Every finding on record at Spectrum Hospice, Inc

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participations regarding initial and Comprehensive Assessments of Patients was met as followed: --- 1. The HA failed to conduct an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for six of 15 sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). (Refer to L 522). 2. The HA failed to ensure the Interdisciplinary Group (IDG, various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met to complete and document patients comprehensive assessment within five (5) calendar days after their start of care for three of 15 sampled patients (Patient 1, Patient 2, and Patient 3). (Refer to L 523). 3. The HA failed to conduct or attempt to conduct an initial bereavement assessment to provide bereavement counseling in accordance with the patient/family/caregivers needs for four of 15 sampled patients (Patient 1, Patient 3, Patient 6, and Patient 14). (Refer to L531). 4. The HA failed to ensure the Interdisciplinary Group (IDG, various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met to discuss and update ten out of 15 sampled patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) comprehensive assessments at least every 15 days. (Refer to L 533). The cumulative effect of these systemic practices resulted in the hospice agency admitting patients who did not meet admission criteria and did not qualify for the Medicare hospice benefit.

Based on observation, interview, and record, the Hospice Agency (HA) staff failed to conduct an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for six of 15 sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- 1. A review of Patient 8s ";Personal Information" record indicated a start of care (SOC) date on 1/26/2022, with a diagnosis of hypertensive heart disease without heart failure (high blood pressure). Patient 8 was transferred from another hospice agency and continued with episode three (3) of hospice care. During an interview and concurrent record review on 2/23/2024 at 11:15 a.m., the Administrator Designee/Director of Patient Care Services Designee (DD) reviewed Patient 8s document titled, ";Comprehensive Assessment", dated 1/26/2022. The record indicated the LCD (Local Coverage Determination, a tool used to determine if a patient qualifies for hospice care) was used for the heart disease and Patient 8 had NYHA (New York Hear Association, a tool used to classify heart failure) class IV (4) (severe limitations, experiences symptoms even at rest). DD stated the physical assessment of the patient need to support the NYHA IV. DD further stated, "based on the assessment, the patient had an oxygen level of 93 percent (%, a ratio) on room air. That already is a no for NYHA IV because the patient would require oxygen or would be uncomfortable with breathing even at rest." DD continued to review Patient 8s medical records and stated there was no doctors notes or CTI (Certification of Terminal Illness, physician summary to explain clinical findings that support a life expectancy of six months or less) documented to support Patient 8s terminal diagnosis. The only documents available were the hospice transfer forms. The HA failed to ensure the comprehensive assessment for Patient 8 clearly identified the need for hospice services. There was no documented evidence to support the terminal illness. 2. A review of Patient 9s ";Personal Information" record indicated a start of care date on 9/9/2022, with a primary diagnosis of unspecified cirrhosis of liver (damage of the liver). This re-admission was the 12th episode of hospice care. During an interview with Patient 9 at the home visit on 2/21/2024, at 11:20 a.m., Patient 9 stated, ";Ive been having a lot of doctors appointments". When asked what type of doctor he is seeing, Patient 9 stated, ";the stomach doctor". During an interview and concurrent record review on 2/23/2024 at 11:04 a.m., DD reviewed Patient 9s document titled, ";Comprehensive Assessment", dated 9/10/2022. The record indicated the LCD used to determine hospice criteria was for liver disease. One of the criteria was a lab result for International Normalized Ratio (INR, a test to show how long it takes for the blood to clot) greater than 1.5. The record indicated Patient 9 met this criterion. DD stated looking strictly on the documentation, it was not accurate because there was no supportive documented evidence of Patient 9s INR values. There was no supportive documented evidence of his condition. The HA failed to ensure the comprehensive assessment for Patient 9 clearly identified the need for hospice services. There was no documented evidence to support the terminal illness. 3. A review of Patient 10s ";Personal Information" record indicated a start of care date on 10/18/2023, with a primary diagnosis of malignant neoplasm of the prostate (cancer). This was the first episode of hospice care. During an interview and concurrent record review on 2/23/2024 at 10:55 a.m., DD reviewed Patient 10s document titled, ";Comprehensive Assessment", dated 10/20/2023. The record indicated there was no information documented. DD stated he was the nurse who assessed him, but DD did not document the findings. DD stated he did not document because there was no time. DD stated Patient 10 was admitted because he had cancer. However, there was no documentation in the medical record about the cancer diagnosis. DD stated he did not remember what was the status of his cancer. DD further stated the LCD was not completed either and there was no indication Patient 10 met the criteria for hospice care. The HA failed to complete a comprehensive assessment for Patient 10 identifying the need for hospice services. There was no documented evidence to support the terminal illness. 4. review of Patient 11s ";Personal Information" record indicated a start of care date on 10/17/2023, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, a lung condition where the lungs are unable to adequately provide oxygen to the body). This was the first episode of hospice care. During an interview and concurrent record review on 2/23/2024 at 10:43 a.m., DD reviewed Patient 11s document titled, ";Comprehensive Assessment", dated 10/20/2023. DD stated there was nothing documented. There was no assessment. There was nothing uploaded into Patient 11s medical record to support the admission to the hospice care. DD stated he looked at the doctors certification of hospice care and the doctor signed the attestation, but there was no doctor narrative, explanation on what the supporting assessment was. DD stated there was nothing in the record to support the diagnosis of COPD. The HA failed to complete a comprehensive assessment for Patient 11 identifying the need for hospice services. There was no documented evidence to support the terminal illness. 5. A review of Patient 12s ";Personal Information" record indicated a start of care date on 1/28/2022, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). Patient 12 was transferred from another hospice agency and continued with episode 14 of hospice care. During an interview and concurrent record review on 2/23/2024 at 10:28 a.m., DD reviewed Patient 12s document titled, ";Comprehensive Assessment", dated 1/28/2022. DD stated the note was incomplete. The note did not indicate who the author was. Continued review of the record indicated that Patient 12 had NYHA (New York Hear Association, a tool used to classify heart failure) class IV (4) (severe limitations, experiences symptoms even at rest). The nursing summary in the comprehensive assessment did not indicate the patient met the criteria for NYHA IV. AD/DD stated Patient 12s medical record did not have notes to support the NYHA IV classification. DD stated, "Class IV was the highest acuity level, end stage. Patient would be very short of breath, even on rest, patient may have frequent chest pain with or without activity, patient would have a problem walking, (fatigued, short of breath), any physical activity would cause tiredness." DD stated the assessment was not accurate and was not complete. When asked if Patient 12 was admitted to hospice without documented evidence of the terminal illness, DD stated, ";Yes, I would say that." The HA failed to ensure the comprehensive assessment for Patient 12 clearly identified the need for hospice services. There was no documented evidence to support the terminal illness. 6. A review of Patient 13s ";Personal Information" record indicated a start of care date on 10/12/2023, with a primary diagnosis of chronic systolic congestive heart failure (heart unable to pump blood effectively to the body). This re-admission was the 30th episode of hospice care. During an interview on 2/23/2024, at 9:53 a.m., DD stated, "The comprehensive assessment was not done. The start of care (SOC) was on 10/12/2023. It was supposed to be done on 10/23/2023, completed no later than 10/14/2023. A Registered Nurse was supposed to do it." DD stated he did not have an answer on why it was not done. DD stated the primary diagnosis was congestive heart failure (CHF) and there were no documents in the record to support a diagnosis of CHF. There was no cardiologist (a doctor who specializes in the heart) report, history and physical (a document that explains the patients past medical history, current treatment, and plan), labs, and/or ultrasounds to support the CHF. DD stated the nursing assessment would collect information (assessment findings) for the doctor to be aware, to support the diagnosis. DD stated the LCD was not completed either. AD/DD stated there was no evidence/documentation that this patient was hospice eligible. The HA failed to complete a comprehensive assessment for Patient 13 identifying the need for hospice services. There was no documented evidence to support the terminal illness. During an interview on 2/22/2024, at 11:06 a.m., the Administrator Designee/Director of Patient Care Services Designee (DD) stated the comprehensive assessment was supposed to be done within 48 hours of start of care by a registered nurse (RN). DD stated the LCD was used to see if the patient qualified for hospice care. DD stated the hospice doctor had to see the patient within five (5) days of admission, in person. During an interview on 2/22/2024, at 11:20 a.m., DD stated the comprehensive assessment was the most important assessment because it lets the care team know the patient, what the problem is, their socioeconomic status, psychosocial status, determination of terminal illness, and spiritual needs, which is used to develop the plan of care. DD stated if there was no comprehensive assessment, the patient does not get admitted into hospice care. A review of HAs policy and procedure titled ";Initial Assessment" revised 4/2020, indicated ";An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care unless otherwise specified by the physician..." A review of HAs policy and procedure titled ";Admission Criteria and Process" revised 4/2020, indicated ";The patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCD). Eligibility criteria will be continually reviewed on an ongoing basis by the interdisciplinary team to assure appropriateness of hospice care. The organization will utilize referral information provided by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician offices in the determination of eligibility for admission to the program. If the patient is accepted for hospice care, a comprehensive assessment of the patient will be performed no later than five (5) calendar days after the election of hospice care.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Interdisciplinary Group (IDG, various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met to complete and document patients comprehensive assessment within five (5) calendar days after their start of care for three of 15 sampled patients (Patient 1, Patient 2, and Patient 3). This failure resulted in the HA not identifying patients need for hospice services/care and claiming reimbursement for patients who did not need hospice service to manage their terminal illness. It also had the potential of the patients not receiving appropriate healthcare services that could affect their health and quality of life. --- 1. A review of Patient 1s ";Personal Information" record indicated a start of care (SOC) date of 10/14/2022, with a diagnosis of unspecified sequelae of cerebral infarction (limited blood flow to the brain). A review of Patient 1s undated medical record form titled ";Current Treatment/Medication/DME (durable medical equipment) List", indicated ";MSW-Bereavement & Psychosocial Assessment should be completed within five (5) days from SOC." A review of Patient 1s medical record form titled ";POC Summary" dated ";as of 2/22/2024," indicated ";MSW-Bereavement & Psychosocial Assessment should be completed within 5 days from SOC." A review of Patient 1s medical record form titled ";POC/IDG Review" dated 10/14/2022, indicated form was not signed by the authors. The form also indicated the nursing, spiritual, psychosocial, and other/physician sections were left blank. A review of Patient 1s medical record form titled ";POC/IDG Review" dated 10/27/2022, indicated form was not signed by the authors. The form also indicated the nursing, spiritual, psychosocial, and other/physician sections were left blank. During an interview and concurrent record review on 2/22/2024 at 12:40 p.m. with the Director of Patient Care Services Designee (DD) of Patient 1s Electronic Medical Record (EMR), DD stated he completed Patient 1s initial assessment on 10/14/2022. DD stated there was no input or IDG members' signatures on Patient 1s comprehensive assessment. DD stated, ";It was not done." The HA failed to ensure the IDG met to discuss and document a comprehensive assessment for Patient 1 within five (5) days of start of care. 2. A review of Patient 2s ";Personal Information" record indicated an SOC date of 1/21/2021, with a diagnosis of unspecified Alzheimers Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest task). A review of Patient 2s undated medical record form titled ";Current Treatment/Medication/DME List", indicated ";MSW-Bereavement & Psychosocial Assessment should be completed within 5 days from SOC." A review of Patient 2s medical record form titled ";POC Summary" dated ";as of 2/22/2024," indicated ";MSW-Bereavement & Psychosocial Assessment should be completed within 5 days from SOC." A review of Patient 2s medical record form titled ";POC/IDG Review" dated 1/21/2021, indicated form was not signed by all the IDG members. The form also indicated the psychosocial and other/physician discussion sections were left blank. During an interview on 2/21/2024 at 10:00 a.m. with Patient 2s Care Giver (CG3), CG3 stated she takes care of Patient 2 every day. CG3 stated, ";He is in good state/good health. He eats really well; he doesnt have any issues. He is not vegetative. Nothing indicates he will die soon. He is engaged, he is alert sometimes; his physical state is quite stable. He doesnt have pain or wounds, he is good." During an interview on 2/21/2024 at 11:10 a.m. with Patient 2s Medical Doctor 3 (MD3), MD3 stated she has seen Patient 2 three times at his residence. MD3 stated. ";He is stable, I didnt refer him to hospice. From the last two months Ive seen him, he is stable. It was not my referral." During a concurrent interview and record review on 2/22/2024 at 1:15 p.m. with the DD of Patient 2s EMR, DD stated Patient 2s comprehensive assessment was not completed or signed by the Medical Social Worker (MSW). DD stated the discussion sections needed to be filled out by each discipline. The HA failed to ensure the IDG met to discuss and document a comprehensive assessment for Patient 2 within five days of start of care. 3. A review of Patient 3s ";Personal Information" record indicated an SOC date of 2/8/2023, with a diagnosis of unspecified chronic obstructive pulmonary disease (COPD, group of diseases the cause airflow blockage and breathing problems). A review of Patient 3s undated medical record form titled ";Current Treatment/Medication/DME List", indicated ";MSW-Bereavement Assessment should be completed within 5 days from SOC." A review of Patient 3s medical record form titled ";POC Summary" dated ";as of 2/22/2024," indicated ";MSW-Bereavement Assessment should be completed within 5 days from SOC." A review of Patient 3s medical record form titled ";POC/IDG Review" dated 2/8/2023, indicated form was not signed by all the IDG members. The form also indicated Patient 3 did not have any identified problems, interventions, goals, or status. The HA failed to ensure the IDG met to discuss and document a comprehensive assessment for Patient 3 within five days of start of care. During an interview on 2/22/2024, at 11:15 a.m., the Director of Patient Care Services Designee (DD) stated the registered nurse begins the plan of care once the need of the patient is determined when the comprehensive assessment is done. The information gathered during the assessment is sent to the IDG members, and they have five days to assess the patients. The IDG members are the doctor, registered nurse, medical social worker, licensed vocational nurse, spiritual counselor, and the volunteer coordinator. During an interview on 2/22/2024, at 11:20 a.m., DD stated the comprehensive assessment was the most important assessment because it lets the care team know the patient, what the problem is, their socioeconomic status, psychosocial status, determination of terminal illness, and spiritual needs, which is used to develop the plan of care. DD stated if there was no comprehensive assessment, the patient does not get admitted into hospice care. A review of HAs policy and procedure titled ";Admission Criteria and Process" revised 4/2020, indicated ";Eligibility criteria will be continually reviewed on an ongoing basis by the interdisciplinary team to assure appropriateness of hospice care. The organization will utilize referral information provided by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician offices in the determination of eligibility for admission to the program. If the patient is accepted for hospice care, a comprehensive assessment of the patient will be performed no later than 5 calendar days after the election of hospice care." A review of HAs policy and procedure titled ";The Plan of Care" revised 4/2020, indicated ";The Case Manger (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care after the consent forms are signed. The Case Manager will then notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings... the plan of care will be reviewed prior to care being delivered. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care. The hospice Medical Director will need to review the patients history and physical, which is also provided, to be able to sign the certification of terminal illness section of the plan of care. Review of the plan of care will be documented in the clinical record." A review of HAs policy and procedure titled ";Interdisciplinary Group Membership and Responsibilities, revised 4/2020, indicated ";The interdisciplinary group will collaborate with the patients attending physician to develop an individualized written plan of care. The hospice interdisciplinary group membership includes at a minimum: Physician, registered nurse, social worker, pastoral or other counselor. The interdisciplinary group responsibilities include but are not limited to: participation in the establishment of the plan of care for each patient admitted to the hospice service. Participation in the periodic review and updating of the plan of care for each patient receiving hospice services." A review of HAs policy and procedure titled ";Comprehensive Assessment" revised 4/2020, indicated ";A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. During the comprehensive patient assessment, all baseline date and other relevant information will be documented, through interview and observation, in the patients clinical record, including at least the following information, as relevant: The patients psychosocial status... A bereavement assessment of the needs of the patient family and other individuals... The assessment should determine: Anticipated discharge needs, including bereavement and funeral needs."

Based on interview and record review, the Hospice Agency (HA) failed to conduct or attempt to conduct an initial bereavement assessment to provide bereavement counseling in accordance with the patient/family/caregivers needs for four of 15 sampled patients (Patient 1, Patient 3, Patient 6, and Patient 14). This deficient practice had the potential for the patient/family/caregiver not being provided social, spiritual, and cultural support related to the patient's pending death and to be able to cope with the patients death. --- 1. A review of Patient 1s ";Personal Information" record indicated a start of care date of 10/14/2022, with a diagnosis of unspecified sequelae of cerebral infarction (limited blood flow to the brain). A review of Patient 1s undated Electronic Medical Record (EMR) titled ";History of Bereavement Assessment", indicated there was nothing documented. A review of Patient 1s undated medical record form titled ";Current Treatment/Medication/DME List", indicated ";MSW-Bereavement & Psychosocial Assessment should be completed within 5 days from SOC." A review of Patient 1s medical record form titled ";POC Summary" dated ";as of 2/22/2024," indicated ";MSW-Bereavement & Psychosocial Assessment should be completed within 5 days from SOC." During a concurrent interview and record review on 2/22/2024 at 12:40 p.m. with the Director of Patient Care Services Designee (DD) of Patient 1s EMR, DD stated there was no documented bereavement assessment in Patient 1s EMR. DD stated he was not familiar with bereavement. The HA failed to ensure Patient 1 was assessed for bereavement needs. This failure resulted in bereavement services not being offered to the surviving relatives. 2. A review of Patient 3s ";Personal Information" record indicated a start of care date of 2/8/2023, with a diagnosis of unspecified chronic obstructive pulmonary disease (COPD, group of diseases the cause airflow blockage and breathing problems). A review of Patient 3s undated EMR titled ";History of Bereavement Assessment", indicated there was nothing documented. A review of Patient 3s undated medical record form titled ";Current Treatment/Medication/DME List", indicated ";MSW-Bereavement Assessment should be completed within 5 days from SOC." A review of Patient 3s medical record form titled ";POC Summary" dated ";as of 2/22/2024," indicated ";MSW-Bereavement Assessment should be completed within 5 days from SOC." During an interview and concurrent record review on 2/22/2024 at 1:05 p.m. with the DD of Patient 3s EMR, DD stated there was no documented bereavement assessment in Patient 3s EMR. DD stated it was not done. The HA failed to ensure Patient 3 was assessed for bereavement needs. This failure resulted in bereavement services not being offered to the surviving relatives. 3. A review of Patient 6s ";Personal Information" record indicated a start of care date of 1/30/2021 and an end of care date of 8/6/2023, with a diagnosis of unspecified Alzheimers Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest task). A review of Patient 6s undated EMR titled ";History of Bereavement Assessment", indicated there was nothing documented. A review of Patient 6s undated medical record form titled ";Current Treatment/Medication/DME List", indicated ";MSW-Bereavement Assessment should be completed within 5 days from SOC." A review of Patient 6s medical record form titled ";POC Summary" dated ";as of 2/22/2024," indicated ";MSW-Bereavement Assessment should be completed within 5 days from SOC." During a concurrent interview and record review on 2/22/2024 at 1:55 p.m. with the DD of Patient 6s EMR, DD stated Patient 6 passed away on 8/6/2023. DD stated there was no bereavement documentation. DD stated Patient 6s authorized representative/emergency contact was not provided bereavement support. DD stated the last documented visit note was made on 7/30/2023. DD stated Patient 6 did not receive postmortem or bereavement care. The HA failed to ensure Patient 6 was assessed for bereavement needs. This failure resulted in bereavement services not being offered to the surviving relatives. 4. A review of Patient 14s ";Personal Information" record indicated a start of care date of 1/24/2022 and an end of care date of 4/3/2023 with a diagnosis of end stage Alzheimers disease (a progressive illness that destroys memory and other important functions). During a concurrent interview and record review on 2/22/2024, at 9:41 a.m., DD reviewed Patient 14s medical record and stated that according to the record the initial bereavement assessment was not documented. DD further stated it might have happened in person, but it was not documented. During a concurrent interview and record review on 2/23/2024 at 9:45 a.m., DD reviewed Patient 14s medical record and stated the initial bereavement assessment was needed to make the bereavement plan of care (POC). The purpose of the bereavement POC, was to help patients family with the grieving process. The psychological issues. It deferred from medical POC. To help the families/grieved with the psychosocial issue of loss. No POC was done for this patient. A review of Patient 14s record titled, ";Visit Note After Death", dated 4/9/2023, indicated the patient passed away on 4/9/2023. There was no indication a bereavement assessment was done. The HA failed to ensure Patient 14 was assessed for bereavement needs. This failure resulted in bereavement services not being offered to the surviving relatives. During an interview on 2/22/2024, at 11:54 a.m., the Director of Patient Care Services Designee (DD) stated the initial bereavement assessment was for grieving families. The time frame for doing the initial bereavement assessment was within five days of admission. The Medical Social Worker (MSW) was responsible in doing it if the patient agreed. During a telephone interview on 2/23/2024 at 9:10 a.m. with the Medical Social Worker (MSW), MSW stated she was not responsible for conducting initial bereavement assessments. MSW stated the HAs Spiritual Counselor (SC) did the patients bereavement assessments. On 2/23/2024 at 9:50 a.m. the SC was called; there was no answer. A message with call back number left. A review of HAs policy and procedure titled ";Comprehensive Assessment" revised 4/2020, indicated ";A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. During the comprehensive patient assessment, all baseline date and other relevant information will be documented, through interview and observation, in the patients clinical record, including at least the following information, as relevant: A bereavement assessment of the needs of the patient family and other individuals... The assessment should determine: Anticipated discharge needs, including bereavement and funeral needs." A review of HAs policy and procedure titled ";Bereavement Assessment" revised 4/2020, indicated ";On admission, the hospice registered nurse will complete a bereavement screening assessment that is given to the Bereavement Coordinator. The bereavement counselor will complete the bereavement risk assessment to determine potential needs of the survivors. After the death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment. The Bereavement Coordinator will develop a plan for intervention based on the findings of the bereavement follow-up assessment. Upon completion all bereavement documentation will be filed."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Interdisciplinary Group (IDG, various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met to discuss and update ten out of 15 sampled patients' (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) comprehensive assessments at least every 15 days. This failure resulted in not knowing the patients current status, in order to identify their need for hospice services. It also had the potential for harm if hospice patients are prevented from reaching their goals, due to IDG not addressing changes in the patient's condition. --- 1. A review of Patient 1s ";Personal Information" record indicated a start of care (SOC) date on 10/14/2022, with a diagnosis of unspecified sequelae of cerebral infarction (limited blood flow to the brain). A review of Patient 1s undated medical record form titled ";Current Treatment/Medication/DME List", indicated ";IDG to review patients status every 14 days and as needed to evaluate changes in condition." A review of Patient 1s medical record form titled ";POC Summary" dated ";as of 2/22/2024," indicated ";IDG to review patients status every 14 days and as needed to evaluate changes in condition." A review of Patient 1s medical record form titled "Re-Cert Assessment" dated 9/29/2023, indicated form was blank. A review of Patient 1s medical record form titled "Re-Cert Assessment" dated 11/24/2023, indicated form was blank. A review of Patient 1s medical record form titled ";POC/IDG Review" dated 12/7/2023, indicated form was not signed by the authors. The form also indicated the nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. A review of Patient 1s medical record form titled ";POC/IDG Review" dated 12/21/2023, indicated form was not signed by the authors. The form also indicated the nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. A review of Patient 1s medical record form titled ";POC/IDG Review" dated 1/4/2024, indicated form was not signed by the authors. The form also indicated the nursing, spiritual, and other/physician discussion sections were left blank. A review of Patient 1s medical record form titled ";POC/IDG Review" dated 1/18/2024, indicated form was not signed by the authors. The form also indicated the nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. A review of Patient 1s medical record form titled ";POC/IDG Review" dated 2/1/2024, indicated form was not signed by the authors. The form also indicated the spiritual discussion section was left blank. During an interview and concurrent record review on 2/22/2024 at 12:40 p.m. with the Director of Patient Care Services Designee (DD) of Patient 1s Electronic Medical Record (EMR) and medical record form titled ";Re-Cert Assessment" dated 11/24/2023, DD stated the last time the IDG members conducted a comprehensive assessment for Patient 1 was on 11/23/2023. The Re-Cert Assessment form was not complete. DD stated the Administrator/Director of Patient Care Services (ADM/DPCS) plotted the note, which meant that data from the previous note was transferred into that one. DD stated the red ";X" on their EMR system indicated the note was plotted. DD stated nurses have 48 to 72 hours to document and complete their visit note. The HA failed to ensure the IDG members met and updated Patient 1s comprehensive assessment at least every 15 days. 2. A review of Patient 2s ";Personal Information" record indicated an SOC date of 1/21/2021, with a diagnosis of unspecified Alzheimers Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest task). A review of Patient 2s undated medical record form titled ";Current Treatment/Medication/DME List", indicated ";IDG to review patients status every 14 days and as needed to evaluate changes in condition." A review of Patient 2s medical record form titled ";POC Summary" dated ";as of 2/22/2024," indicated ";IDG to review patients status every 14 days and as needed to evaluate changes in condition." A review of Patient 2s medical record form titled ";Re-Cert Assessment" dated 10/29/2023, indicated form was blank. The form also indicated it was not signed by HA staff. A review of Patient 2s medical record form titled ";Re-Cert Assessment" dated 12/24/2023, indicated form was blank. The form also indicated it was not signed by HA staff. A review of Patient 2s medical record form titled ";POC/IDG Review" dated 12/21/2023, indicated form was not signed by the authors. The form also indicated the nursing, spiritual, and psychosocial discussion sections were left blank. A review of Patient 2s medical record form titled ";POC/IDG Review" dated 1/4/2024, indicated form was not signed by the authors. The form also indicated the nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. A review of Patient 2s medical record form titled ";POC/IDG Review" dated 1/18/2024, indicated form was not signed by the authors. The form also indicated the nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. A review of Patient 2s medical record form titled ";Updated Assessment" dated 2/1/2024, indicated form was blank. The form also indicated it was not signed by HA staff. A review of Patient 2s medical record form titled ";POC/IDG Review" dated 2/1/2024, indicated form was not signed by the authors. The form also indicated the psychosocial and other/ physician discussion sections were left blank. A review of Patient 2s medical record form titled ";POC/IDG Review" dated 2/15/2024, indicated form was not signed by the authors. The form also indicated the nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. During a concurrent interview and record review on 2/22/2024 at 1:15 p.m. with the DD of Patient 2s EMR, DD stated Patient 2s last comprehensive assessment was completed on 7/10/2022. DD stated that comprehensive assessments need to be completed to identify if the patient continues to be hospice eligible. DD stated that ";as of right now" Patient 2 ";is not a hospice patient". The HA failed to ensure the IDG members met and updated Patient 2s comprehensive assessment at least every 15 days. 3. A review of Patient 3s ";Personal Information" record indicated an SOC date of 2/8/2023, with a diagnosis of unspecified chronic obstructive pulmonary disease (COPD, group of diseases the cause airflow blockage and breathing problems). A review of Patient 3s undated medical record form titled ";Current Treatment/Medication/DME List", indicated ";IDG to review patients status every 14 days and as needed to evaluate changes in condition." A review of Patient 3s medical record form titled ";POC Summary" and dated ";as of 2/22/2024," indicated ";IDG to review patients status every 14 days and as needed to evaluate changes in condition." A review of Patient 3s medical record form titled ";Re-Cert Assessment" dated 10/2/2023, indicated form was blank. The form also indicated it was not signed by HA staff. A review of Patient 3s medical record form titled ";Re-Cert Assessment" dated 11/27/2023, indicated form was blank. The form also indicated it was not signed by HA staff. A review of Patient 3s medical record form titled ";Re-Cert Assessment" dated 1/22/2024, indicated form was blank. The form also indicated it was not signed by HA staff. A review of Patient 3s medical record form titled ";POC/IDG Review" dated 12/21/2023, indicated form was not signed by the authors. The form also indicated the nursing, spiritual, and psychosocial discussion sections were left blank. A review of Patient 3s medical record form titled ";POC/IDG Review" dated 1/4/2024, indicated form was not signed by the authors. The form also indicated the nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. A review of Patient 3s medical record form titled ";POC/IDG Review" dated 1/18/2024, indicated form was not signed by the authors. The form also indicated the nursing, spiritual, and psychosocial discussion sections were left blank. During an interview and concurrent record review on 2/22/2024 at 1:05 p.m. with the DD of Patient 3s EMR, DD stated Patient 3s last comprehensive assessment was completed on 7/24/2023. DD stated Patient 3 was an active patient and he did not know if Patient 3 was hospice eligible. The HA failed to ensure the IDG members met and updated Patient 3s comprehensive assessment at least every 15 days. 4. A review of Patient 8s ";Personal Information" record indicated an SOC date of 1/26/2022, with a diagnosis of hypertensive heart disease without heart failure (high blood pressure). Patient 8 was transferred from another hospice agency and continued with episode three of hospice care. A review of Patient 8s records titled, ";POC/IDG Review", dated 9/14/2023, 9/28/2023, 10/12/2023, 10/26/2023, and 11/9/2023, did not indicate the IDG members had documented a narrative. There were no signatures on the forms to validate the IDGs attendance and participation in the update of Patient 8s comprehensive assessment. Further review of the records indicated the last IDG form in the record was dated 11/9/2023. The HA failed to ensure the IDG members met and updated Patient 8s comprehensive assessment at least every 15 days. 5. A review of Patient 9s ";Personal Information" record indicated an SOC date of 9/9/2022, with a primary diagnosis of unspecified cirrhosis of liver (damage of the liver). This re-admission was the 12th episode of hospice care. A review of Patient 9s records titled, ";POC/IDG Review", dated 12/21/2023, 1/4/2024, 1/18/2024, 2/1/2024, and 2/15/2024, did not indicate the IDG members had documented a narrative. There were no signatures on the forms to validate the IDGs attendance and participation in the update of Patient 9s comprehensive assessment. The HA failed to ensure the IDG members met and updated Patient 9s comprehensive assessment at least every 15 days. 6. A review of Patient 10s ";Personal Information" record indicated an SOC date of 10/18/2023, with a primary diagnosis of malignant neoplasm of the prostate (cancer). This was the first episode of hospice care. A review of Patient 10s records titled, ";POC/IDG Review", dated 12/21/2023, 1/18/2024, 2/1/2024, and 2/15/2024, did not indicate the IDG members had documented a narrative. There were no signatures on the forms to validate the IDGs attendance and participation in the update of Patient 10s comprehensive assessment. ";POC/IDG Review", dated 1/4/2024 had documentation entered in the narrative section. However, there were no signatures by the IDG members to confirm the documentation was theirs. On 2/23/2024, at 9:30 a.m., the Volunteer Coordinator (VC) provided Patient 10s ";POC/IDG Review" records for 12/21/2023, 1/4/2024, 1/18/2024, 2/1/2024, and 2/15/2024. The records indicated there were notes documented in the narrative section. However, there were no signatures by the IDG members to confirm the documentation was theirs. Based on the VC previous interview, the narratives were entered by the VC and not the IDG members. The HA failed to ensure the IDG members met and updated Patient 10s comprehensive assessment at least every 15 days. 7. A review of Patient 11s ";Personal Information" record indicated an SOC date of 10/17/2023, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, a lung condition where the lungs are unable to adequately provide oxygen to the body). This was the first episode of hospice care. A review of Patient 11s records titled, ";POC/IDG Review", dated 12/21/2023, 1/4/2024, 1/18/2024, 2/1/2024, and 2/15/2024, did not indicate the IDG members had documented a narrative. There were no signatures on the forms to validate the IDGs attendance and participation in the update of Patient 11s comprehensive assessment. On 2/23/2024, at 9:30 a.m., the VC provided Patient 11s ";POC/IDG Review" records for 12/21/2023, 1/4/2024, 1/18/2024, 2/1/2024, and 2/15/2024. The records indicated there were notes documented in the narrative section. However, there were no signatures by the IDG members to confirm the documentation was theirs. Based on the VC previous interview, the narratives were entered by the VC and not the IDG members. The HA failed to ensure the IDG members met and updated Patient 11s comprehensive assessment at least every 15 days. 8. A review of Patient 12s ";Personal Information" record indicated an SOC date of 1/28/2022, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). Patient 12 was transferred from another hospice agency, and continued with episode 14. A review of Patient 12s records titled, ";POC/IDG Review", dated 9/14/2023, 9/28/2023, 10/12/2023, 10/26/2023, and 11/9/2023, did not indicate the IDG members had documented a narrative. There were no signatures on the forms to validate the IDGs attendance and participation in the update of Patient 12s comprehensive assessment. Further review of the records indicated the last IDG form in the record was dated 11/9/2023. On 2/23/2024, at 9:30 a.m., the VC provided Patient 12s ";POC/IDG Review" records for 9/14/2023, 9/28/2023, 10/12/2023, 10/26/2023, and 11/9/2023. The records indicated there were notes documented in the narrative section. However, there were no signatures by the IDG members to confirm the documentation was theirs. Based on the VC previous interview, the narratives were entered by the VC and not the IDG members. The HA failed to ensure the IDG members met and updated Patient 12s comprehensive assessment at least every 15 days. 9. A review of Patient 13s ";Personal Information" record indicated an SOC date of 10/12/2023, with a primary diagnosis of chronic systolic congestive heart failure (heart unable to pump blood effectively to the body). This re-admission was the 30th episode of hospice care. A review of Patient 13s records titled, ";POC/IDG Review," dated 12/7/2023, 12/21/2023, 1/4/2024, and 1/18/2024, did not indicate the IDG members had documented a narrative. There were no signatures on the forms to validate the IDGs attendance and participation in the update of Patient 13s comprehensive assessment. Further review of records ";POC/IDG Review", dated 11/23/2023 and 10/12/2023 indicated narratives were documented. However, there were no IDG member signatures to confirm the information entered. On 2/23/2024, at 9:30 a.m., the VC provided Patient 13s ";POC/IDG Review" records for 12/7/2023, 12/21/2023, 1/4/2024, and 1/18/2024. The records indicated there were notes documented in the narrative section. However, there were no signatures by the IDG members to confirm the documentation was theirs. Based on the VC previous interview, the narratives were entered by the VC and not the IDG members. The HA failed to ensure the IDG members met and updated Patient 13s comprehensive assessment at least every 15 days. 10. A review of Patient 14s ";Personal Information" record indicated an SOC date of 1/24/2022 and an end of care date of 4/3/2023 with a diagnosis of end stage Alzheimers disease (a progressive illness that destroys memory and other important functions). A review of Patient 14s records titled, ";POC/IDG Review", dated 1/4/2022, indicated a nursing narrative was entered. There was no nursing signature on the form to confirm the information entered. A review of Patient 14s records titled, ";POC/IDG Review", dated 1/19/2023, indicated narratives were entered for the discussion of the IDG members. There was no signatures of the IDG members on the form to confirm the information entered. A review of Patient 14s record titled, ";POC/IDG Review," dated 2/1/2023, 2/16/2023, 3/2/2023, and 3/16/2023 did not indicate the IDG group met to update the comprehensive assessment. There were no narratives and no signatures documented by the IDG members. Further review of the records indicated the last IDG form in the record was dated 3/16/2023. During an interview on 2/21/2024, at 11:35 a.m., Licensed Vocational Nurse 2 (LVN 2) stated she visited Patient 14 the day prior to her death. Patient 14 had a caregiver and a husband. LVN 2 stated she notified the volunteer coordinator (VC) that Patient 14 was imminently dying. LVN 2 stated the VC told her what to do such as call the mortuary, provi de post mortem care (preparing the body after death) and waste the medications. LVN 2 stated the only person she spoke to was to the VC. During an interview on 2/22/2024, at 11:32 a.m., the Director of Patient Care Services Designee (DD) stated the Medical Doctor (MD), Registered Nurse (RN), Office Coordinator, Medical Social Worker (MSW), Spiritual Counselor (SC), and Licensed Vocational Nurses (LVNs) were the members of the IDG. During an interview on 2/22/2024, at 11:36 a.m., the Volunteer Coordinator (VC) stated the IDG members had to log in to electronic medical record (EMR) and sign the IDG meeting to validate their attendance at the meeting. During an interview on 2/22/2024, at 11:37 a.m., DD stated each IDG member was supposed to document a brief narrative about the basic changes of the patient, to keep track of the changes and discussion done during the meeting. The RN was supposed to document under section ";nursing". The MSW was supposed to document under section ";Psychosocial". The SC was supposed to document under section ";Spiritual". The MD was not writing a narrative and was only expected to sign the document to validate their attendance. DD stated the IDG group met every two weeks to discuss the condition of the patient and determine if the plan of care needed to change based on the identified needs of the patients. DD stated, "the risk of not having IDG meetings was missed communication, which can lead to wrong care for the patient. If the LVN does not report the changes to the whole team, something can get overlooked, different issues may arise, which never get discusses. This can result in a negative outcome. Nobody wants that." During an interview on 2/22/2024, at 12:00 p.m., the Administrator Designee/Director of Patient Care Services Designee (AD/DD), stated when a patient is imminently dying, the IDG group is supposed to meet to discuss the need for continuous care, comfort medications and comfort measures. During an interview on 2/23/2024, at 10:10 a.m., the VC stated she imported the previous/recent visit notes from the nurse, or the discipline such as MSW, SC and saved it in the IDG meeting. The VC stated she did this because it was empty, to print and have something there, since no one logged in to document. The VC stated she input narrative notes in the IDG for all the patients she noticed were missing documentation. The VC stated she ";dragged" the note from the electronic medical record (EMR). Dragging the note is a function of the EMR. The drag function takes the note from the last note documented and puts it in IDG. The VC stated she did not edit, modify the note, she imported the summary the discipline wrote, saved it and print it. During an interview on 2/23/2024, at 10:15 a.m., the AD/DD stated, "dragging or copying and pasting is not best practice. Because if that is done, the IDG notes might not reflect the changes that have happened since the last note was written. The IDG notes supposed to have what was discussed and what changes were done to the plan of care." A review of Patient 14s record titled, ";Visit Note After Death", dated 4/9/2023, indicated the patient passed away on 4/9/2023. Further review of Patient 14s records did not indicate the IDG group met on 4/8/2023 or 4/9/2023 to discuss Patient 14s status and plan of care for her death and post bereavement needs. The HA failed to ensure the IDG members met and updated Patient 14s comprehensive assessment at least every 15 days and when Patient 14 was imminently dying. A review of HAs policy and procedure titled ";Interdisciplinary Group Meeting" revised 4/2020, indicated ";The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients conditions require. The hospice Medical Director and all hospice interdisciplinary group members will be present... Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor. Patient approaching recertification will be reviewed for the appropriateness of continuation of care based on identifiable criteria and progression of the terminal illness. Patient being discharged from hospice will be reviewed to ensure appropriateness of ongoing care." A review of HAs policy and procedure titled ";Comprehensive Assessment" revised 4/2020, indicated ";The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum every 15 days. The interdisciplinary group is required to only update those sections that require updating. If no changes are needed, then that must be documented. If there has been a change in the patients condition/status, then the comprehensive assessment must be updated."

This Condition is not met as evidenced by: Based on 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 Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) regarding care planning and coordination of services for patients was met as follow: --- The HA failed to ensure a Registered Nurse (RN) was responsible in the continuous implementation of the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) program for ten of 15 sample selected patients (Patient 1, Patient 2, Patient 3, Patient 8. Patient 9. Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This deficient practice resulted in lack of continuous comprehensive assessment and updated plan of care of Patient 1, Patient 2, Patient 3, Patient 8. Patient 9. Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14, to meet care goals in physical, psychosocial, spiritual needs. (Refer to L540). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written rules or law) mandated compliance with Federal regulations for Interdisciplinary group, care planning, and coordination of services.

Based on interview and record review the Hospice Agency (HA) failed to ensure the Registered Nurse (RN) was responsible in the continuous implementation of the interdisciplinary group (IDG – various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) program for ten of 15 sampled patients (Patient 1, Patient 2, Patient 3, Patient 8. Patient 9. Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This deficient practice resulted in lack of continuous comprehensive assessment and updated plan of care of Patient 1, Patient 2, Patient 3, Patient 8. Patient 9. Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14, to meet care goals in physical, psychosocial, spiritual needs. --- 1. A review of Patient 1s ";Personal Information" indicated a start of care date on 10/14/2022, with a diagnosis of unspecified sequelae of cerebral infarction (limited blood flow to the brain). A review of Patient 1s ";Current Treatment/Medication/DME List" undated, indicated ";IDG to review patients status every 14 days and as needed to evaluate changes in condition." A review of Patient 1s ";POC (Plan of Care) Summary" dated ";as of 2/22/2024" indicated ";IDG to review patients status every 14 days and as needed to evaluate changes in condition." A review of Patient 1s ";Re-Cert (recertification) Assessment dated, 9/29/2023 and 11/24/2023, indicated the Re-Cert Assessment was blank. A review of Patient 1s ";POC/IDG Review" dated 12/7/2023 and 12/21/2023, indicated ";POC/IDG Review was not signed by the authors and the nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. A review of Patient 1s ";POC/IDG Review" dated 1/4/2024 and 1/18/2024,, indicated the POC/IDG Review was not signed by the authors and the nursing, spiritual, and other/physician discussion sections were left blank. A review of Patient 1s ";POC/IDG Review" dated 2/1/2024, indicated Patient 1's POC/IDG Review was not signed by the authors and the spiritual discussion section was left blank. During an interview on 2/22/2024, at 11:32 a.m., with the Director of Patient Care Services Designee (DD), DD stated the Medical Doctor (MD), Registered Nurse (RN), office coordinator, Medical Social Worker (MSW), Spiritual Counselor (SC), and Licensed Vocational Nurses (LVNs) were the members of the IDG. During an interview on 2/22/2024, at 11:33 a.m., with the Volunteer Coordinator (VC), VC stated she and the Licensed Vocational Nurse 3 (LVN 3) coordinated the IDGs. During a concurrent interview and record review on 2/22/2024 at 12:40 p.m. with the DD of Patient 1s Electronic Medical Record (EMR), DD stated the last time the IDG members conducted a comprehensive assessment for Patient 1 was on 11/23/2023. During an interview on 2/23/2024, at 10:10 a.m., with the VC, VC stated she imported the previous/recent visit notes from the nurse, or the discipline such as MSW, SC and saved it in the IDG meeting notes because the IDG meeting notes was empty and no one logged in to document. The VC stated she input narrative notes in the IDG for all the patients she noticed were missing documentation. The VC stated she ";dragged" the note from the EMR, last note documentation and puts it in IDG meeting notes. The VC stated she did not edit, modify the note, she imports the summary the discipline wrote, save it and print it. During an interview on 2/23/2024, at 10:15 a.m., the DD stated dragging or copying and pasting is not best practice, because the IDG notes might not reflect the changes that had happened since the last note was written. The IDG notes was supposed to have what was discussed and what changes were done to the plan of care. During an interview on 2/23/2024, at 11:55 a.m., the VC stated the Administrator/Director of Patient Care Services (ADM/DPCS) was hardly in the office and was always sick and has other jobs too. 2. A review of Patient 2s ";Personal Information" record indicated a start of care date on 1/21/2021, with a diagnosis of Alzheimers Disease unspecified (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest task). A review of Patient 2s ";Current Treatment/Medication/DME List" undated, indicated ";IDG to review patients status every 14 days and as needed to evaluate changes in condition." A review of Patient 2s ";POC Summary" dated ";as of 2/22/2024" indicated ";IDG to review patients status every 14 days and as needed to evaluate changes in condition." A review of Patient 2s ";Re-Cert Assessment dated 10/29/2023 and 12/24/2023, indicated form was blank. The form also indicated it was not signed by HA staff. A review of Patient 2s ";POC/IDG Review" dated 12/21/2023, 1/4/2024 and 1/18/2024, indicated form was not signed by the authors and the nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Patient 2's ";POC/IDG Review" dated 2/1/2024, indicated form was not signed by the authors. The form also indicated the psychosocial and other/ physician discussion sections were left blank. A review of Patient 2s ";Updated Assessment dated 2/1/2024, indicated form was blank. The form also indicated it was not signed by HA staff. A review of Patient 2s ";POC/IDG Review" dated 2/15/2024, indicated form was not signed by the authors and the nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. During a concurrent interview and record review on 2/22/2024 at 1:15 p.m. with the DD, Patient 2s Electronic Medical Record (EMR) was reviewed. The DD stated Patient 2s last comprehensive assessment was completed on 7/10/2022. DD stated Patient 2's comprehensive assessments need to be completed to identify if the patient continues to be hospice eligible. DD stated that ";as of right now" Patient 2 ";is not a hospice patient". 3. A review of Patient 3s ";Personal Information" record indicated a start of care date on 2/8/2023, with a diagnosis of chronic obstructive pulmonary disease unspecified (COPD – group of diseases the cause airflow blockage and breathing problems). A review of Patient 3s ";Current Treatment/Medication/DME List" undated, indicated ";IDG to review patients status every 14 days and as needed to evaluate changes in condition." A review of Patient 3s ";Re-Cert Assessment dated 10/2/2023, 11/27/2023, and 1/22/2024 indicated form was blank. The form also indicated it was not signed by HA staff. A review of Patient 3s ";POC/IDG Review" dated 12/21/2023, indicated form was not signed by the authors and the nursing, spiritual, and psychosocial discussion sections were left blank. A review of Patient 3s ";POC/IDG Review" dated 1/4/2024, indicated form was not signed by the authors and the nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. A review of Patient 3s ";POC/IDG Review" dated 1/18/2024, indicated form was not signed by the authors and the nursing, spiritual, and psychosocial discussion sections were left blank. A review of Patient 3s ";POC Summary" dated ";as of 2/22/2024" indicated ";IDG to review patients status every 14 days and as needed to evaluate changes in condition." During a concurrent interview and record review on 2/22/2024 at 1:05 p.m. with the DD of Patient 3s EMR, DD stated Patient 3s last comprehensive assessment was completed on 7/24/2023. DD stated Patient 3 was an active patient and he did not know if Patient 3 was hospice eligible. 4. A review of Patient 8s ";Personal Information" record indicated a start of care date on 1/26/2022, with a diagnosis of hypertensive heart disease without heart failure (high blood pressure). Patient 8 was transferred from another hospice agency and continued with episode 3 of hospice care. A record review of Patient 8s ";POC/IDG Review", dated 9/14/2023, 9/28/2023, 10/12/2023, 10/26/2023, and 11/9/2023, did not indicate the IDG members had documentation of a narrative notes. The POC/IDG Review has no signatures to validate the IDGs attendance and participation in the update of Patient 8s comprehensive assessment. Patient 8s POC/IDG Review indicated the last IDG form in the record was dated 11/9/2023. 5. A review of Patient 9s ";Personal Information" indicated a start of care date on 9/9/2022, with a primary diagnosis of unspecified cirrhosis of liver (damage of the liver). This re-admission was the 12th episode of hospice care. A record review of Patient 9s ";POC/IDG Review", dated 12/21/2023, 1/4/2024, 1/18/2024, 2/1/2024, and 2/15/2024, did not indicate the IDG members had documented a narrative notes. Patient 9s ";POC/IDG Review" did not have signatures to validate the IDGs attendance and participation in the update of Patient 9s comprehensive assessment. 6. A review of Patient 10s ";Personal Information" indicated a start of care date on 10/18/2023, with a primary diagnosis of malignant neoplasm of the prostate (cancer). This was the first episode of hospice care. A record review of Patient 10s ";POC/IDG Review", dated 12/21/2023, 1/18/2024, 2/1/2024, and 2/15/2024, did not indicate the IDG members had documented a narrative notes. Patient 10s ";POC/IDG Review" did not have signatures to validate the IDGs attendance and participation in the update of Patient 10s comprehensive assessment. During a review of Patient 10s ";POC/IDG Review" on 2/23/2024, at 9:30 a.m., with VC, Patient 10s ";POC/IDG Review" dated 12/21/2023, 1/4/2024, 1/18/2024, 2/1/2024, and 2/15/2024 was reviewed. Patient 10s ";POC/IDG Review" dated 12/21/2023, 1/4/2024, 1/18/2024, 2/1/2024, and 2/15/2024 did not have signatures in the narrative section. 7. A review of Patient 11s ";Personal Information" indicated a start of care date on 10/17/2023, with a primary diagnosis of chronic obstructive pulmonary disease (COPD- a lung condition where the lungs are unable to adequately provide oxygen to the body). This was the first episode of hospice care. A record review of Patient 11s ";POC/IDG Review", dated 12/21/2023, 1/4/2024, 1/18/2024, 2/1/2024, and 2/15/2024 did not indicate the IDG members had documented a narrative notes. Patient 11s ";POC/IDG Review", dated 12/21/2023, 1/4/2024, 1/18/2024, 2/1/2024, and 2/15/2024, did not have signatures to validate the IDGs attendance and participation in the update of Patient 11s comprehensive assessment. During a record review of Patient 11s ";POC/IDG Review" on 2/23/2024, at 9:30 a.m., with the VC, Patient 11s ";POC/IDG Review" dated 12/21/2023, 1/4/2024, 1/18/2024, 2/1/2024, and 2/15/2024 were reviewed. Patient 11s ";POC/IDG Review" dated 12/21/2023, 1/4/2024, 1/18/2024, 2/1/2024, and 2/15/2024 indicated there were notes documented in the narrative section but were no signatures by the IDG members. 8. A review of Patient 12s ";Personal Information" indicated a start of care date on 1/28/2022, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). Patient 12 was transferred from another hospice agency and continued with episode 14. A record review of Patient 12s ";POC/IDG Review", dated 9/14/2023, 9/28/2023, 10/12/2023, 10/26/2023, and 11/9/2023, did not indicate the IDG members had documented a narrative notes. Patient 12s ";POC/IDG Review", dated 9/14/2023, 9/28/2023, 10/12/2023, 10/26/2023, and 11/9/2023, did not have signatures to validate the IDGs attendance and participation in the update of Patient 12s comprehensive assessment. Further review of the records indicated the last IDG form in the record was 11/9/2023. During a record review of Patient 12s ";POC/IDG Review" on 2/23/2024, at 9:30 a.m., with the VC, Patient 12s ";POC/IDG Review" records for 9/14/2023, 9/28/2023, 10/12/2023, 10/26/2023, and 11/9/2023 were reviewed. Patient 12s ";POC/IDG Review" records for 9/14/2023, 9/28/2023, 10/12/2023, 10/26/2023, and 11/9/2023 indicated there were notes documented in the narrative section but there were no signatures by the IDG members to confirm the documentation of the IDG. 9. A review of Patient 13s, ";Personal Information" indicated a start of care date on 10/12/2023, with a primary diagnosis of chronic systolic congestive heart failure (heart unable to pump blood effectively to the body). This re-admission was the 30th episode of hospice care. A record review of Patient 13s records ";POC/IDG Review", dated 12/7/2023, 12/21/2023, 1/4/2024, and 1/18/2024, Patient 13s records ";POC/IDG Review", dated 12/7/2023, 12/21/2023, 1/4/2024, and 1/18/2024 did not indicate the IDG members had documented a narrative and did not have signatures to validate the IDGs attendance and participation in the update of Patient 13s comprehensive assessment. Further review of records ";POC/IDG Review", dated 11/23/2023 and 10/12/2023 indicated narratives were documented but there were no IDG member signatures to confirm the information entered. During a record review of Patient 13s ";POC/IDG Review" on 2/23/2024, at 9:30 a.m., with the VC, Patient 13s ";POC/IDG Review" dated 12/7/2023, 12/21/2023, 1/4/2024, and 1/18/2024 were reviewed. Patient 13s ";POC/IDG Review" dated 12/7/2023, 12/21/2023, 1/4/2024, and 1/18/2024 indicated there were notes documented in the narrative section but there were no signatures by the IDG members to confirm the documentation. 10. A review of Patient 14s ";Personal Information" indicated a start of care date on 1/24/2022 and an end of care date of 4/3/2023 with a diagnosis of end stage Alzheimers disease (a progressive illness that destroys memory and other important functions). A record review of Patient 14s ";POC/IDG Review", dated 1/4/2022, Patient 14s ";POC/IDG Review", indicated a nursing narrative was entered and did not have nursing signature to confirm the information entered. A record review of Patient 14s ";POC/IDG Review", dated 1/19/2023, indicated narratives were entered for the discussion of the IDG members but did not have signatures of the IDG members to confirm the information entered. A record review of Patient 14s record titled, ";POC/IDG Review", dated 2/1/2023, 2/16/2023, 3/2/2023, and 3/16/2023 did not indicate the IDG group met to update the comprehensive assessment. There were no narratives and no signatures documented by the IDG members and the last IDG was dated 3/16/2023. A record review of Patient 14s ";Visit Note After Death", dated 4/9/2023, indicated the patient passed away on 4/9/2023. Further review of Patient 14s IDG meeting, did not indicate the IDG group met on 4/8/2023 or 4/9/2023 to discuss Patient 14s status and plan of care for her death and post bereavement (the situation of having recently lost a significant person through death) needs. During an interview on 2/21/2024, at 11:35 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she visited Patient 14 the day prior to her death. LVN 2 stated Patient 14 had a caregiver and a husband. LVN 2 stated she notified the volunteer coordinator (VC) that Patient 14 was imminently dying. LVN 2 stated the VC told her what to do such as call the mortuary, provide postmortem care (preparing the body after death) and waste the medications. LVN 2 stated, she only spoke with the VC. During an interview on 2/22/2024, at 12:00 p.m., with the Administrator Designee/Director of Patient Care Services Designee (AD/DD), AD/DD stated when a patient is imminently dying, the IDG group was supposed to meet to discuss the need for continuous care, comfort medications and comfort measures. A review of HAs policy and procedure titled ";Interdisciplinary Group Meeting" revised 4/2020, indicated ";The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients conditions require. The hospice Medical Director and all hospice interdisciplinary group members will be present... Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor. Patient approaching recertification will be reviewed for the appropriateness of continuation of care based on identifiable criteria and progression of the terminal illness. Patient being discharged from hospice will be reviewed to ensure appropriateness of ongoing care." A review of HAs policy and procedure titled ";Comprehensive Assessment" revised 4/2020, indicated ";The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum every 15 days. The interdisciplinary group is required to only update those sections that require updating. If no changes are needed, then that must be documented. If there has been a change in the patients condition/status, then the comprehensive assessment must be updated."

Based on interview and record review the Hospice Agency (HA) failed to ensure hospice care and services were provided in accordance to the plan of care for two of 15 sample selected patients (Patient 10 and Patient 11). This deficient practice resulted in patients not being assessed to determine if they still qualified for hospice care services. --- A review of Patient 11s ";Personal Information" record indicated a start of care date on 10/17/2023, with a primary diagnosis of chronic obstructive pulmonary disease (COPD- a lung condition where the lungs are unable to adequately provide oxygen to the body). This was the first episode of hospice care. A review of Patient 11s record titled, ";POC Summary", dated 2/22/2024, indicated, ";RN (Registered Nurse) Re-Certifications for Period #2 no later than 1/15/2024. During an interview on 2/22/2024, at 11:23 a.m., the Administrator Designee/Director of Patient Care Services Designee (DD) stated a registered nurse is responsible in doing a recertification assessment two weeks prior to the end of the care episode to re-determine if the patient needs to continue hospice care. During a concurrent interview and record review on 2/23/2024, at 10:47 a.m., DD reviewed Patient 11s record titled, ";Recert Assessment", dated 1/12/2024. DD stated the document was no complete because there was nothing written. The DD stated the assessment was probably done but it was not documented because the opportunity didnt arise to document it. A review of Patient 10s ";Personal Information" record indicated a start of care date on 10/18/2023, with a primary diagnosis of malignant neoplasm of the prostate (cancer). This was the first episode of hospice care. A review of Patient 10s record titled, ";POC Summary", dated 2/22/2024, indicated, ";MD (doctor) Re-Certification for Period #2 no later than 1/16/2024...RN Re-Certifications for Period #2 no later than 1/16/2024." During a concurrent interview and record review on 2/23/2024, at 10:58 a.m., DD reviewed Patient 10s record titled, ";Recert Assessment", dated 1/12/2024. The DD stated there was no assessment written. The DD stated he assessed Patient 10, but it was not documented because there was no time. The DD stated the Certification of Terminal Illness was not done by the doctor either. There were no doctor notes in the medical record to support continuation of hospice care.

Based on interview and record review the Hospice Agency (HA) failed to provide bereavement (the situation of having recently lost a significant person through death) services to two of 15 sample selected patients (Patient 6 and Patient 14) and their family/caregiver. This deficient practice resulted in grieving family/caregiver did not receive support by means of the HAs bereavement services after their family member's death --- During an interview on 2/22/2024, at 11:54 a.m., the Director of Patient Care Services Designee (DD) stated the initial bereavement assessment was for grieving families. The time frame for doing the initial bereavement assessment was 5 days from admission. The Medical Social Worker (MSW) was responsible in doing it if the patient agreed. During an interview on 2/22/2024, at 12:00 p.m., DD stated once a patient passes, the Medical Social Worker (MSW) and the Spiritual Counselor (SC) calls to offer services. At the site, the nurse asks the bereaved if they would like the MSW and SC to contact them. If the bereaved decline services, the agency would document it in the patient record. All interventions done should be documented. AD/DD stated the agency sends letters to the bereaved at one, three, and six months after the patient dies. 1. A review of Patient 6s ";Personal Information" record indicated a start of care date on 1/30/2021 and an end of care date of 8/6/2023, with a diagnosis of Alzheimers Disease unspecified (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest task). A review of Patient 6s EMR titled ";History of Bereavement Assessment; History of Bereavement POC; History of Post Death Bereavement Assessment; History or Bereavement Letters; and Post Death Bereavement Support" undated, indicated there was nothing documented. A review of Patient 6s medical record form titled ";Current Treatment/Medication/DME List" undated, indicated ";MSW-Bereavement Assessment should be completed within 5 days from SOC." A review of Patient 6s medical record form titled ";POC Summary" dated ";as of 2/22/2024" indicated ";MSW-Bereavement Assessment should be completed within 5 days from SOC." During a concurrent interview and record review on 2/22/2024 at 1:55 p.m. with DD of Patient 6s EMR, DD stated Patient 6 passed away on 8/6/2023. DD stated there was no bereavement documentation. DD stated Patient 6s authorized representative/emergency contact was not provided bereavement support. DD stated the last documented visit note was made on 7/30/2023. DD stated Patient 6 did not receive postmortem or bereavement care. DD stated families need to be offered the services to assist with their loss/grief. 2. A review of Patient 14s ";Personal Information" record indicated a start of care date on 1/24/2022 and an end of care date of 4/3/2023 with a diagnosis of end stage Alzheimers disease (a progressive illness that destroys memory and other important functions). During an interview on 2/21/2024, at 11:35 a.m., Licensed Vocational Nurse 2 (LVN 2) stated she visited Patient 14 the day prior to her death. Patient 14 had a caregiver and a husband. LVN 2 stated she notified the volunteer coordinator (VC) that Patient 14 was imminently dying. LVN 2 stated the VC told her what to do such as call the mortuary, provide postmortem care (preparing the body after death) and waste the medications. LVN 2 state the only person she spoke to was to the VC. During an interview on 2/22/2024, at 12:12 p.m., the VC stated Patient 14s daughter lived out of the country and refused letters. During a concurrent interview and record review on 2/23/2024 at 9:36 a.m., DD reviewed Patient 14s medical records. DD stated the record did not have anything mentioning about refusal of letters. There was nothing in the record to indicate the daughter refused the letters. The correct process should have been to put a note that bereavement services were offered and declined. The HA also needed to offer MSW and SC services for the bereaved. DD stated he did not see any documentation to support that the agency did that. There was no Chaplain notes, no MSW notes, nothing under Bereavement notes. The purpose of the MSW in bereavement was to bring possible resources to the family they might not be aware are available. The purpose of the SC was to assess the spiritual preferences and help get the representative of the clergy, to help with the grieving process. During a concurrent interview and record review on 2/23/2024 at 9:45 a.m., DD reviewed Patient 14s medical record and stated the initial bereavement assessment was needed to make the bereavement plan of care (POC). The purpose of the bereavement POC, was to help patients family with the grieving process. The psychological issues. It deferred from medical POC. To help the families/grieved with the psychosocial issue of loss. No POC was done for this patient because there was no initial bereavement assessment. During a telephone interview on 2/23/2024 at 9;10 a.m. with the Medical Social Worker (MSW), MSW stated she was not responsible for conducting initial bereavement assessments. MSW stated the HAs Spiritual Counselor (SC) did the patients bereavement assessments. On 2/23/2024 at 9:50 a.m. the SC was called; there was no answer. A message with call back number left. A review of HAs policy and procedure titled ";Comprehensive Assessment" revised 4/2020, indicated ";A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. During the comprehensive patient assessment, all baseline date and other relevant information will be documented, through interview and observation, in the patients clinical record, including at least the following information, as relevant: A bereavement assessment of the needs of the patient family and other individuals... The assessment should determine: Anticipated discharge needs, including bereavement and funeral needs." A review of HAs policy and procedure titled ";Bereavement Services" revised 4/2020, indicated ";(HA) will provide an organized bereavement program supervised by a qualified bereavement Coordinator for up to one (1) year following the death of the patient. The program will provide bereavement services to the families/caregivers of hospice patients both before and after the patients death in accordance with the plan of care. After death has occurred, the bereavement assessment will be updated, and the family/caregiver needs will be discussed at the next interdisciplinary group meeting. Within two (2) weeks after the death of a patient, a sympathy card will be sent to the bereaved. After three (3) weeks, a bereavement letter will be sent to the bereaved giving support and outlining the hospice bereavement services. Within three (3) to five (5) weeks after the patient death, a bereavement assessment will be collected by the bereavement counselor following the family/caregiver. Ongoing bereavement contact will be concluded at the end of up to one (1) year, if the bereaved is no longer in need of hospice bereavement services. Bereavement assessment and clinical notes will be submitted to the patients permanent clinical record." A review of HAs policy and procedure titled ";Bereavement Assessment" revised 4/2020, indicated ";On admission, the hospice registered nurse will complete a bereavement screening assessment that is given to the Bereavement Coordinator. The bereavement counselor will complete the bereavement risk assessment to determine potential needs of the survivors. After the death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment. The Bereavement Coordinator will develop a plan for intervention based on the findings of the bereavement follow-up assessment. Upon completion all bereavement documentation will be filed."

Based on 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 HA failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) had a responsibility for the medical component of the hospices patient care program, including initial certification of terminal illness (CTI) for five of 15 sample selected patients (Patient 5, Patient 9, Patient 10, Patient 11, and Patient 13) by failing to: Ensure there was a physicians signature and documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice are and services. (Refer to L 667). 2. The HA failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for twelve of 15 sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). (Refer to L 668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on interview and record review the Hospice Agency (HA) failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) had a responsibility for the medical component of the hospices patient care program, including initial certification of terminal illness (CTI) for five of 15 sample selected patients (Patient 5, Patient 9, Patient 10, Patient 11, and Patient 13) by failing to: Ensure there was a physicians signature and documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice are and services. These deficient practices resulted in the hospice medical director and/or physician designee certifying the patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- During an interview on 2/22/2024 at 10:58 a.m. with the Volunteer Coordinator (VC), VC stated both the Medical Director 1 (MD1) and Medical Director 2 (MD2) log into their Electronic Medical Record (EMR) system to complete and sign patients CTIs. During an interview on 2/22/2024, at 11:06 a.m., the Director of Patient Care Services Designee (DD) stated the hospice doctor had to assess the patient within 5 days of admission, in person. During an interview on 2/22/2024 at 11:27 a.m. with DD, DD stated the Local Coverage of Determination (LCD) guidelines are used. DD stated the use of LCD guidelines are not optional. During an interview on 2/22/2024, at 11:49 a.m., DD stated the doctor was responsible to document and sign the certification and determination of terminal illness within 5 days from admission. The documentation entailed a written summary, never a huge narrative, and a face-to-face summary, to include the physical assessment. DD stated the doctor used a history and physical report (a document that explains the patients past medical history, current treatment, and plan) for sure and if available, other documents to support the terminal illness such as laboratory tests and hospital discharge documents. DD stated the primary information used to determine if patient was hospice eligible was history and physical, the diagnosis, and the personal assessment. 1. A review of Patient 5s ";Personal Information" record indicated a start of care date on 1/25/2022, with a diagnosis of hypertensive heart disease without heart failure (high blood pressure). It also indicated starting certification was #18. A review of Patient 5s ";Personal Information" medical record from Hospice Agency 2 (HA2) indicated a start of care date on 2/6/2019 and an end of care date of 1/25/2022, with a diagnosis of end stage hypertensive heart disease without heart failure (high blood pressure). It also indicated starting certification was #1. A review of Patient 5s medical record form titled ";Physicians Certification for Hospice Benefit" dated 3/23/2022-5/21/2022, 11/13/2023-1/11/2024, 1/12/2024-3/11/2024, indicated sections Certifying Physician Summary were left blank. The forms also indicated they were not signed by the physician. During a concurrent interview and record review on 2/22/2024 at 1:45 p.m. with the DD of Patient 5s EMR, DD stated he did not know if Patient 5 was eligible to receive hospice services. DD stated there were no physician face to face or a history and physical on file. DD stated Patient 5s CTIs were not signed. DD stated, ";With what I have on hand her diagnosis is a qualifying diagnosis, thats all I can tell you." DD stated Patient 5 was admitted from another hospice agency. The HA failed to ensure MD 1 certified Patient 5 for hospice care. A review of Patient 9s ";Personal Information" record indicated a start of care date on 9/9/2022, with a primary diagnosis of unspecified cirrhosis of liver (damage of the liver). This re-admission was the 12th episode of hospice care. A record review of Patient 9s record titled, ";CTI", for 9/9/2022 to 11/7/2022, indicated this was the 12th certification for hospice care. Further review of the record indicated a physician (doctor) narrative. However, the document was not signed by Medical Doctor 1 (MD 1) A record review of Patient 9s record titled, ";Audit Log", from 10/18/2018 to 2/23/2024. indicated the Physician Narrative of the CTI beginning on 9/9/2022 was documented by Licensed Vocational Nurse 3 (LVN 3). During an interview on 2/23/2024, at 12:00 p.m., LVN 3 stated she added the notes based on what the doctor had emailed her. LVN 3 stated she copied and paste the notes on the email sent by the doctor, onto the CTI. LVN 3 stated the doctor had to sign the CTI. During an interview on 2/23/2024, at 12:09 p.m., the Volunteer Coordinator (VC) stated the HA did not have emails for 2022 because she deleted them. The VC stated, ";Im going to be honest with you, I will not have emails for 2022, I deleted them". The HA failed to ensure MD 1 certified Patient 9 for hospice care. A review of Patient 10s ";Personal Information" record indicated a start of care date on 10/18/2023, with a primary diagnosis of malignant neoplasm of the prostate (cancer). This was the first episode of hospice care. A review of Patient 10s record titled, ";CTI", for certification period 10/16/2023 to 1/15/2024, did not indicate Medical Doctor 1 (MD 1) entered a narrative nor did he sign the document. The HA admitted Patient 10 to hospice services without MD 1s certification for hospice benefit. A review of Patient 11s ";Personal Information" record indicated a start of care date on 10/17/2023, with a primary diagnosis of chronic obstructive pulmonary disease (COPD- a lung condition where the lungs are unable to adequately provide oxygen to the body). This was the first episode of hospice care. A review of Patient 11s record titled, ";CTI", for certification period 10/17/2023 to 1/14/2024, did not indicate Medical Doctor 1 (MD 1) entered a narrative nor did he sign the document. The HA admitted Patient 11 to hospice services without MD 1s certification for hospice benefit. A review of Patient 13s, ";Personal Information" record indicated a start of care date on 10/12/2023, with a primary diagnosis of chronic systolic congestive heart failure (heart unable to pump blood effectively to the body). This re-admission was the 30th episode of hospice care. A review of Patient 13s record titled, ";CTI", for certification period 10/12/2023 to 12/10/2023 indicated notes were entered under the physician (doctor) narrative section. Further review of the record indicated the Medical Director 1 (MD 1) electronically signed the form under the section ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". A review of Patient 13s record titled, ";Audit Log", from 10/18/2018 to 2/23/2024, indicated the narrative entered for 10/12/2023, was entered by the Administrator and Director of Patient Care Services (ADM/DPCS), and not MD 1. The ADM/DPCS was not available during the survey for an interview. Continued review of the ";Audit Log" indicated MD 1 signed the document on 2/15/2024. The HA failed to ensure MD 1 certified Patient 13 for hospice services on the start of care (10/12/2023). A review of HAs policy and procedure titled ";Admission Criteria and Process" revised 4/2020, indicated ";The patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCD). Eligibility criteria will be continually reviewed on an ongoing basis by the interdisciplinary team to assure appropriateness of hospice care. The organization will utilize referral information provided by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician offices in the determination of eligibility for admission to the program." A review of HAs policy and procedure titled ";Certification of Terminal Illness" revised 4/2020, indicated ";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. At the time of admission to hospice, the hospice Medical Director or the patients attending physician will complete a certification narrative that reflects the patients individual circumstances base on: his/her review of the patients medical record, or if applicable, examination of the patient. The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election. Clinical information and other documentation that support the medial prognosis must accompany the certification and must be filed in the clinical record with the written certification. Initially, the clinical information may be provided verbally, and must be documented in the clinical record and included as part of the hospices eligibility assessment. The hospice physician or nurse practitioner must have a face-to-face encounter with the patient within the 30 days prior to the 3rd benefit period recertification and within 30 days prior to each subsequent benefit period recertification. Tools such as the fiscal intermediarys Local Coverage Determination, along with other supporting documentation, can be used to provide guidance in determining and documenting terminal prognosis."

Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for twelve of 15 sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). These deficient practices resulted in the hospice medical director and/or physician designee certifying the patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- During an interview on 2/22/2024 at 10:58 a.m. with the Volunteer Coordinator (VC), VC stated both the Medical Director 1 (MD1) and Medical Director 2 (MD2) log into their Electronic Medical Record (EMR) system to complete and sign patients CTIs. During an interview on 2/22/2024, at 11:06 a.m., the Director of Patient Care Services Designee (DD) stated the hospice doctor had to assess the patient within 5 days of admission, in person. During an interview on 2/22/2024 at 11:27 a.m. with DD, DD stated the Local Coverage of Determination (LCD) guidelines are used. DD stated the use of LCD guidelines are not optional. During an interview on 2/22/2024, at 11:49 a.m., the Director of Patient Care Services Designee (DD) stated the doctor had 14 days prior to the expiration of the episode to recertify the patient for hospice care. 1. A review of Patient 1s ";Personal Information" record indicated a start of care date on 10/14/2022, with a diagnosis of unspecified sequelae of cerebral infarction (limited blood flow to the brain). A review of Patient 1s medical record form titled ";Physicians Certification for Hospice Benefit" dated 10/9/2023-12/7/2023; 12/8/2023-2/5/2024; and 2/6/2024-4/5/2024, indicated sections RN (Registered Nurse) Assessment Narrative and Certifying Physician Summary were left blank. The forms also indicated they were not signed by the physician. During a review of HAs facility form titled ";Audit Log" dated from 10/18/2022-2/23/2024, indicated License Vocational Nurse 3 (LVN3) documented under the physician narrative: Certifying Physician Summary and Face to Face Summary on 2/20/2024 for visit date of 2/6/2024. During a telephone interview on 2/21/2024 at 11:25 a.m. with Patient 1s Care Giver 4 (CG4), CG4 stated she was told Patient 1 had six months to two years to live in 2016 when he was hospitalized. CG4 stated Patient 1 was doing well, and that no one has told her again, that he had six months or less to live. During a concurrent interview and record review on 2/22/2024 at 2:13 p.m. with the Director of Patient Care Services Designee (DD) of Patient 1s medical record form titled ";Physicians Certification for Hospice Benefit" dated 2/6/2024-4/5/2024, DD stated the form was not signed by the physician. DD stated the form needed to be signed five days from the last face to face visit. DD stated Patient 1s last face to face visit was conducted on 2/5/2024. DD stated he was not able to locate documentation that supported Patient 1s findings on the initial assessment conducted by him. DD stated he used his nursing judgement, doctors and familys input to determine Patient 1s hospice eligibility. The HA continued hospice services for Patient 1 without a re-certification from the Medical Director. 2. A review of Patient 2s ";Personal Information" record indicated a start of care date on 1/21/2021, with a diagnosis of Alzheimers Disease unspecified (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest task). A review of Patient 2s medical record form titled ";LCD Hospice Eligibility Determination" dated 2/1/2024 and 12/24/2023, indicated both forms were left blank. A review of Patient 2s medical record form titled ";Physicians Certification for Hospice Benefit" dated 7/10/2023-9/7/2023; 9/8/2023-11/16/2023; 11/17/2023-1/5/2024; 1/6/2024-3/5/2024, indicated sections RN (Registered Nurse) Assessment Narrative and Certifying Physician Summary were left blank. The forms also indicated they were not signed by the physician. During a review of HAs facility form titled ";Audit Log" dated from 10/18/2022-2/23/2024, indicated Administrator/Director of Patient Care Services (ADM/DPCS) documented under the physician narrative: Certifying Physician Summary on 3/23/2022 for visit date of 3/17/2022. During an interview on 2/21/2024 at 10 a.m. with Patient 2s Care Giver (CG3), CG3 stated she takes care of Patient 2 every day. CG3 stated, ";He is in good state/good health. He eats well; he doesnt have any issues. He is not vegetative. Nothing indicates he will die soon. He is engaged, he is alert sometimes; his physical state is quite stable. He doesnt have pain or wounds, he is good." During a concurrent observation and interview on 2/21/2024 at 10:35 a.m. with Patient 2s Medical Doctor 3 (MD3) in Patient 2s residence, MD3 noted walking into Patient 2s bedroom. MD3 stated she was not aware Patient 2 was receiving hospice services. During an interview on 2/21/2024 at 11:10 a.m. with MD3, MD3 stated she has seen Patient 2 three times at his residence, on 12/20/2023, 1/24/2024, and 2/21/2024. MD3 stated. ";He is stable, I didnt refer him to hospice. From the last three months Ive seen him, he is stable. It was not my referral." During a concurrent interview and record review on 2/22/2024 at 1:15 p.m. with the DD of Patient 2s EMR, DD stated the last CTI on record that was filled out and signed by the doctor was on 3/17/2022-5/15/2022. DD stated the last documented face to face Patient 2 had been on 3/14/2022. DD stated Patient 2s diagnosis of Alzheimers made him a candidate for hospice care. DD stated that as of ";right now" Patient 2 is not a hospice patient because his CTI is not filled or signed by the doctor. The HA continued hospice services for Patient 2 without a re-certification from the Medical Director. 3. A review of Patient 3s ";Personal Information" record indicated a start of care date on 2/8/2023, with a diagnosis of chronic obstructive pulmonary disease unspecified (COPD – group of diseases the cause airflow blockage and breathing problems). A review of Patient 3s medical record form titled ";LCD Hospice Eligibility Determination" dated 10/2/2023, 11/27/2023 and 1/22/2024, indicated all forms were left blank. A review of Patient 3s medical record form titled ";Physicians Certification for Hospice Benefit" dated 10/6/2023-12/4/2023, 12/5/2023-2/2/2024, and 2/3/2024-4/2/2024, indicated sections RN (Registered Nurse) Assessment Narrative and Certifying Physician Summary were left blank. The forms also indicated they were not signed by the physician. During a review of HAs facility form titled ";Audit Log" dated from 10/18/2022-2/23/2024, indicated License Vocational Nurse 3 (LVN3) documented under the physician narrative: Face to Face Summary on 5/12/2023 for visit date of 5/9/2023. LVN3 documented under the physician narrative: Certifying Physician Summary and Face to Face Summary on 5/12/2023 for visit date of 2/8/2023. The form also indicated the ADM/DPCS documented under the physician narrative: Certifying Physician Summary and Face to Face Summary on 2/19/2023 for visit date of 2/8/2023. During a concurrent interview and record review on 2/22/2024 at 1:05 p.m. with the DD of Patient 3s EMR, DD stated the last CTI on record that was filled out and signed by the doctor was on 8/7/2023-10/5/2023. DD stated there was no face to face documented for Patient 3. DD stated Patient 3s LCDs did not qualify him for hospice care. The HA continued hospice services for Patient 3 without a re-certification from the Medical Director. 4. A review of Patient 4s ";Personal Information" record indicated a start of care date on 6/3/2020, with a diagnosis of Alzheimers Disease unspecified (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest task). A review of Patient 4s medical record form titled ";LCD Hospice Eligibility Determination" dated 1/7/2024, indicated form was left blank. A review of Patient 4s medical record form titled ";Physicians Certification for Hospice Benefit" dated 1/14/2024-3/13/2024, indicated section Certifying Physician Summary was left blank. The form also indicated it was not signed by the physician. During a review of HAs facility form titled ";Audit Log" dated from 10/18/2022-2/23/2024, indicated LVN3 unlocked Certification MD on 7/17/2021 for visit date of 6/3/2020. LVN3 added to the RN assessment narrative on 7/17/2021 for visit date of 6/3/2020, ";hypertensive heart and chronic kidney disease with heart failure." During a concurrent interview and record review on 2/22/2024 at 1:30 p.m. with the DD of Patient 4s EMR, DD stated the last CTI on record that was filled out and signed by the doctor was on 11/15/2023. DD stated there was no history and physical on file. DD stated he did not know if Patient 4 qualified for hospice care. The HA continued hospice services for Patient 4 without a re-certification from the Medical Director. 5. A review of Patient 5s ";Personal Information" record indicated a start of care date on 1/25/2022, with a diagnosis of hypertensive heart disease without heart failure (high blood pressure). It also indicated starting certification was #18. A review of Patient 5s ";Personal Information" medical record from Hospice Agency 2 (HA2) indicated a start of care date on 2/6/2019 and an end of care date of 1/25/2022, with a diagnosis of end stage hypertensive heart disease without heart failure (high blood pressure). It also indicated starting certification was #1. A review of Patient 5s medical record form titled ";Physicians Certification for Hospice Benefit" dated 3/23/2022-5/21/2022, 11/13/2023-1/11/2024, 1/12/2024-3/11/2024, indicated sections Certifying Physician Summary were left blank. The forms also indicated they were not signed by the physician. During a review of HAs facility form titled ";Audit Log" dated from 10/18/2018-2/23/2024, indicated LVN3 documented under the physician narrative: Face to Face Summary on 5/23/2023 for visit date of 9/19/2022 and on 9/20/2022 for a visit date of 9/19/2022. LVN3 made changes to Certification MD Certification By on 8/23/2023 for visit dates of 7/21/2022, 5/22/2022, and 3/23/2022. During a concurrent interview and record review on 2/22/2024 at 1:45 p.m. with the DD of Patient 5s EMR, DD stated he did not know if Patient 5 was eligible to receive hospice services. DD stated there were no physician face to face or a history and physical on file. DD stated Patient 5s CTIs were not signed. DD stated, ";With what I have on hand her diagnosis is a qualifying diagnosis, thats all I can tell you." DD stated Patient 5 was admitted from another hospice agency. The HA continued hospice services for Patient 5 without a re-certification from the Medical Director. 6. A review of Patient 6s ";Personal Information" record indicated a start of care date on 1/30/2021 and an end of care date of 8/6/2023, with a diagnosis of Alzheimers Disease unspecified (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest task). A review of Patient 6s medical record form titled ";Physicians Certification for Hospice Benefit" dated 5/20/2023-7/18/2023 and 7/19/2023-9/16/2023, indicated sections Certifying Physician Summary were left blank. The forms also indicated they were not signed by the physician. During a concurrent interview and record review on 2/22/2024 at 1:55 p.m. with the DD of Patient 6s EMR, DD stated according to Patient 6 LCD guidelines she qualified for hospice because of weight loss of 10% or an albumin blood lever of <2.5. DD stated he was unable to find documentation to support the weight loss or the albumin blood level. DD stated he did not know where they got that information. DD stated there was no history and physical on file for Patient 6. DD stated that there was no documentation that supported patients admission into hospice care. The HA continued hospice services for Patient 6 without a re-certification from the Medical Director. A review of Patient 8s ";Personal Information" record indicated a start of care date on 1/26/2022, with a diagnosis of hypertensive heart disease without heart failure (high blood pressure). Patient 8 was transferred from another hospice agency and continued with episode 3 of hospice care. During a concurrent interview and record review on 2/23/2024, at 11:22 a.m., the DD reviewed Patient 8s record titled, ";CTI", for certification period 12/30/2023 to 2/27/2024. The record indicated this was the 15th certification. There was no signature from the doctor. DD stated the document was blank and nothing was documented. A review of Patient 8s record titled, ";CTI", for certification period 10/31/2023 to 12/29/2023 indicated this was the 14th certification period. Further review of the record did not indicate a doctor narrative nor a doctor signature. The HA continued hospice services without a re-certification from the Medical Director. A review of Patient 9s ";Personal Information" record indicated a start of care date on 9/9/2022, with a primary diagnosis of unspecified cirrhosis of liver (damage of the liver). This re-admission was the 12th episode of hospice care. A record review of Patient 9s record titled, ";CTI", for 11/3/2023 to 1/1/2024, indicated this was the 19th certification for hospice care. Further review of the record indicated a physician (doctor) narrative. However, the document was not signed by Medical Doctor 2 (MD 2). A record review of Patient 9s record titled, ";CTI", for 1/2/2024 to 3/1/2024, indicated this was the 20th certification for hospice care. The record did not indicate MD 2 wrote a narrative, nor did MD 2 sign the certification. The HA continued hospice services without a re-certification from the Medical Director. A review of Patient 10s ";Personal Information" record indicated a start of care date on 10/18/2023, with a primary diagnosis of malignant neoplasm of the prostate (cancer). This was the first episode of hospice care. During a concurrent interview and record review on 2/23/2024, at 10:58 a.m., the DD reviewed Patient 10s record titled, ";CTI", from 1/16/2024 to 4/14/2024. The record indicated no documentation by MD 1 nor a signature. DD stated the Certification of Terminal Illness was not done by the doctor either. There was no doctor notes in the medical record to support continuation of hospice care. The HA continued hospice services without a re-certification from the Medical Director. A review of Patient 11s ";Personal Information" record indicated a start of care date on 10/17/2023, with a primary diagnosis of chronic obstructive pulmonary disease (COPD- a lung condition where the lungs are unable to adequately provide oxygen to the body). This was the first episode of hospice care. A review of Patient 11s record titled, ";CTI", for certification period 1/15/2024 to 4/13/2024, did not indicate Medical Doctor 1 (MD 1) entered a narrative nor did he sign the document. The record indicated this was the 2nd certification. The HA continued hospice services without a re-certification from the Medical Director. A review of Patient 12s ";Personal Information" record indicated a start of care date on 1/28/2022, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). Patient 12 was transferred from another hospice agency and continued with episode 14. During a concurrent interview and record review on 2/23/2024, at 10:28 a.m., DD reviewed Patient 12s record titled, ";CTI (Physicians Certification for Hospice Benefit", for certification period 2/2/2024 to 4/1/2024. DD stated the document was not complete because there was nothing written. DD stated, ";yes, I would say that because nothing is in the CTI either.", when asked if this patient was recertified for hospice care without assessment or documented evidence on why the patient should remain in hospice? A review of Patient 12s record titled, ";CTI", for certification period 12/4/2023 to 2/1/2024, did not indicate a doctors narrative or a doctors signature. Patient 12 was recertified for hospice care without documented evidence of the need for services. A review of Patient 13s, ";Personal Information" record indicated a start of care date on 10/12/2023, with a primary diagnosis of chronic systolic congestive heart failure (heart unable to pump blood effectively to the body). This re-admission was the 30th episode of hospice care. A review of Patient 13s record titled, ";CTI", for certification period 12/11/2023 to 2/8/2024 indicated the document was for the 31st episode of recertification. Further review of the record indicated the Medical Director 1 (MD 1) documented the date of 12/11/2023, as the date of when the recertification was signed. A review of Patient 13s record titled, ";Audit Log", from 10/18/2018 to 2/23/2024, indicated MD 1 had electronically signed the ";CTI" for visit date 12/11/2023 on 2/15/2024, not 12/11/2023. The HA failed to ensure MD 1 re-certified Patient 13 for hospice services on 12/11/2023. A review of Patient 13s record titled, ";CTI", for certification period 2/9/2023 to 4/8/2024 indicated the document was for the 32nd episode of recertification. Further review of the record indicated the MD 1 documented the date of 2/9/2024, as the date of when the recertification was signed. A review of Patient 13s record titled, ";Audit Log", from 10/18/2018 to 2/23/2024, indicated MD 1 had electronically signed the ";CTI" for visit date 2/9/2024 on 2/15/2024, not 2/9/2024. The HA failed to ensure MD 1 re-certified Patient 13 for hospice services on 2/9/2024. A review of HAs policy and procedure titled ";Admission Criteria and Process" revised 4/2020, indicated ";The patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCD). Eligibility criteria will be continually reviewed on an ongoing basis by the interdisciplinary team to assure appropriateness of hospice care. The organization will utilize referral information provided by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician offices in the determination of eligibility for admission to the program." A review of HAs policy and procedure titled ";Certification of Terminal Illness" revised 4/2020, indicated ";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. Clinical information and other documentation that support the medial prognosis must accompany the certification and must be filed in the clinical record with the written certification. A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice medical director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patients medical record or, in applicable, examination of the patient. 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 to two (2) calendar days after the first day of each period. The hospice physician or nurse practitioner must have a face-to-face encounter with the patient within the 30 days prior to the 3rd benefit period recertification and within 30 days prior to each subsequent benefit period recertification. Tools such as the fiscal intermediarys Local Coverage Determination, along with other supporting documentation, can be used to provide guidance in determining and documenting terminal prognosis."

Based on interview and record review the hospice agency (HA) failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for one of 15 sampled patients (Patient 12). This failure resulted in an unauthorized and inaccurate patient information or assessment entered in the patients clinical record that could affect the patients quality of care and well-being. --- During an interview on 2/22/2024 at 10:58 a.m. with the Director of Patient Care Services Designee (DD), DD stated the documentation on patients notes are identified by staff electronic signatures. DD stated the author of the note is the one who is responsible for making changes. During an interview on 2/22/2024, at 11:26 a.m., the DD stated staff have their own log in access to the Electronic Medical Record (EMR). The staff sign the records electronically. The staff members sign the note by pressing a sign button in the EMR. A review of Patient 12s ";Personal Information" record indicated a start of care date on 1/28/2022, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). Patient 12 was transferred from another hospice agency and continued with episode 14. During a concurrent interview and record review on 2/23/24 at 10:28 a.m., DD reviewed Patient 12s document titled, ";Initial Comprehensive Assessment", dated 1/28/2022. DD stated the note was incomplete. The note did not indicate who the author was.

Upon patient record review, 2 of 11 (Patient #2, #7) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2: There was no evidence in the medical record of an initial bereavement assessment. Patient #7: There was no evidence in the medical record of an initial bereavement assessment.

Upon client record review, 2 of 11 (Patient #4 and #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: The nurse visit frequency was ordered from admission and throughout care as 1xweekly. During the week of 3/6/2022 and 3/13/2022, there was no evidence of nurse visits completed. Patient #7: The nurse made visits throughout the last month, there was not a specific frequency ordered for nursing visits. Ordered as 1prn.

Upon patient record review 2 of 6 applicable medical records (Patient #1, #11) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: Hospice aide was ordered upon admission 2xweekly. During the week of 2/27/2022, the hospice aide completed only one visit. During the week of 3/6/2022, there were no hospice aide visits completed. During the week of 3/13/2022, the hospice aide completed only one visit. Additionally, the aide plan of care assigned the task of recording last bowel movement on each visit. On 2/3/2022 and 3/17/2022 there is no evidence of documentation of the last bowel movement. Patient #11: The hospice aide plan of care included assigned tasks of clean nails, deodorant, shampoo, comb, shave, and record BM on each visit. On the aide visit note completed on 2/15/2022, the aide did not document completion of these tasks.

Upon patient record review, 1 of 3 applicable (Patient #8) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #8: There was no evidence of the physician narrative included on the recertification for recert period 3/13/2022 to 5/11/2022.

Upon patient client record review, 1 of 11 (Patient #7) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #7: The election statement form was blank in the area of elect or not to elect to receive patient notification of hospice non-covered items, services, and drugs.

Upon patient client record review, 1 of 11 (Patient #1) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: On 1/23/2022, the nurse documented on the nurse visit note in the narrative instructions provided including "Any skin breakdown should be reported to Daylight Hospice immediately."