 90-day benefit period was not signed by two physicians and did not contain a physician's certifying summary. (Refer to L 667) h. For Patient 10: The CTI for benefit period number 11 did not contain a face-to-face encounter summary or a physician's certifying summary. And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. (Refer to L 667) i. For Patient 11: The CTI for benefit period number seven (7) did not contain a face-to-face encounter summary or a physician's certifying summary. And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. (Refer to L 667) The cumulative effect of these systemic practices resulted in the potential to cause Patients 1, 2, 3, 4, 5, 6, 7, 10 and 11 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to not being properly evaluated as terminally ill.

Based on interview, and record review, the agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for nine (9) of 11 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 10 and 11) when: 1. For Patient 1: The CTI for benefit period number eight (8) (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) did not contain a face-to-face encounter (an in-person non-certifying physician's or nurse practitioners' clinical assessment of the patient) summary (a brief statement of the clinical findings) or a physician's certifying summary (a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less. The narrative must reflect the patient's individual clinical circumstances and cannot contain check boxes or standard language used for all patients). And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. 2. For Patient 2: The CTI for benefit period number seven (7) did not contain a face-to-face encounter summary or a physician's certifying summary. And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. 3. For Patient 3: The CTI for the first 90-day benefit period was not signed by two physicians and did not contain a physician's certifying summary. The CTI for benefit period number three (3) did not contain a face-to-face encounter summary or a physician's certifying summary. And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. 4. For Patient 4: The CTI for the first 90-day benefit period was not signed by two physicians and did not contain a physician's certifying summary. The CTI for benefit period number three (3) did not contain a face-to-face encounter summary or a physician's certifying summary and was not signed by a physician. And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. 5. For Patient 5: The CTI for the first 90-day benefit period was not signed by two physicians and did not contain a physician's certifying summary. The CTI for benefit period number (4) did not contain a face-to-face encounter summary or a physician's certifying summary and was not signed by a physician. And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. 6. For Patient 6: The CTI for benefit period number four (4) did not contain a face-to-face encounter summary or a physician's certifying summary. And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. 7. For Patient 7: The CTI for the first 90-day benefit period was not signed by two physicians and did not contain a physician's certifying summary. 8. For Patient 10: The CTI for benefit period number 11 did not contain a face-to-face encounter summary or a physician's certifying summary. And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. 9. For Patient 11: The CTI for benefit period number seven (7) did not contain a face-to-face encounter summary or a physician's certifying summary. And there was no face-to-face encounter documented by a non-certifying physician or nurse practitioner. This failure had the potential to cause Patients 1, 2, 3, 4, 5, 6, 7, 10 and 11 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to not being properly evaluated as terminally ill. Findings: 1. A review of Patient 1's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 10, 2021, with a benefit period of May 8, 2022, to July 6, 2022 (benefit period number eight). Patient 1 had diagnoses that included senile degeneration of brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 1's "Physician Certification for Hospice Benefit," dated May 8, 2022, indicated Patient 1 was in her eighth benefit period. Patient 1's "Physician Certification for Hospice Benefit," indicated an area to document a face-to-face encounter summary. The area was blank. Patient 1's "Physician Certification for Hospice Benefit," indicated an area to document a certifying physician's summary. The area indicated, "Pt [patient] seen and evaluated and meds [medications] reviewed. Pt is terminally ill and hospice appropriate." A review of Patient 1's face-to-face encounters from September 10, 2021, to June 29, 2022, was conducted. There was no documented evidence to show a face-to-face encounter had been conducted. A review of Patient 1's claims for payment from September 10, 2021, to June 29, 2022, indicated a claim for payment was submitted on June 20, 2022. During an interview with a Medical Director (MD) and a Licensed Vocational Nurse/Community Relations (LVN/CR 1) on June 29, 2022, at 11:55 AM, the MD stated she was responsible for certifying Patient 1's terminal illness. The MD stated the face-to-face encounter summary area was blank. The MD stated the certifying physician's summary did not reflect the patient's individual clinical circumstances. The MD stated she had been scheduled to conduct Patient 1's face-to-face encounter and did not know the certifying physician was not supposed to conduct the face-to-face encounter. The MD stated there was no documented evidence to show the face-to-face encounter had been conducted by a non-certifying physician or nurse practitioner. LVN/CR 1 stated Patient 1's claim for payment was submitted on June 20, 2022. 2. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of May 25, 2021, with a benefit period of April 12, 2022, to June 10, 2022 (benefit period number seven). Patient 2 had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 2's "Physician Certification for Hospice Benefit," dated April 12, 2022, indicated Patient 2 was in her seventh benefit period. Patient 2's "Physician Certification for Hospice Benefit," indicated an area to document a face-to-face encounter summary. The area was blank. Patient 2's "Physician Certification for Hospice Benefit," indicated an area to document a certifying physician's summary. The area indicated, "Pt [patient] seen and evaluated and meds [medications] reviewed. Pt is terminally ill and hospice appropriate." A review of Patient 2's face-to-face encounters from May 25, 2021, to June 29, 2022, was conducted. There was no documented evidence to show a face-to-face encounter had been conducted. A review of Patient 2's claims for payment from September 10, 2021, to June 29, 2022, indicated a claim for payment was submitted on June 20, 2022. During an interview with a Medical Director (MD) and a Licensed Vocational Nurse/Community Relations (LVN/CR 1) on June 29, 2022, at 12 PM, the MD stated she was responsible for certifying Patient 2's terminal illness. The MD stated the face-to-face encounter summary area was blank. The MD stated the certifying physician's summary did not reflect the patient's individual clinical circumstances. The MD stated she had been scheduled to conduct Patient 2's face-to-face encounter and did not know the certifying physician was not supposed to conduct the face-to-face encounter. The MD stated there was no documented evidence to show the face-to-face encounter had been conducted by a non-certifying physician or nurse practitioner. LVN/CR 1 stated Patient 2's claim for payment was submitted on June 20, 2022. 3. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of November 11, 2021, with a benefit period of November 11, 2021, to February 8, 2022 (First 90-day benefit period) and May 10, 2022, to July 8, 2022, (benefit period number three). Patient 3 had diagnoses that included sepsis (a condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). A review of Patient 3's physician's order (by Attending Physician-AP 1) dated November 11, 2021, indicated a hospice referral to the agency. A review of Patient 3's "Physician Certification for Hospice Benefit," dated November 11, 2021, indicated Patient 3 was in her first 90-day benefit period. Patient 3's "Physician Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. Patient 3's "Physician Certification for Hospice Benefit," indicated the Hospice Medical Director's signature on both lines. There was no documented evidence to show AP 1 had signed Patient 3's "Physician Certification for Hospice Benefit." Patient 3's "Physician Certification for Hospice Benefit," indicated an area to document a certifying physician's summary. The area indicated, "[Name of Patient 3] is an 83-year-old female admitted to hospice today with the diagnosis of sepsis unspecified organism. Pt [patient] is terminally ill and hospice appropriate. Pt was seen via face to face and medications were reviewed." A review of Patient 3's claims for payment from November 11, 2021, to June 29, 2022, indicated a claim for payment was submitted on December 28, 2021. A review of Patient 3's "Physician Certification for Hospice Benefit," dated May 10, 2022, indicated Patient 3 was in her third benefit period. Patient 3's "Physician Certification for Hospice Benefit," indicated an area to document a face-to-face encounter summary. The area was blank. Patient 3's "Physician Certification for Hospice Benefit," indicated an area to document a certifying physician's summary. The area indicated, "Pt [patient] seen and evaluated and meds [medications] were reviewed. Pt is hospice appropriate and terminally ill." A review of Patient 3's face-to-face encounters from November 11, 2021, to June 29, 2022, was conducted. There was no documented evidence to show a face-to-face encounter had been conducted. A review of Patient 3's claims for payment from November 11, 2021, to June 29, 2022, indicated a claim for payment was submitted on June 20, 2022. During an interview with a Medical Director (MD) and a Licensed Vocational Nurse/Community Relations (LVN/CR 1) on June 29, 2022, at 12:05 PM, the MD stated she was responsible for certifying Patient 3's terminal illness. The MD stated she knew two physician signatures were required to certify a patient in their first 90-day benefit period. The MD stated she did not know how she signed as both the Medical Director and Attending Physician. The MD stated the certifying physician's summary for the first 90-day benefit period did not reflect the patient's individual clinical circumstances. The MD stated the third benefit period's face-to-face encounter summary area was blank and the certifying physician's summary did not reflect the patient's individual clinical circumstances. The MD stated she had been scheduled to conduct Patient 3's face-to-face encounter and did not know the certifying physician was not supposed to conduct the face-to-face encounter. The MD stated there was no documented evidence to show the face-to-face encounter had been conducted by a non-certifying physician or nurse practitioner. LVN/CR 1 stated Patient 3's claims for payment were submitted on December 28, 2021, and June 20, 2022. 4. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of November 27, 2021, with a benefit period of November 27, 2021, to February 24, 2022 (First 90-day benefit period) and May 26, 2022, to July 24, 2022, (benefit period number three). Patient 4 had diagnoses that included end stage heart failure (the heart cannot pump blood effectively to meet the body's needs). A review of Patient 4's physician's order (by Attending Physician-AP 2) dated November 22, 2021, indicated a hospice referral to the agency. A review of Patient 4's "Physician Certification for Hospice Benefit," dated November 27, 2021, indicated Patient 4 was in his first 90-day benefit period. Patient 4's "Physician Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. Patient 4's "Physician Certification for Hospice Benefit," indicated the Hospice Medical Director's signature on both lines. There was no documented evidence to show AP 2 had signed Patient 4's "Physician Certification for Hospice Benefit." Patient 4's "Physician Certification for Hospice Benefit," indicated an area to document a certifying physician's summary. The area indicated, "[Name of Patient 4] is a 73-year-old male with a diagnosis of end stage heart disease is admitted to hospice today. Pt [patient] is terminally ill and hospice appropriate." A review of Patient 4's claims for payment from November 27, 2021, to June 29, 2022, indicated a claim for payment was submitted on January 12, 2022. A review of Patient 4's "Physician Certification for Hospice Benefit," dated for the third benefit period, May 26, 2022, to July 24, 2022, indicated Patient 4 was in his third benefit period. Patient 4's "Physician Certification for Hospice Benefit," indicated an area to document a face-to-face encounter summary. The area was blank. Patient 4's "Physician Certification for Hospice Benefit," indicated an area to document a certifying physician's summary. The area was blank. Patient 4's "Physician Certification for Hospice Benefit," dated for the third benefit period May 26, 2022, to July 24, 2022, was not signed by a physician. A review of Patient 4's face-to-face encounters from November 27, 2021, to June 29, 2022, was conducted. There was no documented evidence to show a face-to-face encounter had been conducted. Patient 4's claims for payment for May 2022 was requested. The agency did not provide a claim for payment for May 2022. During an interview with a Medical Director (MD) and a Licensed Vocational Nurse/Community Relations (LVN/CR 1) on June 29, 2022, at 12:10 PM, the MD stated she was responsible for certifying Patient 4's terminal illness. The MD stated she knew two physician signatures were required to certify a patient in their first 90-day benefit period. The MD stated she did not know how she signed as both the Medical Director and Attending Physician. The MD stated the certifying physician's summary for the first 90-day benefit period did not reflect the patient's individual clinical circumstances. The MD stated the third benefit period's face-to-face encounter summary area was blank and the certifying physician's summary was blank. The MD stated she had not signed Patient 4's "Physician Certification for Hospice Benefit," dated for the third benefit period, May 26, 2022, to July 24, 2022. The MD stated she had been scheduled to conduct Patient 4's face-to-face encounter and did not know the certifying physician was not supposed to conduct the face-to-face encounter. The MD stated there was no documented evidence to show the face-to-face encounter had been conducted by a non-certifying physician or nurse practitioner. LVN/CR 1 stated Patient 4's claim for payment was submitted on January 12, 2022. LVN/CR 1 stated she had requested Patient 4's claim for payment for May 2022 but had not received it yet from the billing vendor. 5. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 29, 2021, with a benefit period of September 29, 2021, to December 27, 2021 (First 90-day benefit period) and May 27, 2022, to July 25, 2022, (benefit period number four). Patient 5 had diagnoses that included malignant neoplasm of central nervous system (cancer of the central nervous system). A review of Patient 5's physician's order (by Attending Physician-AP 3) dated September 26, 2021, indicated a hospice referral to the agency. A review of Patient 5's "Physician Certification for Hospice Benefit," dated September 29, 2021, indicated Patient 5 was in her first 90-day benefit period. Patient 5's "Physician Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. Patient 5's "Physician Certification for Hospice Benefit," indicated the Hospice Medical Director's signature on both lines. There was no documented evidence to show AP 3 had signed Patient 5's "Physician Certification for Hospice Benefit." Patient 5's "Physician Certification for Hospice Benefit," indicated an area to document a certifying physician's summary. The area indicated, "Pt [patient] seen and evaluated via face to face and meds [medications] reviewed. Pt has a terminal illness and is hospice appropriate." A review of Patient 5's claims for payment from September 29, 2021, to June 29, 2022, indicated a claim for payment was submitted on October 12, 2021. A review of Patient 5's "Physician Certification for Hospice Benefit," dated for the fourth benefit period, May 27, 2022, to July 25, 2022, indicated Patient 5 was in her fourth benefit period. Patient 5's "Physician Certification for Hospice Benefit," indicated an area to document a face-to-face encounter summary. The area was blank. Patient 5's "Physician Certification for Hospice Benefit," indicated an area to document a certifying physician's summary. The area was blank. Patient 5's "Physician Certification for Hospice Benefit," dated for the fourth benefit period, May 27, 2022, to July 25, 2022, was not signed by a physician. A review of Patient 5's face-to-face encounters from September 29, 2021, to June 29, 2022, was conducted. There was no documented evidence to show a face-to-face encounter had been conducted. Patient 5's claim for payment for May 2022 was requested. The agency did not provide a claim for payment for May 2022. During an interview with a Medical Director (MD) and a Licensed Vocational Nurse/Community Relations (LVN/CR 1) on June 29, 2022, at 12:15 PM, the MD stated she was responsible for certifying Patient 5's terminal illness. The MD stated she knew two physician signatures were required to certify a patient in their first 90-day benefit period. The MD stated she did not know how she signed as both the Medical Director and Attending Physician. The MD stated the certifying physician's summary for the first 90-day benefit period did not reflect the patient's individual clinical circumstances. The MD stated the fourth benefit period's face-to-face encounter summary area was blank and the certifying physician's summary was blank. The MD stated she had not signed Patient 5's "Physician Certification for Hospice Benefit," dated for the fourth benefit period, May 27, 2022, to July 25, 2022. The MD stated she had been scheduled to conduct Patient 5's face-to-face encounter and did not know the certifying physician was not supposed to conduct the face-to-face encounter. The MD stated there was no documented evidence to show the face-to-face encounter had been conducted by a non-certifying physician or nurse practitioner. LVN/CR 1 stated Patient 5's claim for payment was submitted on October 12, 2021. LVN/CR 1 stated she had requested Patient 5's claim for payment for May 2022 but had not received it yet from the billing vendor. 6. A review of Patient 6's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of August 14, 2021, with a benefit period of April 11, 2022, to June 9, 2022 (benefit period number four). Patient 6 had diagnoses that included senile degeneration of brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 6's "Physician Certification for Hospice Benefit," dated April 11, 2022, indicated Patient 6 was in his fourth benefit period. Patient 6's "Physician Certification for Hospice Benefit," indicated an area to document a face-to-face encounter summary. The area was blank. Patient 6's "Physician Certification for Hospice Benefit," indicated an area to document a certifying physician's summary. The area indicated, "Pt [patient] seen and evaluated and meds [medications] were reviewed. Pt is terminally ill and hospice appropriate." A review of Patient 6's face-to-face encounters from August 14, 2021, to June 29, 2022, was conducted. There was no documented evidence to show a face-to-face encounter had been conducted. Patient 6's claim for payment for April 2022 was requested. The agency did not provide a claim for payment for April 2022. During an interview with a Medical Director (MD) and a Licensed Vocational Nurse/Community Relations (LVN/CR 1) on June 29, 2022, at 12:20 PM, the MD stated she was responsible for certifying Patient 6's terminal illness. The MD stated the face-to-face encounter summary area was blank. The MD stated the certifying physician's summary did not reflect the patient's individual clinical circumstances. The MD stated she had been scheduled to conduct Patient 6's face-to-face encounter and did not know the certifying physician was not supposed to conduct the face-to-face encounter. The MD stated there was no documented evidence to show the face-to-face encounter had been conducted by a non-certifying physician or nurse practitioner. LVN/CR 1 stated she had requested Patient 6's claim for payment for April 2022 but had not received it yet from the billing vendor. 7. A review of Patient 7's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of May 22, 2022, with a benefit period of May 22, 2022, to August 19, 2022 (First 90-day benefit period). Patient 7 had diagnoses that included heart failure (a condition that develops when the heart does not pump enough blood for the body's needs). A review of Patient 7's physician's order (by the Medical Director) dated May 21, 2022, indicated a hospice referral to the agency. During an interview with a Licensed Vocational Nurse/Community Relations (LVN/CR 1) on June 29, 2022, at 4:06 PM, LVN/CR 1 stated she had assisted Patient 7 with information about hospice services before admission to the agency. LVN/CR 1 stated due to financial difficulties Patient 7 no longer had access to her attending physician. LVN/CR 1 stated this was why the Medical Director (MD) had written the referral order. A review of Patient 7's "Physician Certification for Hospice Benefit," dated May 22, 2022, indicated Patient 7 was in her first 90-day benefit period. Patient 7's "Physician Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. Patient 7's "Physician Certification for Hospice Benefit," indicated the Hospice Medical Director's signature on both lines. There was no documented evidence to show an Attending Physician had signed Patient 7's "Physician Certification for Hospice Benefit." Patient 7's "Physician Certification for Hospice Benefit," indicated an area to document a certifying physician's summary. The area indicated, "Pt [patient] seen and evaluated meds [medications] were reviewed. Pt is hospice appropriate and terminally ill." A review of Patient 7's claims for payment from May 22, 2022, to June 29, 2022, indicated a claim for payment was submitted on June 20, 2022. During an interview with a Medical Director (MD) and a Licensed Vocational Nurse/Community Relations (LVN/CR 1) on June 29, 2022, at 12:25 PM, the MD stated she was responsible for certifying Patient 7's terminal illness. The MD stated she knew two physician signatures were required to certify a patient in their first 90-day benefit period. The MD stated she did not know how she signed as both the Medical Director and Attending Physician. The MD stated the certifying physician's summary for the first 90-day benefit period did not reflect the patient's individual clinical circumstances. LVN/CR 1 stated Patient 7's claim for payment was submitted on June 20, 2022. 8. A review of Patient 10's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 12, 2021, with a benefit period of January 8, 2022, to March 8, 2022 (benefit period number 11). Patient 10 had diagnoses that included senile degeneration of brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 10's "Physician Certification for Hospice Benefit," dated January 8, 2022, indicated Patient 10 was in her eleventh benefit period. Patient 10's "Physician Certification for Hospice Benefit," indicated an area to document a face-to-face encounter summary. The area indicated, "Pt [patient] seen and evaluated via face to face and meds [medications] were reviewed. Pt. has a terminal illness and is hospice appropriate." Patient 10's "Physician Certification for Hospice Benefit," indicated an area to document a certifying physician's summary. The area indicated, "Pt [patient] seen and evaluated via face to face and meds [medications] were reviewed. Pt. has a terminal illness and is hospice appropriate." A review of Patient 10's face-to-face encounter dated December 24, 2021, by the Medical Director (MD), indicated, "Pt [patient] seen and evaluated via face to face and meds [medications] were reviewed. Pt. has a terminal illness and is hospice appropriate." There was no documented evidence to show any individual clinical assessment or findings. A review of Patient 10's claims for payment from July 12, 2021, to June 29, 2022, indicated a claim for payment was submitted on February 8, 2022. During an interview with a Medical Director (MD) and a Licensed Vocational Nurse/Community Relations (LVN/CR 1) on June 29, 2022, at 12:30 PM, the MD stated she was responsible for certifying Patient 10's terminal illness. The MD stated the face-to-face encounter summary area did not reflect the patient's individual clinical circumstances. The MD stated the certifying physician's summary did not reflect the patient's individual clinical circumstances. The MD stated she had been scheduled to conduct Patient 10's face-to-face encounter and did not know the certifying physician was not supposed to conduct the face-to-face encounter. The MD stated the face-to-face encounter dated December 24, 2021, did not indicate any individual clinical assessment or findings. LVN/CR 1 stated Patient 10's claim for payment was submitted on February 8, 2022. 9. A review of Patient 11's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 11, 2020, with a benefit period of November 5, 2021, to January 3, 2022 (benefit period number seven). Patient 11 had diagnoses that included senile degeneration of brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 11's "Physician Certification for Hospice Benefit," dated November 5, 2021, indicated Patient 11 was in his seventh benefit period. Patient 11's "Physician Certification for Hospice Benefit," indicated an area to document a face-to-face encounter summary. The area was blank. Patient 11's "Physician Certification for Hospice Benefit," indicated an area to document a certifying physician's summary. The area indicated, "99-year-old male with senile degeneration of the brain. Patient is Spanish speaking and granddaughter, [name of granddaughter] translates for us. [Name of granddaughter] reports that he has a poor appetite and must be encouraged to finish his meals. Continues to be confused and combative during personal care. Pt [patient] is terminally ill and hospice appropriate. Pt was seen via face to face and medications were reviewed." A review of Patient 11's face-to-face encounter dated October 20, 2021, by the Medical Director (MD), indicated, "Pt [patient] seen and evaluated via face to face and meds [medications] were reviewed. Pt. has a terminal illness and is hospice appropriate." There was no documented evidence to show any individual clinical assessment or findings. A review of Patient 11's claims for payment from September 11, 2020, to June 29, 2022, indicated a claim for payment was submitted on January 3, 2022. During an interview with a Medical Director (MD) and a Licensed Vocational Nurse/Community Relations (LVN/CR 1) on June 29, 2022, at 12:40 PM, the MD stated she was responsible for certifying Patient 11's terminal illness. The MD stated the face-to-face encounter summary area was blank. The MD stated the certifying physician's summary did not reflect the patient's individual clinical circumstances. The MD stated she had been scheduled to conduct Patient 11's face-to-face encounter and did not know the certifying physician was not supposed to conduct the face-to-face encounter. The MD stated the face-to-face encounter dated October 20, 2021, did not indicate any individual clinical assessment or findings. LVN/CR 1 stated Patient 11's claim for payment was submitted on January 3, 2022. A review of the agency's policy and procedure titled, "Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face Evaluations," undated, indicated the following: "Policy: Hospice will obtain appropriate certification and recertification of terminal illness. Purpose: To define certification/recertification of terminal illness process. Procedure: 1. In order to be eligible to elect Hospice care under Medicare, a patient must be certified as being terminally ill. 2. A patient may elect to receive Hospice care during one or more of the following election periods: An initial 90-day period. A subsequent 90-day period. A subsequent 60-day period. A subsequent extension period of unlimited duration during the patient's lifetime. The periods of care are available in the order listed and may be elected separately at different times. 3. Hospice will obtain written certification of terminal illness for each of the periods listed, even if a single election continues in effect for two, three or four periods. Hospice will obtain the written certification no later than two (2) calendar days after the period begins. If Hospice cannot obtain the written certification within two (2) calendar days, it will obtain oral certification within two (2) calendar days, and written certification prior to submi tting a claim for payment. 4. The Medical Director of physician designee reviews the clinical information and other documentation that supports the medical prognosis for each Hospice patient. This Brief Narrative Statement must accompany the certification and be filed in the patient record. Such information may be provided verbally and will be documented in the patient record. Such information will be included as a part of Hospice's eligibility assessment. The written certification must specify that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: The primary terminal condition. Related diagnosis(es), if any. Current subjective and objective medical findings. Current medication and treatment orders. Information about the medical management of any of the patient's conditions unrelated to the terminal illness. 5. The certification must specify that the patient's prognosis is for a life expectancy of 6 [six] months or less, if the terminal illness runs its normal course. For the initial 90-day period, Hospice must obtain written certification statements (and oral certification statements if required) from: The Medical Director of Hospice or the physician member of the Hospice IDG [interdisciplinary group]; and The patient's attending physician, if the patient has an attending physician. 6. For subsequent periods, the only requirement is recertification by either the Medical Director, physician member of the IDG or patient's attending physician. 7. Before the recertification period for each patient, the Medical Director or physician designee must review the patient's clinical information (as described in #[number] 4 [four]) and develop a Brief Narrative Statement. The Physician Brief Narrative Statement must be completed no more than 15 days prior to recertification. 8. Hospice staff must: Make an appropriate entry in the patient's record as soon as they receive an oral certification; and File written certifications in the patient record. ... 10. A Hospice physician or nurse practitioner (NP) must have a face-to-face encounter with every Hospice patient prior to the patient's third recertification and each subsequent recertification. The encounter must occur no more than 30 calendar days prior to the start of the Hospice patient's third benefit period. The Hospice physician or nurse practitioner must attest that the encounter occurred. The recertifying physician must include a narrative which describes how the clinical findings of the encounter support the patient's terminal prognosis of six months or less: Both the narrative and the attestation must be part of, or an addendum to, the recertification."

Based on interview and record review, the agency failed to follow agency policy and procedure to ensure completeness of requirement for document of service discontinuation and when patients are discharged from hospice for two of eleven sampled patients (Patients 10 and 11), when: 1. For Patient 10: a summary of care provided, and continuing symptoms management needs were not included in the discharge summary for Patient 10. 2. For Patient 11: the discharge summary was not completed and signed by hospice personnel who provided care for Patient 11. This failure had the potential to cause unsafe and ineffective transition for the continuation of care for Patients 10 and 11. Findings: 1. A review of Patient 10's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 12, 2021, with a certification period of January 8, 2022, to March 8, 2022. Patient 10 had diagnoses that included senile degeneration of the brain (older individuals who suffered from cognitive decline, particularly memory loss). A concurrent review of the agency's discharged patients lists as of June 27, 2022, and an interview with the Director of Patient care services 1 (DPCS 1) was conducted. DPCS1 verified Patient 10 was listed as a discharged patient from the agency. During record review on June 28, 2022, at 12:40 PM, of Patient 10's "visit note on call-triage" dated January 25,2022, indicated "...We discussed patient's current condition and both daughters state that they would like their mom to be transported to the hospital for further evaluation... and daughters state they would like to have further treatment at hospital...contacted DPCS for hospice/Hospice medical director and IDT made aware... called 911...ambulance arrived and transported patient to [Name of general acute care hospital] ER (Emergency Room)per both Daughter's wishes for further evaluation...patient left the board and care facility at 7:35 PM...hospice DPCS and IDT made aware..." During record review on June 28, 2022, at 1:45 PM of Patient 10's electronic clinical record "Discharge Summary" signed and dated January 28, 2022, indicated "1/25/22 NOTE FROM ON CALL NURSE: ...{Name of daughter} reports that she was visiting patient and note noted that her mom was congested, breathing heavy which is not normal,...Patient lying in hospital bed alert non-asked questions and patient did not respond verbally...applied oxygen 2 Liters per minute via nasal cannula and raised head of the bed up 30ø...we discussed patient's current condition and both daughters state that they would like their mom to be transported to the hospital for further evaluation. Patient is a full code status, and daughters state they would like to have further treatment at hospital...Contacted DPCS for hospice/IDT report given... Contacted [Name of] Board and Care owner gave her report...called 911. Ambulance arrived and transported patient to [Name of general acute care hospital] per Daughter's wishes for further evaluation...patient left at 7:35 PM. IDT made aware..." During a concurrent record review and interview on June 28, 2022, at 1:50 PM, with the DCPS1 of agency policy and procedure tilted "Discharge Summary" revised November 2011, indicated "POLICY...Each patient discharged from a service and from hospice will have a discharge summary filed in the clinical record... A. The date of discharge, including the date the physician and the patient were informed of discharge...B. The reason for discharge, including the name of the organization to which the patient is being transferred...C. The status of problems identified at admission and during the provision of care...D. The resolution of identified problems...E. Continuing symptom management needs...F. The overall status of the patient...G. A summary of care or services provided...". DCPS 1 stated the discharge summary should have been completed with requirement documentation per the agency policy. 2. A review of Patient 11's face sheet, undated, indicated a start of care date of September 11, 2020, with a certification period of November 5, 2021, to January 3, 2022. Patient 11 had diagnoses that included senile degeneration of the brain (older individuals who suffered from cognitive decline, particularly memory loss) A review of the agency's discharged patients list as of June 27, 2022, was conducted, an interview with the DPCS 1 verified Patient 11 was listed as discharged patient from the agency. During record review on June 28 1:55 PM, of "Discharge Summary" dated January 3, 2022, indicated "...Upon re-assessment with follow-up SN [skilled nurse] visits, the patient has demonstrated no signs of decline and was discussed with an IDT [=Interdisciplinary Team is a group of health care professionals with various areas of expertise who work together toward the goals of their clients] meeting on 12/22/2021 (December 22,2021) with a scheduled discharge date of 01/03/2022 (January 3, 2022) ...Patient and family made aware, medications were refilled for 2 weeks, supplies were sent out for 2 weeks, NOMNOC [Notice of Medicare Non-Coverage is a notice delivered to beneficiaries/enrollees receiving covered hospice services before Medicare covered services end]....was signed by family who understands and accepts day of discharge 01/03/2022 (January 3, 2022) ... IDT made aware of patient`s discharge for extended prognosis on 01/03/2022 (January 3, 2022) ..." During a concurrent record review and interview on June 28, 2022, at 2:00 PM with the DCPS 1 of Patient 11's electronic clinical record "Discharge Summary" electronic signed date January 3,2022, indicated "by Administrator [name of the administrator], ADMIN." DCPS 1 confirmed Patient 11's discharge summary completed and signed by administrator. During a concurrent record review and interview on June 28, 2022, at 2:05 PM with the DCPS1 of agency policy and procedure tilted "discharge summary" revised November 2011 indicated "PROCEDURE...1. Hospice personnel who provide care will complete a discharge summary...". DCPS 1 stated the discharge summary should have been completed and signed by clinician not the administrator per agency policy. A review of the agency's policy and procedure titled, "Discharge Summary" revised November 2011, indicated the following: "PURPOSE To define requirements for documentation of service discontinuation and when patients are discharged from hospice. POLICY Each patient discharged from a service and from hospice will have a discharge summary filed in the clinical record. PROCEDURE Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include, as appropriate: A. The date of discharge, including the date the physician and the patient were informed of discharge B. The reason for discharge, including the name of the organization to which the patient is being transferred C. The status of problems identified at admission and during the provision of care D. The resolution of identified problems E. Continuing symptom management needs F. The overall status of the patient G. A summary of care or services provided."