Every finding on record at Nova Hospice Care, Inc

The agency failed to ensure that the Condition of Participation: L 500 418.52 Patients Rights was in compliance as follows: Based on interview, and record review, the agency failed to provide in advance of providing care, the Hospice Election Statement (an explanation of hospice services, a life expectancy of six months or less to live, and an abandoning of curative treatments and acceptance of palliative care) Consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of the suggested medical care) and Notice of Rights and Responsibilities (Bill of Rights- a document that provides patients with information on how they can reasonably expect to be treated during their hospice care) in a language and manner the patients understood for three of six sampled patients (Patients 1, 4 and 5) when Patients 1, 4 and 5 were Spanish speakers and could not speak and/or read English. (Refer to L 502) The cumulative effect of these systemic practices resulted in Patients 1, 4 and 5 not to understand the meaning of hospice, a life expectancy of six months or less to live, an abandoning of curative treatments and acceptance of palliative care and their Bill of Rights.

Based on interview, and record review, the agency failed to provide in advance of providing care, the Hospice Election Statement (an explanation of hospice services, a life expectancy of six months or less to live, and an abandoning of curative treatments and acceptance of palliative care) Consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of the suggested medical care) and Notice of Rights and Responsibilities (Bill of Rights- a document that provides patients with information on how they can reasonably expect to be treated during their hospice care) in a language and manner the patients understood for three of six sampled patients (Patients 1, 4 and 5) when Patients 1, 4 and 5 were Spanish speakers and could not speak and/or read English. This failure caused Patients 1, 4 and 5 not to understand the meaning of hospice, a life expectancy of six months or less to live, an abandoning of curative treatments and acceptance of palliative care and their Bill of Rights. --- 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 8, 2023, with a benefit period of June 8, 2023, to September 5, 2023 (First 90-day benefit period). Patient 1 had diagnoses that included hypertensive heart disease (heart disease caused by high blood pressure). The face sheet indicated the Medical Director (MD), the referring physician as Attending Physician for Patient 1 (AP 1) and Patient 1s choice of attending physician as Attending Physician for Patient 1 (AP 2). During a home visit and interview with Patient 1, Patient 1s Husband, translation services and in the presence of a Licensed Vocational Nurse (LVN 1), on November 14, 2023, at 12:52 PM, Patient 1 stated she had been admitted to an acute care hospital for an outbreak of shingles (a viral infection that causes a painful rash), vomiting and shortness of breath. Patient 1 stated upon arriving back home a Registered Nurse (RN 3) had shown up at their door offering hospice services and Patient 1 thought the acute care hospital had sent the nurse and she accepted the hospice services. Patient 1 stated she had not requested Hospice Services and there was no discussion of hospice while she was at the hospital. Patient 1 and Patient 1s Husband stated they could not speak or read English. Patient 1 indicated the Hospice Election Statement, Consents and Bill of Rights she signed; the documents were written in English. Patient 1 and Patient 1s Husband stated no Spanish translation had been provided. Patient 1 stated she had been instructed to sign the documents by RN 3 and she did. Patient 1 stated she did not know what hospice was, did not know the life expectancy of six months or less to live or to give up curative care and opt for palliative care. Patient 1 stated RN 3 told them they would get free medication. Patient 1 stated she received dialysis treatments every Tuesday, Thursday, and Saturday but she did not feel she would die in six months. Patient 1s Husband stated, ";She [Patient 1] is not sick like that." Patient 1 stated she did not know nor ever met AP 1, or the MD. Patient 1 stated her doctor was AP 2. Patient 1 stated the MD, AP 1 nor AP 2 had discussed hospice services with her. During a telephone interview with RN 3 on November 15, 2023, at 10:40 AM, RN 3 stated he had conducted an Explanation of Benefits (EOB) and admission assessment for Patient 1. RN 3 stated he did not speak Spanish and a Marketer from the agency had arranged a translator to be present during the EOB and admission. RN 3 stated he could not remember the name of the translator and had not documented a translator had been present. RN 3 confirmed he had provided the Hospice Election Statement, Consents, and Notice of Rights and Responsibilities written in the English language. RN 3 stated he did not have the Spanish language versions with him at the time. During an interview with the Owner, Administrator and Director of Patient Care Services (Owner/Admin/DPCS) on November 15, 2023, at 11:44 AM, the Owner/Admin/DPCS stated the Marketer RN 3 referred to at Patient 1s admission did not work for, nor ever worked for, his agency. The Owner/Admin/DPCS stated he did not know the Marketer. The Owner/Admin/DPCS stated no one should be admitted to his agency without knowing what hospice was, understanding their prognosis of six months or less to live, being prepared to give up curative care and their Bill of Rights. 2. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 8, 2023, with a benefit period of June 8, 2023, to September 5, 2023 (First 90-day benefit period). Patient 4 had diagnoses that included atherosclerosis (the build-up of fats, cholesterol- a waxy substance, and other substances in and on the artery walls). The face sheet indicated the Medical Director (MD), and the referring physician as Attending Physician for Patient 4 (AP 3). Patient 4s choice of attending physician as Attending Physician for Patient 4 (AP 4) was not indicated on the face sheet. During a home visit and interview with Patient 4, Patient 4s Wife, translation provided by Patient 4s adult daughter and in the presence of a Licensed Vocational Nurse (LVN 1), on November 14, 2023, at 11:31 AM, Patient 4s wife stated she had gone to the grocery store to shop and upon leaving the store there were some women outside prompting people to sign up for hospice and get ";free stuff." Patient 4s wife stated she invited one of the women to her home (Patient 4s wife stated she could not remember a name) and was evaluated for hospice. Patient 4s wife stated she was told she did not qualify for hospice, but they could try to qualify her husband (Patient 4). Patient 4 stated he was qualified and admitted to hospice. Patient 4 and Patient 4s wife stated they could not speak or read the English language. Patient 4s daughter stated she had not been present to provide translation for her parents. Patient 4 indicated the Hospice Election Statement, Consents and Bill of Rights he signed; the documents were written in the English language. Patient 4 and Patient 4s Wife stated no Spanish translation had been provided. Patient 4 stated he had been instructed to sign the documents by a Registered Nurse (RN 3) and he did. Patient 4 stated he did not know what hospice was, did not know the life expectancy of six months or less to live or to give up curative care and opt for palliative care. Patient 4 stated, ";Im going to live to be 100 yrs." Patient 4 stated he did not know nor ever met AP 3, or the MD. Patient 4 stated his doctor was AP 4. Patient 4 stated the MD, AP 3 nor AP 4 had discussed hospice services with him. During a telephone interview with RN 3 on November 15, 2023, at 10:51 AM, RN 3 stated he had conducted an Explanation of Benefits (EOB) and admission assessment for Patient 4. RN 3 stated he did not speak Spanish and a Marketer from the agency had arranged a translator to be present during the EOB and admission. RN 3 stated he could not remember the name of the translator and had not documented a translator had been present. RN 3 confirmed he had provided the Hospice Election Statement, Consents, and Notice of Rights and Responsibilities written in the English language. RN 3 stated he did not have the Spanish language versions with him at the time. During an interview with the Owner, Administrator and Director of Patient Care Services (Owner/Admin/DPCS) on November 15, 2023, at 11:44 AM, the Owner/Admin/DPCS stated the Marketer RN 3 referred to at Patient 4s admission did not work for, nor ever worked for, his agency. The Owner/Admin/DPCS stated he did not know the Marketer. The Owner/Admin/DPCS stated no one should be admitted to his agency without knowing what hospice was, understanding their prognosis of six months or less to live, being prepared to give up curative care and their Bill of Rights. 3. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of January 21, 2023, with a benefit period of January 21, 2023, to April 20, 2023 (First 90-day benefit period). Patient 5 had diagnoses that included atherosclerotic heart disease (heart damage caused by narrowing of the coronary arteries, limiting blood flow to the heart). The face sheet indicated the Medical Director (MD), and the referring physician as Attending Physician for Patient 5 (AP 5). During a home visit and interview with Patient 5, no translator present, and in the presence of a Licensed Vocational Nurse (LVN 1), on November 14, 2023, at 10:23 AM, Patient 5 stated her son-in-laws mother who lived with her was on hospice and one day a person from the hospice (Friend of Director of Patient Care Services Designee [Friend/DPCSD]) was visiting her son-in-laws mother and told her she (Patient 5) should be on hospice too. Patient 5 said it was ";OK" with her and she was admitted to hospice. Patient 5 stated she could speak English but could not read English. Patient 5 indicated the Hospice Election Statement, Consents and Bill of Rights she signed; the documents were written in the English language. Patient 5 stated no Spanish translation had been provided. Patient 5 stated she had been instructed to sign the documents by a Registered Nurse (RN 4) and she did. Patient 5 stated she did not know what hospice was, did not know the life expectancy of six months or less to live or to give up curative care and opt for palliative care. Patient 5 stated she did not think she would die in six months. Patient 5 stated she did not know nor ever met the MD. Patient 5 stated her doctor was AP 5. Patient 5 stated the MD, nor AP 5 had discussed hospice services with her. Patient 5 stated she had not seen AP 5 for a very long time. During an interview with the Director of Patient Care Services Designee (DPCSD) on November 15, 2023, at 10:57 AM, The DPCSD stated the individual Patient 5 referred to, was a personal friend of hers (Friend of Director of Patient Care Services Designee [Friend/DPCSD]). The DPCSD stated the Friend/DPCSD did not work for the agency and did not do marketing for the agency. The DPCSD stated she had no knowledge of the Friend/DPCSD requesting hospice services for Patient 5. During an interview with Human Resources (HR) on November 15, 2023, at 1:08 PM, HR stated RN 4 was no longer employed by the agency and was unavailable for interview. During an interview with the Owner, Administrator and Director of Patient Care Services (Owner/Admin/DPCS) on November 15, 2023, at 11:44 AM, the Owner/Admin/DPCS stated he did not know the Friend/DPCSD and the Friend/DPCSD did not work for the agency in any capacity. The Owner/Admin/DPCS stated no one should be admitted to his agency without knowing what hospice was, understanding their prognosis of six months or less to live, being prepared to give up curative care and their Bill of Rights. A review of the agencys policy and procedure titled, ";Rights/Responsibilities," undated, indicated, ";Purpose: To encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. Policy: Each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights and responsibilities as described. ... Procedure: 1. The patient will be informed during the initial assessment visit, in advance of furnishing care, of: ... The right to elect hospice care ... The right to be informed of his/her condition ... The right to choose their attending physician ... The right to have communication needs met. ... 3. Upon admission, each hospice patient and/or his/her representative will be given a written copy of the Patient Rights and Responsibilities. 4. The Patient Rights and Responsibilities will be explained and distributed to the patient prior to the initiation of organization services. This explanation will be in a language that the patient and manager understand. ... B. In the event a communication barrier exists, if possible, special devices or interpreters will be made available. C. Written information will be provided to patients in the predominant languages of the patient population served. ..."

Based on interview and record review, the agency failed to ensure a review of all medications the patients were taking was conducted for two of six sampled patients (Patients 4 and 5) when: 1. For Patient 4: the Medication Profile (MP-a current list of all medications prescribed for a specific patient), indicated one duplicate drug therapy and one medication Patient 4 was taking was not indicated on the MP. 2. For Patient 5: the MP indicated eight medications Patient 5 did not have and was not taking. This failure had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy for Patients 4 and 5. --- 1. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 8, 2023, with a benefit period of September 6, 2023, to December 4, 2023 (Second benefit period). Patient 4 had diagnoses that included atherosclerosis (the build-up of fats, cholesterol- a waxy substance, and other substances in and on the artery walls). During a home visit on November 14, 2023, with a Licensed Vocational Nurse (LVN 1) and in the presence of Patient 4 and Patient 4s daughter to provide translation, an observation of Patient 1s actual medication bottles available in the home were compared with Patient 1s most current Medication Profile (MP). During a concurrent observation and interview on November 14, 2023, at 11:34 AM, with LVN 1 and Patient 4, a bottle indicated carvedilol (lowers blood pressure) 3.125 mg (milligrams-a unit if measurement), 1 (one) tablet, 2 (two) times daily. Patient 4s MP indicated carvedilol 3.125 mg, 1 tablet, 2 times daily and carvedilol 3.125 mg, 1 tablet, 1 time daily. Patient 4 stated he took carvedilol 3.125 mg, 1 tablet, 2 times daily. LVN 1 stated the carvedilol should not have been indicated on the MP twice. A bottle indicated tamsulosin (makes urination easier), 0.4 mg, take 1 (one) tablet every day. The MP did not indicate the tamsulosin. Patient 4 stated he had been taking the tamsulosin for eight years. LVN 1 stated the tamsulosin should have been documented on the MP and was not. During an interview with LVN 1 on November 14, 2023, at 11:55 AM, LVN 1 stated he should have reconciled the medications at each visit by comparing all the bottles and boxes with pharmacy labels against the medication profile and he had not. 2. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of January 21, 2023, with a benefit period of September 18, 2023, to November 16, 2023 (Fourth benefit period). Patient 5 had diagnoses that included atherosclerotic heart disease (heart damage caused by narrowing of the coronary arteries, limiting blood flow to the heart). During a home visit and interview with Patient 5, and in the presence of a Licensed Vocational Nurse (LVN 1), on November 14, 2023, at 10:23 AM, Patient 5 stated she had been suffering from chest pains and shortness of breath. LVN 1 reviewed Patient 5s MP and pointed out the following medications to Patient 5: a. nitroglycerin (a medication to alleviate chest pain) 0.4 mg (milligrams-a unit of measurement) tablet, take one tablet every five minutes as needed, for up to 15 minutes. b. albuterol sulfate (a medication to make breathing easier) 0.083% (percent) solution for inhalation (to breathe in), one unit of solution, take one unit via nebulizer (a device for producing a fine spray of liquid, used for inhaling a medicinal drug) every four hours as needed for shortness of breath and/or for wheezing. Patient 5 stated she did not have nitroglycerin or albuterol sulfate and did not know what a nebulizer was. LVN 1 continued his review of Patient 5s MP with Patient 5 and Patient 5 identified the following medications indicated on the MP as not being in her possession or used by her: a. ondansetron (a medication to stop nausea and vomiting) four mg, dissolve one tablet under the tongue every four hours as needed for nausea/vomiting. b. acetaminophen (a pain medication) 650 mg rectal suppository, insert one suppository into the rectum every six hours as needed for mild pain or fever. c. bisacodyl (a medication to make bowel movements easier) 10 mg rectal suppository, insert one suppository into the rectum daily as needed if no bowel movement for three days. d. levsin (a medication to decrease secretions) 0.125 mg tablet, take one tablet under the tongue every six hours as needed for increased mucus secretions. e. lorazepam (a medication to reduce anxiety) 0.5 mg tablet, take one tablet by mouth, under the tongue, every four hours as needed for anxiety. f. morphine sulfate (a pain medication) 100 mg/ 5 ml (milliliters-a unit of measurement) solution, take 5 mg equals 0.25 ml, under the tongue every 4 hours as needed for pain. Patient 5 stated she did not have the above-mentioned medications and had never used the above-mentioned medications. During an interview with LVN 1 on November 14, 2023, at 10:39 AM, LVN 1 stated he should have reconciled the medications at each visit by comparing all the bottles and boxes with pharmacy labels against the medication profile and he had not. During an interview with the Director of Patient Care Services Designee (DPCSD) on November 16, 2023, at 1:25 PM, the DPCSD stated the skilled nurse who visits the patient needs to do a medication reconciliation at each visit. The DPCSD stated the Medication Profile needed to be compared to the actual medication bottles and packages and ask if the patient is still taking the medications as prescribed. The DPCSD stated the policy and procedure titled, ";Medication Profile," undated, was not followed. A review of the agencys policy and procedure titled, ";Medication Profile," undated, indicated, ";Purpose: To define the use of the medication profile in evaluating a patients current medication regimen. Policy: Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. ... 5. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate the use of the drugs in the home setting. B. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications. C. Using the medication profile as a communication tool for other clinicians involved in care. ... 13. Visiting personnel will do a medication reconciliation on every visit. Medication reconciliation is the process of comparing a patients medication orders to all the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions ..."

The agency failed to ensure that the Condition of Participation: L 664 418.102 Medical director was in compliance as follows: Based on interview, and record review, the agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for five of six sampled patients (Patients 1, 2, 4, 5, and 6) when: 1. For Patients 1, 4, 5, and 6, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by the patients' attending physician (Based on the Code of Federal Regulations CFR-42 CFR 418.3 (2)-the definition of the patients attending physician is: ";(2) Is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual's medical care"). (Refer to L 667) 2. For Patients 2, 5 and 6, the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. (Refer to L 667) The cumulative effect of these systemic practices resulted in the potential to cause Patients 1, 2, 4, 5, and 6 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon.

Based on interview, and record review, the agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for five of six sampled patients (Patients 1, 2, 4, 5, and 6) when: 1. For Patients 1, 4, 5, and 6, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by the patients' attending physician (Based on the Code of Federal Regulations CFR-42 CFR 418.3 (2)-the definition of the patients attending physician is: ";(2) Is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual's medical care"). 2. For Patients 2, 5 and 6, the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. This failure had the potential to cause Patients 1 2, 4, 5, and 6 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to not being properly evaluated as terminally ill. --- 1a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 8, 2023, with a benefit period of June 8, 2023, to September 5, 2023 (First 90-day benefit period). Patient 1 had diagnoses that included hypertensive heart disease (heart disease caused by high blood pressure). The face sheet indicated the Medical Director (MD), the referring physician as Attending Physician for Patient 1 (AP 1) and Patient 1s choice of attending physician as Attending Physician for Patient 1 (AP 2). A review of Patient 1s physicians orders from June 8, 2023, to November 13, 2023, was conducted. There was no documented evidence to show a physicians referral order from AP 1 or AP 2. A review of Patient 1s ";Physicians Certification for Hospice Benefit," dated June 8, 2023, to September 5, 2023, was signed by the MD on June 8, 2023. A review of Patient 1s ";Physicians Certification for Hospice Benefit," dated June 8, 2023, to September 5, 2023, was signed by AP 1 on June 8, 2023. During a home visit and interview with Patient 1, Patient 1s Husband, translation services and in the presence of a Licensed Vocational Nurse (LVN 1), on November 14, 2023, at 12:52 PM, Patient 1 stated she had been admitted to an acute care hospital for an outbreak of shingles (a viral infection that causes a painful rash), vomiting and shortness of breath. Patient 1 stated upon arriving back home a Registered Nurse (RN 3) had shown up at their door offering hospice services and Patient 1 thought the acute care hospital had sent the nurse and she accepted the hospice services. Patient 1 stated she had not requested Hospice Services and there was no discussion of hospice while she was at the hospital. Patient 1 stated she did not know what hospice was, did not know the life expectancy of six months or less to live or to give up curative care and opt for palliative care. Patient 1 stated she received dialysis treatments every Tuesday, Thursday, and Saturday but she did not feel she would die in six months. Patient 1s Husband stated, ";She [Patient 1] is not sick like that." Patient 1 stated she did not know nor ever met AP 1, or the MD. Patient 1 stated her doctor was AP 2. Patient 1 stated the MD, AP 1 nor AP 2 had discussed hospice services with her. A phone call was made to AP 1 on November 15, 2023, at 3:10 PM requesting a telephone interview. AP 1 did not respond to the request. During an interview with AP 2 on November 15, 2023, at 2:22 PM, AP 2 stated she was Patient 1s attending physician. AP 2 stated she did not know Patient 1 was on Hospice, did not know of (name of hospice agency), and no one had reached out to her to discuss a terminal prognosis for Patient 1. AP 2 stated she did not know AP 1, or the MD. AP 2 reviewed the records from Patient 1s visit to the acute care hospital and there was no documentation discussing hospice care. AP 2 confirmed Patient 1 received dialysis treatments and added Patient 1 was working with the acute care hospitals transplant team to obtain a kidney transplant. During an interview with the MD on November 15, 2023, at 3:45 PM, the MD confirmed there was no referral order. The MD stated she did not know who AP 1 was and had not spoken with her. The MD stated she did not know who AP 2 was and had not spoken with her. The MD stated she did not know Patient 1 was receiving dialysis treatments. The MD stated a nurse (she could not remember the name) from the hospice agency had called her and asked her to evaluate and admit Patient 1 to the hospice. The MD stated she had assessed Patient 1 over a telephone video call and felt Patient 1 was very sick. The MD confirmed AP 1 had not met the 42 CFR 418.3 (2)s definition of attending physician. A review of Patient 1s claims for payment, indicated claims for payment were submitted on July 3, 2023, August 3, 2023, September 6, 2023, October 3, 2023, and November 2, 2023. 1b. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 8, 2023, with a benefit period of June 8, 2023, to September 5, 2023 (First 90-day benefit period). Patient 4 had diagnoses that included atherosclerosis (the build-up of fats, cholesterol- a waxy substance, and other substances in and on the artery walls). The face sheet indicated the Medical Director (MD), and the referring physician as Attending Physician for Patient 4 (AP 3). Patient 4s choice of attending physician as Attending Physician for Patient 4 (AP 4) was not indicated on the face sheet. A review of Patient 4s physicians referral order dated June 7, 2023, indicated AP 3s signature. A review of Patient 4s ";Physicians Certification for Hospice Benefit," dated June 8, 2023, to September 5, 2023, was signed by the MD on June 8, 2023. A review of Patient 4s ";Physicians Certification for Hospice Benefit," dated June 8, 2023, to September 5, 2023, was signed by AP 3 on June 8, 2023. During a home visit and interview with Patient 4, Patient 4s Wife, translation provided by Patient 4s adult daughter and in the presence of a Licensed Vocational Nurse (LVN 1), on November 14, 2023, at 11:31 AM, Patient 4s wife stated she had gone to the grocery store to shop and upon leaving the store there were some women outside prompting people to sign up for hospice and get ";free stuff." Patient 4s wife stated she invited one of the women to her home (Patient 4s wife stated she could not remember a name) and was evaluated for hospice. Patient 4s wife stated she was told she did not qualify for hospice, but they could try to qualify her husband (Patient 4). Patient 4 stated he was qualified and admitted to hospice. Patient 4 stated he did not know what hospice was, did not know the life expectancy of six months or less to live or to give up curative care and opt for palliative care. Patient 4 stated, ";Im going to live to be 100 yrs." Patient 4 stated he did not know nor ever met AP 3, or the MD. Patient 4 stated his doctor was AP 4. Patient 4 stated the MD, AP 3 nor AP 4 had discussed hospice services with him. A phone call was made to AP 4 on November 15, 2023, at 3:19 PM requesting a telephone interview. AP 4 did not respond to the request. During an interview with AP 3 on November 15, 2023, at 3:36 PM, AP 3 stated he was not Patient 4s attending physician and did not remember who Patient 4 was. AP 3 stated he assisted different hospices with face-to-face assessments but did not remember working with (name of hospice agency). AP 3 stated he would not have written a hospice referral order and would not have signed a CTI for Patient 4 because he did not provide this type of service. During an interview with the MD on November 15, 2023, at 4:15 PM, the MD stated she did not know who AP 3 was and had not spoken with him. The MD stated she did not know who AP 4 was and had not spoken with him. The MD confirmed AP 3 had not met the 42 CFR 418.3 (2)s definition of attending physician. A review of Patient 4s claims for payment, indicated claims for payment were submitted on July 3, 2023, August 3, 2023, September 6, 2023, October 3, 2023, and November 2, 2023. 1c. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of January 21, 2023, with a benefit period of January 21, 2023, to April 20, 2023 (First 90-day benefit period). Patient 5 had diagnoses that included atherosclerotic heart disease (heart damage caused by narrowing of the coronary arteries, limiting blood flow to the heart). The face sheet indicated the Medical Director (MD), and the referring physician as Attending Physician for Patient 5 (AP 5). A review of Patient 5s physicians referral order dated January 20, 2023, indicated AP 5s signature. A review of Patient 5s ";Physicians Certification for Hospice Benefit," dated January 21, 2023, to April 20, 2023, was signed by the MD on January 21, 2023. A review of Patient 5s ";Physicians Certification for Hospice Benefit," dated January 21, 2023, to April 20, 2023, was signed by AP 5 on April 17, 2023. During a home visit and interview with Patient 5, no translator present, and in the presence of a Licensed Vocational Nurse (LVN 1), on November 14, 2023, at 10:23 AM, Patient 5 stated her son-in-laws mother who lived with her was on hospice and one day a person from the hospice (Friend of Director of Patient Care Services Designee [Friend/DPCSD]) was visiting her son-in-laws mother and told her she (Patient 5) should be on hospice too. Patient 5 said it was ";OK" with her and she was admitted to hospice. Patient 5 stated she did not know what hospice was, did not know the life expectancy of six months or less to live or to give up curative care and opt for palliative care. Patient 5 stated she did not think she would die in six months. Patient 5 stated she did not know nor ever met the MD. Patient 5 stated her doctor was AP 5. Patient 5 stated the MD, nor AP 5 had discussed hospice services with her. Patient 5 stated she had not seen AP 5 for a very long time. A phone call was made with the phone number indicated on Patient 5s face sheet for AP 5 on November 15, 2023, at 2:03 PM, the staff person who answered the phone stated AP 5 was not on staff at the facility and the facility did not have Patient 5 as a patient. During an interview with the Director of Patient Care Services Designee (DPCSD) on November 15, 2023, at 2:31 PM, the DPCSD stated she could not locate a contact phone number for AP 5 and had no way to reach the physician. During an interview with the MD on November 15, 2023, at 4:26 PM, the MD stated she did not know who AP 5 was and had not spoken with her. The MD stated she could not confirm or deny if AP 5 had met the 42 CFR 418.3 (2)s definition of attending physician. A review of Patient 5s claims for payment, indicated claims for payment were submitted on February 3, 2023, March 3, 2023, April 5, 2023, May 3, 2023, June 5, 2023, July 3, 2023, August 3, 2023, September 6, 2023, October 3, 2023, and November 2, 2023. 1d. A review of Patient 6s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 19, 2022, with a benefit period of April 19, 2022, to July 17, 2022 (First 90-day benefit period). Patient 6 had diagnoses that included atherosclerotic heart disease (heart damage caused by narrowing of the coronary arteries, limiting blood flow to the heart). The face sheet indicated the Medical Director (MD), and the referring physician as the MD. A review of Patient 6s physicians orders from April 19, 2022, to November 13, 2023, was conducted. There was no documented evidence to show a physicians referral order. A review of Patient 6s ";Physicians Certification for Hospice Benefit," dated April 19, 2022, to July 17, 2022, was signed by the MD on April 19, 2022. A review of Patient 6s ";Physicians Certification for Hospice Benefit," dated April 19, 2022, to July 17, 2022, was signed by the MD on April 19, 2022. During an interview with the MD on November 15, 2023, at 5 PM, the MD verified there was no referral order for Patient 6. The MD stated she knew there needed to be two physicians signatures on the first benefit periods CTI but she did not know who Patient 6s attending physician was. The MD stated she should not have signed both CTIs. The MD stated she did not meet the 42 CFR 418.3 (2)s definition of attending physician. A review of Patient 6s claims for payment, indicated claims for payment were submitted on May 3, 2022, June 3, 2022, July 1, 2022, August 2, 2022, September 2, 2022, October 4, 2022, November 3, 2022, December 5, 2022, January 4, 2023, February 3, 2023, March 3, 2023, April 5, 2023, May 3, 2023, June 5, 2023, July 3, 2023, August 3, 2023, September 6, 2023, October 3, 2023, and November 2, 2023. 2a. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 8, 2023, with a benefit period of October 9, 2023, to December 7, 2023 (Fifth benefit period). Patient 2 had diagnoses that included hypertensive heart disease (heart disease caused by high blood pressure). A review of Patient 2s ";Physicians Certification for Hospice Benefit," dated October 9, 2023, to December 7, 2023 (Fifth benefit period), indicated a signature by the Medical Director (MD). A review of Patient 2s face-to-face encounter for the fifth benefit period dated October 7, 2023, indicated the face-to-face encounter had been conducted by the MD. A review of Patient 2s claims for payment, indicated claims for payment were submitted on January 4, 2023, February 3, 2023, March 3, 2023, April 5, 2023, May 3, 2023, June 5, 2023, July 3, 2023, August 3, 2023, September 6, 2023, October 3, 2023, and November 2, 2023. 2b. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of January 21, 2023, with a benefit period of September 18, 2023, to November 16, 2023 (Fourth benefit period). Patient 5 had diagnoses that included atherosclerotic heart disease (heart damage caused by narrowing of the coronary arteries, limiting blood flow to the heart). A review of Patient 5s ";Physicians Certification for Hospice Benefit," dated September 18, 2023, to November 16, 2023 (Fourth benefit period), indicated a signature by the Medical Director (MD). A review of Patient 5s face-to-face encounter for the fourth benefit period dated September 14, 2023, indicated the face-to-face encounter had been conducted by the MD. A review of Patient 5s claims for payment, indicated claims for payment were submitted on February 3, 2023, March 3, 2023, April 5, 2023, May 3, 2023, June 5, 2023, July 3, 2023, August 3, 2023, September 6, 2023, October 3, 2023, and November 2, 2023. 2c. A review of Patient 6s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 19, 2022, with a benefit period of October 11, 2023, to December 9, 2023 (Ninth benefit period). Patient 6 had diagnoses that included atherosclerotic heart disease (heart damage caused by narrowing of the coronary arteries, limiting blood flow to the heart). A review of Patient 6s ";Physicians Certification for Hospice Benefit," dated October 11, 2023, to December 9, 2023 (Ninth benefit period), indicated a signature by the Medical Director (MD). A review of Patient 6s face-to-face encounter for the ninth benefit period dated October 8, 2023, indicated the face-to-face encounter had been conducted by the MD. A review of Patient 6s claims for payment, indicated claims for payment were submitted on May 3, 2022, June 3, 2022, July 1, 2022, August 2, 2022, September 2, 2022, October 4, 2022, November 3, 2022, December 5, 2022, January 4, 2023, February 3, 2023, March 3, 2023, April 5, 2023, May 3, 2023, June 5, 2023, July 3, 2023, August 3, 2023, September 6, 2023, October 3, 2023, and November 2, 2023. During a concurrent interview and record review with the Medical Director (MD) on November 15, 2023, from 4:40 PM to 5 PM, Patients 1, 5, and 6s Physicians Certifications for Hospice Benefit and face to face encounters were reviewed. The MD stated she had signed Patients 1, 5, and 6s ";Physicians Certification for Hospice Benefit," dated October 9, 2023, to December 7, 2023, September 18, 2023, to November 16, 2023, and October 11, 2023, to December 9, 2023, respectively. The MD stated she had conducted Patients 2, 5, and 6s face to face encounters, dated October 7, 2023, September 14, 2023, and October 8, 2023, respectively. The MD stated she did not know the certifying doctor could not conduct the face-to-face encounter. A review of the agencys policy and procedure titled, ";Certification of Terminal Illness," undated, indicated, ";PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver choose hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. ... PROCEDURE: 1. At the time of admission to hospice, the hospice Medical Director and the patients attending physician will complete and sign the certification of terminal illness and authorization for hospice services forms ... 4. Both the attending physicians and Medical Directors signed and dated initial certification forms must be on file prior to billing the first claim. ..." A policy and procedure for the ";Face-to-Face Encounter," was not provided by the agency.

Based on interview and record review, the agency failed to follow Federal Law [42 Code of Federal Regulations (CFR) § 418.25(a)], requiring a written physicians referral order, when the patients clinical record did not contain a physician's referral order for hospice services, a confirmation of service needs, a verification of the patients' medical prognosis and supporting documentation for four of six sampled patients (Patients 1, 4, 5, and 6). This failure had the potential to cause Patients 1, 4, 5, and 6 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and referring to hospice care. --- 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 8, 2023, with a benefit period of June 8, 2023, to September 5, 2023 (First 90-day benefit period). Patient 1 had diagnoses that included hypertensive heart disease (heart disease caused by high blood pressure). The face sheet indicated the Medical Director (MD), the referring physician as Attending Physician for Patient 1 (AP 1) and Patient 1s choice of attending physician as Attending Physician for Patient 1 (AP 2). A review of Patient 1s physicians orders from June 8, 2023, to November 13, 2023, was conducted. There was no documented evidence to show a physicians referral order from AP 1 or AP 2. There was no documented evidence to show AP 1 or AP 2 was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During a home visit and interview with Patient 1, Patient 1s Husband, translation services and in the presence of a Licensed Vocational Nurse (LVN 1), on November 14, 2023, at 12:52 PM, Patient 1 stated she had been admitted to an acute care hospital for an outbreak of shingles (a viral infection that causes a painful rash), vomiting and shortness of breath. Patient 1 stated upon arriving back home a Registered Nurse (RN 3) had shown up at their door offering hospice services and Patient 1 thought the acute care hospital had sent the nurse and she accepted the hospice services. Patient 1 stated she had not requested Hospice Services and there was no discussion of hospice while she was at the hospital. Patient 1 stated she did not know what hospice was, did not know the life expectancy of six months or less to live or to give up curative care and opt for palliative care. Patient 1 stated she received dialysis treatments every Tuesday, Thursday, and Saturday but she did not feel she would die in six months. Patient 1s Husband stated, ";She [Patient 1] is not sick like that." Patient 1 stated she did not know nor ever met AP 1, or the MD. Patient 1 stated her doctor was AP 2. Patient 1 stated the MD, AP 1 nor AP 2 had discussed hospice services with her. A phone call was made to AP 1 on November 15, 2023, at 3:10 PM requesting a telephone interview. AP 1 did not respond to the request. During an interview with AP 2 on November 15, 2023, at 2:22 PM, AP 2 stated she was Patient 1s attending physician. AP 2 stated she did not know Patient 1 was on Hospice, did not know of (name of hospice agency), and no one had reached out to her to discuss a terminal prognosis for Patient 1. AP 2 stated she did not know AP 1, or the MD. AP 2 reviewed the records from Patient 1s visit to the acute care hospital and there was no documentation discussing hospice care. AP 2 confirmed Patient 1 received dialysis treatments and added Patient 1 was working with the acute care hospitals transplant team to obtain a kidney transplant. During an interview with the MD on November 15, 2023, at 3:45 PM, the MD confirmed there was no referral order. The MD stated she did not know who AP 1 was and had not spoken with her. The MD stated she did not know who AP 2 was and had not spoken with her. The MD stated she did not know Patient 1 was receiving dialysis treatments. The MD stated a nurse (she could not remember the name) from the hospice agency had called her and asked her to evaluate and admit Patient 1 to the hospice. The MD stated she had assessed Patient 1 over a telephone video call and felt Patient 1 was very sick. 2. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 8, 2023, with a benefit period of June 8, 2023, to September 5, 2023 (First 90-day benefit period). Patient 4 had diagnoses that included atherosclerosis (the build-up of fats, cholesterol- a waxy substance, and other substances in and on the artery walls). The face sheet indicated the Medical Director (MD), and the referring physician as Attending Physician for Patient 4 (AP 3). Patient 4s choice of attending physician as Attending Physician for Patient 4 (AP 4) was not indicated on the face sheet. A review of Patient 4s physicians referral order dated June 7, 2023, indicated AP 3s signature. There was no documented evidence to show AP 3 or AP 4 was contacted to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During a home visit and interview with Patient 4, Patient 4s Wife, translation provided by Patient 4s adult daughter and in the presence of a Licensed Vocational Nurse (LVN 1), on November 14, 2023, at 11:31 AM, Patient 4s wife stated she had gone to the grocery store to shop and upon leaving the store there were some women outside prompting people to sign up for hospice and get ";free stuff." Patient 4s wife stated she invited one of the women to her home (Patient 4s wife stated she could not remember a name) and was evaluated for hospice. Patient 4s wife stated she was told she did not qualify for hospice, but they could try to qualify her husband (Patient 4). Patient 4 stated he was qualified and admitted to hospice. Patient 4 stated he did not know what hospice was, did not know the life expectancy of six months or less to live or to give up curative care and opt for palliative care. Patient 4 stated, ";Im going to live to be 100 yrs." Patient 4 stated he did not know nor ever met AP 3, or the MD. Patient 4 stated his doctor was AP 4. Patient 4 stated the MD, AP 3 nor AP 4 had discussed hospice services with him. A phone call was made to AP 4 on November 15, 2023, at 3:19 PM requesting a telephone interview. AP 4 did not respond to the request. During an interview with AP 3 on November 15, 2023, at 3:36 PM, AP 3 stated he was not Patient 4s attending physician and did not remember who Patient 4 was. AP 3 stated he assisted different hospices with face-to-face assessments but did not remember working with (name of hospice agency). AP 3 stated he would not have written a hospice referral order and would not have signed a CTI for Patient 4 because he did not provide this type of service. During an interview with the MD on November 15, 2023, at 4:15 PM, the MD stated she did not know who AP 3 was and had not spoken with him. The MD stated she did not know who AP 4 was and had not spoken with him. 3. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of January 21, 2023, with a benefit period of January 21, 2023, to April 20, 2023 (First 90-day benefit period). Patient 5 had diagnoses that included atherosclerotic heart disease (heart damage caused by narrowing of the coronary arteries, limiting blood flow to the heart). The face sheet indicated the Medical Director (MD), and the referring physician as Attending Physician for Patient 5 (AP 5). A review of Patient 5s physicians referral order dated January 20, 2023, indicated AP 5s signature. There was no documented evidence to show AP 5 was contacted to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During a home visit and interview with Patient 5, no translator present, and in the presence of a Licensed Vocational Nurse (LVN 1), on November 14, 2023, at 10:23 AM, Patient 5 stated her son-in-laws mother who lived with her was on hospice and one day a person from the hospice (Friend of Director of Patient Care Services Designee [Friend/DPCSD]) was visiting her son-in-laws mother and told her she (Patient 5) should be on hospice too. Patient 5 said it was ";OK" with her and she was admitted to hospice. Patient 5 stated she did not know what hospice was, did not know the life expectancy of six months or less to live or to give up curative care and opt for palliative care. Patient 5 stated she did not think she would die in six months. Patient 5 stated she did not know nor ever met the MD. Patient 5 stated her doctor was AP 5. Patient 5 stated the MD, nor AP 5 had discussed hospice services with her. Patient 5 stated she had not seen AP 5 for a very long time. During an interview with the Director of Patient Care Services Designee (DPCSD) on November 15, 2023, at 10:57 AM, The DPCSD stated the individual Patient 5 referred to, was a personal friend of hers (Friend of Director of Patient Care Services Designee [Friend/DPCSD]). The DPCSD stated the Friend/DPCSD did not work for the agency and did not do marketing for the agency. The DPCSD stated she had no knowledge of the Friend/DPCSD requesting hospice services for Patient 5. A phone call was made with the phone number indicated on Patient 5s face sheet for AP 5 on November 15, 2023, at 2:03 PM, the staff person who answered the phone stated AP 5 was not on staff at the facility and the facility did not have Patient 5 as a patient. During an interview with the Director of Patient Care Services Designee (DPCSD) on November 15, 2023, at 2:31 PM, the DPCSD stated she could not locate a contact phone number for AP 5 and had no way to reach the physician. During an interview with the MD on November 15, 2023, at 4:26 PM, the MD stated she did not know who AP 5 was and had not spoken with her. 4. A review of Patient 6s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 19, 2022, with a benefit period of April 19, 2022, to July 17, 2022 (First 90-day benefit period). Patient 6 had diagnoses that included atherosclerotic heart disease (heart damage caused by narrowing of the coronary arteries, limiting blood flow to the heart). The face sheet indicated the Medical Director (MD), and the referring physician as the MD. A review of Patient 6s physicians orders from April 19, 2022, to November 13, 2023, was conducted. There was no documented evidence to show a physicians referral order. There was no documented evidence to show a referring or attending physician was contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. During an interview with the MD on November 15, 2023, at 5 PM, the MD verified there was no referral order for Patient 6. The MD stated she did not know who Patient 6s referring or attending physician was. A review of the agencys policy and procedure titled, ";Admission Criteria and Process," undated, indicated, ";Purpose: To establish standards and a process by which a patient can be evaluated and accepted for admission. ... Admission Criteria: 1. [name of hospice agency] will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician, if any. The information can be obtained from the hospice nurse or other sharing the attending physicians knowledge of the patient. The patients physician ... must order and approve the provision of hospice care ... 3. The patient must have a life-limiting illness with a life expectancy of six (6) months or less as determined by the attending physician and hospice Medical Director, ... 4. The patient must desire hospice services and be aware of the diagnosis and prognosis. 5. The focus of care desired must be palliative vs. curative. ... Procedure: 1. Referral information provided by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician offices will assist in the determination of eligibility for admission to the program. If the request for service is not made by the patients physician, he/she will be consulted prior to the evaluation visit/initiation of services. A review of the agencys policy and procedure titled, ";Intake Process," undated, indicated, ";Purpose: To establish the process for acceptance and entry of patients into hospice. ... Procedure: ... D. If the referral call is not from a physician, the physician ... will be contacted to confirm service needs, as well as the patients medical prognosis and supporting documentation, and to obtain verbal orders." ";§ 418.25 Admission to hospice care. (a) The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient's attending physician (if any). (b) In reaching a decision to certify that the patient is terminally ill, the hospice medical director must consider at least the following information: (1) Diagnosis of the terminal condition of the patient. (2) Other health conditions, whether related or unrelated to the terminal condition. (3) Current clinically relevant information supporting all diagnoses."