Every finding on record at Miracle Hands Hospice

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill [a condition or disease that cannot be cured] patients who has six months or less to live) failed to ensure the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) regarding Patients Rights was met as follow: The HA failed to informed five of 14 sampled patients (Patient 1, Patient 5, Patient 6, Patient 9, and Patient 12) about the services the HA provided and the limitations of those services for (Refer to L519). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily mandated Federal compliance for Patients Rights to ensure their rights are not violated and receive the highest quality of hospice care.

Based on observation, interview, and record review, the Hospice Agency (HA- hospice agency providing care to terminally ill [a disease or condition that cannot be cured] patients who has six months or less to live) failed to inform five of 14 sampled patients (Patient 1, Patient 5, Patient 6, Patient 9, and Patient 12) about the services the HA provided and the limitations of these services. This deficient practice resulted for the patients and/or the patient's family member/caregiver not being informed about their rights to receive information about the hospice services and limitations to those services. --- Findings: b. A review of Patient 5s admission record indicated a start of care (SOC) date of 4/10/23 with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) without heart failure. A review of Patient 5's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 9/18/23, indicated the frequency of visits of skilled nurse (SN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit 1 per month, and hospice aide to visit once a week. Volunteer service was declined. During a joint home visit, on 10/8/23 at 10:20 a.m. with the Licensed Vocational Nurse (LVN 2) at Patient 5s residence, Patient 5 was observed lying in bed, alert but confused. During an interview on 10/8/23, at 10:32 a.m. with the patients caregiver (PCG 1), PCG 1 stated no doctor or nurses told her or the patient that Patient 8 had six months or less to live. PCG 1 stated Patient 8 was her normal patient, a ";good patient", was not dying, and did not know that hospice care was for those patients with terminal illness. c. A review of Patient 6s admission record indicated a start of care (SOC) date of 4/17/23 with a terminal diagnosis of hypertensive heart disease without heart failure. A review of Patient 6's POC/IDG form, dated 7/24/23, indicated the frequency of visits of skilled nurse to one visit per week, the spiritual counselor and the social worker to visit 1 per month. Volunteer and hospice aide services were declined. During a phone interview on 10/8/23 at 11:49 a.m., Patient 6 stated he was not dying, and no doctor or any nurses from the agency told him that he has six months or less to live. Patient 6 stated his understanding of hospice care was to have a regular nurse that visits him regularly, and to provide his medications. Patient 6 further stated he goes out to walk regularly, had no chest pain, no shortness of breath and further stated, ";I still drive sometimes". A review of the agencys undated policy and procedure titled, ";Patient Bill of Rights", indicated The Patient Bill of Rights statement defines the right of the patient to: Be informed in advance about care to be furnished, organizations scope of services and service limitations and of any changes in the care to be furnished. a. A review of Patient 1's clinical record indicated Patient 1 was admitted to the hospice agency on 4/8/23, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. On 10/6/23, at 12 p.m., during a phone interview with Family Member 1, she stated Patient 1 does not need hospice services, that a nurse from this hospice agency came to the house to offer free diapers, groceries and blood pressure medications to sign up to their hospice services. She further stated that the hospice agency did not inform them about the purpose of hospice care services. b. A review of Patient 9's clinical record indicated a start of care (SOC) date of 8/1/23, with a terminal diagnosis of atherosclerosis heart disease (build up of fats, cholesterol and other substances in and on the artery walls). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. On 10/7/23, at 11 a.m., a joint home visit was conducted to Patient 9's residence, with the License Vocational Nurse (LVN 1). Patient 9 was observed lying in her bed, awake, alert, oriented. At 11:15 a.m., during an interview with Patient 9, she stated she was never told that she had six months or less to live. When asked if she knows what hospice care was, Patient 9 stated that a nurse will come to visit her every week to take her blood pressure readings. She further stated she never had an attending physician at all. c. A review of Patient 12's clinical record indicated a start of care (SOC) date of 6/22/23, with a terminal diagnosis of unspecified heart disease (disorder in which the inability of the heart to pump blood at an adequate volume to meet tissue metabolic needs). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. On 10/8/23, at 10 a.m., during a phone interview with Patient 12, she stated she was never told that she had six months or less to live. and she was offered free blood pressure medications and incontinent pads every month by the hospice nurse just to be their patient.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding Initial and 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) of the Patient was met as follows: 1. The hospice agency licensed nursing staff (in general) failed to ensure a completed pressure injury (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) assessments were conducted that included the location, stage, size, tunneling (a wound that's progressed to form passageways underneath the surface of the skin), undermining (the region underneath the overlying loose skin around a pressure ulcer), peri-wound description, exudates (drainage), color, odor, necrotic (dead) tissue, and granulation (a wound progressing from the inflammatory phase of healing to the proliferative phase of healing) in accordance with the hospice policy and procedure for three of 14 sampled patients (Patient 1, Patient 2 and Patient 3). (Refer to L524) 2. The hospice agency failed to maintain an accurate and current medication profile for one of 14 sampled patients (Patient 3). (Refer to L 530). 3. The hospice agency failed to provide an initial bereavement assessment (emotional, psychosocial, and spiritual support services provided to the family before and after the death of the patient to assist the family in coping with issues related to grief, loss, and adjustment) for one of 14 sampled patients (Patient 7). (Refer to L531) 4. The hospice agency failed to ensure the patient's eligibility for hospice services related to the palliation (relief of symptoms and suffering cause by life threatening diseases) and management of the terminal illness and related conditions were accurately assessed, for six of 14 sampled patients (Patient 1, Patient 4, Patient 5, Patient 6, Patient 9, and Patient 12). (Refer to L532) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on interview and record review, the hospice agency licensed nursing staff (in general) failed to ensure a completed pressure injury (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) assessments were conducted that included the location, stage, size, tunneling (a wound that's progressed to form passageways underneath the surface of the skin), undermining (the region underneath the overlying loose skin around a pressure ulcer), peri-wound description, exudates (drainage), color, odor, necrotic (dead) tissue, and granulation (a wound progressing from the inflammatory phase of healing to the proliferative phase of healing) in accordance with the hospice policy and procedure for three of 14 sampled patients (Patient 1, Patient 2 and Patient 3). This deficient practice resulted in the delayed provision of wound treatment that could lead to infection and deterioration of the wounds causing discomfort and or pain. to Patient 1, Patient 2 and Patient 3 --- Findings: b. A review of Patient 2s admission record indicated a start of care (SOC) date of 3/5/23 with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 4/17/23, indicated the frequency of visits of skilled nurse (SN) to one visit per week to assess alteration in skin integrity every visit, and to teach/instruct importance of preventing skin breakdown. A review of Patient 2s Plan of Care (POC) Summary and Skin Assessment dated 4/27/23, indicated Patient 2 had a stage II pressure ulcer (are usually open wounds, like an ulcer, with swelling, discoloration, and pain) on center midline sacrum. The wound assessment was not completed. There was no assessment of the pressure ulcer identifying the location, stage, size, tunneling, undermining, peri-wound description, exudates, color, odor, necrotic tissue, and granulation. A review of Patient 2's ";Skin Impairment Assessment" indicated assessment was not completed on the following dates: On 5/14/23- Right foot: Stage IV (full-thickness skin loss extending through the fascia with considerable tissue loss) measuring 2 centimeters (cm) by 1.7 cm, sacrum - Stage II measuring 2.44 cm by 3.66 cm with a depth of 0.1 cm. The assessment was not completed that included tunneling, undermining, peri-wound description, exudates, color, odor, necrotic tissue, and granulation. On 7/8/23 – Left foot: Stage III (a full-thickness loss of skin that extends to the subcutaneous tissue). The assessment did not indicate wound measurement, peri-wound description, exudates, color, odor, necrotic tissue, and granulation. On 7/15/23 – Left hip: Stage III. The assessment did not indicate wound measurement, peri-wound description, exudates, color, odor, necrotic tissue, and granulation. c. A review of Patient 3s admission record indicated a start of care (SOC) date of 12/12/22 with a terminal diagnosis of Alzheimers disease with late onset. A review of Patient 3's POC/IDG form, dated 3/6/23, indicated the frequency of visits of skilled nurse (SN) to one visit per week, social worker (MSW) and the spiritual counselor to visit once a month, and the hospice aide to visit two times a week. A review of Patient 3s POC Summary indicated an order, dated 3/2/23, Mupirocin 2% topical cream (used to treat secondarily infected traumatic skin lesions due to specific bacteria) apply to coccyx (a small triangular bone at the base of the spinal column) every other day indicated for ";sore". A review of Patient 3s clinical record indicated wound assessment on the coccyx wound was not done. There was no assessment of the wound identifying the size, peri-wound description, exudates, color, odor, necrotic tissue, and granulation. During an interview on 10/9/23 at 11:45 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find the documented evidence the wounds on sacrum, right foot, left foot and left hip were assessed completely by the agencys SN with the size measurement, and wound status on the above days. The DPCS stated the patient's wound should have been assessed completely. A review of the agency's undated policy procedure titled " Assessment/Staging of Pressure Ulcers" indicated in assessing pressure ulcer, the following parameters should be addressed consistently. - Site, stage of ulcer, and size of ulcer (include length, width, and depth). - Presence of tunneling and undermining. - Presence of necrotic tissue (slough or eschar). - Drainage amount, color, and odor. - Granulation. - Pain. - Condition of surrounding tissue. A review of Patient 1's clinical record indicated Patient 1 was admitted to the hospice agency on 4/8/23, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 4/8/23, indicated the frequency of visits of skilled nurse (SN) to one visit per week to assess alteration in skin integrity every visit, and to teach/instruct importance of preventing skin breakdown. A review of Patient 1s Plan of Care (POC) Summary indicated an order, dated 6/17/23, to cleanse the wound with wound cleanser, pat dry, apply Tetracyte, Therhoney and impregnated gauze to wound bed, followed by Alginate Silver, then cover with foam dressing three times a week. A review of Patient 1's Visit Note LVN (license vocational nurse) dated 6/22 and 6/25/23, indicated the wound assessment on the coccyx wound was not done. There was no assessment of the wound identifying the size, peri-wound description, exudates, color, odor, necrotic tissue, and granulation. During an interview on 10/9/23 at 12 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find the documented evidence the wounds on sacrum was assessed, and the visiting nurse should have done a skin assessment on every visits.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to maintain an accurate and current medication profile for one of 14 sampled patients (Patient 3). This deficient practice had the potential to place Patient 3 at risk for medication errors (any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer) and adverse drug reactions (is when someone is harmed by a medicine). --- Findings: A review of Patient 3's Demographics (form that includes identifying information such as name, date of birth and address, along with insurance information) indicated a start of care (SOC) date of 12/12/2022, with a terminal diagnosis of Alzheimers disease with late onset (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Patient 3s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 10/2/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week to assess/monitor pain and severity every visit, to assess/monitor effectiveness of medications, and to instruct patient and patient caregiver (PCG) regarding new medications or treatment order and side effects. On 10/7/2023, at 3 p.m., a joint home visit was conducted at Patient 3's residence, with the Licensed Vocational Nurse (LVN 1). Patient 3 was observed laying in a hospital bed, asleep but arousable. On 10/7/2023, at 3:22 p.m., during a review of Patient 3s current medications with the patients caregiver (PCG 1), the following medications could not be found: 1. Temazepam (medication to help sleep)15 milligram (mg, a unit of measurement) one capsule oral daily at bedtime as needed for insomnia (persistent problems falling and staying asleep), 2. Tramadol Hydrochloride (pain relief medication) 50 mg one tablet oral every 6 hours as needed for pain, 3. Divalproex Sodium 250 mg extended-release tablet oral two times a day for seizure (a sudden, uncontrolled burst of electrical activity in the brain), 4. Escitalopram 10 mg 1 tablet oral daily for depression (a common mental health problem that involves a low mood and a loss of interest in activities), 5. Furosemide 20 mg (used to reduce extra fluid in the body [edema] caused by conditions such as heart failure, liver disease, and kidney disease) ½ tablet oral once a day. The patients current medication profile provided by the HA indicated Patient 3 was currently taking these medications. During an interview with PCG 1, she stated Patient 3 stopped taking these medications per physicians order for several months. On 10/9/23, at 11:35 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated hospice nursing staff need to review patients current medication on every visit and update the medication profile in the patients clinical record immediately. A review of the hospice agencys policy and procedure titled, ";Medication Profile", revised November 2021, indicated patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.

Based on interview and record review, the hospice agency (HA) failed to provide initial bereavement assessment for one out of 14 sampled patients (Patient 7). This deficient practice had the potential to impact a family members' abilities to cope with the patients' death. --- Findings: A review of Patient 7's Demographics (a form that includes identifying information such as name, date of birth and address, along with insurance information) indicated a start of care date (SOC) of 5/1/2023, with a terminal diagnosis of senile degeneration of brain, not elsewhere classified (the mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age). A review of Patient 7's POC (Plan of Care)/IDG (Interdisciplinary Group - a team responsible for the holistic care of the hospice beneficiary) form dated 5/1/2023, indicated the frequency of visits for the skilled nurse (SN) to one visit per week, hospice aide (HA) to visit twice a week, social worker (MSW) to do initial assessment within five days of admission to provide psycho-social support to patient and family, and spiritual counselor (SC) to do initial assessment within five days of admission to provide spiritual support to patient and family. A review of Patient 7's clinical record indicated that there was no initial bereavement assessment was conducted. During an interview with the Director of Patient Care Services (DPCS) on 10/9/2023 at 11:35 p.m., the DPCS stated that a bereavement assessment should be conducted on admission. The DPCS further stated that Patient 7 did not have an initial bereavement assessment conducted on admission. A review of the agency's policy and procedure titled "Bereavement Services," revised November 2021, indicated a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented as needed.

Based on observation, interview, and record review, the hospice agency failed to assessed the patient's eligibility for hospice services related to the palliation (relief of symptoms and suffering cause by life threatening diseases) and management of the terminal illness (disease or condition that cannot be cured) and related conditions for six of 14 sampled patients (Patient 1, Patient 4, Patient 5, Patient 6, Patient 9, and Patient 12). This deficient practice had the potential to result in misuse of the hospice services that could result in substandard (below) provision (supplying something for use) of patient care for Patient 1, Patient 4, Patient 5, Patient 6, Patient 9, and Patient 12. --- a. A review of Patient 1's clinical record indicated Patient 1 was admitted to the hospice agency on 4/8/23, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 1's Physicians Certification for Hospice Benefit, dated 4/8/23 to 7/6/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 10/6/23, at 12 p.m., during a phone interview with Family Member 1, she stated Patient 1 does not need hospice services, that a nurse from this hospice agency came to the house to offer free diapers, groceries and blood pressure medications to sign up to their hospice services. b. A review of Patient 9's clinical record indicated a start of care (SOC) date of 8/1/23, with a terminal diagnosis of atherosclerosis heart disease (build up of fats, cholesterol and other substances in and on the artery walls). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 9's Physicians Certification for Hospice Benefit, dated 8/1/23 to 10/29/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 9 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 10/7/23, at 11 a.m., a joint home visit was conducted to Patient 9's residence, with the License Vocational Nurse (LVN 1). Patient 9 was observed lying in her bed, awake, alert, oriented. At 11:15 a.m., during an interview with Patient 9, she stated she was never told that she had six months or less to live. When asked if she knows what hospice care was, Patient 9 stated that a nurse will come to visit her every week to take her blood pressure readings. She further stated she never had an attending physician at all. On 10/7/23, at 11:35 a.m., during an interview with the boarding care facility owner, when asked who referred Patient 9 to the hospice agency, she stated a friend of hers did, then she called the hospice agency to send a nurse to see Patient 9. c. A review of Patient 12's clinical record indicated a start of care (SOC) date of 6/22/23, with a terminal diagnosis of unspecified heart disease (disorder in which the inability of the heart to pump blood at an adequate volume to meet tissue metabolic needs). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 12's Physicians Certification for Hospice Benefit, dated 6/22/23 to 9/19/23, benefit period #1, indicated the Medical Director signed the attending physician referral section to indicate Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 10/8/23, at 10 a.m., during a phone interview with Patient 12, she stated she was never told that she had six months or less to live. and she was offered free blood pressure medications and incontinent pads every month by the hospice nurse just to be their patient. On 10/8/23, at 11 a.m., during an interview with the DPCS, she 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, if not a referral from a social worker or a physician from the hospital where the patient gets discharged from. On 10/8/23, at 12 p.m., during a phone interview with Physician 1, he stated that he was not the attending physician, and he does not know who the attending physicians for Patients 1,5,6,9 and 12). Physician 1 stated since Patients 1,5,6,9 and 12 were admitted for hospice service, he now becomes the patient's attending physician, signed the referral attending physician section because no one would sign it. Physician 1 further stated that he determined the patients were 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 patients. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated PRN Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). PRN Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. b. A review of Patient 4's admission record indicated a start of care (SOC) date of 4/28/2023, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (refers to the accumulation of plaque on the inner walls of blood vessels, and this plaque consists of substances found in the bloodstream, such as fat, cholesterol, and calcium) with unspecified angina pectoris (medical term for chest pain or discomfort due to coronary heart disease). A review of Patient 4's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the first 90-day period from 4/28/23 to 7/26/23, the Medical Director (MD) indicated Patient 4 had a life expectancy of six months or less if the terminal illness ran its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. The "RN (registered nurse) Assessment Narrative" section indicated hospice philosophy and services was explained to patient family and patient was appropriate for hospice care meeting criteria for LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits eligibility). A review of Patient 4s LCD Hospice Eligibility Determination form for Heart Disease, dated 4/28/23, indicated Patient 4 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 4 was optimally treated for heart disease with diuretics (medications that are useful in treating heart failure, a condition in which the body holds too much water) and vasodilators (medicines that useful in managing high blood pressure). Section 2 was marked "yes" that Patient 4s heart disease met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). A review of Patient 4's Comprehensive Nursing 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), done by the registered nurse, dated 4/28/23, indicated Patient 4 was awake, alert, oriented, ambulatory, had regular pulse rate (the number of times your heart beats per minute) and normal respirations (breathing), and had periods of elevated blood pressure and tachycardia (rapid heartbeat) managed by rest and medications. The Comprehensive Nursing Assessment also indicated Patient 4 was on NYHA IV stage of heart failure. A review of Patient 4's clinical record indicated there was no documented evidence Patient 4 had been optimally treated for heart disease with diuretics and vasodilator. There was also no documentation Patient 4 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. c. A review of Patient 5s admission record indicated a start of care date of 4/10/23 with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) without heart failure. A review of Patient 5's "Physician Certification for Hospice Benefit" for the first 90-day period from 4/10/23 to 7/8/23, the Medical Director indicated Patient 5 had a life expectancy of six months or less if the terminal illness ran its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 5s LCD form for Heart Disease, dated 4/10/23, indicated Patient 5 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 5 was optimally treated for heart disease with diuretics and vasodilators. Section 2 was marked "yes" that Patient 5s heart disease met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). A review of Patient 5's clinical record indicated there was no documented evidence Patient 5 had been optimally treated for heart disease with diuretics and vasodilator. There was also no documentation Patient 5 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a joint home visit, on 10/8/23 at 10:20 a.m. with the Licensed Vocational Nurse (LVN 2) at Patient 5s residence, Patient 5 was observed lying in bed, alert but confused. During an interview, on 10/8/23 at 10:32 a.m. with the patients caregiver (PCG 1), PCG 1 stated no doctor or nurses told her or the patient that Patient 5 had six months or less to live. PCG 1 stated Patient 5 was her ";normal patient", a ";good patient", was not dying, and did not know that hospice care was for those patients with terminal illness. d. A review of Patient 6s admission record indicated a start of care date of 4/17/23 with a terminal diagnosis of hypertensive heart disease without heart failure. A review of Patient 6's "Physician Certification for Hospice Benefit" for the first 90-day period from 4/17/23 to 7/15/23, the Medical Director indicated Patient 6 had a life expectancy of six months or less if the terminal illness ran its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 6s LCD form for Heart Disease, dated 4/17/23, indicated Patient 6 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 5 was optimally treated for heart disease with diuretics and vasodilators. Section 2 was marked "yes" that Patient 6s heart disease met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). A review of Patient 6's clinical record indicated there was no documented evidence Patient 6 had been optimally treated for heart disease with diuretics and vasodilator. There was also no documentation Patient 6 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a phone interview on 10/8/23 at 11:49 a.m., Patient 6 stated he was not dying, and no doctor or any nurses from the agency told him that he has six months or less to live. Patient 6 stated his understanding of hospice care was to have a regular nurse that visits him regularly, and to provide his medications. Patient 6 stated he goes out to walk regularly and further stated, ";I still drive sometimes". During an interview on 10/9/23 at 11:45 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find the documented evidence Patient 4, Patient 5 and Patient 6 had been optimally treated for heart disease with diuretics and vasodilator, and had met the criteria for NYHA Class IV level for heart disease.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Medical Director was met as evidenced by: 1. The hospice agency failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for six out of 14 sampled patients (Patient 1, Patient 4, Patient 5, Patient 6, Patient 9, and Patient 12). (Refer to L667) 2. The hospice agency failed to ensure the Medical Director and/or physician designee conducted a review and verified the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for three out of 14 sampled patients (Patient 4, Patient 5, and Patient 6). (Refer to L 668) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was 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 and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for six out of 14 sampled patients (Patient 1, Patient 4, Patient 5, Patient 6, Patient 9, and Patient 12). This deficient practice resulted in patients being admitted for hospice care with no documented evidence of patients' written clinical information was being reviewed and evaluated by the Medical Director and/or physician designee to support their diagnoses of terminal illness. --- a. A review of Patient 1's clinical record indicated Patient 1 was admitted to the hospice agency on 4/8/23, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 1's Physicians Certification for Hospice Benefit, dated 4/8/23 to 7/6/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 10/6/23, at 12 p.m., during a phone interview with Family Member 1, she stated Patient 1 does not need hospice services, that a nurse from this hospice agency came to the house to offer free diapers, groceries and blood pressure medications to sign up to their hospice services. b. A review of Patient 9's clinical record indicated a start of care (SOC) date of 8/1/23, with a terminal diagnosis of atherosclerosis heart disease (build up of fats, cholesterol and other substances in and on the artery walls). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 9's Physicians Certification for Hospice Benefit, dated 8/1/23 to 10/29/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 9 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 10/7/23, at 11 a.m., a joint home visit was conducted to Patient 9's residence, with the License Vocational Nurse (LVN 1). Patient 9 was observed lying in her bed, awake, alert, oriented. At 11:15 a.m., during an interview with Patient 9, she stated she was never told that she had six months or less to live. When asked if she knows what hospice care was, Patient 9 stated that a nurse will come to visit her every week to take her blood pressure readings. She further stated she never had an attending physician at all. On 10/7/23, at 11:35 a.m., during an interview with the boarding care facility owner, when asked who referred Patient 9 to the hospice agency, she stated a friend of hers did, then she called the hospice agency to send a nurse to see Patient 9. c. A review of Patient 12's clinical record indicated a start of care (SOC) date of 6/22/23, with a terminal diagnosis of unspecified heart disease (disorder in which the inability of the heart to pump blood at an adequate volume to meet tissue metabolic needs). The clinical record further indicated the ";referring/attending/patient choice" physician was Physician 1. A review of Patient 12's Physicians Certification for Hospice Benefit, dated 6/22/23 to 9/19/23, benefit period #1, indicated the Medical Director signed the attending physician referral section to indicate Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 10/8/23, at 10 a.m., during a phone interview with Patient 12, she stated she was never told that she had six months or less to live. and she was offered free blood pressure medications and incontinent pads every month by the hospice nurse just to be their patient. On 10/8/23, at 11 a.m., during an interview with the DPCS, she 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, if not a referral from a social worker or a physician from the hospital where the patient gets discharged from. On 10/8/23, at 12 p.m., during a phone interview with Physician 1, he stated that he was not the attending physician, and he does not know who the attending physicians for Patients 1,5,6,9 and 12). Physician 1 stated since Patients 1,5,6,9 and 12 were admitted for hospice service, he now becomes the patient's attending physician, signed the referral attending physician section because no one would sign it. Physician 1 further stated that he determined the patients were 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 patients. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated PRN Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). PRN Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. b. A review of Patient 4's admission record indicated a start of care (SOC) date of 4/28/2023, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (refers to the accumulation of plaque on the inner walls of blood vessels, and this plaque consists of substances found in the bloodstream, such as fat, cholesterol, and calcium) with unspecified angina pectoris (medical term for chest pain or discomfort due to coronary heart disease). Patient 4's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. A review of Patient 4's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the first 90-day period from 4/28/23 to 7/26/23, the Medical Director (MD) signed the attending physician referral section to indicate Patient 4 had a life expectancy of six months or less if the terminal illness ran its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. The "RN (registered nurse) Assessment Narrative" section indicated hospice philosophy and services was explained to patient family and patient was appropriate for hospice care meeting criteria for LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits eligibility). A review of Patient 4s LCD Hospice Eligibility Determination form for Heart Disease, dated 4/28/23, indicated Patient 4 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 4 was optimally treated for heart disease with diuretics (medications that are useful in treating heart failure, a condition in which the body holds too much water) and vasodilators (medicines that useful in managing high blood pressure). Section 2 was marked "yes" that Patient 4s heart disease met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). A review of Patient 4's Comprehensive Nursing 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), done by the registered nurse, dated 4/28/23, indicated Patient 4 was awake, alert, oriented, ambulatory, had regular pulse rate (the number of times your heart beats per minute) and normal respirations (breathing), and had periods of elevated blood pressure and tachycardia (rapid heartbeat) managed by rest and medications. The Comprehensive Nursing Assessment also indicated Patient 4 was on NYHA IV stage of heart failure. A review of Patient 4's clinical record indicated there was no documented evidence Patient 4 had been optimally treated for heart disease with diuretics and vasodilator. There was also no documentation Patient 4 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. c. A review of Patient 5s admission record indicated a start of care date of 4/10/23 with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) without heart failure. Patient 5's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. A review of Patient 5's "Physician Certification for Hospice Benefit" for the first 90-day period from 4/10/23 to 7/8/23, the Medical Director signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less if the terminal illness ran its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 5s LCD form for Heart Disease, dated 4/10/23, indicated Patient 5 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 5 was optimally treated for heart disease with diuretics and vasodilators. Section 2 was marked "yes" that Patient 5s heart disease met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). A review of Patient 5's clinical record indicated there was no documented evidence Patient 5 had been optimally treated for heart disease with diuretics and vasodilator. There was also no documentation Patient 5 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a joint home visit, on 10/8/23 at 10:20 a.m. with the Licensed Vocational Nurse (LVN 2) at Patient 5s residence, Patient 5 was observed lying in bed, alert but confused. During an interview, on 10/8/23 at 10:32 a.m. with the patients caregiver (PCG 1), PCG 1 stated no doctor or nurses told her or the patient that Patient 5 had six months or less to live. PCG 1 stated Patient 5 was her ";normal patient", a ";good patient", was not dying, and did not know that hospice care was for those patients with terminal illness. d. A review of Patient 6s admission record indicated a start of care date of 4/17/23 with a terminal diagnosis of hypertensive heart disease without heart failure. Patient 6's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. A review of Patient 6's "Physician Certification for Hospice Benefit" for the first 90-day period from 4/17/23 to 7/15/23, the Medical Director signed the attending physician referral section to indicate Patient 6 had a life expectancy of six months or less if the terminal illness ran its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 6s LCD form for Heart Disease, dated 4/17/23, indicated Patient 6 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 5 was optimally treated for heart disease with diuretics and vasodilators. Section 2 was marked "yes" that Patient 6s heart disease met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). A review of Patient 6's clinical record indicated there was no documented evidence Patient 6 had been optimally treated for heart disease with diuretics and vasodilator. There was also no documentation Patient 6 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a phone interview on 10/8/23 at 11:49 a.m., Patient 6 stated he was not dying, and no doctor or any nurses from the agency told him that he has six months or less to live. Patient 6 stated his understanding of hospice care was to have a regular nurse that visits him regularly, and to provide his medications. Patient 6 stated he goes out to walk regularly, had no chest pain, no shortness of breath and further stated, ";I still drive sometimes". During an interview on 10/9/23 at 11:45 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find the documented evidence Patient 4, Patient 5 and Patient 6 had been optimally treated for heart disease with diuretics and vasodilator and had met the criteria for NYHA Class IV level for heart disease. During a telephone interview on 10/9/23 at 1 ;00 p.m. with the hospice Medical Director (MD 1), MD 1 stated he was not the attending physician and did not know who the attending physician for Patient 4, Patient 5, and Patient 6. MD 1 stated he would be the attending physician for the patients once admitted to their hospice service, that he signed the referral attending physician section because no one would sign it. MD 1 further stated that he determined the patients were eligible for hospice services by reviewing patient's medical records, and assessment report by the registered nurse upon their initial visit to the patients. A review of the agency's policy and procedure titled, ";"Admission Criteria and Process", revised November 2021, indicated Miracle Hands Hospice Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of six months or less will be determine by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Miracle Hands Hospice Inc reserves the right not to accept any patient who does not meet criteria. Miracle Hands Hospice Inc will admit a patient only on recommendation of the Medical Director in consultation with, or input from, the patients attending physician. A review of the agency's policy and procedure titled, ";"Physician Services – Medical Director", revised November 2021, indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The duties and responsibilities of the Medical Director will include, but not limited to reviewing 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.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the hospice services were provided by a physician who reviewed the patient's clinical information prior to approving another 90 days of hospice service to obtain justification for continuing hospice services for three out of 14 sampled patients (Patient 4, Patient 5, and Patient 6). This deficient practice resulted for these patients to be re-certified for hospice care lacking verification of the clinical information to continue provision of hospice care which can affect their quality of life and well-being. --- Findings: a. A review of Patient 4's admission record indicated a start of care (SOC) date of 4/28/2023, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (refers to the accumulation of plaque on the inner walls of blood vessels, and this plaque consists of substances found in the bloodstream, such as fat, cholesterol, and calcium) with unspecified angina pectoris (medical term for chest pain or discomfort due to coronary heart disease). Patient 4's Face Sheet indicated the hospice Medical Director (MD 1) was also the patient's referring and attending physician. A review of Patient 4's Nursing Re-Cert (Recertification) Assessment, dated 7/21/2023, indicated Patient 4 was awake, alert, and oriented (to person, place, and time). Patient 4 was ambulatory, using a cane, and able to perform Activities of Daily Living (ADLs, activities related to personal care which includes bathing, grooming, dressing, toileting, and eating) with moderate to maximum assistance. Patient 4 has no cardiac-related pain, regular pulse, has mild shortness of breath, and has normal respirations and blood pressure. Patient 4s NYHA documented classification was IV (New York Heart Association Class IV (severe) - a classification of heart failure, when patient should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest). A review of Patient 4's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the 2nd benefit period from 7/27/2023 to 10/24/2023, indicated there was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Registered nurse (RN) Assessment Narrative" section indicated hospice philosophy and services was explained to patient family, patient was appropriate for hospice care and meeting criteria for LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits eligibility). A review of Patient 4s LCD Hospice Eligibility Determination form for Heart Disease, dated 7/21/2023, indicated Patient 4 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 4 was optimally treated for heart disease with diuretics (medications that are useful in treating heart failure, a condition in which the body holds too much water) and vasodilators (medicines that useful in managing high blood pressure). Section 2 was marked "yes" that Patient 4s heart disease met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). A review of Patient 4's clinical record indicated there was no documented evidence that Patient 4 had been optimally treated for heart disease with diuretics and vasodilator. There was no documentation that Patient 4 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptoms occurs at rest. b. A review of Patient 5s admission record indicated an SOC date of 4/10/2023 with a terminal diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) without heart failure. Patient 5's face sheet indicated the hospice Medical Director (MD 1) was also the patient's referring and attending physician. A review of Patient 5's Nursing Re-Cert Assessment, dated 7/3/2023, indicated Patient 5 was awake, alert, and oriented (to person and place). Patient 5 has no cardiac-related pain, has normal blood pressure, no edema, and has normal respirations. Patient 5s NYHA documented classification was Class IV. A review of Patient 5's "Physician Certification for Hospice Benefit" for the 2nd benefit period from 7/9/2023 to 10/6/2023, indicated Patient 5 had a life expectancy of six months or less if the terminal illness ran its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 5s LCD form for Heart Disease, dated 7/17/2023, indicated Patient 5 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 5 was optimally treated for heart disease with diuretics and vasodilators. Section 2 was marked "yes" that Patient 5s heart disease met the criteria for NYHA Class IV level. A review of Patient 5's clinical record indicated there was no documented evidence Patient 5 had been optimally treated for heart disease with diuretics and vasodilator. There was also no documentation Patient 5 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptoms occurs at rest. During a joint home visit, on 10/8/2023, at 10:20 a.m., with the Licensed Vocational Nurse (LVN 1) at Patient 5s residence, Patient 5 was observed lying in bed, alert, but confused. During an interview, on 10/8/2023, at 10:32 a.m., with the patients caregiver (PCG 2), PCG 2 stated no doctor or nurses told her or the patient that Patient 5 had six months or less to live. PCG 1 stated Patient 5 was her ";normal patient", a ";good patient", was not dying, and did not know that hospice care was for those patients with terminal illness. c. A review of Patient 6s admission record indicated an SOC date of 4/17/2023 with a terminal diagnosis of hypertensive heart disease without heart failure. Patient 6's face sheet indicated the hospice Medical Director (MD 1) was also the patient's referring and attending physician. A review of Patient 6's Nursing Re-Cert Assessment, dated 7/10/2023, indicated Patient 6 was awake, alert, and oriented (to person and place). Patient 6 has no cardiac-related pain, has normal blood pressure, no edema and has normal respirations. Patient 6s NYHA documented classification was Class IV. A review of Patient 6's "Physician Certification for Hospice Benefit" for the 2nd benefit period from 7/16/2023 to 10/13/2023, indicated Patient 6 had a life expectancy of six months or less if the terminal illness run its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 6s LCD form for Heart Disease, dated 7/24/2023, indicated Patient 6 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 5 was optimally treated for heart disease with diuretics and vasodilators. Section 2 was marked "yes" that Patient 6s heart disease met the criteria for NYHA Class IV level. A review of Patient 6's clinical record indicated there was no documented evidence Patient 6 had been optimally treated for heart disease with diuretics and vasodilator. There was no documentation Patient 6 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptoms occurs at rest. During a phone interview on 10/8/2023, at 11:49 a.m., Patient 6 stated he was not dying, and no doctor or any nurses from the agency told him that he has six months or less to live. Patient 6 stated his understanding of hospice care was to have a regular nurse that visits him regularly, and to provide his medications. Patient 6 stated he goes out to walk regularly, had no chest pain, no shortness of breath, and further stated, ";I still drive sometimes". During an interview on 10/9/2023, at 11:45 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find the documented evidence Patient 4, Patient 5 and Patient 6 had been optimally treated for heart disease with diuretics and vasodilator and had met the criteria for NYHA Class IV level for heart disease. During a telephone interview on 10/9/2023, at 1:00 p.m., with the hospice Medical Director (MD 1), MD 1 stated he was not the attending physician and did not know who the attending physician was for Patient 4, Patient 5, and Patient 6. MD 1 stated he would be the attending physician for the patients once admitted to their hospice service, that he signed the referral attending physician section because no one would sign it. MD 1 further stated that he determined the patients were eligible for hospice services by reviewing patient's medical records, and assessment report by the registered nurse upon their initial visit to the patients. A review of the agency's policy and procedure titled, ";"Admission Criteria and Process", revised November 2021, indicated HA will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of six months or less will be determine by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). The policy indicated HA reserves the right not to accept any patient who does not meet criteria. The policy further indicated HA will admit a patient only on recommendation of the Medical Director in consultation with, or input from, the patients attending physician. A review of the agency's policy and procedure titled, ";"Physician Services – Medical Director", revised November 2021, indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The duties and responsibilities of the Medical Director will include, but not limited to reviewing 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.