Every finding on record at Hoosier Uplands Economic Development Corporation

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed it was revealed that the agency did not ensure that the initial comprehensive assessments were completed within the required 5-day time frame. CLINICAL RECORD 3: The patient elected the hospice benefit on 10/06/2025. Review of the clinical record revealed the social worker did not complete the initial comprehensive assessment within the required 5 calendar days. The assessment was completed on 10/17/2025 (9 days). There was no documentation explaining a missed visit or the reason for the delay. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/02/2025. Review of the clinical record revealed that the social worker did not complete the initial comprehensive assessment within the required 5 calendar days. A missed visit was documented on 10/06/2025 due to scheduling conflicts, and the full assessment was not completed until 10/18/2025 (12 days). There was no documentation explaining the missed visit or the delay in completing the assessment. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/13/2025. Review of the clinical record revealed that the social worker did not complete the initial comprehensive assessment within the required 5 calendar days. The assessment was completed on 03/20/2025 (7 days). There was no documentation explaining a missed visit or the delay in completing the assessment. During a joint record review and interview on 12/05/2025, the Director of Nursing confirmed that social worker assessments were not completed within the required 5 calendar days.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed it was revealed that the agency did not ensure that the plans of care include all services necessary for palliation and management of the terminal illness including interventions to manage pain and symptoms. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/03/2025. Review of the clinical record revealed that the most recent plan of care for the certification period 11/30/2025–01/28/2026 did not include specific instructions for Foley catheter management. Under interventions, the plan only stated, “catheter care,” without detailed guidance such as frequency of catheter changes, monitoring for signs and symptoms of infection, maintaining catheter patency, or actions to take if complications occur. There was no evidence that the plan of care included all interventions related to Foley catheter management. CLINICAL RECORD 10: The patient elected the hospice benefit on 09/19/2025. Review of the clinical record revealed that the initial plan of care sated 09/19/2025 did not include specific instructions for Foley catheter management. The plan only stated, “catheter care,” without detailed guidance such as frequency of catheter changes, monitoring for signs and symptoms of infection, maintaining catheter patency, or actions to take if complications occur. There was no evidence that the plan of care included all interventions related to Foley catheter management. Following a joint review of records and an interview on 12/05/2025 with the Director of Nursing, she confirmed that the patients’ written plans of care did not fully address all interventions required for effective pain and symptom management.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following, measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed it was revealed that the agency did not ensure that the patients' current plans of care included all services necessary for palliation and management of the terminal illness including measurable outcomes from implementing and coordinating the plan of care. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/03/2025. Review of the clinical record revealed that the patient was admitted with a Foley catheter, and the current plan of care did not specify interventions related to the maintenance of the foley catheter just "catheter care". The plan of care did not include goals related to Foley catheter management or genitourinary status. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/02/2025. Review of the clinical record revealed that the initial comprehensive assessment completed on 10/02/2025 identified multiple problems, including pain, fall risk, confusion, and altered cardiopulmonary function. The plan of care, however, did not include individualized measurable goals addressing these issues. For example, a goal noted was “Maintain adequate cardiopulmonary status equal to disease process” and "demonstrate adequate ventilation and oxygenation”. CLINICAL RECORD 8: The patient elected the hospice benefit on 09/28/2024. Review of the clinical record showed that the comprehensive assessment dated 09/28/2024 and subsequent assessments identified multiple problems, including pain and shortness of breath, with the patient requiring oxygen at 2–4 liters via nasal cannula as needed. However, the plan of care did not include individualized, measurable goals based on these assessed needs. Goals noted were generic, such as “Maintain adequate cardiopulmonary status equal to disease process” and “Demonstrate adequate ventilation and oxygenation.” CLINICAL RECORD 9: The patient elected the hospice benefit on 10/11/2025. Review of the clinical record indicated that the comprehensive assessment on 10/11/2025 identified multiple problems, including confusion, hallucinations, forgetfulness, and leg pain. However, the plan of care did not include individualized goals addressing these issues. Specifically, there were no goals related to pain management, cognitive symptoms (confusion/hallucinations), or safety—such as fall prevention, the patient was assessed as high fall risk. CLINICAL RECORD 10: The patient elected the hospice benefit on 09/19/2025. Review of the clinical record revealed that the patient was admitted with a Foley catheter and had physician orders for catheter changes every three weeks. However, the plan of care did not include goals related to Foley catheter management or genitourinary status, despite the patient’s documented history of recurrent urinary tract infections. Following a joint review of records and an interview with the Director of Nursing, she acknowledged that the goals were neither individualized to the assessed problems nor measurable.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 7 of 14 (50%) clinical records reviewed it was revealed that the agency did not ensure that the plan of care was reviewed and revised as frequently as the patient's condition requires but no less that every 15 days. CLINICAL RECORD 1: The patient elected the hospice benefit on 09/28/2022. Review of the clinical record revealed the individualized plan of care was not revised to reflect changes in the patient’s condition. On 11/06/2025, nursing documented persistent abdominal pain rated 2.5/5, described as constant and cramp-like; the physician was notified, and liquid morphine was increased to 25 mg every 1–4 hours as needed. On 11/20/2025, nursing documented bilateral foot pain fluctuating up to 3/5. However, the Interdisciplinary Group (IDG) documentation for 11/26/2025 reflected only “Abdomen cramp-like medications effective” under the pain problem. There was no evidence of a comprehensive review of the prior two weeks, no indication of plan revisions based on ongoing assessments, and no documented plan for managing pain over the next two weeks. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/03/2025. Review of the clinical record revealed the individualized plan of care was not revised to reflect changes in the patient’s condition. Nursing documentation on 10/22/2025 noted a reddened gluteal area with wound care interventions and a Dulcolax suppository for constipation. However, the Interdisciplinary Group (IDG) documentation for 10/30/2025 did not include any skin/integumentary concerns and, under GU/GI, only noted “F/C sediment.” There was no evidence of a comprehensive review of the prior two weeks, no indication of plan revisions based on ongoing assessments, and no documented plan for the next two weeks CLINICAL RECORD 3: The patient elected the hospice benefit on 10/06/2025. Review of the clinical record revealed the individualized plan of care was not revised to reflect changes in the patient’s condition. Nursing documentation noted a right lower arm skin tear on 10/28/2025 and additional skin tears with wound care orders on 11/05/2025. On 11/05/2025, nursing also documented chest pain, increased shortness of breath, and initiation of oxygen. However, the IDG documentation for 11/13/2025 only stated “skin tears noted” and did not address the chest pain episode. There was no evidence of a comprehensive review of the prior two weeks, no indication of plan revisions based on ongoing assessments, and no documented plan for the next two weeks CLINICAL RECORD 8: The patient elected the hospice benefit on 09/28/2024. Review of the clinical record revealed the individualized plan of care was not revised to reflect changes in the patient’s condition. Nursing documentation noted increased pain and significant right shoulder edema on 10/08/2025, pain radiating from the shoulder to the hand on 10/14/2025 and continued right shoulder pain with noticeable swelling on 10/29/2025. Pain management progressed from tramadol to oxycodone and morphine as needed. However, the IDG documentation for 11/13/2025 only stated “pain right shoulder, medications effective,” with no evidence of a comprehensive review of the prior two weeks, no indication of plan revisions based on ongoing assessments, and no documented plan for the next two weeks CLINICAL RECORD 10: The patient elected the hospice benefit on 09/19/2025. Review of the clinical record revealed the individualized plan of care was not revised to reflect changes in the patient’s condition. Nursing documentation on 10/27/2025 indicated the patient was started on Septra DS twice daily for a urinary tract infection (UTI). On 11/05/2025, doxycycline was ordered due to continued UTI symptoms. However, IDG documentation on 10/30/2025 noted only “F/C with sediment” under GI/GU status, and on 11/13/2025 noted “F/C urine clear.” There was no evidence of a comprehensive review of the prior two weeks, no indication of plan revisions based on ongoing assessments, and no documented plan for the next two weeks. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/25/2025. Review of the clinical record revealed the individualized plan of care was not revised to reflect changes in the patient’s condition. Nursing documentation on 09/16/2025 indicated the patient’s granddaughter took the patient to the emergency room due to combative behavior and suspected urinary tract infection (UTI). However, IDG documentation on 09/18/2025 contained no update regarding UTI symptoms or the emergency room visit. There was no evidence of a comprehensive review of the prior two weeks, no indication of plan revisions based on ongoing assessments, and no documented plan for the next two weeks CLINICAL RECORD 13: The patient elected the hospice benefit on 06/02/2022. Review of the clinical record revealed the individualized plan of care was not revised to reflect changes in the patient’s condition. Nursing documentation on 11/04/2023 noted an open area on the left buttock; however, the IDG meeting on 11/14/2023 contained no update regarding skin/integumentary status. On 11/26/2024, the patient was documented as impending death with daily visits ordered, yet the IDG meeting on 11/27/2024 only reflected “non-verbal, incontinent of bladder/bowel.” The patient died on 11/28/2024. There was no evidence of a comprehensive review of the prior two weeks, no indication of plan revisions based on ongoing assessments, and no documented plan for the next two weeks. During a joint record review and interview with the Director of Nursing on 12/05/2025, she confirmed that individualized care plans were not being updated as required to reflect changes in the patient’s condition.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by interview and observation. In 2 of 3 (67%) home visits it was revealed that the agency did not ensure that standards of practice to prevent transmission of infections and communicable diseases were followed related to hand hygiene. Hand Washing Policy: The agency policy "HAND WASHING POLICY", which is undated, page 32 ,states: "POLICY: In an effort to reduce the risk for infection in clients and staff members, thorough hand washing is required of all employees. PURPOSE: To prevent the transmission of infectious agents between clients and health care workers or between staff via hands. SPECIAL INSTRUCTIONS: . Use of an alcohol based hand sanitizer is acceptable, unless: A. Hands are visibly soiled b. After known or suspected exposure to patients with infectious diarrhea during norovirus outbreaks. When washing hands with soap and water, wet hands first with water, apply soap to hands and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable paper towel. Use towel to turn off faucet. Avoid using hot water, to prevent drying of skin. You should keep soap and paper towels in an outer pocket of your bag. When decontaminating hands with an alcohol based hand sanitizer, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. This should take around 20 seconds. 4. Indications for hand washing include, but are not limited to: a. Before and after patient contact, b. After contact with objects in the immediate vicinity of the patient, before eating, drinking, or handling food, after using a restroom, After contact with blood, body fluids or excretions, mucous membranes, non-intact skin or wound dressing. Before and after invasive procedures (in addition to wearing gloves) Before and after performing aseptic technique (e.g. insertion of an IV, preparing an injection, performing wound care.) Between each glove change. Between activities on the same client involving different body site. Moving from a contaminated body site to a clean body site during patient care. After any contact with contaminated articles or surfaces; including PPE. HOME VISIT 2: The patient elected the hospice benefit on 08/05/2021. During a home visit, observation with the licensed practical nurse (LPN) (Personnel Record 4), the LP was observed accessing and re-accessing her nursing bag multiple times without sanitizing her hands before or after contact with the bag or patient care items. HOME VISIT 3: The patient elected the hospice benefit on 10/06/2025. During a home visit, observation with the licensed practical nurse (LPN) (Personnel Record 4), the LP was observed accessing and re-accessing her nursing bag multiple times without sanitizing her hands before or after contact with the bag or patient care items. During an interview on 12/05/2025, the Director of Nursing confirmed that, based on the observed practices, the nurse did not follow the agency’s hand hygiene protocol as required by infection control standards.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 4 of 10 (40%) clinical records reviewed of patients receiving hospice aide service it was revealed that the agency did not ensure that the registered nurse completed a hospice aide supervisory visit no less than every 14 days. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/02/2025 and was ordered hospice aide services weekly. The hospice aide began providing services on 10/15/2025; however, the only documented supervisory visit occurred on 11/20/2025 (36 days). CLINICAL RECORD 10: The patient elected the hospice benefit on 09/19/2025 and was ordered hospice aide services twice weekly. The documented supervisory visits occurred on 10/08/2025 (16 days after the first hospice aide visit) and 10/27/2025 (19 days). CLINICAL RECORD 11: The patient elected the hospice benefit on 03/13/2025 and was ordered hospice aide services weekly. Documented supervisory visits occurred on 04/02/2025, 04/28/2025 (26 days), 05/08/2025, and 05/27/2025 (19 days.) CLINICAL RECORD 12: The patient elected the hospice benefit on 01/25/2025 and was ordered hospice aide services twice weekly. Documented supervisory visits occurred on 07/21/2025, 08/25/2025 (19 days), and 09/15/2025 (19 days) During a joint record review and interview conducted on 12/03/2025 with both the Director of Clinical Services and the Hospice Patient Care Coordinator, it was confirmed that the hospice aide supervisory visits were not conducted every 14 days as required. Both individuals acknowledged the oversight and agreed that the required supervisory visits had not been conducted as outlined in the plan of care.

It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. If the administrator is not available, another individual is assigned the administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidenced by document review and interview. A review of "Board of Directors" (Governing Board) documented meeting dated 10/15/2024, 11/19/2024, 01/21/2025, 03/18/2025, 04/15/2025, 05/20/2025, 07/15/2025, 08/19/2025, 09/16/2025 and 10/01/2025 revealed that the agency did not ensure that when the Administrator is not available, a qualified, predesignated person, who is authorized in writing by the Administrator and the organization’s governance, assumes the same responsibilities and obligations as the Administrator. An unlabeled and undated document stated in part, “(Name), RN, has been appointed the Alternate Director of Nursing effective 12/09/24, in addition to her current duties,” and also stated, “(Name), CEO, has taken back the duties of Administrator to which he was previously appointed in 03/23/87.” This document did not clearly reflect the date on which the Administrator role was assumed and was not identifiable as a governing-body appointment. In a separate document, a letter dated 12/04/2024 was sent to the state department of health indicating that (Name) was re-appointed as the Administrator, effective 12/09/2024. Separately, a document dated "December 2, 2025," documented the appointment of the Administrator and Alternate Administrator as approved by the board on August 25, 2025, and was signed by both the Administrator and Alternate Administrator for their roles. During an interview on 12/03/2025, the Administrator and Clinical Manager confirmed the evidence by stating they did not have board approval and authorization from the Administrator for approval of a predesignated person as the Alternate Administrator. A review of "Board of Directors" (Governing Board) documented meeting dated 10/15/2024, 11/19/2024, 01/21/2025, 03/18/2025, 04/15/2025, 05/20/2025, 07/15/2025, 08/19/2025, 09/16/2025 and 10/01/2025 revealed that the agency did not ensure that when the Administrator is not available, a qualified, predesignated person, who is authorized in writing by the Administrator and the organization’s governance, assumes the same responsibilities and obligations as the Administrator. An unlabeled and undated document stated in part, “Amanda Berent, RN, has been appointed the Alternate Director of Nursing effective 12/09/24, in addition to her current duties,” and also stated, “David Miller, CEO, has taken back the duties of Administrator to which he was previously appointed in 03/23/87.” This document did not clearly reflect the date on which the Administrator role was assumed and was not identifiable as a governing-body appointment. In a separate document, a letter dated 12/04/2024 was sent to the state department of health indicating that David Miller was re-appointed as the Administrator, effective 12/09/2024. Separately, a document dated "December 2, 2025," documented the appointment of the Administrator and Alternate Administrator as approved by the board on August 25, 2025, and was signed by both the Administrator and Alternate Administrator for their roles.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following, a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients discharged from the agency it was revealed that discharge summaries did not include all required elements. Missing components included, but were not limited to, a summary of the patient's hospice stay, the patient's current plan of care and the patient's latest physician orders. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/13/2025 and was discharged on 06/23/2025 due to admission to a hospital, which is outside the agency’s service area. Upon review of the discharge summary, it was noted that the document did not include all required elements as per agency policy and regulatory standards. The summary only listed the start of care date, discharge date, and discharge disposition (“hospital”), with a brief note stating, “Pt discharged d/t out of service area.” No additional information regarding the patient’s condition at discharge, services provided, a comprehensive summary of the hospice episode, the current plan of care, most recent physician orders, medication reconciliation, or follow-up instructions was documented. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/25/2025 and was discharged on 10/10/2025 following transfer to the emergency room. The discharge summary noted that the patient’s family was seeking aggressive treatment for stroke-like symptoms, including an episode of unconsciousness and facial drooping, and included the statement: “Caregiver frequently seeking treatment for patient; patient is not hospice appropriate.” However, the discharge summary did not include all required elements. Specifically, it lacked documentation of the patient’s condition at discharge, services provided, a comprehensive summary of the hospice stay, the current plan of care, and the most recent physician orders. During a joint record review and interview conducted on 12/05/2025 with the Director of Nursing she acknowledged that the discharge summaries reviewed did not contain all required information.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address the development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment and the documented discussion of the plan provided to the patient/family and maintained by the hospice. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 11 (9%) records reviewed it was revealed that the agency did not ensure there was documentation of discussion on emergency preparedness as part of the comprehensive assessment. Clinical Record 1: The hospice election of benefits date was 08/02/2022. There was no evidence of emergency preparedness discussion to date. During the home visit, the admission booklet that was left for the patient had an emergency plan that was blank. Interview: During interview on 01/11/2021 the Alternate Administrator stated the admitting clinician was to leave a completed emergency plan in the home and document the discussion of the plan with the patient/family.

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. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 11 (9%) records reviewed the agency did not ensure the medication profile included all prescription medications. Clinical Record 1: The registered nurse visit dated12/29/2022 and the interdisciplinary team meeting documentation dated 12/29/2022 indicated the patient was utilizing Oxygen at 2-4 liters via nasal cannula. Oxygen was not included on the medication profile to date. Interview: During interview on 01/11/2023, the Alternate Administrator stated the agency considers Oxygen a medication that should be included on the medication profile.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by a review of clinical records and interviews. In 11 of 11 (100%) records reviewed the agency did not ensure an initial bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 1: The hospice election of benefits date was 08/02/2022. The initial bereavement assessment was not completed until 09/08/2022. Clinical Record 2: The hospice election of benefits date was 08/05/2020. The initial bereavement assessment was not completed to date. Clinical Record 3: The hospice election of benefits date was 08/05/2021. The initial bereavement assessment was not completed to date. Clinical Record 4: The hospice election of benefits date was 12/21/2022. The initial bereavement assessment was not completed to date. Clinical Record 5: The hospice election of benefits date was 09/50/2021. The initial bereavement assessment was not completed to date. Clinical Record 6: The hospice election of benefits date was 09/28/2022. The initial bereavement assessment was not completed until 10/22/2022. Clinical Record 7: The hospice election of benefits date was 12/31/2022. The initial bereavement assessment was not completed until 01/07/2023. Clinical Record 8: The hospice election of benefits date was 03/22/2022. The initial bereavement assessment was not completed to date. Clinical Record 9: The hospice election of benefits date was 12/27/2022. The initial bereavement assessment was not completed to date. Clinical Record 10: The hospice election of benefits date was 11/05/2022. The initial bereavement assessment was not completed to date. Clinical Record 11: The hospice election of benefits date was 10/27/2022. The initial bereavement assessment was not completed to date. Interview: During interview on 01/11/2023, the Alternate Administrator stated bereavement assessments not completed timely.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 11 (9%) records reviewed it was revealed that the agency did not ensure the plan of care included a detailed scope and frequency for disciplines providing care. Clinical Record 11: The hospice plan of care dated 10/27/2022 and the associated interdisciplinary meeting updates did not include a visit frequency for the social worker. The social worker documented visits on 10/27/2022 and 11/10/2022. Interview: During interview on 01/11/2023, the Alternate Administrator reviewed the clinical record and stated there was no visit frequency for the social worker documented on the plan of care to date.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 11 (9%) records reviewed the agency did not ensure the plan of care included the durable medical equipment. Clinical Record 8: The hospice plan of care dated 09/18/2022 read "DME NA". The 11/08/2022 and the 11/15/2022 registered nurse visit documentation indicated the patient was utilizing a wheelchair and a walker. Interview: During interview on 01/11/2023, the Alternate Administrator stated the clinician had inadvertently failed to add equipment to the hospice plan of care.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by interviews and home visit observations. In 2 of 3 (67%) home visit observations it was revealed that the agency did not ensure measures to prevent transmission of infection were practiced. The agency's 'Bag Technique' policy read "Keep soap and paper towels in an outer pocket of bag... wash hands before replacing equipment into the bag.... never re-enter bag unless you have washed your hands". Home Visit 2: During the home visit the registered nurse was observed placing hands in and out of bag without cleansing prior. Supplies such as paper towels and hand sanitizer were not kept in the outer pockets or on the outside of the bag. Home Visit 3: During the home visit the registered nurse was observed placing hands in and out of bag without cleansing prior. Supplies such as paper towels and hand sanitizer were not kept in the outer pockets or on the outside of the bag. Interview: During an interview on 01/11/2023, the Alternate Administrator reviewed the process and stated education would need to be provided as the clinician was not following the bag technique process.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 4 of 4 (100%) records reviewed that included the provision of aide services the agency did not ensure the aide was providing services ordered by the interdisciplinary group and included in the plan of care. Clinical Record 5: The hospice aide assignment dated 11/24/2022 read, nail care and incontinence care every visit. On aide visit documentation dated 11/30/22-12/21/2022 the aide did not document completion of nail care or incontinence care. The aide visit documentation dated 11/30/2022, 12/02/2022, 12/05/2022, 12/09/2022, 12/14/2022, 12/19/2022 and 12/21/2022 the aide documented completion of making the bed which was not assigned to date. Clinical Record 8: The hospice aide assignment dated 10/12/2022 read nail care, oral care, linen change and take out trash every visit. The aide visit documentation dated 10/13/22 and 10/17/2022 the aide did not document completion of nail care, oral care or linen change. Clinical Record 10: The hospice aide assignment dated 11/05/2022 read shower, nail care, assist with dressing, oral care, clean bathroom and ambulation assistance every visit. The aide visit documentation dated 11/17/2022 the aide did not document completion of nail care, assist with dressing, oral care, clean bathroom and ambulation assistance, however, did include documentation of the completion of a partial bed bath which was not assigned to date. Clinical Record 11: The hospice aide assignment dated 10/27/2022 read nail care, oral care incontinence care, and ambulation assistance every visit. The aide visit documentation dated 11/01/2022 11/15/2022 the aide did not document completion of nail care or oral care. The aide visit documentation dated 11/01/2022 the aide did not document completion of incontinence care. The aide visit documentation dated 11/01/2022 and 11/22/2022, the aide documented completion of clean bathroom which was not an assigned task to date. Interview: During interview on 01/11/2023, the Alternate Administrator reviewed the clinical record and stated the aide had not followed the plan of care.

A patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 11 (18%) records reviewed it was revealed that the agency did not ensure the clinical record included all treatment orders. Clinical Record 3: The hospice plan of care dated 11/28/2022 did not include orders for in and out catheter twice daily to be completed by the patient. The documentation by the registered nurse dated 12/28/2022 and the documentation dated 01/11/2023 indicated the patient was performing the procedure. Clinical Record 10 The registered nurse visit documentation dated 11/17/2022 read "Red area to coccyx covered with mepilex". The hospice plan of care dated 11/05/2022 and the 11/17/2022 Interdisciplinary Team meeting care plan update did not include orders for mepilex application to the coccyx. Interview: During interview on 01/11/2023, the Alternate Administrator stated orders were not included in the clinical record.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 11 (27%) records reviewed it was revealed that the agency did not ensure all entries were appropriately signed and dated by the person performing the care. Clinical Record 7: The start of care visit note dated 12/31/2022 by the registered nurse included a signature of the first initial of first name, the full last name and credentials and no date. The signature to be used in the clinician's staff record was full first and last name. Clinical Record 10: The start of care visit note dated 11/05/2022 by the registered nurse included a signature of the first initial of first name, the full last name and credentials and no date. The signature to be used in the clinician's staff record was full first and last name. Clinical Record 11: The start of care visit note dated 10/27/2022 by the registered nurse included the first initial of first name, the full last name and credentials and no date. The signature to be used in the clinician's staff record was full first and last name. Interview: During interview on 01/11/2023, the Alternate Administrator confirmed that the clinician signature on file to be used was not used in the clinical record documentation.

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 and 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 a review of clinical records and interviews. In 2 of 2 (100%) records reviewed in which the patient resided in a SNF the agency did not ensure that the plan of care included a delineation of care responsibilities between providers. Clinical Record 9: The hospice plan of care dated 12/27/2022 did not show delineation of care provision between the hospice staff and the facility staff. Clinical Record 8: The hospice plan of care dated 09/18/2022 did not show delineation of care provision between the hospice staff and the facility staff. Interview: During interview on 01/11/2023, the Alternate Administrator stated there was no delineation of care on the hospice plans of care reviewed.

Based on record review and interview, the agency failed to ensure all ordered medications, including standing orders, were listed on the patient's drug profile and failed to check for actual or potential drug interactions and effectiveness of drug therapy for 11 of 11 clinical records reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11). Findings include: 1. A policy titled "Hoosier Uplands Health Care Division Drug Regimen Review Policy and Procedure" was provided by the Administrator on 7/19/2022 at 3:20 p.m. The document indicated, but was not limited to; "Upon admission and anytime that a medication is added ... The SN (skilled nurse) signs their initials in the clinician's initial section and signs their names, with title and date in the Reviewed/Revises by section ... a hospice Patient Care Coordinator or Home Health RN Team Leader, or designee is to review the drug regimen for compatibility with the POC (plan of care) to determine effectiveness, and to report any problems to the attending physician or allowed practitioner ... The Hospice Patient Care Coordinator or Team Leader, or designee is to review and revise the Drug Regimen Review at least every 60 days as part of the 60-day review/recertification process." 2. A review of the clinical records for patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 all evidenced a document titled "Hoosier Uplands Hospice Standing Orders" signed by the medical director. The standing order included Schedule II Controlled substances Roxanol (medication used for severe pain) liquid and nebulized forms, Oxycodone (medication used for severe pain), Hydrocodone/Acetaminophen (medication used for severe pain), Schedule IV Controlled substance Tramadol (medication used for moderate pain) and Ativan (medication used for anxiety). Prescription and over counter medications included on the standing order for nausea/vomiting: Phenergan, Compazine, Reglan, Omeprazole, and Ondansetron, for sleep: Diphenhydramine, Melatonin, and Mirtazapine, for Cough: Guaifenesin and Mucinex, for antibiotics: Keflex, for Constipation: Milk of Magnesia, Colace, Senokot, Dulcolax, Miralax, Sorbital, and Fleets enema, for Mild Pain/Fever: Acetaminophen tablets and suppositories, for itching: Diphenhydramine, for Oral Care: Mary's Magic Mouth Wash, for Hiccups: Baclophen and Chlorpromazine, for Port Flush: Normal Saline, For Depression: Mirtazapine, for Diarrhea: Imodium and Lomotil, for Respiratory: Oxygen, Roezit, Albuterol/Atrovent, Prednisone, and Atropine, for Bladder Management: Foley Cath 16-18 French, for Skin Care: Duoderm/Tegaderm/Mepilex/Barrier Cream/Ointment/Normal Saline, for Services: home health aide, social services, chaplain, volunteer, occupational therapist, speech therapist, speech therapist, registered nurse or licensed practical nurse, and for Durable Medical Equipment (DME): Hospital Bed, Bed side table, side rails, wheelchair, Hoyer lift, Cane, raised toilet seat, shower chair, bedside commode, and lift chair. 3. A review of the clinical records for patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 failed to evidence all medications listed on the standing orders were included in the patient's drug regimen review and failed to evidence all medications had been checked along with all patients' other prescribed medications to check for severe interactions or duplicate therapy. 4. During an interview on 7/21/2022 at 10:05 a.m. the administrator stated the medication on the standing order was only added to the drug profile when those specific medications were used for the patients. When asked if the patients all had standing orders for the medications included on the standing order and it was signed by the physician and nursing was able to use any of the ordered medication deemed necessary at any time how could they ensure there was no drug interaction, the administrator stated they communicate with the medical director in advance when using the medications on the standing order.

Based on record review observation, and interview the agency failed to ensure standing medication orders were individualized to address the patients' specific needs for 11 of 11 clinical records reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11). Findings include: 1. A policy titled "Hoosier Uplands Health Care Division Drug Regimen Review Policy and Procedure" was provided by the administrator on 7/19/2022 at 3:20 p.m. The document indicated, but was not limited to; "Upon admission and anytime that a medication is added ... The SN (skilled nurse) signs their initials in the clinician's initial section and signs their names, with title and date in the Reviewed/Revises by section ... a hospice Patient Care Coordinator or Home Health RN Team Leader, or designee is to review the drug regimen for compatibility with the POC (plan of care) to determine effectiveness, and to report any problems to the attending physician or allowed practitioner ... The Hospice Patient Care Coordinator or Team Leader, or designee is to review and revise the Drug Regimen Review at least every 60 days as part of the 60-day review/recertification process." 2. A review of the clinical records for patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 all evidenced a document titled "Hoosier Uplands Hospice Standing Orders" signed by the medical director. The standing order included Schedule II Controlled substances Roxanol (medication used for severe pain) liquid and nebulized forms, Oxycodone (medication used for severe pain), Hydrocodone/Acetaminophen (medication used for severe pain), Schedule IV Controlled substance Tramadol (medication used for moderate pain) and Ativan (medication used for anxiety). Prescription and over counter medications included on the standing order for nausea/vomiting: Phenergan, Compazine, Reglan, Omeprazole, and Ondansetron, for sleep: Diphenhydramine, Melatonin, and Mirtazapine, for Cough: Guaifenesin and Mucinex, for antibiotics: Keflex, for Constipation: Milk of Magnesia, Colace, Senokot, Dulcolax, Miralax, Sorbital, and Fleets enema, for Mild Pain/Fever: Acetaminophen tablets and suppositories, for itching: Diphenhydramine, for Oral Care: Mary's Magic Mouth Wash, for Hiccups: Baclophen and Chlorpromazine, for Port Flush: Normal Saline, For Depression: Mirtazapine, for Diarrhea: Imodium and Lomotil, for Respiratory: Oxygen, Roezit, Albuterol/Atrovent, Prednisone, and Atropine, for Bladder Management: Foley Cath 16-18 French, for Skin Care: Duoderm/Tegaderm/Mepilex/Barrier Cream/Ointment/Normal Saline, for Services: home health aide, social services, chaplain, volunteer, occupational therapist, speech therapist, speech therapist, registered nurse or licensed practical nurse, and for Durable Medical Equipment (DME): Hospital Bed, Bed side table, side rails, wheelchair, Hoyer lift, Cane, raised toilet seat, shower chair, bedside commode, and lift chair. The standing order failed to include any parameters including which medication to try first, how to determine if the medication was effective, frequency and duration of services, guidelines for DME, and was not individualized to each patient. The standing order allowed for nursing to oversee the medical component of the patients' care without the oversight of the medical director. 3. A review of the clinical records for patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 failed to evidence all medications listed on the standing orders were included in the patient's drug regimen review and failed to evidence all medications had been checked along with all patients' other prescribed medications to check for severe interactions or duplicate therapy. 4. A review of the clinical records for patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 failed to evidence any of the 11 patients reviewed had a port that would require flushing. 5. During a home visit on 7/19/2022 at 12:00 p.m. patient #6's hospice folder was observed on top of the kitchen table and written in large black letters across the front of the folder was "No Morphine." Patient #6 had a standing order for Roxanol, liquid morphine. 6. During a home visit on 07/19/2022 at 10:43 a.m. with patient #7, a full unopened bottle of Roxanol (a controlled substance category II narcotic used to treat severe pain) and a full bottle of unopened hydrocodone/acetaminophen (a controlled substance category II narcotic used to treat severe pain) were observed on the patient's countertop. During an interview on 7/19/2022 at 10:50 a.m. with the spouse of patient #7, they stated the hospice provided the Roxanol and Hydrocodone/Acetaminophen, but they did not need it. When asked if the hospice had discussed with them how to dispose of the controlled substance after patient #7 passed, they stated no they hadn't, but they (the spouse) planned to flush the narcotics down the toilet. 7. During an interview on 7/21/2022 at 10:05 a.m. the administrator stated the physician has the option to mark out items with an X on the standing orders if they do not want certain medications for the patient when informed 0 of the 11 clinical records reviewed had any items marked out and all 11 had port flushes as a standing order and 0 of the 11 had ports that could be flushed the administrator stated they understood the concern.

Based on record review and interview the Medical Director failed to review the clinical information for each hospice patient and provide a written certification the patients' anticipated life expectancy was less than 6 months if the illness ran its normal course (See S667); failed to provide proper recertification of terminal illness including an explanation of why the clinical findings of the face-to-face encounter supported a life expectancy of 6 months or less for patients' 3rd benefit period and every subsequent recertification (See S668); and failed to assume overall responsibility of the medical components of the hospice's patient care program (See S669). The cumulative effect of this systemic problem resulted in the agency being out of compliance with §418.102 Condition of participation: Medical Director.

Based on record review and interview, the Medical director failed to provide a written certification narrative reflecting an individual's clinical circumstances and synthesizing the patient's comprehensive medical information for clinical justification anticipating the patient had a life expectancy of 6 months or less if the illness ran its normal course for 4 of 4 initial certifications of terminal illness records reviewed (Patients #1, #2, #3, and #4). Findings include: 1. A 10-10-2021 revised document titled "Medicare Benefit Policy Manual" was reviewed on 07/19/2022. The document indicated but was not limited to; Chapter 9, Section 20.1 Timing and Content of Certification "A complete written certification must include: 1. The statement that the individual's medical prognosis is that their life expectancy is 6 months or less if the terminal illness runs its normal course; 2. Specific clinical findings or other documentation supporting a life expectancy of 6 months or less ... 4. As of October 1, 2009, ... The narrative must reflect the patient's individual clinical circumstances and cannot contain check boxes or standard language used for all patients. The physician must synthesize the patient's comprehensive medical information in order to compose this brief clinical narrative." 2. A policy titled "Certification Statement Policy and Procedure" was provided by the Hospice Intake Coordinator on 7/19/2022 at 3:50 p.m. The document indicated but was not limited to; "Hoosier Uplands Hospice will obtain physician certification of terminal illness on each hospice patient attesting to the appropriateness on the patient for hospice, i.e., prognosis <6 months as determined by the attending physician." 3. A document titled "Hospice Medical Director Services Contract" indicated but was not limited to; "Responsibilities of Contract ... Certifying that the patient meets the medical criteria for hospice admission based on available diagnostic and prognostic indicators, related diagnosis(es) if any, current subjective and objective medical findings, current medications and treatment orders, information about the medical management of any of the patient's conditions unrelated to the terminal illness ... Re-certifying patients, as appropriate, for the continuation of Medicare Hospice Benefit at appropriate levels of care." 4. The complete clinical record for patient #1 was reviewed on 7/18/2022 and evidenced the following: A document titled Hospice Physician Certification of Terminal Illness signed by the Medical Director on 3/8/2022 was reviewed on 7/18/2022. The document indicated but was not limited to; "Physician's Narrative ...Pt (patient) CVA (cerebral vascular accident/stroke), would like to be home & comfortable <6 months life expectancy." 5. The complete clinical record for patient #2 was reviewed on 7/18/2022 and evidenced the following: A document titled Hospice Physician Certification of Terminal Illness signed by the Medical Director on 2/14/2022 was reviewed on 7/18/2022. The document indicated but was not limited to; "Physician's Narrative ... Pt is very poor condition, <6 months life expectancy." 6. The complete clinical record for patient #3 was reviewed on 7/18/2022 and evidenced the following: A document titled Hospice Physician Certification of Terminal Illness signed by the Medical Director on 3/25/2022 was reviewed on 7/18/2022. The document indicated but was not limited to; "Physician's Narrative ... Pt w/ (with) hepatic (liver) failure, no further interventions desired <6 months life expectancy." 7. The complete clinical record for patient #4 was reviewed on 7/19/2022 and evidenced the following: A document titled Hospice Physician Certification of Terminal Illness signed by the Medical Director on 7/07/2021 was reviewed on 7/18/2022. The document indicated but was not limited to; "Physician's Narrative" which evidenced 10 illegible words signed by the physician's designee on 7-07-2021. 8. During an interview on 7/19/2022 at 3:06 p.m. the Medical Director when asked what component were considered when determining if a patient's life expectancy was 6 months or less if the illness ran its normal course stated, "I don't make that decision. I am not consulted on this. Nursing does the evaluations and makes the decision. I just review them."

Based on record review and interview, the Medical director failed to review patients clinical record prior to each recertifications of terminal illness for 7 of 11 records reviewed (Patient #5, #6, #7, #8, #9, #10, and #11). Findings include: 1. A 10-10-2021 revised document titled "Medicare Benefit Policy Manual" was reviewed on 07/19/2022. The document indicated but was not limited to; Chapter 9, Section 20.1 Timing and Content of Certification "A complete written certification must include: 1. The statement that the individual's medical prognosis is that their life expectancy is 6 months or less if the terminal illness runs its normal course; 2. Specific clinical findings or other documentation supporting a life expectancy of 6 months or less ... 4. As of October 1, 2009, ... The narrative must reflect the patient's individual clinical circumstances and cannot contain check boxes or standard language used for all patients. The physician must synthesize the patient's comprehensive medical information in order to compose this brief clinical narrative. For recertifications on or after January 1, 2011, the narrative associated with the third benefit period recertification and every subsequent recertification must include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of 6 months or less." 2. A document titled "Hospice Medical Director Services Contract" indicated but was not limited to; "Responsibilities of Contract ... Certifying that the patient meets the medical criteria for hospice admission based on available diagnostic and prognostic indicators, related diagnosis(es) if any, current subjective and objective medical findings, current medications and treatment orders, information about the medical management of any of the patient's conditions unrelated to the terminal illness ... Re-certifying patients, as appropriate, for the continuation of Medicare Hospice Benefit at appropriate levels of care." 3. The complete clinical record for patient #5 for the 6th benefit period of 6/21/2022 through 8/19/2022 was reviewed on 7/20/2022 and evidenced the following: A document titled Face-To-Face, and Narrative for Recertification of Terminal Illness for Hospice signed by the patient's attending physician (non-agency physician 1) was undated and signed by the Medical Director on 6/22/2022. The document indicated but was not limited to; "Physician Narrative ... Pt (patient) w/ (with) CHF (Congestive Heart Failure), CAD (coronary artery disease), and SOA (Shortness of Air), requires ADL (Activities of Daily Living) assistance, incontinent of the bladder, gradual decline w/ < (less than) 6 months life expectancy." 4. The complete clinical record for patient #6 for the 2nd benefit period of 6-27-2022 through 9-24-22 was reviewed on 7/20/2022 and evidenced the following: A document titled Hospice Physician Certification of Terminal Illness for Hospice for the 2nd benefit period for patient #6. The document's physician narrative section was left blank. A second copy of the document titled Hospice Physician Certification of Terminal Illness for Hospice for the 2nd benefit period signed by the Medical Director on 6/28/22 included with the 1st was reviewed on 7/20/2022. The document's physician narrative section included 8 illegible words signed by the physician designee on 7/5/2022. 5. The complete clinical record for patient #7 for the 3rd benefit period of 6-08-2022 through 9-05-22 was reviewed on 7/20/2022 and evidenced the following: A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the medical director and dated 6/9/2022 was reviewed on 7/20/2022. The document indicated but was not limited to; "Physician Narrative ... Pt w/ CHF, completely dependent for ADLs, incontinent of B & B (Bowel and Bladder), Hoyer lift, <6 months life expectancy." 6. The complete clinical record for patient #8 for the 10th benefit period was reviewed on 7/21/2022 and evidenced the following: A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the patient's attending physician was reviewed on 7/21/2022. The document indicated but was not limited to; "Physician Narrative ... Colon Cancer." 7. The complete clinical record for patient #8 for the 12th benefit period of 7-13-2022 through 9-10-22 was reviewed on 7/21/2022 and evidenced the following: A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the Medical Director on 7/20/2022 was reviewed on 7/21/2022. The document indicated but was not limited to; a "Physician Narrative" section that was left blank. A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the Medical Director on 6/9/2022 was reviewed on 7/21/2022. The document indicated but was not limited to; "Physician Narrative ... Pt w/ CHF, completely dependent for ADLs, incontinent of B & B (Bowel and Bladder), Hoyer lift, <6 months life expectancy." 8. The complete clinical record for patient #9 for the 13th benefit period of 6/11/2022 through 8/09/2022 was reviewed on 7/21/2022 and evidenced the following: A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the Medical Director on 6/20/2022 was reviewed on 7/21/2022. The document indicated but was not limited to; "Physician Narrative ... Pt w/ heart failure, SOA (short of air) w/ exertion, some dysphagia (difficulty swallowing), total assist w/ ADLs, weakness, <6 months life expectancy." 9. The complete clinical record for patient #10 for benefit periods from 07/07/2020 through 7/23/2022 was reviewed on 7/21/2022 and evidenced the following: A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the physician designee on 7/11/2020 was reviewed on 7/21/2022. The document indicated but was not limited to; "Physician Narrative ... Hospice Appropriate." A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the physician designee on 6/20/2020 was reviewed on 7/21/2022. The document indicated but was not limited to; a "Physician Narrative" section that was left blank. A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice was signed by the patient's Family Nurse Practitioner on 5/14/2020,7/10/2020, 9/15/2020, and 1/18/2021 without the Medical Director's signature and was reviewed on 7/21/2022. A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice was signed by the Medical Director on 3/12/2021 and signed a second time by the Medical Director on 5/14/2021 in the physician attending's signature location was reviewed on 7/21/2022. The document indicated but was not limited to; "Physician Narrative ... Known CKD (chronic kidney disease), not seeking any further tx (treatment) for this condition." A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the Medical Director on 5/24/2021 was reviewed on 7/21/2022. The document indicated but was not limited to; "Physician Narrative ... CKD pt is not interested in seeking any further medical tx or curative measures." A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the Medical Director on 7/03/2021 was reviewed on 7/21/2022. The document indicated but was not limited to; "Physician Narrative ... Known CKD, not seeking any further care or tx for this condition <6 months life expectancy." A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the Medical Director on 9/03/2021 was reviewed on 7/21/2022. The document indicated but was not limited to; "Physician Narrative ... COPD (chronic obstructive pulmonary disorder), gradually worsening <6months life expectancy." A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the Medical Director on 11/16/2021 was reviewed on 7/21/2022. The document indicated but was not limited to; "Physician Narrative ... Pt w/ COPD, no interventions desired. <6 months life expectancy." A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the Medical Director on 1/11/2022 was reviewed on 7/21/2022. The document indicated but was not limited to; "Physician Narrative ... Pt w/ COPD, & gradually declining, <6 months life expectancy." A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the Medical Director on 3/18/2022 was reviewed on 7/21/2022. The document indicated but was not limited to; "Physician Narrative ... Pt w/ COPD, no interventions desired, <6 months life expectancy." A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the Medical Director on 5/06/2022 was reviewed on 7/21/2022. The document indicated but was not limited to; "Physician Narrative ... COPD, oriented to self only, dependent on all ADL's (activities of daily living) other than feeding, trace edema, <6 months life expectancy." 10. The complete clinical record for patient #11 for the benefit period 6/1/2022 through 7/20/2022 and evidenced the following: A document titled Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice signed by the Attending Physician on 6/03/2022 was reviewed on 7/21/2022. The document indicated but was not limited to; "Physician Narrative ... Known debilitating arthritis [with] progressive weakness. Afib." The Medical Director failed to sign the recertification.. 11. During an interview on 7/19/2022 at 3:06 p.m. with the Medical Director when asked what component were considered when determining if a patient's life expectancy was 6 months or less if the illness ran its normal course they stated, "I don't make that decision. I am not consulted on this. Nursing does the evaluations and makes the decision. I just review them."

Based on record review and interview, the medical director failed to be responsible for the medical component of the hospice agency for 1 of 1 agency reviewed. Findings include: 1. A document titled "Hospice Medical Director Services Contract" indicated but was not limited to; "Job Summary The Medical Director is generally responsible for the overall medical direction of the Hospice Patient Care program and for developing and maintaining appropriate policies and standards for medical activities ... Responsibilities of Contract ... Certifying that the patient meets the medical criteria for hospice admission based on available diagnostic and prognostic indicators, related diagnosis(es) if any, current subjective and objective medical findings, current medications and treatment orders, information about the medical management of any of the patient's conditions unrelated to the terminal illness ... Re-certifying patients, as appropriate, for the continuation of Medicare Hospice Benefit at appropriate levels of care ... Documenting care provided in the patient's clinical record proving evidence of progression of the end-stage disease process ... participates in performance improvement programs/quality enhancement." 2. During an interview on 7/19/2022 at 3:06 p.m. with the Medical Director when asked what components were considered when determining if a patient's life expectancy was 6 months or less if the illness ran its normal course they stated, "I don't make that decision. I am not consulted on this. Nursing does the evaluations and makes the decision. I just review them." When asked who the administrator of the hospice was they stated, "I am not sure maybe [Governing Body Member]" and when asked who was responsible for the medical component of the hospice they stated, "Nursing is, the director of nursing does it all, but I approve it." When asked what role they had in the QAPI (Quality Measurement & Process Improvement Program) they stated. "I am involved but not sure of my role." When asked what their role was with training the Medical Director stated, "I have very little to do with training. I guess I have a more indirect role." When asked what their roles or responsibilities at the hospice were, the Medical Director stated, "I review the plans of care that nursing writes and patient orders, mostly medications. I am very responsive and available 24/7 if nursing has any questions." 3. During an interview on 7/21/2022 at 3:00 p.m. when discussing the Medical Director's interview, the administrator stated they did not know why the Medical Director answered the questions the way they did, and it wasn't like them and that the Medical Director "had a family dinner with multiple people coming over and maybe [the Medical Director] was in a rush to get off the phone."

Based on record review and interview, the agency failed to ensure all entries in the clinical record were legible, dated, and/or signed appropriately for 5 of 8 active clinical records reviewed (Patients #4, #5, #6, #8, and #10). Findings include: 1. A policy titled "Medical Records Policy & Procedure" was provided by the Hospice Intake Coordinator on 7/19/2022 at 3:19 p.m. The document indicated but was not limited to; "The medical records shall include the following ... appropriate, current and signed medical orders as determined by physician and in compliance with regulatory and accrediting bodies ... All record entries shall be made in black or blue, non-erasable, ink, dated, signed, legible, and identified as to the credentials of the individual signing ... physician notes reflecting review of medications and care plan oversight including justification for certification and recertification ... supplements to the medical record must include the date the entry is actually made; the information that was originally omitted and the date on which the information was available, the signature and title of the employee who supplements the records." 2. The complete clinical record for patient #4 was reviewed on 7/19/2022 and evidenced the following: A document titled "Hospice Physician Certification of Terminal Illness" indicated but was not limited to; a section titled "Physician's Narrative" that evidenced 10 illegible words signed by the physician's designee on 7-07-2021. 3. The complete clinical record for patient #5 for the 6th benefit period of 6/21/2022 through 8/19/2022 was reviewed on 7/20/2022 and evidenced the following: A second copy of the document titled "Hospice Physician Certification of Terminal Illness for Hospice." The document's physician narrative section was left blank and signed by the attending physician with a date of 6/22/2022. 4. The complete clinical record for patient #6 for the 2nd benefit period of 6-27-2022 through 9-24-22 was reviewed on 7/20/2022 and evidenced the following: A document titled "Hospice Physician Certification of Terminal Illness for Hospice" for the 2nd benefit period for patient #6. The document's physician narrative section was left blank and signed by the Medical Director on 6/28/22. A second copy of the document titled "Hospice Physician Certification of Terminal Illness for Hospice" for the 2nd benefit period was included with the 1st. The document's physician narrative section included 8 illegible words and was signed by the physician designee on 7/5/2022. 5. The complete clinical record for patient #8 for the 12th benefit period of 7-13-2022 through 9-10-22 was reviewed on 7/21/2022 and evidenced the following: A document titled "Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice" that indicated but was not limited to; a "Physician Narrative" section that was left blank and signed by the Medical Director on 7/20/2022. 6. The complete clinical record for patient #10 for benefit periods from 07/07/2020 through 7/23/2022 was reviewed on 7/21/2022 and evidenced the following: A document titled "Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice" indicated but was not limited to; a "Physician Narrative" section that was left blank and signed by the physician designee on 6/20/2020. A document titled "Face-To-Face and Narrative for Recertification of Terminal Illness for Hospice" was signed by the patient's Family Nurse Practitioner on 5/14/2020, 7/10/2020, 9/15/2020, and 1/18/2021 without the Medical Director's signature. 7. During an interview on 7/21/2022 at 12:45 p.m. the administrator viewed the 2 physician narratives that were illegible, she stated she could not make out the 2nd narrative and stated it was completed by the physician designee.