Every finding on record at Sharing Care Hospice

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Patient Rights was met as evidenced by: 1. The hospice agency failed to ensure patients rights to be informed of the services the HA provides and the limitations of these services for two out of 10 sampled patients (Patients 1, Patient 2) certified to receive hospice care and services. (Refer to L519). This systemic practice resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Patient Rights to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on observation, interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure patients rights to be informed of the services the HA provides and the limitations of these services for two out of seven sampled patients (Patients 1 and Patient 2) certified to receive hospice care and services. This deficient practice resulted in the patients' rights being violated for not being fully informed about the purpose of the hospice care services and its limitations. --- a. A review of Patient 1s admission record indicated a start of care (SOC) date of 1/31/2024, with a terminal diagnosis of cerebrovascular disease ( a condition that affect blood flow and the blood vessels in the brain senile degeneration (older individuals who suffered from cognitive decline, particularly memory loss). 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 1/31/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week, registered nurse (RN) to conduct initial evaluation within five days of admission then every recertification. On 2/22/2024, at 1 p.m., a joint home visit was conducted at Patient 1's residence. Patient 1 lived in the second floor of a two story building apartment. Patient 1 was observed walking up and down the stairs from first to second floor using a cane without exertion. On 2/22/2024, at 1:30 p.m., during an interview with Patient 1, when asked if he was informed about the purpose of the hospice care services, he stated a PT (physical therapist) from the agency would come visit every week to help him assist with ambulation and provide strengthening exercises for his legs. Patient 1 also stated he had no attending physician and his friend referred him to the hospice agency. Patient 1 further stated that the agency offered to provide free medical supplies such as lotions, incontinent pads and shampoo upon patient admission to their hospice service. b. A review of Patient 2's admission record indicated an SOC date of 12/16/2023, with a terminal diagnosis of hypertensive heart disease (constellation of changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation). A review of Patient 2's Plan of Care/Interdisciplinary Group form, dated 2/9/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week, to conduct initial evaluation within five days of admission then every recertification. During a phone interview on 2/22/2024, at 3 p.m., with Patient 2's FM 1(family member), when he was asked if the hospice agency informed the patient and family members about the purpose of the hospice care services, he stated the hospice service will provide a nurse to visit every week to take her blood pressure and provide her with her prescribed medications. FM 1 also stated that Patient 2 was not sick and not be dying in six months, and that a family friend referred Patient 2 to the hospice agency. During an interview with the director of patient care services (DPCS) on 2/22/2024, at 4 p.m., the DPCS stated the visiting nurse should have informed the patient regarding hospice services upon their admission. A review of the agencys undated policy and procedure titled, ";Patient Bill of Rights/Responsibilities", indicated each patient will be an active, informed participant in his/her plan of care. The Patient Bill of Rights/Responsibilities statement defines the right of the patient to be informed in advance of service about the care to be furnished, the organizations scope of services, services under the Medicare Hospice Benefit and any limitations on these services.

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 regarding Initial and Comprehensive Assessment of the Patient was met as follows: --- 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 regarding Initial and Comprehensive Assessment of the Patient was met as follows: - 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 five of 10 sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, and Patient 7). (Refer to L524) This systemic practice 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. 2. the hospice agency (HA) failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status, and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness for two out of 10 sampled patients (Patient's 1and 2). (Refer to L532).

Based on observation, interview, and record review, the hospice agency (HA) 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 four of 10 sampled patients (Patient's 1, Patient 2, Patient 6 and Patient 7). This deficient practice resulted in the hospice agency certifying patients who did not meet the criteria required to receive the hospice benefits and service management of terminal illness that could affect their quality of life. --- d. During a review of Patient 6s admission record indicated a start of care (SOC) date of 12/7/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), unspecified. The admission record further indicated the hospice Medical Director (Physician 1) was also the patient's referring/attending/patient choice physician. During a review of Patient 6'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), dated 12/7/2023, indicated Patient 6 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related (anything that's connected or related to the heart) pain, had normal respirations (breathing), had moderate dyspnea (difficult or labored breathing) with mild exertion, dependent on walker or cane, and needed moderate assistance with ambulation, toileting, transfer and maximum assistance with dressing, and bathing. During a review of Patient 6's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the 3rd benefit period from 12/7/2023 to 2/4/2024, indicated Patient 6's primary terminal diagnoses was COPD. The Medical Director indicated Patient 6 had a life expectancy of six months or less if the terminal illness runs 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. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 6s terminal illness diagnosis. The physician summary further indicated Patient 6 met LCD guidelines for hospice eligibility. During a review of Patient 6s 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) Hospice Eligibility Determination form for Pulmonary (pertaining to the lungs) Disease, dated 12/7/2023, indicated Patient 16 was eligible per LCD guidelines. The LCD form indicated in Section 1 and 2 should be met. It was marked "yes" in Section 1 that Patient 6 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways) resulting in decreased functional capacity. Section 2 was marked "yes" that Patient 6 had respiratory failure, had an increasing emergency room (ER) and physician home visits prior to hospice admission, and was hospitalized for pulmonary infections. During a review of Patient 6's clinical record indicated there was no documented evidence Patient 6 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, had respiratory failure, had an increasing emergency room and physician home visits prior to hospice admission, and was hospitalized for pulmonary infections. On 2/22/2024 at 12:20 p.m., during a joint home visit at Patient 6s residence with a licensed vocational nurse (LVN 1), Patient 6 was observed awake, alert, oriented x 3, walking outside of the house with a steady gait without the use of a cane or a walker. Patient 6 was observed having normal breathing and not using supplemental oxygen. During a concurrent interview with Patient 6, Patient 6 stated he has no problem with his lungs or his heart, go to the market on most days of the week, and never had shortness of breath. Patient 6 further stated he has been fully independent with ADLs (or activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating). Patient 6 further stated Physician 1 was not his attending physician. On 2/23/2024 at 2:15 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 6 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, had respiratory failure, had an increasing emergency room and physician home visits prior to hospice admission, and was hospitalized for pulmonary infections. e. During a review of Patient 7s admission record indicated a start of care (SOC) date of 1/13/2024 with a terminal diagnosis of chronic obstructive pulmonary disease, unspecified. The admission record further indicated the hospice Medical Director (Physician 1) was also the patient's referring/attending/patient choice physician. During a review of Patient 7's Comprehensive Nursing Assessment, dated 1/13/2024, indicated Patient 7 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related pain, had mild dyspnea with mild exertion, dependent on walker or cane, and needed maximum assistance with ambulation, toileting, transfer, dressing, and bathing. During a review of Patient 7's "Physician Certification for Hospice Benefit" for the 1st benefit period from 1/13/2024 to 4/11/2024, indicated Patient 7's primary terminal diagnoses was COPD. The Medical Director indicated Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary (MD note)" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 7s terminal illness diagnosis. During a review of Patient 7s LCD Hospice Eligibility Determination form for Pulmonary Disease, dated 1/13/2024, indicated Patient 7 was eligible per LCD guidelines. The LCD form indicated Section 1 and 2 should be met. It was marked "yes" in Section 1 that Patient 7 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators resulting in decreased functional capacity and had increasing visits to emergency room (ER). Section 2 was marked "yes" that Patient 7 had an O2 sat (Oxygen saturation, is the amount of oxygen circulating in your blood. For most people, a normal oxygen saturation level is above 92%) less than or equal to 88% determined either by arterial blood gases (measures the balance of oxygen and carbon dioxide in your blood to see how well your lungs are working) or O2 saturation monitors. During a review of Patient 7's clinical record indicated there was no documented evidence Patient 7 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, had an increasing emergency room visit, or had an O2 saturation level less than or equal to 88%. On 2/22/2024 at 9:45 a.m., during a joint home visit at Patient 7s residence with a licensed vocational nurse (LVN 2), Patient 7 was observed sitting in a wheelchair, awake, alert, and oriented x 3. Patient 7 was observed having normal breathing and not using supplemental oxygen. During a concurrent interview with Patient 7, Patient 7 stated she was doing fine, had no shortness of breath, and used albuterol inhaler (a type of medication called a short-acting bronchodilator) to help improved her breathing during an asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe) attack. Patient 7 further stated Physician 1 was not her attending physician, and she was scheduled to see her orthopedic doctor (physician that diagnoses, and treats conditions affecting muscles, joints, and bones) in March 2024 to schedule her for a long-planned hip replacement surgery (the damaged bone and cartilage is removed and replaced with prosthetic [an artificial body part] components). On 2/23/2024 at 2:15 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 7 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, had an increasing emergency room visits or had an O2 saturation level less than or equal to 88% prior to hospice admission. During a review of the agencys policy and procedure titled "Admission Criteria and Process", revised November 2022, indicated Sharing Care 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 determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Sharing Care Hospice, Inc will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. During a review of the agencys policy and procedure titled ";Certification of Terminal Illness", revised November 2022, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, physician member of the interdisciplinary team and/or the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. a. A review of Patient 1s admission record indicated a start of care (SOC) date of 1/31/24, with a terminal diagnosis of cerebrovascular disease ( a condition that affect blood flow and the blood vessels in the brain senile degeneration (older individuals who suffered from cognitive decline, particularly memory loss). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 1/31/24 to 4/29/24, 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 (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. On 2/22/24, at 1 p.m., a joint home visit was conducted at Patient 1's residence. Patient 1 lived in the second floor of a two story building apartment. Patient 1 was observed walking up and down the stairs from first to second floor using a cane without exertion. On 2/22/24, at 1:30 p.m., during an interview with Patient 1, when asked if he was informed about the purpose of the hospice care services, he stated a PT (physical therapist) from the agency would come visit every week to help him assist with ambulation and provide strengthening exercises for his legs. Patient 1 also stated he had no attending physician and his friend referred him to the hospice agency. Patient 1 further stated that the agency offered to provide free medical supplies such as lotions, incontinent pads and shampoo upon patient admission to their hospice service. b. A review of Patient 2's admission record indicated an SOC date of 12/16/2023, with a terminal diagnosis of hypertensive heart disease (constellation of changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 12/16/24 to 3/12/24, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 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 (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a phone interview on 2/22/24, at 3 p.m., with Patient 2's FM 1(family member), when he was asked if the hospice agency informed the patient and family members about the purpose of the hospice care services, he stated the hospice service will provide a nurse to visit every week to take her blood pressure and provide her with her prescribed medications. FM 1 also stated that Patient 2 was not sick and not be dying in six months, and that a family friend referred Patient 2 to the hospice agency. On 2/22/24, at 4 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated in order for a new patient to be admitted to their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital from where the patient gets discharged. During a telephone interview on 2/23/2024 at 12:30 p.m. with the hospice Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient's 1 and 2 and have not spoken and/or discussed Patient's 1 and 2's medical history with them. Physician 1 stated he determined patient was eligible for hospice care through his 20 years of experience as well as training in the medical school, reviewing patients previous hospital records and discharge planning, and following CMS (The Centers for Medicare & Medicaid Services, is a federal agency within the United States Department of Health and Human Services that administers the Medicare program) and Medicare guidelines in admitting patients in hospice service.

Based on observation, interview, and record review, the hospice agency (HA) failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status, and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness for two out of 10 sampled patients (Patient's 1 and Patient 2). This deficient practice resulted in patients admitted for hospice care were not appropriately evaluated by the health care professionals and certified to receive the benefits. --- a. A review of Patient 1s admission record indicated a start of care (SOC) date of 1/31/2024, with a terminal diagnosis of cerebrovascular disease (a condition that affect blood flow and the blood vessels in the brain). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 1/31/2024 to 4/29/2024, benefit period #1, indicated 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 that a comprehensive assessment was conducted in coordination with the patient's primary physician which included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. On 2/22/2024, at 1:00 p.m., a joint home visit was conducted at Patient 1's residence. Patient 1 lived in the second floor of a two story building apartment. Patient 1 was observed walking up and down the stairs from first to second floor using a cane without exertion (an effort). On 2/22/2024, at 1:30 p.m., during an interview with Patient 1, when asked Patient 1 if he was informed about the purpose of the hospice care services, Patient 1 stated a physical therapist (PT) from the agency would come visit every week to help him assist with ambulation and provide strengthening exercises for his legs. Patient 1 also stated he had no attending physician and his friend referred him to the hospice agency. Patient 1 further stated that the agency offered to provide free medical supplies such as lotions, incontinent pads, and shampoo upon patient admission to their hospice service. b. A review of Patient 2's admission record indicated an SOC date of 12/16/2023, 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). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 12/16/2024 to 3/12/2024, benefit period #1, indicated Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence that a comprehensive assessment was conducted in coordination with the patient's primary physician which included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a phone interview on 2/22/2024, at 3:00 p.m., with Patient 2's family member (FM 1), when asked if the hospice agency informed the patient and family members about the purpose of the hospice care services, FM 1 stated the hospice service will provide a nurse to visit every week to take her blood pressure and provide her with her prescribed medications. FM 1 also stated that Patient 2 was not sick and will not be dying in six months. FM 1 further stated that a family friend referred Patient 2 to the hospice agency. On 2/22/2024, at 4:00 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated in order for a new patient to be admitted to their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital from where the patient gets discharged. During a telephone interview on 2/23/2024 at 12:30 p.m. with the hospice Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient 1 and Patient 2 and have not spoken and/or discussed Patients 1's and Patient 2's medical history with them. Physician 1 stated he determined patient was eligible for hospice care through his 20 years of experience as well as the training in the medical school, reviewing patients previous hospital records and discharge planning, and following CMS (Centers for Medicare & Medicaid Services, a federal agency within the United States Department of Health and Human Services that administers the Medicare program) and Medicare guidelines in admitting patients in the hospice service. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated Hospice 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 determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Hospice 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 undated policy and procedure titled "Physician Services-Attending Physician's Role", indicated the attending physician or designee will approve the referral of the patient and family/caregiver to the hospice program, and provide written initial certification of the terminal illness. The policy indicated supportive documentation will be included.

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: --- 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 one out of 10 sampled patients (Patient 7). (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 one out of 10 sampled patients (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 (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 three out of 10 sampled patients (Patient's 1, 2 and 7). (Refer to L667)

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 three out of 10 sampled patients (Patient 1, Patient 2, and Patient 7). 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. --- Findings: During a review of Patient 7s admission record indicated a start of care (SOC) date of 1/13/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), unspecified. The admission record further indicated the hospice Medical Director (Physician 1) was also the patient's referring/attending/patient choice physician. During a review of Patient 7'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), dated 1/13/2024, indicated Patient 7 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related pain (anything that's connected or related to the heart), had mild dyspnea (shortness of breath) with mild exertion, dependent on walker or cane, and needed maximum assistance with ambulation, toileting, transfer, dressing, and bathing. During a review of Patient 7's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the 1st benefit period from 1/13/2024 to 4/11/2024, indicated Patient 7's primary terminal diagnoses was COPD. The Medical Director indicated Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary (MD note)" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 7s terminal illness diagnosis. During a review of Patient 7s LCD Hospice Eligibility Determination (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) form for Pulmonary Disease, dated 1/13/2024, indicated Patient 7 was eligible per LCD guidelines. The LCD form indicated Section 1 and 2 should be met. It was marked "yes" in Section 1 that Patient 7 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways) resulting in decreased functional capacity and had increasing visits to emergency room (ER). Section 2 was marked "yes" that Patient 7 had an O2 sat (Oxygen saturation, is the amount of oxygen circulating in your blood. For most people, a normal oxygen saturation level is above 92%) less than or equal to 88% determined either by arterial blood gases (measures the balance of oxygen and carbon dioxide in your blood to see how well your lungs are working) or O2 saturation monitors. During a review of Patient 7's clinical record indicated there was no documented evidence Patient 7 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, had an increasing emergency room visit, or had an O2 saturation level less than or equal to 88%. On 2/22/2024 at 9:45 a.m., during a joint home visit at Patient 7s residence with a licensed vocational nurse (LVN 2), Patient 7 was observed sitting in a wheelchair, awake, alert, and oriented x 3. Patient 7 was observed having normal breathing and not using supplemental oxygen. During a concurrent interview with Patient 7, Patient 7 stated she was doing fine, had no shortness of breath, and used albuterol inhaler (a type of medication called a short-acting bronchodilator) to help improved her breathing during an asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe) attack. Patient 7 further stated Physician 1 was not her attending physician, and she was scheduled to see her orthopedic doctor (physician that diagnoses, and treats conditions affecting muscles, joints, and bones) in March 2024 to schedule her for a long-planned hip replacement surgery (the damaged bone and cartilage is removed and replaced with prosthetic [an artificial body part] components). During a telephone interview on 2/23/2024 at 12:30 p.m. with the hospice Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient 7 and have not spoken and/or discussed Patient 7s medical history with them. Physician 1 stated he determined patient was eligible for hospice care through his 20 years of experience as well as training in the medical school, reviewing patients previous hospital records and discharge planning, and following CMS (The Centers for Medicare & Medicaid Services, is a federal agency within the United States Department of Health and Human Services that administers the Medicare program) and Medicare guidelines in admitting patients in hospice service. On 2/23/2024 at 2:15 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 7 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, had an increasing emergency room visits or had an O2 saturation level less than or equal to 88% prior to hospice admission. DPCS was also not able to provide Patient 7s previous hospital records, hospital discharge planning, and attending physician progress notes when requested. During a review of the agencys policy and procedure titled, ";Physician Services-Medical Director", revised November 2022, indicated the hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. 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, including written certification of terminal illness. During a review of the agencys policy and procedure titled ";Certification of Terminal Illness", revised November 2022, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, physician member of the interdisciplinary team and/or the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. a. A review of Patient 1s admission record indicated a start of care (SOC) date of 1/31/24, with a terminal diagnosis of cerebrovascular disease ( a condition that affect blood flow and the blood vessels in the brain senile degeneration (older individuals who suffered from cognitive decline, particularly memory loss). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 1/31/24 to 4/29/24, 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 (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. On 2/22/24, at 1 p.m., a joint home visit was conducted at Patient 1's residence. Patient 1 lived in the second floor of a two story building apartment. Patient 1 was observed walking up and down the stairs from first to second floor using a cane without exertion. On 2/22/24, at 1:30 p.m., during an interview with Patient 1, when asked if he was informed about the purpose of the hospice care services, he stated a PT (physical therapist) from the agency would come visit every week to help him assist with ambulation and provide strengthening exercises for his legs. Patient 1 also stated he had no attending physician and his friend referred him to the hospice agency. Patient 1 further stated that the agency offered to provide free medical supplies such as lotions, incontinent pads and shampoo upon patient admission to their hospice service. b. A review of Patient 2's admission record indicated an SOC date of 12/16/2023, with a terminal diagnosis of hypertensive heart disease (constellation of changes in the left ventricle, left atrium and coronary arteries as a result of chronic blood pressure elevation). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 12/16/24 to 3/12/24, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 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 (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a phone interview on 2/22/24, at 3 p.m., with Patient 2's FM 1(family member), when he was asked if the hospice agency informed the patient and family members about the purpose of the hospice care services, he stated the hospice service will provide a nurse to visit every week to take her blood pressure and provide her with her prescribed medications. FM 1 also stated that Patient 2 was not sick and not be dying in six months, and that a family friend referred Patient 2 to the hospice agency. On 2/22/24, at 4 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated in order for a new patient to be admitted to their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital from where the patient gets discharged. During a telephone interview on 2/23/2024 at 12:30 p.m. with the hospice Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient's 1 and 2 and have not spoken and/or discussed Patient's 1 and 2's medical history with them. Physician 1 stated he determined patient was eligible for hospice care through his 20 years of experience as well as training in the medical school, reviewing patients previous hospital records and discharge planning, and following CMS (The Centers for Medicare & Medicaid Services, is a federal agency within the United States Department of Health and Human Services that administers the Medicare program) and Medicare guidelines in admitting patients in hospice service.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) 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 one out of 10 sampled patients (Patient 6). This deficient practice resulted for Patient 6, 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 review of Patient 6s admission record indicated a start of care (SOC) date of 12/7/2023 with a terminal diagnosis of unspecified chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). The admission record further indicated the hospice Medical Director (Physician 1) was also the patient's referring/attending/patient choice physician. A review of Patient 6'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), dated 12/7/2023, indicated Patient 6 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related (anything that's connected or related to the heart) pain, had normal respirations (breathing), had moderate dyspnea (difficult or labored breathing) with mild exertion, dependent on walker or cane, and needed moderate assistance with ambulation, toileting, transfer, and maximum assistance with dressing and bathing. A review of Patient 6's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the 3rd benefit period from 12/7/2023 to 2/4/2024, indicated Patient 6's primary terminal diagnoses was COPD. The Medical Director indicated Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence that 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. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 6s terminal illness diagnosis. The physician summary further indicated Patient 6 met LCD guidelines for hospice eligibility. A review of Patient 6s 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) Hospice Eligibility Determination form for Pulmonary (pertaining to the lungs) Disease, dated 12/7/2023, indicated Patient 16 was eligible per LCD guidelines. The LCD form indicated in Section 1 and Section 2 should be met. It was marked "yes" in Section 1 that Patient 6 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways) resulting in decreased functional capacity, had increasing emergency room and physician home visits, was hospitalized for pulmonary infections, and had a respiratory failure (a serious condition that makes it difficult to breathe on your own). Section 2 was marked "yes" that Patient 6 had an O2 sat (Oxygen saturation, is the amount of oxygen circulating in your blood. For most people, a normal oxygen saturation level is above 92%) less than or equal to 88% determined either by arterial blood gases (measures the balance of oxygen and carbon dioxide in the blood to see how well person's lungs are working) or O2 saturation monitors. A review of Patient 6's clinical record indicated there was no documented evidence that Patient 6 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, had respiratory failure, had an increasing emergency room and physician home visits prior to hospice admission, was hospitalized for pulmonary infections, had a respiratory failure, or had an O2 sat less than or equal to 88% prior to SOC. On 2/22/2024 at 12:20 p.m., during a joint home visit at Patient 6s residence with a licensed vocational nurse (LVN 1), Patient 6 was observed awake, alert, oriented x 3, walking outside of the house with a steady gait without the use of a cane or a walker. Patient 6 was observed having normal breathing and not using supplemental oxygen. During a concurrent interview with Patient 6, Patient 6 stated he has no problem with his lungs or his heart, go to the market on most days of the week, and never had shortness of breath. Patient 6 further stated he has been fully independent with ADLs (or activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating). Patient 6 further stated Physician 1 was not his attending physician. During a telephone interview on 2/23/2024 at 12:30 p.m. with the hospice Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient 6 and have not spoken and/or discussed Patient 6s medical history with them. Physician 1 stated he determined patient was eligible for hospice care through his 20 years of experience as well as training in the medical school, reviewing patients previous hospital records and discharge planning, and following CMS (Centers for Medicare & Medicaid Services, a federal agency within the United States Department of Health and Human Services that administers the Medicare program) and Medicare guidelines in admitting patients in hospice service. On 2/23/2024 at 2:15 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence that Patient 6 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, had respiratory failure, had an increasing emergency room and physician home visits prior to hospice admission, was hospitalized for pulmonary infections, had a respiratory failure, or had an O2 sat less than or equal to 88% prior to SOC. During a review of the agencys policy and procedure titled, ";Physician Services-Medical Director", revised November 2022, indicated the hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. 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, including written certification of terminal illness. During a review of the agencys policy and procedure titled ";Certification of Terminal Illness", revised November 2022, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, physician member of the interdisciplinary team and/or the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization did not provide education and training to the patient/family based on the patient's assessed needs. In review of the record for HV#1, the patient was assessed at high risk for falls due to total dependence, limited range of motion, joint pain, decrease mobility/endurance, and abnormal balance. The plan of care indicated assessment and instruction related the patient's equipment in the home, including grab bars, tub stool, and shower bench. There was no documentation that the patient's/family's use of this equipment was assessed or education provided. This was reveiwed and verified with the Administrator.