Every finding on record at Heart to Heart Hospice of Lansing, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, document review, and interview. Agency policy # PE.1 "Patient Assessments" (revised 010120) stated in part, "The Comprehensive Assessment will identify a review of all of the patient's prescription and over-the-counter drugs, herbal remedies, and other alternative treatments." In 4 of 4 (100%) home visits observed, the agency did not ensure that comprehensive assessment included a review of the patient's current medications. Home Visit 1/Clinical Record 1: The patient elected hospice care on 9/13/2023 and resided in an assisted living facility (ALF). The patient's documented terminal diagnosis was Chronic Obstructive Pulmonary Disease (COPD). During the home visit with the registered nurse (RN) [Personnel Record 7] on 11/29/2023, a medication reconciliation was performed comparing the hospice medication profile dated 11/29/2023 and the ALF medication administration record dated 11/29/2023. The ALF medication administration record documented, "L-ProAir HFA 108 mcg inhalation spray. Inhale two (2) puffs into the lungs every six (6) hours as needed (PRN) for wheezing or shortness of breath." The ALF medication administration record documented, "L-stomach relief 525 mg, take 30 ml every hour as needed, a maximum of eight (8) doses in twenty-four (24) hours. The hospice medication profile did not document L-stomach relief. There was no evidence the review of the patient's medication regimen included L-stomach relief. Home Visit 2/Clinical Record 2: The patient elected hospice care on 2/1/2023 with a terminal diagnosis of Cerebral Infarction due to Thrombosis. During the home visit with the RN [Personnel Record 8] on 11/29/2023, a medication reconciliation was performed, comparing the hospice medication profile and the patient's medications in the home. The hospice medication profile documented, "Tizanidine 2 mg, take one (1) capsule two (2) times daily." The medication bottle documented "Tizanidine 2 mg, take one (1) capsule three (3) times daily. The patient's caregiver stated the patient takes "Tizanidine 2 mg, one (1) tablet once daily." The hospice medication profile documented, "Tylenol Extra Strength 500 mg, take two (2) tablets three (3) times a day as needed (PRN) for pain. The caregiver stated the patient takes Tylenol Extra Strength 500 mg. one tablet every day for pain. The hospice medication profile did not document the patient's current medication regimen. Home Visit 3/Clinical Record 3: The patient elected hospice care on 11/13/2023 and resided in an ALF. The patient's documented terminal diagnosis was Cerebral Atherosclerosis. During the home visit with the hospice aide [Personnel Record 3] on 11/29/2023, a medication reconciliation was performed comparing the hospice medication profile dated 11/29/2023 and the ALF medication administration record dated 11/29/2023. The ALF medication administration record documented, "Atorvastatin 20 mg, take one (1) tablet daily.” The hospice medication profile did not document Atorvastatin. There was no evidence the review of the patient's medication regimen included Atorvastatin. The ALF medication administration record documented, "Tamsulosin cap 0.4 mg, take one (1) capsule by mouth every other day." The hospice medication profile documented, "Tamsulosin cap 0.4 mg, take one (1) capsule by mouth daily." The hospice medication profile did not document the patient's current medication regimen. Home Visit 4/Clinical Record 4: The patient elected hospice care on 1/24/2023 and resided in a skilled nursing facility (SNF). During the home visit with the Social Worker (SW) [Personnel Record 6] on 11/29/2023, a medication reconciliation was performed by comparing the hospice medication profile dated 11/29/2023 to the SNF medication administration record dated 11/29/2023. The SNF medication administration record documented, "Ivabradine HCL 5 mg, take one (1) tablet two (2) times daily;" Loratadine 10 mg, take one (1) tablet daily for allergies; and Sertraline 50 mg, take one (1) tablet daily for depression; and "Sertraline 25 mg, take one (1) tablet daily with the 50 mg tablet to equal a total of 75 mg daily." The hospice medication profile did not document Ivabradine HCL, loratadine, or sertraline. There was no evidence the review of the patient's medication regimen included Ivabradine HCL, loratadine, or sertraline. During the joint observations, record review, and interviews completed on 11/29/2023, the Executive Director, present for the visit, confirmed the hospice agency medication profiles did not match the patient's current medication regimens.

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. Agency policy #TX.06 (revised 010120) "Plan of Care Process" stated in part, "The hospice will develop an individualized plan of care for each patient. The POC must reflect patient and family goals and interventions based on the patient's problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal illness and related conditions." In 3 of 19 (16%) clinical records reviewed, the hospice did not ensure the written plan of care contained current goals and interventions based on the comprehensive assessment. Clinical Record 3: The patient elected hospice care on 11/13/2023. The Certificate of Terminal Illness (CTI) signed by the physician on 11/14/2023 documented, "Had poor safety awareness [when] with attempted to ambulate despite growing weakness." The initial comprehensive assessment completed by the registered nurse (RN) dated 11/13/2023 documented, "Patient has very poor safety awareness and attempts to self-transfer often resulting in multiple falls in the last six (6) months." The plan of care dated 11/13/20 included no documentation of problems, goals, or interventions related to the patient's safety or falls. The problems documented included, "tension and anxiety, spiritual anxiety, acer coordination, volunteer companionship, gastrointestinal, and neurological. During a joint record review and interview on 11/28/2023, the Executive Director confirmed the plan of care did not contain goals, problems, or interventions related to safety or falls. Clinical Record 8: The patient elected hospice care on 7/8/2021 with a terminal diagnosis of end-stage heart failure. The CTI signed by the physician on 10/31/202 documented "Patient experiences frequent falls because he forgets to use his walker." The Interdisciplinary Team Meeting (IDT) dated 10/5/2023 documented the patient received an as-needed, unscheduled assessment on 9/23/2023 due to a fall. The Hospice IDG Comprehensive Assessment and Plan of Care Update for 9/1/2023 through 10/30/2022 included no documentation of problems, goals, or interventions related to safety or falls. The problems documented in the updated plan of care included anticipatory grief; cardiopulmonary; coping and depression; and edema. During a joint record review and interview on 11/31/2023, the Executive Director confirmed the plan of care did not contain goals, problems, or interventions related to safety or falls. Clinical Record 12: The patient elected hospice care on 6/2/2022. The CTI signed by the physician 11/9/2023 documented, "often falls and is restless." The RN assessment dated 10/23/2023 documented a post-fall evaluation. The plan of care dated 9/25/2023 through 11/23/2023 included no documentation of problems, goals, or interventions related to safety or falls. The comprehensive assessment completed by the RN on 10/30/2023 documented a "Co-Morbid Diagnosis...history of falls." During a joint record review and interview on 11/31/2023, the Executive Director confirmed the plan of care did not contain goals, problems, or interventions related to safety or falls.

It is required that each patient’s individualized written plan of care includes all drugs and treatments necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 3 of 19 (16%) clinical records reviewed and home visits observed, the hospice agency did not ensure the plan of care contained all drugs necessary for the palliation of the patient. Clinical Record 1/Home Visit 1: The patient elected hospice care on 9/13/2023 and resided in an assisted living facility (ALF). The patient's documented terminal diagnosis was Chronic Obstructive Pulmonary Disease (COPD). During the home visit with the registered nurse (RN) [Personnel Record 7] on 11/29/2023, a medication reconciliation was performed comparing the hospice medication profile and plan of care dated 11/29/2023 and the ALF medication administration record dated 11/29/2023. The ALF medication administration record documented, "L-ProAir HFA 108 micrograms (mcg) inhalation spray. Inhale two (2) puffs into the lungs every six (6) hours as needed (PRN) for wheezing or shortness of breath." The ALF medication administration record documented, "L-stomach relief 525 mg, take 30 ml every hour as needed, a maximum of eight (8) doses in twenty-four (24) hours. The plan of care dated 11/29/2023 did not document L-ProAir HFA and L-stomach relief. Clinical Record 3/Home Visit 3: The patient elected hospice care on 11/13/2023 and resided in an ALF. The patient's documented terminal diagnosis was Cerebral Atherosclerosis. During the home visit on 11/29/2023, a medication reconciliation was performed comparing the hospice medication profile and plan of care dated 11/29/2023 and the ALF medication administration record dated 11/29/2023. The ALF medication administration record documented, "Atorvastatin 20 mg, take one (1) tablet daily." The plan of care dated 11/29/2023 did not document Atorvastatin. Clinical Record 4/Home Visit 4: The patient elected hospice care on 1/24/2023 and resided in a skilled nursing facility (SNF). During the home visit on 11/29/2023, a medication reconciliation was performed by comparing the hospice medication profile to the SNF medication administration record. The SNF medication administration record dated 11/29/2023 documented, "Ivabradine HCL 5 mg, take one (1) tablet two (2) times daily; "Loratadine 10 mg, take one (1) tablet daily for allergies;" and "Sertraline 50 mg, take one (1) tablet daily for depression;" and "Sertraline 25 mg, take one (1) tablet daily with the 50 mg tablet to equal a total of 75 mg daily." The plan of care dated 11/29/2023 did not document Ivabradine HCL, loratadine, or sertraline. In addition, the patient was actively using a bilevel-positive airway pressure (BiPAP) machine. The plan of care did not include documentation of the BiPAP use or settings. During a joint record review and interview on 11/29/2023, the Executive Director, present for the visit, confirmed the agency was not aware of the BiPAP, and the agency had not included the BiPAP on the patient's plans of care to date. During the joint observations, record review, and interviews on 11/29/2023, the Executive Director, present for the visit, confirmed the hospice agency plans of care did not contain all of the patient's current medications and treatments.

It is required that each patient’s individualized written plan of care includes medical supplies and appliances necessary to meet the needs of the patient This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 19 (11%) clinical records reviewed, the hospice agency did not ensure the plan of care (POC) contained all medical supplies and appliances necessary for the palliation of the patient. Clinical Record 2/Home Visit 2: The patient elected hospice care on 12/1/2021 with a terminal diagnosis of Cerebral Infarction due to Thrombosis. The POC dated 10/1/2023 through 11/29/2023 documented "none" under the headings durable medical equipment (DME) and supplies. The RN comprehensive assessment dated 10/4/2023 sub-section genitourinary documented, "patient is incontinent." A review of the agency's manual supply form documented with the patient's name revealed two (2) large briefs, two (2) wipes, and two (2) Chux being provided. It was signed by the caregiver on 11/23/2023 as evidence of supply delivery. During the home visit on 11/29/2023, it was confirmed the patient did receive briefs, wipes, and gloves. The POC did not include documentation of the supplies. In addition, the patient had an oxygen concentrator in the home, which the Executive Director, present for the visit, confirmed was not on the patient's plan of care dated 11/29/2023 Clinical Record 4/Home Visit 4: The patient elected hospice care on 1/24/2023 with a terminal diagnosis of heart failure with a secondary diagnosis of Duchenne Muscular Dystrophy. The patient resided in a skilled nursing facility (SNF). During the home visit on 11/29/2023, the patient used a bilevel-positive airway pressure (BiPAP) machine. The BiPAP was not documented with DME and supplies on the plan of care. During a joint record review and interview on 11/29/2023, the Executive Director, present for the visit, confirmed the agency was not aware of the BiPAP, and the agency had not included the BiPAP on the patient's plans of care to date.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a 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 1 of 16 (6%) clinical records reviewed of patients that accepted hospice aide services, the hospice agency did not ensure the hospice aide received specific written instructions regarding the patient's type of bath. Clinical Record 11: The patient elected hospice care on 3/17/2023 with the terminal diagnosis of Huntington's Disease. The hospice aide care plan dated 9/15/2023 with no end date assigned the hospice aide two types of baths. The care plan stated in part, "Bed bathe every visit, and shower every visit." During the week of 10/8/2023 through 10/14/2023, the hospice aide visit notes dated 10/10/2023 and 10/12/2023 documented that a shower was completed, and the bed bath was not completed. The hospice aide documented the RN was notified the bed bath was not completed. The hospice aide was not provided clear instructions regarding the patient's type of bath. During a joint record review and interview on 11/31/2023, the Executive Director confirmed the RN did not provide clear and specific instructions to the hospice aide, thus forcing the aide to make decisions not within their scope of practice.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, permitted to be performed under State law, and included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy #TX.06 (revised 010120) "Plan of Care Process" stated in part, "To ensure that care is provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient and family's specific needs." Sub-section Roman Numeral one (I) stated in part, "All hospice care and services furnished to patients and their families will follow an individualized written plan of care." In 3 of 16 (19%) clinical records reviewed of patients that accepted hospice aide services, the hospice agency did not ensure the hospice aide provided services according to the care plan. Clinical Record 3: The patient elected hospice care on 11/13/2023 with the terminal diagnosis Cerebral Atherosclerosis. The hospice aide care plan dated 11/13/2023 assigned the hospice aide the task: linens to be changed one time weekly. The week of 11/19/2023 through 11/25/2023, the hospice aide visit notes documented that linens were changed on 11/20/2023 and 11/22/2023, two (2) times a week. During a joint record review and an interview on 11/28/2023, the Executive Director confirmed the hospice aide did not follow the plan of care because the linens were changed twice a week Clinical Record 5: The patient elected hospice care on 6/5/2023. The hospice aide care plan dated 9/3/2023 through 12/1/2023 assigned the hospice aide the task: "bed bath first and third visit of the week." During the week of 11/5/2023 through 11/11/2023, the hospice aide documented the patient received a bed bath for the visits dated 11/7/2023, 11/8/2023, and 11/9/2023. During a joint record review and an interview on 11/29/2023, the Executive Director confirmed the hospice aide did not follow the plan of care because a bed bath was provided during all three (3) visits the week of 11/7/2023 through 11/11/2023. Clinical Record 10: The patient elected hospice care on 3/28/2023 with a terminal diagnosis of Alzheimer's disease. The hospice aide care plan dated 9/6/2023 with no end date assigned the hospice aide the tasks "bed bath to be completed the first and third visit of the week, turn and position every visit to assist with toileting every visit." During the week of 9/24/2023 through 9/30/2023, the patient received hospice aide visits on 9/25/2023, 9/26/2023, and 9/29/2023. The hospice aide visit note dated 9/25/2023 documented, "turn and position in bed not completed per frequency not required this visit, assist with toileting not completed per frequency not required this visit, shower not completed per frequency not required this visit, and shampoo not completed per frequency not required this visit. During a joint record review and an interview on 11/30/2023, the Executive Director confirmed the hospice aide did not follow the plan of care because the interventions, turn and position, and assistance with toileting were to be completed every visit.

It is required that only a physician, a nurse practitioner, or a physician assistant (who is the patient’s attending physician and not an employee of or under arrangement with the hospice) in accordance with the plan of care and state law, may order drugs for the patient. If the drug order is verbal or given by or through electronic transmission: it is given only to a licensed nurse, nurse practitioner (where appropriate), pharmacist or physician. The individual receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal law and regulation. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #TX.16 "Medication Administration and Management" (revised 082115) stated in part, "Agency nurse will transcribe written physician's medication orders as soon as possible after they are received. These will be signed within sixty (60) days by the physician." In 1 of 19 (5%) clinical records reviewed, the hospice agency did not ensure the licensed nurse receiving a verbal order recorded and signed the order immediately and had the prescribing person sign it in accordance with state and federal law and regulation. Clinical Record 9: The patient elected hospice care on 9/28/2023. The comprehensive assessment completed by the registered nurse (RN) on 10/13/2023 documented, "Spoke with the patient about steroid that was ordered to help patient with jaw and neck discomfort due to tumor." There was no documented evidence of a physician's orders for the steroid medication. A review of the clinical record revealed no evidence the patient's medication profile was updated to include documentation of the steroid medication as of 11/31/2023. During an interview and a joint record review, the RN Case Manager confirmed the patient was started on the steroid Decadron "in October" and confirmed there was no physician's order for the decadron. The RN Case manager reported they must have forgotten to enter the order in the electronic medical record but they had received a verbal order from the physician for the medication. During a joint record review and an interview on 11/31/2023, the Executive Director confirmed the clinical record did not contain a physician's order for the steroid medication.

It is required that the hospice assumes responsibility for the professional management of the SNF/NF or ICF/IDF resident's hospice services in accordance with the hospice plan of care (POC) and the hospice conditions of participation. Any arrangements necessary for hospice-related inpatient care are made in a participating Medicare/Medicaid facility per the inpatient standards (HSIC chapter in this Manual). THIS IS A CMS CONDITION-LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record review, document review, and interview with the Executive Director which revealed the hospice failed to ensure the Interdisciplinary Group (IDG) maintained responsibility for the professional management for the provision and coordination of all hospice services provided to the patient residing in a Skilled Nursing Facility (SNF) [HSRF.4.I/L762]; Failed to ensure that all hospice care provided in the SNF was provided in accordance with the hospice plan of care [HSRF.6.I/L775]; and Failed to ensure that a written plan of care was established in consultation with the SNF and specified which provider was responsible for performing the functions that were agreed upon and included in the plan of care. [HSRF.6.I/L774]. The cumulative effect of these systemic problems has resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation 42 CFR 484.112: Hospices that provide hospice care to residents of a SNF/NF or ICF/IID. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients residing in a skilled facility cared for by the agency.

It is required that the hospice is responsible for providing all hospice services to the residents/hospice patients including: ongoing assessment, monitoring, care planning, coordination, and provision of care by the hospice Interdisciplinary Group (IDG); assessment, coordination, and provision of needed general inpatient or continuous care; consultation about the patient’s/resident’s care with the facility staff; coordination by the hospice RN for the implementation of the plan of care for the patient/resident; provision of hospice aide services, if these services are determined to be necessary by the IDG to supplement the nurse aide services provided by the facility; provision, in a timely manner, of all supplies, medications, and durable medical equipment (DME) needed for the palliation and management of the terminal illness and related conditions; financial management responsibilities for all supplies, appliances, medications, and biologicals related to the terminal illness and related conditions; determination of the appropriate level of care to be given to the patient/resident (i.e., routine homecare, inpatient or continuous care); [and] arranging any necessary transfers from the facility of residence in consultation with the facility staff. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #TX.08 Interdisciplinary Group Roles and Responsibilities" (revised 2/26/2021) stated in part, "The agency will designate a registered nurse that is a member of the IDG to provide coordination of care and to ensure continuous assessment of each patient's and [family's] families needs, and implementation of the IDG plans of care." In 1 of 7 (14%) clinical records reviewed of patients residing in a skilled nursing facility (SNF), the hospice did not ensure the IDG maintained responsibility for the provision and coordination of all hospice services provided to the patient. Specifically ongoing assessment, monitoring, care planning, coordination, and provision of care by the hospice Interdisciplinary Group (IDG). Clinical Record 4/Home Visit 4: The patient elected hospice care on 1/24/2023 with a terminal diagnosis of heart failure with a secondary diagnosis of Duchenne Muscular Dystrophy. The patient resided in a skilled nursing facility (SNF). During the home visit on 11/29/2023, the patient used a bilevel-positive airway pressure (BiPAP) machine. The BiPAP machine was not documented on the hospice plan of care dated 11/29/2023. The plan of care did not contain documentation of the use of the BiPAP machine or physician orders for the settings. The SNF treatment profile dated 11/29/2023 documented the patient's use of the BiPAP machine. The Skilled Nursing Facility treatment profile stated in part, "BiPAP settings: IPAP 16 cm, H2O, EPAP 8 cm H2O, Bleed oxygen 2 liters per minute. Height seventy-two (72) inches, weight two hundred (245) pounds." During a joint observation, record review, and interview on 11/29/2023, the Executive Director confirmed the hospice was not aware of the BiPAP use and the hospice clinical record did not contain a physician order for the BiPAP use and settings. The Executive Director confirmed the BiPAP was not on the patient's plans of care dated 1/24/2023 through 11/29/2023. The Executive Director placed a phone call to the DME provider in the presence of the site visitor, and it was revealed the hospice agency was not being billed for the BiPAP machine. The Executive Director provided billing information for the BiPAP machine. In addition, Respiratory Therapy was contacted to make an in-person visit so that BiPAP settings could be verified.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #TX.08 "Interdisciplinary Group Roles and Responsibilities" (revised 2/26/2021) stated in part, "The agency will designate a registered nurse that is a member of the IDG to provide coordination of care and to ensure continuous assessment of each patient's and [family's] families needs, and implementation of the IDG plans of care." In 1 of 7 (14%) clinical records reviewed of patients residing in a skilled nursing facility (SNF), the agency did not ensure that a written plan of care was established in consultation with the SNF and specified which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 4/Home Visit 4: The patient elected hospice care on 1/24/2023 with a terminal diagnosis of heart failure with a secondary diagnosis of Duchenne Muscular Dystrophy. The patient resided in a skilled nursing facility (SNF). During the home visit on 11/29/2023, the patient used a bilevel-positive airway pressure (BiPAP) machine. The BiPAP machine was not documented on the hospice plan of care dated 11/29/2023. The plan of care did not contain documentation of the use of the BiPAP machine or physician orders for the settings. The SNF treatment profile dated 11/29/2023 documented the patient's use of the BiPAP machine. The Skilled Nursing Facility treatment profile stated in part, "BiPAP settings: IPAP 16 cm, H2O, EPAP 8 cm H2O, Bleed oxygen 2 liters per minute. Height seventy-two (72) inches, weight two hundred (245) pounds." The hospice plan of care did not specify the services the SNF was responsible for or what the hospice agency was responsible for concerning the BiPAP use, education, and maintenance. During a joint observation, record review, and interview on 11/29/2023, the Executive Director confirmed the hospice was unaware of the BiPAP use and that the hospice clinical record did not contain a physician order for the BiPAP use and settings. The Executive Director confirmed the BiPAP was missing from the patient's plans of care dated 1/24/2023 through 11/29/2023. The Executive Director placed a phone call to the DME provider in the presence of the site visitor, and it was revealed the hospice agency was not being billed for the BiPAP machine. The Executive Director provided billing information for the BiPAP machine. In addition, Respiratory Therapy was contacted to make an in-person visit so that BiPAP settings could be verified.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The plan of care reflects the participation of the hospice, the SNF/NF or ICF/IDF, and the patient and family to the extent possible. All hospice care is provided in the facility in accordance with the hospice plan of care. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #TX.08 "Interdisciplinary Group Roles and Responsibilities" (revised 2/26/2021) stated in part, "The agency will designate a registered nurse that is a member of the IDG to provide coordination of care and to ensure continuous assessment of each patient's and [family's] families needs, and implementation of the IDG plans of care." In 1 of 7 (14%) clinical records reviewed of patients residing in a skilled nursing facility (SNF), the hospice did not ensure that all hospice care provided in the SNF was provided in accordance with the hospice plan of care. Clinical Record 4/Home Visit 4: The patient elected hospice care on 1/24/2023 with a terminal diagnosis of heart failure with a secondary diagnosis of Duchenne Muscular Dystrophy. The patient resided in a skilled nursing facility (SNF). During the home visit on 11/29/2023, the patient used a bilevel-positive airway pressure (BiPAP) machine. The BiPAP machine was not documented on the hospice plan of care dated 11/29/2023. The plan of care did not contain documentation of the use of the BiPAP machine or physician orders for the settings. The SNF treatment profile dated 11/29/2023 documented the patient's use of the BiPAP machine. The Skilled Nursing Facility treatment profile stated in part, "BiPAP settings: IPAP 16 cm, H2O, EPAP 8 cm H2O, Bleed oxygen 2 liters per minute. Height seventy-two (72) inches, weight two hundred (245) pounds." During a joint observation, record review, and interview on 11/29/2023, the Executive Director confirmed the hospice was unaware of the BiPAP use and that the hospice clinical record did not contain a physician order for the BiPAP use and settings. The Executive Director confirmed the BiPAP was missing from the patient's plans of care dated 1/24/2023 through 11/29/2023. The Executive Director placed a phone call to the DME provider in the presence of the site visitor, and it was revealed the hospice agency was not being billed for the BiPAP machine. The Executive Director provided billing information for the BiPAP machine. In addition, Respiratory Therapy was contacted to make an in-person visit so that BiPAP settings could be verified.