Every finding on record at San Bernardino Hospice Care, Inc.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 9 (11%) clinical records where a recertification of terminal illness was required, a written physician recertification of terminal illness was completed later than two (2) calendar days after the first day of the benefit period. Clinical Record 3: The patient was admitted on 10/6/2022. The recertification of terminal illness dated 12/5/2022 for the certification period 12/5/22 to 2/2/23 was present in the record but lacked a physician signature and date. The Face-to-Face Encounter was conducted 11/25/22 by the attending physician. Agency Policy: Agency Certification of Terminal Illness Policy #1-007, "Certification of Terminal Illness (Dated: 11/2020)," stated in part, "Procedure: 5. A subsequent recertification . . . A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than fifteen (15) calendar days prior or two (2) calendar days after the first day of each period." Interview with the Alternate Director of Patient Care Services and Quality Coordinator on 12/14/22, confirmed that the recertification of terminal illness was completed later than two (2) calendar days after the first day of the benefit period.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I, and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 3 of 3 (100%) clinical records reviewed for patients that transferred to a facility (another Hospice or Hospital) the clinical record lacked evidence that the hospice forwarded a copy of the hospice discharge summary to the receiving facility. Clinical Record 6: The patient was admitted 8/5/2021. The patient revoked hospice on 7/7/2022 and was transferred to the hospital to pursue aggressive treatment. The record lacked evidence that the discharge summary being forwarded to the receiving hospital. Clinical Record 10: The patient was admitted 6/2/2020. The patient revoked hospice on 9/6/2022 and was transferred to the hospital to pursue aggressive treatment. The record lacked evidence that the discharge summary being forwarded to the receiving hospital. Clinical Record 5: The patient was admitted on 8/11/2022. The patient was transferred to another hospice on 10/1/2022. The record lacked evidence that the discharge summary was forwarded to the receiving hospice. Agency Policy: Agency Transfer Information Policy #1-022, "Transfer Information (Dated: 11/2020)," stated in part, "Procedure: 4. Completed transfer summaries will be given to a clinical records clerk who will send a copy to the receiving organization within 72 hours of transfer and file the original in the clinical record." Interview with the Alternate Director of Patient Care Services and the Quality Coordinator on 12/14/2022, the Alternate Director of Patient Care Services and the Assistant Quality Coordinator confirmed there was no evidence that a discharge summary was forwarded to the receiving hospital/hospice when the patient transferred to a Medicare/Medicaid-certified facility/hospice.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 4 of 5 (80%) clinical records reviewed where the patient/family either revoked hospice services or was discharged from hospice, the clinical record lacked evidence that the hospice forwarded a copy of the hospice discharge summary to the patient's attending physician. Clinical Record 10: The patient was admitted on 6/2/2020. The patient revoked hospice on 9/6/2022. The record lacked evidence that the discharge summary was forwarded to the patient's attending physician. Clinical Record 6: The patient was admitted on 8/5/2021. The patient revoked hospice on 7/7/2022. The record lacked evidence that the discharge summary was forwarded to the attending physician. There was documentation in the discharge summary that indicated the attending physician was notified of the patient's revocation; further evidence of this communication was noted in the interdisciplinary group meeting on 7/19/2022. Clinical Record 9: The patient was admitted on 9/23/2020. The patient was discharged for extended prognosis on 9/20/2022. The record lacked evidence that the discharge summary being forwarded to the patient's attending physician. Clinical Record 11: The patient was admitted on 11/12/2021. The patient was discharged for extended prognosis on 8/15/2022. The record lacked evidence that the discharge summary was forwarded to the patient's attending physician. Agency Policy: Agency Revocation of Hospice Benefit Policy #1-024, "Revocation of Hospice Benefit (Dated: 11/2020)," stated in part, "Procedure: 3. The Case Manager will notify the attending physician and interdisciplinary group about the revocation and reason. A discharge summary will be sent to the attending physician." Agency Policy: Discharge from Hospice Program Policy #1-025, "Discharge from Hospice Program (Dated: 11/2020)," stated in part, "Procedure: 9. A copy of the discharge summary will be sent to the attending physician. If requested, the patient's clinical record will be provided." Interview with the Alternate Director of Patient Care Services and Quality Coordinator on 12/14/2022, confirmed that a discharge summary was not forwarded to the patient's attending physician when the patient revoked the hospice benefit or was discharged from the hospice.