Every finding on record at Wellhouse Care, Inc.

Based on interview and record review, the agency failed to implement an alternate office site to ensure business operations will continue during an actual emergency, which was necessary for ensuring the continuity of care in a universe of nine patients, when staff members were unable to provide information regarding the agency's Emergency Preparedness Plan of the designated alternate office site during emergency event. This failure had the potential to disrupt the agency’s ability to maintain continuous care, placing the agency's patients at risk, and compromising their safety and quality of care during an emergency event. --- Findings: During an interview on September 16, 2025, at 10:30 AM, with Chaplain (a trained professional who provides spiritual and emotional support to patients and their families during end-of-life care), Chaplain stated uncertainty regarding the timing of the agency’s Emergency Preparedness Plan in-services and the last one might have been around March 2025, approximately six months ago.  Chaplain further stated that he does not recall the location of the alternate office site in case of an emergency. During an interview on September 16, 2025, at 12:30 PM, with Certified Nursing Assistant/Hospice Aid  (CNA/HA), CNA/HA stated the last time the agency’s Emergency Plan in-services were provided to her was last month which is August 2025. CNS/HA further stated the alternate office site during emergencies will be the office parking lot.    During an interview on September 16, 2025, at 1:30 PM, with Registered Nurse (RN), RN stated that the agency’s Emergency Preparedness Plan in-services were provided to the staff monthly, with the most recent session conducted in August 2025. RN further stated that she was not sure about the location of the alternate office site during an emergency, but her best guess was that it would be in the office parking lot. During an interview on September 18, 2025, at 10:30 AM, with the Administrator (Admin) and Director of Patient Care Services (DPCS), the Admin stated that he was responsible for the agency’s Emergency Preparedness Plan and confirmed that the agency's Emergency Preparedness Plan in-services were conducted monthly, but he did not recall if he mentioned the alternate office site during these sessions to all staff.  During a follow-up interview on September 18, 2025, at 11:05 AM, with the Admin and DPCS, the Admin acknowledged the importance of all staff being aware of the alternate office site during an emergency to ensure the continuity of essential functions. The Admin stated that this information should have been included in the agency's monthly Emergency Preparedness Plan in-services but was not. During a concurrent interview and record review, on September 18, 2025, at 11:15 AM, with the Admin and DPCS, the agency’s policy and procedure titled, “Emergency Operation Plan”, reviewed on March 5, 2025, was reviewed.  The P&P indicated, “POLICY. It is the policy of [Name of the Hospice agency] to have an Emergency Management Plan in place to ensure that the organization will be able to respond to a disaster. An emergency in the hospice organization or its community could suddenly and significantly affect the ability to provide hospice services. The goal is to develop processes for establishing the means and methods to continue care, treatment, and services during and after the potential emergencies. … The Administrator is ultimately responsible for assuring continuation of service. If cell phones are not available and all land lines are down, or for the requirement of an indoor command post to support additional functions at the original site or in case the original site is incapacitated, all hospice personnel should report to the home of the Administrator/DPCS. Emergency supplies will be available (refer to the Emergency Kit section below). The address is as follows:  [Admin name] 10984 Harris Dr. Loma Linda, CA 92354 …” Both Admin and DPCS stated the agency did not follow the policy.

Based on interview and record review, the agency failed to ensure that the current patient roster contained the required acuity level (a system of classifying patients according to the urgency of their medical needs during an emergency situation) for each patient, was readily available to support continuity of care during an emergency in accordance with the agency’s policy. This failure had the potential to impact the agency's ability to adequately assess and address the needs of the patients to implement immediate intervention during emergencies, compromising the safety and well-being of nine patients at risk. --- Findings: A review of the agency's “Emergency Operation Plan” (EOP) binder for the period from June 1, 2024, to September 18, 2025, indicating that a patient roster with required acuity levels was not readily available to ensure adequate support and maintain continuity of care during an emergency. During a concurrent interview and record review on September 18, 2025, at 11:30 AM with the Administrator (Admin) and Director of Patient Care Services (DPCS), the Admin stated that he was responsible for the agency’s Emergency Preparedness Plan including updating the patient roster. Upon reviewing the agency’s EOP binder, the Admin was unable to provide an explanation as to why the patient roster, containing the required acuity levels, was not implemented in accordance with the agency’s policy. During a sequent concurrent interview and record review on September 18, 2025, at 11:40 AM, with the Admin and DPCS, the agency’s policy and procedure titled, “Emergency Operation Plan”, reviewed on March 5, 2025, was reviewed.  The P&P indicated, “POLICY. It is the policy of [Name of the Hospice agency] to have an Emergency Management Plan in place to ensure that the organization will be able to respond to a disaster. An emergency in the hospice organization or its community could suddenly and significantly affect the ability to provide hospice services. The goal is to develop processes for establishing the means and methods to continue care, treatment, and services during and after the potential emergencies… CATEGORIES OF PATIENT CARE [name of the agency]… The hospice will identify patients at risk and the types of services the hospice has the ability to provide in the event of emergency. Hospice will maintain a list of patients with acuity level established. The list will be updated weekly and the Administrative person on-call maintains the list. …”. The Admin stated he was not aware the patient roster needed to be updated weekly as per the agency’s P&P. The Admin further stated the agency did not follow the policy.

Based on observation, interview, and record review, the agency failed to ensure a medication reconciliation (the process of identifying the most accurate list of all medications that the patient is taking) was conducted during the initial and recertification assessment for one of nine sampled patients (Patients 3) when one medication Patient 3 was taking was not on the Medication Profile (MP-a current list of all medications prescribed for a specific patient) and was available to use after the expiration date. This failure had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy. --- Findings: A review of Patient 3’s demographic (a document that gives a summary of patient’s information), indicated a start of care date of May 2, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of July 31, 2025, to October 28, 2025.  Patient 3 had diagnoses that included chronic obstructive pulmonary disease (COPD is a term for lung and airway diseases that restrict your breathing) and hypertension (high blood pressure). During an observation at the home visit on September 16, 2025, at 1:45 PM, with Registered Nurse (RN), an observation of Patient 3’s actual medications, available in the home, were compared with Patient 3’s most current MP.   During a concurrent observation and interview on September 16, 2025, at 1:50 PM, with RN, RN checked a bottle of Enulos solution (lactulose is prescription medication used to treat chronic constipation [a problem with passing stool]) 10 g (gram-a unit of measure)/15 ml (milliliter -a unit of measure). RN reviewed Patient 3’s MP, and she acknowledged that there was no indication of the order for Enulos and it was not part of Patient 3’s MP. Further observation on September 16, 2025, at 1:55 PM, with RN, indicated the Enulos solution expiration date was June 2025. The RN verified Patient 3’s bottle of Enulos solution had passed the expiration day (three months expired) and was available to use for Patient 3. During an interview on September 16, 2025, at 2:00 PM, with Patient’s 3, Patient 3 stated that he had been taking Enulos since the beginning of starting hospice and  his doctor is aware of it. Furthermore, Patient 3 stated that the last time he [Patient 3] took the medication was two nights ago [September 14, 2025]. A follow-up interview on September 16, 2025, at 2:05 PM, with RN, RN stated that the medication reconciliation should have been completed, and the MP updated during each visit, but it had not been done. During an interview on September 18, 2025, at 10:30 AM, with the Director of Patient Care Services (DPCS), the DPCS stated, “It was Case Manager Nurse responsibility to update Medication Profile when there's any new order or changes. Nurses should have been reviewing and updating medication profile on their visits.” During a concurrent interview and record review on September 18, 2025, at 10:35 AM, with the DPCS, the agency’s policy and procedure (P&P) titled, “Medication Profile,” revised 2009, was reviewed.  The P&P indicated, “POLICY Hospice provides a mechanism for documentation of patient prescriptions, nonprescription ( over-the-counter) medications and home remedies, including vitamins and herbs. PROCEDURE. 1. The initial assessment performed by the RN includes a review of all medications that the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicative drug therapy and non compliance with drug therapy.… 5. The RN or LPN reviews the medications with the patient on an ongoing basis to ensure the understanding of medication use. The review will include side effects, storage and administration of all medications …”. The DPCS stated the agency did not follow the policy. During a concurrent interview and record review on September 18, 2025, at 10:40 AM, with the DPCS, the agency’s P&P titled, “Initial Assessment/Comprehensive Assessment,” revised 2009, was reviewed.  The P&P indicated, “POLICY. Each patient admitted by Hospice will have an appropriate initial assessment and comprehensive. Procedure… Each patient's comprehensive assessment includes a review of all medications the patient is currently taking (prescription, non-prescription, herbs, home remedies, other alternative treatments, etc.) to identify: assessment performed and documented. • Drug effectiveness. • Side effects. • Actual or potential drug interactions. • Noncompliance with medications. • Duplicate therapy. • Ineffective therapy. • Potential adverse effects. • Medication reactions.• Drug therapy associated with lab monitoring… “. The DPCS stated the agency did not follow the policy.

Based on observation, interview, and record review, the agency failed to follow its policy and procedure to develop and maintain a system of communication and integration for three out of nine sampled patients (Patient 1, 2 and Patient 3), when the patients’ home clinical record binders did not contain their current care plans (a guide that lists their medical and emotional needs, including treatments, medications, and personal wishes, to ensure their comfort and care) including their most current Medication Profile (MP-a current list of all medications prescribed for a specific patient). This failure had the potential to result in ineffective care coordination, unmanaged symptoms, and medication errors (mistakes with medicines that can cause harm or stop proper treatment), which could place Patient 1, 2 and Patient 3’s safety, comfort, and overall well-being at serious risk in his end-of-life care. --- Findings:  1. A review of Patient 1’s demographic (document that gives a summary of patient’s information), indicated, a start of care date of October 4, 2023 with a certification period (a specific timeframe during which a patient is eligible to receive hospice (medical care for people who are expected to live six months or less) services) of July 25, 2025 to September 22, 2025.  Patient 1 had primary diagnoses that included multiple sclerosis (is a condition that affects nerves in your central nervous system) During a concurrent observation and interview at the home visit on September 16, 2025, at 10:45 AM, with Chaplain (a trained professional who provides spiritual and emotional support to patients and their families during end-of-life care), in the presence of Patient 1’s brother, a review of Patient 1’s home clinical record binder and the surrounding area was conducted. Patient 1’s current care plan including the most recent MP were not found in the binder or anywhere in the house. Both Chaplain and Patient 1's brother confirmed that these essential documents were not available. 2. A review of Patient 2’s demographic, indicated, a start of care date of January 13, 2025 with a certification period of  September 10, 2025 to November 8, 2025.  Patient 2 had primary diagnoses that included congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply) and included Chronic obstructive pulmonary disease (COPD is a term for lung and airway diseases that restrict your breathing) and hypertension (high blood pressure). During a concurrent observation and interview at the home visit on September 16, 2025, at 12:45 PM, with Certified Nursing Assistant/Hospice Aid  (CNA/HA), in the presence of Patient 2, a review of Patient 2’s home clinical record binder and the surrounding area was conducted. Patient 2’s current care plan including the most recent MP were not found in the  binder or anywhere in the house. Both CNA/HA and Patient 2 confirmed that these essential documents were not available. 3. A review of Patient 3’s demographic, indicated a start of care date of May 2, 2025, with a certification period of July 31, 2025 to October 28, 2025.  Patient 3 had diagnoses that included COPD and hypertension (high blood pressure). During a concurrent observation and interview at the home visit on September 16, 2025, at 2:10 PM, with Registered Nurse (RN), in the presence of Patient 3, a review of Patient 3’s home clinical record binder and the surrounding area was conducted. Patient 3’s current care plan including the most recent MP were not found in the binder or anywhere in the house. Both RN and Patient 3 confirmed that these essential documents were not available. During an interview and record review on September 18, 2025, at 10:45 AM, with the Administrator (Admin) and Director of Patient Care Services (DPCS), both Admin and DPCS stated that it is the responsibility of the visiting nurse and case manager to ensure that the current care plan including the most recent Medication Profile (MP), and other essential documents are left at the patient’s location and are easily accessible.” Furthermore, the Admin stated the current care plan including the most recent MP were crucial for maintaining effective care coordination, proper medication management, timely clinical responses and to facilitate continuity of care. During a concurrent interview and record review on September 18, 2025, at 10:50 AM, with the Admin and DPCS, the agency’s policy and procedure (P&P) titled, “Medication Profile,” revised 2009, was reviewed.  The P&P indicated, “POLICY Hospice provides a mechanism for documentation of patient prescriptions, nonprescription ( over-the-counter) medications and home remedies, including vitamins and herbs. PROCEDURE…6. The original medication record will be filled in the patients’ record. A copy may be placed in the patient’s home…”. Both Admin and DPCS stated the agency did not follow the policy. During a concurrent interview and record review on September 18, 2025, at 10:55 AM, with the Admin and DPCS, the agency’s P&P titled, “Patient Record Content,” revised 2009, was reviewed.  The P&P indicated, “POLICY. Hospice will provide an accurate and current patient record for every patient seen by hospice. The record weather hard copy or electronic form , will be made readily available… Procedure… 3. Each patient record will contain the following as applicable: … initial assessment. Comprehensive assessment. Updates to comprehensive assessment… A current medication profile to include medication/allergies/sensitivities and every medication, dose, frequency and route of administration for prescription and non-prescription medications, herbal products and home remedies…. “Both Admin and DPCS stated the agency did not follow the policy.

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: 1. Based on interview and record review, the agency failed to ensure the patients' comprehensive assessments were completed within five days after the election of hospice care for three of 11 sampled patients (Patients 2, 3 and 9) when the initial psychosocial assessment was not conducted. (Refer to L 523) 2. Based on interview, and record review, the agency failed to ensure a comprehensive assessment (describes in detail a patient's medical, physical and psychosocial condition and needs) was documented during the Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) meeting to explain how it was determined that the patients were no longer "terminally ill" (the patient has stabilized within their condition and will live longer than six months). In addition, the discharge plan of care was developed after the patients were discharged, for eight of 11 sampled patients (Patients 4, 5, 6, 7, 8, 9, 10 and 11) when: a. For Patients 4, 5, 6, 7, 8, 10 and 11, the IDG meeting notes did not document evidence that a comprehensive assessment was done to determine that the patients were no longer "terminally ill," or a plan of care initiated for the discharge process before the patients were discharged. (Refer to L 533) b. For Patient 9, the IDG meeting notes did not document an update to the plan of care to determine assistance needed for Patient 9 who had revoked hospice services (a patient decides to cancel hospice services to pursue more aggressive treatment) until after Patient 9 was discharged. (Refer to L 533) The cumulative effect of these systemic practices resulted in the potential to cause: the patients and family's psychosocial and emotional needs to go unmet, Patients 4, 5, 6, 7, 8, 10 and 11 to lose hospice services without a comprehensive and interdisciplinary assessment of their condition and Patient 9 to suffer a break in the continuity of care when the receiving organization did not receive a completed transfer summary documenting Patient 9's progression of care.

Based on interview and record review, the agency failed to ensure the patients' comprehensive assessment (describes in detail a patient's medical, physical and psychosocial condition and needs) were completed within five days after the election of hospice care for three of 11 sampled patients (Patients 2, 3 and 9) when the initial psychosocial assessment was not conducted. These failures had the potential to cause the patients and family's psychosocial and emotional needs to go unmet. Findings: 1. A review of Patient 2's face sheet undated, indicated a start of care date of June 17, 2021, with diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on August 22, 2022, at 3:36 PM, there was no documented evidence to show an initial psychosocial assessment was conducted for Patient 2. The DPCS stated that an initial psychosocial assessment should have been done as part of the comprehensive assessment for Patient 2. During a concurrent interview and record review with the DPCS on August 22, 2022, at 4:00 PM, of the agency's policy and procedure (P&P), titled, "Comprehensive Assessment," revised October 2012, indicated, " ...Procedure 1. During the comprehensive patient assessment, all baseline data and other relevant information will be conducted in the patient's clinical record, including at least the following information, as relevant: ...S. The patient's psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanism and the patient's and family/caregiver's reaction to illness ..." The DPCS stated they did not follow their policy on comprehensive assessment. 2. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 27, 2020, with diagnoses that included multiple sclerosis (a potentially disabling disease of the brain and spinal cord). During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on August 24, 2022, at 11:14 AM, there was no documented evidence to show an initial psychosocial assessment was conducted for Patient 3. The DPCS stated that an initial psychosocial assessment should have been done as part of the comprehensive assessment for Patient 3. During a concurrent interview and record review with the DPCS on August 24, 2022, at 11:22 AM, of the agency's policy and procedure (P&P), titled, "Comprehensive Assessment," revised October 2012, indicated, " ...Procedure 1. During the comprehensive patient assessment, all baseline data and other relevant information will be conducted in the patient's clinical record, including at least the following information, as relevant: ...S. The patient's psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanism and the patient's and family/caregiver's reaction to illness ..." The DPCS stated they did not follow their policy on comprehensive assessment. 3. A review of Patient 9's face sheet undated, indicated a start of care date of October 12, 2021, with diagnoses that included chronic systolic heart failure (a condition where the left ventricle of your heart, which pumps most of the blood, has become weak). During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on August 24, 2022, at 1:30 PM, there was no documented evidence to show an initial psychosocial assessment was conducted for Patient 9. The DPCS stated that an initial psychosocial assessment should have been done as part of the comprehensive assessment for Patient 9. During a concurrent interview and record review with the DPCS on August 24, 2022, at 3:15 PM, of the agency's policy and procedure (P&P), titled, "Comprehensive Assessment," revised October 2012, indicated, " ...Procedure 1. During the comprehensive patient assessment, all baseline data and other relevant information will be conducted in the patient's clinical record, including at least the following information, as relevant: ...S. The patient's psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanism and the patient's and family/caregiver's reaction to illness ..." The DPCS stated they did not follow their policy on comprehensive assessment.

Based on interview, and record review, the agency failed to ensure a comprehensive assessment (describes in detail a patient's medical, physical and psychosocial condition and needs) was documented during the Interdisciplinary Group (IDG - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient) meeting to explain how it was determined that the patients were no longer "terminally ill" (the patient has stabilized within their condition and will live longer than six months). In addition, the discharge plan of care was developed after the patients were discharged, for eight of 11 sampled patients (Patients 4, 5, 6, 7, 8, 9, 10 and 11) when: 1. For Patients 4, 5, 6, 7, 8, 10 and 11, the IDG meeting notes did not document evidence that a comprehensive assessment was done to determine that the patients were no longer "terminally ill," or a plan of care initiated for the discharge process before the patients were discharged. This failure had the potential to cause Patients 4, 5, 6, 7, 8, 10 and 11 to lose hospice services without a comprehensive and interdisciplinary assessment of their condition. 2. For Patient 9, the IDG meeting notes did not document an update to the plan of care to determine assistance needed for Patient 9 who had revoked hospice services (a patient decides to cancel hospice services to pursue more aggressive treatment) until after Patient 9 was discharged. This failure had the potential to cause Patient 9 to suffer a break in the continuity of care when the receiving organization did not receive a completed transfer summary documenting Patient 9's progression of care. Findings: 1a. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of April 18, 2021, with a benefit period of June 12, 2022, to August 10, 2022 (an unlimited 60-day benefit period). Patient 4 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 4's physician's discharge order, dated July 15, 2022, indicated, "Discharge patient from [name of agency] due to extended prognosis [no longer terminally ill]." A review of Patient 4's IDG meeting note, dated July 13, 2022, was conducted. There was no documented evidence to show a discussion and determination that Patient 4 was no longer "terminally ill" and to begin the discharge process. A review of Patient 4's IDG meeting note, dated July 27, 2022, indicated, "Patient is for possible discharge." (Patient 4 was discharged 12 days prior) During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 2:19 PM, the AMD stated the members of the IDG needed to discuss and update the comprehensive assessment when it was determined that the patients were no longer "terminally ill." The AMD stated the IDG needed to update and initiate the discharge plan of care before discharging the patients. The AMD stated this update of the comprehensive assessment and discharge plan of care should have been documented on the IDG meeting notes and it was not. The DPCS stated she could not explain why the dates of the IDG meeting notes were so far off. The DPCS stated she could not show Patient 4's comprehensive assessment and care plan had been updated with the change in prognosis or initiation of the discharge plan. 1b. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 30, 2021, with a benefit period of May 26, 2022, to July 24, 2022 (an unlimited 60-day benefit period). Patient 5 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 5's physician's discharge order, dated July 14, 2022, indicated, "Discharge patient from [name of agency] due to extended prognosis [no longer terminally ill]." A review of Patient 5's IDG meeting note, dated July 13, 2022, indicated, "Discharge Plan is to discontinue before end of certification period." A review of Patient 5's IDG meeting note, dated July 27, 2022, indicated, "For possible discharge." (Patient 5 was discharged 13 days prior) During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 2:34 PM, the AMD stated the members of the IDG needed to discuss and update the comprehensive assessment when it was determined that the patients were no longer "terminally ill." The AMD stated the IDG needed to update and initiate the discharge plan of care before discharging the patients. The AMD stated this update of the comprehensive assessment and discharge plan of care should have been documented on the IDG meeting notes and it was not. The DPCS stated she could not explain why the dates of the IDG meeting notes were so far off. The DPCS stated she could not show Patient 5's comprehensive assessment and care plan had been updated with the change in prognosis or initiation of the discharge plan. 1c. A review of Patient 6's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of January 20, 2022, with a benefit period of April 20, 2022, to July 18, 2022 (Second 90-day benefit period). Patient 6 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 6's physician's discharge order, dated May 23, 2022, indicated, "Discharge patient from [name of agency] due to extended prognosis [no longer terminally ill] ..." A review of Patient 6's IDG meeting note, dated May 18, 2022, was conducted. There was no documented evidence to show a discussion and determination that Patient 6 was no longer "terminally ill" and to begin the discharge process. A review of Patient 6's IDG meeting note, dated June 1, 2022, was conducted. There was no documented evidence to show a discussion and determination that Patient 6 was no longer "terminally ill" and to begin the discharge process. (Patient 6 was discharged 9 days prior) A review of Patient 6's IDG meeting note, dated June 15, 2022, indicated, "Patient is discharged on May 23, 2022 due to Extended Prognosis. Patient thankful for services done." (Patient 6 was discharged 23 days prior) During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 2:49 PM, the AMD stated the members of the IDG needed to discuss and update the comprehensive assessment when it was determined that the patients were no longer "terminally ill." The AMD stated the IDG needed to update and initiate the discharge plan of care before discharging the patients. The AMD stated this update of the comprehensive assessment and discharge plan of care should have been documented on the IDG meeting notes and it was not. The DPCS stated she could not explain why the dates of the IDG meeting notes were so far off. The DPCS stated she could not show Patient 6's comprehensive assessment and care plan had been updated with the change in prognosis or initiation of the discharge plan. 1d. A review of Patient 7's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 24, 2020, with a benefit period of May 17, 2022, to July 15, 2022 (an unlimited 60-day benefit period). Patient 7 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 7's physician's discharge order, dated July 15, 2022, indicated, "Discharge patient from [name of agency] due to extended prognosis [no longer terminally ill] ..." A review of Patient 7's IDG meeting note, dated July 13, 2022, was conducted. There was no documented evidence to show a discussion and determination that Patient 7 was no longer "terminally ill" and to begin the discharge process. A review of Patient 7's IDG meeting note, dated July 27, 2022, indicated, "Patient is for possible discharge." (Patient 7 was discharged 12 days prior) During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:04 PM, the AMD stated the members of the IDG needed to discuss and update the comprehensive assessment when it was determined that the patients were no longer "terminally ill." The AMD stated the IDG needed to update and initiate the discharge plan of care before discharging the patients. The AMD stated this update of the comprehensive assessment and discharge plan of care should have been documented on the IDG meeting notes and it was not. The DPCS stated she could not explain why the dates of the IDG meeting notes were so far off. The DPCS stated she could not show Patient 7's comprehensive assessment and care plan had been updated with the change in prognosis or initiation of the discharge plan. 1e. A review of Patient 8's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 16, 2020, with a benefit period of July 6, 2022, to September 3, 2022 (an unlimited 60-day benefit period). Patient 8 had diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 8's physician's discharge order, dated July 15, 2022, indicated, "Discharge patient from [name of agency] due to extended prognosis [no longer terminally ill]." A review of Patient 8's IDG meeting note, dated July 13, 2022, was conducted. There was no documented evidence to show a discussion and determination that Patient 8 was no longer "terminally ill" and to begin the discharge process. A review of Patient 8's IDG meeting note, dated July 27, 2022, indicated, "For possible discharge." (Patient 8 was discharged 12 days prior) During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:19 PM, the AMD stated the members of the IDG needed to discuss and update the comprehensive assessment when it was determined that the patients were no longer "terminally ill." The AMD stated the IDG needed to update and initiate the discharge plan of care before discharging the patients. The AMD stated this update of the comprehensive assessment and discharge plan of care should have been documented on the IDG meeting notes and it was not. The DPCS stated she could not explain why the dates of the IDG meeting notes were so far off. The DPCS stated she could not show Patient 8's comprehensive assessment and care plan had been updated with the change in prognosis or initiation of the discharge plan. 1f. A review of Patient 10's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 18, 2020, with a benefit period of May 9, 2022, to July 7, 2022 (an unlimited 60-day benefit period). Patient 10 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 10's physician's discharge order, dated June 10, 2022, indicated, "Discharge patient from [name of agency] due to extended prognosis [no longer terminally ill] ..." A review of Patient 10's IDG meeting note, dated June 1, 2022, was conducted. There was no documented evidence to show a discussion and determination that Patient 10 was no longer "terminally ill" and to begin the discharge process. A review of Patient 10's IDG meeting note, dated June 15, 2022, indicated, "Patient is for possible discharge," (Patient 10 was discharged 5 days prior) A review of Patient 10's IDG meeting note, dated June 29, 2022, indicated, "Patient is discharged on June 10, 2022, due to Extended Prognosis [no longer "terminally ill"] ..." (Patient 10 was discharged 19 days ago) During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:34 PM, the AMD stated the members of the IDG needed to discuss and update the comprehensive assessment when it was determined that the patients were no longer "terminally ill." The AMD stated the IDG needed to update and initiate the discharge plan of care before discharging the patients. The AMD stated this update of the comprehensive assessment and discharge plan of care should have been documented on the IDG meeting notes and it was not. The DPCS stated she could not explain why the dates of the IDG meeting notes were so far off. The DPCS stated she could not show Patient 10's comprehensive assessment and care plan had been updated with the change in prognosis or initiation of the discharge plan. 1g. A review of Patient 11's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 23, 2021, with a benefit period of December 22, 2021, to March 21, 2022 (Second 90-day benefit period). Patient 11 had diagnoses that included Chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 11's physician's discharge order, dated March 21, 2022, indicated, "Discharge patient from [name of agency] due to extended prognosis [no longer terminally ill] ..." A review of Patient 11's IDG meeting note, dated March 9, 2022, was conducted. There was no documented evidence to show a discussion and determination that Patient 11 was no longer "terminally ill" and to begin the discharge process. A review of Patient 11's IDG meeting note, dated March 23, 2022, indicated, "Patient is for possible discharge," (Patient 11 was discharged 2 days prior) A review of Patient 11's IDG meeting note, dated April 6, 2022, indicated, "Discharged on March 21, 2022, due to Extended Prognosis [no longer terminally ill]," (Patient 11 was discharged 16 days prior) During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:49 PM, the AMD stated the members of the IDG needed to discuss and update the comprehensive assessment when it was determined that the patients were no longer "terminally ill." The AMD stated the IDG needed to update and initiate the discharge plan of care before discharging the patients. The AMD stated this update of the comprehensive assessment and discharge plan of care should have been documented on the IDG meeting notes and it was not. The DPCS stated she could not explain why the dates of the IDG meeting notes were so far off. The DPCS stated she could not show Patient 11's comprehensive assessment and care plan had been updated with the change in prognosis or initiation of the discharge plan. A review of the agency's policy and procedure titled, "Interdisciplinary Group Meeting," dated revised October 2012, indicated the following: "Purpose: To define the process for interdisciplinary group meetings and documenting patient status in the clinical record. Policy: The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. ... Procedure: ... Level of services will be reviewed for new and ongoing patients based on hospice team assessments. The group will approve recommendation for a change in the level of care. The patient's plan of care will be updated no less frequently than every 15 days or more frequently if the patient's condition requires; social, cultural, and physical environments presenting obstacles to effective intervention; integration of alternative therapies into medical regime to assist in effectiveness; and any special needs of the patient. A plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment. An interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes, ... Patient approaching recertification will be reviewed for the appropriateness of continuation of care based on identifiable criteria and progression of the terminal illness. ... Patient being discharged from hospice will be reviewed to ensure appropriateness of ongoing care. Problem solving for optimal care of the patient and family/caregiver will occur, and changes will be documented on the interdisciplinary group meeting form. ..." 2. A review of Patient 9's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of October 12, 2021, with diagnoses that included chronic systolic heart failure (a condition where the left ventricle of your heart, which pumps most of the blood, has become weak). During a record review on August 24, 2022, at 11:30 AM, of Patient 9's "Physician's Orders," dated March 8, 2022, indicated, "Discharge patient from [name of agency] due to moved out of service area..." During a record review on August 24, 2022, at 1:00 PM, of Patient 9's "IDT Meeting Notes" (IDT-Interdisciplinary team- consists of the agency's department heads or designees that integrate different areas of care and concerns of a patient), dated March 9, 2022, did not indicate that Patient 9 was discharged on March 8, 2022. Further review of Patient 9's "IDT Meeting Notes," dated March 23, 2022, (14 days after Patient 9 was discharged from the agency's services), indicated, "Discharged on March 8, 2022 due to Revocation (the act of dropping out of the hospice coverage and benefits) ..." There was no documentation of assistance provided to complete the revocation process and continuity of care. During an interview with the Director of Patient Care Services on August 24, 2022, at 1:30 PM, the DPCS stated the agency updated their comprehensive assessments and care plan for patients through their IDT [IDG] meetings. The DPCS further stated Patient 9's son notified the agency on March 8, 2022, that they were dropping out of hospice service and would pursue treatment at the hospital due to a fall. The DPCS stated in situations where a patient was brought to the hospital without the agency's knowledge, they put "moved out of service area" as the reason for discharge. The DPCS was unable to provide documentation showing how the agency assisted Patient 9 in transitioning from hospice care to the hospital for treatment, and further stated the IDT [IDG] meeting conducted on March 9, 2022, and March 23, 2022, did not reflect an updated comprehensive assessment or plan of care following the revocation of services for Patient 9. During a concurrent interview and record with the DPCS, on August 24, 2022, at 3:15 PM, of the agency's policy and procedure (P&P), titled, "Revocation of Hospice Benefit Election," revised October 2012, indicated, "...Procedure...2. The Case Manager will facilitate the patient's revocation and assist with a smooth transition to another setting or independent care..." The DPCS stated they did not follow their P&P and did not update their plan for continuity of care following the revocation of services. During a concurrent interview and record review with the DPCS, on August 24, 2022, at 3:20 PM, of the agency's P&P, titled, "Interdisciplinary Group Meeting," revised October 2012, indicated, "...Procedure...13. Patient requesting transfer to another hospice or revocation of the hospice benefit will be reviewed to determine any assistance he [or] she may need to complete these processes." The DPCS stated that the IDT [IDG] meetings for March 9, 2022, and March 23, 2022, did not include the required assistance and services needed for the transition and continuity of care.

Based on interview and record review, the agency failed to conduct and document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had undertaken, the reasons for conducting the PIP and measurable goals to show progress achieved, in a universe of 3 patients. This failure had the potential to cause problems in health outcomes, patient safety and quality of care to go unaddressed and continue. Findings: A review of the agency's data collection and analysis titled, "Patient Infections 1st Quarter 2022," dated January 1, 2022, to March 31, 2022, indicated, "Goal not met this quarter: 58% [percent] of active patients on the 1st Quarter 2022 acquired infections. Goal on the next quarter: No more than 10% [percent] of average daily census will acquire infections." A review of the agency's data collection and analysis titled, "Patient Infections 2nd Quarter 2022," dated April 1, 2022, to June 30, 2022, indicated, "Goal not met this quarter: 30% [percent] of active patients on the 2nd Quarter 2022 acquired infections. Goal on the next quarter: No more than 10% [percent] of average daily census will acquire infections." A review of the agency's data collection and analysis titled, "Patient Falls 1st Quarter 2022," dated January 1, 2022, to March 31, 2022, indicated, "Goal not met this quarter: 8% [percent] of active patients attained falls on the 1st Quarter 2022. Goal on the next quarter: No Hospitalization will be reported due to Fall on the next quarter and no more than 10% [percent] of average census per day will attain falls." A review of the agency's data collection and analysis titled, "Patient Falls 2nd Quarter 2022," dated April 1, 2022, to June 30, 2022, indicated, "Goal not met this quarter: 20% [percent] of active patients attained falls on the 2nd Quarter 2022. Goal on the next quarter: No Hospitalization will be reported due to Fall on the next quarter and no more than 10% [percent] of average census per day will attain falls." A review of the agency's Quality Assurance and Performance Improvement (QAPI) Binder, dated 2021-2022, was conducted. There was no documented evidence to show a Performance Improvement Project (PIP) had been initiated or conducted for the 2021-2022 time period. During an interview with the Director of Patient Care Services (DPCS) on August 23, 2022, at 2:20 PM, the DPCS stated she was also the QAPI Coordinator (QAPI Coord) and responsible for the QAPI program. The QAPI Coord stated no Performance Improvement Projects had been done for 2021 or 2022. The QAPI Coord stated, "I didn't get any done." The QAPI Coord stated she had identified a problem with patients falls and infections but had not initiated a PIP and should have. A review of the agency's policy and procedure titled, "Quality Assessment and Performance Improvement (QAPI) Plan," dated 2011, indicated the following: "Policy: Hospice has established an ongoing program of quality assessment and performance improvement. Objectives: ...To collect and analyze data to improve identified processes of patient care/services as well as outcomes of patient care, leadership, and managerial processes, as indicated. ... Responsibility/Accountability: ...The QAPI committee will be responsible for coordinating all QAPI activities, reviewing collection of data, analyzing data, assisting staff in developing design or improvement activities, planning actions, collecting data, analyzing the effectiveness of actions, and implementing effective actions. Achieved and Sustained Improvement: ... The number and scope of annual performance improvement projects is based on patients' needs and internal organization needs. The projects reflect the scope, complexity, and past performance of services. Hospice will document what performance improvement projects are being conducted, the reasons for conducting these projects and measurable progress achieved on them. ..."

The agency failed to ensure that the Condition of Participation: L 664 418.102 Medical Director was in compliance as follows: Based on interview, and record review, the agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment (it is required by the Centers for Medicare and Medicaid Services-CMS-for an agency to properly certify a patient before submitting a claim for payment), for 11 of 11 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) when: 1. For Patient 1: The CTI for benefit period number one (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 (the CTI for the first 90-day benefit period is required by the Centers for Medicare and Medicaid Services-CMS-to be signed by a Medical Director and the patients' attending physician so two medical professionals determine a prognosis of six months or less to live). (Refer to L 667) 2. For Patient 2: The CTI for benefit period number one (first 90-day benefit period) was not signed by two physicians. (Refer to L 667) 3. For Patient 3: The CTI for an unlimited 60-day benefit period did not contain a face-to-face encounter (an in-person non-certifying physician's or nurse practitioners' clinical assessment of the patient to help determine a prognosis of six months or less to live) conducted by a non-certifying physician or nurse practitioner (a face-to-face encounter is required by the Centers for Medicare and Medicaid Services-CMS-to be conducted by a non-certifying physician or nurse practitioner so two medical professionals evaluate a prognosis of six months or less to live). (Refer to L 667) 4. For Patient 4: The CTI for an unlimited 60-day benefit period did not contain a face-to-face encounter conducted by a non-certifying physician or nurse practitioner. (Refer to L 667) 5. For Patient 5: The CTI for an unlimited 60-day benefit period did not contain a face-to-face encounter conducted by a non-certifying physician or nurse practitioner. (Refer to L 667) 6. For Patient 6: The CTI for benefit period number one (first 90-day benefit period) was not signed by two physicians. (Refer to L 667) 7. For Patient 7: The CTI for an unlimited 60-day benefit period did not contain a face-to-face encounter conducted by a non-certifying physician or nurse practitioner. (Refer to L 667) 8. For Patient 8: The CTI for an unlimited 60-day benefit period did not contain a face-to-face encounter conducted by a non-certifying physician or nurse practitioner. (Refer to L 667) 9. For Patient 9: The CTI for benefit period number one (first 90-day benefit period) was not signed by two physicians. (Refer to L 667) 10. For Patient 10: The CTI for an unlimited 60-day benefit period did not contain a face-to-face encounter conducted by a non-certifying physician or nurse practitioner. (Refer to L 667) 11. For Patient 11: The CTI for benefit period number one (first 90-day benefit period) was not signed by two physicians. (Refer to L 667) The cumulative effect of these systemic practices resulted in the potential to cause Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care too soon due to not being properly evaluated as terminally ill. The agency failed to ensure that the Condition of Participation: L 664 418.102 Medical Director was in compliance as follows: Based on interview, and record review, the agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for 11 of 11 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) when: a. For Patient 1: 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) b. For Patient 2: The CTI for the first 90-day benefit period was not signed by two physicians. (Refer to L 667) c. For Patient 3: The CTI for the unlimited 60-day period did not contain a face-to-face encounter documented by a non-certifying physician or nurse practitioner. (Refer to L 667) d. For Patient 4: The CTI for the unlimited 60-day period did not contain a face-to-face encounter documented by a non-certifying physician or nurse practitioner. (Refer to L 667) e. For Patient 5: The CTI for the unlimited 60-day period did not contain a face-to-face encounter documented by a non-certifying physician or nurse practitioner. (Refer to L 667) f. For Patient 6: The CTI for the first 90-day benefit period was not signed by two physicians. (Refer to L 667) g. For Patient 7: The CTI for the unlimited 60-day period did not contain a face-to-face encounter documented by a non-certifying physician or nurse practitioner. (Refer to L 667) h. For Patient 8: The CTI for the unlimited 60-day period did not contain a face-to-face encounter documented by a non-certifying physician or nurse practitioner. (Refer to L 667) i. For Patient 9: The CTI for the first 90-day benefit period was not signed by two physicians. (Refer to L 667) j. For Patient 10: The CTI for the unlimited 60-day period did not contain a face-to-face encounter documented by a non-certifying physician or nurse practitioner. (Refer to L 667) k. For Patient 11: The CTI for the first 90-day benefit period was not signed by two physicians. (Refer to L 667) The cumulative effect of these systemic practices resulted in the potential to cause Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care too soon due to not being properly evaluated as terminally ill.

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 (it is required by the Centers for Medicare and Medicaid Services-CMS-for an agency to properly certify a patient before submitting a claim for payment), for 11 of 11 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) when: 1. For Patient 1: The CTI for benefit period number one (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 (the CTI for the first 90-day benefit period is required by the Centers for Medicare and Medicaid Services-CMS-to be signed by a Medical Director and the patients' attending physician so two medical professionals determine a prognosis of six months or less to live). 2. For Patient 2: The CTI for benefit period number one (first 90-day benefit period) was not signed by two physicians. 3. For Patient 3: The CTI for an unlimited 60-day benefit period did not contain a face-to-face encounter (an in-person non-certifying physician's or nurse practitioners' clinical assessment of the patient to help determine a prognosis of six months or less to live) conducted by a non-certifying physician or nurse practitioner (a face-to-face encounter is required by the Centers for Medicare and Medicaid Services-CMS-to be conducted by a non-certifying physician or nurse practitioner so two medical professionals evaluate a prognosis of six months or less to live). 4. For Patient 4: The CTI for an unlimited 60-day benefit period did not contain a face-to-face encounter conducted by a non-certifying physician or nurse practitioner. 5. For Patient 5: The CTI for an unlimited 60-day benefit period did not contain a face-to-face encounter conducted by a non-certifying physician or nurse practitioner. 6. For Patient 6: The CTI for benefit period number one (first 90-day benefit period) was not signed by two physicians. 7. For Patient 7: The CTI for an unlimited 60-day benefit period did not contain a face-to-face encounter conducted by a non-certifying physician or nurse practitioner. 8. For Patient 8: The CTI for an unlimited 60-day benefit period did not contain a face-to-face encounter conducted by a non-certifying physician or nurse practitioner. 9. For Patient 9: The CTI for benefit period number one (first 90-day benefit period) was not signed by two physicians. 10. For Patient 10: The CTI for an unlimited 60-day benefit period did not contain a face-to-face encounter conducted by a non-certifying physician or nurse practitioner. 11. For Patient 11: The CTI for benefit period number one (first 90-day benefit period) was not signed by two physicians. This failure had the potential to cause Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to not being properly evaluated as terminally ill. Findings: 1. A review of Patient 1's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of June 27, 2022, with diagnoses that included lung cancer stage four (4) (Stage IV means the lung cancer has spread to more than one area in the other lung, the fluid surrounding the lung or the heart, or distant parts of the body through the bloodstream). A review of Patient 1's physician's orders, dated June 27, 2022, indicated a first benefit period from June 27, 2022, to September 24, 2022. A review of Patient 1's Certification of Terminal Illness (CTI), dated June 27, 2022, and signed by Acting Medical Director (AMD), did not show a signature from another physician certifying the terminal illness of Patient 1. During an interview with the AMD on August 24, 2022, at 3:00 PM, the AMD stated he knew two physician signatures were required for a patient's initial 90-day CTI. The AMD stated there should have been two physician signatures on the CTI as required for Patient 1's initial 90-day CTI but there was not. A review of Patient 1's billing statement that covered the period from July 1, 2022, through July 31, 2022, indicated a claim for payment was submitted. 2. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of June 17, 2021, with diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 2's physician's orders, dated, June 17, 2021, indicated a first benefit period from June 17, 2021, to September 14, 2021. A review of Patient 2's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," dated June 17, 2021, to September 14, 2021, indicated Patient 2 was in her first 90-day benefit period. Patient 2's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. The Medical Director's signature line was signed by the Acting Medical Director (AMD) on June 17, 2021. The Attending Physician's signature line was blank. During an interview with the Acting Medical Director (AMD) on August 24, 2022, at 3:00 PM, the AMD stated there should have been two physician signatures on the CTI as required for a patient's initial 90-day CTI and there was not. A review of Patient 2's claims for payment from June 1, 2021, to June 31, 2021, indicated a claim for payment was submitted on August 11, 2021. 3. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 27, 2020, with diagnoses that included multiple sclerosis (a potentially disabling disease of the brain and spinal cord). A review of Patient 3's "Physician Certification/Recertification of Terminal Illness [CTI] Unlimited 60-Day Period," dated July 18, 2022 to September 15, 2022, indicated, "I recertify that I have reviewed the clinical record prior to recertification for the above noted patient and that patient is still considered to be terminally ill and has a life expectancy of six (6) months or less, if the terminal illness runs its normal course." The CTI was signed by the Acting Medical Director (AMD) on July 18, 2022. A review of Patient 3's "[Name of agency] Face-To-Face Encounter Report," dated July 18, 2022, indicated, "Attestation: I certify that I performed the face-to-face encounter with this patient and provided the clinical findings of the above visit for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course." The Face-To-Face Encounter was signed by the Acting Medical Director (AMD). During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:00 PM, the AMD verified he had certified Patient 3's terminal illness, as well as conducted the face-to-face encounter. The AMD stated he knew the certifying physician was not supposed to conduct the face-to-face encounter and should have been done by a non-certifying physician or nurse practitioner. A review of Patient 3's claims for payment from July 1, 2022, to July 31, 2022, indicated a claim for payment was submitted on August 1, 2022. 4. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of April 18, 2021, with a benefit period of June 12, 2022, to August 10, 2022 (an unlimited 60-day benefit period). Patient 4 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 4's "Physician Certification/Recertification of Terminal Illness [CTI] Unlimited 60-Day Period," dated June 12, 2022 to August 10, 2022, indicated, "I recertify that I have reviewed the clinical record prior to recertification for the above noted patient and that patient is still considered to be terminally ill and has a life expectancy of six (6) months or less, if the terminal illness runs its normal course." The CTI was signed by the Acting Medical Director (AMD) on June 12, 2022. A review of Patient 4's "[Name of agency] Face-To-Face Encounter Report," dated June 12, 2022, indicated, "Attestation: I certify that I performed the face-to-face encounter with this patient and provided the clinical findings of the above visit for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course." The Face-To-Face Encounter was signed by the Acting Medical Director (AMD) on June 12, 2022. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 2:19 PM, the AMD verified he had certified Patient 4's terminal illness, as well as conducted the face-to-face encounter. The AMD stated he knew the certifying physician was not supposed to conduct the face-to-face encounter and had spoken to the DPCS about the problem, but it had not been fixed. The DPCS stated she knew about the problem, but it had not been fixed. A review of Patient 4's claims for payment from June 12, 2022, to August 10, 2022, indicated a claim for payment was submitted on August 1, 2022. 5. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 30, 2021, with a benefit period of May 26, 2022, to July 24, 2022 (an unlimited 60-day benefit period). Patient 5 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 5's "Physician Certification/Recertification of Terminal Illness [CTI] Unlimited 60-Day Period," dated May 26, 2022, to July 24, 2022, indicated, "I recertify that I have reviewed the clinical record prior to recertification for the above noted patient and that patient is still considered to be terminally ill and has a life expectancy of six (6) months or less, if the terminal illness runs its normal course." The CTI was signed by the Acting Medical Director (AMD) on May 22, 2022. A review of Patient 5's "[Name of agency] Face-To-Face Encounter Report," dated May 22, 2022, indicated, "Attestation: I certify that I performed the face-to-face encounter with this patient and provided the clinical findings of the above visit for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course." The Face-To-Face Encounter was signed by the Acting Medical Director (AMD) on May 22, 2022. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 2:34 PM, the AMD verified he had certified Patient 5's terminal illness, as well as conducted the face-to-face encounter. The AMD stated he knew the certifying physician was not supposed to conduct the face-to-face encounter and had spoken to the DPCS about the problem, but it had not been fixed. The DPCS stated she knew about the problem, but it had not been fixed. A review of Patient 5's claims for payment from May 26, 2022, to July 24, 2022, indicated a claim for payment was submitted on July 9, 2022. 6. A review of Patient 6's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of January 20, 2022, with a benefit period of January 20, 2022, to April 19, 2022 (first 90-day benefit period). Patient 6 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 6's physician's orders from January 20, 2022, to April 19, 2022, was conducted. There was no documented evidence to show a physician's referral order for hospice services. (a patient's referring physician is often the patient's attending physician so a referral order can help the agency identify the patient's attending physician to provide the second signature on the Certification of Terminal Illness-CTI). A review of Patient 6's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," January 20, 2022, to April 19, 2022, indicated Patient 6 was in her first 90-day benefit period. Patient 6's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. The Medical Director's signature line was signed by the Acting Medical Director (AMD) on January 21, 2022. The Attending Physician's signature line was blank. During an interview with the Acting Medical Director (AMD) and the Director of Patient Care Services (DPCS) on August 24, 2022, at 2:49 PM, the DPCS stated Patient 6 had been referred by an owner of a board and care facility. The DPCS stated she had not asked Patient 6 or Patient 6's family who Patient 6's attending physician was. The DPCS stated she had not reached out to Patient 6's attending physician for a referral order or to sign Patient 6's initial 90-day CTI. The AMD stated he knew two physician signatures were required for a patient's initial 90-day CTI. The AMD stated he knew there was a problem with the initial 90-day CTI and had discussed it with the DPCS, but it had not been fixed. The DPCS stated she knew there was a problem with the initial 90-day CTI process however it had not been fixed. A review of Patient 6's claims for payment from January 20, 2022, to April 19, 2022, indicated a claim for payment was submitted on February 7, 2022. 7. A review of Patient 7's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 24, 2020, with a benefit period of May 17, 2022, to July 15, 2022 (an unlimited 60-day benefit period). Patient 7 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 7's "Physician Certification/Recertification of Terminal Illness [CTI] Unlimited 60-Day Period," dated May 17, 2022, to July 15, 2022, indicated, "I recertify that I have reviewed the clinical record prior to recertification for the above noted patient and that patient is still considered to be terminally ill and has a life expectancy of six (6) months or less, if the terminal illness runs its normal course." The CTI was signed by the Acting Medical Director (AMD) on May 16, 2022. A review of Patient 7's "[Name of agency] Face-To-Face Encounter Report," dated May 16, 2022, indicated, "Attestation: I certify that I performed the face-to-face encounter with this patient and provided the clinical findings of the above visit for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course." The Face-To-Face Encounter was signed by the Acting Medical Director (AMD) on May 16, 2022. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:04 PM, the AMD verified he had certified Patient 7's terminal illness, as well as conducted the face-to-face encounter. The AMD stated he knew the certifying physician was not supposed to conduct the face-to-face encounter and had spoken to the DPCS about the problem, but it had not been fixed. The DPCS stated she knew about the problem, but it had not been fixed. A review of Patient 7's claims for payment from May 17, 2022, to July 15, 2022, indicated a claim for payment was submitted on July 9, 2022. 8. A review of Patient 8's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 16, 2020, with a benefit period of July 6, 2022, to September 3, 2022 (an unlimited 60-day benefit period). Patient 8 had diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 8's "Physician Certification/Recertification of Terminal Illness [CTI] Unlimited 60-Day Period," dated July 6, 2022, to September 3, 2022, indicated, "I recertify that I have reviewed the clinical record prior to recertification for the above noted patient and that patient is still considered to be terminally ill and has a life expectancy of six (6) months or less, if the terminal illness runs its normal course." The CTI was signed by the Acting Medical Director (AMD) on July 6, 2022. A review of Patient 8's "[Name of agency] Face-To-Face Encounter Report," dated June 28, 2022, indicated, "Attestation: I certify that I performed the face-to-face encounter with this patient and provided the clinical findings of the above visit for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course." The Face-To-Face Encounter was signed by the Acting Medical Director (AMD) on June 28, 2022. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:19 PM, the AMD verified he had certified Patient 8's terminal illness, as well as conducted the face-to-face encounter. The AMD stated he knew the certifying physician was not supposed to conduct the face-to-face encounter and had spoken to the DPCS about the problem, but it had not been fixed. The DPCS stated she knew about the problem, but it had not been fixed. A review of Patient 8's claims for payment from July 6, 2022, to September 3, 2022, indicated a claim for payment was submitted on August 1, 2022. 9. A review of Patient 9's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of October 12, 2021, with diagnoses that included chronic systolic heart failure (a condition where the left ventricle of your heart, which pumps most of the blood, has become weak.) A review of Patient 9's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," dated October 12, 2021, to January 9, 2022, indicated Patient 9 was in her first 90-day benefit period. Patient 9's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. The Medical Director's signature line was signed by the Acting Medical Director (AMD). The Attending Physician's signature line was blank. During an interview with the Acting Medical Director (AMD) on August 24, 2022, at 3:00 PM, the AMD stated there should have been two physician signatures on the CTI as required for a patient's initial 90-day CTI and there was not. 10. A review of Patient 10's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 18, 2020, with a benefit period of May 9, 2022, to July 7, 2022 (an unlimited 60-day benefit period). Patient 10 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 10's "Physician Certification/Recertification of Terminal Illness [CTI] Unlimited 60-Day Period," dated May 9, 2022, to July 7, 2022, indicated, "I recertify that I have reviewed the clinical record prior to recertification for the above noted patient and that patient is still considered to be terminally ill and has a life expectancy of six (6) months or less, if the terminal illness runs its normal course." The CTI was signed by the Acting Medical Director (AMD) on May 9, 2022. A review of Patient 10's "[Name of agency] Face-To-Face Encounter Report," dated May 9, 2022, indicated, "Attestation: I certify that I performed the face-to-face encounter with this patient and provided the clinical findings of the above visit for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course." The Face-To-Face Encounter was signed by the Acting Medical Director (AMD) on May 9, 2022. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:34 PM, the AMD verified he had certified Patient 10's terminal illness, as well as conducted the face-to-face encounter. The AMD stated he knew the certifying physician was not supposed to conduct the face-to-face encounter and had spoken to the DPCS about the problem, but it had not been fixed. The DPCS stated she knew about the problem, but it had not been fixed. A review of Patient 10's claims for payment from May 9, 2022, to July 7, 2022, indicated a claim for payment was submitted on July 9, 2022. 11. A review of Patient 11's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 23, 2021, with a benefit period of September 23, 2021, to December 21, 2021 (first 90-day benefit period). Patient 11 had diagnoses that included Chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 11's physician's orders from September 23, 2021, to December 21, 2021, was conducted. There was no documented evidence to show a physician's referral order for hospice services (a patient's referring physician is often the patient's attending physician so a referral order can help the agency identify the patient's attending physician to provide the second signature on the Certification of Terminal Illness-CTI). A review of Patient 11's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," September 23, 2021, to December 21, 2021, indicated Patient 11 was in her first 90-day benefit period. Patient 11's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. The Medical Director's signature line was signed by the Acting Medical Director (AMD) on September 23, 2021. The Attending Physician's signature line was blank. During an interview with the Acting Medical Director (AMD) and the Director of Patient Care Services (DPCS) on August 24, 2022, at 3:49 PM, the DPCS stated Patient 11 had been referred by a marketer. The DPCS stated she had not asked Patient 11 or Patient 11's family who Patient 11's attending physician was. The DPCS stated she had not reached out to Patient 11's attending physician for a referral order or to sign Patient 11's initial 90-day CTI. The AMD stated he knew two physician signatures were required for a patient's initial 90-day CTI and Patient 11's CTI did not have two physician signatures. The AMD stated he knew there was a problem with the initial 90-day CTI and had discussed it with the DPCS, but it had not been fixed. The DPCS stated she knew there was a problem with the initial 90-day CTI process however it had not been fixed. A review of Patient 11's claims for payment from September 23, 2021, to December 21, 2021, indicated a claim for payment was submitted on November 4, 2021. A review of the agency's policy and procedure titled, "Certification of Terminal Illness," dated October 2012, indicated the following: "PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver choose hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. ... 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. Hospice services will be provided in two (2) 90-day periods and an unlimited number of 60-day periods if the patient is recertified at the beginning of each benefit period. PROCEDURE: ...The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms. ... ... written certification must be obtained before the hospice submits a claim for payment. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim." A review of the agency's policy and procedure titled, "Face-to-Face Encounter," dated October 2012, indicated the following: "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: 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. 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. 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 interviews and record reviews, the agency failed to ensure the Medical Director certified the patients' terminal illness (Certification of Terminal Illness [CTI]- anticipated six months or less life expectancy if the disease runs its normal course) for the following benefit periods (hospice services are provided in two 90-day periods and an unlimited number of 60-day periods) when: 1. The CTI for Patient 1 for the first 90-day benefit period was not signed by two physicians. 2. The CTI for Patient 2 for the first 90-day benefit period was not signed by two physicians. 3. The CTI for Patient 3 for the unlimited 60-day period did not have a face-to-face encounter documented by a non-certifying physician or nurse practitioner. 4. The CTI for Patient 4 for the unlimited 60-day period did not have a face-to-face encounter documented by a non-certifying physician or nurse practitioner. 5. The CTI for Patient 5 for the unlimited 60-day period did not have a face-to-face encounter documented by a non-certifying physician or nurse practitioner. 6. The CTI for Patient 6 for the first 90-day benefit period was not signed by two physicians. 7. The CTI for Patient 7 for the unlimited 60-day period did not have a face-to-face encounter documented by a non-certifying physician or nurse practitioner. 8. The CTI for Patient 8 for the unlimited 60-day period did not have a face-to-face encounter documented by a non-certifying physician or nurse practitioner. 9. The CTI for Patient 9 for the first 90-day benefit period was not signed by two physicians. 10. The CTI for Patient 10 for the unlimited 60-day period did not have a face-to-face encounter documented by a non-certifying physician or nurse practitioner. 11. The CTI for Patient 11 for the first 90-day benefit period was not signed by two physicians. This failure had the potential to cause Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care too soon due to not being properly evaluated as terminally ill. Findings: 1. A review of Patient 1's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of June 27, 2022, with diagnoses that included lung cancer stage 4. A review of Patient 1's physician's orders, dated June 27, 2022, indicated a first certification period from June 27, 2022, to September 24, 2022. A review of Patient 1's Certification of Terminal Illness (CTI), dated June 27, 2022, and signed by Acting Medical Director (AMD), did not show a signature from another physician certifying the terminal illness of Patient 1. During an interview with the AMD on August 24, 2022, at 3:00 PM, the AMD stated he knew two physician signatures were required for a patient's initial 90-day CTI. The AMD stated there should have been two physician signatures on the CTI as required for a Patient 1's initial 90-day CTI. A review of Patient 1's billing statement that covers the period from July 1, 2022, through July 31, 2022, indicated a claim for payment was submitted for that covered period. 2. A review of Patient 2's face sheet undated, indicated a start of care date of June 17, 2021, with diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 2's physician's orders, dated, June 17, 2021, indicated there was no documented evidence to show a physician's referral order for hospice services. A review of Patient 2's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," dated June 17, 2021, to September 14, 2021, indicated Patient 2 was in her first 90-day benefit period. Patient 2's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. The Medical Director's signature line was signed by the Acting Medical Director (AMD) on June 17, 2021. The Attending Physician's signature line was blank. During an interview with the Acting Medical Director (AMD) on August 24, 2022, at 3:00 PM, the AMD stated there should have been two physician signatures on the CTI as required for a patient's initial 90-day CTI. A review of Patient 2's claims for payment from June 1, 2021, to June 31, 2021, indicated a claim for payment was submitted on August 11, 2021. 3. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 27, 2020, with diagnoses that included multiple sclerosis (a potentially disabling disease of the brain and spinal cord). A review of Patient 3's "Physician Certification/Recertification of Terminal Illness [CTI] Unlimited 60-Day Period," dated July 18, 2022 to September 15, 2022, indicated, "I recertify that I have reviewed the clinical record prior to recertification for the above noted patient and that patient is still considered to be terminally ill and has a life expectancy of six (6) months or less, if the terminal illness runs its normal course." The CTI was signed by the Acting Medical Director (AMD) on July 18, 2022. A review of Patient 3's "[Name of agency] Face-To-Face Encounter Report," dated July 18, 2022, indicated, "Attestation: I certify that I performed the face-to-face encounter with this patient and provided the clinical findings of the above visit for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course." The Face-To-Face Encounter was signed by the Acting Medical Director (AMD). During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:00 PM, the AMD verified he had certified Patient 3's terminal illness, as well as conducted the face-to-face encounter. The AMD stated he knew the certifying physician was not supposed to conduct the face-to-face encounter and should have been done by a non-certifying physician or nurse practitioner. A review of Patient 3's claims for payment from July 1, 2022, to July 31, 2022, indicated a claim for payment was submitted on August 1, 2022. 4. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of April 18, 2021, with a benefit period of June 12, 2022, to August 10, 2022 (an unlimited 60-day benefit period). Patient 4 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 4's "Physician Certification/Recertification of Terminal Illness [CTI] Unlimited 60-Day Period," dated June 12, 2022 to August 10, 2022, indicated, "I recertify that I have reviewed the clinical record prior to recertification for the above noted patient and that patient is still considered to be terminally ill and has a life expectancy of six (6) months or less, if the terminal illness runs its normal course." The CTI was signed by the Acting Medical Director (AMD) on June 12, 2022. A review of Patient 4's "[Name of agency] Face-To-Face Encounter Report," dated June 12, 2022, indicated, "Attestation: I certify that I performed the face-to-face encounter with this patient and provided the clinical findings of the above visit for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course." The Face-To-Face Encounter was signed by the Acting Medical Director (AMD) on June 12, 2022. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 2:19 PM, the AMD verified he had certified Patient 4's terminal illness, as well as conducted the face-to-face encounter. The AMD stated he knew the certifying physician was not supposed to conduct the face-to-face encounter and had spoken to the DPCS about the problem, but it had not been fixed. The DPCS stated she knew about the problem, but it had not been fixed. A review of Patient 4's claims for payment from June 12, 2022, to August 10, 2022, indicated a claim for payment was submitted on August 1, 2022. 5. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 30, 2021, with a benefit period of May 26, 2022, to July 24, 2022 (an unlimited 60-day benefit period). Patient 5 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 5's "Physician Certification/Recertification of Terminal Illness [CTI] Unlimited 60-Day Period," dated May 26, 2022, to July 24, 2022, indicated, "I recertify that I have reviewed the clinical record prior to recertification for the above noted patient and that patient is still considered to be terminally ill and has a life expectancy of six (6) months or less, if the terminal illness runs its normal course." The CTI was signed by the Acting Medical Director (AMD) on May 22, 2022. A review of Patient 5's "[Name of agency] Face-To-Face Encounter Report," dated May 22, 2022, indicated, "Attestation: I certify that I performed the face-to-face encounter with this patient and provided the clinical findings of the above visit for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course." The Face-To-Face Encounter was signed by the Acting Medical Director (AMD) on May 22, 2022. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 2:34 PM, the AMD verified he had certified Patient 5's terminal illness, as well as conducted the face-to-face encounter. The AMD stated he knew the certifying physician was not supposed to conduct the face-to-face encounter and had spoken to the DPCS about the problem, but it had not been fixed. The DPCS stated she knew about the problem, but it had not been fixed. A review of Patient 5's claims for payment from May 26, 2022, to July 24, 2022, indicated a claim for payment was submitted on July 9, 2022. 6. A review of Patient 6's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of January 20, 2022, with a benefit period of January 20, 2022, to April 19, 2022 (first 90-day benefit period). Patient 6 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 6's physician's orders from January 20, 2022, to April 19, 2022, was conducted. There was no documented evidence to show a physician's referral order for hospice services. A review of Patient 6's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," January 20, 2022, to April 19, 2022, indicated Patient 6 was in her first 90-day benefit period. Patient 6's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. The Medical Director's signature line was signed by the Acting Medical Director (AMD) on January 21, 2022. The Attending Physician's signature line was blank. During an interview with the Acting Medical Director (AMD) and the Director of Patient Care Services (DPCS) on August 24, 2022, at 2:49 PM, the DPCS stated Patient 6 had been referred by an owner of a board and care facility. The DPCS stated she had not asked Patient 6 or Patient 6's family who Patient 6's attending physician was. The DPCS stated she had not reached out to Patient 6's attending physician for a referral order or to sign Patient 6's initial 90-day CTI. The AMD stated he knew two physician signatures were required for a patient's initial 90-day CTI. The AMD stated he knew there was a problem with the initial 90-day CTI and had discussed it with the DPCS, but it had not been fixed. The DPCS stated she knew there was a problem with the initial 90-day CTI process however it had not been fixed. A review of Patient 6's claims for payment from January 20, 2022, to April 19, 2022, indicated a claim for payment was submitted on February 7, 2022. 7. A review of Patient 7's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 24, 2020, with a benefit period of May 17, 2022, to July 15, 2022 (an unlimited 60-day benefit period). Patient 7 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 7's "Physician Certification/Recertification of Terminal Illness [CTI] Unlimited 60-Day Period," dated May 17, 2022, to July 15, 2022, indicated, "I recertify that I have reviewed the clinical record prior to recertification for the above noted patient and that patient is still considered to be terminally ill and has a life expectancy of six (6) months or less, if the terminal illness runs its normal course." The CTI was signed by the Acting Medical Director (AMD) on May 16, 2022. A review of Patient 7's "[Name of agency] Face-To-Face Encounter Report," dated May 16, 2022, indicated, "Attestation: I certify that I performed the face-to-face encounter with this patient and provided the clinical findings of the above visit for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course." The Face-To-Face Encounter was signed by the Acting Medical Director (AMD) on May 16, 2022. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:04 PM, the AMD verified he had certified Patient 7's terminal illness, as well as conducted the face-to-face encounter. The AMD stated he knew the certifying physician was not supposed to conduct the face-to-face encounter and had spoken to the DPCS about the problem, but it had not been fixed. The DPCS stated she knew about the problem, but it had not been fixed. A review of Patient 7's claims for payment from May 17, 2022, to July 15, 2022, indicated a claim for payment was submitted on July 9, 2022. 8. A review of Patient 8's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 16, 2020, with a benefit period of July 6, 2022, to September 3, 2022 (an unlimited 60-day benefit period). Patient 8 had diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 8's "Physician Certification/Recertification of Terminal Illness [CTI] Unlimited 60-Day Period," dated July 6, 2022, to September 3, 2022, indicated, "I recertify that I have reviewed the clinical record prior to recertification for the above noted patient and that patient is still considered to be terminally ill and has a life expectancy of six (6) months or less, if the terminal illness runs its normal course." The CTI was signed by the Acting Medical Director (AMD) on July 6, 2022. A review of Patient 8's "[Name of agency] Face-To-Face Encounter Report," dated June 28, 2022, indicated, "Attestation: I certify that I performed the face-to-face encounter with this patient and provided the clinical findings of the above visit for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course." The Face-To-Face Encounter was signed by the Acting Medical Director (AMD) on June 28, 2022. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:19 PM, the AMD verified he had certified Patient 8's terminal illness, as well as conducted the face-to-face encounter. The AMD stated he knew the certifying physician was not supposed to conduct the face-to-face encounter and had spoken to the DPCS about the problem, but it had not been fixed. The DPCS stated she knew about the problem, but it had not been fixed. A review of Patient 8's claims for payment from July 6, 2022, to September 3, 2022, indicated a claim for payment was submitted on August 1, 2022. 9. A review of Patient 9's face sheet undated, indicated a start of care date of October 12, 2021, with diagnoses that included chronic systolic heart failure (a condition where the left ventricle of your heart, which pumps most of the blood, has become weak.) A review of Patient 9's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," dated October 12, 2021, to January 9, 2022, indicated Patient 9 was in her first 90-day benefit period. Patient 9's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. The Medical Director's signature line was signed by the Acting Medical Director (AMD). The Attending Physician's signature line was blank. During an interview with the Acting Medical Director (AMD) on August 24, 2022, at 3:00 PM, the AMD stated there should have been two physician signatures on the CTI as required for a patient's initial 90-day CTI. 10. A review of Patient 10's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 18, 2020, with a benefit period of May 9, 2022, to July 7, 2022 (an unlimited 60-day benefit period). Patient 10 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 10's "Physician Certification/Recertification of Terminal Illness [CTI] Unlimited 60-Day Period," dated May 9, 2022, to July 7, 2022, indicated, "I recertify that I have reviewed the clinical record prior to recertification for the above noted patient and that patient is still considered to be terminally ill and has a life expectancy of six (6) months or less, if the terminal illness runs its normal course." The CTI was signed by the Acting Medical Director (AMD) on May 9, 2022. A review of Patient 10's "[Name of agency] Face-To-Face Encounter Report," dated May 9, 2022, indicated, "Attestation: I certify that I performed the face-to-face encounter with this patient and provided the clinical findings of the above visit for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course." The Face-To-Face Encounter was signed by the Acting Medical Director (AMD) on May 9, 2022. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:34 PM, the AMD verified he had certified Patient 10's terminal illness, as well as conducted the face-to-face encounter. The AMD stated he knew the certifying physician was not supposed to conduct the face-to-face encounter and had spoken to the DPCS about the problem, but it had not been fixed. The DPCS stated she knew about the problem, but it had not been fixed. A review of Patient 10's claims for payment from May 9, 2022, to July 7, 2022, indicated a claim for payment was submitted on July 9, 2022. 11. A review of Patient 11's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 23, 2021, with a benefit period of September 23, 2021, to December 21, 2021 (first 90-day benefit period). Patient 11 had diagnoses that included Chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 11's physician's orders from September 23, 2021, to December 21, 2021, was conducted. There was no documented evidence to show a physician's referral order for hospice services. A review of Patient 11's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," September 23, 2021, to December 21, 2021, indicated Patient 11 was in her first 90-day benefit period. Patient 11's "Physician Certification/Recertification of Terminal Illness [CTI] Initial/2nd [second] 90-Day Period," indicated two physician signature lines. One line indicated where the Hospice Medical Director should sign, and one line indicated where the Attending Physician should sign. The Medical Director's signature line was signed by the Acting Medical Director (AMD) on September 23, 2021. The Attending Physician's signature line was blank. During an interview with the Acting Medical Director (AMD) and the Director of Patient Care Services (DPCS) on August 24, 2022, at 3:49 PM, the DPCS stated Patient 11 had been referred by a marketer. The DPCS stated she had not asked Patient 11 or Patient 11's family who Patient 11's attending physician was. The DPCS stated she had not reached out to Patient 11's attending physician for a referral order or to sign Patient 11's initial 90-day CTI. The AMD stated he knew two physician signatures were required for a patient's initial 90-day CTI. The AMD stated he knew there was a problem with the initial 90-day CTI and had discussed it with the DPCS, but it had not been fixed. The DPCS stated she knew there was a problem with the initial 90-day CTI process however it had not been fixed. A review of Patient 11's claims for payment from September 23, 2021, to December 21, 2021, indicated a claim for payment was submitted on November 4, 2021. A review of the agency's policy and procedure titled, "Certification of Terminal Illness," dated October 2012, indicated the following: "PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver choose hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. ... 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. Hospice services will be provided in two (2) 90-day periods and an unlimited number of 60-day periods if the patient is recertified at the beginning of each benefit period. PROCEDURE: ...The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms. ... ... written certification must be obtained before the hospice submits a claim for payment. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim." A review of the agency's policy and procedure titled, "Face-to-Face Encounter," dated October 2012, indicated the following: "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: 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. 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. 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."

The agency failed to ensure that the Condition of Participation: L 797 418.116 Compliance with Federal, State, and local laws was in compliance as follows: Based on interview, and record review, the agency failed to operate and furnish services in compliance with all Federal and State regulations for nine of 11 sampled patients (Patients 2, 3, 4, 5, 6, 7, 8, 10 and 11) and the Acting Medical Director (AMD), in a universe of three patients when: 1. For Patients 4, 5, 6, 7, 8, 10 and 11, the agency failed to furnish services in compliance with Federal Law [Social Security Act §1879(g)(2)] when the agency did not issue an "Advance Beneficiary Notice of Noncoverage" (ABN-a notice that explains the patient's right to appeal discharge from hospice services); once it was determined Patients 4, 5, 6, 7, 8, 10 and 11, were no longer terminally ill (extended prognosis-physician determines patient will live longer than six months). This failure caused Patients 4, 5, 6, 7, 8, 10 and 11, to lose hospice services without the opportunity to appeal. (Refer to L 798) 2. For Patients 2, 3, 4, 5, 6, 7, 8, 10 and 11, the agency failed to furnish services in compliance with Federal Law [42 Code of Federal Regulations (CFR) § 418.25(a)], when the agency failed to obtain a physician's referral order for hospice services, confirm service needs, verify the patients' medical prognosis and secure supporting documentation. This failure had the potential to cause Patients 2, 3, 4, 5, 6, 7, 8, 10 and 11, to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to not being properly evaluated as terminally ill. (Refer to L 798) 3. For the Acting Medical Director (AMD), the agency failed to furnish services in compliance with State Law [Standards of Quality Hospice Care, Article (ART) 6-6.2(B)(1) Contractual Services] when the agency failed to create a written agreement with the Acting Medical Director (AMD) defining the nature and scope of services to be provided. This failure had the potential to cause patients to receive services that were not in accordance with hospice standards or the patients' Plans of Care. (Refer to L 798) The cumulative effect of these systemic practices resulted in the potential to cause: Patients 4, 5, 6, 7, 8, 10 and 11, to lose hospice services without the opportunity to appeal, Patients 2, 3, 4, 5, 6, 7, 8, 10 and 11, to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to not being properly evaluated as terminally ill, and patients to receive services that were not in accordance with hospice standards or the patients' Plans of Care.

Based on interview, and record review, the agency failed to operate and furnish services in compliance with all Federal and State regulations for nine of 11 sampled patients (Patients 2, 3, 4, 5, 6, 7, 8, 10 and 11) and the Acting Medical Director (AMD), in a universe of three patients when: 1. For Patients 4, 5, 6, 7, 8, 10 and 11, the agency failed to furnish services in compliance with Federal Law [Social Security Act §1879(g)(2)] when the agency did not issue an "Advance Beneficiary Notice of Noncoverage" (ABN-a notice that explains the patient's right to appeal discharge from hospice services); once it was determined Patients 4, 5, 6, 7, 8, 10 and 11, were no longer terminally ill (extended prognosis-physician determines patient will live longer than six months). This failure caused Patients 4, 5, 6, 7, 8, 10 and 11, to lose hospice services without the opportunity to appeal. 2. For Patients 2, 3, 4, 5, 6, 7, 8, 10 and 11, the agency failed to furnish services in compliance with Federal Law [42 Code of Federal Regulations (CFR) § 418.25(a)], when the agency failed to obtain a physician's referral order for hospice services, confirm service needs, verify the patients' medical prognosis and secure supporting documentation. This failure had the potential to cause Patients 2, 3, 4, 5, 6, 7, 8, 10 and 11, to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to not being properly evaluated as terminally ill. 3. For the Acting Medical Director (AMD), the agency failed to furnish services in compliance with State Law [Standards of Quality Hospice Care, Article (ART) 6-6.2(B)(1) Contractual Services] when the agency failed to create a written agreement with the Acting Medical Director (AMD) defining the nature and scope of services to be provided. This failure had the potential to cause patients to receive services that were not in accordance with hospice standards or the patients' Plans of Care. Findings: 1a. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of April 18, 2021, with a benefit period of June 12, 2022, to August 10, 2022 (an unlimited 60-day benefit period). Patient 4 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 4's physician's discharge order, dated July 15, 2022, indicated, "Discharge patient from [name of agency] due to extended prognosis [no longer terminally ill]." A review of Patient 4's "Hospice Discharge/Transfer Summary," dated July 15, 2022, indicated, "Reason for Discharge/Transfer: Extended Prognosis [no longer terminally ill]." A review of Patient 4's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from June 12, 2022, to August 24, 2022, was conducted. There was no documented evidence to show Patient 4 or Patient 4's responsible party had been given an ABN. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 2:19 PM, the AMD stated Patient 4 or Patient 4's responsible party should have been given an ABN and they were not. The DPCS stated, "It was missed. I was supposed to do it." 1b. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 30, 2021, with a benefit period of May 26, 2022, to July 24, 2022 (an unlimited 60-day benefit period). Patient 5 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 5's physician's discharge order, dated July 14, 2022, indicated, "Discharge patient from [name of agency] due to extended prognosis [no longer terminally ill]." A review of Patient 5's "Hospice Discharge/Transfer Summary," dated July 14, 2022, indicated, "Reason for Discharge/Transfer: Extended Prognosis [no longer terminally ill]." A review of Patient 5's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from May 26, 2022, to August 24, 2022, was conducted. There was no documented evidence to show Patient 5 or Patient 5's responsible party had been given an ABN. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 2:34 PM, the AMD stated Patient 5 or Patient 5's responsible party should have been given an ABN and they were not. The DPCS stated, "It was missed. I was supposed to do it." 1c. A review of Patient 6's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of January 20, 2022, with a benefit period of April 20, 2022, to July 18, 2022 (Second 90-day benefit period). Patient 6 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 6's physician's discharge order, dated May 23, 2022, indicated, "Discharge patient from [name of agency] due to extended prognosis [no longer terminally ill] ..." A review of Patient 6's "Hospice Discharge/Transfer Summary," dated May 23, 2022, indicated, "Reason for Discharge/Transfer: Extended Prognosis [no longer terminally ill]." A review of Patient 6's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from April 20, 2022, to August 24, 2022, was conducted. There was no documented evidence to show Patient 6 or Patient 6's responsible party had been given an ABN. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 2:49 PM, the AMD stated Patient 6 or Patient 6's responsible party should have been given an ABN and they were not. The DPCS stated, "It was missed. I was supposed to do it." 1d. A review of Patient 7's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 24, 2020, with a benefit period of May 17, 2022, to July 15, 2022 (an unlimited 60-day benefit period). Patient 7 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 7's physician's discharge order, dated July 15, 2022, indicated, "Discharge patient from [name of agency] due to extended prognosis [no longer terminally ill] ..." A review of Patient 7's "Hospice Discharge/Transfer Summary," dated July 15, 2022, indicated, "Reason for Discharge/Transfer: Extended Prognosis [no longer terminally ill]." A review of Patient 7's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from May 17, 2022, to August 24, 2022, was conducted. There was no documented evidence to show Patient 7 or Patient 7's responsible party had been given an ABN. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:04 PM, the AMD stated Patient 7 or Patient 7's responsible party should have been given an ABN and they were not. The DPCS stated, "It was missed. I was supposed to do it." 1e. A review of Patient 8's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 16, 2020, with a benefit period of July 6, 2022, to September 3, 2022 (an unlimited 60-day benefit period). Patient 8 had diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 8's physician's discharge order, dated July 15, 2022, indicated, "Discharge patient from [name of agency] due to extended prognosis [no longer terminally ill]." A review of Patient 8's "Hospice Discharge/Transfer Summary," dated July 15, 2022, indicated, "Reason for Discharge/Transfer: Extended Prognosis [no longer terminally ill]." A review of Patient 8's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from July 6, 2022, to August 24, 2022, was conducted. There was no documented evidence to show Patient 8 or Patient 8's responsible party had been given an ABN. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:19 PM, the AMD stated Patient 8 or Patient 8's responsible party should have been given an ABN and they were not. The DPCS stated, "It was missed. I was supposed to do it." 1f. A review of Patient 10's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 18, 2020, with a benefit period of May 9, 2022, to July 7, 2022 (an unlimited 60-day benefit period). Patient 10 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 10's physician's discharge order, dated June 10, 2022, indicated, "Discharge patient from [name of agency] due to extended prognosis [no longer terminally ill] ..." A review of Patient 10's "Hospice Discharge/Transfer Summary," dated June 10, 2022, indicated, "Reason for Discharge/Transfer: Extended Prognosis [no longer terminally ill]." A review of Patient 10's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from May 9, 2022, to August 24, 2022, was conducted. There was no documented evidence to show Patient 10 or Patient 10's responsible party had been given an ABN. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:34 PM, the AMD stated Patient 10 or Patient 10's responsible party should have been given an ABN and they were not. The DPCS stated, "It was missed. I was supposed to do it." 1g. A review of Patient 11's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 23, 2021, with a benefit period of December 22, 2021, to March 21, 2022 (Second 90-day benefit period). Patient 11 had diagnoses that included Chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 11's physician's discharge order, dated March 21, 2022, indicated, "Discharge patient from [name of agency] due to extended prognosis [no longer terminally ill] ..." A review of Patient 11's "Hospice Discharge/Transfer Summary," dated March 21, 2022, indicated, "Reason for Discharge/Transfer: Extended Prognosis [no longer terminally ill]." A review of Patient 11's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from December 22, 2021, to August 24, 2022, was conducted. There was no documented evidence to show Patient 11 or Patient 11's responsible party had been given an ABN. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:49 PM, the AMD stated Patient 11 or Patient 11's responsible party should have been given an ABN and they were not. The DPCS stated, "It was missed. I was supposed to do it." A review of the agency's policy and procedure titled, "Financial Responsibility and Medicare Written Notices," dated October 2012, indicated the following: "Procedure: ...The ABN will be given less frequently for the hospice benefit than in other settings, for reasons including bundled per-diem payment and less advent of discharges for coverage reasons and non-covered care. ...There are three situations in which hospice services may be denied that could trigger liability protection under §1879 and require issuance of an ABN. A. Ineligibility because the beneficiary is not "terminally ill" as defined in §1879(g)(2) of the Act; ... In the past, hospice providers would have only used the general ABN for all terminations where the beneficiary faced financial liability. Now hospice providers will be required to issue the Notice of Medicare Provider Non-Coverage (generic notice) under the expedited review process for termination when covered care is ending for coverage reasons. ... After reading the Notice of Provider Non-Coverage (generic notice), the patient or his/her representative must sign and date the form indicating they have received the notice and understand they can appeal the decision by contacting a QIO [Quality Improvement Organization]. A Detailed Notice is given to a patient or his/her representative when QIO review is requested in order to provide more explanation on why coverage is ending. ... CMS [Centers for Medicare and Medicaid Services] has provided explicit instructions including but not limited to when and how to fill out all required forms, the delivery of notices, time frames for delivery, and who pays for care while the QIO is reviewing the determination. ...Agency leadership is responsible for educating staff on current CMS requirements regarding the ABN, ... All written and verbal notifications of the patient's financial responsibility will be documented in the clinical and billing records. Original versions of the completed ABN, whether annotated or signed and copies of signed Notice of Provider Non-Coverage (generic notice), will be kept on file at the agency." 2a. A review of Patient 2's face sheet undated, indicated a start of care date of June 17, 2021, with diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 2's "Patient Intake," undated, indicated, "Referred By: [a marketer]." A review of Patient 2's physician's orders from June 17, 2021, to August 24, 2022, was conducted. There was no documented evidence to show an attending physician's referral order. A review of Patient 2's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from June 17, 2021, to August 24, 2022, was conducted. There was no documented evidence to show the agency asked Patient 2 or Patient 2's family who the attending physician was. There was no documented evidence to show Patient 2's attending physician was contacted for a referral order for hospice services, to confirm service needs, verify the patient's medical prognosis or secure supporting documentation. During an interview with the Acting Medical Director (AMD) and the Director of Patient Care Services (DPCS) on August 24, 2022, at 3:00 PM, the DPCS stated Patient 2 was referred to the agency by a marketer. The DPCS stated Patient 2 or Patient 2's family were not asked who the attending physician was. The DPCS stated Patient 2's attending physician was not contacted for a referral order for hospice services, to confirm service needs, verify the patients' medical prognosis or secure supporting documentation. The AMD stated a referral order should have been obtained from Patient 2's attending physician. The AMD stated he could not write a referral order to refer a patient to himself. The AMD stated it was very important for him to talk with Patient 2's attending physician to establish the prognosis of six months or less to live as well as confirm Patient 2's care needs. 2b. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 27, 2020, with diagnoses that included multiple sclerosis (a potentially disabling disease of the brain and spinal cord). A review of Patient 3's "Patient Intake," undated, indicated, "Referred By: [the owner of a board and care]." A review of Patient 3's physician's orders from September 27, 2020, to August 24, 2022, was conducted. There was no documented evidence to show an attending physician's referral order. A review of Patient 3's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from September 27, 2020, to August 24, 2022, was conducted. There was no documented evidence to show the agency asked Patient 3 or Patient 3's family who the attending physician was. There was no documented evidence to show Patient 3's attending physician was contacted for a referral order for hospice services, to confirm service needs, verify the patient's medical prognosis or secure supporting documentation. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:00 PM, the DPCS stated Patient 3 was referred to the agency by an owner of a board and care facility. The DPCS stated Patient 3 or Patient 3's family were not asked who the attending physician was. The DPCS stated Patient 3's attending physician was not contacted for a referral order for hospice services, to confirm service needs, verify the patients' medical prognosis or secure supporting documentation. The AMD stated a referral order should have been obtained from Patient 3's attending physician. The AMD stated a hospice physician could not write a referral order to refer a patient to himself. The AMD stated it was very important for him to talk with Patient 3's attending physician to establish the prognosis of six months or less to live as well as confirm Patient 3's care needs. 2c. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of April 18, 2021, with a benefit period of June 12, 2022, to August 10, 2022 (an unlimited 60-day benefit period). Patient 4 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 4's "Patient Intake," undated, indicated, "Referred By: [the owner of a board and care]." A review of Patient 4's physician's orders from April 18, 2021, to August 24, 2022, was conducted. There was no documented evidence to show an attending physician's referral order. A review of Patient 4's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from April 18, 2021, to August 24, 2022, was conducted. There was no documented evidence to show the agency asked Patient 4 or Patient 4's family who the attending physician was. There was no documented evidence to show Patient 4's attending physician was contacted for a referral order for hospice services, to confirm service needs, verify the patient's medical prognosis or secure supporting documentation. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 2:19 PM, the DPCS stated Patient 4 was referred to the agency by an owner of a board and care facility. The DPCS stated Patient 4 or Patient 4's family were not asked who the attending physician was. The DPCS stated Patient 4's attending physician was not contacted for a referral order for hospice services, to confirm service needs, verify the patients' medical prognosis or secure supporting documentation. The AMD stated a referral order should have been obtained from Patient 4's attending physician. The AMD stated he could not write a referral order to refer a patient to himself. The AMD stated it was very important for him to talk with Patient 4's attending physician to establish the prognosis of six months or less to live as well as confirm Patient 4's care needs. 2d. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 30, 2021, with a benefit period of May 26, 2022, to July 24, 2022 (an unlimited 60-day benefit period). Patient 5 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 5's "Patient Intake," undated, indicated, "Referred By: [a marketer]." A review of Patient 5's physician's orders from July 30, 2021, to August 24, 2022, was conducted. There was no documented evidence to show an attending physician's referral order. A review of Patient 5's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from July 30, 2021, to August 24, 2022, was conducted. There was no documented evidence to show the agency asked Patient 5 or Patient 5's family who the attending physician was. There was no documented evidence to show Patient 5's attending physician was contacted for a referral order for hospice services, to confirm service needs, verify the patient's medical prognosis or secure supporting documentation. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 2:34 PM, the DPCS stated Patient 5 was referred to the agency by a marketer. The DPCS stated Patient 5 or Patient 5's family were not asked who the attending physician was. The DPCS stated Patient 5's attending physician was not contacted for a referral order for hospice services, to confirm service needs, verify the patients' medical prognosis or secure supporting documentation. The AMD stated a referral order should have been obtained from Patient 5's attending physician. The AMD stated he could not write a referral order to refer a patient to himself. The AMD stated it was very important for him to talk with Patient 5's attending physician to establish the prognosis of six months or less to live as well as confirm Patient 5's care needs. 2e. A review of Patient 6's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of January 20, 2022, with a benefit period of April 20, 2022, to July 18, 2022 (Second 90-day benefit period). Patient 6 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 6's "Patient Intake," undated, indicated, "Referred By: [the owner of a board and care]." A review of Patient 6's physician's orders from January 20, 2022, to August 24, 2022, was conducted. There was no documented evidence to show an attending physician's referral order. A review of Patient 6's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from January 20, 2022, to August 24, 2022, was conducted. There was no documented evidence to show the agency asked Patient 6 or Patient 6's family who the attending physician was. There was no documented evidence to show Patient 6's attending physician was contacted for a referral order for hospice services, to confirm service needs, verify the patient's medical prognosis or secure supporting documentation. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 2:49 PM, the DPCS stated Patient 6 was referred to the agency by an owner of a board and care facility. The DPCS stated Patient 6 or Patient 6's family were not asked who the attending physician was. The DPCS stated Patient 6's attending physician was not contacted for a referral order for hospice services, to confirm service needs, verify the patients' medical prognosis or secure supporting documentation. The AMD stated a referral order should have been obtained from Patient 6's attending physician. The AMD stated he could not write a referral order to refer a patient to himself. The AMD stated it was very important for him to talk with Patient 6's attending physician to establish the prognosis of six months or less to live as well as confirm Patient 6's care needs. 2f. A review of Patient 7's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 24, 2020, with a benefit period of May 17, 2022, to July 15, 2022 (an unlimited 60-day benefit period). Patient 7 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 7's "Patient Intake," undated, indicated, "Referred By: [a marketer]." A review of Patient 7's physician's orders from September 24, 2020, to August 24, 2022, was conducted. There was no documented evidence to show an attending physician's referral order. A review of Patient 7's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from September 24, 2020, to August 24, 2022, was conducted. There was no documented evidence to show the agency asked Patient 7 or Patient 7's family who the attending physician was. There was no documented evidence to show Patient 7's attending physician was contacted for a referral order for hospice services, to confirm service needs, verify the patient's medical prognosis or secure supporting documentation. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:04 PM, the DPCS stated Patient 7 was referred to the agency by a marketer. The DPCS stated Patient 7 or Patient 7's family were not asked who the attending physician was. The DPCS stated Patient 7's attending physician was not contacted for a referral order for hospice services, to confirm service needs, verify the patients' medical prognosis or secure supporting documentation. The AMD stated a referral order should have been obtained from Patient 7's attending physician. The AMD stated he could not write a referral order to refer a patient to himself. The AMD stated it was very important for him to talk with Patient 7's attending physician to establish the prognosis of six months or less to live as well as confirm Patient 7's care needs. 2g. A review of Patient 8's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 16, 2020, with a benefit period of July 6, 2022, to September 3, 2022 (an unlimited 60-day benefit period). Patient 8 had diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 8's "Patient Intake," undated, indicated, "Referred By: [the owner of a board and care]." A review of Patient 8's physician's orders from July 16, 2020, to August 24, 2022, was conducted. There was no documented evidence to show an attending physician's referral order. A review of Patient 8's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from July 16, 2020, to August 24, 2022, was conducted. There was no documented evidence to show the agency asked Patient 8 or Patient 8's family who the attending physician was. There was no documented evidence to show Patient 8's attending physician was contacted for a referral order for hospice services, to confirm service needs, verify the patient's medical prognosis or secure supporting documentation. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:19 PM, the DPCS stated Patient 8 was referred to the agency by an owner of a board and care facility. The DPCS stated Patient 8 or Patient 8's family were not asked who the attending physician was. The DPCS stated Patient 8's attending physician was not contacted for a referral order for hospice services, to confirm service needs, verify the patients' medical prognosis or secure supporting documentation. The AMD stated a referral order should have been obtained from Patient 8's attending physician. The AMD stated he could not write a referral order to refer a patient to himself. The AMD stated it was very important for him to talk with Patient 8's attending physician to establish the prognosis of six months or less to live as well as confirm Patient 8's care needs. 2h. A review of Patient 10's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of July 18, 2020, with a benefit period of May 9, 2022, to July 7, 2022 (an unlimited 60-day benefit period). Patient 10 had diagnoses that included atherosclerotic cardiovascular disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). A review of Patient 10's "Patient Intake," undated, indicated, "Referred By: [a marketer]." A review of Patient 10's physician's orders from July 18, 2020, to August 24, 2022, was conducted. There was no documented evidence to show an attending physician's referral order. A review of Patient 10's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from July 18, 2020, to August 24, 2022, was conducted. There was no documented evidence to show the agency asked Patient 10 or Patient 10's family who the attending physician was. There was no documented evidence to show Patient 10's attending physician was contacted for a referral order for hospice services, to confirm service needs, verify the patient's medical prognosis or secure supporting documentation. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:34 PM, the DPCS stated Patient 10 was referred to the agency by a marketer. The DPCS stated Patient 10 or Patient 10's family were not asked who the attending physician was. The DPCS stated Patient 10's attending physician was not contacted for a referral order for hospice services, to confirm service needs, verify the patients' medical prognosis or secure supporting documentation. The AMD stated a referral order should have been obtained from Patient 10's attending physician. The AMD stated he could not write a referral order to refer a patient to himself. The AMD stated it was very important for him to talk with Patient 10's attending physician to establish the prognosis of six months or less to live as well as confirm Patient 10's care needs. 2i. A review of Patient 11's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 23, 2021, with a benefit period of December 22, 2021, to March 21, 2022 (Second 90-day benefit period). Patient 11 had diagnoses that included Chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 11's "Patient Intake," undated, indicated, "Referred By: [a marketer]." A review of Patient 11's physician's orders from September 23, 2021, to August 24, 2022, was conducted. There was no documented evidence to show an attending physician's referral order. A review of Patient 11's skilled nursing visit notes, medical social worker visit notes and the care coordination notes from September 23, 2021, to August 24, 2022, was conducted. There was no documented evidence to show the agency asked Patient 11 or Patient 11's family who the attending physician wa s. There was no documented evidence to show Patient 11's attending physician was contacted for a referral order for hospice services, to confirm service needs, verify the patient's medical prognosis or secure supporting documentation. During an interview with the Acting Medical Director (AMD) and Director of Patient Care Services (DPCS) on August 24, 2022, at 3:49 PM, the DPCS stated Patient 11 was referred to the agency by a marketer. The DPCS stated Patient 11 or Patient 11's family were not asked who the attending physician was. The DPCS stated Patient 11's attending physician was not contacted for a referral order for hospice services, to confirm service needs, verify the patients' medical prognosis or secure supporting documentation. The AMD stated a referral order should have been obtained from Patient 11's attending physician. The AMD stated he could not write a referral order to refer a patient to himself. The AMD stated it was very important for him to talk with Patient 11's attending physician to establish the prognosis of six months or less to live as well as confirm Patient 11's care needs. A review of the agency's policy and procedure titled, "Intake Process," dated October 2012, indicated the following: "Process: To establish the process for acceptance and entry of patients into hospice. Policy: ... [Name of agency] will accept only those patients whose needs can be met by the services it provides and who meet the hospice admission criteria. Procedure: ... Intake personnel will document information regarding patient demographics, diagnoses, services needed, medications, attending physician, hospitalization, etc., in order to make the initial determination whether the patient's needs can be met by hospice and if he/she meets eligibility criteria. ... If the referral call is not from a physician, the physician (or other authorized licensed independent practitioner) will be contacted to confirm service needs, as well as the patient's medical prognosis and supporting documentation, and to obtain verbal orders. ..." 3. During a record review on August 25, 2022, at 11:00 AM, the employee file for Acting Medical Director (AMD) did not show a current and existing written agreement between the agency and the AMD that defined the scope of services to be provided. During an interview with the Administrator (Admin) on August 25, 2022, the Admin stated the agency did not initiate and secure a contract with the AMD. The Admin stated an agreement should have been executed and signed to define the scope of services and expectations between the agency and the AMD. During a concurrent interview and record review, with the Admin on August 25, 2022, at 11:30 AM, of the agency's policy and procedure (P&P), titled, "Written Agreements for Contracted Services," revised October 2012, indicated, "Purpose: To specify the contents of a written agreement by defining the nature and scope of services provided by clinician and others not directly employed by hospice..." Further review of the P&P indicated, "...Policy...These contracted services will be defined by a written agreement before individuals from that source will be permitted to provide services on behalf of hospice." The Admin stated they should have executed a contract between the agency and the AMD, and further stated they did not follow their policy.