Every finding on record at Kairos Hospice, Inc.

Based on interview and record review, the hospice agency failed to ensure the emergency preparedness policy was reviewed and the staff were trained on an annual basis. This failure had the potential to result in the staff lacking of knowledge and inability to respond effectively during an emergency situation. Findings: During a review of the emergency preparedness policy and training record on 6/14/22 at 11 a.m., the agency did not have evidence of emergency preparedness training/disaster drill for all staff and policy review. During an interview with the Director of Patient Care Services on 6/14/22, at 11:05 a.m., she stated she will ensure that all staff receive disaster drill training and all governing body members review and sign the emergency preparedness policy. The agency's undated policy and procedure titled "Emergency Operations Plan", describes the approach to responding to internal and external emergencies that would suddenly and significantly affect the need for services or the ability to provide such services.

Based on observation, interview and record review, the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, Coordination of Services was not met as follows: 1. The hospice agency (HA) failed to follow plan of care (POC) and develop individualized care plan for one of eleven sampled patients (Patient 1). The HA failed to follow Patient 1's POC to provide 2 liters of oxygen via nasal cannula (flexible tube used to deliver supplemental oxygen), for shortness of breath. (Refer to 543) For Patient 1, the HA failed to notify the physician on the patient stage 1 pressure ulcer (a superficial reddening of the skin that when pressed does not turn white (non-blanchable erythema) to obtain an order for the patient use of low air loss (LAL, a pressure-relieving mattress that provide airflow to help keep skin dry, as well as to relieve pressure) mattress and Licensed Vocational Nurse 1 (LVN 1) did not know the setting and the use of the LAL mattress. (Refer to 543) The HA failed to follow and implement the Patient 1's POC, to provide thickened liquid (a medical dietary adjustment that thickens the consistency of fluids to prevent choking) and provide education/instruction to the patient's caregiver on aspiration (when food, liquid, or other material enters in the airway and eventually the lungs by accident) precaution, due to the patient's difficulty of swallowing. (Refer to L543). 2. The HA's Interdisciplinary Group (IDG) failed to review, revise, and document the individualized plan of care every 15 days for nursing, spiritual, psychosocial, or other/physician services for 1 of 11 patients (Patient 2). (Refer to L552). The cumulative effect of these systemic practices resulted in the failure of the HA to delivery statutorily mandated compliance with the Federal regulations for Interdisciplinary group, Care planning, and Coordination of services of patients to ensure hospice care and services were provided to meet the patient's care goals.

Based on interview and record review, the hospice agency failed to coordinate Interdisciplinary Group (Idg) meetings with the medical director to discuss the patients' needs related to the terminal illness and related conditions, for two of 11 patients (Patients 2 and 8). This failure had the potential to affect the patient's medical needs and treatments. Findings: a. A review of Patient 8's face sheet indicated admission to hospice on 11/7/21, with a primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions. A review of Patient 8's "Plan of Care (POC)" dated 5/4/22, indicated the Skilled Nurse (SN) visit was once a week. A review of Patient 8's clinical record indicated the Medical Director was not in attendance in the Idg meetings. During an interview with the Medical Director on 6/10/22, at 1:08 p.m., he stated he has not been to any of the Idg meetings and was never invited. He stated he is aware that he should be participating in the Idg meetings but the agency does not communicate the meeting schedule. The agency's policy and procedure dated 4/2017 and titled "Interdisciplinary Group Meeting", indicated the Idg group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances. b. A review of Patient 2's Face Sheet indicated the patient was admitted to hospice on 10/4/2021 with a primary diagnosis of hypertensive heart disease (a heart condition caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). A review of Patient 2's Comprehensive Nursing Assessment dated 10/04/2021 indicated Patient 2 had a peaceful demeanor, was awake, alert, and oriented to time, place, and person. During an interview on 6/10/2022 at 1:30 pm, Medical Director stated he was not invited and has not attended Interdisciplinary group (IDG) meetings to discussthe specific needs relate to the terminal illness for Patient 2.

Based on observation, interview, and record review, the hospice agency failed to develop and implement the individualized plan of care (POC) for three of eleven sampled patients (Patient 1, Patient 2, and Patient 3) by failing to ensure: a). Patient 1 and Patient 2 received anticoagulant (blood thinners-to prevent and treat blood clots) medications as indicated in the plan of care. b). Patient 3 was administered oxygen five liters as ordered for shortness of breath. This failure had the potential to cause serious complications that could affect the patients' health status and well-being. Findings: a) A review of Patient 1's Patient Profile indicated a start of Care date (SOC) of 6/23/2022 with diagnoses that include Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), hypertensive heart disease (heart conditions caused by high blood pressure), and peripheral vascular disease (PVD) (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm). A review of Patient 1's Plan of Care (POC) for the certification period from 6/23/2022 to 9/20/2022, included an order for a licensed vocational nurse (LVN) to visit once per week with three additional visits as needed (PRN) to assess all systems, evaluate patient care needs, and to provide pain management and comfort measures. A review of Patient 9's Medication Profile file indicated to administer Clopidogrel (anticoagulant) 75 milligram (mg), one tablet, by mouth once a day, for peripheral vascular disease (PVD). On 9/7/2022 at 3:00 pm, a home visit was conducted at Patient 1's home residence accompanied by Licensed Vocational Nurse (LVN 1). Patient 1 was observed sitting in a reclining chair with a plate of food on a folding table in front of him. Patient 1 was alert and oriented and was hard of hearing. Further review of Patient 1's clinical record indicated there was no care plan developed to identify and address the use of anticoagulant medications. During an interview on 9/8/2022 at 11:13 pm, the Director of Patient Care Services designee (DPCSD) stated it was important to educate the patient and caregiver on patients taking anticoagulants regarding safety precautions such as bruising, bleeding, diet restriction and fall precautions. The DPCSD stated these safety measures and patient/caregiver education should have been included in the care plan. A review of the hospice agency's policy, "The Plan of Care" dated 12/2011, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The policy indicated the plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. b). A review of Patient 3's face sheet indicated Patient 3 was admitted to the hospice agency on 8/18/20, with a primary diagnosis of unspecified malignant neoplasm of the colon (a cancer of the colon or rectum located at the lower end of the digestive tract). A review of Patient 3's "Interdisciplinary Group (IDG) /Update to Plan of Care (POC)" dated 7/5/22 indicated the Skilled Nurse (SN) was to visit Patient 3 once a week for 60 days and as needed, to administer medications during care and follow the medication regimen as prescribed. The physician's orders dated 8/18/22, included in the plan of care indicated to administer oxygen five liters via nasal cannula as needed for shortness of breath to Patient 3. . A review of Patient 3's Visit Notes dated 8/31/22, indicated Patient 3 was assessed as having moderate shortness of breath. However, there was no documented evidence the visiting nurse administered oxygen as ordered for Patient 3. On 9/9/22, at 2 p.m., during an interview with the DPCS (Director of Patient Care Services), she stated the visiting nurse should have documented that oxygen five liters was provided as ordered to relieve Patient 3 from having shortness of breath.

Based on interview, and record review, the Interdisciplinary Group (IDG) failed to document the individualized plan of care on the HospiceMD program (an accessible and secure web-based application used to manage, access and update patient electronic health records) every 15 days for two of 11 patients (Patient 1), and to ensure the MD, MSW and RN and SC attended the IDG meetings on 8/2, 8/16 and 8/30 for Patient 2. This failure had the potential to result in the care and services provided to patient 1 and Patient 2 to not be evaluated and updated to meet their needs and achieve their patient care goals. Findings: a. A review of Patient 1's Patient Profile indicated a start of Care date (SOC) 6/23/2022 with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), hypertensive heart disease (heart conditions caused by high blood pressure), and peripheral vascular disease (PVD) (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm). A review of Patient 1's Plan of Care (POC) for the certification period form 6/23/2022 to 9/20/2022, included an order for a licensed vocational nurse (LVN) to visit once per week with three additional visits as needed (PRN) to assess all systems, evaluate patient care needs, and to provide pain management and comfort measures. A review of Patient 1's Plan of Care/ Interdisciplinary Group (POC/IDG) Review for 8/30/2022 indicated the medical director (MD), medical social worker (MSW), registered nurse (RN), and chaplain (SC) did not attend the IDT meeting. A review of Patient 1's POC/IDG Review for 8/2/2022 and 8/16/2022 indicated the MD, MSW and the SC did not attend the IDT meeting. During a telephone interview and record review on 9/8/2022 at 11:45 am, the Director of Patient Care Services designee (DPCSD) stated the hospice agency started using Hospice electronic charting on 8/1/2022. The DPCSD stated not everyone was trained how to use the HospiceMD program (an accessible and secure web-based application used to manage, access and update patient electronic health records). The DPCSD stated we held a teleconference meeting, talked about any updates regarding the patients and later, when I saw an IDG member, I had them sign a sign-in sheet. The DPCSD stated the IDG sign in sheets were kept in a binder in the office. The sign in sheet provided had signatures of attendees however there was no meeting title, no meeting minutes, no indication of what was discussed or if there were any updates to a patient's plan of care. The DPCSD stated IDG meetings were important so we know what is going on with the patient and can update the patient's plan of care as needed. A review of the hospice agency's policy, Interdisciplinary Group Meeting, dated 12/2011, indicated the plan of care will be established and maintained for each individual admitted to the Hospice Program. The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. The policy indicated the review of the plan of care will be documented in the clinical record.

Based on interview and record review, the hospice agency failed to follow the plan of care (POC) by failing to document that the patient's mid arm circumference was measured every visit to evaluate nutritional and weight status for two of 11 patients (Patients 8 and 10). This failure had the potential to result in the agency's inability to assess and evaluate the patients' nutritional and weight status. Findings: a. A review of Patient 8's face sheet indicated admission to hospice on 11/7/21, with a primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions. A review of Patient 8's "Plan of Care (POC)" dated 5/4/22, indicated the Skilled Nurse (SN) visit was once a week and as needed. The physician's order dated 11/7/21 indicated the SN may measure the mid arm circumference every visit and as needed for nutritional and weight status. A review of the "Comprehensive Nursing Assessment" dated 11/7/21 indicated the mid arm circumference (MAC) was not measured. During an interview with the Director of Patient Care Services (DPCS) on 6/14/22, at 12 p.m., she stated the MAC should have been documented. b. A review of Patient 10's face sheet indicated admission to hospice on 7/19/20, with a primary diagnosis of Alzheimer's disease. A review of Patient 10's "Plan of Care (POC)" dated 11/6/21, indicated the SN visit was once a week and as needed. A review of the "Comprehensive Nursing Assessment" dated 7/19/20 indicated the MAC was not measured. During an interview with the DPCS on 6/14/22, at 12 p.m., she stated the MAC should have been documented. The agency's policy and procedure dated 11/2020 and titled "The Plan of Care" indicated the plan of care will be established and maintained for each individual in the hospice program.

Based on interview and record review, the agency failed to ensure the Condition of Participation for Quality assessment/performance improvement were met as follows: Failed to ensure a performance improvement projects (PIP, a concentrated effort on a particular problem in one area of the facility or facility wide that involves gathering of informations systematically to clarify issues or problems, and intervening for improvements) were conducted every year. (Refer to L572) The cumulative effect of these systemic practices resulted in the agencies failure to ensure that issues, problems and other interventions necessary to the improvement of quality patient care will not be discussed and presented to the caregivers involved in direct patient care.

Based on interview and record review, the hospice agency failed to ensure a performance improvement projects (PIP, a concentrated effort on a particular problem in one area of the facility or facility wide involving gathering of informations systematically to clarify issues or problems, and intervening for improvements) conducted every year. This failure had the potential to affect the highest quality of care provided to all the patients under agency's care. Findings: A request was made on 6/14/2022, at 11 a.m., to the Director of Patient Care Services (DPCS) for the performance improvement projects (PIP) derived from the data collected from the Quality Assurance and Performance Improvement (QAPI, the coordinated application of two mutually-reinforcing aspects of a quality management system. QAPI takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) program. The DPCS stated she stated she is aware of the requirement but they do not have any performance improvement projects and could not provide any evidence of past projects. The agency's policy and procedure titled "Quality Assessment and Performance Improvement Plan and Program" and dated 1/2019, indicated the agency will have an organized system assessing and improving the quality of care and services. This system shall be designed to improve performance on a systematic and continuous basis. The policy stated there should be coordination of performance improvement activities.

Based on interview and record review, the agency failed to ensure the Condition of Participation for Volunteers were met by failing to ensure volunteer services programs were maintained, offered and provided to the two of 11 patients, (Patients 6 and 7). (Refer to L 642) The cumulative effect of these systemic practices resulted in the agencies failure to ensure that through the volunteer program, patients will receive other benefit services that will contribute to the improvement of patient care and services.

Based on observation, interview and record review, the hospice agency failed to ensure volunteer services program were maintained, offered and provided to three of 11 sampled patients,(Patients 6, 7 and 8). This deficient practice prevented the patients from receiving other hospice benefits available through the volunteer program. Findings: a. A review of Patient 6's face sheet (admission record) indicated Patient 6 was admitted to the hospice agency on 11/24/2021, with primary diagnosis of unspecified chronic kidney disease (longstanding disease of the kidneys leading to renal failure). A review of Patient 6's "Plan of Care (POC)" dated 5/18/2022, indicated the Skilled Nurse (SN) visit was once per week and as needed, the Medical Social Worker (MSW) visit was one time then as needed. On 6/8/2022, at 11:30 a.m., a home visit was conducted at Patient 6's residence. Patient 6 was observed sitting on his couch at his bedroom, alert and oriented, well groomed and able to move both upper and lower extremities. On 6/8/22, at 11:55 a.m., during an interview with Patient 6, when asked if he was offered volunteer services by the hospice agency, he stated he was not offered at all. He further stated that he wanted help to run errands for him and he was upset that he was not told that the hospice agency can offer those services to him. A review of the patient's clinical record indicated there was no documented evidence the patient was informed or being offered of their volunteer services as part of their core services b. A review of Patient 7's face sheet indicated Patient 7 was admitted to the hospice agency on 7/27/2020, with primary diagnosis of Alzhemier's disease ( a progressive disease that destroys memory and other important mental functions). A review of Patient 7's "Plan of Care (POC)" dated 5/18/2022, indicated the Skilled Nurse (SN) visit was once per week and as needed, the Medical Social Worker (MSW) visit was one time then as needed. . On 6/920/2022, at 12:45 p.m., during a phone interview with Patient 7's Family Member 1, when asked if Patient 7 was offered volunteer services by the hospice agency, he stated not at all but he thinks that Patient 7 would really need those assistance at this time. On 6/14/2022, at 1 p.m., during an interview with the Director of Patient Care Services (DPCS), she was not able to provide the documented evidence the hospice agency staff had explained the volunteer services program to the patient and caregiver, assessed the need of volunteer services nor had offered or provided the volunteer services to Patient 6. c. A review of Patient 8's face sheet indicated Patient 8 was admitted to the hospice agency on 11/7/2021, with a primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions. A review of Patient 8's "Plan of Care (POC)" dated 5/4/2022, indicated the Skilled Nurse (SN) visit was once a week and as needed with the volunteer noted as declined. On 6/7/2022 at 11:40 a.m. a home visit was conducted with Licensed Vocational Nurse 1 (LVN). On 6/7/2022 at 11:45 a.m., Patient 8's caregiver stated he feels like he needs more help at home. He stated that volunteer services was never offered to him. A review of the patient's clinical record indicated there was no documented evidence that Patient 8 was informed regarding the agency's volunteer services nor the agency had provided or offered the volunteer services to Patient 8 without any cost. The agency's policy and procedure titled, "Volunteer Services", dated 4/2017, indicated the qualified volunteers provide appropriate services in accordance with the interdisciplinary plan of care and hospice program needs.

Based on observation, interview and record review, the agency failed to ensure the Condition of Participation for Medical Director was met as follows: The hospice agency's Medical Director failed to coordinate with the patients' attending physicians to review the patient clinical information to determine certification for eligibility for admission to the hospice program among four of 11 sampled patients (Patients 2, 6, 7, and 8). This deficient practice resulted in the provision of hospice services with anticipation of life expectancy of six months of less to Patients 2, 6, 7 and 8, who were not clinically eligible to receive hospice service (refer to L 667). The cumulative effect of these systemic practice resulted in the failure to deliver statutorily mandated compliance with federal regulations for Medical Director services to ensure the highest quality of patient care are provided to the patients certified to receive hospice services.

Based on interview, and record review, the hospice agency failed to ensure four of 11 patients (Patient 2, 6, 7, and 8) were appropriate to receive hospice services. Based on record review, observation, and interview, the hospice agency's Medical Director failed to coordinate with the patients' attending physicians to review the patient clinical information to determine certification for eligibility for admission to the hospice program among four of 11 sampled patients (Patients 2, 6, 7, and 8). This deficient practice resulted in the provision of hospice services with anticipation of life expectancy of six months of less to Patients 2, 6, 7 and 8, who were not clinically eligible to receive hospice service. Findings: a. A review of Patient 2's Face Sheet indicated the patient was admitted to hospice on 10/4/2021 with a primary diagnosis of hypertensive heart disease (a heart condition caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). A review of Patient 2's Certificate of Terminal Illness (CTI), Benefit period #4, dated 5/20/2022, indicated the Medical Director (MD 1) and MD 2 signed for the Attestation/Certification that Patient 2 had a life expectancy of six months or less, if the terminal illness runs its normal course. During an interview on 6/10/2022 at 12:12 pm, Patient 2 stated she was referred to the hospice agency from a friend. Patient 2 stated she did not know who MD 2 was and that her primary doctor was at a clinic near her home. Patient 2 was not aware that being on hospice meant she was terminally ill and had six months to live. Patient 2 stated she only had bad allergies and was not planning to die any time soon. During an interview on 6/10/2022 at 1:30 pm, MD 1 stated he did not perform Patient 2's recertification because he was not notified by the hospice agency to do it. MD 1 stated he performed the Patient 1's initial certification and thought Patient 1 would be stable enough not to continue with hospice, but he was not notified by the hospice agency to see her and make these decisions. MD 1 stated he did not know why his name was on the Patient 2's CTI for Benefit #4 because he did not review medical records or perform an assessment of the patient. MD 1 stated MD 2 does not call me, does not communicate with me and I have asked Kairos to stop using her. A review of the hospice agency's policy and procedure, titled, Certification of Terminal Illness, dated 4/2017, 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. The policy further indicated at recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient's medical record or, if applicable, examination of the patient. b. A review of Patient 6's face sheet indicated admission to hospice on 11/24/21, with primary diagnosis of unspecified chronic kidney disease (longstanding disease of the kidneys leading to renal failure). A review of Patient 6's "Plan of Care (POC)" dated 5/18/22, indicated the Skilled Nurse (SN) visit was once per week and as needed, the Medical Social Worker (MSW) visit was one time then as needed. A review of Patient 1's Certificate of Terminal Illness (CTI), dated 11/24/21, Benefit period #1 indicated the Medical Director signed the attending physician referral section that indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 6/8/22, at 11:30 a.m., a home visit was conducted at Patient 6's residence. Patient 6 was observed sitting on his couch at his bedroom, alert and oriented, well groomed and able to move both upper and lower extremities. On 6/8/22, at 11:55 a.m., during an interview with Patient 6, he stated he does not need hospice care and he was not dying. He also stated that his attending physician did not refer him to hospice services. c. A review of Patient 7's face sheet indicated admission to hospice on 7/27/20, with primary diagnosis of Alzhemier's disease ( a progressive disease that destroys memory and other important mental functions). A review of Patient 7's "Plan of Care (POC)" dated 5/18/22, indicated the Skilled Nurse (SN) visit was once per week and as needed, the Medical Social Worker (MSW) visit was one time then as needed. A review of Patient 7's Certificate of Terminal Illness (CTI), dated /27/20, Benefit period #1 indicated the Medical Director signed the attending physician referral section that indicated Patient 7 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 6/9/22, at 12:45 p.m., during a phone interview with Patient 7's Family Member 1, he stated Patient 7 does not need hospice care and she was not dying. Family Member 1 also stated that Patient 7's attending physician did not refer her to the hospice services. During an interview with the Medical Director on 6/14/22, at 12 p.m., he stated that he was not the attending physician and he does not know who the attending physicians are for Patient 6 and Patient 7. He stated since these patients were admitted to their hospice service, he is now the patient's attending physician, that he signed the referral attending physician section because no one would signed it. He further stated that he did not do a face to face encounter with Patient 6 and Patient 7 during their admissions and from the review of patient's medical records provided by the hospital and assessment report given by the registered nurse upon her initial visit to the patient, he determines the patient is eligible for hospice services. He also stated that both Patient 6 and 7's medical condition were not declining and they no longer needed hospice services at this time. On 6/9/22, at 1 p.m., during an interview with the Administrator, when asked how their hospice agency admits their patients, she stated that all patients being admitted to their hospice service should be referred by their attending physician with a referral order for hospice service. A review of the agency's policy and procedures 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'sintermediary local coverage determination. d. A review of Patient 8's face sheet indicated admission to hospice on 11/7/21, with a primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 8's "Plan of Care (POC)" dated 5/4/22, indicated the Skilled Nurse (SN) visit was once a week and as needed. A review of Patient 8's Certificate of Terminal Illness (CTI), dated 11/7/21, was signed by Physician 1 with no attending physician signature. The CTI indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 6/8/22, at 11:40 a.m., a home visit was conducted at Patient 8's residence. Patient 8 was observed lying in bed, alert and oriented. On 6/8/22 during a concurrent interview, Patient 8's responsible party stated he was unsure who referred Patient 8 to hospice agency. He stated there has not been any issues with the patient and she is breathing fine without the use of oxygen. During an interview with the Medical Director on 6/10/22, at 1:21 p.m., he stated that Physician 1 has not communicated with him regarding the progress of Patient 8's condition. He stated he does not think Patient 8 is declining and should be discharged from hospice care. He stated the patient needs to be terminally ill to be appropriate for hospice care and confirmed that Patient 8 was in a stable condition and should not be under the hospice services. On 6/14/22, at 11:34 a.m., during an interview with the DPCS (director of patient care services, when asked how their hospice agency admits their patients, she stated that all patients being admitted to their hospice service should be referred by their attending physician with a referral order for hospice service. The DPCS stated the agency would send their registered nurse to do the initial visit to the patient's residence for a head to toe assessment and to use the Local Coverage Determination (LCD- provide guidance in determining medical necessity of services) guidelines to determine if the patient is hospice eligible and would report findings to their medical director. The DPCS stated that if the medical director does not confirm the patient should be under hospice services then the patient should be discharged, The agency's policy and procedures dated 4/2017 and titled, "Certification of Terminal Illness" indicated at the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient's attending physician, if any, would certify the patient's terminal illness.