Every finding on record at I Care Hospice & Palliative Providers, Inc.

The agency failed to ensure that the Condition of Participation: L 500 418.52 Patients’ Rights were in compliance as follows:Based on interview and record review, the agency failed to thoroughly investigate a complaint, take corrective action specifically and related to the complaint, provide resolution information in writing to the complainant or immediately take action to prevent further potential violations while the alleged violation was being verified for two of two sampled patients (Patients 5 and 7) when the agency received a cease and desist letter (a document sent by one party, often a business, to warn another party that they believe the other party is committing an unlawful act) from an Acute Care Hospital (ACH) alleging “[ACH] has information to believe that [name of hospice agency] has obtained and used confidential medical information of terminally ill (characterized by an incurable disease that is expected to result in death, often within a short timeframe, like 6 months or less patients) of [ACH] for the purpose of procuring [obtaining] patients for your hospice services in violation of several federal and state laws and regulations, including the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") [sets requirements for the privacy and security of health data, aiming to protect the confidentiality and security of healthcare information] and the California Confidentiality of Medical Information Act ("CMIA") [state law that protects the privacy of individuals' medical information. It generally prohibits the disclosure of medical information without written authorization from the patient or their legal representative].” (Refer to L 509)The cumulative effect of these systemic practices had the potential to result in continued future occurrences of illegally obtaining patients’ Protected Health Information (PHI- any information that can be used to identify an individual and is related to their past, present, or future physical or mental health, the provision of healthcare to that individual, or the payment for healthcare provision) leading to the patients suffering identity theft (use of a person's private identifying information for financial gain), financial fraud (someone being scammed out of their money through theft or deceit), discrimination (unfair or prejudicial treatment of patients based on characteristics like race, ethnicity, gender, age, disability, sexual orientation, or socioeconomic status), damage to reputation through stigmatization (unfairly regarded by people as being bad or having something to be ashamed of), and ruining of trust in healthcare providers.

Based on interview and record review, the agency failed to thoroughly investigate a complaint, take corrective action specifically and related to the complaint, provide resolution information in writing to the complainant or immediately take action to prevent further potential violations while the alleged violation was being verified for two of two sampled patients (Patients 5 and 7) when the agency received a cease and desist letter (a document sent by one party, often a business, to warn another party that they believe the other party is committing an unlawful act) from an Acute Care Hospital (ACH) alleging “[ACH] has information to believe that [name of hospice agency] has obtained and used confidential medical information of terminally ill patients (characterized by an incurable disease that is expected to result in death, often within a short timeframe, like 6 months or less) of [ACH] for the purpose of procuring [obtaining] patients for your hospice services in violation of several federal and state laws and regulations, including the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") [sets requirements for the privacy and security of health data, aiming to protect the confidentiality and security of healthcare information] and the California Confidentiality of Medical Information Act ("CMIA") [state law that protects the privacy of individuals' medical information. It generally prohibits the disclosure of medical information without written authorization from the patient or their legal representative].”This failure had the potential to cause continued future occurrences of illegally obtaining patients’ Protected Health Information (PHI- any information that can be used to identify an individual and is related to their past, present, or future physical or mental health, the provision of healthcare to that individual, or the payment for healthcare provision) leading to the patients suffering identity theft (use of a person's private identifying information for financial gain), financial fraud (someone being scammed out of their money through theft or deceit), discrimination (unfair or prejudicial treatment of patients based on characteristics like race, ethnicity, gender, age, disability, sexual orientation, or socioeconomic status), damage to reputation through stigmatization (unfairly regarded by people as being bad or having something to be ashamed of), and ruining of trust in healthcare providers. --- Findings:A review of an official report from “The California Department of Public Health, Licensing and Certification Program, Medical Breach Enforcement Section [A governmental entity that is responsible for ensuring the quality and safety of healthcare facilities in California. The Medical Breach Enforcement Section specifically focuses on investigating and enforcing compliance with laws and regulations related to the protection of patient medical information], dated October 4, 2022, indicated an employee at the ACH had unlawfully accessed patients’ PHI (Patients 1, 2, 3, 4, 5, 6, and 7) and provided the PHI to a hospice agency for the purpose of procuring patients for their hospice services.A review of the hospice agency’s “Active Census,” from January 1, 2021, to January 31, 2022, was conducted. The Active Census indicated Patient 5 had been admitted on January 12, 2022, and expired on January 26, 2022, and Patient 7 had been admitted on December 30, 2021, and expired on January 16, 2022. A review of the hospice agency’s non-admission log and “Active Census,” from January 1, 2021, to January 31, 2022, was conducted. There was no documentation to show evidence of staff contact or admission of Patients 1, 2, 3, 4, or 6.1. A review of Patient 5’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 12, 2022, with a benefit period of January 12, 2022, to April 11, 2022 (Benefit Period one). Patient 5 had diagnoses that included rectal cancer (cancer that develops in the rectum, the final part of the large intestine). Patient 5 passed away on January 26, 2022.A review of Patient 5’s physician’s orders from January 12, 2022, to January 26, 2022, was conducted. There was no documented evidence to show a physician’s referral order had been received. Further review indicated there was no documented evidence to show an Attending Physician (AP) had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation.A review of Patient 5’s “Physician’s Certification for Hospice (specialized care that focuses on improving the comfort and quality of life for people with a serious illness, particularly those near the end of life, when a cure is no longer possible) Benefit,” dated January 12, 2022, to April 11, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the Previous Medical Director (P/MD) on January 12, 2022.A review of Patient 5’s “Physician’s Certification for Hospice Benefit,” dated January 12, 2022, to April 11, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG [Interdisciplinary group - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient] Meetings and Plan of Care if I choose to follow the Patient,” signed by the P/MD on January 12, 2022.During a review of Patient 5's clinical record, there was no documented evidence to show that an AP had been contacted and supporting documentation obtained. There was no documented evidence to show an AP confirmed Patient 5’s hospice service needs or provided a signature verifying Patient 5’s prognosis of six months or less life expectancy.A review of Patient 5’s claims for payment indicated a claim for payment was submitted in January 2022.During an interview with the current MD on May 8, 2025, from 12:04 PM, to 1:02 PM, the MD stated he had not been the MD at the time Patient 5 was admitted to the agency. The MD verified there was no physician’s referral order, or H&P (History and Physical-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), or documented evidence to show the P/MD had reached out to the AP to confirm service needs, verify Patient 5’s medical prognosis, or request supporting documentation. The MD stated he was aware the CTI for the first and second benefit periods required a signature from the MD and AP and verified the P/MD had signed Patient 5’s Certification of Terminal Illness (CTI) in place of the AP.During an interview with the Administrator/Owner (Admin/Owner) on May 8, 2025, at 1:22 PM, the Admin/Owner confirmed there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 5’s medical prognosis, or request supporting documentation. The Admin/Owner confirmed the P/MD had signed Patient 5’s CTI in place of the AP.2. A review of Patient 7’s face sheet, undated, indicated a start of care date of December 30, 2021, with a benefit period of December 30, 2021, to March 29, 2022 (Benefit Period one). Patient 7 had diagnoses that included ovarian (ovaries--two small, almond-shaped glands located in the female reproductive system) cancer. Patient 7 passed away on January 16, 2022. A review of Patient 7’s physician’s orders from December 30, 2021, to January 16, 2022, was conducted. There was no documented evidence to show a physician’s referral order had been received. Further review indicated there was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation. A review of Patient 7’s “Physician’s Certification for Hospice Benefit,” dated December 30, 2021, to March 29, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the P/MD on December 30, 2021. A review of Patient 7’s “Physician’s Certification for Hospice Benefit,” dated December 30, 2021, to March 29, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient,” signed by the P/MD on December 30, 2021. During a review of Patient 7's clinical record, there was no documented evidence to show that an AP had been contacted and supporting documentation obtained. There was no documented evidence to show an AP confirmed Patient 7’s hospice service needs or provided a signature verifying Patient 7’s prognosis of six months or less life expectancy.A review of Patient 7’s claims for payment indicated a claim for payment was submitted in December 2021, and January 2022.During an interview with the current MD on May 8, 2025, from 12:04 PM, to 1:02 PM, the MD stated he had not been the MD at the time Patient 7 was admitted to the agency. The MD verified there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 7’s medical prognosis, or request supporting documentation. The MD stated he was aware the CTI for the first and second benefit periods required a signature from the MD and AP. The MD verified the P/MD had signed Patient 7’s CTI in place of the AP.During an interview with the Admin/Owner on May 8, 2025, at 1:22 PM, the Admin/Owner confirmed there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 7’s medical prognosis, or request supporting documentation. The Admin/Owner confirmed the P/MD had signed Patient 7’s CTI in place of the AP.During an interview with the Admin/Owner on May 8, 2025, at 2:03 PM, the Admin/Owner stated she had accepted the position as Administrator for the agency on February 2, 2021, purchased the agency on October 6, 2022, and owned 100 percent of the agency. The Admin/Owner stated the agency received a cease and desist letter from the ACH dated January 31, 2022.A review of the ACH’s cease and desist letter, dated January 31, 2022, indicated, “I represent [ACH] and send this letter to you in your capacity as the publicly identified Chief Executive Officer of [name of hospice agency] …, [ACH] has recently become aware of numerous fraudulent, illegal, and unethical business practices by employees of [name of hospice agency] directed at patients of [ACH]. As discussed further, [ACH] demands that [name of hospice agency] immediately cease its illegal activities and immediately take the actions described below as corrective measures in response to its unlawful conduct. Please confirm your acknowledgment of this correspondence and [name of hospice agency] agreement to abide by the actions demanded herein within 7 [seven] days. First, and most significantly, [ACH] has information to believe that [name of hospice agency] has obtained and used confidential medical information of terminally ill patients of [ACH] for the purpose of procuring patients for your hospice services in violation of several federal and state laws and regulations, including the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and the California Confidentiality of Medical Information Act ("CMIA"). Specifically, [ACH] is aware of multiple instances in which [name of hospice agency] employees have contacted the family members of [ACH] patients before a member of [ACH] case management team was able to communicate with the family about the provision of hospice services. [ACH] recently learned that one of its employees, who is no longer employed by [ACH], illegally accessed confidential medical information, including for the same patients whose family members were prematurely contacted by employees of [name of hospice agency]. This strongly suggests that [name of hospice agency] obtained and used confidential medical information from [ACH] patients in violation of HIPAA and CMIA. [ACH] is in the process of reporting this information to the relevant federal, state, and local authorities. Additionally, [ACH] is aware that in communications with the family members of [ACH] patients, [name of hospice agency] employees have represented that [name of hospice agency] is the preferred hospice provider of [ACH] or that [ACH] referred or arranged for [name of hospice agency] to provide hospice services to patients. These representations are false. As you know, there is no business or contractual relationship between [ACH] and [name of hospice agency], let alone an arrangement whereby [name of hospice agency] is [ACH] preferred hospice agency. … Given the serious and harmful actions described in this letter, [ACH] demands that [name of hospice agency] do the following immediately: Cease using any and all confidential medical information of [ACH] patients to procure patients for your hospice services. Identify how and/or from whom [name of hospice agency] acquired the hospice orders, or other related confidential medical information, of patients treated [ACH]. Cease any and all claims and statements that [name of hospice agency]and [ACH] have any business or contractual relationship, including that [name of hospice agency] is the preferred hospice agency of [ACH]. Cease any and all claims and statements that [ACH] referred or otherwise arranged for [name of hospice agency] to provide hospice services to patients of [ACH], …”In a continued interview, the Admin/Owner stated she had conducted the investigation into the ACH’s complaint. The Admin/Owner stated the agency employed a Previous Community Liaison (P/CL 1) who marketed the hospice agency to the ACH, and no other employee had marketed the hospice agency to the ACH. The Admin/Owner stated the P/CL 1’s date of hire was March 31, 2021, and resignation date was August 8, 2024, the Admin/Owner stated she had not suspended the P/CL 1 from his marketing duties during her investigation of the complaint. The Admin/Owner stated she had identified all the ACH’s patients admitted to the hospice agency and verified with the P/MD that all the patients were hospice appropriate, therefore none of the ACH’s patients had been discharged from the hospice’s services. The Admin/Owner stated she did not investigate or identify if any of the identified ACH’s patients had hospice referral orders, if the hospice had identified and reached out to an AP for consultation, or the patients in their first and second benefit period had a second physician signature from the AP on their CTI. In a continued interview, The Admin/Owner verified Patients 5 and 7 had come from the ACH and there was no documented evidence to show a physician’s referral order had been received or an AP had been identified and contacted to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation. In addition, the Admin/Owner verified Patients 5 and 7’s CTIs had not been signed by their APs. The Admin/Owner stated Patients 5 and 7’s Hospice Election Statements (a form required by Medicare for individuals electing to receive care under the Medicare Hospice Benefit. It is a formal agreement between the patient (or their representative), the hospice agency, and Medicare, outlining the terms and conditions of the hospice election) dated January 12, 2022, and December 21, 2021, respectively had been co-signed by the P/CL 1 confirming his involvement with their admission. The Admin/Owner stated she had not asked the P/CL 1 if he received, and from whom, hospice referral orders for the ACH’s patients. The Admin/Owner stated she asked the P/CL 1 how he received the PHI on the ACH’s patients, and the P/CL 1 stated “from his people” at the ACH. The Admin/Owner stated she did not ask for the names of the P/CL 1’s “people” because they were friends of his and the Admin/Owner stated she did not think it was appropriate. The Admin/Owner stated she asked the P/CL 1 if he had posed as an ACH employee in order to gain access to the ACH’s patients PHI and the P/CL 1 told her he had not. The Admin/Owner stated she concluded her investigation, determined that no wrongdoing had occurred and allowed the P/CL 1 to continue to market for the hospice agency until August 8, 2024, an additional two and a half years from the time of the ACH’s complaint dated January 31, 2022.In a continued interview, The Admin/Owner stated she decided to no longer market the hospice agency’s services to the ACH or admit ACH’s patients to the hospice agency. The Admin/Owner stated she did not provide resolution information in writing to the ACH or provide the ACH with the information demanded in the ACH’s cease and desist letter, dated January 31, 2022. The Admin/Owner stated she had her lawyer send a letter to the ACH, but did not provide a copy of or describe the contents of the letter her lawyer sent to the ACH.A review of the agency’s policy and procedure titled “Complaint/Grievance Process,” undated, indicated, “PURPOSE: To set forth guidelines for the resolution of patient concerns, dissatisfaction, or complaints and to protect patient and family rights. POLICY: Patients can freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care, treatment, and services. Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and I Care Hospice, Inc. concerning any aspect of services or the application of policies or procedures will be considered a grievance. The Executive Director/Administrator will be informed of situations that may become detrimental to good patient relations and will be committed to maintaining a consistently high level of patient relations. This grievance procedure will be included in the Patient Bill of Rights document given to each patient upon admission. PROCEDURE: 1. The organization personnel receiving the complaint will discuss, verbally and in writing, the grievance with the Clinical Supervisor/Nursing Supervisor within five (5) days of the alleged grievance. The Clinical Supervisor/Nursing Supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt. 2. If the grievance cannot be resolved to the patient's satisfaction, the patient or his/her representative is to notify, verbally or in writing, the Executive Director/Administrator. The grievance must state the problem or action alleged and the date the Clinical Supervisor/Nursing Supervisor was notified. The Executive Director/Administrator or designee will then investigate the grievance and contact the patient or his/her representative regarding the grievance in an attempt to resolve the differences. The Executive Director/Administrator will respond to the patient within ten (10) days of notification of failure to resolve the complaint. 3. If the patient feels his/her grievance has not been resolved after working with I Care Hospice, Inc. personnel, he/she will be informed of his/her right to notify the state via the respective toll-free telephone numbers, or other methods such as ombudsman, legal services, or adult protective services. The written admission guidelines, provided to the patient upon admission, list sources of assistance for complaint resolution. 4. Complaints and any action taken will be documented on a complaint form. 5. Corrective action will be specific and related to the complaint. 6. Resolution information will be communicated in writing to the patient or his/her representative filing the complaint. 7. Risk management personnel will be notified of any complaints which may involve litigation by the clinician involved completing an organization incident report or unusual occurrence form and forwarding a copy to the Risk Management Department. 8. Complaints received on patient satisfaction surveys (mail) will be documented on a complaint form and addressed as outlined above. 9. All complaints from patients who believe their privacy rights have been violated will be forwarded for review to the designated organization personnel or office specified in the organization's Notice of Privacy Practices. …”

The agency failed to ensure the Condition of Participation: L 648 §418.100 Organization and administration of services was in compliance when: Based on interview, and record review, the Governing Body (GB) failed to operate and manage the agency from December 30, 2021, to May 8, 2025, for five of five sampled patients (Patients 5, 7, 8, 9, and 10), when: 1a-b. The agency failed to thoroughly investigate a complaint, take corrective action specifically and related to the complaint, provide resolution information in writing to the complainant or immediately take action to prevent further potential violations while the alleged violation was being verified for two of two sampled patients (Patients 5 and 7) when the agency received a cease and desist letter (a document sent by one party, often a business, to warn another party that they believe the other party is committing an unlawful act) from an Acute Care Hospital (ACH) alleging “[ACH] has information to believe that [name of hospice agency] has obtained and used confidential medical information of terminally ill patients of [ACH] for the purpose of procuring [obtaining] patients for your hospice services in violation of several federal and state laws and regulations, including the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") [sets requirements for the privacy and security of health data, aiming to protect the confidentiality and security of healthcare information] and the California Confidentiality of Medical Information Act ("CMIA") [state law that protects the privacy of individuals' medical information. It generally prohibits the disclosure of medical information without written authorization from the patient or their legal representative].” (Refer to L 651) 2a-e. The agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for five of five sampled patients (Patients 5, 7, 8, 9, and 10) when the CTIs for the first and second 90-day benefit periods (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) were not signed by two physicians, the MD and the patients’ Attending Physicians (AP). (Refer to L 651) 3a-e. The MD failed his responsibility for the medical component of the hospice program for five of five sampled patients (Patients: 5, 7, 8, 9, and 10) when:  For Patients 5, 7, 8, and 9, a physician's referral order was not obtained and for Patients 5, 7, 8, 9, and 10, an AP’s confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. In addition, the MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. (Refer to L 651) The cumulative effect of these systemic practices resulted in the potential to cause continued future occurrences of illegally obtaining patients’ Protected Health Information (PHI- any information that can be used to identify an individual and is related to their past, present, or future physical or mental health, the provision of healthcare to that individual, or the payment for healthcare provision) leading to the patients suffering identity theft (use of a person's private identifying information for financial gain), financial fraud (someone being scammed out of their money through theft or deceit), discrimination (unfair or prejudicial treatment of patients based on characteristics like race, ethnicity, gender, age, disability, sexual orientation, or socioeconomic status), damage to reputation through stigmatization (unfairly regarded by people as being bad or having something to be ashamed of), and ruining of trust in healthcare providers. In addition, This failure had the potential to cause Patients 5, 7, 8, 9, and 10 not to be given the opportunity to try curative treatments and opt for palliative care, too soon due to their APs not identifying them as terminally ill and referring to hospice care and the MD not correctly evaluating Patients 5, 7, 8, 9, and 10’s terminal diagnosis and prognosis of six months or less to live.

Based on interview, and record review, the Governing Body (GB) failed to operate and manage the agency from December 30, 2021, to May 8, 2025, for five of five samples patients (Patients 5, 7, 8, 9, and 10), when:1a-b. The agency failed to thoroughly investigate a complaint, take corrective action specifically and related to the complaint, provide resolution information in writing to the complainant or immediately take action to prevent further potential violations while the alleged violation was being verified for two of two sampled patients (Patients 5 and 7) when the agency received a cease and desist letter (a document sent by one party, often a business, to warn another party that they believe the other party is committing an unlawful act) from an Acute Care Hospital (ACH) alleging “[ACH] has information to believe that [name of hospice agency] has obtained and used confidential medical information of terminally ill patients of [ACH] for the purpose of procuring [obtaining] patients for your hospice services in violation of several federal and state laws and regulations, including the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") [sets requirements for the privacy and security of health data, aiming to protect the confidentiality and security of healthcare information] and the California Confidentiality of Medical Information Act ("CMIA") [state law that protects the privacy of individuals' medical information. It generally prohibits the disclosure of medical information without written authorization from the patient or their legal representative].”This failure had the potential to cause continued future occurrences of illegally obtaining patients’ Protected Health Information (PHI- any information that can be used to identify an individual and is related to their past, present, or future physical or mental health, the provision of healthcare to that individual, or the payment for healthcare provision) leading to the patients suffering identity theft (use of a person's private identifying information for financial gain), financial fraud (someone being scammed out of their money through theft or deceit), discrimination (unfair or prejudicial treatment of patients based on characteristics like race, ethnicity, gender, age, disability, sexual orientation, or socioeconomic status), damage to reputation through stigmatization (unfairly regarded by people as being bad or having something to be ashamed of), and ruining of trust in healthcare providers.2a-e. The agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for five of five sampled patients (Patients 5, 7, 8, 9, and 10) when the CTIs for the first and second 90-day benefit periods (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) were not signed by two physicians, the MD and the patients’ Attending Physicians (AP).These failures had the potential to cause Patients 5, 7, 8, 9, and 10, not be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to the MD not consulting with the patients’ APs leading to an inaccurate evaluation of  Patients 5, 7, 8, 9, and 10’s terminal diagnosis and prognosis of six months or less to live.3a-e. The MD failed his responsibility for the medical component of the hospice program for five of five sampled patients (Patients: 5, 7, 8, 9, and 10) when: For Patients 5, 7, 8, and 9 a physician's referral order was not obtained and for Patients 5, 7, 8, 9, and 10, an AP’s confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. In addition, the MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services.This failure had the potential to cause Patients 5, 7, 8, 9, and 10 not to be given the opportunity to try curative treatments and opt for palliative care, too soon due to their APs not identifying them as terminally ill and referring to hospice care and the MD not correctly evaluating Patients 5, 7, 8, 9, and 10’s terminal diagnosis and prognosis of six months or less to live. --- An unannounced visit was made to the agency from May 5, 2025, to May 8, 2025, to investigate a complaint regarding an allegation of unlawful access and procurement of patients’ PHI.A review of an official report from “The California Department of Public Health, Licensing and Certification Program, Medical Breach Enforcement Section [A governmental entity that is responsible for ensuring the quality and safety of healthcare facilities in California. The Medical Breach Enforcement Section specifically focuses on investigating and enforcing compliance with laws and regulations related to the protection of patient medical information], dated October 4, 2022, indicated an employee at the ACH had unlawfully accessed patients’ PHI (Patients 1, 2, 3, 4, 5, 6, and 7) and provided the PHI to a hospice agency for the purpose of procuring patients for their hospice services.A review of the hospice agency’s “Active Census,” from January 1, 2021, to January 31, 2022, was conducted. The Active Census indicated Patient 5 had been admitted on January 12, 2022, and expired on January 26, 2022, and Patient 7 had been admitted on December 30, 2021, and expired on January 16, 2022. A review of the hospice agency’s non-admission log and “Active Census,” from January 1, 2021, to January 31, 2022, was conducted. There was no documented evidence of staff contact or admission of Patients 1, 2, 3, 4, or 6).1a. A review of Patient 5’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 12, 2022, with a benefit period of January 12, 2022, to April 11, 2022 (Benefit Period one). Patient 5 had diagnoses that included rectal cancer (cancer that develops in the rectum, the final part of the large intestine). Patient 5 passed away on January 26, 2022.A review of Patient 5’s physician’s orders from January 12, 2022, to January 26, 2022, was conducted. There was no documented evidence to show a physician’s referral order had been received. Further review indicated there was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation.A review of Patient 5’s “Physician’s Certification for Hospice Benefit,” dated January 12, 2022, to April 11, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the Previous Medical Director (P/MD) on January 12, 2022.A review of Patient 5’s “Physician’s Certification for Hospice Benefit,” dated January 12, 2022, to April 11, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG [Interdisciplinary group - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient] Meetings and Plan of Care if I choose to follow the Patient,” signed by the P/MD on January 12, 2022.There was no documented evidence to show that an AP had been contacted and supporting documentation obtained. There was no documented evidence to show an AP confirmed Patient 5’s hospice service needs or provided a signature verifying Patient 5’s prognosis of six months or less life expectancy.A review of Patient 5’s claims for payment indicated a claim for payment was submitted in January 2022.During an interview with the current MD on May 8, 2025, from 12:04 PM, to 1:02 PM, the MD stated he had not been the MD at the time Patient 5 was admitted to the agency. The MD verified there was no physician’s referral order, or H&P (History and Physical-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), or documented evidence to show the P/MD had reached out to the AP to confirm service needs, verify Patient 5’s medical prognosis, or request supporting documentation. The MD stated he was aware the CTI for the first and second benefit periods required a signature from the MD and AP and verified the P/MD had signed Patient 5’s CTI in place of the AP.During an interview with the Administrator/Owner (Admin/Owner) on May 8, 2025, at 1:22 PM, the Admin/Owner confirmed there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 5’s medical prognosis, or request supporting documentation. The Admin/Owner confirmed the P/MD had signed Patient 5’s CTI in place of the AP.1b. A review of Patient 7’s face sheet, undated, indicated a start of care date of December 30, 2021, with a benefit period of December 30, 2021, to March 29, 2022 (Benefit Period one). Patient 7 had diagnoses that included ovarian (ovaries--two small, almond-shaped glands located in the female reproductive system) cancer. Patient 7 passed away on January 16, 2022. A review of Patient 7’s physician’s orders from December 30, 2021, to January 16, 2022, was conducted. There was no documented evidence to show a physician’s referral order had been received. Further review indicated there was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation. A review of Patient 7’s “Physician’s Certification for Hospice Benefit,” dated December 30, 2021, to March 29, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the P/MD on December 30, 2021. A review of Patient 7’s “Physician’s Certification for Hospice Benefit,” dated December 30, 2021, to March 29, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient,” signed by the P/MD on December 30, 2021. There was no documented evidence to show that an AP had been contacted and supporting documentation obtained. There was no documented evidence to show an AP confirmed Patient 7’s hospice service needs or provided a signature verifying Patient 7’s prognosis of six months or less life expectancy.A review of Patient 7’s claims for payment indicated a claim for payment was submitted in December 2021, and January 2022.During an interview with the current MD on May 8, 2025, from 12:04 PM, to 1:02 PM, the MD stated he had not been the MD at the time Patient 7 was admitted to the agency. The MD verified there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 7’s medical prognosis, or request supporting documentation. The MD stated he was aware the CTI for the first and second benefit periods required a signature from the MD and AP and verified the P/MD had signed Patient 7’s CTI in place of the AP.During an interview with the Admin/Owner on May 8, 2025, at 1:22 PM, the Admin/Owner confirmed there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 7’s medical prognosis, or request supporting documentation. The Admin/Owner confirmed the P/MD had signed Patient 7’s CTI in place of the AP.During an interview with the Admin/Owner on May 8, 2025, at 2:03 PM, the Admin/Owner stated she had accepted the position as Administrator for the agency on February 2, 2021, purchased the agency on October 6, 2022, and owned 100 percent of the agency. The Admin/Owner stated the agency received a cease and desist letter from the ACH dated January 31, 2022.A review of the ACH’s cease and desist letter, dated January 31, 2022, indicated, “I represent [ACH] and send this letter to you in your capacity as the publicly identified Chief Executive Officer of [name of hospice agency] …, [ACH] has recently become aware of numerous fraudulent, illegal, and unethical business practices by employees of [name of hospice agency] directed at patients of [ACH]. As discussed further, [ACH] demands that [name of hospice agency] immediately cease its illegal activities and immediately take the actions described below as corrective measures in response to its unlawful conduct. Please confirm your acknowledgment of this correspondence and [name of hospice agency] agreement to abide by the actions demanded herein within 7 [seven] days. First, and most significantly, [ACH] has information to believe that [name of hospice agency] has obtained and used confidential medical information of terminally ill patients of [ACH] for the purpose of procuring patients for your hospice services in violation of several federal and state laws and regulations, including the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and the California Confidentiality of Medical Information Act ("CMIA"). Specifically, [ACH] is aware of multiple instances in which [name of hospice agency] employees have contacted the family members of [ACH] patients before a member of [ACH] case management team was able to communicate with the family about the provision of hospice services. [ACH] recently learned that one of its employees, who is no longer employed by [ACH], illegally accessed confidential medical information, including for the same patients whose family members were prematurely contacted by employees of [name of hospice agency]. This strongly suggests that [name of hospice agency] obtained and used confidential medical information from [ACH] patients in violation of HIPAA and CMIA. [ACH] is in the process of reporting this information to the relevant federal, state, and local authorities. Additionally, [ACH] is aware that in communications with the family members of [ACH] patients, [name of hospice agency] employees have represented that [name of hospice agency] is the preferred hospice provider of [ACH] or that [ACH] referred or arranged for [name of hospice agency] to provide hospice services to patients. These representations are false. As you know, there is no business or contractual relationship between [ACH] and [name of hospice agency], let alone an arrangement whereby [name of hospice agency] is [ACH] preferred hospice agency. … Given the serious and harmful actions described in this letter, [ACH] demands that [name of hospice agency] do the following immediately: Cease using any and all confidential medical information of [ACH] patients to procure patients for your hospice services. Identify how and/or from whom [name of hospice agency] acquired the hospice orders, or other related confidential medical information, of patients treated [ACH]. Cease any and all claims and statements that [name of hospice agency]and [ACH] have any business or contractual relationship, including that [name of hospice agency] is the preferred hospice agency of [ACH]. Cease any and all claims and statements that [ACH] referred or otherwise arranged for [name of hospice agency] to provide hospice services to patients of [ACH], …”In a continued interview, the Admin/Owner stated she had conducted the investigation into the ACH’s complaint. The Admin/Owner stated the agency employed a Previous Community Liaison (P/CL 1) who marketed the hospice agency to the ACH, and no other employee had marketed the hospice agency to the ACH. The Admin/Owner stated the P/CL 1’s date of hire was March 31, 2021, and resignation date was August 8, 2024, the Admin/Owner stated she had not suspended the P/CL 1 from his marketing duties during her investigation of the complaint. The Admin/Owner stated she had identified all the ACH’s patients admitted to the hospice agency and verified with the P/MD that all the patients were hospice appropriate, therefore none of the ACH’s patients had been discharged from the hospice’s services. The Admin/Owner stated she did not investigate or identify if any of the identified ACH’s patients had hospice referral orders, if the hospice had identified and reached out to an AP for consultation, or the patients in their first and second benefit period had a second physician signature from the AP on their CTI. In a continued interview, The Admin/Owner verified Patients 5 and 7 had come from the ACH and there was no documented evidence to show a physician’s referral order had been received or an AP had been identified and contacted to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation. In addition, the Admin/Owner verified Patients 5 and 7’s CTIs had not been signed by their APs. The Admin/Owner stated Patients 5 and 7’s Hospice Election Statements (a form required by Medicare for individuals electing to receive care under the Medicare Hospice Benefit. It is a formal agreement between the patient (or their representative), the hospice agency, and Medicare, outlining the terms and conditions of the hospice election) dated January 12, 2022, and December 21, 2021, respectively had been co-signed by the P/CL 1 confirming his involvement with their admission. The Admin/Owner stated she had not asked the P/CL 1 if he received, and from whom, hospice referral orders for the ACH’s patients. The Admin/Owner stated she asked the P/CL 1 how he received the PHI on the ACH’s patients, and the P/CL 1 stated “from his people” at the ACH. The Admin/Owner stated she did not ask for the names of the P/CL 1’s “people” because they were friends of his and the Admin/Owner stated she did not think it was appropriate. The Admin/Owner stated she asked the P/CL 1 if he had posed as an ACH employee in order to gain access to the ACH’s patients PHI and the P/CL 1 told her he had not. The Admin/Owner stated she concluded her investigation, determined that no wrongdoing had occurred and allowed the P/CL 1 to continue to market for the hospice agency until August 8, 2024, an additional two and a half years from the time of the ACH’s complaint dated January 31, 2022.In a continued interview, The Admin/Owner stated she decided to no longer market the hospice agency’s services to the ACH or admit ACH’s patients to the hospice agency. The Admin/Owner stated she did not provide resolution information in writing to the ACH or provide the ACH with the information demanded in the ACH’s cease and desist letter, dated January 31, 2022. The Admin/Owner stated she had her lawyer send a letter to the ACH, but did not provide a copy of or describe the contents of the letter her lawyer sent to the ACH.A review of the agency’s policy and procedure titled “Complaint/Grievance Process,” undated, indicated, “PURPOSE: To set forth guidelines for the resolution of patient concerns, dissatisfaction, or complaints and to protect patient and family rights. POLICY: Patients can freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care, treatment, and services. Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and I Care Hospice, Inc. concerning any aspect of services or the application of policies or procedures will be considered a grievance. The Executive Director/Administrator will be informed of situations that may become detrimental to good patient relations and will be committed to maintaining a consistently high level of patient relations. This grievance procedure will be included in the Patient Bill of Rights document given to each patient upon admission. PROCEDURE: 1. The organization personnel receiving the complaint will discuss, verbally and in writing, the grievance with the Clinical Supervisor/Nursing Supervisor within five (5) days of the alleged grievance. The Clinical Supervisor/Nursing Supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt. 2. If the grievance cannot be resolved to the patient's satisfaction, the patient or his/her representative is to notify, verbally or in writing, the Executive Director/Administrator. The grievance must state the problem or action alleged and the date the Clinical Supervisor/Nursing Supervisor was notified. The Executive Director/Administrator or designee will then investigate the grievance and contact the patient or his/her representative regarding the grievance in an attempt to resolve the differences. The Executive Director/Administrator will respond to the patient within ten (10) days of notification of failure to resolve the complaint. 3. If the patient feels his/her grievance has not been resolved after working with I Care Hospice, Inc. personnel, he/she will be informed of his/her right to notify the state via the respective toll-free telephone numbers, or other methods such as ombudsman, legal services, or adult protective services. The written admission guidelines, provided to the patient upon admission, list sources of assistance for complaint resolution. 4. Complaints and any action taken will be documented on a complaint form. 5. Corrective action will be specific and related to the complaint. 6. Resolution information will be communicated in writing to the patient or his/her representative filing the complaint. 7. Risk management personnel will be notified of any complaints which may involve litigation by the clinician involved completing an organization incident report or unusual occurrence form and forwarding a copy to the Risk Management Department. 8. Complaints received on patient satisfaction surveys (mail) will be documented on a complaint form and addressed as outlined above. 9. All complaints from patients who believe their privacy rights have been violated will be forwarded for review to the designated organization personnel or office specified in the organization's Notice of Privacy Practices. …”2a. A review of Patient 5’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 12, 2022, with a benefit period of January 12, 2022, to April 11, 2022 (Benefit Period one). Patient 5 had diagnoses that included rectal cancer (cancer that develops in the rectum, the final part of the large intestine). Patient 5 passed away on January 26, 2022.A review of Patient 5’s physician’s orders from January 12, 2022, to January 26, 2022, was conducted. There was no documented evidence to show a physician’s referral order had been received. Further review indicated there was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation.A review of Patient 5’s “Physician’s Certification for Hospice Benefit,” dated January 12, 2022, to April 11, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the Previous Medical Director (P/MD) on January 12, 2022.A review of Patient 5’s “Physician’s Certification for Hospice Benefit,” dated January 12, 2022, to April 11, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG [Interdisciplinary group - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient] Meetings and Plan of Care if I choose to follow the Patient,” signed by the P/MD on January 12, 2022.There was no documented evidence to show that an AP had been contacted and supporting documentation obtained. There was no documented evidence to show an AP confirmed Patient 5’s hospice service needs or provided a signature verifying Patient 5’s prognosis of six months or less life expectancy.A review of Patient 5’s claims for payment indicated a claim for payment was submitted in January 2022.During an interview with the current MD on May 8, 2025, from 12:04 PM, to 1:02 PM, the MD stated he had not been the MD at the time Patient 5 was admitted to the agency. The MD verified there was no physician’s referral order, or H&P (History and Physical-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), or documented evidence to show the P/MD had reached out to the AP to confirm service needs, verify Patient 5’s medical prognosis, or request supporting documentation. The MD stated he was aware the CTI for the first and second benefit periods required a signature from the MD and AP and verified the P/MD had signed Patient 5’s CTI in place of the AP.During an interview with the Administrator/Owner (Admin/Owner) on May 8, 2025, at 1:22 PM, the Admin/Owner confirmed there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 5’s medical prognosis, or request supporting documentation. The Admin/Owner confirmed the P/MD had signed Patient 5’s CTI in place of the AP.2b. A review of Patient 7’s face sheet, undated, indicated a start of care date of December 30, 2021, with a benefit period of December 30, 2021, to March 29, 2022 (Benefit Period one). Patient 7 had diagnoses that included ovarian (ovaries--two small, almond-shaped glands located in the female reproductive system) cancer. Patient 7 passed away on January 16, 2022. A review of Patient 7’s physician’s orders from December 30, 2021, to January 16, 2022, was conducted. There was no documented evidence to show a physician’s referral order had been received. Further review indicated there was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation. A review of Patient 7’s “Physician’s Certification for Hospice Benefit,” dated December 30, 2021, to March 29, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the P/MD on December 30, 2021. A review of Patient 7’s “Physician’s Certification for Hospice Benefit,” dated December 30, 2021, to March 29, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient,” signed by the P/MD on December 30, 2021. There was no documented evidence to show that an AP had been contacted and supporting documentation obtained. There was no documented evidence to show an AP confirmed Patient 7’s hospice service needs or provided a signature verifying Patient 7’s prognosis of six months or less life expectancy.A review of Patient 7’s claims for payment indicated a claim for payment was submitted in December 2021, and January 2022.During an interview with the current MD on May 8, 2025, from 12:04 PM, to 1:02 PM, the MD stated he had not been the MD at the time Patient 7 was admitted to the agency. The MD verified there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 7’s medical prognosis, or request supporting documentation. The MD stated he was aware the CTI for the first and second benefit periods required a signature from the MD and AP and verified the P/MD had signed Patient 7’s CTI in place of the AP.During an interview with the Admin/Owner on May 8, 2025, at 1:22 PM, the Admin/Owner confirmed there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 7’s medical prognosis, or request supporting documentation. The Admin/Owner confirmed the P/MD had signed Patient 7’s CTI in place of the AP.2c. A review of Patient 8’s face sheet, undated, indicated a start of care date of December 27, 2024, with a benefit period of December 27, 2024, to March 26, 2025 (Benefit Period one). Patient 8 had diagnoses that included heart failure (a condition where the heart cannot pump enough blood to meet the body's needs).A review of Patient 8’s physician’s orders from December 27, 2024, to May 8, 2025, was conducted. There was no documented evidence to show a physician’s referral order had been received. Further review indicated there was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation.A review of Patient 8’s “Physician’s Certification for Hospice Benefit,” dated December 27, 2024, to March 26, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the current MD on December 27, 2024. A review of Patient 8’s “Physician’s Certification for Hospice Benefit,” dated December 27, 2024, to March 26, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient,” signed by the MD on December 27, 2024. There was no documented evidence to show that an AP had been contacted and supporting documentation obtained. There was no documented evidence to show an AP confirmed Patient 8’s hospice service needs or provided a signature verifying Patient 8’s prognosis of six months or less life expectancy.A review of Patient 8’s claims for payment indicated a claim for payment was submitted in December 2024, January 2025, February 2025, and March 2025. April 2025 was pending.During an interview with Patient 8’s AP 2 on May 8, 2025, at 8:31 AM, AP 2 stated she was Patient 8’s neurologist (a medical specialist in the diagnosis and treatment of disorders of the nervous system) and was currently treating Patient 8’s Parkinson’s disease (a progressive neurodegenerative disorder that affects movement, primarily due to a loss of brain cells that produce dopamine, a chemical messenger in the brain). AP 2 stated she did not know Patient 8 was on hospice, did not refer Patient 8 to hospice and “I was stunned to hear [Patient 8] was on hospice.” AP 2 stated she did not have a discussion with Patient 8 or her family about hospice services because Patient 8 was nowhere near the point of her life where she needed hospice. AP 2 stated the hospice’s terminal diagnosis of heart failure was inappropriate as Patient 8 had no active heart failure and was not on medication to treat heart failure. AP 2 stated Patient 8 had begun to have memory issues due to the Parkinson’s disease but could still hold a meaningful conversation, so Patient 8 was not in, end stage dementia (the final phase of dementia as characterized by severe cognitive and physical decline, requiring constant care and assistance. Individuals in this stage experience significant difficulties with communication, daily tasks, and mobility). AP 2 stated if the hospice was taking Patient 8’s bed bound status (a person unable to leave their bed due to illness, injury, or other medical condition that limits their mobility) into consideration, Patient 8 was bed bound due to orthopedic issues (a wide range of conditions affecting the musculoskeletal system, including bones, joints, ligaments, tendons, muscles, and nerves) not for being debilitated (a person in a severely weakened state, often due to disease or illness). AP 2 stated her husband was Patient 8’s orthopedic doctor (a medical specialist who focuses on the diagnosis and treatment of conditions affecting the musculoskeletal system) and had replaced multiple joints for Patient 8. AP 2 stated the hospice agency had not reached out to her to consult on Patient 8 and hospice services, “If they had I would have said No, not appropriate.” During an interview with the MD on May 8, 2025, from 12:04 PM to 1:02 PM, the MD stated he was not aware Patient 8 did not have a physician’s referral order, but it was not unusual for this agency because the patients rarely had APs. The MD stated he did not consult with Patient 8’s AP to confirm service needs, verify Patient 8’s medical prognosis, or request supporting documentation because the agency told him Patient 8 did not have an AP. The MD stated he was aware the CTI for the first and second benefit periods required a signature from the MD and AP and verified he had signed Patient 8’s CTI, in place of the AP, because the agency told him Patient 8 did not have an AP. The MD stated he had determined Patient 8’s terminal diagnosis from his face-to-face visit (an in-person physician’s clinical assessment of a patient) with Patient 8, but no family present, and the Registered Nurse’s (RN) admission assessment. The MD stated he did not review Patient 8’s H&P because it had not been available at the time he signed Patient 8’s CTI. The MD reviewed the interview with Patient 8’s AP 2 and stated he was not provided this information by the agency, “I am very concerned about what I am hearing.”During an interview with Patient 8’s AP 1 on May 9, 2025, at 9:50 AM, AP 1 stated she was Patient 8’s primary care doctor and had a visit with Patient 8 about a year ago. AP 1 stated she did not know Patient 8 was on hospice, did not refer Patient 8 to hospice and “I was taken aback when I heard [Patient 8] was on hospice.” AP 1 stated she did not have a discussion with Patient 8 or her family about hospice services because there was no identified need. AP 1 stated there was no formal diagnosis of heart failure and Patient 8 exhibited no symptoms which would prompt them to assess for heart failure. AP 1 stated when she last saw Patient 8, Patient 8 was not having difficulty with her memory and there were no signs of dementia, “this must be a recent occurrence.” AP 1 stated the hospice agency had not reached out to her to consult on Patient 8 and hospice services, “I don’t think she needs hospice.”2d. A review of Patient 9’s face sheet, undated, indicated a start of care date of April 5, 2025, with a benefit period of April 5, 2025, to July 3, 2025 (Benefit Period one). Patient 9 had diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris (the build-up of plaque in the heart's arteries, which can restrict blood flow to the heart muscle, but without the typical chest pain associated with angina pectoris).A review of Patient 9’s physician’s orders from April 5, 2025, to May 8, 2025, was conducted. There was no documented evidence to show a physician’s referral order had been received. There was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation. A review of Patient 9’s “Physician’s Certification for Hospice Benefit,” dated April 5, 2025, to July 3, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MD on April 5, 2025.  A review of Patient 9’s “Physician’s Certification for Hospice Benefit,” dated April 5, 2025, to July 3, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient,” signed by the MD on April 5, 2025.  There was no documented evidence to show that an AP had been contacted and supporting documentation obtained. There was no documented evidence to show an AP confirmed Patient 9’s hospice service needs or provided a signature verifying Patient 9’s prognosis of six months or less life expectancy.A review of Patient 9’s claims for payment indicated a claim for payment for April 2025 was pending.During a telephone interview with a Regional Director (RD) from Patient 9’s medical group on May 7, 2025, at 2:42 PM, the RD confirmed AP 3 as Patient 9’s attending physician. The RD reviewed Patient 9’s clinical record and stated there was no indication of a referral to hospice services, or a discussion of hospice. The RD stated Patient 9 was still receiving chemotherapy (the treatment of disease by the use of chemical substances) for her stomach cancer and there was a physician’s order dated April 22, 2025, to do laboratory testing (analyzing samples of blood, urine, or other bodily fluids or tissues to provide insights into a person's health) every three weeks to monitor. The RD stated Patient 9’s medical group had its own hospice protocol, and it had not been initiated for Patient 9. The RD requested an email with the questions for AP 3 and the RD would facilitate the response from AP 3. During an interview with the MD on May 8, 2025, from 12:04 PM to 1:02 PM, the MD stated he was not aware Patient 9 did not have a physician’s referral order, but it was not unusual for this agency because the patients rarely had APs. The MD stated he did not consult with Patient 9’s AP to confirm service needs, verify Patient 9’s medical prognosis, or request supporting documentation because the agency told him Patient 9 did not have an AP. The MD stated he was aware the CTI for the first and second benefit periods required a signature from the MD and AP and verified he had signed Patient 9’s CTI, in place of the AP, because the agency told him Patient 9 did not have an AP. The MD stated he had determined Patient 9’s terminal diagnosis from his face-to-face visit with Patient 9, but no family was present, and the RN’s admission assessment. The MD stated he did not review Patient 9’s H&P because it had not been available at the time he signed Patient 9’s CTI. The MD stated he did not know Patient 9 was still receiving chemotherapy treatments and if he had known, he would not have certified Patient 9. The MD stated he was familiar with Patient 9’s medical group and knew about their hospice protocol. The MD stated if he had reviewed Patient 9’s H&P we would have seen the name of the medical group on the paperwork and questioned the agency on why Patient 9 was coming to their agency, instead of following the medical group’s hospice protocol. A review of an email response from AP 3, on May 9, 2025, at 10:42 AM, indicated,“1. Did [AP 3] know the patient was [receiving] hospice services? No2. Did [AP 3] refer the patient to hospice? No3. Did [AP 3] have a discussion with the patient and the patient's family about hospice services? No4. Does [AP 3] think [Patient 9] is appropriate for hospice services and if so, with what terminal diagnosis? No, the [Patient 9] is not appropriate.5. Does [AP 3] feel the diagnosis of [atherosclerotic heart disease of native coronary artery without angina pectoris] is an appropriate terminal diagnosis for [Patient 9]? No6. Does [AP 3] feel the patient is in, end stage dementia? No7. Did [Name of Hospice Agency] reach out to [AP 3] to consult on [Patient 9’s] terminal diagnosis? No.”2e. A review of Patient 10’s face sheet, undated, indicated a start of care date of April 11, 2025, with a benefit period of April 11, 2025, to July 9, 2025 (Benefit Period one). Patient 10 had diagnoses that included hypertensive heart disease with heart failure (when sustained, elevated blood pressure causes the heart to weaken and eventually fail to pump blood effectively).A review of Patient 10’s hospice referral order by Patient 10’s AP 4, dated April 9, 2025, indicated, “Order: Consult to Hospice (Hospice Consult) … Reason for Consult patient removing NG tube [a nasogastric tube is a thin, flexible tube that is inserted through the nose, down the throat, and into the stomach. It is used to deliver liquid nutrition and medications, or to remove stomach contents. NG tubes are often used for individuals who cannot eat or drink normally due to various medical conditions] and family requesting discussion of discharge with hospice.”A review of Patient 10’s “Physician’s Certification for Hospice Benefit,” dated April 11, 2025, to July 9, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MD on April 11, 2025.  A review of Patient 10’s “Physician’s Certification for Hospice Benefit,” dated April 11, 2025, to July 9, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient,” signed by the MD on April 11, 2025.  There was no documented evidence to show that AP 4 had been contacted and supporting documentation obtained. There was no documented evidence to show AP 4 confirmed Patient 10’s hospice service needs or provided a signature verifying Patient 10’s prognosis of six months or less life expectancy.A review of Patient 10’s claims for payment indicated a claim for payment for April 2025 was pending.During an interview with the MD on May 8, 2025, from 12:04 PM to 1:02 PM, the MD stated he was aware of AP 4’s name and contact information on the hospice referral order but he did not consult with AP 4 to confirm service needs, verify Patient 10’s medical prognosis, or request supporting documentation. The MD stated he was aware the CTI for the first and second benefit periods required a signature from the MD and AP and verified he had signed Patient 10’s CTI, in place of the AP 4, and should not have. The MD stated he had not created a physician’s summary with a brief narrative explanation of the clinical findings that supported a life expectancy of 6 months or less or provided a narrative that reflected Patient 10’s individual clinical circumstances, “I forgot.” A review of the agency’s policy and procedure titled, “Certification of Terminal Illness,” undated, indicated, “PURPOSE:  To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. … PROCEDURE: 1. At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on: his/her review of the patient's medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms. … 3. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. Initially, the clinical information may be provided verbally and must be documented in the medical record and included as part of the hospice's eligibility assessment. 4. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. …”3a. A review of Patient 5’s face sheet, undated, indicated a start of care date of January 12, 2022, with a benefit period of January 12, 2022, to April 11, 2022 (Benefit Period one). Patient 5 had diagnoses that included rectal cancer. Patient 5 passed away on January 26, 2022.A review of Patient 5’s physician’s orders from January 12, 2022, to January 26, 2022, was conducted. Further review indicated there was no documented evidence to show a physician’s referral order had been received. There was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation.A review of Patient 5’s clinical record from January 12, 2022, to January 26, 2022, was conducted. There was no documented evidence to show H&P, had been obtained from a referral source or Patient 5’s AP. There was no documented evidence to show that an AP had been identified and contacted to obtain supporting documentation. There was no documented evidence to show an AP confirmed Patient 5’s hospice service needs or verified Patient 5’s prognosis of six months or less life expectancy.During an interview with the current MD on May 8, 2025, from 12:04 PM, to 1:02 PM, the MD stated he had not been the MD at the time Patient 5 was admitted to the agency. The MD verified there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 5’s medical prognosis, or request supporting documentation.During an interview with the Admin/Owner on May 8, 2025, at 1:22 PM, the Admin/Owner confirmed there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 5’s medical prognosis, or request supporting documentation.3b. A review of Patient 7’s face sheet, undated, indicated a start of care date of December 30, 2021, with a benefit period of December 30, 2021, to March 29, 2022 (Benefit Period one). Patient 7 had diagnoses that included ovarian cancer. Patient 7 passed away on January 16, 2022. A review of Patient 7’s physician’s orders from December 30, 2021, to January 16, 2022, was conducted. There was no documented evidence to show a physician’s referral order had been received. Further review indicated there was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation. A review of Patient 7’s clinical record from December 30, 2021, to March 29, 2022, was conducted. There was no documented evidence to show H&P had been obtained from a referral source or Patient 7’s AP. There was no documented evidence to show that an AP had been identified and contacted to obtain supporting documentation. There was no documented evidence to show an AP confirmed Patient 7’s hospice service needs or verified Patient 7’s prognosis of six months or less life expectancy.During an interview with the current MD on May 8, 2025, from 12:04 PM, to 1:02 PM, the MD stated he had not been the MD at the time Patient 7 was admitted to the agency. The MD verified there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 7’s medical prognosis, or request supporting documentation. During an interview with the Admin/Owner on May 8, 2025, at 1:22 PM, the Admin/Owner confirmed there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 7’s medical prognosis, or request supporting documentation.3c. A review of Patient 8’s face sheet, undated, indicated a start of care date of December 27, 2024, with a benefit period of December 27, 2024, to March 26, 2025 (Benefit Period one). Patient 8 had diagnoses that included heart failure.A review of Patient 8’s physician’s orders from December 27, 2024, to May 8, 2025, was conducted. There was no documented evidence to show a physician’s referral order had been received. There was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation.A review of Patient 8’s H&P dated June 13, 2024, indicated an ER visit after a fall with a dislocation of the left shoulder. H&P dated November 15, 2024, indicated a visit to prepare for neurosurgery to replace a deep brain stimulator for treatment of Patient 8’s Parkinson’s disease and H&P dated December 5, 2024, indicated surgery to replace a deep brain stimulator for treatment of Patient 8’s Parkinson’s disease, there was no documented evidence to show a terminal diagnosis had been identified or a discussion of hospice services had occurred. During a interview with Patient 8’s daughter on May 6, 2025, at 11:27 AM, Patient 8’s daughter stated Patient 8 had early onset Parkinson's disease, “[Patient 8] is only 61 years old.” Patient 8’s daughter stated the Parkinson’s disease started getting bad about (two) to (three) years ago with memory problems and tremors and Patient 8 had a deep brain stimulator placed in 2023, but “[Patient 8] does not have full blown dementia.” Patient 8’s daughter stated she was not sure who talked to them about hospice services because her dad took care of it, and she signed the hospice paperwork because she was easier to get ahold of than her dad. Patient 8’s daughter stated Patient 8 would try to do things she was not capable of doing, making Patient 8’s safety an issue. Patient 8’s daughter stated Patient 8’s primary care physician was AP 1 and helped them place Patient 8 in a Board and Care Facility (B&C a licensed, non-medical facility providing room, board, and 24-hour care and supervision for individuals who need help with daily living activities but not 24-hour nursing care) due to the safety issue. Patient 8’s daughter stated she had heard hospice was for people who were terminal but the staff at the B&C stated hospice was not just for terminal patients. Patient 8’s daughter stated she did not know hospice was about giving up curative care and just receiving palliative care. Patient 8’s daughter stated she did not believe Patient 8’s Parkinson’s disease would lead to Patient 8 dying in 6 (six) months and she did not know the hospice gave Patient 8 a terminal diagnosis of heart failure.During a interview with Patient 8’s ex-husband on May 6, 2025, at 4:22 PM, Patient 8’s ex-husband stated he had stopped by the B&C one day to visit Patient 8, and the B&C staff had told him Patient 8 was on hospice, “I didn’t know [Patient 8] was on hospice.” Patient 8’s ex-husband stated his daughter had signed the hospice paperwork and if he gave consent, he did not remember giving consent. Patient 8’s ex-husband stated he knew hospice provided end of life services but did not know curative care stopped, “If anything happened to [Patient 8] we would get her the appropriate treatment.” Patient 8’s ex-husband stated his daughter did not know what she was signing, “I think it was about getting additional services to help with [Patient 8’s] care.” Patient 8’s ex-husband stated he had never heard about heart failure and when Patient 8 lived with him he gave her medications and Patient 8 was not on heart failure medication. Patient 8’s ex-husband stated Patient 8’s neurologist AP 2, told him Patient 8 had Parkinson’s dementia and Patient 8 had trouble stringing words together. Patient 8’s ex-husband stated Patient 8 had just visited AP 2 on March 27, 2025, to follow up on her deep brain stimulator. Patient 8’s ex-husband stated, “I think someone jumped the gun on this one.” During an interview with Patient 8’s AP 2 on May 8, 2025, at 8:31 AM, AP 2 stated she was Patient 8’s neurologist and was currently treating Patient 8’s Parkinson’s disease. AP 2 stated she did not know Patient 8 was on hospice, did not refer Patient 8 to hospice and “I was stunned to hear [Patient 8] was on hospice.” AP 2 stated she did not have a discussion with Patient 8 or her family about hospice services because Patient 8 was nowhere near the point of her life where she needed hospice. AP 2 stated the hospice’s terminal diagnosis of heart failure was inappropriate as Patient 8 had no active heart failure and was on no medication to treat heart failure. AP 2 stated Patient 8 had begun to have memory issues due to the Parkinson’s disease but could still hold a meaningful conversation, so Patient 8 was not in, end stage dementia. AP 2 stated if the hospice was taking Patient 8’s bed bound status into consideration, Patient 8 was bed bound due to orthopedic issues not for being debilitated AP 2 stated her husband was Patient 8’s orthopedic doctor and had replaced multiple joints for Patient 8. AP 2 stated the hospice agency had not reached out to her to consult on Patient 8 and hospice services, “If they had I would have said No, not appropriate.” During an interview with the MD on May 8, 2025, from 12:04 PM to 1:02 PM, the MD stated he was not aware Patient 8 did not have a physician’s referral order, but it was not unusual for this agency because the patients rarely had APs. The MD stated he did not consult with Patient 8’s AP to confirm service needs, verify Patient 8’s medical prognosis, or request supporting documentation because the agency told him Patient 8 did not have an AP. The MD stated he had determined Patient 8’s terminal diagnosis from his face-to-face visit with Patient 8, but no family present, and the RN admission assessment. The MD stated he did not review Patient 8’s H&P because it had not been available at the time he signed Patient 8’s CTI. The MD reviewed the interview with Patient 8’s AP 2 and stated he was not provided this information by the agency, “I am very concerned about what I am hearing.”During an interview with Patient 8’s AP 1 on May 9, 2025, at 9:50 AM, AP 1 stated she was Patient 8’s primary care doctor and had a visit with Patient 8 about a year ago. AP 1 stated she did not know Patient 8 was on hospice, did not refer Patient 8 to hospice and “I was taken aback when I heard [Patient 8] was on hospice.” AP 1 stated she did not have a discussion with Patient 8 or her family about hospice services because there was no identified need. AP 1 stated there was no formal diagnosis of heart failure and Patient 8 exhibited no symptoms which would prompt them to assess for heart failure. AP 1 stated when she last saw Patient 8, Patient 8 was not having difficulty with her memory and there were no signs of dementia, “this must be a recent occurrence.” AP 1 stated the hospice agency had not reached out to her to consult on Patient 8 and hospice services, “I don’t think she needs hospice.”1d. A review of Patient 9’s face sheet, undated, indicated a start of care date of April 5, 2025, with a benefit period of April 5, 2025, to July 3, 2025 (Benefit Period one). Patient 9 had diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris.A review of Patient 9’s physician’s orders from April 5, 2025, to May 8, 2025, was conducted. There was no documented evidence to show a physician’s referral order had been received. There was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation. A review of Patient 9’s H&P dated September 5, 2024, indicated an ER visit for urinary tract infection with septicemia, H&P dated January 6, 2025, indicated surgery for stomach cancer, there was no documented evidence to show a terminal diagnosis had been identified or a discussion of hospice services had occurred. During an interview with Patient 9’s daughter on May 7, 2025, from 12:33 PM, to 12:53 PM, Patient 9’s daughter stated Patient 9 had stomach cancer surgery in January 2025 and “I was amazed on how well she was doing after the surgery.” Patient 9’s daughter started she noticed dementia symptoms, like memory problems, where Patient 9 would go to the kitchen, start cooking, forget what she was doing, leave the kitchen with whatever she started cooking, still cooking. Patient 9’s daughter stated she became afraid Patient 9 would burn down the apartment when she was at work, so Patient 9’s daughter quit her job and stayed home with Patient 9 to keep her safe. Patient 9’s daughter stated she knew she would have to place Patient 9 in a facility but did not have the money to pay for a facility, so Patient 9’s daughter reached out to Patient 9’s medical group. Patient 9’s daughter stated the medical group provided a respite program for a caregiver to stay with Patient 9 in the home but it only lasted three months, in addition, the medical group provided Patient 9’s daughter with a list of facility names that could help her apply for a waiver program so her mother could be placed in an Assisted Living Facility (ALF-a living arrangement in which people with special needs, especially seniors, live in a facility that provides help with everyday tasks such as bathing, dressing, and taking medication) without cost. Patient 9’s daughter stated this was where she found the hospice agency’s name and phone number, but she had not called the hospice agency for hospice services but to get help with filing for the waiver. Patient 9’s daughter stated she called the hospice agency, and they said they could help her file for the waiver, but Patient 9 had to be placed on the list, and it could take over a year to obtain a waiver. Patient 9’s daughter stated she did not have a year to wait to get Patient 9 placement, because Patient 9’s daughter needed to work, or they would be out on the street. Patient 9’s daughter stated the hospice agency offered Patient 9 hospice services and she was desperate, so she accepted any services she could get without cost, but the hospice services did not solve the problem of Patient 9’s placement in a facility. Patient 9’s daughter stated Patient 9 was still receiving chemotherapy (the treatment of disease by the use of chemical substances) for her stomach cancer, “[Patient 9] gets nine rounds and has received four rounds.” The doctors at Patient 9’s medical group did not discuss hospice services for Patient 9 and hospice was for people who could not pay for care services, “it's not for someone who is passing away.” Patient 9’s daughter stated Patient 9 was not on her way to dying and Patient 9 wanted to exercise all her options to stay alive, “None of the [medical group’s] doctors said [Patient 9] was dying, [Patient 9] has options.” Patient 9’s daughter became emotional and stated, “I am living day to day because I don't know how I am going to pay to place [Patient 9] in a facility or pay the rent on the apartment.”During an interview with the Director for Assisted Living Waiver (DALW), the Admin/Owner, the Office Manager (OM) and Director of Patient Care Services (DPCS) on May 7, 2025, at 1:07 PM, the DALW stated he helped people get into the waiver program for their loved ones to live in an ALF for free. The DALW stated he was a staff member of the hospice but did not market hospice services and admission to hospice services was not required for the DALW to process the waiver. The DALW stated the process of the waiver could take over a year and many families were desperate for services so he would talk to the families about hospice services and if they wanted the services he would refer them to the hospice. The DALW stated he spoke with Patient 9’s daughter and she told him Patient 9 was declining due to dementia, so he referred her to the hospice. The Admin/Owner stated she asked the OM to get Patient 9’s H&P. The OM stated she asked Patient 9’s medical group for Patient 9’s H&P but did not ask for a hospice referral order. The DPCS stated it was her responsibility to get a hospice referral order, and she did not.During a telephone interview with an RD from Patient 9’s medical group on May 7, 2025, at 2:42 PM, the RD confirmed AP 3 as Patient 9’s attending physician. The RD reviewed Patient 9’s clinical record and stated there was no indication of a referral to hospice services, or a discussion of hospice. The RD stated Patient 9 was still receiving chemotherapy for her stomach cancer and there was a physician’s order dated April 22, 2025, to do laboratory testing every three weeks to monitor. The RD stated Patient 9’s medical group had its own hospice protocol, and it had not been initiated for Patient 9. The RD requested an email with the questions for AP 3 and the RD would facilitate the response from AP 3. During an interview with the MD on May 8, 2025, from 12:04 PM to 1:02 PM, the MD stated he was not aware Patient 9 did not have a physician’s referral order, but it was not unusual for this agency because the patients rarely had APs. The MD stated he did not consult with Patient 9’s AP to confirm service needs, verify Patient 9’s medical prognosis, or request supporting documentation because the agency told him Patient 9 did not have an AP. The MD stated he had determined Patient 9’s terminal diagnosis from his face-to-face visit with Patient 9, but no family was present, and the RN’s admission assessment. The MD stated he did not review Patient 9’s H&P because it had not been available at the time he signed Patient 9’s CTI. The MD stated he did not know Patient 9 was still receiving chemotherapy treatments and if he had known, he would not have certified Patient 9. The MD stated he was familiar with Patient 9’s medical group and knew about their hospice protocol. The MD stated if he had reviewed Patient 9’s H&P he would have seen the name of the medical group on the paperwork and questioned the agency on why Patient 9 was coming to their agency, instead of following the medical group’s protocol. The MD stated he was not aware of Patient 9’s need for placement in a facility because of safety issues due to dementia and memory loss. A review of an email response from AP 3, on May 9, 2025, at 10:42 AM, indicated,“1. Did [AP 3] know the patient was [receiving] hospice services? No2. Did [AP 3] refer the patient to hospice? No3. Did [AP 3] have a discussion with the patient and the patient's family about hospice services? No4. Does [AP 3] think [Patient 9] is appropriate for hospice services and if so, with what terminal diagnosis? No, the [Patient 9] is not appropriate.5. Does [AP 3] feel the diagnosis of [atherosclerotic heart disease of native coronary artery without angina pectoris] is an appropriate terminal diagnosis for [Patient 9]? No6. Does [AP 3] feel the patient is in, end stage dementia? No7. Did [Name of Hospice Agency] reach out to [AP 3] to consult on [Patient 9’s] terminal diagnosis? No.”1e. A review of Patient 10’s face sheet, undated, indicated a start of care date of April 11, 2025, with a benefit period of April 11, 2025, to July 9, 2025 (Benefit Period one). Patient 10 had diagnoses that included hypertensive heart disease with heart failure.A review of Patient 10’s hospice referral order by Patient 10’s AP 4, dated April 9, 2025, indicated, “Order: Consult to Hospice (Hospice Consult) … Reason for Consult patient removing NG tube and family requesting discussion of discharge with hospice.”A review of Patient 8’s H&P dated April 1, 2025, indicated an Acute Care Hospital admission for acute cholecystitis with cholangitis after percutaneous cholecystostomy tube placement on April 1, 2025. “Patient pulled NG tube twice last night and family/patient communicated wish to not attempt replacement. Family and patient would like to prioritize patient comfort and hopes for discharge home, they would like to speak with hospice.” There was no documented evidence to show that a terminal diagnosis had been identified.A review of Patient 10’s clinical record from April 11, 2025, to May 8, 2025, was conducted. There was no documented evidence to show that AP 4 had been contacted and supporting documentation obtained. There was no documented evidence to show AP 4 confirmed Patient 10’s hospice service needs or provided a terminal diagnosis and verification of Patient 10’s prognosis of six months or less life expectancy.During an interview with the MD on May 8, 2025, from 12:04 PM to 1:02 PM, the MD stated he was aware of AP 4’s name and contact information on the hospice referral order but he did not consult with AP 4 to confirm service needs, verify Patient 10’s medical prognosis, or request supporting documentation. The MD stated he determined Patient 10’s terminal diagnosis by reviewing Patient 10’s H&P.A review of the agency’s policy and procedure titled “Intake Process,” undated, indicated, “PURPOSE: To establish the process for acceptance and entry of patients into hospice. POLICY: … [name of agency] will accept only those patients whose needs can be met by the services it provides and who meet the hospice admission criteria. PROCEDURE: … A. Intake personnel will document information regarding patient demographics, diagnoses, services needed, medications, attending physician, hospitalization, etc., in order to make the initial determination whether the patient's needs can be met by hospice and if he/she meets eligibility criteria. … D. If the referral call is not from a physician, the physician (or other authorized licensed independent practitioner) will be contacted to confirm service needs, as well as the patient's medical prognosis and supporting documentation, and to obtain verbal orders. …”A review of the agency’s policy and procedure titled “Admission Criteria and Process,” undated, indicated, “PURPOSE: To establish standards and a process by which a patient can be evaluated and accepted for admission. … Admission Criteria 1. [name of agency] will admit a patient only on the recommendation of the medical director in consultation with, or input from, the patient's attending physician, if any. The information can be obtained from the hospice nurse or others sharing the attending physician’s knowledge of the patient. The patient's physician (or other authorized licensed independent practitioner) must order and approve the provision of hospice care, be willing to sign or have a representative who is willing to sign the death certificate and be willing to discuss the patient's resuscitation status with the patient and family/caregiver. … The patient must have a life-limiting illness with a life expectancy of six (6) months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria in the organization's intermediary Local coverage Determinations. … The focus of care desired must be palliative vs. curative. … PROCEDURE: 1. Referral information provided by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician offices will assist in the determination of eligibility for admission to the program. If the request for service is not made by the patient's physician, he/she will be consulted prior to the evaluation visit/initiation of services. …” A review of the agency’s policy and procedure titled, “Certification of Terminal Illness,” undated, indicated, “PURPOSE:  To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. … PROCEDURE: 1. At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on: his/her review of the patient's medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms. … 3. Clinical information and other documentation that supports the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. Initially, the clinical information may be provided verbally and must be documented in the medical record and included as part of the hospice's eligibility assessment. 4. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. …”During an interview with the Admin/Owner on May 8, 2025, at 3:42 PM, the Admin/Owner stated she was a member of the Governing Body (GB) and assumed full legal authority and responsibility for the operation of the agency, and for the quality of care and services provided. The Admin/Owner stated the GB had not identified:1a-b. that the agency failed to thoroughly investigate a complaint, take corrective action specifically and related to the complaint, provide resolution information in writing to the complainant or immediately take action to prevent further potential violations while the alleged violation was being verified for Patients 5 and 7 when the agency received a cease and desist letter from an ACH alleging “[ACH] has information to believe that [name of hospice agency] has obtained and used confidential medical information of terminally ill patients of [ACH] for the purpose of procuring patients for your hospice services in violation of several federal and state laws and regulations, including the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and the California Confidentiality of Medical Information Act ("CMIA").”2a-e. that the agency failed to ensure the MD certified the patients' terminal illnesses before the agency submitted a claim for payment, for Patients 5, 7, 8, 9, and 10 when the CTIs for the first and second 90-day benefit periods were not signed by two physicians, the MD and the patients’ AP.3a-e. The MD failed his responsibility for the medical component of the hospice program for Patients: 5, 7, 8, 9, and 10 when: For Patients 5, 7, 8, and 9 a physician's referral order was not obtained and for Patients 5, 7, 8, 9, and 10, an AP’s confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. In addition, the MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services.A review of the agency’s policy and procedure titled “Governing Body,” dated February 1, 2021, indicated, “POLICY: The Governing Body of [name of hospice agency] is legally responsible for the overall operation, management, and quality of services provided. The Governing Body shall ensure the organization complies with applicable federal, state, and local laws, and accreditation standards. The Governing Body provides strategic direction, oversight, and governance to support the mission and goals of [name of hospice agency].”

The agency failed to ensure that the Condition of Participation: L 664 §418.102 Medical director was in compliance as follows: 1. The agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for five of five sampled patients (Patients 5, 7, 8, 9, and 10) when the CTIs for the first and second 90-day benefit periods (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) were not signed by two physicians, the MD and the patients’ Attending Physicians (AP). (Refer to L 667) 2. Based on interview, and record review, the Medical Director (MD) failed his responsibility for the medical component of the hospice program for five of five sampled patients (Patients 5, 7, 8, 9, and 10) when:  For Patients 5, 7, 8, and 9, a physician's referral order was not obtained and for Patients 5, 7, 8, 9, and 10, an attending physician's confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. In addition, the MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. (Refer to L 669) The cumulative effect of these systemic practices resulted in the potential to cause Patients 5, 7, 8, 9, and 10 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and referring to hospice care and the Medical Director not correctly evaluating Patients 5, 7, 8, 9, and 10’s terminal diagnosis and prognosis of six months or less to live.

Based on interview, and record review, the agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for five of five sampled patients (Patients 5, 7, 8, 9, and 10) when the CTIs for the first and second 90-day benefit periods (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) were not signed by two physicians, the MD and the patients’ Attending Physicians (AP). These failures had the potential to cause Patients 5, 7, 8, 9, and 10, not be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to the MD not consulting with the patients’ APs leading to an inaccurate evaluation of  Patients 5, 7, 8, 9, and 10’s terminal diagnosis and prognosis of six months or less to live. --- 1. A review of Patient 5’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 12, 2022, with a benefit period of January 12, 2022, to April 11, 2022 (Benefit Period one). Patient 5 had diagnoses that included rectal cancer (cancer that develops in the rectum, the final part of the large intestine). Patient 5 passed away on January 26, 2022.A review of Patient 5’s physician’s orders from January 12, 2022, to January 26, 2022, was conducted. There was no documented evidence to show a physician’s referral order had been received. Further review indicated there was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation.A review of Patient 5’s “Physician’s Certification for Hospice Benefit,” dated January 12, 2022, to April 11, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the Previous Medical Director (P/MD) on January 12, 2022.A review of Patient 5’s “Physician’s Certification for Hospice Benefit,” dated January 12, 2022, to April 11, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG [Interdisciplinary group - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient] Meetings and Plan of Care if I choose to follow the Patient,” signed by the P/MD on January 12, 2022.There was no documented evidence to show that an AP had been contacted and supporting documentation obtained. There was no documented evidence to show an AP confirmed Patient 5’s hospice service needs or provided a signature verifying Patient 5’s prognosis of six months or less life expectancy.A review of Patient 5’s claims for payment indicated a claim for payment was submitted in January 2022.During an interview with the current MD on May 8, 2025, from 12:04 PM, to 1:02 PM, the MD stated he had not been the MD at the time Patient 5 was admitted to the agency. The MD verified there was no physician’s referral order, or H&P (History and Physical-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), or documented evidence to show the P/MD had reached out to the AP to confirm service needs, verify Patient 5’s medical prognosis, or request supporting documentation. The MD stated he was aware the CTI for the first and second benefit periods required a signature from the MD and AP and verified the P/MD had signed Patient 5’s CTI in place of the AP.During an interview with the Administrator/Owner (Admin/Owner) on May 8, 2025, at 1:22 PM, the Admin/Owner confirmed there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 5’s medical prognosis, or request supporting documentation. The Admin/Owner confirmed the P/MD had signed Patient 5’s CTI in place of the AP.2. A review of Patient 7’s face sheet, undated, indicated a start of care date of December 30, 2021, with a benefit period of December 30, 2021, to March 29, 2022 (Benefit Period one). Patient 7 had diagnoses that included ovarian (ovaries--two small, almond-shaped glands located in the female reproductive system) cancer. Patient 7 passed away on January 16, 2022. A review of Patient 7’s physician’s orders from December 30, 2021, to January 16, 2022, was conducted. There was no documented evidence to show a physician’s referral order had been received. Further review indicated there was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation. A review of Patient 7’s “Physician’s Certification for Hospice Benefit,” dated December 30, 2021, to March 29, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the P/MD on December 30, 2021. A review of Patient 7’s “Physician’s Certification for Hospice Benefit,” dated December 30, 2021, to March 29, 2022, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient,” signed by the P/MD on December 30, 2021. There was no documented evidence to show that an AP had been contacted and supporting documentation obtained. There was no documented evidence to show an AP confirmed Patient 7’s hospice service needs or provided a signature verifying Patient 7’s prognosis of six months or less life expectancy.A review of Patient 7’s claims for payment indicated a claim for payment was submitted in December 2021, and January 2022.During an interview with the current MD on May 8, 2025, from 12:04 PM, to 1:02 PM, the MD stated he had not been the MD at the time Patient 7 was admitted to the agency. The MD verified there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 7’s medical prognosis, or request supporting documentation. The MD stated he was aware the CTI for the first and second benefit periods required a signature from the MD and AP and verified the P/MD had signed Patient 7’s CTI in place of the AP.During an interview with the Admin/Owner on May 8, 2025, at 1:22 PM, the Admin/Owner confirmed there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 7’s medical prognosis, or request supporting documentation. The Admin/Owner confirmed the P/MD had signed Patient 7’s CTI in place of the AP.3. A review of Patient 8’s face sheet, undated, indicated a start of care date of December 27, 2024, with a benefit period of December 27, 2024, to March 26, 2025 (Benefit Period one). Patient 8 had diagnoses that included heart failure (a condition where the heart cannot pump enough blood to meet the body's needs).A review of Patient 8’s physician’s orders from December 27, 2024, to May 8, 2025, was conducted. There was no documented evidence to show a physician’s referral order had been received. Further review indicated there was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation.A review of Patient 8’s “Physician’s Certification for Hospice Benefit,” dated December 27, 2024, to March 26, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the current MD on December 27, 2024. A review of Patient 8’s “Physician’s Certification for Hospice Benefit,” dated December 27, 2024, to March 26, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient,” signed by the MD on December 27, 2024. There was no documented evidence to show that an AP had been contacted and supporting documentation obtained. There was no documented evidence to show an AP confirmed Patient 8’s hospice service needs or provided a signature verifying Patient 8’s prognosis of six months or less life expectancy.A review of Patient 8’s claims for payment indicated a claim for payment was submitted in December 2024, January 2025, February 2025, and March 2025. April 2025 was pending.During an interview with Patient 8’s AP 2 on May 8, 2025, at 8:31 AM, AP 2 stated she was Patient 8’s neurologist (a medical specialist in the diagnosis and treatment of disorders of the nervous system) and was currently treating Patient 8’s Parkinson’s disease (a progressive neurodegenerative disorder that affects movement, primarily due to a loss of brain cells that produce dopamine, a chemical messenger in the brain). AP 2 stated she did not know Patient 8 was on hospice, did not refer Patient 8 to hospice and “I was stunned to hear [Patient 8] was on hospice.” AP 2 stated she did not have a discussion with Patient 8 or her family about hospice services because Patient 8 was nowhere near the point of her life where she needed hospice. AP 2 stated the hospice’s terminal diagnosis of heart failure was inappropriate as Patient 8 had no active heart failure and was not on medication to treat heart failure. AP 2 stated Patient 8 had begun to have memory issues due to the Parkinson’s disease but could still hold a meaningful conversation, so Patient 8 was not in, end stage dementia (the final phase of dementia as characterized by severe cognitive and physical decline, requiring constant care and assistance. Individuals in this stage experience significant difficulties with communication, daily tasks, and mobility). AP 2 stated if the hospice was taking Patient 8’s bed bound status (a person unable to leave their bed due to illness, injury, or other medical condition that limits their mobility) into consideration, Patient 8 was bed bound due to orthopedic issues (a wide range of conditions affecting the musculoskeletal system, including bones, joints, ligaments, tendons, muscles, and nerves) not for being debilitated (a person in a severely weakened state, often due to disease or illness). AP 2 stated her husband was Patient 8’s orthopedic doctor (a medical specialist who focuses on the diagnosis and treatment of conditions affecting the musculoskeletal system) and had replaced multiple joints for Patient 8. AP 2 stated the hospice agency had not reached out to her to consult on Patient 8 and hospice services, “If they had I would have said No, not appropriate.” During an interview with the MD on May 8, 2025, from 12:04 PM to 1:02 PM, the MD stated he was not aware Patient 8 did not have a physician’s referral order, but it was not unusual for this agency because the patients rarely had APs. The MD stated he did not consult with Patient 8’s AP to confirm service needs, verify Patient 8’s medical prognosis, or request supporting documentation because the agency told him Patient 8 did not have an AP. The MD stated he was aware the CTI for the first and second benefit periods required a signature from the MD and AP and verified he had signed Patient 8’s CTI, in place of the AP, because the agency told him Patient 8 did not have an AP. The MD stated he had determined Patient 8’s terminal diagnosis from his face-to-face visit (an in-person physician’s clinical assessment of a patient) with Patient 8, but no family present, and the Registered Nurse’s (RN) admission assessment. The MD stated he did not review Patient 8’s H&P because it had not been available at the time he signed Patient 8’s CTI. The MD reviewed the interview with Patient 8’s AP 2 and stated he was not provided this information by the agency, “I am very concerned about what I am hearing.”During an interview with Patient 8’s AP 1 on May 9, 2025, at 9:50 AM, AP 1 stated she was Patient 8’s primary care doctor and had a visit with Patient 8 about a year ago. AP 1 stated she did not know Patient 8 was on hospice, did not refer Patient 8 to hospice and “I was taken aback when I heard [Patient 8] was on hospice.” AP 1 stated she did not have a discussion with Patient 8 or her family about hospice services because there was no identified need. AP 1 stated there was no formal diagnosis of heart failure and Patient 8 exhibited no symptoms which would prompt them to assess for heart failure. AP 1 stated when she last saw Patient 8, Patient 8 was not having difficulty with her memory and there were no signs of dementia, “this must be a recent occurrence.” AP 1 stated the hospice agency had not reached out to her to consult on Patient 8 and hospice services, “I don’t think she needs hospice.”4. A review of Patient 9’s face sheet, undated, indicated a start of care date of April 5, 2025, with a benefit period of April 5, 2025, to July 3, 2025 (Benefit Period one). Patient 9 had diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris (the build-up of plaque in the heart's arteries, which can restrict blood flow to the heart muscle, but without the typical chest pain associated with angina pectoris).A review of Patient 9’s physician’s orders from April 5, 2025, to May 8, 2025, was conducted. There was no documented evidence to show a physician’s referral order had been received. There was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation. A review of Patient 9’s “Physician’s Certification for Hospice Benefit,” dated April 5, 2025, to July 3, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MD on April 5, 2025.  A review of Patient 9’s “Physician’s Certification for Hospice Benefit,” dated April 5, 2025, to July 3, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient,” signed by the MD on April 5, 2025.  There was no documented evidence to show that an AP had been contacted and supporting documentation obtained. There was no documented evidence to show an AP confirmed Patient 9’s hospice service needs or provided a signature verifying Patient 9’s prognosis of six months or less life expectancy.A review of Patient 9’s claims for payment indicated a claim for payment for April 2025 was pending.During a telephone interview with a Regional Director (RD) from Patient 9’s medical group on May 7, 2025, at 2:42 PM, the RD confirmed AP 3 as Patient 9’s attending physician. The RD reviewed Patient 9’s clinical record and stated there was no indication of a referral to hospice services, or a discussion of hospice. The RD stated Patient 9 was still receiving chemotherapy (the treatment of disease by the use of chemical substances) for her stomach cancer and there was a physician’s order dated April 22, 2025, to do laboratory testing (analyzing samples of blood, urine, or other bodily fluids or tissues to provide insights into a person's health) every three weeks to monitor. The RD stated Patient 9’s medical group had its own hospice protocol, and it had not been initiated for Patient 9. The RD requested an email with the questions for AP 3 and the RD would facilitate the response from AP 3. During an interview with the MD on May 8, 2025, from 12:04 PM to 1:02 PM, the MD stated he was not aware Patient 9 did not have a physician’s referral order, but it was not unusual for this agency because the patients rarely had APs. The MD stated he did not consult with Patient 9’s AP to confirm service needs, verify Patient 9’s medical prognosis, or request supporting documentation because the agency told him Patient 9 did not have an AP. The MD stated he was aware the CTI for the first and second benefit periods required a signature from the MD and AP and verified he had signed Patient 9’s CTI, in place of the AP, because the agency told him Patient 9 did not have an AP. The MD stated he had determined Patient 9’s terminal diagnosis from his face-to-face visit with Patient 9, but no family was present, and the RN’s admission assessment. The MD stated he did not review Patient 9’s H&P because it had not been available at the time he signed Patient 9’s CTI. The MD stated he did not know Patient 9 was still receiving chemotherapy treatments and if he had known, he would not have certified Patient 9. The MD stated he was familiar with Patient 9’s medical group and knew about their hospice protocol. The MD stated if he had reviewed Patient 9’s H&P we would have seen the name of the medical group on the paperwork and questioned the agency on why Patient 9 was coming to their agency, instead of following the medical group’s hospice protocol. A review of an email response from AP 3, on May 9, 2025, at 10:42 AM, indicated,“1. Did [AP 3] know the patient was [receiving] hospice services? No2. Did [AP 3] refer the patient to hospice? No3. Did [AP 3] have a discussion with the patient and the patient's family about hospice services? No4. Does [AP 3] think [Patient 9] is appropriate for hospice services and if so, with what terminal diagnosis? No, the [Patient 9] is not appropriate.5. Does [AP 3] feel the diagnosis of [atherosclerotic heart disease of native coronary artery without angina pectoris] is an appropriate terminal diagnosis for [Patient 9]? No6. Does [AP 3] feel the patient is in, end stage dementia? No7. Did [Name of Hospice Agency] reach out to [AP 3] to consult on [Patient 9’s] terminal diagnosis? No.”5. A review of Patient 10’s face sheet, undated, indicated a start of care date of April 11, 2025, with a benefit period of April 11, 2025, to July 9, 2025 (Benefit Period one). Patient 10 had diagnoses that included hypertensive heart disease with heart failure (when sustained, elevated blood pressure causes the heart to weaken and eventually fail to pump blood effectively).A review of Patient 10’s hospice referral order by Patient 10’s AP 4, dated April 9, 2025, indicated, “Order: Consult to Hospice (Hospice Consult) … Reason for Consult patient removing NG tube [a nasogastric tube is a thin, flexible tube that is inserted through the nose, down the throat, and into the stomach. It is used to deliver liquid nutrition and medications, or to remove stomach contents. NG tubes are often used for individuals who cannot eat or drink normally due to various medical conditions] and family requesting discussion of discharge with hospice.”A review of Patient 10’s “Physician’s Certification for Hospice Benefit,” dated April 11, 2025, to July 9, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MD on April 11, 2025.  A review of Patient 10’s “Physician’s Certification for Hospice Benefit,” dated April 11, 2025, to July 9, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient,” signed by the MD on April 11, 2025.  There was no documented evidence to show that AP 4 had been contacted and supporting documentation obtained. There was no documented evidence to show AP 4 confirmed Patient 10’s hospice service needs or provided a signature verifying Patient 10’s prognosis of six months or less life expectancy.A review of Patient 10’s claims for payment indicated a claim for payment for April 2025 was pending.During an interview with the MD on May 8, 2025, from 12:04 PM to 1:02 PM, the MD stated he was aware of AP 4’s name and contact information on the hospice referral order but he did not consult with AP 4 to confirm service needs, verify Patient 10’s medical prognosis, or request supporting documentation. The MD stated he was aware the CTI for the first and second benefit periods required a signature from the MD and AP and verified he had signed Patient 10’s CTI, in place of the AP 4, and should not have. The MD stated he had not created a physician’s summary with a brief narrative explanation of the clinical findings that supported a life expectancy of 6 months or less or provided a narrative that reflected Patient 10’s individual clinical circumstances, “I forgot.” A review of the agency’s policy and procedure titled, “Certification of Terminal Illness,” undated, indicated, “PURPOSE:  To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. … PROCEDURE: 1. At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on: his/her review of the patient's medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms. … 3. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. Initially, the clinical information may be provided verbally and must be documented in the medical record and included as part of the hospice's eligibility assessment. 4. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. …”

Based on interview, and record review, the Medical Director (MD) failed his responsibility for the medical component of the hospice program for five of five sampled patients (Patients: 5, 7, 8, 9, and 10) when: For Patients 5, 7, 8, and 9 a physician's referral order was not obtained and for Patients 5, 7, 8, 9, and 10, an attending physician's confirmation of service needs, verification of the patients' medical prognosis and supporting documentation was not obtained. In addition, the MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services.This failure had the potential to cause Patients 5, 7, 8, 9, and 10 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and referring to hospice care and the MD not correctly evaluating Patients 5, 7, 8, 9, and 10’s terminal diagnosis and prognosis of six months or less to live. --- 1a. A review of Patient 5’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 12, 2022, with a benefit period of January 12, 2022, to April 11, 2022 (Benefit Period one). Patient 5 had diagnoses that included rectal cancer (cancer that develops in the rectum, the final part of the large intestine). Patient 5 passed away on January 26, 2022.A review of Patient 5’s physician’s orders from January 12, 2022, to January 26, 2022, was conducted. Further review indicated there was no documented evidence to show a physician’s referral order had been received. There was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation.A review of Patient 5’s clinical record from January 12, 2022, to January 26, 2022, was conducted. There was no documented evidence to show H&P (History and Physical-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), had been obtained from a referral source or Patient 5’s Attending Physician (AP). There was no documented evidence to show that an AP had been identified and contacted to obtain supporting documentation. There was no documented evidence to show an AP confirmed Patient 5’s hospice service needs or verified Patient 5’s prognosis of six months or less life expectancy.During an interview with the current MD on May 8, 2025, from 12:04 PM, to 1:02 PM, the MD stated he had not been the MD at the time Patient 5 was admitted to the agency. The MD verified there was no physician’s referral order, or H&P, or documented evidence to show the Previous Medical Director (P/MD) had reached out to the attending physician to confirm service needs, verify Patient 5’s medical prognosis, or request supporting documentation.During an interview with the Administrator/Owner (Admin/Owner) on May 8, 2025, at 1:22 PM, the Admin/Owner confirmed there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 5’s medical prognosis, or request supporting documentation.1b. A review of Patient 7’s face sheet, undated, indicated a start of care date of December 30, 2021, with a benefit period of December 30, 2021, to March 29, 2022 (Benefit Period one). Patient 7 had diagnoses that included ovarian (ovaries--two small, almond-shaped glands located in the female reproductive system) cancer. Patient 7 passed away on January 16, 2022. A review of Patient 7’s physician’s orders from December 30, 2021, to January 16, 2022, was conducted. There was no documented evidence to show a physician’s referral order had been received. Further review indicated there was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation. A review of Patient 7’s clinical record from December 30, 2021, to March 29, 2022, was conducted. There was no documented evidence to show H&P had been obtained from a referral source or Patient 7’s AP. There was no documented evidence to show that an AP had been identified and contacted to obtain supporting documentation. There was no documented evidence to show an AP confirmed Patient 7’s hospice service needs or verified Patient 7’s prognosis of six months or less life expectancy.During an interview with the current MD on May 8, 2025, from 12:04 PM, to 1:02 PM, the MD stated he had not been the MD at the time Patient 7 was admitted to the agency. The MD verified there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 7’s medical prognosis, or request supporting documentation. During an interview with the Admin/Owner on May 8, 2025, at 1:22 PM, the Admin/Owner confirmed there was no physician’s referral order, or H&P, or documented evidence to show the P/MD had reached out to the attending physician to confirm service needs, verify Patient 7’s medical prognosis, or request supporting documentation.1c. A review of Patient 8’s face sheet, undated, indicated a start of care date of December 27, 2024, with a benefit period of December 27, 2024, to March 26, 2025 (Benefit Period one). Patient 8 had diagnoses that included heart failure (a condition where the heart cannot pump enough blood to meet the body's needs).A review of Patient 8’s physician’s orders from December 27, 2024, to May 8, 2025, was conducted. There was no documented evidence to show a physician’s referral order had been received. There was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation.A review of Patient 8’s H&P dated June 13, 2024, indicated an Emergency Room (ER) visit after a fall with a dislocation of the left shoulder (the upper arm bone moves out of its joint socket in the shoulder blade), H&P dated November 15, 2024, indicated a visit to prepare for neurosurgery to replace a deep brain stimulator (a medical device used to treat various neurological disorders by delivering electrical pulses to specific areas of the brain) for treatment of Patient 8’s Parkinson’s disease (a progressive neurodegenerative disorder that affects movement, primarily due to a loss of brain cells that produce dopamine, a chemical messenger in the brain) and H&P dated December 5, 2024, indicated surgery to replace a deep brain stimulator for treatment of Patient 8’s Parkinson’s disease, there was no documented evidence to show a terminal diagnosis had been identified or a discussion of hospice services had occurred. During a interview with Patient 8’s daughter on May 6, 2025, at 11:27 AM, Patient 8’s daughter stated Patient 8 had early onset Parkinson's disease, “[Patient 8] is only 61 years old.” Patient 8’s daughter stated the Parkinson’s disease started getting bad about (two) to (three) years ago with memory problems and tremors (an involuntary rhythmic shaking that often occurs when the limbs are at rest) and Patient 8 had a deep brain stimulator placed in 2023, but “[Patient 8] does not have full blown dementia [the final stage of the disease, characterized by severe cognitive decline, loss of communication abilities, and a significant need for assistance with daily living tasks].” Patient 8’s daughter stated she was not sure who talked to them about hospice services because her dad took care of it, and she signed the hospice paperwork because she was easier to get ahold of than her dad. Patient 8’s daughter stated Patient 8 would try to do things she was not capable of doing, making Patient 8’s safety an issue. Patient 8’s daughter stated Patient 8’s primary care physician was AP 1 and helped them place Patient 8 in a Board and Care Facility (B&C a licensed, non-medical facility providing room, board, and 24-hour care and supervision for individuals who need help with daily living activities but not 24-hour nursing care) due to the safety issue. Patient 8’s daughter stated she had heard hospice was for people who were terminal but the staff at the B&C stated hospice was not just for terminal patients. Patient 8’s daughter stated she did not know hospice was about giving up curative care and just receiving palliative care. Patient 8’s daughter stated she did not believe Patient 8’s Parkinson’s disease would lead to Patient 8 dying in 6 (six) months and she did not know the hospice gave Patient 8 a terminal diagnosis of heart failure.During a interview with Patient 8’s ex-husband on May 6, 2025, at 4:22 PM, Patient 8’s ex-husband stated he had stopped by the B&C one day to visit Patient 8, and the B&C staff had told him Patient 8 was on hospice, “I didn’t know [Patient 8] was on hospice.” Patient 8’s ex-husband stated his daughter had signed the hospice paperwork and if he gave consent, he did not remember giving consent. Patient 8’s ex-husband stated he knew hospice provided end of life services but did not know curative care stopped, “If anything happened to [Patient 8] we would get her the appropriate treatment.” Patient 8’s ex-husband stated his daughter did not know what she was signing, “I think it was about getting additional services to help with [Patient 8’s] care.” Patient 8’s ex-husband stated he had never heard about heart failure and when Patient 8 lived with him he gave her medications and Patient 8 was not on heart failure medication. Patient 8’s ex-husband stated Patient 8’s neurologist (a medical specialist in the diagnosis and treatment of disorders of the nervous system), AP 2, told him Patient 8 had Parkinson’s dementia and Patient 8 had trouble stringing words together. Patient 8’s ex-husband stated Patient 8 had just visited AP 2 on March 27, 2025, to follow up on her deep brain stimulator. Patient 8’s ex-husband stated, “I think someone jumped the gun on this one.” During an interview with Patient 8’s AP 2 on May 8, 2025, at 8:31 AM, AP 2 stated she was Patient 8’s neurologist and was currently treating Patient 8’s Parkinson’s disease. AP 2 stated she did not know Patient 8 was on hospice, did not refer Patient 8 to hospice and “I was stunned to hear [Patient 8] was on hospice.” AP 2 stated she did not have a discussion with Patient 8 or her family about hospice services because Patient 8 was nowhere near the point of her life where she needed hospice. AP 2 stated the hospice’s terminal diagnosis of heart failure was inappropriate as Patient 8 had no active heart failure and was on no medication to treat heart failure. AP 2 stated Patient 8 had begun to have memory issues due to the Parkinson’s disease but could still hold a meaningful conversation, so Patient 8 was not in, end stage dementia. AP 2 stated if the hospice was taking Patient 8’s bed bound status (a person unable to leave their bed due to illness, injury, or other medical condition that limits their mobility) into consideration, Patient 8 was bed bound due to orthopedic issues (a wide range of conditions affecting the musculoskeletal system, including bones, joints, ligaments, tendons, muscles, and nerves) not for being debilitated (a person in a severely weakened state, often due to disease or illness). AP 2 stated her husband was Patient 8’s orthopedic doctor (a medical specialist who focuses on the diagnosis and treatment of conditions affecting the musculoskeletal system) and had replaced multiple joints for Patient 8. AP 2 stated the hospice agency had not reached out to her to consult on Patient 8 and hospice services, “If they had I would have said No, not appropriate.” During an interview with the MD on May 8, 2025, from 12:04 PM to 1:02 PM, the MD stated he was not aware Patient 8 did not have a physician’s referral order, but it was not unusual for this agency because the patients rarely had APs. The MD stated he did not consult with Patient 8’s AP to confirm service needs, verify Patient 8’s medical prognosis, or request supporting documentation because the agency told him Patient 8 did not have an AP. The MD stated he had determined Patient 8’s terminal diagnosis from his face-to-face visit (an in-person physician’s clinical assessment of a patient) with Patient 8, but no family present, and the Registered Nurse’s (RN) admission assessment. The MD stated he did not review Patient 8’s H&P because it had not been available at the time he signed Patient 8’s CTI (Certification of Terminal Illness). The MD reviewed the interview with Patient 8’s AP 2 and stated he was not provided this information by the agency, “I am very concerned about what I am hearing.”During an interview with Patient 8’s AP 1 on May 9, 2025, at 9:50 AM, AP 1 stated she was Patient 8’s primary care doctor and had a visit with Patient 8 about a year ago. AP 1 stated she did not know Patient 8 was on hospice, did not refer Patient 8 to hospice and “I was taken aback when I heard [Patient 8] was on hospice.” AP 1 stated she did not have a discussion with Patient 8 or her family about hospice services because there was no identified need. AP 1 stated there was no formal diagnosis of heart failure and Patient 8 exhibited no symptoms which would prompt them to assess for heart failure. AP 1 stated when she last saw Patient 8, Patient 8 was not having difficulty with her memory and there were no signs of dementia, “this must be a recent occurrence.” AP 1 stated the hospice agency had not reached out to her to consult on Patient 8 and hospice services, “I don’t think she needs hospice.”1d. A review of Patient 9’s face sheet, undated, indicated a start of care date of April 5, 2025, with a benefit period of April 5, 2025, to July 3, 2025 (Benefit Period one). Patient 9 had diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris (the build-up of plaque in the heart's arteries, which can restrict blood flow to the heart muscle, but without the typical chest pain associated with angina pectoris).A review of Patient 9’s physician’s orders from April 5, 2025, to May 8, 2025, was conducted. There was no documented evidence to show a physician’s referral order had been received. There was no documented evidence to show an AP had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patient’s medical prognosis or secure supporting documentation. A review of Patient 9’s H&P dated September 5, 2024, indicated an Emergency Room (ER) visit for urinary tract infection with septicemia (bacterial infection that enters the blood stream), H&P dated January 6, 2025, indicated surgery for stomach cancer, there was no documented evidence to show a terminal diagnosis had been identified or a discussion of hospice services had occurred. During an interview with Patient 9’s daughter on May 7, 2025, from 12:33 PM, to 12:53 PM, Patient 9’s daughter stated Patient 9 had stomach cancer surgery in January 2025 and “I was amazed on how well she was doing after the surgery.” Patient 9’s daughter started she noticed dementia symptoms, like memory problems, where Patient 9 would go to the kitchen, start cooking, forget what she was doing, leave the kitchen with whatever she started cooking, still cooking. Patient 9’s daughter stated she became afraid Patient 9 would burn down the apartment when she was at work, so Patient 9’s daughter quit her job and stayed home with Patient 9 to keep her safe. Patient 9’s daughter stated she knew she would have to place Patient 9 in a facility but did not have the money to pay for a facility, so Patient 9’s daughter reached out to Patient 9’s medical group. Patient 9’s daughter stated the medical group provided a respite program for a caregiver to stay with Patient 9 in the home but it only lasted three months, in addition, the medical group provided Patient 9’s daughter with a list of facility names that could help her apply for a waiver program so her mother could be placed in an Assisted Living Facility (ALF-a living arrangement in which people with special needs, especially seniors, live in a facility that provides help with everyday tasks such as bathing, dressing, and taking medication) without cost. Patient 9’s daughter stated this was where she found the hospice agency’s name and phone number, but she had not called the hospice agency for hospice services but to get help with filing for the waiver. Patient 9’s daughter stated she called the hospice agency, and they said they could help her file for the waiver, but Patient 9 had to be placed on the list, and it could take over a year to obtain a waiver. Patient 9’s daughter stated she did not have a year to wait to get Patient 9 placement, because Patient 9’s daughter needed to work, or they would be out on the street. Patient 9’s daughter stated the hospice agency offered Patient 9 hospice services and she was desperate, so she accepted any services she could get without cost, but the hospice services did not solve the problem of Patient 9’s placement in a facility. Patient 9’s daughter stated Patient 9 was still receiving chemotherapy (the treatment of disease by the use of chemical substances) for her stomach cancer, “[Patient 9] gets nine rounds and has received four rounds.” The doctors at Patient 9’s medical group did not discuss hospice services for Patient 9 and hospice was for people who could not pay for care services, “it's not for someone who is passing away.” Patient 9’s daughter stated Patient 9 was not on her way to dying and Patient 9 wanted to exercise all her options to stay alive, “None of the [medical group’s] doctors said [Patient 9] was dying, [Patient 9] has options.” Patient 9’s daughter became emotional and stated, “I am living day to day because I don't know how I am going to pay to place [Patient 9] in a facility or pay the rent on the apartment.”During an interview with the Director for Assisted Living Waiver (DALW), the Admin/Owner, the Office Manager (OM) and Director of Patient Care Services (DPCS) on May 7, 2025, at 1:07 PM, the DALW stated he helped people get into the waiver program for their loved ones to live in an ALF for free. The DALW stated he was a staff member of the hospice but did not market hospice services and admission to hospice services was not required for the DALW to process the waiver. The DALW stated the process of the waiver could take over a year and many families were desperate for services so he would talk to the families about hospice services and if they wanted the services he would refer them to the hospice. The DALW stated he spoke with Patient 9’s daughter and she told him Patient 9 was declining due to dementia, so he referred her to the hospice. The Admin/Owner stated she asked the OM to get Patient 9’s H&P. The OM stated she asked Patient 9’s medical group for Patient 9’s H&P but did not ask for a hospice referral order. The DPCS stated it was her responsibility to get a hospice referral order, and she did not.During a telephone interview with a Regional Director (RD) from Patient 9’s medical group on May 7, 2025, at 2:42 PM, the RD confirmed AP 3 as Patient 9’s attending physician. The RD reviewed Patient 9’s clinical record and stated there was no indication of a referral to hospice services, or a discussion of hospice. The RD stated Patient 9 was still receiving chemotherapy for her stomach cancer and there was a physician’s order dated April 22, 2025, to do laboratory testing (analyzing samples of blood, urine, or other bodily fluids or tissues to provide insights into a person's health) every three weeks to monitor. The RD stated Patient 9’s medical group had its own hospice protocol, and it had not been initiated for Patient 9. The RD requested an email with the questions for AP 3 and the RD would facilitate the response from AP 3. During an interview with the MD on May 8, 2025, from 12:04 PM to 1:02 PM, the MD stated he was not aware Patient 9 did not have a physician’s referral order, but it was not unusual for this agency because the patients rarely had APs. The MD stated he did not consult with Patient 9’s AP to confirm service needs, verify Patient 9’s medical prognosis, or request supporting documentation because the agency told him Patient 9 did not have an AP. The MD stated he had determined Patient 9’s terminal diagnosis from his face-to-face visit with Patient 9, but no family was present, and the RN’s admission assessment. The MD stated he did not review Patient 9’s H&P because it had not been available at the time he signed Patient 9’s CTI. The MD stated he did not know Patient 9 was still receiving chemotherapy treatments and if he had known, he would not have certified Patient 9. The MD stated he was familiar with Patient 9’s medical group and knew about their hospice protocol. The MD stated if he had reviewed Patient 9’s H&P he would have seen the name of the medical group on the paperwork and questioned the agency on why Patient 9 was coming to their agency, instead of following the medical group’s protocol. The MD stated he was not aware of Patient 9’s need for placement in a facility because of safety issues due to dementia and memory loss. A review of an email response from AP 3, on May 9, 2025, at 10:42 AM, indicated,“1. Did [AP 3] know the patient was [receiving] hospice services? No2. Did [AP 3] refer the patient to hospice? No3. Did [AP 3] have a discussion with the patient and the patient's family about hospice services? No4. Does [AP 3] think [Patient 9] is appropriate for hospice services and if so, with what terminal diagnosis? No, the [Patient 9] is not appropriate.5. Does [AP 3] feel the diagnosis of [atherosclerotic heart disease of native coronary artery without angina pectoris] is an appropriate terminal diagnosis for [Patient 9]? No6. Does [AP 3] feel the patient is in, end stage dementia? No7. Did [Name of Hospice Agency] reach out to [AP 3] to consult on [Patient 9’s] terminal diagnosis? No.”1e. A review of Patient 10’s face sheet, undated, indicated a start of care date of April 11, 2025, with a benefit period of April 11, 2025, to July 9, 2025 (Benefit Period one). Patient 10 had diagnoses that included hypertensive heart disease with heart failure (is when sustained, elevated blood pressure causes the heart to weaken and eventually fail to pump blood effectively).A review of Patient 10’s hospice referral order by Patient 10’s AP 4, dated April 9, 2025, indicated, “Order: Consult to Hospice (Hospice Consult) … Reason for Consult patient removing NG tube [a nasogastric tube is a thin, flexible tube that is inserted through the nose, down the throat, and into the stomach. It is used to deliver liquid nutrition and medications, or to remove stomach contents. NG tubes are often used for individuals who cannot eat or drink normally due to various medical conditions] and family requesting discussion of discharge with hospice.”A review of Patient 8’s H&P dated April 1, 2025, indicated an Acute Care Hospital admission for acute cholecystitis (a sudden inflammation of the gallbladder) with cholangitis (a serious infection of the bile ducts, typically caused by a bacterial infection that occurs when a bile duct is blocked) after percutaneous cholecystostomy tube placement (a drain has been placed into the gallbladder) on April 1, 2025. “Patient pulled NG tube [a nasogastric tube is a thin, flexible tube that is inserted through the nose, down the throat, and into the stomach. It is used to deliver liquid nutrition and medications, or to remove stomach contents. NG tubes are often used for individuals who cannot eat or drink normally due to various medical conditions] twice last night and family/patient communicated wish to not attempt replacement. Family and patient would like to prioritize patient comfort and hopes for discharge home, they would like to speak with hospice.” There was no documented evidence to show that a terminal diagnosis had been identified.A review of Patient 10’s clinical record from April 11, 2025, to May 8, 2025, was conducted. There was no documented evidence to show that AP 4 had been contacted and supporting documentation obtained. There was no documented evidence to show AP 4 confirmed Patient 10’s hospice service needs or provided a terminal diagnosis and verification of Patient 10’s prognosis of six months or less life expectancy.During an interview with the MD on May 8, 2025, from 12:04 PM to 1:02 PM, the MD stated he was aware of AP 4’s name and contact information on the hospice referral order but he did not consult with AP 4 to confirm service needs, verify Patient 10’s medical prognosis, or request supporting documentation. The MD stated he determined Patient 10’s terminal diagnosis by reviewing Patient 10’s H&P.A review of the agency’s policy and procedure titled “Intake Process,” undated, indicated, “PURPOSE: To establish the process for acceptance and entry of patients into hospice. POLICY: … [name of agency] will accept only those patients whose needs can be met by the services it provides and who meet the hospice admission criteria. PROCEDURE: … A. Intake personnel will document information regarding patient demographics, diagnoses, services needed, medications, attending physician, hospitalization, etc., in order to make the initial determination whether the patient's needs can be met by hospice and if he/she meets eligibility criteria. … D. If the referral call is not from a physician, the physician (or other authorized licensed independent practitioner) will be contacted to confirm service needs, as well as the patient's medical prognosis and supporting documentation, and to obtain verbal orders. …”A review of the agency’s policy and procedure titled “Admission Criteria and Process,” undated, indicated, “PURPOSE: To establish standards and a process by which a patient can be evaluated and accepted for admission. … Admission Criteria 1. [name of agency] will admit a patient only on the recommendation of the medical director in consultation with, or input from, the patient's attending physician, if any. The information can be obtained from the hospice nurse or others sharing the attending physician’s knowledge of the patient. The patient's physician (or other authorized licensed independent practitioner) must order and approve the provision of hospice care, be willing to sign or have a representative who is willing to sign the death certificate and be willing to discuss the patient's resuscitation status with the patient and family/caregiver. … The patient must have a life-limiting illness with a life expectancy of six (6) months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria in the organization's intermediary Local coverage Determinations. … The focus of care desired must be palliative vs. curative. … PROCEDURE: 1. Referral information provided by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician offices will assist in the determination of eligibility for admission to the program. If the request for service is not made by the patient's physician, he/she will be consulted prior to the evaluation visit/initiation of services. …” A review of the agency’s policy and procedure titled, “Certification of Terminal Illness,” undated, indicated, “PURPOSE:  To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. … PROCEDURE: 1. At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on: his/her review of the patient's medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms. … 3. Clinical information and other documentation that supports the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. Initially, the clinical information may be provided verbally and must be documented in the medical record and included as part of the hospice's eligibility assessment. 4. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. …”

Based on interview and record review, the agency failed to implement an alternate office site to ensure business operations will continue during an actual emergency, which is necessary for supporting the care continuation, in a universe of 65 patients, when staff members provided differing information regarding the agency's Emergency Preparedness Plan of the designated alternate office site during emergency event. This failure had the potential to disrupt the agencys ability to maintain continuous care, placing the agency's patients at risk, and compromising their safety and quality of care during an emergency event. Findings: During an interview with the Director of Patient Care Services (DPCS) on May 21, 2024, at 10:35 AM, the DPCS stated the last time the agencys Emergency Plan in-services were provided to the staff was sometime in January 2024. He further stated the alternate office site during emergency will be the office parking lot. During an interview with a Hospice Aid 1 (HA 1), on May 21, 2024, at 11:45 AM, HA 1 stated she does not remember the last time she received an Emergency Preparedness Plan in-service. She also stated that she does not remember being told where the alternate office site will be during emergency. HA 1 further stated she does not know where the alternative office site was to get more instruction during an emergency event. During an interview with a Hospice Aid 2 (HA 2), on May 21, 2024, at 2:35 PM, HA 2 stated she was not sure when the agencys Emergency Preparedness Plan in-services was given. She further stated it might have been 2 months ago, around February 2024. She further stated she was not sure where the alternate office site was during an emergency, but her guess was maybe in the lobby of the office building. During an interview with a Registered Nurse 1 (RN 1), on May 22, 2024, at 10:35 AM, RN 1 stated the last time the agencys Emergency Preparedness Plan in-services was provided to the staff was sometimes in November 2023. She further stated the alternate office site during emergency will be the Ontario office parking lot near [name of restaurant]. During a concurrent interview and record review, on May 23, 2024, at 2:10 PM, with the Administrator (Admin), the Admin reviewed the agencys policy and procedure (P&P) titled, ";Emergency Management Plan," revised January 4, 2024, which indicated, ";... Continuity of Operations Plan. Destruction of Office Site: In the event of the destruction of the agency office site, or the need to evacuate the agency office, an alternate location shall be predetermined and ready for use. An alternate location must be: - Located in a central area available to the staff. - Equipped with a telephone. - Have access to basic medical supplies. - An alternate office site available for the organization is the CEO's house. All agency personnel have been provided with the address of the CEO..." The Admin stated she was responsible for the agencys Emergency Preparedness Plan. The Admin further stated she did not have documentation to show the alternate office site had been provided to all staff to maintain essential functions during emergency even. During a further concurrent interview and record review, on May 23, 2024, at 2:30 PM, with the Admin, the agencys P&P revised January 4, 2024, titled ";Emergency Management Plan", indicated ";... Procedures... Once there is an emergency the CEO will activate the organization's response activities. During an emergency, the organization will utilize Emergency patient and employee call logs to ensure that patients and staff are accounted for during an emergency. After calling twice, local, state and federal emergency personnel will be called and notified regarding any unaccounted patients or employees. CEO will initiate the Chain of Command -Personnel must listen to organization identified Emergency Broadcasting System for instructions and updates, if no phones and leadership staff is unable to initiate the PPCP - Meet in designated area if office is down - Director/ Administrator /supervisor will be responsible for assigning staff to cover all essential functions..." The Admin stated the agency did not follow the policy.

Based on observation, interview, and record review, the agency failed to ensure patients rights were protected when the state toll free home health telephone hotline, its contact information, hours of operation and its purpose to receive complaints were inaccurate and not updated for three of four sampled patients (Patients 2, 3 and 4). These failures had the potential to cause Patients 2, 3, and 4 a reduced ability of patients to lodge a complaint, resulting in continued delivery of substandard care by the agency. Findings: 1. A review of Patient 2s face sheet (a document that gives a summary of patients information), indicated a start of care date of December 30, 2023, with a recertification period of April 28, 2024, to June 26, 2023. Further review indicated Patient 2 had diagnoses that included Alzheimer disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). During an onsite visit at Patient 2s home, on May 21, 2024, at 12:10 PM, with a Hospice Aide 1 (HA 1), Patient 2s home notebook (a paper folder containing home health agency and Patient 2s medical information) was reviewed. It indicated ";... To report any concern/grievance about any aspect of the hospice care received from any representative of [name of the agency] without discrimination or reprisal, please call: 1. The Patient Care Manager at the [name of the agency]... if the problem is not resolved to your satisfaction, you may contact: 3. ... 2025 N Glenoaks Blvd, Ste 202, Burbank, CA 91504 [The agencys old address]... If you still do not receive satisfaction, you may contact: 5. The Department of Health Services Licensing & Certification Division 1.800.228.1019 (24-hour HOTLINE) [wrong district office phone number] Or write to: The Department of Health Services Licensing & Certification Division 3400 Aerojet Ave., #323 El Monte, CA 91731 Phone: (626) 569-3724 Toil Free: (800) 228-1019 [wrong district office phone number] Or Call: Joint Commission for Accreditation of Healthcare Organization 1.800.994.6610 [The agency is not Accredited by Joint Commission]..." HA 1 verified that state free hospice telephone hot line with supporting information were inaccurate and not updated. Patient 2s son confirmed that the state free hospice telephone hotline and information were inaccurate and not updated. He also stated he did not know about the patients right to file a complaint with the state. 2. A review of Patient 3s face sheet, indicated a start of care date of April 5, 2024, with a certification period of April 5, 2024 to June 19, 2024. Further review indicated Patient 2 had diagnoses that included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body). During an onsite visit at Patient 3s home, on May 21, 2024, at 2:50 PM, with a HA 2, Patient 3s home notebook was reviewed. It indicated ";... To report any concern/grievance about any aspect of the hospice care received from any representative of [name of the agency] without discrimination or reprisal, please call: 1. The Patient Care Manager at the [name of the agency]... if the problem is not resolved to your satisfaction, you may contact: 3. ... 2025 N Glenoaks Blvd, Ste 202, Burbank, CA 91504 [The agencys old address]... If you still do not receive satisfaction, you may contact: 5. The Department of Health Services Licensing & Certification Division 1.800.228.1019 (24-hour HOTLINE) [wrong district office phone number] Or write to: The Department of Health Services Licensing & Certification Division 3400 Aerojet Ave., #323 El Monte, CA 91731 Phone: (626) 569-3724 Toil Free: (800) 228-1019 [wrong district office phone number] Or Call: Joint Commission for Accreditation of Healthcare Organization 1.800.994.6610 [The agency is not Accredited by Joint Commission]..." HA 2 verified that state free hospice telephone hotline with supporting information were inaccurate and not updated. During a phone interview on May 21, 2024, at 3:20 PM, with Patient 3s wife, she stated she was not aware there were phone numbers in the hospice binder for her to file complaint. She further stated she did not know about the right to file a complaint with the state. 3. A review of Patient 4s face sheet, indicated a start of care date of July 18, 2023, with a certification period of May 13, 2024, to July 11, 2024. Further review indicated Patient 4 had diagnoses that included Alzheimer disease. During an onsite visit at Patient 4s home, May 22, 2024, at 10:30 AM, with a Registered Nurse 1 (RN 1) , Patient 4s home notebook was reviewed. It indicated ";... To report any concern/grievance about any aspect of the hospice care received from any representative of [name of the agency] without discrimination or reprisal, please call: 1. The Patient Care Manager at the [name of the agency]... if the problem is not resolved to your satisfaction, you may contact: 3. ... 2025 N Glenoaks Blvd, Ste 202, Burbank, CA 91504 [The agencys old address]... If you still do not receive satisfaction, you may contact: 5. The Department of Health Services Licensing & Certification Division 1.800.228.1019 (24-hour HOTLINE) [wrong district office phone number] Or write to: The Department of Health Services Licensing & Certification Division 3400 Aerojet Ave., #323 El Monte, CA 91731 Phone: (626) 569-3724 Toil Free: (800) 228-1019 [wrong district office phone number] Or Call: Joint Commission for Accreditation of Healthcare Organization 1.800.994.6610 [The agency is not Accredited by Joint Commission]..." RN 1 verified that state free hospice telephone hotline with supporting information were inaccurate and not updated. Patient 4s caregiver confirmed that the state free hospice telephone hotline and information were inaccurate and not updated. He also stated he did not know about the right to file a complaint with the state. During an interview with a Director Patient Care Services (DPCS), on May 24, 2024, at 1:00 PM, the DCPS stated the admitting nurse should have made sure the information in the home notebook left in the patients home was accurate and updated. The DPCS stated it was very importance for the patients to have the correct phone number and any related information to facilitate voicing their concern or complaint. The DPCS further stated ";I do not know why it is not updated." During a concurrent interview and record review, on May 24, 2024, at 1:10 PM, with the DPCS, the agencys undated policy and procedure (P&P) titled, ";Rights/Responsibilities" was reviewed. The P&P indicated, ";PURPOSE To encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. POLICY Each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights and responsibilities as described... To assist with fully understanding patient rights and responsibilities, all policies are available to organization personnel, the patient, and his/her representatives as well as other organizations and the interested public. PROCEDURE 1. The patient will be informed during the initial assessment visit, in advance of furnishing care, of: ... O. The right to voice a complaint/concern (grievance) regarding care or service without fear of reprisal for exercising this right... The availability of other sources to receive questions and complaints and assist in resolution..." The DPCS stated the agency did not follow the policy.

Based on observation, interview, and record review, the agency failed to ensure patients medication profile (a written summary of all the medicines you take regularly, including over the counter and complementary medicines.) was being reviewed in accordance with the agencys policy and procedure for two of 19 sampled patients (Patients 3, and 4) when: 1. For Patient 3: one medication the patient was not taking was indicated on the Medication Profile (MP) 2. For Patient 4: one medication the patient was taking was not indicated on the MP and one medication the patient was not taking was indicated on the MP These failures had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy for Patients 3 and 4. Findings: 1. A review of Patient 3s face sheet (a document that gives a summary of patients information), indicated a start of care date of April 5, 2024, with a certification period of April 5, 2024 to June 19, 2024. Further review indicated Patient 2 had diagnoses that included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body). During an onsite visit on May 21, 2024, at 2:45 PM with Hospice Aid 2 (HA 2) and Facility Nurse (FN), Patient 3s actual medications, which were available in the nursing home, were compared with Patient 3s most current (MP). During a concurrent observation and interview on May 21, 2024, at 3:00 PM, with the FN 1, the FN 1 verified that Patient 3 quetiapine fumarate (also known as Seroquel is medication that treats several kinds of mental health conditions) 400 mg (milligram-a unit of measure) 1 tablet by mouth, was still listed in the MP. FN 1 stated Patient 3 had not been on quetiapine fumarate since readmission to the facility on April 4,2024. 2. A review of Patient 4s face sheet, indicated a start of care date of July 18, 2023, with a certification period of May 13, 2024, to July 11, 2024. Patient 4 had diagnoses that included Alzheimer disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). During a home visit on May 22, 2024, at 9:30 AM, with Registered Nurse 1 (RN 1) and in the presence of Patient 4 and Patient 4s care giver, Patient 4s actual medications, which were available in the patient home, were compared with Patient 4s most current MP. During a concurrent observation, interview, and record review, on May 22, 2024, at 10:05 AM, with RN 1, RN 1 inspected a bottle of Fluticasone prop (medication that treats allergy symptoms like sneezing, itching and a runny or stuffy nose) 50 mcg (microgram-a unit of measure). The bottle was labeled it belonged to Patient 4 and was dated on May 16, 2024 (Six days ago). It had a direction which read, ";one spray intra nasal (into the nose) daily." RN 1 reviewed Patient 4s MP and was unable to find Fluticasone prop on the record. During further observation, interview, and record review, on May 22, 2024, at 10:10 AM, RN 1 stated Patient 4 no longer receives seroquel 50 mg 1 tablet by mouth, but it was still listed in the MP. RN 1 stated that the last visit from the RN were May 17, 2024, and May 20, 2024. RN 1 further stated the printed MP should have been updated. During an interview on May 24, 2024, at 2:20 PM, with the Director of Patient Care Services (DPCS), the DPCS stated, ";It was Case Manager's responsibility to update the Medication Profile when there's any new order or changes. Nurses should have been reviewing and updating medication profile on their visits." During a concurrent interview and record review, on May 24, 2024, at 2:30 PM, with the DPCS, the agencys undated policy and procedure (P&P) titled, ";Medication Profile" was reviewed. The P&P indicated, ";PURPOSE. To define the use of the medication profile in evaluating a patient's current medication regimen. POLICY. Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. PROCEDURE. 1. For accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient's current medications upon the patient's entry to the organization. A comparison of the medications ordered for the patient while under the organization's care will be made to those on the list.... 5. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate... B. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications..." The DPCS stated the policy was not followed.

Based on interview and record review, the agency failed to develop, implement, and evaluate performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) from May 20, 2023, to May 20, 2024. This failure had the potential to cause problems in health outcomes, patient safety, and quality of care to go unaddressed and continue in a universe of 65 patients. Findings: A review of the agencys ";Quality Assessment and Performance Improvement (QAPI)" binder for period of May 20, 2023, to May 20, 2024, was conducted on May 23, 2024, at 9:00 AM. There was no documented evidence to show PIPs had been initiated, were in process or had been completed, after the quality indicator was identified from the data collection and analysis reviewed. During an interview with the Director Patient Care Services (DPCS) and the Administrator (Admin) on May 23, 2024, at 11:45 AM, the Admin stated she and the DPCS were responsible for the QAPI Program. The Admin further stated no PIPs had been initiated from the quality indicator identified, and it should had been initiated. During a concurrent interview and record review, with the Admin, on May 23, 2024, at 2:00 PM, the Admin reviewed the agencys policy and procedure (P&P) titled ";QAPI Plan," revised April 3, 2024, the P&P, indicated, ";... Our organization will conduct Performance Improvement Projects that are designed to take a systematic approach to revise and improve care or services in areas that we identify as needing attention. We will conduct PIPS that will lead to changes and guide corrective actions in our systems, which cross multiple departments, and have impact on the quality of care of our patients. We will conduct PIPs that will improve care and service delivery, increase efficiencies, lead to improved staff and patient outcomes, and lead to greater staff and patient satisfaction. An important aspect of our PiPs is a plan to determine the effectiveness of our performance improvement activities and whether the improvement is sustained. Once any QAPI indicator does not meet our established goal, the indicator will generate into a pool of indicators requiring performance improvement. ...The team will develop an action plan using the organization's usual format. Interventions that will make change will be implemented by the team. The team will use root cause analysis to ensure that the root cause and contributing factors are identified. When determining and implementing interventions, ... The team will select and/or create measurement tools to ensure that the changes they are implementing are having the desired effect.... The number and scope of performance improvement projects are based on the patients' needs and internal organization needs. Project: - Scope - Complexity - Past performances Document: - Performance improvement projects being conducted - Reasons for conducting the PIP - Measurable progress to achieve them...QAPI Coordinator Job Description Summary Gives Report To: Director of Quality/Director of Patient Care Services. The Performance Improvement Coordinator is a professional responsible for the quality activities of the organization. The Performance Improvement Coordinator has accountabilities for the monitoring, implementation and evaluation of process and program to meet regulatory, accreditation and standards of practice...". The Admin stated the agency did not follow the policy.

Based on observation, interview and record review, the hospice agency failed to provide the patient, family/representative a written notice of patient's rights and responsibilities in a language and manner that the patient understands for one of 19 sampled patients, (Patient 11). This deficient practice had a potential for the patient and their family, misinformation and opportunity to exercise their rights to decline the care and services offered by the hospice agency. --- Findings: A review of Patients11's clinical record indicated a start of care (SOC) on 10/24/22, with diagnoses of hypertensive heart disease (refers to a heart problems that occurs because of high blood pressure that is present over a long time) without heart failure. A review of Patient 11's plan of care dated 10/24/22 indicated, Registered Nurse (RN) visit once a week for assessment and Licensed Vocational Nurse (LVN) once a week for assessment. A review of Patient's 11 admission packet indicated that it contained all English language documents. On 3/8/23, at 12 noon, during joint home visit with LVN 1 at Patient's 11 residence, the patient was observed sitting in wheelchair with Patient 11's family member as the caregiver. During an observation and an interview, Patient 11 and the patient's caregiver spoke non English language. Patient 11 and the caregiver stated, they did not understood the admission packet documents. Patient 11 and the caregiver stated, it would be better to provide them with the documents that they could read and understand. During an interview on 3/8/23 at 12 p.m., LVN 1 could not state the reason, Patient 11 was not provided non English admission packet that the patient and the caregiver could understand, and will report to the agency's Administrator.

Based on record review and interview, the hospice agency (HA) failed to conduct an assessment of the patient current health status to identify patient care and services needs related to terminal illness for one of 19 sampled patients (Patient 19). The HA did not assess the patient's pain management and symptoms control related to his terminal illness. This deficient practice had a potential not to meet patient care goals. --- Findings: A review of Patient 19's medical record indicated, the patient was admitted on 3/18/23, with admitting diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities) with Lewy bodies (affect chemicals in the brain, that lead to problems with thinking, movement, behavior, and mood). A review of Patient 19's comprehensive assessment dated 3/18/22, in the pain screening section indicated the patient was alert and able to verbalize pain. The assessment indicated Patient 19 required maximum assistance with his activities of daily living. A review of Patient 19's skilled visit notes dated 4/22/22, indicated Patient 19 assessed with pain scale of 10/10 (0 as no pain and 10 as the worst pain). The clinical notes intervention indicated, Patient 19 was provided hydromorphone (used to relieve severe pain) 8 mg. every 4 hours; fentanyl (a powerful synthetic opioid analgesic) patch and lidocaine cream 4%. The skilled notes did not indicate an assessment of the medication effectiveness. There was no documentation of the result of pain management. There was no documentation that the physician was notified of Patient 19's pain level of 10/10(sever pain). The agencys policy for pain management stipulated ";To manage patients pain after therapeutic or pharmacological modalities have been used for pain greater that 6/10 – all patients with pain level of 6 or above will be advised to continue with their current medication regimen and pain that is not controlled with current regimen will be communicated to the physician to obtain orders for a more effective regime".

Based on observation, interview, and record review the agency failed to maintain an updated medication profile for one of 19 sampled patient's (Patient 2). This deficient practice placed Patient 2 at risk for not to receive medication in a timely and could cause medication error and side effect. --- A review of Patient 2's clinical record indicated a start of care (SOC) date of 09/8/2022, with a diagnoses of Alzheimer's Disease (progressive mental deterioration of brain function and activity). A review of Patient 2's Plan of Care (POC) dated 3/7/23 indicated an order for Skilled Nursing (SN) to visit once per week and CHHA visits of twice per week. The POC indicated for SN to monitor vital signs, Coronavirus Disease (COVID-19, an infectious disease of severe acute respiratory syndrome that can spread from person to person) symptoms, and to manage symptoms of pain. On 3/7/23 at 12:00 p.m., a joint home visit was conducted with Registered Nurse (RN1) at Patient 2s residence. During the home visit, observation, interview, and review of Patient 2's medication profile with RN1, some the following medication was not available at the patient home, for the patient to take as ordered by the physician. Meclizine 25mg 1 tab by mouth twice a day as needed for dizziness Olanzapine (medication used to treat several mental health conditions) 5 mg 1 tab by mouth once a day Lidocaine+menthol 1% topical apply to affected area 3 times/day 4 Zolpidem tartrate 10 mg 1tab by mouth for insomnia (inability to sleep) During an interview on 3/7/23 at 11:35 a.m., RN1 stated, these medications were listed on the current medication profile and should be available. RN1 stated, she would verify the medication order with the physician, and would update the patient's medication profile. During a review of the agencys policy entitled ";Medication Profile" it indicated patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new/or discontinued medications.

Based on observation, interview, and record review, the hospice agency (HA) failed to provide medication and treatment necessary to meet the needs of the two of 19 sampled patients (Patient 11 and 12).. HA did not provide Patient 11 and Patient 12 the ";comfort kit" (a small supply of medications kept in the home, available to rapidly treat symptoms that may occur in a patient with terminal illness), easily accessible and available to manage patient symptoms that may occur. This deficient practice had a potential for lack and delay care and services, when the patient experience a severe symptoms. --- Findings: A review of Patient 11's clinical record indicated, the patient was admitted on10/24/22, with diagnoses of hypertensive heart disease without heart failure. On 3/8/23, at 12 noon, during joint home visit with LVN 1, at Patient 11's residence, she was observed sitting in her wheelchair with a family member as the caregiver. During an observation, there was no comfort kit presented when requested. LVN 1 and the PCG were not able to find the comfort kit at the Patient 11 medication bag. 2. A review of patient 12 clinical record indicated a start of care date of 10/14/22, with diagnoses taken as hypertensive heart disease without heart failure. A review of Patient 12s medication profile with LVN 1 was conducted. There was no comfort kit found in the record. There was no documentation why the comfort kit was not documented and not available at the patient home. During an interview on 3/10/23 at 10 a.m., LVN 1 could not state a reason, the patient has no comfort kit easily accessible for immediate use, and would call the agency regarding the comfort kit. The agency policy and procedure for comfort kit stipulated ";All hospice patients not residing in a nursing home will receive a comfort kit containing emergency medication to hospice patients. The hospice primary nurse will be responsible to follow up with education to the patient and family and ensure the comfort kit medications are listed on the medication list in the patients chart."

Based on interview, and record review, the hospice agency (HHA) failed to ensure the emergency preparedness training for all staffs was conducted at least annually. This failure had the potential to result in the hospice staffs lack of knowledge to readily and effectively respond during an emergency crisis situation. --- On 1/20/23, at 11:30 a.m., during an interview with the administrator, she stated she did not conduct the emergency preparedness training for all staffs. During a review of the agency's emergency preparedness program documentation, the agency had no documented evidence the emergency preparedness training was conducted for all HHA staffs. A review of the HHA's undated policy and procedure titled, "Emergency Preparedness Plan" indicated, the plan uses the term "all hazard" to address all types of incidents. The incidents which may require action by home care and emergency service personnel to prevent or minimize loss of life or damage to property and environment.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of Patients was met as followed: The hospice agency failed to accurately assess the patient's eligibility for hospice services related to the palliation and management of the terminal illness and related conditions for four of nine sampled patients (Patient 5, 6, 7 and 8). (Refer to L 521) The hospice agency failed to ensure the patient's height and weight was assessed during comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) for two of nine sampled patients (Patients 5, 6). (Refer to L 524) The cumulative effects of these systemic practices resulted in the hospice agency admitting patients who did not meet admission criteria and did not qualify for the Medicare hospice benefits. --- .

Based on observation, interview, and record review, the hospice agency (HA) failed to accurately assess the patient's eligibility for hospice services related to the palliation and management of the terminal illness and related conditions for four of nine sampled patients (Patient 5, 6, 7 and 8). This deficient practice has potential to result in the misuse of the hospice provision of services that could result in a substandard provision of patient care. --- c. A review of Patient 7's face sheet indicated admission to hospice on 11/26/22, with a primary diagnosis of chronic obstructive pulmonary disease ( a lung disease that blocks airflow and makes it difficult to breathe). A review of Patient 7's face sheet indicated that Physician 7 was the Referring/Attending /Patient's choice doctor. A review of Patient 7's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 11/26/22, indicated the Licensed Vocational Nurse (LVN) was to visit once per week and one visit as needed. The Registered Nurse (RN) was to visit once per two weeks. The spiritual counselor was to visit once per month, and the Medical social worker service was declined. A review of Patient 7's "LCD Hospice Eligibility Determination" (LCD), dated 11/26/22, indicated Section 1 and 2 should be met. It indicated Patient 7 was assessed as "Yes" in Section 1 and 2 as follows: *Poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity (e.g. bed to chair existence, fatigue and cough). *Documentation of forced expiratory volume in one second (FEV1) after bronchodilator, less than 30 percent of predicted (if available)? *Hospitalizations for pulmonary infections. *Respiratory failure. *O2 saturation less than or equal to 88 percent determined either by arterial blood gases or O2 saturation monitors. A review of Patient 7's record indicated there was no documentation supporting the LCD assessment. On 1/19/23, at 12 p.m., a home visit was conducted at Patient 7's residence with RN 7. The patient was observed walking with a steady gait, breathing normally with no exertion. When Patient 7 was asked who buys her groceries, she stated she goes out and takes the bus to get her groceries. She also stated one of the staff from the hospice agency referred her to this hospice agency. On 1/19/23, at 2 p.m., during a phone interview with Physician 7, he stated Patient 7 was not his patient at all and the hospice agency was just using his name and credential. During an interview with the Director of Patient Care Services (DPCS) on 1/20/2022, at 12:10 p.m., he stated he was not able to find the documented evidence Patient 7 has been hospitalized for pulmonary infection and respiratory failure. The DPCS was not able to answer why it was indicated ";Yes" for the criteria of poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity and documentation of Forced Expiratory Volume in one second after bronchodilator, less than 30 percent predicted. He further stated the agency staff should have assessed the patients correctly after reviewing the patients information, that was verified with the patients primary care physician. d. A review of Patient 8's face sheet indicated admission to hospice on 10/2/22, with a primary diagnosis of hypertensive chronic kidney disease (long standing disease of the kidneys leading to renal failure). It was indicated on the face sheet that Physician 8 was the Referring/Attending /Patient's choice doctor. A review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 10/2/22, indicated the Licensed Vocational Nurse (LVN) was to visit once per week and one additional visit as needed. The Registered Nurse (RN) was to visit once per two week. The spiritual counselor was to visit once per month, and the Medical social worker service visit was declined. A review of Patient 8's "LCD Hospice Eligibility Determination" (LCD), dated 10/2/22, indicated Section 1 and 2 should be met. It indicated Patient 6 was assessed as "Yes" in the Sections 1 and 2 as follows: * Has patient been ruled out as a candidate for surgical procedures? * Has patient declined surgical procedures? * Is patient optimally treated for heart disease with diuretics and vasodilator? * Is patient unable to be on vasodilators due to medical condition? * Does this CHF (Chronic Heart Failure, a chronic condition in which the heart doesn't pump blood as well as it should) or angina patient meet the criteria for NYHA Class IV (New York Heart Association, classification provides a simple way of classifying the extent of heart failure -Class IV is the Stage any physical activity brings discomfort and symptoms occur at rest)) level? A review of Patient 8s clinical record indicated there was no documented evidence Patient 8 had been ruled out as a candidate for surgical procedures or declined surgical procedures. A review of the ";Current Treatment/Medication /DME List" indicated Patient 8 was not on any diuretics (drugs that causes the kidneys to make more urine) but was on vasodilator. A review of Patient 8's record indicated there was no documentation supporting the LCD assessment. On 1/19/23, at 11 a.m., during a phone interview with Patient 8, she stated that one of her friends referred her to hospice service. She also stated that she was not sick that she will pass away in six months. On 1/19/23, at 3 p.m., during a phone interview with Physician 8, he stated Patient 8 was his patient, but he did not refer her to hospice services. He also stated that Patient 8 does not need hospice services at all. During an interview with the Director of Patient Care Services (DPCS) on 1/20/2022, at 12 p.m., he stated he was not able to find the documented evidence Patient 8 had been ruled out as a candidate for surgical procedures or declined surgical procedures or had been treated with diuretics (drugs that causes the kidneys to make more urine). The DPCS was not able to answer why it was indicated ";Yes" for the question "; Is patient unable to be on vasodilators due to medical condition?" while the patient was on vasodilator. The DPCS was not able to answer why Patient 8 was assessed to be in NYHA Class IV while Patient 8 was able to perform the activities. He further stated the agency staff should have assessed the patient correctly after reviewing the patients information that was verified with the patients primary care physician. a. A review of Patient 5's admission record indicated the patient was admitted to the HA on 9/22/2022, with diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 5's face sheet indicated Physician 5 was the Referring/Attending /Patient's choice doctor. A review of Patient 5's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 1/10/2023, indicated the skilled nurse (SN) was to visit once per week and two visits as needed. The spiritual counselor (SC) and medical social worker (MSW) was to visit one time, as needed. A review of the form of "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" of pulmonary disease dated 9/22/2022, indicated Section 1 and Section 2 must be met. It was marked "Yes" in section (1a.) that Patient 5 had a disabling dyspnea (shortness of breath) at rest, as evidenced by documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator (medication that make breathing easier by relaxing the muscle in the lungs), less than 30 percent of predicted. Section (1b) was mark "yes" that Patient 5 had increased visits to emergency room, hospitalization for pulmonary infections, and respiratory failure. Section (2a) was marked ";Yes" that Patient 5 had hypoxemia (when oxygen levels in the blood are lower than the normal) at rest on room air, as evidenced by pO2 less than or equal to 55 mmHg. Section (2b) was marked ";Yes" that Patient 5 had an oxygen saturation (amount of oxygen circulating in the blood) less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitors. A review of Patient 5s clinical record indicated there was no documented evidence Patient 5 had a disabling dyspnea at rest as evidenced by documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, less than 30 percent of predicted. There was no documented evidence Patient 5 had increased visits to emergency room, hospitalization for pulmonary infections, and respiratory failure. There was no documented evidence Patient 5 had hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mmHg. There was no documented evidence Patient 5 had an oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitors. A review of Patient 5's record indicated there was no documentation supporting the LCD assessment. On 1/19/2023, at 10:30 a.m., when a joint home visit was made for Patient 5 with the Registered Nurse (RN 1) at the patient's residence, Patient 4 was sitting on a sofa, and Patient 5 was lying down on another sofa. Patient 5 was alert and oriented, and was able to communicate. When asked Patient 5 whether Physician 5 was his attending physician who referred him to the hospice service (as indicated in the face sheet), he stated Physician 5 was not his doctor and he did not even know Physician 5. Patient 5 stated he was admitted to the agency because one of his neighbors referred him to the agency. He stated he had not visited the emergency room or was hospitalized recently, and he did not think he was dying. During an interview with Patient 4 (Patient 5s family member) who was alert and oriented and able to communicate well, stated Patient 5 had not visited the emergency room or was hospitalized since he was admitted to the hospital 2 years ago due to traffic accident. During an interview with the Director of Patient Care Services (DPCS) on 1/20/2022, at 2 p.m., he stated he was not able to find the documented evidence Patient 5 had a disabling dyspnea (shortness of breath) at rest as evidenced by documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, or Patient 5 had increased visits to emergency room, hospitalization for pulmonary infections, and respiratory failure, or Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mmHg, or Patient 5 had oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitors. The DPCS was not able to provide the documentation that supporting the LCD assessment. b. A review of Patient 6's clinical record indicated a start of care (SOC) date of 12/1/2022, with a primary diagnosis of heart disease (refers to several types of heart conditions). A review of Patient 6's face sheet indicated that Physician 6 was the Referring/Attending /Patient's choice doctor. A review of Patient 6's "LCD Hospice Eligibility Determination" (LCD), dated 12/1/2022, indicated the section 1 and 2 should be met. It indicated Patient 6 was assessed as "Yes" in the section 1 and 2 as follows: * Has patient been ruled out as a candidate for surgical procedures? * Has patient declined surgical procedures? * Is patient optimally treated for heart disease with diuretics and vasodilator? * Does this CHF (Chronic Heart Failure, a chronic condition in which the heart doesn't pump blood as well as it should) or angina patient meet the criteria for NYHA Class IV (New York Heart Association, classification provides a simple way of classifying the extent of heart failure -Class IV is the Stage any physical activity brings discomfort and symptoms occur at rest)) level? A review of Patient 6's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 1/10/2023, indicated the skilled nurse (SN) was to visit once per week and two visits as needed. The spiritual counselor (SC) and medical social worker (MSW) visits were declined. A review of Patient 6s clinical record indicated there was no documented evidence Patient 6 had been ruled out as a candidate for surgical procedures or declined surgical procedures. A review of the ";Current Treatment/Medication /DME List" indicated Patient 6 was not on any diuretics (drugs that causes the kidneys to make more urine) but was on a vasodilator. A review of Patient 6's record indicated there was no documentation supporting the LCD assessment. During a telephone interview with Patient 6 on 1/19/2023, at 4:20 p.m., he stated he was at the store doing grocery shopping and asked to call him back 35 minutes later. During a telephone interview with Patient 6 on 1/19/2023, at 5:40 p.m., Patient 6 stated he was cooking ";right now." Patient 6 stated he had high blood pressure but did not have heart disease. He stated sometimes he had shortness of breath (SOB) when he move around, but no SOB while at rest. He stated he could walk, cook, bathe, and drive a car, and he did not think he was dying. Patient 6 stated he was admitted to the agency because one of his friends referred him to the agency. When asked whether Physician 6 was his doctor, he stated Physician 6 was not his doctor and he did not even know Physician 6. During an interview with the Director of Patient Care Services (DPCS) on 1/20/2022, at 2 p.m., he stated he was not able to find the documented evidence Patient 6 had been ruled out as a candidate for surgical procedures or declined surgical procedures or had been treated with diuretics (drugs that causes the kidneys to make more urine). The DPCS was not able to answer why Patient 6 was assessed to be in NYHA Class IV while Patient 6 was able to perform the activities including grocery shopping and cooking. During an interview with the DPCS on 1/23/2023, at 2:30 p.m., he stated the agency staff should have assessed the patients correctly after reviewing the patients information and verifying with the patients primary care physician. A review of the agency's undated policy and procedure titled, "Admission Criteria and Process" indicated the patient must have a life-limiting illness with life expectancy of six (6) months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria in the organizations intermediary Local Coverage Determinations.

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the patients' height and weight were assessed during the comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) for two of nine sampled patients (Patients 5, 6). This deficient practice has the potential risk to prevent assessing disease processes and prevent determining the effectiveness of nutrition prescribed. --- a. A review of Patient 5's admission record indicated the patient was admitted to the Hospice agency on 9/22/2022, with a diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 5's Plan of Care (POC)/Interdisciplinary Group (IDG) Review dated 11/15/2022, indicated the skilled nurse (SN) was to visit once per week and two visits, as needed. The spiritual counselor (SC) and medical social worker (MSW)was to conduct a visit one time, then as needed. The POC indicated Patient 5 had a potential for altered nutritional status related to 50% percent meal intake per meal served. One of the interventions indicated the SN will assess and monitor nutritional needs at every visit. A review of the Comprehensive Nursing Assessment dated 9/22/2022, and 12/15/2022 indicated the spaces for MAC (Mid-arm circumference, an important measure of nutritional status in hospice patients), height and weight, were blank. During an interview with the Director of Patient Care Services (DPCS) on 1/20/2023, at 2 p.m., he was not able to provide the documented evidence Patient 5s height , weight, or MAC was assessed on 9/22/2022 and 12/15/2022. The DPCS stated Patient 5s height, weight, and MAC should have been assessed on initial assessment on 9/22/2022 and a recertification assessment on 12/15/2022. b. A review of Patient 6's clinical record indicated a Start of care (SOC) date of 12/1/2022, with a primary diagnosis of heart disease. A review of Patient 6's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 1/10/2023, indicated the skilled nurse (SN) was to visit once per week and two visits as needed. The spiritual counselor (SC) and medical social worker (MSW) visits were declined. The POC indicated Patient 6 had a poor appetite. The interventions included to assess and monitor nutritional needs at every visit and to provide ongoing assessment of intake, indigestion, food preference and weight change. A review of the Comprehensive Nursing Assessment dated 12/1/2022, 12/15/2022, and 12/29/2022 indicated the spaces for MAC, height and weight were blank. During an interview with the Director of Patient Care Services (DPCS) on 1/20/2023, at 2 p.m., he was not able to provide the documented evidence Patient 6s height, weight, or MAC was assessed on 12/1/2022., and stated Patient 6s height, weight, and MAC should have been assessed on initial assessment on 12/1/2022. A review of the agency's undated policy titled, "Comprehensive Assessment" indicated, all baseline data and other relevant information will be documented in the patient's clinical record including a physical assessment, including blood pressure, temperature, pulse, respiration skin, and other relevant data related to pertinent physical findings

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met by as followed: 1. The hospice agency failed to have every member of the interdisciplinary group (IDG) participate in the interdisciplinary group meeting for two of nine sample patients (Patient 1 and 3). (Refer to L541) 2. The hospice agency failed to ensure the IDG including the Medical Director had communicated with the patients primary physician to verify the patient's eligibility for hospice care services for eight of nine sampled patients (Patient 1, 2, 3, 4, 5, 6, 7 and 8). (Refer to L554) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients accurately assessed to receive hospice care and services. --- .

Based on interview and record review, the hospice agency failed to ensure every member of the interdisciplinary group (IDG) participated in the interdisciplinary group meeting for two of nine sample patients (Patient 1 and 3). This deficient practice had the potential to result in members of the IDG not contributing to the patients comprehensive and ongoing assessments and care planning process. --- a. A review of Patient 1's clinical record indicated a Start of Care date (SOC) of 10/24/2022, with a diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure. A review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 01/10/2023, indicated a Licensed Vocational Nurse (LVN) was scheduled to visit once per week to perform an assessment. A review of Patient 1s Interdisciplinary Group Meeting dated 10/24/2022, 11/15/2022, 11/29/2022, 12/13/2022 and 1/10/2023 indicated the chaplains signature was blank. Further review of the Interdisciplinary Group Meeting dated 10/24/2022 indicated the registered nurse signature was blank. b. A review of Patient 3's clinical record indicated a start of care date (SOC) of 08/29/2022, with diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure. A review of Patient 3's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 01/10/2023, indicated that a Licensed Vocational Nurse (LVN) is scheduled to visit once per week for assessment and hospice aide (HA) twice per week for assistance with activities of daily living (ADL). A review of Patient 3s Interdisciplinary Group Meeting dated 11/15/2022, 11/29/2022, 12/13/2022, 12/27/2022 and 1/10/2023 indicated the chaplains signature was blank. During an interview with the Director of Patient Care Services (DPCS) on 1/20/2023, at 1:50 p.m. and 1/23/2023 at 1:40 p.m., he stated the IDG is done every two weeks on Tuesdays and the members include the Medical Director, Social Worker, Chaplain, Registered Nurse and Administrator. The DPCS stated members who attended the meeting either physically sign in person, electronically or attendance is taken via Google Meet (video conferencing service). DPCS further stated the IDG should be signed within 48 hours. A review of the agencys undated policy and procedure titled ";Interdisciplinary Group Meeting," indicated the meeting will be facilitated by the hospice clinical supervisor/nursing supervisor or designee. The policy and procedure further indicated the hospice medical director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. Additionally, the policy and procedure indicated members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice clinical supervisor/nursing supervisor.

Based on observation, interview and record review, the hospice agency failed to ensure the Interdisciplinary Group (IDG) including the Medical Director had communicated with the patients primary physician to verify the patient's eligibility for hospice care services for eight of nine sampled patients (Patient 1, 2, 3, 4, 5, 6, 7 and 8). This deficient practice resulted in certifying patients for hospice services without documentation of clinical evidence to support the diagnoses, and allowed the hospice agency to provide care/services to the patient who was not qualified for the Medicare hospice benefit. --- g. A review of Patient 7's face sheet indicated Patient 7 was admitted to hospice on 11/26/22, with a primary diagnosis of chronic obstructive pulmonary disease ( a lung disease that block airflow and make it difficult to breathe). It was indicated on the face sheet that Physician 7 was the Referring/Attending /Patient's choice doctor. A review of Patient 7's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 11/26/22, indicated the Licensed Vocational Nurse (LVN) was to visit once per week and one visit as needed. The Registered Nurse (RN) was to visit once per two weeks. The spiritual counselor was to visit once per month, and the Medical social worker service was declined. A review of Patient 7's Certificate of Terminal Illness (CTI), dated 11/26/22 to 2/23/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section which indicated Patient 7 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 1/19/23, at 12 p.m., a home visit was conducted at Patient 7's residence with RN 7. The patient was observed walking with a steady gait and breathing normally with no exertion. When Patient 7 was asked who buys her groceries, she stated she goes out and takes the bus to buy groceries. She also stated one of the staff from the hospice agency referred her to this hospice agency. On 1/19/23, at 2 p.m., during a phone interview with Physician 7, he stated Patient 7 was not his patient at all and the hospice agency was just using his name and credential. On 1/20/23, at 12 p.m., during an interview with the Medical Director 1, he stated he was not the attending physician and he does not know who was the attending physician for Patient 7. He stated since this patient was admitted to their hospice service, he is now the patient's attending physician, that he signed the referral attending physician section because no one will sign it. He further stated that he did not do a face to face encounter with Patient 7 during her admission to hospice service but he determines the patient is eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. On 1/20/23, at 1 p.m., during an interview with the DPCS (director of patient care services), he stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. h. A review of Patient 8's face sheet indicated admission to hospice on 10/2/22, with primary diagnosis of hypertensive chronic kidney disease (long standing disease of the kidneys leading to renal failure). It was indicated in the face sheet that Physician 8 was the Referring/Attending /Patient's choice doctor. A review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 10/2/22, indicated the Licensed Vocational Nurse (LVN) was to visit once per week and one additional visit as needed. The Registered Nurse (RN) was to visit once per two weeks. The spiritual counselor was to visit once per month, and the Medical social worker service was declined. A review of Patient 8's Certificate of Terminal Illness (CTI), dated 10/2/22 to 12/30/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section which indicated Patient 8 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 1/19/23, at 11 a.m., during a phone interview with Patient 8, she stated that one of her friends referred her to hospice service. She also stated that she was not sick that she will pass away in 6 months. On 1/19/23, at 3 p.m., during a phone interview with Physician 8, he stated that Patient 8 was his patient he did not refer her to the hospice services. He also stated Patient 8 does not need hospice services at all. On 1/20/23, at 12 p.m., during an interview with the Medical Director 1, he stated he was not the attending physician and he does not know who was the attending physician for Patient 8. He stated since this patient was admitted to their hospice service, he is now the patient's attending physician, and that he signed the referral attending physician section because no one will sign it. He further stated that he did not do a face to face encounter with Patient 8 during her admission to hospice service, but he determines the patient is eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. On 1/20/23, at 1 p.m., during an interview with the DPCS (director of patient care services), he stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. d. A review of Patient 4's admission record indicated the patient was admitted to the HA on 12/1/2022, with a diagnosis of heart disease (refers to several types of heart conditions). A review of Patient 4's face sheet indicated that Physician 4 was the Referring/Attending /Patient's choice doctor. A review of Patient 4's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 12/1/2022, indicated the Licensed Vocational Nurse (LVN) was to visit once per week and one visit as needed. The Registered Nurse (RN) was to visit once per two weeks,. The spiritual counselor was to visit once per month, and the Medical social worker service was declined. A review of Patient 4s ";Physicians Certification for Hospice Benefit" dated 12/1/2022 indicated previous DPCS obtained Physician 4s verbal referral for Patient 4 to the agency. It was indicated it was Physician 4s clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. However, a review of Patient 4s clinical record indicated there was no supporting documentation from Physician 4 (including History and Physical) that Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. On 1/19/2023, at 10:30 a.m., when a joint home visit was made for Patient 4 with the Registered Nurse (RN 1) at the patient's residence, Patient 4 was sitting on a sofa, alert and oriented, and was able to communicate well. During an interview with Patient 4, she stated Physician 4 was not her primary care physician (PCP) and she did not even know Physician 4. Patient 4 stated her PCP was Physician 10, but she had not seen Physician 10 ";for a while". When asked Physician 10s phone number, she stated she did not remember at the moment. On 1/19/2023, at 12:10 p.m., during a telephone interview with Personnel 1 of Physician 4s office, she stated Physician 4 did not refer Patient 4 to the agency because Patient 4 was not Physician 4s patient, and Patient 4s name was not in their record. On 1/20/2022, at 1:30 p.m., during a telephone interview with the previous DPCS, she stated she did not call Physician 4 and obtained verbal referral from Physician 4. She stated when she gets referral from the office, she starts reviewing the information and performs assessment, but had not communicated with the referring/attending physician. e. A review of Patient 5's admission record indicated the patient was admitted to the HA on 9/22/2022, with a diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). It was indicated in the face sheet that Physician 5 was the Referring/Attending /Patient's choice doctor. A review of Patient 5's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 1/10/2023, indicated the skilled nurse (SN) was to visit once per week and two visits as needed. The spiritual counselor (SC) and medical social worker (MSW) were to visit one time, then as needed. A review of Patient 5s ";Physicians Certification for Hospice Benefit" dated 9/22/2022 indicated previous DPCS obtained Physician 5s verbal referral for Patient 5 to the agency. It was indicated it was Physician 5s clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. However, a review of Patient 5s clinical record indicated there was no supporting documentation from Physician 5 (including History and Physical) that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. On 1/19/2023, at 10:30 a.m., when a joint home visit was made for Patient 5 with the Registered Nurse (RN 1) at the patient's residence, Patient 5 was lying down on a sofa. Patient 5 was alert and oriented, and was able to communicate. When asked Patient 5 whether Physician 5 was his attending physician who referred him to the hospice service (as indicated in the face sheet), he stated Physician 5 was not his doctor and he did not even know Physician 5. Patient 5 stated he was admitted to the agency because one of his neighbors referred him to the agency. He stated he had not visited the emergency room or was hospitalized recently, and he did not think he was dying. On 1/19/2023, at 4:35 p.m., during a telephone interview with Physician 5, he stated Patient 5 was not his patient and he did not refer Patient 5 to the agency. He stated he did not even know the agency and the agencys medical director. On 1/20/2022, at 1:30 p.m., during a telephone interview with the previous DPCS, she stated she did not call Physician 5 and obtained verbal referral from Physician 5. She stated when she gets referral from the office, she starts reviewing the information and performs assessment, but had not called the referring physician. f. A review of Patient 6's clinical record indicated a Start of Care (SOC) date of 12/1/2022, with a primary diagnosis of heart disease (refers to several types of heart conditions). It was indicated in the face sheet that Physician 6 was the Referring/Attending /Patient choice doctor. A review of Patient 6's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 12/1/2022, indicated the Registered (RN) was to visit every 14 days. The skilled nurse (SN) was to visit once per week and two additional visits as needed,. The spiritual counselor (SC) and medical social worker (MSW) was to do a visit for an initial evaluation. A review of Patient 6s ";Physicians Certification for Hospice Benefit" dated 12/1/2022 indicated previous DPCS obtained Physician 6s verbal referral for Patient 6 to the agency. It was indicated it was Physician 5s clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. However, a review of Patient 6s clinical record indicated there was no supporting documentation from Physician 6 (including History and Physical) that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. On 1/19/2023, at 4:15 p.m., when Physician 6s office was called using the number listed on the face sheet, there was a recording ";Sorry, you have reached a number that has been disconnected or is no longer in service" During a telephone interview with Patient 6 on 1/19/2023, at 4:20 p.m., he stated he enrolled with the hospice agency because one of his friends referred him to the agency. When asked whether Physician 6 was his doctor, he stated Physician 6 was not his doctor and he did not even know Physician 6. On 1/20/2022, at 1:30 p.m., during a telephone interview with the previous DPCS, she stated she did not call Physician 6 and obtained verbal referral from Physician 6. She stated when she receives a referral from the office, she starts reviewing the information and performs assessment, but had not called the referring physician (Physician 6). On 1/23/2023, at 11:40 a.m., during an interview with the Administrator, she stated the agency had received the referral for Patient 4, Patient 5, and Patient 6 from their friend/neighbor, and the office manager should have notified the attending physician for changing attending physician. On 1/23/2023, at 2:50 p.m., during an interview with the office manager/Administrator designee, she stated when the agency receives a referral, the Medical Director is to contact the primary care physician, and any staff at the office will contact the agencys IDG member. On 1/23/2023, at 11:45 a.m., during a telephone interview with the Medical Director, he stated he had not communicated with the patients PCP (primary care physician) because he did not have time. He stated he does not contact the patients PCP unless there is issue. On 1/23/2023, at 2:30 p.m., during an interview with the DPCS, he stated the agency staff should have communicated with the patients PCP to coordinate care. A review of the agencys undated policy titled, ";Physician Services – Attending Physicians role" indicated communication between the attending physician and other members of the Interdisciplinary group will be ongoing and documented in the hospice clinical record. It indicated the attending physician or designee will approve the referral of the patient and family/caregiver to the hospice program. Once the patient and the family chooses a hospice provider, the attending physician will notify the hospice program and make a referral. a. A review of Patient 1's clinical record indicated a Start of Care date (SOC) of 10/24/2022, with a diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure. A review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 1/10/2023, indicated that a Licensed Vocational Nurse (LVN) is scheduled to visit once per week to perform an assessment. A review of Patient 1s ";Physicians Certification for Hospice Benefit" dated 10/24/2022 indicated the previous DPCS obtained verbal authorization from Physician 1. The verbal authorization indicated that Patient 1 was being referred to hospice and it was the physicians clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. The ";Physicians Certification for Hospice Benefit" further indicated that Physician 1 did not want to follow the patient. During an interview with Physician 1 on 1/19/2023, at 11:39 a.m. he stated he did not refer Patient 1 to hospice. Physician 1 further stated it was impossible for him to refer Patient 1 to hospice on 10/24/2022 because he had already moved to a different job and Patient 1 was no longer his patient at that time. b. A review of Patient 2's clinical record indicated a Start of Care date (SOC) of 8/27/2022, with a diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure. A review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 1/10/2023, indicated a skilled nurse (SN) is scheduled to visit once per week. A review of Patient 2s ";Physicians Certification for Hospice Benefit" dated 8/27/2022 indicated the previous DPCS obtained verbal authorization from Physician 2. The verbal authorization indicated Patient 2 was being referred to hospice and it was the physicians clinical judgement the patient had a life expectancy of six months or less if the terminal illness runs its normal course. The ";Physicians Certification for Hospice Benefit" further indicated that Physician 2 did not want to follow the patient. During an interview with Physician 2 on 1/19/2023, at 4:14 p.m. he stated that he did not refer Patient 2 to hospice on 8/27/2022. Physician 2 further stated he just saw Patient 2 today, 1/19/2023 and patient is not hospice appropriate. c. A review of Patient 3's clinical record indicated a Start of Care date (SOC) of 8/29/2022, with diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure. A review of Patient 3s ";Physicians Certification for Hospice Benefit" dated 8/29/2022 indicated the previous DPCS obtained verbal authorization from Physician 3. The verbal authorization indicated Patient 3 was being referred to hospice and it was the physicians clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. The ";Physicians Certification for Hospice Benefit" further indicated Physician 3 did not want to follow the patient. During an interview with Physician 3 on 1/19/2023, at 4:55 p.m. he stated he did not refer Patient 3 to hospice on 8/29/2022. Physician 3 further stated he saw Patient 3 on 12/05/2022 and at that time he would not recommend hospice for the patient. During an interview with the previous Director of Patient Care Services (DPCS) on 1/20/2022, at 1:30 p.m., she stated that she did not receive verbal authorization from Physician 1, 2, and 3 and she did not contact the primary physicians of Patient 1, 2 and 3. The previous DPCS further stated she receives emails from the agency office regarding referrals and she does not call or communicate with the referring or primary care physician regarding the patients. During an interview with the previous Medical Director on 1/23/2023, at 3:02 p.m., he stated it is the responsibility of the DPCS or assigned nurse who admitted the patient to contact the primary care physician. The previous Medical Director further stated that he did not contact the primary care physicians and that ultimately the medical director is responsible for all medical care. A review of the agencys undated, policy and procedure titled "Admission Criteria and Process", indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination.

Based on interview and record review, the hospice agency failed to provide documented evidence of a Quality Assessment and Performance Improvement (QAPI) program. This failure had the potential to affect the care provided to the patients. --- During a record review of the QAPI program on 1/20/23 at 10:45 a.m., the QAPI program policy had not been approved since 1/15/2022. The policy indicated the program will objectively and systematically monitor and evaluate the effectiveness and safety of services and quality of care provided for patient and families. During an interview with the Administrator on 1/20/23, at 10:45 a.m., she could not provide the QAPI meeting minutes. The Administrator confirmed the policy should be reviewed annually and there should be evidence of a functioning QAPI program. She confirmed she could not provide any current documentation with signatures of core staff that attended. She stated the QAPI program is important to improve operations.

Based on interview and record review, the hospice agency failed to provide documented evidence of performance improvement projects. This failure had the potential to affect the care provided to the patients. --- During a record review on 1/20/23, at 11 a.m., the hospice agency did not have any ongoing performance improvement projects. During an interview with the Administrator, on 1/20/23, at 11:10 a.m., she stated they should have at least four projects but could not provide any evidence of performance improvement projects and signatures of core staff that attended to discuss any projects pending.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows: The hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications of five of nine sampled patients, (Patient 4, 5, 6, 7 8) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. (Refer to L 667) 2. The hospice agency failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, reviewing, and verifying patient clinical information necessary for initial certification and recertification of terminal illness for eight of nine sampled patients (Patient 1, 2, 3, 4, 5, 6, 7 and 8). (Refer L 669) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services. --- .

Based on observation, interview, and record review, the hospice agency failed to ensure the medical director conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial certifications for five of nine sampled patients, (Patient 4, 5, 6, 7, 8) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The agency failed to obtain and review the patients documented clinical information necessary for initial certification of hospice care and services that included patient's history and physicals, laboratory and imaging data, biopsy results, etc. These deficient practices resulted in the hospice medical director and/or the hospice attending physicians to certify the patients for hospice care, without documentation of clinical evidence to support the terminal illness diagnoses, and could result in the lack of and inappropriate care being provided to the patients. --- d. A review of Patient 7's face sheet indicated admission to hospice on 11/26/22, with primary diagnosis of chronic obstructive pulmonary disease ( a lung disease that block airflow and make it difficult to breathe). It was indicated in the face sheet that Physician 7 was the Referring/Attending /Patient choice doctor. A review of Patient 7's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 11/26/22, indicated the Licensed Vocational Nurse (LVN) visit once per week and one visit as needed, Registered Nurse (RN) visit once per two weeks, the spiritual counselor visit once per month, and the Medical social worker service was declined. A review of Patient 7's Certificate of Terminal Illness (CTI), dated 11/26/22 to 2/23/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 7 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 1/19/23, at 12 p.m., a home visit was conducted at Patient 7's residence with RN 7. The patient was observed walking with steady gait, breathing normally with no exertion. When Patient 7 was asked who buys her grocery stuff, she stated that she goes out and takes the bus to the groceries. She also stated that one of the staff from the hospice agency referred her to this hospice agency. On 1/19/23, at 2 p.m., during a phone interview with Physician 7, he stated that Patient 7 was not his patient at all and the hospice agency was just using his name and credential. On 1/20/23, at 12 p.m., during an interview with the Medical Director 1, he stated that he was not the attending physician and he does not know who the attending physician for Patient 7. He stated since this patient was admitted to their hospice service, he is now the patient's attending physician, that he signed the referral attending physician section because no one will sign it.. He further stated that he did not do a face to face encounter with Patient 7 during her admission to hospice service but he determines the patient is eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. On 1/20/23, at 1 p.m., during an interview with the DPCS (director of patient care services), he stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. e. A review of Patient 8's face sheet indicated admission to hospice on 10/2/22, with primary diagnosis of hypertensive chronic kidney disease (long standing disease of the kidneys leading to renal failure). It was indicated in the face sheet that Physician 8 was the Referring/Attending /Patient choice doctor. A review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 10/2/22, indicated the Licensed Vocational Nurse (LVN) visit once per week and one visit as needed, Registered Nurse (RN) visit once per two weeks, the spiritual counselor visit once per month, and the Medical social worker service was declined. A review of Patient 8's Certificate of Terminal Illness (CTI), dated 10/2/22 to 12/30/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 8 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 1/19/23, at 11 a.m., during a phone interview with Patient 8, she stated that one of her friends referred her to hospice service. She also stated that she was not sick that she will pass away in 6 months. On 1/19/23, at 3 p.m., during a phone interview with Physician 8, he stated that Patient 8 was his patient he did not refer her to hospice services. He also stated that Patient 8 does not need hospice services at all. On 1/20/23, at 12 p.m., during an interview with the Medical Director 1, he stated that he was not the attending physician and he does not know who the attending physician for Patient 8. He stated since this patient was admitted to their hospice service, he is now the patient's attending physician, that he signed the referral attending physician section because no one will sign it.. He further stated that he did not do a face to face encounter with Patient 8 during her admission to hospice service but he determines the patient is eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. On 1/20/23, at 1 p.m., during an interview with the DPCS (director of patient care services), he stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. A review of the policy "Admission Criteria and Process", indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination. A review of the policy "Admission Criteria and Process", indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination. a. A review of Patient 4's admission record indicated the patient was admitted to the HA on 12/1/2022, with diagnosis of heart disease (refers to several types of heart conditions). It was indicated in the face sheet that Physician 4 was the Referring/Attending /Patient choice doctor. A review of Patient 4's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 12/1/2022, indicated the Licensed Vocational Nurse (LVN) visit once per week and one visit as needed, Registered Nurse (RN) visit once per two weeks, the spiritual counselor visit once per month, and the Medical social worker service was declined. A review of Patient 4s ";Physicians Certification for Hospice Benefit" dated 12/1/2022 indicated previous DPCS obtained Physician 4s verbal referral for Patient 4 to the agency. It was indicated it was Physician 4s clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. However, a review of Patient 4s clinical record indicated there was no supporting documentation from Physician 4 (including History and physical) that Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. A review Patient 4's "Physician Certification for Hospice Benefit" for the first 90-day period from 12/1/2022 to 2/28/2023 indicated Patient 4's terminal diagnosis was heart failure. In the physicians narrative, the Medical Director documented ";Based on my collaboration with referring MD, review of available medical record, and the hospice comprehensive assessment, I certify that this patient meets hospice criteria of having less than six months to live if the terminal illness runs its normal course." However, there was only the Medical directors electronical signature in the form, not Physician 4s signature. On 1/19/2023, at 10:30 a.m., when a joint home visit was made for Patient 4 with the Registered Nurse (RN 1) at the patient's residence, Patient 4 was sitting in a sofa, alert and oriented, and was able to communicate well. During an interview with Patient 4, she stated Physician 4 was not her primary care physician (PCP) and she did not even know Physician 4. Patient 4 stated her PCP was Physician 10, but she had not seen Physician 10 ";for a while". When asked for Physician 10s phone number, she stated she did not remember at that moment. On 1/19/2023, at 12:10 p.m., during a telephone interview with Personnel 1 of Physician 4s office, she stated Physician 4 did not refer Patient 4 to the agency because Patient 4 was not Physician 4s patient, and patient 4s name was not in their record. A review of Patient 4s clinical record indicated there was no documented evidence the medical director collaborated with the referring physician and had reviewed medical records that the Medical Director was able to certify Patient 5 met the hospice criteria of having less than six months to live if the terminal illness runs its normal course. b. A review of Patient 5's admission record indicated the patient was admitted to the HA on 9/22/2022, with diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). It was indicated in the face sheet that Physician 5 was the Referring/Attending /Patient choice doctor. A review of Patient 5's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 1/10/2023, indicated the skilled nurse (SN) visit once per week and two visits as needed, the spiritual counselor (SC) and medical social worker (MSW) to do visit one time then as needed. A review of Patient 5s ";Physicians Certification for Hospice Benefit" dated 9/22/2022 indicated previous DPCS obtained Physician 5s verbal referral for Patient 5 to the agency. It was indicated it was Physician 5s clinical judgement the patient had a life expectancy of six months or less if the terminal illness runs its normal course. However, a review of Patient 5s clinical record indicated there was no supporting documentation from Physician 5 (including History and Physical) Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. A review Patient 5's "Physician Certification for Hospice Benefit" for the first 90-day period from 9/22/2022 to 12/20/2022 indicated Patient 5's terminal diagnosis was COPD. In the physicians narrative, the previous Medical Director documented ";Based on my collaboration with referring MD, review of available medical record, and the hospice comprehensive assessment, I certify that this patient meets hospice criteria of having less than 6 months to live if the terminal illness runs its normal course". However, there was only previous Medical directors electronical signature in the form, not Physician 5s signature. On 1/19/2023, at 10:30 a.m., when a joint home visit was made for Patient 5 with the Registered Nurse (RN 1) at the patient's residence, Patient 5 was lying down in a sofa. Patient 5 was alert and oriented, and was able to communicate. When asked Patient 5 whether Physician 5 was his attending physician who referred him to the hospice service (as indicated in the face sheet), he stated Physician 5 was not his doctor and he did not even know Physician 5. Patient 5 stated he was admitted to the agency because one of his neighbors referred him to the agency. He stated he had not visited the emergency room or was hospitalized recently, and he did not think he was dying. On 1/19/2023, at 4:35 p.m., during a telephone interview with Physician 5, he stated Patient 5 was not his patient and he did not refer Patient 5 to the agency. He stated he did not even know the agency and the agencys medical director. A review of Patient 5s clinical record indicated there was no documented evidence the medical director collaborated with the referring physician and had reviewed medical records that the Medical Director was able to certify Patient 5 met the hospice criteria of having less than six months to live if the terminal illness runs its normal course. c. A review of Patient 6's clinical record indicated a Start of Care (SOC) date of 12/1/2022, with a primary diagnosis of heart disease (refers to several types of heart conditions). It was indicated in the face sheet that Physician 6 was the Referring/Attending /Patient choice doctor. A review of Patient 6's "LCD Hospice Eligibility Determination" (LCD), dated 12/1/2022, indicated the section 1 and 2 should be met. It indicated Patient 6 was assessed as "Yes" in the section 1 and 2 as follows: * Has patient been ruled out as a candidate for surgical procedures? * Has patient declined surgical procedures? * Is patient optimally treated for heart disease with diuretics and vasodilator? * Does this CHF (Chronic Heart Failure, a chronic condition in which the heart doesn't pump blood as well as it should) or angina patient meet the criteria for NYHA Class IV (New York Heart Association, classification provides a simple way of classifying the extent of heart failure -Class IV is the Stage any physical activity brings discomfort and symptoms occur at rest)) level? A review of Patient 6s clinical record indicated there was no documented evidence Patient 6 had been ruled out as a candidate for surgical procedures or declined surgical procedures. A review of the ";Current Treatment/Medication /DME List" indicated Patient 6 was not on any diuretics (drugs that causes the kidneys to make more urine) but was on vasodilator. A review of Patient 6's record indicated there was no documentation supporting the LCD assessment. On 1/19/2023, at 4:15 p.m., when Physician 6s office was called with the number in the face sheet, there was a recording ";Sorry, you have reached the number that has disconnected or no longer in service" During a telephone interview with Patient 6 on 1/19/2023, at 4:20 p.m., he stated he was at the store doing grocery shopping and asked to call him back 35 minutes later. During a telephone interview with Patient 6 on 1/19/2023, at 5:40 p.m., Patient 6 stated he was cooking ";right now". Patient 6 stated he had high blood pressure but did not have heart disease. He stated sometimes he had shortness of breath (SOB) when he move around, but no SOB on the rest. He stated he could walk, cook, bathe, and drive a car, and he did not think he was dying. Patient 6 stated he was admitted to the agency because one of his friends referred him to the agency. When asked whether Physician 6 was his doctor, he stated Physician 6 was not his doctor and he did not even know Physician 6. During an interview with the Director of Patient Care Services (DPCS) on 1/20/2022, at 2 p.m., he stated he was not able to find the documented evidence Patient 6 had been ruled out as a candidate for surgical procedures or declined surgical procedures or had been treated with diuretics (drugs that causes the kidneys to make more urine). The DPCS was not able to answer why Patient 6 was assessed to be in NYHA Class IV while Patient 6 was able to perform the activities (including shopping and cooking). A review Patient 6's "Physician Certification for Hospice Benefit" for the first 90-day period from 12/2/2022 to 2/28/2023 indicated Patient 6's terminal diagnosis was heart disease. In the physicians narrative, the Medical Director documented ";Based on my collaboration with referring MD, review of medical record, and the hospice comprehensive assessment, I certify that this patient meets hospice criteria of having less than six months to live if the terminal illness runs its normal course". However, there was only Medical directors electronical signature in the form, not Physician 6s signature. A review of Patient 6s clinical record indicated there was no documented evidence that the medical director had collaborated with the referring physician and had reviewed medical record that the Medical Director was able to certify Patient 6 met the hospice criteria of having less than six months to live if the terminal illness runs its normal course. On 1/23/2023, at 11:45 a.m., during a telephone interview with the Medical Director, he stated he was not a primary physician for all of the agency's patients, and he was not aware 100 percent of the agencys patients. He stated he had not communicated with the attending physicians of Patient 4, 5, 6 because he did not have time. He further stated he does not contact the patients PCP unless there is issue. When asked admission process, he stated he reviews the RN/DPCSs assessment along with blood test and history & physical, if available. The Medical Director stated he trusted and relied on the nurses assessment. When informed there was no documentation supporting the LCD assessment and the patient's diagnoses. The medical director stated the agency should have supporting documentation after verified with the attending physician/hospital. On 1/23/2023, at 3:05 p.m., during a telephone interview with the previous Medical Director, he stated he had determined the hospice eligibility based on RN assessment, LCD guideline and diagnoses. He stated he had not contacted the patients PCP because the DPCS or the assigned nurse/staff should have communicated with the PCP and requested documentation needed. He stated the agencys DPCS/staffs should have verified the LCD assessment. A review of the agency's undated policy and procedure titled, "Admission Criteria and Process" indicated the patient must have a life-limiting illness with life expectancy of six (6) months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria in the organizations intermediary Local Coverage Determinations. A review of the agencys undated policy titled "; Professional Services agreement for Medical Director" indicated the duties and responsibilities of the Medical Director will include, but not be limited to reviewing the patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness.

Based on observation, interview and record review, The hospice agency failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, reviewing, and verifying patient clinical information necessary for initial certification and recertification of terminal illness for eight of nine sampled patients (Patient 1, 2, 3, 4, 5, 6, 7 and 8). These deficient practices resulted in the hospice medical director and/or the hospice attending physicians certifying patients for hospice care, without reviewing and verifying patients clinical information. --- h. A review of Patient 7's face sheet indicated admission to hospice on 11/26/22, with primary diagnosis of chronic obstructive pulmonary disease ( a lung disease that block airflow and make it difficult to breathe). It was indicated in the face sheet that Physician 7 was the Referring/Attending/Patient's choice doctor. A review of Patient 7's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 11/26/22, indicated the Licensed Vocational Nurse (LVN) was to visit once per week and one visit as needed. The Registered Nurse (RN) was to visit once per two weeks. The spiritual counselor was to visit once per month, and the Medical social worker service was declined. A review of Patient 7's Certificate of Terminal Illness (CTI), dated 11/26/22 to 2/23/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicating Patient 7 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 1/19/23, at 12 p.m., a home visit was conducted at Patient 7's residence with RN 7. The patient was observed walking with a steady gait without using any assistive device. When Patient 7 was asked who buys her groceries, she stated she goes out and takes the bus to buy groceries. She also stated that one of the staff from the hospice agency referred her to this hospice agency. On 1/19/23, at 2 p.m., during a phone interview with Physician 7, he stated Patient 7 was not his patient at all and the hospice agency was just using his name and credential. On 1/20/23, at 12 p.m., during an interview with Medical Director 1, he stated he was not the attending physician and he does not know who is the attending physician for Patient 7. He stated since this patient was admitted to their hospice service, he is now the patient's attending physician, and he signed the referral attending physician section because no one will sign it. He further stated that he did not do a face to face encounter with Patient 7 during her admission to hospice service but he determines the patient is eligible for hospice services by reviewing of the patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. On 1/20/23, at 1 p.m., during an interview with the DPCS (director of patient care services), he stated in order for a new patient to be admitted to their hospice service, there should be a referral from the patient's attending physician. i. A review of Patient 8's face sheet indicated admission to hospice on 10/2/22, with primary diagnosis of hypertensive chronic kidney disease (long standing disease of the kidneys leading to renal failure). It was indicated in the face sheet that Physician 8 was the Referring/Attending /Patient's choice doctor. A review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 10/2/22, indicated the Licensed Vocational Nurse (LVN) was to visit once per week and one visit as needed. The Registered Nurse (RN) was to visit once per two weeks. The spiritual counselor was to visit once per month, and the Medical social worker service was declined. A review of Patient 8's Certificate of Terminal Illness (CTI), dated 10/2/22 to 12/30/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section which indicated Patient 8 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 1/19/23, at 11 a.m., during a phone interview with Patient 8, she stated one of her friends referred her to the hospice service. She also stated she was not that sick that she will pass away in six months. On 1/19/23, at 3 p.m., during a phone interview with Physician 8, he stated that Patient 8 was his patient, but he did not refer her to hospice services. He also stated Patient 8 does not need hospice services at all. On 1/20/23, at 12 p.m., during an interview with Medical Director 1, he stated he was not the attending physician and he does not know who is the attending physician for Patient 8. He stated since this patient was admitted to their hospice service, he is now the patient's attending physician, and he signed the referral attending physician section because no one will sign it. He further stated that he did not do a face to face encounter with Patient 8 during her admission to hospice service, but he determines the patient is eligible for hospice services by reviewing of the patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. On 1/20/23, at 1 p.m., during an interview with the DPCS (director of patient care services), he stated in order for a new patient to be admitted to their hospice service, there should be a referral from the patient's attending physician. d. A review of Patient 4's admission record indicated the patient was admitted to the HA on 12/1/2022, with diagnosis of heart disease (refers to several types of heart conditions). It was indicated in the face sheet that Physician 4 was the Referring/Attending /Patient choice doctor. A review of Patient 4's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 12/1/2022, indicated the Licensed Vocational Nurse (LVN) visit was once per week and one visit as needed. The Registered Nurse (RN) visit was once per two weeks. The spiritual counselor visit was once per month, and the Medical social worker service was declined. A review of Patient 4s ";Physicians Certification for Hospice Benefit" dated 12/1/2022 indicated previous DPCS obtained Physician 4s verbal referral for Patient 4 to the agency. It was indicated it was Physician 4s clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. However, a review of Patient 4s clinical record indicated there was no supporting documentation from Physician 4 (including History and physical) that Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. A review Patient 4's "Physician Certification for Hospice Benefit" for the first 90-day period from 12/1/2022 to 2/28/2023 indicated Patient 4's terminal diagnosis was heart failure. In the physicians narrative, the Medical Director documented ";Based on my collaboration with referring MD, review of available medical record, and the hospice comprehensive assessment, I certify that this patient meets hospice criteria of having less than six months to live if the terminal illness runs its normal course." However, there was only the Medical directors electronical signature in the form, not Physician 4s signature. e. A review of Patient 5's admission record indicated the patient was admitted to the HA on 9/22/2022, with diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). It was indicated in the face sheet that Physician 5 was the Referring/Attending /Patient's choice doctor. A review of Patient 5's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 1/10/2023, indicated the skilled nurse (SN) visit once per week and two visits as needed, the spiritual counselor (SC) and medical social worker (MSW) to do visit one time then as needed. A review of Patient 5s ";Physicians Certification for Hospice Benefit" dated 9/22/2022 indicated previous DPCS obtained Physician 5s verbal referral for Patient 5 to the agency. It was indicated it was Physician 5s clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. However, a review of Patient 5s clinical record indicated there was no supporting documentation from Physician 5 (including History and Physical) that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. A review Patient 5's "Physician Certification for Hospice Benefit" for the first 90-day period from 9/22/2022 to 12/20/2022 indicated Patient 5's terminal diagnosis was COPD. In the physicians narrative, the previous Medical Director documented ";Based on my collaboration with referring MD, review of available medical record, and the hospice comprehensive assessment, I certify that this patient meets hospice criteria of having less than six months to live if the terminal illness runs its normal course." However, there was only the previous Medical directors electronical signature in the form, not Physician 5s signature. A review of Patient 5s clinical record indicated there was no supporting documentation that the previous Medical Director was able to certify Patient 5 met the hospice criteria of having less than six months to live if the terminal illness runs its normal course. f. A review of Patient 6's clinical record indicated a Start of Care (SOC) date of 12/1/2022, with a primary diagnosis of heart disease (refers to several types of heart conditions). It was indicated in the face sheet that Physician 6 was the Referring/Attending /Patient choice doctor. A review of Patient 6s ";Physicians Certification for Hospice Benefit" dated 12/1/2022 indicated previous DPCS obtained Physician 6s verbal referral for Patient 6 to the agency. It was indicated it was Physician 5s clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. However, a review of Patient 6s clinical record indicated there was no supporting documentation from Physician 6 (including History and Physical) that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. A review Patient 6's "Physician Certification for Hospice Benefit" for the first 90-day period from 12/1/2022 to 2/28/2023 indicated Patient 6's terminal diagnosis was heart disease. In the physicians narrative, the previous Medical Director documented ";Based on my collaboration with referring MD, review of available medical record, and the hospice comprehensive assessment, I certify that this patient meets hospice criteria of having less than six months to live if the terminal illness runs its normal course". However, there was only the Medical directors electronical signature in the form, not Physician 6s signature. A review of Patient 6s clinical record indicated there was no supporting documentation the Medical Director was able to certify Patient 6 met the hospice criteria of having less than six months to live if the terminal illness runs its normal course. On 1/23/2023, at 11:45 a.m., during a telephone interview with the Medical Director, he stated he was not a primary physician for all of the agency's patients, and he was not aware 100 percent of the agencys patients. When asked about determining hospice criteria, he stated he reviews the supporting documented evidence to determine hospice eligibility such as the record from the hospital, records from primary doctors, labs, diagnostic records, reviews the chart, and review RN assessment. The Medical Director stated he had not communicated with the attending physicians of Patient 4, 5, 6 because he did not have time. He also stated he does not contact the patients PCP (primary care physician) unless there is an issue. The Medical Director stated he trusted and relied on the nurses assessment. On 1/23/2023 at 2:30 p.m., the DPCS and Administrator was requested to provide all supporting evidence, such as labs, records from the primary doctor and diagnostic results that the MD stated he reviewed for the sample patients, but the DPCS and the Administrator were unable to find the requested documents. On 1/23/2023, at 3:05 p.m., during a telephone interview with the previous Medical Director, he stated he had determined the hospice eligibility based on RN assessment, LCD guideline and diagnoses. He stated he had not contacted the patients PCP because the DPCS or the assigned nurse/staff should have communicated with the PCP and requested documentation needed. He stated the agencys DPCS/staffs should have verified the LCD assessment. When the previous Medical Director was informed about no supporting documentation of LCD assessment/incorrect LCD assessment, he stated that should not have occurred. A review of the agency's undated policy and procedure titled, "Admission Criteria and Process" indicated the patient must have a life-limiting illness with life expectancy of six (6) months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria in the organizations intermediary Local Coverage Determinations. A review of the agencys undated policy titled "; Professional Services agreement for Medical Director" indicated the duties and responsibilities of the Medical Director will include, but not be limited to reviewing the patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care and written certification of terminal illness. a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 10/24/2022, with diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure. A review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 01/10/2023, indicated a Licensed Vocational Nurse (LVN) is scheduled to visit once per week for assessment. A review of Patient 1s ";Physicians Certification for Hospice Benefit" dated 10/24/2022 indicated that the previous DPCS obtained verbal authorization from Physician 1. The verbal authorization indicated Patient 1 was being referred to hospice and it was the physicians clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. The ";Physicians Certification for Hospice Benefit" further indicated that Physician 1 did not want to follow the patient. A review of Patient 1s ";Physicians Certification for Hospice Benefit" Certification number four (4), dated 10/24/2022 indicated the previous medical director electronically signed on 10/24/2022 confirming he composed Patient1s narrative based on review of Patient 1"s medical record, team and/or examination of the patient. A review of documents provided by the Administrator indicated that a fax was sent on 03/01/2022 requesting Patient 1s medical records from the general acute care hospital (GACH). Further review of the documents provided by the Administrator did not indicate that a request for medical records was obtained for her current admission to the hospice agency. During an interview with Family Member (FM 1) on 1/20/2023, at 10:39 a.m. he stated a friend of his wife was receiving hospice services, so he decided to ask around and called places and that is when he came across the hospice agency his wife is currently in. During an interview with Physician 1 on 1/19/2023, at 11:39 a.m. he stated he did not refer Patient 1 to hospice. Physician 1 further stated it was impossible for him to refer Patient 1 to hospice on 10/24/2022 because he had already moved to a different job and that Patient 1 was no longer his patient at that time. b. A review of Patient 2's clinical record indicated a start of care date (SOC) of 8/27/2022, with diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure. A review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 1/10/2023, indicated a skilled nurse (SN) is scheduled to visit once per week. A review of Patient 2s ";Physicians Certification for Hospice Benefit" dated 8/27/2022 indicated the previous DPCS obtained verbal authorization from Physician 2. The verbal authorization indicated Patient 2 was being referred to hospice and it was the physicians clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. The ";Physicians Certification for Hospice Benefit" further indicated Physician 2 did not want to follow the patient. A review of Patient 2s ";Physicians Certification for Hospice Benefit" Certification number one (1), dated 8/27/2022 indicated the previous medical director electronically signed on 8/27/2022 confirming he composed Patient 2s narrative based on review of Patient 2's medical record, team and/or examination of the patient. A review of documents provided by the Administrator indicated that an email was sent on 9/13/2022 requesting Patient 2s medical records from the general acute care hospital (GACH). Further review of the documents provided by the Administrator did not indicate that records were requested prior to Patient 2 being certified for hospice benefits. During an interview with Physician 2 on 1/19/2023, at 4:14 p.m. he stated he did not refer Patient 2 to hospice on 8/27/2022. Physician 2 further stated he just saw Patient 2 today, 1/19/2023 and that Patient 2 is not hospice appropriate. c. A review of Patient 3's clinical record indicated a Start of Care date (SOC) of 8/29/2022, with diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure. A review of Patient 3s ";Physicians Certification for Hospice Benefit" dated 8/29/2022 indicated the previous DPCS obtained verbal authorization from Physician 3. The verbal authorization indicated Patient 3 was being referred to hospice and it was the physicians clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. The ";Physicians Certification for Hospice Benefit" further indicated Physician 3 did not want to follow the patient. A review of Patient 3s ";Physicians Certification for Hospice Benefit" Certification number one (1), dated 8/29/2022 indicated the previous medical director electronically signed on 8/29/2022 confirming he composed Patient 3s narrative based on review of patients medical record, team and/or examination of the patient. A review of documents provided by the Administrator indicated that a fax was sent on 9/12/2022 requesting Patient 3s medical records from the general acute care hospital. Further review of the documents provided by the Administrator did not indicate that records were requested prior to Patient 3 being certified for hospice benefits. During an interview with Physician 3 on 1/19/2023, at 4:55 p.m. he stated he did not refer Patient 3 to hospice on 8/29/2022. Physician 3 further stated he saw Patient 3 on 12/05/2022 and at that time he would not recommend hospice for the patient. During an interview with the previous Medical Director on 1/23/2023, at 3:02 p.m., he stated it is the responsibility of the DPCS or assigned nurse who admitted the patient to contact the primary care physician. The previous Medical Director further stated that he did not contact the primary care physicians and that ultimately the medical director is responsible for all medical care. Additionally, the previous Medical Director stated he determines patient hospice eligibility based on LCD (Local Coverage Determination) guidelines, nursing assessment and review of patients recent history and physical or progress note from the clinician. A review of the agencys undated policy and procedure titled "Admission Criteria and Process," indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination. A review of the agencys undated policy and procedure titled ";Physician Services – Medical Director," indicated the purpose of the policy and procedure is to ensure qualified medical direction and consultation for the delivery of hospice services and programs. The policy and procedure further indicated the purpose of the policy and procedure is to demonstrate that the medical director/hospice team physician has overall responsibility for patient care through documentation that demonstrates interaction/communication with attending physician as necessary for appropriate medical care.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the patient's clinical record was complete and accurate for three of nine sampled patients (Patient 4, 5, 6). The IDG members who participated in the IDG meeting, did not sign their signatures within 48 hours after IDG meeting is over. This deficient practice resulted in incomplete records and had potential for inability to evaluate the care provided to Patient 4, 5, 6. --- a. A review of Patient 4's admission record indicated the patient was admitted to the HA on 12/1/2022, with diagnosis of heart disease . A review of Patient 4's Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 12/1/2022, indicated the Licensed Vocational Nurse (LVN) was to visit once per week and one visit as needed. The Registered Nurse (RN) was to visit once per two weeks. The spiritual counselor was to visit once per month, and the Medical social worker service was declined. On 1/19/2022, at 5 p.m., a review of the POC)/IIDG Review dated 12/1/2022, 12/202022, 1/3/2022, and 1/17/2022 indicated the space for signature of the spiritual care were blank. However, on 1/20/23, at 2:30 p.m., a review of the POC/IDG Review of above dates again indicated the space for signature of the spiritual care were filled with the SC's name dated as the SC had signed on above dates. b. A review of Patient 5's admission record indicated the patient was admitted to the HA on 9/22/2022, with diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 5's POC/IDG Review, dated 1/10/2023, indicated the skilled nurse (SN) was to visit once per week and two visits as needed. The spiritual counselor (SC) and medical social worker (MSW) was to visit one time then as needed. On 1/19/2022, at 5:10 p.m., a review of the "POC/IDG Review dated 11/15/2022, 11/29/2022, 12/13/2022, 12/27/2022, and 1/10/2023 indicated the spaces for signature of SC were blank. However, on 1/20/23, at 2:30 p.m., a review of the POC/IDG Review of above dates again indicated the space for signature of the spiritual care were filled with the SC's name dated as the SC had signed on above dates. c. A review of Patient 6's clinical record indicated a Start of Care (SOC) date of 12/1/2022, with a primary diagnosis of heart disease (refers to several types of heart conditions). A review of Patient 6's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 12/1/2022, indicated the Registered (RN) was to visit every 14 days. The skilled nurse (SN) was to visit once per week and two visits as needed. The spiritual counselor (SC) and medical social worker (MSW) was visit for an initial evaluation. On 1/19/2022, at 5:20 p.m., a review of the "POC/IDG Review dated 12/1/2022, 12/13/2022, 12/27/2022 and 1/10/2023 indicated the spaces for signature for SC were blank. However, on 1/20/23, at 2:30 p.m., a review of the POC/IDG Review of above dates again indicated the space for signature of the spiritual care were filled with the SC's name dated as the SC had signed on above dates. During a telephone interview with the SC on 1/20/2023, at 3 p.m., he stated he attends the IDG meeting via google meet and signs after meeting is over. He stated however, he had not signed some of IDG meetings and he had to sign electronically ";today" for some IDG meeting that he had attended before because the agency office staff called him to sign. A review of the agency's "Hospice MD Audit Log" for Patient 4 indicated the SC had signed on 1/20/2023 at 1:32 p.m. for the IDG meeting dated 12/1/2022, 12/202022, 1/3/2022, and 1/17/2022. A review of the agency's "Hospice MD Audit Log" for Patient 5 indicated the SC had signed on 1/20/2023 at 1:37 p.m. for the IDG meeting dated 11/15/2022, 11/29/2022, 12/13/2022, 12/27/2022, and 1/10/2023. A review of the agency's "Hospice MD Audit Log" for Patient 6 indicated the SC had signed on 1/20/2023 at 1:44 p.m. for the IDG meeting dated 12/1/2022, 12/13/2022, 12/27/2022, 1/10/2023. During an interview with the DPCS on 1/23/2023, at 2:25 p.m., he stated all the IDG members who had participated In IDG meeting should have signed their signatures at each IDG meeting. A review of the agencys undated policy titled ";Interdisciplinary Group Meeting" indicated all hospice interdisciplinary group members will be present and the members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice clinical supervisor/nursing supervisor. A review of the agencys undated policy titled ";Computer Access to information" indicated all the employees must sign all documents within 48 hours after note is created.

Based on interview and record review, the hospice agency (HA) failed to ensure the clinical records were authenticated and dated for three of 9 sampled patients (Patients 4, 5, 6). This deficient practice had the potential to result in patient care records not being validated for the care received. --- a. A review of Patient 4's admission record indicated the patient was admitted to the HA on 12/1/2022, with diagnosis of heart disease (refers to several types of heart conditions). A review of Patient 4's clinical record titled, "Updated Assessment (visit date:12/1/2022)", indicated a visit was made. However, the record did not have the name and signature of the staff who provided care. b. A review of Patient 5's admission record indicated the patient was admitted to the HA on 9/22/2022, with a diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 5's clinical record titled, "Comprehensive Nursing Assessment (visit date: 9/22/2022)", and ";Re-Cert Assessment" (visit date: 12/15/2022) indicated visits were made. However, the record did not have the name and signature of the staff who provided care. c. A review of Patient 6's clinical record indicated a start of care (SOC) date of 12/1/2022, with a primary diagnosis of heart disease (refers to several types of heart conditions). A review of Patient 6's clinical record titled, "Comprehensive Nursing Assessment" visit dated 12/1/2022, 12/15/2022, 12/29/2022, and 1/12/2023 indicated visits was made. However, the record did not have the name and signature of the staff who provided care. During an interview with the DPCS on 1/23/2023, at 2:30 p.m., he stated the nursing staff should sign their signature and put the date after he/she documents the patients clinical record within 48 hours. A review of the hospice agencys undated policy titled ";Entries into the Clinical Record" indicated the documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. The clinical note will include a signature of the clinician and his/her credentials. A review of the agencys undated policy titled ";Computer access to information" indicated all employees must sign all documents within 48 hours after note is created.