Every finding on record at Touching Hearts Hospice, LLC

The agency failed to ensure that the Condition of Participation: L 500 418.52 Patients Rights was in compliance as follows: 1. Based on interview and record review, the agency failed to provide the Hospice Election Statement (an explanation of hospice services, a life expectancy of six months or less to live, and an abandoning of curative treatments and acceptance of palliative care), Consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of the suggested medical care), and Notice of Rights and Responsibilities (Bill of Rights- a document that provides patients with information on how they can reasonably expect to be treated during their hospice care) in a language and manner the patients understood for two of five sampled patients (Patients 1 and 2) when Patients 1 and 2 were Spanish speakers and could not speak and/or read English. (Refer to L 502) 2. Based on interview and record review, the agency failed to ensure the patients had a confidential clinical record for two of five sampled patients (Patients 1 and 2) when the agency allowed two unauthorized people to have access to Patient 1 and 2's protected health information (PHI-individually identifiable health data related to an individual's past, present, or future medical condition, treatment, and payment). (Refer to L 516) The cumulative effect of these systemic practices had the potential to result in Patients 1 and 2 not to understand the meaning of hospice, a life expectancy of six months or less to live, an abandoning of curative treatments and acceptance of palliative care and their Bill of Rights. In addition, these failures had the potential to cause Patients 1 and 2 to suffer identity theft (use of a person's private identifying information for financial gain), financial fraud (someone being scammed out of their money through theft or deceit), discrimination (unfair or prejudicial treatment of patients based on characteristics like race, ethnicity, gender, age, disability, sexual orientation, or socioeconomic status), damage to reputation through stigmatization (unfairly regarded by people as being bad or having something to be ashamed of), and ruining trust in healthcare providers.

Based on interview and record review, the agency failed to provide the Hospice Election Statement (an explanation of hospice services, a life expectancy of six months or less to live, and an abandoning of curative treatments and acceptance of palliative care) Consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of the suggested medical care) and Notice of Rights and Responsibilities (Bill of Rights- a document that provides patients with information on how they can reasonably expect to be treated during their hospice care) in a language and manner the patients understood for two of five sampled patients (Patients 1 and 2) when Patients 1 and 2 were Spanish speakers and could not speak and/or read English. This failure had the potential to cause Patients 1 and 2 not to understand the meaning of hospice, a life expectancy of six months or less to live, an abandoning of curative treatments and acceptance of palliative care and their Bill of Rights. --- Findings: An unannounced visit was made to the agency on March 10, 2025, at 10:16 AM, to investigate a complaint of Hospice fraud (falsely billing Medicare for unneeded or undelivered hospice services, including enrolling ineligible patients and providing non-covered services, often with the intent to profit illegally). 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated Patient 1 was a non-admission (non-admit: patients who do not meet the hospice admission criteria or cannot be cared for by the agency) and Patient 1s primary language was Spanish. A review of Patient 1s Comprehensive Nursing Assessment, dated January 14, 2025, indicated the following: a. Is there a need for an interpreter? Yesb. If Yes, offer of interpreter, Declinedc. Primary admitting diagnosis: Atherosclerotic heart disease of native coronary arteries, (or coronary artery disease (CAD), a condition where plaque buildup (atherosclerosis) narrows the arteries that supply blood to the heart, potentially leading to reduced blood flow and heart problems like chest pain or a heart attack)d. Cardiovascular (relating to the heart and blood vessels): Stasis Ulcer (an open sore that develops on the lower legs or ankles due to poor blood flow and vein failure, where blood pools in the veins instead of returning to the heart), Left leg ulcer.e. Integumentary-Skin: Patient has open wound on her left lower leg. States due to poor circulation.f. Narrative & Disease Trajectory (course): ";Received referral to our office to evaluate and admit this 88 [year old] Hispanic American female to [name of hospice agency] with hospice [diagnosis] of [Atherosclerotic heart disease of native coronary arteries] ... Skilled assessment of whole-body functions performed. Patient is sitting in [her] chair resting when assessed. Patient is alert and responding appropriately to questions asked. Breathing pattern normal and regular, no cough or congestions, normal lung sound heard upon [listening with the stethoscope]. Patient is ambulatory [can walk], high risk for fall. Patient has open wound on her left lower leg. States due to poor circulation. Heart sounds s1 and s2 [can hear normal closing of the hearts valves], without murmurs [an extra sound, like a whooshing or swishing], [outlying] pulses [can be felt]. [Belly] is soft, non-distended, non-tender, bowel sound present in all [four sections]. No constipation or diarrhea reported. Appetite is good tolerating 70% [percent] to 80% of meal. SN [Skilled Nurse] reinforced the importance of hand washing, infection control and fall precaution." A review of Patient 1s ";Release of Information and Consent for Patient," dated January 14, 2025, written in the English language and signed by Patient 1, indicated, ";THIS IS TO REQUEST THAT [Patient 1] BE ADMITTED TO THE [Name of the hospice agency] PROGRAM, IN RELATION OF THAT, I ACKNOWLEDGE, CONSENT, AND AGREE TO FOLLOWING: PROGRAM GOALS: We understand that hospice care is palliative, not curative, in its goal and techniques, that the program emphasizes controlling physical symptoms, including pain, and meeting emotional and spiritual needs of patient and family in dealing with the illness for which patient is admitted. PATIENT SELF DETERMINATION ACT AND BILL OF RIGHTS: I have received a written statement of rights as a patient of [Name of the agency]. I understand my rights because they have been explained to me and my questions have been answered. I have received written and verbal information about advance directives, company policies, applicable by law, my rights state law, the state hot line number, and other information necessary to make decisions about advance directives and my care in accordance with the Patient Self Determination Act of 1990. ..." A review of Patient 1s ";Hospice Election Statement," dated January 14, 2025, written in the English language and signed by Patient 1, indicated, ";Patient Name: [Name of Patient 1], Hospice Agency Name: [Name of Hospice Agency], Hospice Election: I, (Patient Name) choose to elect the Medicare hospice benefit and receive Hospice services from (Name of Hospice Agency) to begin on (Start of Care Date). ..." 2. A review of Patient 2s face sheet, undated, indicated Patient 2 was a non-admit and Patient 2s primary language was Spanish. A review of Patient 2s Comprehensive Nursing Assessment, dated January 14, 2025, indicated the following: a. Is there a need for an interpreter? Yesb. If Yes, offer of interpreter, Acceptedc. Primary admitting diagnosis: Atherosclerotic heart disease of native coronary arteries.d. Narrative & Disease Trajectory: ";On assessment time, patient is [Patient 1 was alert and oriented to person, place, and time] and able to verbalize needs. Lungs are clear in all [areas] on auscultation and [blood contains oxygen at] 94% on [room air] ... patient is getting enough sleep, about [eight to nine hours in 24 hours]. Appetite is good with no problem." A review of Patient 2s ";Release of Information and Consent for Patient," dated January 14, 2025, written in the English language and signed by Patient 2, indicated, ";THIS IS TO REQUEST THAT [Patient 2] BE ADMITTED TO THE [Name of the hospice agency] PROGRAM, IN RELATION OF THAT, I ACKNOWLEDGE, CONSENT, AND AGREE TO FOLLOWING: PROGRAM GOALS: We understand that hospice care is palliative, not curative, in its goal and techniques, that the program emphasizes controlling physical symptoms, including pain, and meeting emotional and spiritual needs of patient and family in dealing with the illness for which patient is admitted. PATIENT SELF DETERMINATION ACT AND BILL OF RIGHTS: I have received a written statement of rights as a patient of [Name of the agency]. I understand my rights because they have been explained to me and my questions have been answered. I have received written and verbal information about advance directives, company policies, applicable by law, my rights state law, the state hot line number, and other information necessary to make decisions about advance directives and my care in accordance with the Patient Self Determination Act of 1990. ..." A review of Patient 2s ";Hospice Election Statement," dated January 14, 2025, written in the English language and signed by Patient 2, indicated, ";Patient Name: [Name of Patient 2], Hospice Agency Name: [Name of Hospice Agency], Hospice Election: I, (Patient Name) choose to elect the Medicare hospice benefit and receive Hospice services from (Name of Hospice Agency) to begin on (Start of Care Date). ..." During an interview with a Registered Nurse (RN 1) on March 11, 2025, at 11:46 AM, RN 1 stated she had been scheduled to conduct an initial assessment and a hospice evaluation for Patients 1 and 2, who were husband and wife, on January 14, 2025. RN 1 stated she met a Potential/Marketer/Interpreter (P/M/I) at Patients 1 and 2s home to translate because Patients 1 and 2 did not speak or read English and RN 1 did not speak Spanish. RN 1 stated the P/M/I began translating her questions to Patients 1 and 2 but started to have difficulty and called her son to take over the translation. RN 1 stated the P/M/Is son conducted the translation for the rest of the visit over the phone and she did not know nor ever met the P/M/I or her son before this visit. RN 1 stated she did not know if the P/M/Is son explained what hospice was, the hospice election statement or the patients bill of rights because she could not understand what the P/M/Is son was saying. RN 1 stated it became clear to her after the evaluation that neither Patient 1 nor Patient 2 were appropriate for hospice services, but she was concerned about Patient 1s left leg ulcer because her leg was swollen, oozing and ";just looked terrible." RN 1 stated she was told the P/M/I had referred Patients 1 and 2 to the agency for hospice services and she told the P/M/I not to refer patients to the agency who were not sick enough to be on hospice because it cost the agency money to send her out to assess and evaluate the patients. RN 1 stated there was no physicians order referring Patients 1 and 2 for hospice services, RN 1 did not know who Patients 1 and 2s attending physician was and she had no H&P (History and Physical-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), to review before her visit. During an interview with the Director of Patient Care Services (DPCS) on March 12, 2025, from 10:31 AM to 11:04 AM, the DPCS stated the P/M/I had contacted the Administrator/Owner (Admin/Owner) of the agency requesting a position as a marketer and Spanish language interpreter and had referred Patients 1 and 2 to the agency for hospice services. The DPCS stated the P/M/I had not been hired by the agency and a background check, credential verification or previous employment history or reference check had not been conducted. The DPCS stated she had no knowledge of the P/M/Is son. The DPCS stated the agency proceeded with the initial assessment/hospice evaluation visit for Patients 1 and 2 and knew the P/M/I would need to be present to translate because Patients 1 and 2 only spoke and read Spanish. The DPCS stated the agency did not have any staff who spoke Spanish and did not have or provided Spanish language, Hospice Election Statements, Consents, or Notices of Rights and Responsibilities. A review on the agencys policy and procedure titled ";Patient Bill of Rights," dated April 2023, indicated, ";PURPOSE: To encourage awareness of patient rights, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. POLICY: Each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights as described. The rights contained within this policy include the basic rights of the patient. ... PROCEDURE: ... The Patient Bill of Rights will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand. ... Written information will be provided to patients in the predominant languages of the population served. ..."

Based on interview and record review, the agency failed to ensure the patients had a confidential clinical record for two of five sampled patients (Patients 1 and 2) when the agency allowed two unauthorized people to have access to Patient 1 and 2's protected health information (PHI-individually identifiable health data related to an individual's past, present, or future medical condition, treatment, and payment). This failure had the potential to cause Patients 1 and 2 to suffer identity theft (use of a person's private identifying information for financial gain), financial fraud (someone being scammed out of their money through theft or deceit), discrimination (unfair or prejudicial treatment of patients based on characteristics like race, ethnicity, gender, age, disability, sexual orientation, or socioeconomic status), damage to reputation through stigmatization (unfairly regarded by people as being bad or having something to be ashamed of), and ruining trust in healthcare providers. --- Findings: During an interview with the Complainant on March 5, 2025, at 12:39 PM, the Complainant stated her mother (Patient 1) was phoned by a woman (a potential/marketer/interpreter for the hospice agency-P/M/I) who told (Patient 1) she had reached out to her a year ago and that (Patient 1) did not qualify for a program but that (Patient 1) did now, could she visit (Patient 1). The complainant stated (Patient 1) agreed to meet but did not remember meeting the P/M/I a year ago but that the P/M/I spoke with (Patient 1) as if they were friends and the P/M/I said the program provided free medications, free medical equipment, including a hospital bed and wound care for (Patient 1s) ulcers. The Complainant stated during the visit (Patient 1) said that at no time was the word hospice mentioned, and (Patient 1) was not aware she was placed in hospice at home and that (Patient 1) would lose her right to see her doctors. The Complainant stated when she confronted the agency, she was told the P/M/I had said (Patient 1) was her friend, but (Patient 1) has no memory of ever meeting the P/M/I or being acquainted with her. The Complainant stated the agency enrolled her father (Patient 2) at the same visit and (Patient 2) should not be on hospice either. 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated Patient 1 was a non-admission (non-admit: patients who do not meet the hospice admission criteria or cannot be cared for by the agency) and Patient 1s primary language was Spanish. A review of Patient 1s Comprehensive Nursing Assessment, dated January 14, 2025, indicated the following: a. Is there a need for an interpreter? Yesb. If Yes, offer of interpreter, Declinedc. Primary admitting diagnosis: Atherosclerotic heart disease of native coronary arteries, (or coronary artery disease (CAD), a condition where plaque buildup (atherosclerosis) narrows the arteries that supply blood to the heart, potentially leading to reduced blood flow and heart problems like chest pain or a heart attack)d. Cardiovascular (relating to the heart and blood vessels): Stasis Ulcer (an open sore that develops on the lower legs or ankles due to poor blood flow and vein failure, where blood pools in the veins instead of returning to the heart), Left leg ulcer.e. Integumentary-Skin: Patient has open wound on her left lower leg. States due to poor circulation.f. Narrative & Disease Trajectory (course): ";Received referral to our office to evaluate and admit this 88 [year old] Hispanic American female to [name of hospice agency] with hospice [diagnosis] of [Atherosclerotic heart disease of native coronary arteries] ... Skilled assessment of whole-body functions performed. Patient is sitting in [her] chair resting when assessed. Patient is alert and responding appropriately to questions asked. Breathing pattern normal and regular, no cough or congestions, normal lung sound heard upon [listening with the stethoscope]. Patient is ambulatory [can walk], high risk for fall. Patient has open wound on her left lower leg. States due to poor circulation. Heart sounds s1 and s2 [can hear normal closing of the hearts valves], without murmurs [an extra sound, like a whooshing or swishing], [outlying] pulses [can be felt]. [Belly] is soft, non-distended, non-tender, bowel sound present in all [four sections]. No constipation or diarrhea reported. Appetite is good tolerating 70% [percent] to 80% of meal. SN [Skilled Nurse] reinforced the importance of hand washing, infection control and fall precaution." A review of Patient 1s ";Release of Information and Consent for Patient," dated January 14, 2025, written in the English language and signed by Patient 1, indicated, ";THIS IS TO REQUEST THAT [Patient 1] BE ADMITTED TO THE [Name of the hospice agency] PROGRAM, IN RELATION OF THAT, I ACKNOWLEDGE, CONSENT, AND AGREE TO FOLLOWING: PROGRAM GOALS: We understand that hospice care is palliative, not curative, in its goal and techniques, that the program emphasizes controlling physical symptoms, including pain, and meeting emotional and spiritual needs of patient and family in dealing with the illness for which patient is admitted. PATIENT SELF DETERMINATION ACT AND BILL OF RIGHTS: I have received a written statement of rights as a patient of [Name of the agency]. I understand my rights because they have been explained to me and my questions have been answered. I have received written and verbal information about advance directives, company policies, applicable by law, my rights state law, the state hot line number, and other information necessary to make decisions about advance directives and my care in accordance with the Patient Self Determination Act of 1990. ..." A review of Patient 1s ";Hospice Election Statement," dated January 14, 2025, written in the English language and signed by Patient 1, indicated, ";Patient Name: [Name of Patient 1], Hospice Agency Name: [Name of Hospice Agency], Hospice Election: I, (Patient Name) choose to elect the Medicare hospice benefit and receive Hospice services from (Name of Hospice Agency) to begin on (Start of Care Date). ..." 2. A review of Patient 2s face sheet, undated, indicated Patient 2 was a non-admit and Patient 2s primary language was Spanish. A review of Patient 2s Comprehensive Nursing Assessment, dated January 14, 2025, indicated the following: a. Is there a need for an interpreter? Yesb. If Yes, offer of interpreter, Acceptedc. Primary admitting diagnosis: Atherosclerotic heart disease of native coronary arteries.d. Narrative & Disease Trajectory: ";On assessment time, patient is [Patient 1 was alert and oriented to person, place, and time] and able to verbalize needs. Lungs are clear in all [areas] on auscultation and [blood contains oxygen at] 94% on [room air] ... patient is getting enough sleep, about [eight to nine hours in 24 hours]. Appetite is good with no problem." A review of Patient 2s ";Release of Information and Consent for Patient," dated January 14, 2025, written in the English language and signed by Patient 2, indicated, ";THIS IS TO REQUEST THAT [Patient 2] BE ADMITTED TO THE [Name of the hospice agency] PROGRAM, IN RELATION OF THAT, I ACKNOWLEDGE, CONSENT, AND AGREE TO FOLLOWING: PROGRAM GOALS: We understand that hospice care is palliative, not curative, in its goal and techniques, that the program emphasizes controlling physical symptoms, including pain, and meeting emotional and spiritual needs of patient and family in dealing with the illness for which patient is admitted. PATIENT SELF DETERMINATION ACT AND BILL OF RIGHTS: I have received a written statement of rights as a patient of [Name of the agency]. I understand my rights because they have been explained to me and my questions have been answered. I have received written and verbal information about advance directives, company policies, applicable by law, my rights state law, the state hot line number, and other information necessary to make decisions about advance directives and my care in accordance with the Patient Self Determination Act of 1990. ..." A review of Patient 2s ";Hospice Election Statement," dated January 14, 2025, written in the English language and signed by Patient 2, indicated, ";Patient Name: [Name of Patient 2], Hospice Agency Name: [Name of Hospice Agency], Hospice Election: I, (Patient Name) choose to elect the Medicare hospice benefit and receive Hospice services from (Name of Hospice Agency) to begin on (Start of Care Date). ..." During an interview with a Registered Nurse (RN 1) on March 11, 2025, at 11:46 AM, RN 1 stated she had been scheduled to conduct an initial assessment and a hospice evaluation for Patients 1 and 2, who were husband and wife, on January 14, 2025. RN 1 stated she met a Potential/Marketer/Interpreter (P/M/I) at Patients 1 and 2s home to translate because Patients 1 and 2 did not speak or read English and RN 1 did not speak Spanish. RN 1 stated the P/M/I began translating her questions to Patients 1 and 2 but started to have difficulty and called her son to take over the translation. RN 1 stated the P/M/Is son conducted the translation for the rest of the visit over the phone and she did not know nor ever met the P/M/I or her son before this visit. RN 1 stated she did not know if the P/M/Is son explained what hospice was, the hospice election statement or the patients bill of rights because she could not understand what the P/M/Is son was saying. RN 1 stated it became clear to her after the evaluation that neither Patient 1 nor Patient 2 were appropriate for hospice services, but she was concerned about Patient 1s left leg ulcer because her leg was swollen, oozing and ";just looked terrible." RN 1 stated she was told the P/M/I had referred Patients 1 and 2 to the agency for hospice services and she told the P/M/I not to refer patients to the agency who were not sick enough to be on hospice because it cost the agency money to send her out to assess and evaluate the patients. RN 1 stated there was no physicians order referring Patients 1 and 2 for hospice services, RN 1 did not know who Patients 1 and 2s attending physician was and she had no H&P (History and Physical-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), to review before her visit. During an interview with the Director of Patient Care Services (DPCS) on March 12, 2025, from 10:31 AM to 11:04 AM, the DPCS stated the P/M/I had contacted the Administrator/Owner (Admin/Owner) of the agency requesting a position as a marketer and Spanish language interpreter and had referred Patients 1 and 2 to the agency for hospice services. The DPCS stated the P/M/I had not been hired by the agency and a background check, credential verification or previous employment history or reference check had not been conducted. The DPCS stated she had no knowledge of the P/M/Is son. The DPCS stated the agency proceeded with the initial assessment/hospice evaluation visit for Patients 1 and 2 and knew the P/M/I would need to be present to translate because Patients 1 and 2 only spoke and read Spanish. The DPCS stated the agency did not have any staff who spoke Spanish and did not have or provided Spanish language, Hospice Election Statements, Consents, or Notices of Rights and Responsibilities. During an interview with a Licensed Vocational Nurse/Intake Coordinator/Marketer (LVN/IC/M) on March 13, 2025, from 9:51 AM to 10:22 AM, the LVN/IC/M stated the Admin/Owner gave her the information for Patients 1 and 2 and the referral source and contact person as the P/M/I and asked her to check the patients eligibility for hospice services. The LVN/IC/M stated she talked to the P/M/I and asked how to get in touch with the patients to set up a meeting and the P/M/I told her the two patients were Spanish speakers and the P/M/I would coordinate and schedule the visit, and the P/M/I would be there to translate. The LVN/IC/M stated the P/M/I called her back with the schedule and then she called RN 1 and scheduled her for the initial assessment/hospice evaluation visit. The LVN/IC/M stated she heard from the Admin/Owner the P/M/I knew the patients through a family friend and she did not ask the P/M/I who the attending physician was. The LVN/IC/M stated the P/M/I sent her pictures of the patients Medicare cards and drivers licenses. The LVN/IC/M stated she sends out the RN to assess and evaluate the patients for hospice services before asking who or contacting the attending physician for a referral order and H&P and it was her expectation the P/M/I had obtained permission from the patients themselves to come and make the visit. The LVN/IC/M stated RN 1 told her the patients were not hospice appropriate, so the agency did not proceed with the admission and the patients were put under the non-admit area of the clinical record. The LVN/IC/M stated she received a call from a physician who identified himself as Patients 1 and 2s attending physician and asked if Patients 1 and 2 were on our services and asked for a discharge order proving they were not on our service. The LVN/IC/M stated she created a verbal order indicating the patients had declined services, sent it to the attending physician then deleted it and she did not keep the name or phone number of the physician. The LVN/IC/M stated she received a call from Patients 1 and 2s daughter asking how the agency got the information on her parents and the LVN/IC/M told the daughter about the P/M/I, gave her the P/M/Is phone number and said the P/M/I told the agency she knew Patients 1 and 2. The LVN/IC/M stated the daughter was upset because she did not know how the P/M/I had gotten her parents information, the LVN/IC/M stated she told the daughter because the P/M/I said she knew your parents and ";As far as I know your parents know her." During an interview with the Admin/Owner on March 13, 2025, at 12:14 PM, the Admin/Owner stated he had been talking with his friends looking for candidates to fill the positions for Administrator, Marketer and Spanish language interpreter and a close friend of his gave him the name and phone number of the P/M/I for the Marketer and Spanish language interpreter positions. The Admin/Owner stated he called the P/M/I and conducted a telephone interview and during the interview the P/M/I told him she had close family friends who needed help, needed hospice. The Admin/Owner stated he asked the P/M/I to come into the office to fill out an application, employment paperwork and gather information for a background check but the P/M/I never came, the P/M/I was asked again and she said she would come but she never did, so the Admin/Owner did not pursue employing the P/M/I and did not speak with her again. The Admin/Owner stated he gave the LVN/IC/M the information on Patients 1 and 2 and the contact information for the P/M/I and ask her to call the P/M/I to coordinate the hospice evaluation process for Patients 1 and 2. The Admin/Owner stated he did not know anything about Patients 1 and 2s evaluation visit or what happened during the visit because that was his teams job. The Admin/Owner stated he knew Patients 1 and 2 only spoke Spanish and he had set in motion an evaluation visit with the P/M/I translating when he knew the agency had not conducted a background check, credential verification or previous employment history or reference check on the P/M/I. The Admin/Owner stated, ";This is my fault, and I shouldnt have let it happen." The P/M/I was not available for interview. A review on the agencys policy and procedure titled ";Patient Bill of Rights," dated April 2023, indicated, ";PURPOSE: To encourage awareness of patient rights, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. POLICY: Each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights as described. The rights contained within this policy include the basic rights of the patient. ... PROCEDURE: 1. The Patient Bill of Rights statement defines the right of the patient to: ... H. Confidentiality of the patient and clinical records maintained by the organization and the policies and procedures regarding disclosure. ... P. Be able to identify visiting personnel through proper identification. ... The Patient Bill of Rights will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand. ..."

The agency failed to ensure that the Condition of Participation: L 520 §418.54 Initial and Comprehensive assessment of the patient was in compliance as follows: Based on interview and record review, the agency failed to ensure the findings during the initial assessment of non-admit (non-admission: patients who do not meet the hospice admission criteria or cannot be cared for by the agency) patients were reported to the Director of Patient Care Services (DPCS) in order for appropriate referrals to other sources of care were made, the patients attending physicians were notified of the assessment findings from the non-admit and the record of the non-admit indicated the date of the referral, services required, attending physicians, reasons for the non-admit, and referrals to other care facilities, for two of five sampled patients (Patients 1 and 2). (Refer to L 522) The cumulative effect of these systemic practices resulted in the potential to cause Patients 1 and 2s immediate care needs to go untreated, Patients 1 and 2s attending physicians to be unaware hospice services were not provided and an inaccurate clinical record leading to incorrect diagnoses, treatments and fraudulent billing practices.

Based on interview and record review, the agency failed to ensure the findings during the initial assessment of non-admit (non-admission: patients who do not meet the hospice admission criteria or cannot be cared for by the agency) patients were reported to the Director of Patient Care Services (DPCS) in order for appropriate referrals to other sources of care were made, the patients attending physicians were notified of the assessment findings from the non-admit and the record of the non-admit indicated the date of the referral, services required, attending physicians, reasons for the non-admit, and referrals to other care facilities, for two of five sampled patients (Patients 1 and 2). This failure had the potential to cause Patients 1 and 2s immediate care needs to go untreated, Patients 1 and 2s attending physicians to be unaware hospice services were not provided and an inaccurate clinical record leading to incorrect diagnoses, treatments and fraudulent billing practices. --- Findings: 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated Patient 1 was a non-admit and Patient 1s primary language was Spanish. A review of Patient 1s Comprehensive Nursing Assessment, dated January 14, 2025, indicated the following: a. Is there a need for an interpreter? Yesb. If Yes, offer of interpreter, Declinedc. Primary admitting diagnosis: Atherosclerotic heart disease of native coronary arteries, (or coronary artery disease (CAD), a condition where plaque buildup (atherosclerosis) narrows the arteries that supply blood to the heart, potentially leading to reduced blood flow and heart problems like chest pain or a heart attack)d. Cardiovascular (relating to the heart and blood vessels): Stasis Ulcer (an open sore that develops on the lower legs or ankles due to poor blood flow and vein failure, where blood pools in the veins instead of returning to the heart), Left leg ulcer.e. Integumentary-Skin: Patient has open wound on her left lower leg. States due to poor circulation.f. Narrative & Disease Trajectory (course): ";Received referral to our office to evaluate and admit this 88 [year old] Hispanic American female to [name of hospice agency] with hospice [diagnosis] of [Atherosclerotic heart disease of native coronary arteries] ... Skilled assessment of whole-body functions performed. Patient is sitting in [her] chair resting when assessed. Patient is alert and responding appropriately to questions asked. Breathing pattern normal and regular, no cough or congestions, normal lung sound heard upon [listening with the stethoscope]. Patient is ambulatory [can walk], high risk for fall. Patient has open wound on her left lower leg. States due to poor circulation. Heart sounds s1 and s2 [can hear normal closing of the hearts valves], without murmurs [an extra sound, like a whooshing or swishing], [outlying] pulses [can be felt]. [Belly] is soft, non-distended, non-tender, bowel sound present in all [four sections]. No constipation or diarrhea reported. Appetite is good tolerating 70% [percent] to 80% of meal. SN [Skilled Nurse] reinforced the importance of hand washing, infection control and fall precaution." 2. A review of Patient 2s face sheet, undated, indicated Patient 2 was a non-admit and Patient 2s primary language was Spanish. A review of Patient 2s Comprehensive Nursing Assessment, dated January 14, 2025, indicated the following: a. Is there a need for an interpreter? Yesb. If Yes, offer of interpreter, Acceptedc. Primary admitting diagnosis: Atherosclerotic heart disease of native coronary arteries.d. Narrative & Disease Trajectory: ";On assessment time, patient is [Patient 1 was alert and oriented to person, place, and time] and able to verbalize needs. Lungs are clear in all [areas] on auscultation and [blood contains oxygen at] 94% on [room air] ... patient is getting enough sleep, about [eight to nine hours in 24 hours]. Appetite is good with no problem." During an interview with a Registered Nurse (RN 1) on March 11, 2025, at 11:46 AM, RN 1 stated she had been scheduled to conduct an initial assessment and a hospice evaluation for Patients 1 and 2, who were husband and wife, on January 14, 2025. RN 1 stated she met a Potential/Marketer/Interpreter (P/M/I) at Patients 1 and 2s home to translate because Patients 1 and 2 did not speak or read English and RN 1 did not speak Spanish. RN 1 stated it became clear to her after the evaluation that neither Patient 1 nor Patient 2 were appropriate for hospice services, but she was concerned about Patient 1s left leg ulcer because her leg was swollen, oozing and ";just looked terrible." RN 1 stated she was told the P/M/I had referred Patients 1 and 2 to the agency for hospice services. RN 1 stated there was no physicians order referring Patients 1 and 2 for hospice services, RN 1 did not know who Patients 1 and 2s attending physician was and she had no H&P (History and Physical-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), to review before her visit. RN 1 stated she reported her assessment findings to a Licensed Vocational Nurse/Intake Coordinator/Marketer (LVN/IC/M) and indicated Patients 1 and 2 were not appropriate for hospice services. RN 1 stated she did nothing further in regard to Patients 1 and 2. During an interview with the DPCS on March 12, 2025, from 10:31 AM to 11:04 AM, the DPCS stated the P/M/I had contacted the Administrator/Owner (Admin/Owner) of the agency requesting a position as a marketer and Spanish language interpreter and had referred Patients 1 and 2 to the agency for hospice services. The DPCS stated the agency proceeded with the initial assessment/hospice evaluation visit for Patients 1 and 2 and knew the P/M/I would need to be present to translate because Patients 1 and 2 only spoke and read Spanish. The DPCS stated RN 1 had not reported to her the findings or assessment that Patients 1 and 2 were not appropriate for hospice services but this report would go to the LVN/IC/M, and she was responsible to complete all the requirements for a non-admit. The DPCS confirmed Patients 1 and 2 had not received appropriate referrals to other sources of care, Patients 1 and 2s attending physicians were not identified or notified of the assessment findings from the non-admit and Patients 1 and 2s record of the non-admit did not indicate the date of the referral, services required, attending physicians, reasons for the non-admit, or referrals to other care facilities. During an interview with the LVN/IC/M on March 13, 2025, from 9:51 AM to 10:22 AM, the LVN/IC/M stated the Admin/Owner gave her the information for Patients 1 and 2 and the referral source and contact person as the P/M/I and asked her to check the patients eligibility for hospice services. The LVN/IC/M stated she talked to the P/M/I and asked how to get in touch with the patients to set up a meeting and the P/M/I told her the two patients were Spanish speakers and she would coordinate and schedule the visit, and she would be there to translate. The LVN/IC/M stated the P/M/I called her back with the schedule and then she called RN 1 and scheduled her for the initial assessment/hospice evaluation visit. The LVN/IC/M stated she heard from the Admin/Owner the P/M/I knew the patients through a family friend and she did not ask the P/M/I who the attending physician was. The LVN/IC/M stated she sends out the RN to assess and evaluate the patients for hospice services before asking who or contacting the attending physician for a referral order and H&P and it was her expectation the P/M/I had obtained permission from the patients themselves to come and make the visit. The LVN/IC/M stated RN 1 told her the patients were not hospice appropriate, so the agency did not proceed with the admission and the patients were put under the non-admit area of the clinical record. The LVN/IC/M stated she received a call from a physician who identified himself as Patients 1 and 2s attending physician and asked if Patients 1 and 2 were on our services and asked for a discharge order proving they were not on our service. The LVN/IC/M stated she created a verbal order indicating the patients had declined services, sent it to the attending physician then deleted it and she did not keep the name or phone number of the physician. The LVN/IC/M stated she had not provided the physician with RN 1s assessment findings from the initial assessment visit and she had not reported Patients 1 and 2s non-admit status or any of the circumstances surrounding Patients 1 and 2s non-admission to the DPCS. The LVN/IC/M confirmed Patients 1 and 2 had not received appropriate referrals to other sources of care, Patients 1 and 2s attending physicians were not identified or notified of the assessment findings from the non-admit and Patients 1 and 2s record of the non-admit did not indicate the date of the referral, services required, attending physicians, reasons for the non-admit, or referrals to other care facilities. The LVN/IC/M stated none of this was necessary because the agency had not admitted Patients 1 and 2 to the hospice agency. A review of the agencys policy and procedure titled ";Admission Criteria and Process," dated April 2023, indicated, ";PURPOSE: To establish standards and a process by which a patient can be evaluated and accepted for admission. POLICY: ... [Name of the agency] reserves the right not to accept any patient who does not meet the admission criteria. A patient will be referred to other resources if [Name of the agency] cannot meet his/her needs. ... PROCEDURE: ... 15. The hospice registered nurse will complete an initial assessment during this visit within 48 hours after the election of the hospice care. ... 20. If a patient does not meet the admission criteria or cannot be cared for by [Name of the agency] the Clinical Supervisor should be notified and appropriate referrals to other sources of care made on behalf of the patient. 21. The following individuals should be notified of non-admits: A. Patient B. Physician C. Referral source (if not physician). 22. A record of non-admits will be kept for statistical purposes, with date of referral, date of assessment, patient name, services required, physician, reason for non-admit, referral to other hospice care facilities, etc. ..."

The agency failed to ensure the Condition of Participation: L 648 §418.100 Organization and administration of services was in compliance when: Based on interview and record review, the Governing Body (GB) failed to operate and manage the agency from January 3, 2024, to March 13, 2025, for five of five samples patients (Patients 1, 2, 3, 4, and 5), when: 1. The agency failed to provide the Hospice Election Statement (an explanation of hospice services, a life expectancy of six months or less to live, and an abandoning of curative treatments and acceptance of palliative care), Consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of the suggested medical care), and Notice of Rights and Responsibilities, (Bill of Rights- a document that provides patients with information on how they can reasonably expect to be treated during their hospice care) in a language and manner the patients understood for two of five sampled patients (Patients 1 and 2) when Patients 1 and 2 were Spanish speakers and could not speak and/or read English. (Refer to L 651) 2. The agency failed to ensure the patients had a confidential clinical record for two of five sampled patients (Patients 1 and 2) when the agency allowed two unauthorized people to have access to Patient 1 and 2's protected health information (PHI-individually identifiable health data related to an individual's past, present, or future medical condition, treatment, and payment). (Refer to L 651) 3. The agency failed to ensure the findings during the initial assessment of non-admit (non-admission: patients who do not meet the hospice admission criteria or cannot be cared for by the agency) patients were reported to the Director of Patient Care Services (DPCS) in order for appropriate referrals to other sources of care were made, the patients attending physicians were notified of the assessment findings from the non-admit and the record of the non-admit indicated the date of the referral, services required, attending physicians, reasons for the non-admit, and referrals to other care facilities, for two of five sampled patients (Patients 1 and 2). (Refer to L 651) 4. The agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for three of five sampled patients (Patients 3, 4 and 5) when: a. For Patients 3, 4, and 5 the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. (Refer to L 651) b. For Patient 5, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. (Refer to L 651) 5. The MD failed his responsibility for the medical component of the hospice program when a physician's referral order for hospice services, a confirmation of service needs, a verification of the patients' medical prognosis and supporting documentation was not obtained for three of five sampled patients (Patients 3, 4 and 5). (Refer to L 651) The cumulative effect of these systemic practices resulted in the potential to cause Patients 1 and 2 not to understand the meaning of hospice, a life expectancy of six months or less to live, an abandoning of curative treatments and acceptance of palliative care and their Bill of Rights, Patients 1 and 2 to suffer identity theft (use of a person's private identifying information for financial gain), financial fraud (someone being scammed out of their money through theft or deceit), discrimination (unfair or prejudicial treatment of patients based on characteristics like race, ethnicity, gender, age, disability, sexual orientation, or socioeconomic status), damage to reputation through stigmatization (unfairly regarded by people as being bad or having something to be ashamed of), and ruining trust in healthcare providers, Patients 1 and 2s immediate care needs to go untreated, Patients 1 and 2s attending physicians to be unaware hospice services were not provided and an inaccurate clinical record leading to incorrect diagnoses, treatments and fraudulent billing practices. In addition, these failures had the potential to cause Patients 3, 4 and 5, not be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to the Medical Director (MD) not correctly evaluating Patients 3, 4 and 5s terminal diagnosis and prognosis of six months or less to live.

Based on interview and record review, the Governing Body (GB) failed to operate and manage the agency from January 3, 2024, to March 13, 2025, for five of five samples patients (Patients 1, 2, 3, 4, and 5), when: 1.The agency failed to provide the Hospice Election Statement (an explanation of hospice services, a life expectancy of six months or less to live, and an abandoning of curative treatments and acceptance of palliative care (a specialized form of medical care that focuses on providing comfort and improving the quality of life for people with serious or life-limiting illnesses)), Consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of the suggested medical care), and Notice of Rights and Responsibilities, (Bill of Rights- a document that provides patients with information on how they can reasonably expect to be treated during their hospice care) in a language and manner the patients understood for two of five sampled patients (Patients 1 and 2) when Patients 1 and 2 were Spanish speakers and could not speak and/or read English. This failure had the potential to cause Patients 1 and 2 not to understand the meaning of hospice, a life expectancy of six months or less to live, an abandoning of curative treatments and acceptance of palliative care and their Bill of Rights. 2. The agency failed to ensure the patients had a confidential clinical record for two of five sampled patients (Patients 1 and 2) when the agency allowed two unauthorized people to have access to Patient 1 and 2's protected health information (PHI-individually identifiable health data related to an individual's past, present, or future medical condition, treatment, and payment). This failure had the potential to cause Patients 1 and 2 to suffer identity theft (use of a person's private identifying information for financial gain), financial fraud (someone being scammed out of their money through theft or deceit), discrimination (unfair or prejudicial treatment of patients based on characteristics like race, ethnicity, gender, age, disability, sexual orientation, or socioeconomic status), damage to reputation through stigmatization (unfairly regarded by people as being bad or having something to be ashamed of), and ruining trust in healthcare providers. 3. The agency failed to ensure the findings during the initial assessment of non-admit (non-admission: patients who do not meet the hospice admission criteria or cannot be cared for by the agency) patients were reported to the Director of Patient Care Services (DPCS) in order for appropriate referrals to other sources of care were made, the patients attending physicians were notified of the assessment findings from the non-admit and the record of the non-admit indicated the date of the referral, services required, attending physicians, reasons for the non-admit, and referrals to other care facilities, for two of five sampled patients (Patients 1 and 2). This failure had the potential to cause Patients 1 and 2s immediate care needs to go untreated, Patients 1 and 2s attending physicians to be unaware hospice services were not provided and an inaccurate clinical record leading to incorrect diagnoses, treatments and fraudulent billing practices. 4. The agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for three of five sampled patients (Patients 3, 4 and 5) when: a-c. For Patients 3, 4, and 5 the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. d. For Patient 5, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. These failures had the potential to cause Patients 3, 4 and 5, not be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to the MD not correctly evaluating Patients 3, 4 and 5s terminal diagnosis and prognosis of six months or less to live. 5. The MD failed his responsibility for the medical component of the hospice program when a physician's referral order for hospice services, a confirmation of service needs, a verification of the patients' medical prognosis and supporting documentation was not obtained for three of five sampled patients (Patients 3, 4 and 5). This failure had the potential to cause Patients 3, 4 and 5 not to be given the opportunity to try curative treatments and opt for palliative care, too soon due to their attending physicians not identifying them as terminally ill and referring to hospice care and the Medical Director not correctly evaluating Patients 3, 4 and 5s terminal diagnosis and prognosis of six months or less to live. --- Findings: 1a. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated Patient 1 was a non-admission (non-admit: patients who do not meet the hospice admission criteria or cannot be cared for by the agency) and Patient 1s primary language was Spanish. A review of Patient 1s Comprehensive Nursing Assessment, dated January 14, 2025, indicated the following: a. Is there a need for an interpreter? Yesb. If Yes, offer of interpreter, Declinedc. Primary admitting diagnosis: Atherosclerotic heart disease of native coronary arteries, (or coronary artery disease (CAD), a condition where plaque buildup (atherosclerosis) narrows the arteries that supply blood to the heart, potentially leading to reduced blood flow and heart problems like chest pain or a heart attack)d. Cardiovascular (relating to the heart and blood vessels): Stasis Ulcer (an open sore that develops on the lower legs or ankles due to poor blood flow and vein failure, where blood pools in the veins instead of returning to the heart), Left leg ulcer (wound).e. Integumentary-Skin: Patient has open wound on her left lower leg. States due to poor circulation.f. Narrative & Disease Trajectory (course): ";Received referral to our office to evaluate and admit this 88 [year old] Hispanic American female to [name of hospice agency] with hospice [diagnosis] of [Atherosclerotic heart disease of native coronary arteries] ... Skilled assessment of whole-body functions performed. Patient is sitting in [her] chair resting when assessed. Patient is alert and responding appropriately to questions asked. Breathing pattern normal and regular, no cough or congestions, normal lung sound heard upon [listening with the stethoscope (a medical instrument for listening to the action of someone's heart or breathing)]. Patient is ambulatory [can walk], high risk for fall. Patient has open wound on her left lower leg. States due to poor circulation. Heart sounds s1 and s2 [can hear normal closing of the hearts valves], without murmurs [an extra sound, like a whooshing or swishing], [outlying] pulses [can be felt]. [Belly] is soft, non-distended, non-tender, bowel sound present in all [four sections]. No constipation or diarrhea reported. Appetite is good tolerating 70% [percent] to 80% of meal. SN [Skilled Nurse] reinforced the importance of hand washing, infection control and fall precaution." A review of Patient 1s ";Release of Information and Consent for Patient," dated January 14, 2025, written in the English language and signed by Patient 1, indicated, ";THIS IS TO REQUEST THAT [Patient 1] BE ADMITTED TO THE [Name of the hospice agency] PROGRAM, IN RELATION OF THAT, I ACKNOWLEDGE, CONSENT, AND AGREE TO FOLLOWING: PROGRAM GOALS: We understand that hospice care is palliative, not curative, in its goal and techniques, that the program emphasizes controlling physical symptoms, including pain, and meeting emotional and spiritual needs of patient and family in dealing with the illness for which patient is admitted. PATIENT SELF DETERMINATION ACT AND BILL OF RIGHTS: I have received a written statement of rights as a patient of [Name of the agency]. I understand my rights because they have been explained to me and my questions have been answered. I have received written and verbal information about advance directives, company policies, applicable by law, my rights state law, the state hot line number, and other information necessary to make decisions about advance directives [a written document that tells physician about patient's medical decision] and my care in accordance with the Patient Self Determination Act of 1990. ..." A review of Patient 1s ";Hospice Election Statement," dated January 14, 2025, written in the English language and signed by Patient 1, indicated, ";Patient Name: [Name of Patient 1], Hospice Agency Name: [Name of Hospice Agency], Hospice Election: I, (Patient Name) choose to elect the Medicare hospice benefit and receive Hospice services from (Name of Hospice Agency) to begin on (Start of Care Date). ..." 1b. A review of Patient 2s face sheet, undated, indicated Patient 2 was a non-admit and Patient 2s primary language was Spanish. A review of Patient 2s Comprehensive Nursing Assessment, dated January 14, 2025, indicated the following: a. Is there a need for an interpreter? Yesb. If Yes, offer of interpreter, Acceptedc. Primary admitting diagnosis: Atherosclerotic heart disease of native coronary arteries.d. Narrative & Disease Trajectory: ";On assessment time, patient is [Patient 1 was alert and oriented to person, place, and time] and able to verbalize needs. Lungs are clear in all [areas] on auscultation [listening] and [blood contains oxygen at] 94% [percent] on [room air] ... patient is getting enough sleep, about [eight to nine hours in 24 hours]. Appetite is good with no problem." A review of Patient 2s ";Release of Information and Consent for Patient," dated January 14, 2025, written in the English language and signed by Patient 2, indicated, ";THIS IS TO REQUEST THAT [Patient 2] BE ADMITTED TO THE [Name of the hospice agency] PROGRAM, IN RELATION OF THAT, I ACKNOWLEDGE, CONSENT, AND AGREE TO FOLLOWING: PROGRAM GOALS: We understand that hospice care is palliative, not curative, in its goal and techniques, that the program emphasizes controlling physical symptoms, including pain, and meeting emotional and spiritual needs of patient and family in dealing with the illness for which patient is admitted. PATIENT SELF DETERMINATION ACT AND BILL OF RIGHTS: I have received a written statement of rights as a patient of [Name of the agency]. I understand my rights because they have been explained to me and my questions have been answered. I have received written and verbal information about advance directives, company policies, applicable by law, my rights state law, the state hot line number, and other information necessary to make decisions about advance directives and my care in accordance with the Patient Self Determination Act of 1990. ..." A review of Patient 2s ";Hospice Election Statement," dated January 14, 2025, written in the English language and signed by Patient 2, indicated, ";Patient Name: [Name of Patient 2], Hospice Agency Name: [Name of Hospice Agency], Hospice Election: I, (Patient Name) choose to elect the Medicare hospice benefit and receive Hospice services from (Name of Hospice Agency) to begin on (Start of Care Date). ..." During an interview with a Registered Nurse (RN 1) on March 11, 2025, at 11:46 AM, RN 1 stated she had been scheduled to conduct an initial assessment and a hospice evaluation for Patients 1 and 2, on January 14, 2025. RN 1 stated she met a Potential/Marketer/Interpreter (P/M/I) at Patients 1 and 2s home to translate because Patients 1 and 2 did not speak or read English and RN 1 did not speak Spanish. RN 1 stated the P/M/I began translating her questions to Patients 1 and 2 but started to have difficulty and called the P/M/I's son to take over the translation. RN 1 stated the P/M/Is son conducted the translation for the rest of the visit over the phone and she did not know nor ever met the P/M/I or the P/M/I's son before this visit. RN 1 stated she did not know if the P/M/Is son explained what hospice was, the hospice election statement or the patients bill of rights because she could not understand what the P/M/Is son was saying. RN 1 stated it became clear to her after the evaluation that neither Patient 1 nor Patient 2 were appropriate for hospice services, but she was concerned about Patient 1s left leg ulcer because her leg was swollen, oozing and ";just looked terrible." RN 1 stated she was told the P/M/I had referred Patients 1 and 2 to the agency for hospice services and she told the P/M/I not to refer patients to the agency who were not sick enough to be on hospice because it cost the agency money to send her out to assess and evaluate the patients. RN 1 stated there was no physicians order referring Patients 1 and 2 for hospice services, RN 1 did not know who Patients 1 and 2s attending physician was and she had no H&P (History and Physical-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), to review before her visit. During an interview with the DPCS on March 12, 2025, from 10:31 AM to 11:04 AM, the DPCS stated the P/M/I had contacted the Administrator/Owner (Admin/Owner) of the agency requesting a position as a marketer and Spanish language interpreter and had referred Patients 1 and 2 to the agency for hospice services. The DPCS stated the P/M/I had not been hired by the agency and a background check, credential verification or previous employment history or reference check had not been conducted. The DPCS stated she had no knowledge of the P/M/Is son. The DPCS stated the agency proceeded with the initial assessment/hospice evaluation visit for Patients 1 and 2 and knew the P/M/I would need to be present to translate because Patients 1 and 2 only spoke and read Spanish. The DPCS stated the agency did not have any staff who spoke Spanish and did not have or provided Spanish language, Hospice Election Statements, Consents, or Notices of Rights and Responsibilities. A review on the agencys policy and procedure titled ";Patient Bill of Rights," dated April 2023, indicated, ";PURPOSE: To encourage awareness of patient rights, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. POLICY: Each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights as described. The rights contained within this policy include the basic rights of the patient. ... PROCEDURE: ... The Patient Bill of Rights will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand. ... Written information will be provided to patients in the predominant languages of the population served. ..." 2. During an interview with the Complainant on March 5, 2025, at 12:39 PM, the Complainant stated Patient 1 was phoned by the P/M/I who told Patient 1 about a year ago and that Patient 1 did not qualify for a program but that Patient 1 did now, and the P/M/I requested permission to visit Patient 1. The complainant stated Patient 1 agreed to meet but did not remember meeting the P/M/I a year ago and the P/M/I said the program provided free medications, free medical equipment, including a hospital bed and wound care for Patient 1s ulcers. The Complainant stated during the visit Patient 1 said that at no time was the word hospice mentioned, and Patient 1 was not aware she was placed in hospice at home and that Patient 1 would lose her right to see her doctors. The Complainant stated when the Complainant confronted the agency, the Complainant was told the P/M/I had said Patient 1 was her friend and needed the hospice care. The Complainant also stated the agency enrolled Patient 2 at the same visit and Patient 2 should not be on hospice either. 2a. A review of Patient 1s face sheet, undated, indicated Patient 1 was a non-admission and Patient 1s primary language was Spanish. A review of Patient 1s Comprehensive Nursing Assessment, dated January 14, 2025, indicated the following: a. Is there a need for an interpreter? Yesb. If Yes, offer of interpreter, Declinedc. Primary admitting diagnosis: Atherosclerotic heart disease of native coronary arteries, (or coronary artery disease (CAD), a condition where plaque buildup (atherosclerosis) narrows the arteries that supply blood to the heart, potentially leading to reduced blood flow and heart problems like chest pain or a heart attack)d. Cardiovascular (relating to the heart and blood vessels): Stasis Ulcer (an open sore that develops on the lower legs or ankles due to poor blood flow and vein failure, where blood pools in the veins instead of returning to the heart), Left leg ulcer.e. Integumentary-Skin: Patient has open wound on her left lower leg. States due to poor circulation.f. Narrative & Disease Trajectory (course): ";Received referral to our office to evaluate and admit this 88 [year old] Hispanic American female to [name of hospice agency] with hospice [diagnosis] of [Atherosclerotic heart disease of native coronary arteries] ... Skilled assessment of whole-body functions performed. Patient is sitting in [her] chair resting when assessed. Patient is alert and responding appropriately to questions asked. Breathing pattern normal and regular, no cough or congestions, normal lung sound heard upon [listening with the stethoscope]. Patient is ambulatory [can walk], high risk for fall. Patient has open wound on her left lower leg. States due to poor circulation. Heart sounds s1 and s2 [can hear normal closing of the hearts valves], without murmurs [an extra sound, like a whooshing or swishing], [outlying] pulses [can be felt]. [Belly] is soft, non-distended, non-tender, bowel sound present in all [four sections]. No constipation or diarrhea reported. Appetite is good tolerating 70% [percent] to 80% of meal. SN [Skilled Nurse] reinforced the importance of hand washing, infection control and fall precaution." A review of Patient 1s ";Release of Information and Consent for Patient," dated January 14, 2025, written in the English language and signed by Patient 1, indicated, ";THIS IS TO REQUEST THAT [Patient 1] BE ADMITTED TO THE [Name of the hospice agency] PROGRAM, IN RELATION OF THAT, I ACKNOWLEDGE, CONSENT, AND AGREE TO FOLLOWING: PROGRAM GOALS: We understand that hospice care is palliative, not curative, in its goal and techniques, that the program emphasizes controlling physical symptoms, including pain, and meeting emotional and spiritual needs of patient and family in dealing with the illness for which patient is admitted. PATIENT SELF DETERMINATION ACT AND BILL OF RIGHTS: I have received a written statement of rights as a patient of [Name of the agency]. I understand my rights because they have been explained to me and my questions have been answered. I have received written and verbal information about advance directives, company policies, applicable by law, my rights state law, the state hot line number, and other information necessary to make decisions about advance directives and my care in accordance with the Patient Self Determination Act of 1990. ..." A review of Patient 1s ";Hospice Election Statement," dated January 14, 2025, written in the English language and signed by Patient 1, indicated, ";Patient Name: [Name of Patient 1], Hospice Agency Name: [Name of Hospice Agency], Hospice Election: I, (Patient Name) choose to elect the Medicare hospice benefit and receive Hospice services from (Name of Hospice Agency) to begin on (Start of Care Date). ..." 2b. A review of Patient 2s face sheet, undated, indicated Patient 2 was a non-admit and Patient 2s primary language was Spanish. A review of Patient 2s Comprehensive Nursing Assessment, dated January 14, 2025, indicated the following: a. Is there a need for an interpreter? Yesb. If Yes, offer of interpreter, Acceptedc. Primary admitting diagnosis: Atherosclerotic heart disease of native coronary arteries.d. Narrative & Disease Trajectory: ";On assessment time, patient is [Patient 1 was alert and oriented to person, place, and time] and able to verbalize needs. Lungs are clear in all [areas] on auscultation and [blood contains oxygen at] 94% on [room air] ... patient is getting enough sleep, about [eight to nine hours in 24 hours]. Appetite is good with no problem." A review of Patient 2s ";Release of Information and Consent for Patient," dated January 14, 2025, written in the English language and signed by Patient 2, indicated, ";THIS IS TO REQUEST THAT [Patient 2] BE ADMITTED TO THE [Name of the hospice agency] PROGRAM, IN RELATION OF THAT, I ACKNOWLEDGE, CONSENT, AND AGREE TO FOLLOWING: PROGRAM GOALS: We understand that hospice care is palliative, not curative, in its goal and techniques, that the program emphasizes controlling physical symptoms, including pain, and meeting emotional and spiritual needs of patient and family in dealing with the illness for which patient is admitted. PATIENT SELF DETERMINATION ACT AND BILL OF RIGHTS: I have received a written statement of rights as a patient of [Name of the agency]. I understand my rights because they have been explained to me and my questions have been answered. I have received written and verbal information about advance directives, company policies, applicable by law, my rights state law, the state hot line number, and other information necessary to make decisions about advance directives and my care in accordance with the Patient Self Determination Act of 1990. ..." A review of Patient 2s ";Hospice Election Statement," dated January 14, 2025, written in the English language and signed by Patient 2, indicated, ";Patient Name: [Name of Patient 2], Hospice Agency Name: [Name of Hospice Agency], Hospice Election: I, (Patient Name) choose to elect the Medicare hospice benefit and receive Hospice services from (Name of Hospice Agency) to begin on (Start of Care Date). ..." During an interview with a Registered Nurse (RN 1) on March 11, 2025, at 11:46 AM, RN 1 stated she had been scheduled to conduct an initial assessment and a hospice evaluation for Patients 1 and 2, on January 14, 2025. RN 1 stated she met a Potential/Marketer/Interpreter (P/M/I) at Patients 1 and 2s home to translate because Patients 1 and 2 did not speak or read English and RN 1 did not speak Spanish. RN 1 stated the P/M/I began translating her questions to Patients 1 and 2 but started to have difficulty and called the P/M/I's son to take over the translation. RN 1 stated the P/M/Is son conducted the translation for the rest of the visit over the phone and she did not know nor ever met the P/M/I or the P/M/I's son before this visit. RN 1 stated she did not know if the P/M/Is son explained what hospice was, the hospice election statement or the patients bill of rights because she could not understand what the P/M/Is son was saying. RN 1 stated it became clear to her after the evaluation that neither Patient 1 nor Patient 2 were appropriate for hospice services, but she was concerned about Patient 1s left leg ulcer because her leg was swollen, oozing and ";just looked terrible." RN 1 stated she was told the P/M/I had referred Patients 1 and 2 to the agency for hospice services and she told the P/M/I not to refer patients to the agency who were not sick enough to be on hospice because it cost the agency money to send her out to assess and evaluate the patients. RN 1 stated there was no physicians order referring Patients 1 and 2 for hospice services, RN 1 did not know who Patients 1 and 2s attending physician was and she had no H&P (History and Physical-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), to review before her visit. During an interview with the DPCS on March 12, 2025, from 10:31 AM to 11:04 AM, the DPCS stated the P/M/I had contacted the Admin/Owner of the agency requesting a position as a marketer and Spanish language interpreter and had referred Patients 1 and 2 to the agency for hospice services. The DPCS stated the P/M/I had not been hired by the agency and a background check, credential verification or previous employment history or reference check had not been conducted. The DPCS stated she had no knowledge of the P/M/Is son. The DPCS stated the agency proceeded with the initial assessment/hospice evaluation visit for Patients 1 and 2 and knew the P/M/I would need to be present to translate because Patients 1 and 2 only spoke and read Spanish. The DPCS stated the agency did not have any staff who spoke Spanish and did not have or provided Spanish language, Hospice Election Statements, Consents, or Notices of Rights and Responsibilities. During an interview with a Licensed Vocational Nurse/Intake Coordinator/Marketer (LVN/IC/M) on March 13, 2025, from 9:51 AM to 10:22 AM, the LVN/IC/M stated the Admin/Owner gave her the information for Patients 1 and 2 and the referral source and contact person as the P/M/I and asked her to check the patients eligibility for hospice services. The LVN/IC/M stated she talked to the P/M/I and asked how to get in touch with the patients to set up a meeting and the P/M/I told her the two patients were Spanish speakers and the P/M/I would coordinate and schedule the visit, and the P/M/I would be there to translate. The LVN/IC/M stated the P/M/I called her back with the schedule and then she called RN 1 and scheduled her for the initial assessment/hospice evaluation visit. The LVN/IC/M stated she heard from the Admin/Owner the P/M/I knew the patients through a family friend and she did not ask the P/M/I who the attending physician was. The LVN/IC/M stated the P/M/I sent her pictures of the patients Medicare cards and drivers licenses. The LVN/IC/M stated she sends out the RN to assess and evaluate the patients for hospice services before asking who or contacting the attending physician for a referral order and H&P and it was her expectation the P/M/I had obtained permission from the patients themselves to come and make the visit. The LVN/IC/M stated RN 1 told her the patients were not hospice appropriate, so the agency did not proceed with the admission and the patients were put under the non-admit area of the clinical record. The LVN/IC/M stated she received a call from a physician who identified himself as Patients 1 and 2s attending physician and asked if Patients 1 and 2 were on our services and asked for a discharge order proving they were not on our service. The LVN/IC/M stated she created a verbal order indicating the patients had declined services, sent it to the attending physician then deleted it and she did not keep the name or phone number of the physician. The LVN/IC/M stated she received a call from Patients 1 and 2s daughter asking how the agency got the information on her parents and the LVN/IC/M told the daughter about the P/M/I, gave her the P/M/Is phone number and said the P/M/I told the agency she knew Patients 1 and 2. The LVN/IC/M stated the daughter was upset because she did not know how the P/M/I had gotten her parents information, the LVN/IC/M stated she told the daughter because the P/M/I said she knew your parents and ";As far as I know your parents know her." During an interview with the Admin/Owner on March 13, 2025, at 12:14 PM, the Admin/Owner stated he had been talking with his friends looking for candidates to fill the positions for Administrator, Marketer and Spanish language interpreter and a close friend of his gave him the name and phone number of the P/M/I for the Marketer and Spanish language interpreter positions. The Admin/Owner stated he called the P/M/I and conducted a telephone interview and during the interview the P/M/I told him she had close family friends who needed help, needed hospice. The Admin/Owner stated he asked the P/M/I to come into the office to fill out an application, employment paperwork and gather information for a background check but the P/M/I never came, the P/M/I was asked again and she said she would come but she never did, so the Admin/Owner did not pursue employing the P/M/I and did not speak with her again. The Admin/Owner stated he gave the LVN/IC/M the information on Patients 1 and 2 and the contact information for the P/M/I and ask her to call the P/M/I to coordinate the hospice evaluation process for Patients 1 and 2. The Admin/Owner stated he did not know anything about Patients 1 and 2s evaluation visit or what happened during the visit because that was his teams job. The Admin/Owner stated he knew Patients 1 and 2 only spoke Spanish and he had set in motion an evaluation visit with the P/M/I translating when he knew the agency had not conducted a background check, credential verification or previous employment history or reference check on the P/M/I. The Admin/Owner stated, ";This is my fault, and I shouldnt have let it happen." The P/M/I was not available for interview. A review on the agencys policy and procedure titled ";Patient Bill of Rights," dated April 2023, indicated, ";PURPOSE: To encourage awareness of patient rights, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. POLICY: Each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights as described. The rights contained within this policy include the basic rights of the patient. ... PROCEDURE: 1. The Patient Bill of Rights statement defines the right of the patient to: ... H. Confidentiality of the patient and clinical records maintained by the organization and the policies and procedures regarding disclosure. ... P. Be able to identify visiting personnel through proper identification. ... The Patient Bill of Rights will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand. ..." 3a. A review of Patient 1s face sheet, undated, indicated Patient 1 was a non-admit and Patient 1s primary language was Spanish. A review of Patient 1s Comprehensive Nursing Assessment, dated January 14, 2025, indicated the following: a. Is there a need for an interpreter? Yesb. If Yes, offer of interpreter, Declinedc. Primary admitting diagnosis: Atherosclerotic heart disease of native coronary arteries, (or coronary artery disease (CAD), a condition where plaque buildup (atherosclerosis) narrows the arteries that supply blood to the heart, potentially leading to reduced blood flow and heart problems like chest pain or a heart attack)d. Cardiovascular (relating to the heart and blood vessels): Stasis Ulcer (an open sore that develops on the lower legs or ankles due to poor blood flow and vein failure, where blood pools in the veins instead of returning to the heart), Left leg ulcer.e. Integumentary-Skin: Patient has open wound on her left lower leg. States due to poor circulation.f. Narrative & Disease Trajectory (course): ";Received referral to our office to evaluate and admit this 88 [year old] Hispanic American female to [name of hospice agency] with hospice [diagnosis] of [Atherosclerotic heart disease of native coronary arteries] ... Skilled assessment of whole-body functions performed. Patient is sitting in [her] chair resting when assessed. Patient is alert and responding appropriately to questions asked. Breathing pattern normal and regular, no cough or congestions, normal lung sound heard upon [listening with the stethoscope]. Patient is ambulatory [can walk], high risk for fall. Patient has open wound on her left lower leg. States due to poor circulation. Heart sounds s1 and s2 [can hear normal closing of the hearts valves], without murmurs [an extra sound, like a whooshing or swishing], [outlying] pulses [can be felt]. [Belly] is soft, non-distended, non-tender, bowel sound present in all [four sections]. No constipation or diarrhea reported. Appetite is good tolerating 70% [percent] to 80% of meal. SN [Skilled Nurse] reinforced the importance of hand washing, infection control and fall precaution." 3b. A review of Patient 2s face sheet undated, indicated Patient 2 was a non-admit and Patient 2s primary language was Spanish. A review of Patient 2s Comprehensive Nursing Assessment, dated January 14, 2025, indicated the following: a. Is there a need for an interpreter? Yesb. If Yes, offer of interpreter, Acceptedc. Primary admitting diagnosis: Atherosclerotic heart disease of native coronary arteries.d. Narrative & Disease Trajectory: ";On assessment time, patient is [Patient 1 was alert and oriented to person, place, and time] and able to verbalize needs. Lungs are clear in all [areas] on auscultation and [blood contains oxygen at] 94% on [room air] ... patient is getting enough sleep, about [eight to nine hours in 24 hours]. Appetite is good with no problem." During an interview with RN 1 on March 11, 2025, at 11:46 AM, RN 1 stated she had been scheduled to conduct an initial assessment and a hospice evaluation for Patients 1 and 2, who were husband and wife, on January 14, 2025. RN 1 stated she met the P/M/I at Patients 1 and 2s home to translate because Patients 1 and 2 did not speak or read English and RN 1 did not speak Spanish. RN 1 stated it became clear to her after the evaluation that neither Patient 1 nor Patient 2 were appropriate for hospice services, but she was concerned about Patient 1s left leg ulcer because her leg was swollen, oozing and ";just looked terrible." RN 1 stated she was told the P/M/I had referred Patients 1 and 2 to the agency for hospice services. RN 1 stated there was no physicians order referring Patients 1 and 2 for hospice services, RN 1 did not know who Patients 1 and 2s attending physician was and she had no H&P, to review before her visit. RN 1 stated she reported her assessment findings to a LVN/IC/M and indicated Patients 1 and 2 were not appropriate for hospice services. RN 1 stated she did nothing further in regard to Patients 1 and 2. During an interview with the DPCS on March 12, 2025, from 10:31 AM to 11:04 AM, the DPCS stated the P/M/I had contacted the Administrator/Owner (Admin/Owner) of the agency requesting a position as a marketer and Spanish language interpreter and had referred Patients 1 and 2 to the agency for hospice services. The DPCS stated the agency proceeded with the initial assessment/hospice evaluation visit for Patients 1 and 2 and knew the P/M/I would need to be present to translate because Patients 1 and 2 only spoke and read Spanish. The DPCS stated RN 1 had not reported to her the findings or assessment that Patients 1 and 2 were not appropriate for hospice services but this report would go to the LVN/IC/M, and she was responsible to complete all the requirements for a non-admit. The DPCS confirmed Patients 1 and 2 had not received appropriate referrals to other sources of care, Patients 1 and 2s attending physicians were not identified or notified of the assessment findings from the non-admit and Patients 1 and 2s record of the non-admit did not indicate the date of the referral, services required, attending physicians, reasons for the non-admit, or referrals to other care facilities. During an interview with the LVN/IC/M on March 13, 2025, from 9:51 AM to 10:22 AM, the LVN/IC/M stated the Admin/Owner gave her the information for Patients 1 and 2 and the referral source and contact person as the P/M/I and asked her to check the patients eligibility for hospice services. The LVN/IC/M stated she talked to the P/M/I and asked how to get in touch with the patients to set up a meeting and the P/M/I told her the two patients were Spanish speakers and she would coordinate and schedule the visit, and she would be there to translate. The LVN/IC/M stated the P/M/I called her back with the schedule and then she called RN 1 and scheduled her for the initial assessment/hospice evaluation visit. The LVN/IC/M stated she heard from the Admin/Owner the P/M/I knew the patients through a family friend and she did not ask the P/M/I who the attending physician was. The LVN/IC/M stated she sends out the RN to assess and evaluate the patient for hospice services before asking who or contacting the attending physician for a referral order and H&P and it was her expectation the P/M/I had obtained permission from the patients themselves to come and make the visit. The LVN/IC/M stated RN 1 told her the patients were not hospice appropriate, so the agency did not proceed with the admission and the patients were put under the non-admit area of the clinical record. The LVN/IC/M stated she received a call from a physician who identified himself as Patients 1 and 2s attending physician and asked if Patients 1 and 2 were on our services and asked for a discharge order proving they were not on our service. The LVN/IC/M stated she created a verbal order indicating the patients had declined services, sent it to the attending physician then deleted it and she did not keep the name or phone number of the physician. The LVN/IC/M stated she had not provided the physician with RN 1s assessment findings from the initial assessment visit and she had not reported Patients 1 and 2s non-admit status or any of the circumstances surrounding Patients 1 and 2s non-admission to the DPCS. The LVN/IC/M confirmed Patients 1 and 2 had not received appropriate referrals to other sources of care, Patients 1 and 2s attending physicians were not identified or notified of the assessment findings from the non-admit and Patients 1 and 2s record of the non-admit did not indicate the date of the referral, services required, attending physicians, reasons for the non-admit, or referrals to other care facilities. The LVN/IC/M stated none of this was necessary because the agency had not admitted Patients 1 and 2 to the hospice agency. A review of the agencys policy and procedure titled ";Admission Criteria and Process," dated April 2023, indicated, ";PURPOSE: To establish standards and a process by which a patient can be evaluated and accepted for admission. POLICY: ... [Name of the agency] reserves the right not to accept any patient who does not meet the admission criteria. A patient will be referred to other resources if [Name of the agency] cannot meet his/her needs. ... PROCEDURE: ... 15. The hospice registered nurse will complete an initial assessment during this visit within 48 hours after the election of the hospice care. ... 20. If a patient does not meet the admission criteria or cannot be cared for by [Name of the agency] the Clinical Supervisor should be notified and appropriate referrals to other sources of care made on behalf of the patient. 21. The following individuals should be notified of non-admits: A. Patient B. Physician C. Referral source (if not physician). 22. A record of non-admits will be kept for statistical purposes, with date of referral, date of assessment, patient name, services required, physician, reason for non-admit, referral to other hospice care facilities, etc. ..." 4a. A review of Patient 3s face sheet, undated, indicated a start of care date of December 31, 2024, with a benefit period of December 31, 2024, to February 28, 2025 (Benefit Period Four). Patient 3 had diagnoses that included difficulty speaking following a stroke. A review of Patient 3s CTI dated December 31, 2024, to February 28, 2025 (Benefit Period Four), indicated certification of Patient 3s prognosis of six months or less life expectancy by the MD. A review of Patient 3s face-to-face encounter for the fourth benefit period dated December 31, 2024, to February 28, 2025, indicated the face-to-face encounter had been conducted by the MD. A review of Patient 3s claims for payment, indicated a claim for payment was submitted December 2024, January 2025 and February 2025. During an interview with the MD on March 13, 2025, at 1:43 PM, the MD stated he had certified Patient 3s terminal illness and performed the face-to-face encounter. The MD stated he did not know the certifying doctor could not conduct the face-to-face encounter. 4b. A review of Patient 4s face sheet, undated, indicated a start of care date of February 20, 2024, with a benefit period of December 24, 2024, to February 22, 2025 (Benefit Period Eight). Patient 4 had diagnoses that included Alzheimer`s disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 4s CTI dated December 24, 2024, to February 22, 2025 (Benefit Period Eight), indicated certification of Patient 4s prognosis of six months or less life expectancy by the MD. A review of Patient 4s face-to-face encounter for the eighth benefit period dated December 24, 2024, to February 22, 2025, indicated the face-to-face encounter had been conducted by the MD. A review of Patient 4s claims for payment, indicated a claim for payment was submitted December 2024, January 2025 and February 2025. During an interview with the MD on March 13, 2025, at 1:55 PM, the MD stated he did not remember Patient 4 and was not confident he had certified Patient 4s terminal diagnosis or performed the face-to-face encounter and he could not explain why these documents indicated his electronic signature. The MD stated he refused to accept responsibility for Patient 4. The MD stated even with this concern he did not know the certifying doctor could not conduct the face-to-face encounter. 4c. A review of Patient 5s face sheet, undated, indicated a start of care date of January 3, 2024, with a benefit period of December 28, 2024, to February 25, 2025 (Benefit Period Six). Patient 5 had diagnoses that included Alzheimer`s disease. A review of Patient 5s CTI dated December 28, 2024, to February 25, 2025 (Benefit Period Six), indicated certification of Patient 5s prognosis of six months or less life expectancy by the MD. A review of Patient 5s face-to-face encounter for the sixth benefit period dated December 28, 2024, to February 25, 2025, indicated the face-to-face encounter had been conducted by the MD. A review of Patient 5s claims for payment, indicated a claim for payment was submitted December 2024, January 2025 and February 2025. During an interview with the MD on March 13, 2025, at 2 PM, the MD stated he did not remember Patient 5 and was not confident he had certified Patient 5s terminal diagnosis or performed the face-to-face encounter and he could not explain why these documents indicated his electronic signature. The MD stated he refused to accept responsibility for Patient 5. The MD stated even with this concern he did not know the certifying doctor could not conduct the face-to-face encounter. 4d. A review of Patient 5s face sheet, undated, indicated a start of care date of January 3, 2024, with a benefit period of January 3, 2024, to April 1, 2024 (First 90-day benefit period). Patient 5 had diagnoses that included Alzheimer`s disease. A review of Patient 5s CTI dated January 3, 2024, to April 1, 2024 (First 90-day benefit period), indicated ";Signature on File/Verified by ... (MD)" There was no documented evidence to show an Attending Physician (AP) for Patient 5 had been identified, contacted, or supporting documentation obtained. There was no documented evidence to show an AP had confirmed Patient 5s hospice service needs or provided a signature verifying Patient 5s prognosis of six months or less life expectancy. A review of Patient 5s claims for payment, indicated a claim for payment was submitted January, February, March and April 2024. During an interview with the MD on March 13, 2025, at 2 PM, the MD stated he did not remember Patient 5 and was not confident he had certified Patient 5s terminal diagnosis and could not explain why this document indicated he had verified his signature. The MD stated he refused to accept responsibility for Patient 5. The MD stated even with this concern he did not know a patients first and second benefit periods required two physicians signatures certifying the patients as terminally ill. A review of the agencys policy and procedure titled ";Certification of Terminal Illness," dated April 2023, indicated, ";PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. When certifying the patient as terminally ill, the hospice Medical Director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. PROCEDURE: 1. At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on: his/her review of the patient's medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms.) The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election. ... 4. Both the attending physician and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. ..." A review of the agencys policy and procedure titled ";Face-to-Face Encounter," dated April 2023, indicated, ";PURPOSE: To establish a process to comply with the Face-to-Face Encounter requirement. POLICY: A face-to-face encounter will be performed for patients entering the third and all subsequent benefit periods. PROCEDURE: 1. The hospice director (employed, volunteer, or under contract) or a hospice employed nurse practitioner (NP) will perform a face-to-face encounter within 30 days prior to the hospice recertification for the third and all subsequent benefit periods. 2. During the Face-to-Face encounter, the hospice medical director or NP must gather and document clinical findings to determine the patient's continued hospice eligibility. 3. The physician/NP who performs the face-to-face encounter will attest in writing that he/she had the face-to-face encounter, including the date of the visit. The NP must also attest that the clinical findings were provided to the certifying physician. ..." 5a. A review of Patient 3s face sheet, undated, indicated a start of care date of December 31, 2024, with a benefit period of December 31, 2024, to February 28, 2025 (Benefit Period Four). Patient 3 had diagnoses that included difficulty speaking following a stroke. A review of Patient 3s physicians orders from December 31, 2024, to February 28, 2025, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. Patient 3s H&P (History and Physical-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), contained within Patient 3s clinical record indicated, An acute care hospital admission dated December 23, 2024, indicated, ";Medical Decision-Making: [Patient 3] is a 63-year-old male brought in from boarding care facility. Concern generalized weakness. Possible fever. Also, brother states that he has been more agitated for the past [three] weeks at least. Behavior kind of waxes and wanes [increase and decrease in strength and/or intensity]. ... vital signs [clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions] are stable, No fevers noted. Patient was alert. Follows commands. Gestures, No leukocytosis [no increase in the number of white cells in the blood]. [Computed Tomography scan] finding is noted [past stroke]. Chest x-ray without obvious pneumonia [lung infection]. [Urinalysis] without obvious signs of infection. Blood cultures were sent. ... COVID flu negative. Has been monitored for multiple hours. Unclear if patient can go back to facility. He was unable to get hold of caretaker. Did speak with the mother. We will have social work speak with staff. But states he normally is not ambulatory but caregiver states that he does ambulate with a walker. We will also place and [Physical Therapy] evaluation. ... Clinical Impression: 1. Tremor 2. Malaise [ a general sense of being unwell] and Fatigue [a feeling of weariness, tiredness, or lack of energy] Plan: Continue monitor, Social work consultation ..." There was no documented evidence to show additional H&P for Patient 3 and the H&P from the acute care hospital admission did not indicate a discussion or recommendation for hospice services. During an interview with Patient 3s brother on March 12, 2025, at 9:47 AM, Patient 3s brother stated he and their father helped care for Patient 3. Patient 3s brother stated Patient 3 had bounced in and out of hospices for some time and in December 2024 he went to the hospital for a mental issue and other health issues. When the hospital discharged Patient 3 his priority was finding somewhere for Patient 3 to live and with the hospitals help, Patient 3 was placed in a Board and Care (B&C a licensed, non-medical facility providing room, board, and 24-hour care and supervision for individuals who need help with daily living activities but not 24-hour nursing care) facility. Patient 3s brother stated Patient 3 had been placed on hospice shortly after arriving at the B&C which was odd to him because ";my family is bullet proof as far as death goes." Patient 3s brother stated he felt his brother could benefit from Speech Therapy services (ST-addresses communication and swallowing difficulties in individuals, aiming to improve speech clarity, language comprehension, and overall communication skills), Occupational Therapy services (OT-helps improve an individuals ability to independently perform activities of daily living such as bathing, dressing, and eating) and Physical Therapy Services (PT-helps individuals improve movement, manage pain, and enhance function through exercises, manual therapy, and other treatments, often after an injury, illness, or surgery) but Patient 3 was not going to get these services from hospice. Patient 3s brother provided the name and location of Patient 3s Attending Physician (AP 1) and stated, ";I doubt [AP 1] knows my brother is on hospice." During an interview with a LVN/IC/M on March 13, 2025, from 10:35 AM to 11:10 AM, the LVN/IC/M stated she had conducted the intake process for Patient 3 and had received the referral for hospice services from the agencys Administrator/Owners (Admin/Owner) Wife. The LVN/IC/M stated she called Patient 3s brother, explained hospice services and scheduled the admission. The LVN/IC/M stated she did not ask Patient 3s brother who Patient 3s attending physician was and did not reach out to Patient 3s attending physician for a referral order or secure supporting documentation to provide to the MD. During an interview with the MD on March 13, 2025, at 1:43 PM, the MD stated he was unaware the agency had not obtained a physicians referral order or identified and contacted Patient 3s attending physician to obtain supporting documentation. The MD stated he was not aware the referral source for Patient 3 was the Admin/Owners Wife, ";I do not tolerate business practices such as these." The MD stated it was his expectation the agency would obtain a physicians referral order before any assessment/evaluation visit to the patient was made and obtain the attending physicians information. After review of Patient 3s H&P information available in Patient 3s clinical record, the MD stated, ";I have no idea what I was presented with," but this information was insufficient to make a judgment for a terminal illness with a prognosis of six months or less to live and he clearly missed key aspects of Patient 3s admission to hospice services. The MD stated he did not know who Patient 3s attending physician was and he had not reached out to the attending physician to confirm service needs, verify Patient 3s medical prognosis, or request supporting documentation. 5b. A review of Patient 4s face sheet, undated, indicated a start of care date of February 20, 2024, with a benefit period of December 24, 2024, to February 22, 2025 (Benefit Period Eight). Patient 4 had diagnoses that included Alzheimer`s disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 4s physicians orders from February 20, 2024, to February 22, 2025, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. Patient 4s H&P contained within Patient 4s clinical record indicated, a. A nursing plan of care with a medication list dated February 20, 2024, from a previous hospice agency.b. A physicians visit dated May 26, 2023, indicated, ";Assessment and Plan: [Patient 4] is an 80 [year old] female with a [PMH-Past Medical History] of [Atrial fibrillation (AFib) a common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly], Alzheimer's [disease], and recurrent [UTI-urinary tract infections]. Recent hospital admission for UTI, [Computed Tomography scan indicated] Normal kidneys, no hydro [hydronephrosis-no evidence of swelling or dilation due to a buildup of urine], no stones [hard masses formed in the kidneys], Bladder ultrasound ... for evaluation of bladder emptying. Post void residual [remaining] 27 [milliliters-a unit of measurement]. Urinary retention [urine remaining in bladder after voiding]: Mild. This was utilized today, as I needed to know if patient has an elevated postvoid residual or evidence of urinary retention that is contributing to the current bladder symptoms. No incontinence [ability to control, the involuntary loss of urine or bowel movements]. PLAN: Given the frequency of the UTIs we will start patient on [medication] daily ... Increase fluid intake. Perineal hygiene [cleaning ones private areas]. Return in about 1 [one] year (around [May 26, 2024]). ... PMH: [Patient 4] is an 82 [year old] female who has a past medical history of [Hepatocellular carcinoma (HCC) - a type of liver cancer that originates in the liver cells] Diabetes mellitus [a disease that results in too much sugar in the blood], and Memory loss. ..." c. A CTI from a previous hospice agency dated November 30, 2023, with a terminal diagnosis of Alzheimer`s disease. There was no documented evidence to show additional H&P for Patient 4 and the H&P from the physicians visit did not indicate a discussion or recommendation for hospice services. During an interview with Patient 4s son on March 11, 2025, at 3:30 PM, Patient 4s son stated he and his father helped care for Patient 4. Patient 4s son stated his mother had been at a previous B&C facility and receiving hospice services from a previous hospice agency, but the previous B&C facility was not providing good care for his mother, so she was moved to the current B&C facility, and he was not happy with the previous hospice agency so Patient 4 was transferred to the current hospice agency. Patient 4s son stated his understanding of hospice was, ";It doesn't mean youre going to die, it's not about the end of life, it's about someone taking care of you when you cant take care of yourself. If you need to go to ER [Emergency Room] that's ok, and you can still see all your doctors if you want to." Patient 4s son provided the name and phone number of Patient 4s Attending Physician (AP 2) and stated he did not know if AP 2 knew his mother was on hospice or not. During an interview with the LVN/IC/M on March 13, 2025, from 10:35 AM to 11:10 AM, the LVN/IC/M stated she was the Owner and Administrator of the B&C facility where Patient 4 lived and Patient 4s son had reached out to her and stated his mother was on hospice but he was not happy with the hospice and if she could recommend another hospice agency, she recommended [name of current hospice agency] where she worked. The LVN/IC/M stated she handled the intake and admission to the hospice and Patient 4s son stated Patient 4 did not have an attending physician because Patient 4 was already on hospice. The LVN/IC/M stated since Patient 4 had already been on hospice services she did not obtain a physicians referral order or secure supporting documentation to provide to the MD, other than what the previous hospice had supplied. During an interview with the Admin/Owner on March 13, 2025, at 12:04 PM, the Admin/Owner stated he knew the LVN/IC/M was the Administrator and Owner of the B&C facility where Patient 4 lived and conducted the intake and admission process to the hospice agency for Patient 4. During an interview with the MD on March 13, 2025, at 1:55 PM, the MD stated he was unaware the agency had not obtained a physicians referral order or identified and contacted Patient 4s attending physician to obtain supporting documentation. The MD stated he was not aware the referral source for Patient 4 was also the Administrator and Owner of the B&C facility were Patient 4 lived, ";I do not tolerate business practices such as these." The MD stated it was his expectation the agency would obtain a physicians referral order before any assessment/evaluation visit to the patient was made and obtain the attending physicians information even if Patient 4 was transferring from another hospice. After review of Patient 4s H&P information available in Patient 4s clinical record, the MD stated the information was insufficient to make a judgment for a terminal illness with a prognosis of six months or less to live. The MD stated he did not know who Patient 4s attending physician was and he had not reached out to the attending physician to confirm service needs, verify Patient 4s medical prognosis, or request supporting documentation. The MD stated he did not remember Patient 4 and was not confident he had certified Patient 4s terminal diagnosis or performed the face-to-face encounter and he could not explain why these documents indicated his electronic signature. The MD stated he refused to accept responsibility for Patient 4. 5c. A review of Patient 5s face sheet, undated, indicated a start of care date of January 3, 2024, with a benefit period of January 3, 2024, to April 1, 2024 (First 90-day benefit period). Patient 5 had diagnoses that included Alzheimer`s disease. A review of Patient 5s physicians orders from January 3, 2024, to April 1, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. A review of Patient 5s H&P contained within Patient 5s clinical record from January 3, 2024, to April 1, 2024, was conducted. There was no documented evidence to show H&P for Patient 5. Patient 5s daughter was unavailable for interview. During an interview with the LVN/IC/M on March 13, 2025, from 10:35 AM to 11:10 AM, the LVN/IC/M stated she was the Owner and Administrator of the B&C facility where Patient 5 lived. The LVN/IC/M stated her B&C caregivers were having difficulty taking care of Patient 5 so she approached the daughter and explained what hospice services could do to help, and she could explore hospice services with Patient 5s attending physician. The LVN/IC/M stated she handled Patient 5s intake and admission to hospice with the daughter but did not get a referral order or secure supporting documentation to provide to the MD, from Patient 5s attending physician. The LVN/IC/M stated she did not know why there was no H&P in Patient 5s clinical record. During an interview with the Admin/Owner on March 13, 2025, at 12:04 PM, the Admin/Owner stated he knew the LVN/IC/M was the Administrator and Owner of the B&C facility where Patient 5 lived and conducted the intake and admission process to the hospice agency for Patient 5. During an interview with the MD on March 13, 2025, at 2 PM, the MD stated he was unaware the agency had not obtained a physicians referral order or identified and contacted Patient 5s attending physician to obtain supporting documentation. The MD stated he was not aware the referral source for Patient 5 was also the Administrator and Owner of the B&C facility were Patient 5 lived, ";I do not tolerate business practices such as these." The MD stated it was his expectation the agency would obtain a physicians referral order before any assessment/evaluation visit to the patient was made and obtain the attending physicians information. The MD stated he was unaware Patient 4s clinical record did not contain H&P information, and he did not know who Patient 5s attending physician was, he had not reached out to the attending physician to confirm service needs, verify Patient 5s medical prognosis, or request supporting documentation. The MD stated he did not remember Patient 5 and was not confident he had certified Patient 5s terminal diagnosis and could not explain why this document indicated he had verified his signature. The MD stated he refused to accept responsibility for Patient 5. A review of the agencys policy and procedure titled ";Intake Process," dated April 2023, indicated, ";PURPOSE: To establish the process for acceptance and entry of patient into the organization. PROCEDURE: ... A. To accept referrals, information regarding a patient's demographics, diagnosis, services needed, medications, attending physician, and hospitalization, will be taken in order to make the initial determination of whether the patient's needs can be met and if he/she meets the eligibility criteria. ... C. Intake information is given to the Clinical Supervisor to accept the referral information and complete a referral and intake form. D. If the referral is not from a physician, the patient's physician (or other authorized licensed independent practitioner) will be contacted to confirm service needs and to obtain verbal orders. ..." A review of the agencys policy and procedure titled ";Admission Criteria and Process," dated April 2023, indicated, ";PURPOSE: To establish standards and a process by which a patient can be evaluated and accepted for admission. ... Admission Criteria: 1. The patient must be under the care of a physician. The patient's physician (or other authorized independent practitioner) must order and approve the provision of hospice care, be willing to sign or have a representative who is willing to sign the death certificate and be willing to discuss the patient's resuscitation status with the patient and family/caregiver. ... 3. The patient must have a life-limiting illness with a life expectancy of six (6) months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by LCD [Local Coverage Determination] ... PROCEDURE: 1. 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 request for service is not made by the patient's physician, he/she will be consulted prior to the evaluation visit/initiation of services. ..." A review of the agencys policy and procedure titled ";Certification of Terminal Illness," dated April 2023, indicated, ";PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: ... 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. ..." During an interview with the Admin/Owner on March 13, 2025, at 3:02 PM, the Admin/Owner stated he was the sole member of the Governing Body (GB) and assumed full legal authority and responsibility for the operation of the agency, and for the quality of care and services provided. The Admin/Owner stated the GB had not identified: 1 a-b. That the agency did not provide the Hospice Election Statement, Consents, and Notice of Rights and Responsibilities, in a language and manner the patients understood for Patients 1 and 2 when Patients 1 and 2 were Spanish speakers and could not speak and/or read English. 2 a-b. That the agency did not ensure the patients had a confidential clinical record for Patients 1 and 2 when the agency allowed two unauthorized people to have access to Patient 1 and 2's protected health information. 3 a-b. That the agency did not ensure the findings during the initial assessment of non-admit patients were reported to the DPCS in order for appropriate referrals to other sources of care were made, the patients attending physicians were notified of the assessment findings from the non-admit and the record of the non-admit indicated the date of the referral, services required, attending physicians, reasons for the non-admit, and referrals to other care facilities, for Patients 1 and 2. 4. That the agency did not ensure the MD certified the patients' terminal illnesses before the agency submitted a claim for payment, for Patients 3, 4 and 5 when: a-c. For Patients 3, 4, and 5 the CTI did not contain a face-to-face encounter conducted by a non-certifying physician or nurse practitioner. d. For Patient 5, the CTI for the first 90-day benefit period was not signed by two physicians. 5 a-c. That the MD fai led his responsibility for the medical component of the hospice program when a physician's referral order for hospice services, a confirmation of service needs, a verification of the patients' medical prognosis and supporting documentation was not obtained for Patients 3, 4 and 5. A review of the agencys policy and procedure titled, ";Governing Body," dated April 2023, indicated, ";PURPOSE: To outline the roles and responsibilities of the Governing Body. POLICY: The Governing Body will assume full legal authority, responsibility, decision-making and accountability for the overall management and operations, the provision of services, fiscal operations, human resource management, review of the organization's budget and operational plans, and its quality assessment and performance improvement (QAPI) program. The Governing Body of [name of agency] will serve as the governing authority for the home care program, which will function according to [name of agency] bylaws. ..."

The agency failed to ensure that the Condition of Participation: L 664 §418.102 Medical director was in compliance as follows: 1. Based on interview and record review, the agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for three of five sampled patients (Patients 3, 4 and 5) when: a. For Patients 3, 4, and 5 the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. (Refer to L 667) b. For Patient 5, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. (Refer to L 667) 2. Based on interview and record review, MD failed his responsibility for the medical component of the hospice program when a physician's referral order for hospice services, a confirmation of service needs, a verification of the patients' medical prognosis and supporting documentation was not obtained for three of five sampled patients (Patients 3, 4 and 5). (Refer to L 669) The cumulative effect of these systemic practices resulted in the potential to cause Patients 3, 4 and 5 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and referring to hospice care and the Medical Director not correctly evaluating Patients 3, 4 and 5s terminal diagnosis and prognosis of six months or less to live.

Based on interview and record review, the agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for three of five sampled patients (Patients 3, 4 and 5) when: 1. For Patients 3, 4, and 5 the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. 2. For Patient 5, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. These failures had the potential to cause Patients 3, 4 and 5, not be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to the MD not correctly evaluating Patients 3, 4 and 5s terminal diagnosis and prognosis of six months or less to live. --- Findings: 1a. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of December 31, 2024, with a benefit period of December 31, 2024, to February 28, 2025 (Benefit Period Four). Patient 3 had diagnoses that included difficulty speaking following a stroke. A review of Patient 3s CTI dated December 31, 2024, to February 28, 2025 (Benefit Period Four), indicated certification of Patient 3s prognosis of six months or less life expectancy by the MD. A review of Patient 3s face-to-face encounter for the fourth benefit period dated December 31, 2024, to February 28, 2025, indicated the face-to-face encounter had been conducted by the MD. A review of Patient 3s claims for payment, indicated a claim for payment was submitted December 2024, January 2025 and February 2025. During an interview with the MD on March 13, 2025, at 1:43 PM, the MD stated he had certified Patient 3s terminal illness and performed the face-to-face encounter. The MD stated he did not know the certifying doctor could not conduct the face-to-face encounter. 1b. A review of Patient 4s face sheet, undated, indicated a start of care date of February 20, 2024, with a benefit period of December 24, 2024, to February 22, 2025 (Benefit Period Eight). Patient 4 had diagnoses that included Alzheimer`s disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 4s CTI dated December 24, 2024, to February 22, 2025 (Benefit Period Eight), indicated certification of Patient 4s prognosis of six months or less life expectancy by the MD. A review of Patient 4s face-to-face encounter for the eighth benefit period dated December 24, 2024, to February 22, 2025, indicated the face-to-face encounter had been conducted by the MD. A review of Patient 4s claims for payment, indicated a claim for payment was submitted December 2024, January 2025 and February 2025. During an interview with the MD on March 13, 2025, at 1:55 PM, the MD stated he did not remember Patient 4 and was not confident he had certified Patient 4s terminal diagnosis or performed the face-to-face encounter and he could not explain why these documents indicated his electronic signature. The MD stated he refused to accept responsibility for Patient 4. The MD stated even with this concern he did not know the certifying doctor could not conduct the face-to-face encounter. 1c. A review of Patient 5s face sheet, undated, indicated a start of care date of January 3, 2024, with a benefit period of December 28, 2024, to February 25, 2025 (Benefit Period Six). Patient 5 had diagnoses that included Alzheimer`s disease. A review of Patient 5s CTI dated December 28, 2024, to February 25, 2025 (Benefit Period Six), indicated certification of Patient 5s prognosis of six months or less life expectancy by the MD. A review of Patient 5s face-to-face encounter for the sixth benefit period dated December 28, 2024, to February 25, 2025, indicated the face-to-face encounter had been conducted by the MD. A review of Patient 5s claims for payment, indicated a claim for payment was submitted December 2024, January 2025 and February 2025. During an interview with the MD on March 13, 2025, at 2 PM, the MD stated he did not remember Patient 5 and was not confident he had certified Patient 5s terminal diagnosis or performed the face-to-face encounter and he could not explain why these documents indicated his electronic signature. The MD stated he refused to accept responsibility for Patient 5. The MD stated even with this concern he did not know the certifying doctor could not conduct the face-to-face encounter. 2. A review of Patient 5s face sheet, undated, indicated a start of care date of January 3, 2024, with a benefit period of January 3, 2024, to April 1, 2024 (First 90-day benefit period). Patient 5 had diagnoses that included Alzheimer`s disease. A review of Patient 5s CTI dated January 3, 2024, to April 1, 2024 (First 90-day benefit period), indicated ";Signature on File/Verified by ... (MD)" There was no documented evidence to show an Attending Physician (AP) for Patient 5 had been identified, contacted, or supporting documentation obtained. There was no documented evidence to show an AP had confirmed Patient 5s hospice service needs or provided a signature verifying Patient 5s prognosis of six months or less life expectancy. A review of Patient 5s claims for payment, indicated a claim for payment was submitted January, February, March and April 2024. During an interview with the MD on March 13, 2025, at 2 PM, the MD stated he did not remember Patient 5 and was not confident he had certified Patient 5s terminal diagnosis and could not explain why this document indicated he had verified his signature. The MD stated he refused to accept responsibility for Patient 5. The MD stated even with this concern he did not know a patients first and second benefit periods required two physicians signatures certifying the patients as terminally ill. A review of the agencys policy and procedure titled ";Certification of Terminal Illness," dated April 2023, indicated, ";PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. When certifying the patient as terminally ill, the hospice Medical Director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. PROCEDURE: 1. At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on: his/her review of the patient's medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms.) The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election. ... 4. Both the attending physician and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. ..." A review of the agencys policy and procedure titled ";Face-to-Face Encounter," dated April 2023, indicated, ";PURPOSE: To establish a process to comply with the Face-to-Face Encounter requirement. POLICY: A face-to-face encounter will be performed for patients entering the third and all subsequent benefit periods. PROCEDURE: 1. The hospice director (employed, volunteer, or under contract) or a hospice employed nurse practitioner (NP) will perform a face-to-face encounter within 30 days prior to the hospice recertification for the third and all subsequent benefit periods. 2. During the Face-to-Face encounter, the hospice medical director or NP must gather and document clinical findings to determine the patient's continued hospice eligibility. 3. The physician/NP who performs the face-to-face encounter will attest in writing that he/she had the face-to-face encounter, including the date of the visit. The NP must also attest that the clinical findings were provided to the certifying physician. ..."

Based on interview and record review, the Medical Director (MD) failed his responsibility for the medical component of the hospice program when a physician's referral order for hospice services, a confirmation of service needs, a verification of the patients' medical prognosis and supporting documentation was not obtained for three of five sampled patients (Patients 3, 4 and 5). This failure had the potential to cause Patients 3, 4 and 5 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and referring to hospice care and the Medical Director not correctly evaluating Patients 3, 4 and 5s terminal diagnosis and prognosis of six months or less to live. --- Findings: 1. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of December 31, 2024, with a benefit period of December 31, 2024, to February 28, 2025 (Benefit Period Four). Patient 3 had diagnoses that included difficulty speaking following a stroke. A review of Patient 3s physicians orders from December 31, 2024, to February 28, 2025, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. Patient 3s H&P (History and Physical-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), contained within Patient 3s clinical record indicated, An acute care hospital admission dated December 23, 2024, indicated, ";Medical Decision-Making: [Patient 3] is a 63-year-old male brought in from boarding care facility. Concern generalized weakness. Possible fever. Also, brother states that he has been more agitated for the past [three] weeks at least. Behavior kind of waxes and wanes [increase and decrease in strength and/or intensity]. ... vital signs [clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions] are stable, No fevers noted. Patient was alert. Follows commands. Gestures, No leukocytosis [no increase in the number of white cells in the blood]. [Computed Tomography scan] finding is noted [past stroke]. Chest x-ray without obvious pneumonia [lung infection]. [Urinalysis] without obvious signs of infection. Blood cultures were sent. ... COVID flu negative. Has been monitored for multiple hours. Unclear if patient can go back to facility. He was unable to get hold of caretaker. Did speak with the mother. We will have social work speak with staff. But states he normally is not ambulatory but caregiver states that he does ambulate with a walker. We will also place and [Physical Therapy] evaluation. ... Clinical Impression: 1. Tremor 2. Malaise [ a general sense of being unwell] and Fatigue [a feeling of weariness, tiredness, or lack of energy] Plan: Continue monitor, Social work consultation ..." There was no documented evidence to show additional H&P for Patient 3 and the H&P from the acute care hospital admission did not indicate a discussion or recommendation for hospice services. During an interview with Patient 3s brother on March 12, 2025, at 9:47 AM, Patient 3s brother stated he and their father helped care for Patient 3. Patient 3s brother stated Patient 3 had bounced in and out of hospices for some time and in December 2024 he went to the hospital for a mental issue and other health issues. When the hospital discharged Patient 3 his priority was finding somewhere for Patient 3 to live and with the hospitals help, Patient 3 was placed in a Board and Care (B&C a licensed, non-medical facility providing room, board, and 24-hour care and supervision for individuals who need help with daily living activities but not 24-hour nursing care) facility. Patient 3s brother stated Patient 3 had been placed on hospice shortly after arriving at the B&C which was odd to him because ";my family is bullet proof as far as death goes." Patient 3s brother stated he felt his brother could benefit from Speech Therapy services (ST-addresses communication and swallowing difficulties in individuals, aiming to improve speech clarity, language comprehension, and overall communication skills), Occupational Therapy services (OT-helps improve an individuals ability to independently perform activities of daily living such as bathing, dressing, and eating) and Physical Therapy Services (PT-helps individuals improve movement, manage pain, and enhance function through exercises, manual therapy, and other treatments, often after an injury, illness, or surgery) but Patient 3 was not going to get these services from hospice. Patient 3s brother provided the name and location of Patient 3s Attending Physician (AP 1) and stated, ";I doubt [AP 1] knows my brother is on hospice." During an interview with a Licensed Vocational Nurse/Intake Coordinator/Marketer (LVN/IC/M) on March 13, 2025, from 10:35 AM to 11:10 AM, the LVN/IC/M stated she had conducted the intake process for Patient 3 and had received the referral for hospice services from the agencys Administrator/Owners (Admin/Owner) Wife. The LVN/IC/M stated she called Patient 3s brother, explained hospice services and scheduled the admission. The LVN/IC/M stated she did not ask Patient 3s brother who Patient 3s attending physician was and did not reach out to Patient 3s attending physician for a referral order or secure supporting documentation to provide to the MD. During an interview with the Admin/Owner on March 13, 2025, at 12:04 PM, the Admin/Owner confirmed his Wife was currently the manager of the B&C where Patient 3 lived and was in the process of taking over the ownership of the B&C. The Admin/Owner stated his Wife had sent her application in approximately two to three months ago to take over the B&Cs license. During an interview with the MD on March 13, 2025, at 1:43 PM, the MD stated he was unaware the agency had not obtained a physicians referral order or identified and contacted Patient 3s attending physician to obtain supporting documentation. The MD stated he was not aware the referral source for Patient 3 was the Admin/Owners Wife, ";I do not tolerate business practices such as these." The MD stated it was his expectation the agency would obtain a physicians referral order before any assessment/evaluation visit to the patient was made and obtain the attending physicians information. After review of Patient 3s H&P information available in Patient 3s clinical record, the MD stated, ";I have no idea what I was presented with," but this information was insufficient to make a judgment for a terminal illness with a prognosis of six months or less to live and he clearly missed key aspects of Patient 3s admission to hospice services. The MD stated he did not know who Patient 3s attending physician was and he had not reached out to the attending physician to confirm service needs, verify Patient 3s medical prognosis, or request supporting documentation. 2. A review of Patient 4s face sheet, undated, indicated a start of care date of February 20, 2024, with a benefit period of December 24, 2024, to February 22, 2025 (Benefit Period Eight). Patient 4 had diagnoses that included Alzheimer`s disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 4s physicians orders from February 20, 2024, to February 22, 2025, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. Patient 4s H&P contained within Patient 4s clinical record indicated, a. A nursing plan of care with a medication list dated February 20, 2024, from a previous hospice agency.b. A physicians visit dated May 26, 2023, indicated, ";Assessment and Plan: [Patient 4] is an 80 [year old] female with a [PMH-Past Medical History] of [Atrial fibrillation (AFib) a common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly], Alzheimer's [disease], and recurrent [UTI-urinary tract infections]. Recent hospital admission for UTI, [Computed Tomography scan indicated] Normal kidneys, no hydro [hydronephrosis-no evidence of swelling or dilation due to a buildup of urine], no stones [hard masses formed in the kidneys], Bladder ultrasound [a test to see the structure of kidneys]... for evaluation of bladder emptying. Post void residual [the amount of urine left after urinate] 27 [milliliters-a unit of measurement]. Urinary retention [urine remaining in bladder after voiding]: Mild. This was utilized today, as I needed to know if patient has an elevated postvoid residual or evidence of urinary retention that is contributing to the current bladder symptoms. No incontinence [ability to control, the involuntary loss of urine or bowel movements]. PLAN: Given the frequency of the UTIs we will start patient on [medication] daily ... Increase fluid intake. Perineal hygiene [cleaning ones private areas]. Return in about 1 [one] year (around [May 26, 2024]). ... PMH: [Patient 4] is an 82 [year old] female who has a past medical history of [Hepatocellular carcinoma (HCC) - a type of liver cancer that originates in the liver cells] Diabetes mellitus [a disease that results in too much sugar in the blood], and Memory loss. ..." c. A Certification of Terminal Illness (CTI) from a previous hospice agency dated November 30, 2023, with a terminal diagnosis of Alzheimer`s disease. There was no documented evidence to show additional H&P for Patient 4 and the H&P from the physicians visit did not indicate a discussion or recommendation for hospice services. During an interview with Patient 4s son on March 11, 2025, at 3:30 PM, Patient 4s son stated he and his father helped care for Patient 4. Patient 4s son stated his mother had been at a previous B&C facility and receiving hospice services from a previous hospice agency, but the previous B&C facility was not providing good care for his mother, so she was moved to the current B&C facility, and he was not happy with the previous hospice agency so Patient 4 was transferred to the current hospice agency. Patient 4s son stated his understanding of hospice was, ";It doesn't mean youre going to die, it's not about the end of life, it's about someone taking care of you when you cant take care of yourself. If you need to go to ER [Emergency Room] that's ok, and you can still see all your doctors if you want to." Patient 4s son provided the name and phone number of Patient 4s Attending Physician (AP 2) and stated he did not know if AP 2 knew his mother was on hospice or not. During an interview with the LVN/IC/M on March 13, 2025, from 10:35 AM to 11:10 AM, the LVN/IC/M stated she was the Owner and Administrator of the B&C facility where Patient 4 lived and Patient 4s son had reached out to her and stated his mother was on hospice but he was not happy with the hospice and if she could recommend another hospice agency, she recommended [name of current hospice agency] where she worked. The LVN/IC/M stated she handled the intake and admission to the hospice and Patient 4s son stated Patient 4 did not have an attending physician because Patient 4 was already on hospice. The LVN/IC/M stated since Patient 4 had already been on hospice services she did not obtain a physicians referral order or secure supporting documentation to provide to the MD, other than what the previous hospice had supplied. During an interview with the Admin/Owner on March 13, 2025, at 12:04 PM, the Admin/Owner stated he knew the LVN/IC/M was the Administrator and Owner of the B&C facility where Patient 4 lived and conducted the intake and admission process to the hospice agency for Patient 4. During an interview with the MD on March 13, 2025, at 1:55 PM, the MD stated he was unaware the agency had not obtained a physicians referral order or identified and contacted Patient 4s attending physician to obtain supporting documentation. The MD stated he was not aware the referral source for Patient 4 was also the Administrator and Owner of the B&C facility were Patient 4 lived, ";I do not tolerate business practices such as these." The MD stated it was his expectation the agency would obtain a physicians referral order before any assessment/evaluation visit to the patient was made and obtain the attending physicians information even if Patient 4 was transferring from another hospice. After review of Patient 4s H&P information available in Patient 4s clinical record, the MD stated the information was insufficient to make a judgment for a terminal illness with a prognosis of six months or less to live. The MD stated he did not know who Patient 4s attending physician was and he had not reached out to the attending physician to confirm service needs, verify Patient 4s medical prognosis, or request supporting documentation. The MD stated he did not remember Patient 4 and was not confident he had certified Patient 4s terminal diagnosis or performed the face-to-face encounter and he could not explain why these documents indicated his electronic signature. The MD stated he refused to accept responsibility for Patient 4. 3. A review of Patient 5s face sheet, undated, indicated a start of care date of January 3, 2024, with a benefit period of January 3, 2024, to April 1, 2024 (First 90-day benefit period). Patient 5 had diagnoses that included Alzheimer`s disease. A review of Patient 5s physicians orders from January 3, 2024, to April 1, 2024, was conducted. There was no documented evidence to show a physicians referral order had been received. There was no documented evidence to show an Attending Physician (AP) had been identified and contacted for a referral order for hospice services, to confirm service needs, verify the patients medical prognosis or secure supporting documentation. A review of Patient 5s H&P contained within Patient 5s clinical record from January 3, 2024, to April 1, 2024, was conducted. There was no documented evidence to show H&P for Patient 5. Patient 5s daughter was unavailable for interview. During an interview with the LVN/IC/M on March 13, 2025, from 10:35 AM to 11:10 AM, the LVN/IC/M stated she was the Owner and Administrator of the B&C facility where Patient 5 lived. The LVN/IC/M stated her B&C caregivers were having difficulty taking care of Patient 5 so she approached the daughter and explained what hospice services could do to help, and she could explore hospice services with Patient 5s attending physician. The LVN/IC/M stated she handled Patient 5s intake and admission to hospice with the daughter but did not get a referral order or secure supporting documentation to provide to the MD, from Patient 5s attending physician. The LVN/IC/M stated she did not know why there was no H&P in Patient 5s clinical record. During an interview with the Admin/Owner on March 13, 2025, at 12:04 PM, the Admin/Owner stated he knew the LVN/IC/M was the Administrator and Owner of the B&C facility where Patient 5 lived and conducted the intake and admission process to the hospice agency for Patient 5. During an interview with the MD on March 13, 2025, at 2 PM, the MD stated he was unaware the agency had not obtained a physicians referral order or identified and contacted Patient 5s attending physician to obtain supporting documentation. The MD stated he was not aware the referral source for Patient 5 was also the Administrator and Owner of the B&C facility were Patient 5 lived, ";I do not tolerate business practices such as these." The MD stated it was his expectation the agency would obtain a physicians referral order before any assessment/evaluation visit to the patient was made and obtain the attending physicians information. The MD stated he was unaware Patient 4s clinical record did not contain H&P information, and he did not know who Patient 5s attending physician was, he had not reached out to the attending physician to confirm service needs, verify Patient 5s medical prognosis, or request supporting documentation. The MD stated he did not remember Patient 5 and was not confident he had certified Patient 5s terminal diagnosis and could not explain why this document indicated he had verified his signature. The MD stated he refused to accept responsibility for Patient 5. A review of the agencys policy and procedure titled ";Intake Process," dated April 2023, indicated, ";PURPOSE: To establish the process for acceptance and entry of patient into the organization. PROCEDURE: ... A. To accept referrals, information regarding a patient's demographics, diagnosis, services needed, medications, attending physician, and hospitalization, will be taken in order to make the initial determination of whether the patient's needs can be met and if he/she meets the eligibility criteria. ... C. Intake information is given to the Clinical Supervisor to accept the referral information and complete a referral and intake form. D. If the referral is not from a physician, the patient's physician (or other authorized licensed independent practitioner) will be contacted to confirm service needs and to obtain verbal orders. ..." A review of the agencys policy and procedure titled ";Admission Criteria and Process," dated April 2023, indicated, ";PURPOSE: To establish standards and a process by which a patient can be evaluated and accepted for admission. ... Admission Criteria: 1. The patient must be under the care of a physician. The patient's physician (or other authorized independent practitioner) must order and approve the provision of hospice care, be willing to sign or have a representative who is willing to sign the death certificate and be willing to discuss the patient's resuscitation status with the patient and family/caregiver. ... 3. The patient must have a life-limiting illness with a life expectancy of six (6) months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by LCD [Local Coverage Determination] ... PROCEDURE: 1. 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 request for service is not made by the patient's physician, he/she will be consulted prior to the evaluation visit/initiation of services. ..." A review of the agencys policy and procedure titled ";Certification of Terminal Illness," dated April 2023, indicated, ";PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: ... 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. ..."

Upon patient record review 10 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patients 1-10: There was not a comprehensive assessment done for spiritual care. All patients spiritual assessment are blank except for narrative stating refused.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: The patient is prescribed Acetaminophen 650mg supp. 1 pr every 6 hours prn. They are also prescribed Acetaminophen 500mg, 2 tablets q 6 hours prn. Neither order includes the maximum dose of 4000mg in 24 hours.

Upon patient record review, 1 of 14 (Patient #6) 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 6: There was no initial bereavement assessment completed on this patient.

Upon patient record review, 4 of 14 (Patient #2, 4, 6, 10) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #2: On 01/16/24, call received from wife that patient had foul and dark urine. Order received for Levaquin. There was a nursing visit completed on 01/17/24, though no assessment of urinary symptoms. No mention of new antibiotic. Patient #4: This patient was admitted 07/16/24. They were admitted with a thoracic abscess. The discharge summary included measurements of 5x2. The wound was never subsequently measured by the nurse. the wound was documented as resolved on 09/24/24. Wound assessments were not documented at other nurse visits during this time. Patient #6: Patient was admitted with a stage 3 wound to the coccyx on 08/29/24. No measurements obtained. On 09/16/24, nurse documented that the wound was resolved. All nurse assessments until 10/07 stated skin intact. However, beginning 10/07/24, the nurse documented that she provided wound care to the stage 3 wound on coccyx. The wound is mentioned in subsequent visits though no measurements or thorough wound assessment completed. Patient #10: Patient was admitted on 10/23/24. He had a G-tube which required a dressing change and assessment. This was not completed on any subsequent visits.

Upon patient record review, 4 of 14 (Patient #1, 3, 4, 10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The patient plan of care does not include individualized interventions or goals for safety, agitation, or for use of nebulizer, suction machine, and oxygen. Patient #3: The patient plan of care is not individualized to include interventions and goals for insomnia and requirement for initiation of ambien. Patient #4: The patient does not have an individualized POC, as evidenced by interventions and goals for the GU system include instructing caregiver on incontinent care, however, the patient is continent. Interventions and goals for mobility include intervention of instructing caregiver on safety care of a bedbound patient, the use of siderails, hoyer, and trapeze. This patient is up ad lib with a cane. The patient does not have a hoyer or trapeze in the home. Patient #10: The patient plan of care does not include interventions or goals for the G-tube, nor for care of the G-tube site.

Upon patient record review, 3 of 14 (Patients#4, 6, 10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #4: The patient had an order written for wound care that read, "Cleanse with NS, pat dry, repack wound with gauze, cover with 4x4, secure with tape every day and prn. The order does not state if gauze packing is dry or with wound product. It does not delineate at which visits the hospice nurse will change versus caregiver. It does not state a reason for prn needs. Patient #6: The patient was admitted with a stage 3 coccyx wound. The order read, "cleanse with wound spray, pat dry, apply hydrogel to wound and cover with dry dressing qd and prn soiled /dislodged. The order does not state who is to change the dressing. Patient #10: The patient was admitted with a G-Tube and an order for site care. There is an order that reads, "G-tube site care q visit." This order does not state what the site care entails, nor does it state who is to perform site care.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: On 04/25/24, a wound physician saw the patient. The note requested an air mattress. There was no air mattress ordered for the patient.

Upon patient record review 2 of 14 (Patient #1, 2) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #1: On 04/25/24, a wound physician saw the patient. The note requested an air mattress. There was no air mattress ordered for the patient.

Upon personnel record review, 1 of 14 (Personnel #13) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. Personnel #13: This employee did not have evidence in the personnel file of documentation of receipt for the job description for the Bereavement Coordinator.

Upon patient record review, 2 of 14 (Patient #1,5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: Aide POC states Diet as tolerated and has task for aide to assist with feeding. The order for diet in the chart is for pureed diet. Patient 5: Aide POC states diet is NCS (no concentrated sugars); the diet order in the record is for mechanical soft.

Upon personnel record review, 1 of 14 (Personnel #14) did not have evidence the individual who supervises volunteers is qualified by meeting the hospice's policies and procedures and/or job description criteria and is a designated hospice employee. Personnel #14: This employee did not have evidence in the personnel file of documentation of receipt for the job description for the Volunteer Coordinator.

Upon personnel record review, 1 of 14 (Personnel #3) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #3: This employee did not have evidence in the personnel file of documentation of receipt for the job description for the Alternate Administrator or for the Alternate DPCS.

Upon personnel record review, 3 of 14 (Personnel #3, 13, 14) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #3: This personnel record did not have evidence of orientation for alternate administrator or the alternate DPCS. Personnel #13: This personnel record did not have evidence of orientation for the bereavement coordinator. Personnel #14: This personnel record did not have evidence of orientation for the volunteer coordinator.

Upon patient record review, 3 of 14 (Patient #1,2,4) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient #1: Patient caregiver called stating patient having increased pain on 03/04/24. Physician ordered Diclofenac topical. A nursing visit was done on 03/05/24 however there is no documentation of follow on response to diclofenac order for use, side effects or effectiveness. Patient #2: On 01/22/24 caregiver called stating patient had been up all night. Order received for Ambien. A visit was done for follow up but no mention of sleep or of new medication, effectiveness or side effects. Patient #4: This patient was admitted 07/16/24. They were admitted with a thoracic abscess. The patient was started on doxycycline at the admission visit. There was no documented follow up on the antibiotic.

Upon personnel record review, 8 of 14 (Personnel #2, 3, 4, 7, 11, 12, 13, 14) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #2, 3, 4, 7, 11, 12, 13, 14 did not have evidence of state criminal background checks.

Upon patient record review 1 of 5 (Patient #4) did not have evidence in the patient record that the comprehensive assessment identifies the psychosocial needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 4: There is no evidence of an initial psychosocial assessment.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component completed timely. Patient 1: The patient's initial bereavement risk assessment is dated 08.13.2021; the patient's hospice services were initiated on 08.27.2021. All components of the bereavement risk assessment appear to be appropriate and related to the patient - the patient's sister is cited as the primary bereaved, the narrative statement refers to the patient and her sister, etc. However, it is unclear what date the bereavement assessment was performed, though it was clearly not performed prior to the initial referral of the patient and admission for hospice services.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The plan of care does not contain evidence of the DME required by the the patient for management of the terminal illness. The comprehensive initial assessment indicates that the patient utilizes a hospital bed and walker for palliation; additionally, the skilled nursing note dated 10.16.2021 indicates the patient utilizes a wheelchair. (corrected on site)

Upon client record review, 1 of 5 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The narrative portion of the chaplain's initial spiritual assessment indicates that he will make monthly visits to support the patient's needs. He then made routine visits on 09.28.2021 and 10.16.2021 in accordance with this stated plan. However, no written discipline orders were established for ongoing spiritual counselor visits. (corrected on site)