Every finding on record at Western Care Hospice, Inc.

2. A review of Patient 4's profile indicated a start of care date of 11/2/21, with diagnosis including hypertensive heart disease with heart failure (the heart cannot pump blood effectively to the body). During an interview on 9/2/22, at 11:46 a.m., the administrator (ADM) stated the Chaplain was responsible in conducting a spiritual assessment. The ADM stated if patient's declined a chaplain visit on the initial comprehensive assessment, then no spiritual assessment was made. A review of Patient 4's record titled, "Comprehensive Hospice Assessment", dated 11/2/21, indicated a Registered Nurse completed the comprehensive assessment. Further review of the record did not indicate a spiritual assessment was done. Based on interview and record review, the Hospice Agency (HA) failed to ensure the comprehensive assessment identified spiritual needs related to the terminal illness for 3 of 11 sampled patients (Patients 1, 4, and 9). This deficient practice had the potential for the patient/family spiritual needs will not be identified and addressed related to the patient's death. Findings: 1. A review of Patient 1's "Patient Intake" indicated the patient was admitted on 3/22/2022, with a primary diagnosis of heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood). A review of Patient 1's "Physician Certification for Medicare Hospice Benefit" with certification period dated 6/20/22 to 9/17/22 indicated Medical Director 1 (MD1) certified Patient 1 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 1's "Spiritual Assessment Note" dated 3/30/2022 indicated Patient 1 had an initial Spiritual Assessment conducted on 3/30/2022, eight days later. A review of facility's police titled, "Spiritual Care Services" dated 4/1/2011, indicated "The spiritual counselor will complete a spiritual assessment for all hospice and families at time of admission or within 5 days thereafter ". 3. A review of Patient 9's "Patient Intake" indicated the patient admitted on 6/28/19 with a primary diagnosis of Alzheimer's Disease (the most common cause of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life). A review of Patient 9's "Physician Certification for Medicare Hospice Benefit" with certification period dated 10/15/21 to 12/13/21 indicated Medical Director 1 (MD1) certified that Patient 9 was terminally ill with a life expectancy of six months or less if the terminal illness ran its normal course. A review of Patient 9's "Spiritual Assessment Note" indicated Patient 9 had an initial Spiritual Assessment conducted on 8/21/19. An interview on 9/2/2022, at 11:10 a.m., with Administrator (ADM), ADM stated, "Chaplain supposed to see patients on admission and at patients request". A review of the Hospice Agency's (HA), undated policy and procedure titled, "Initial and Comprehensive Assessment", indicated "The comprehensive assessment must identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort and dignity throughout the dying process." A review of facility's police titled, "Spiritual Care Services" dated 4/1/2011, indicated "The spiritual counselor will complete a spiritual assessment for all hospice and families at time of admission or within 5 days thereafter ".

Based on observation, interview, and record review, the Hospice Agency (HA) failed to review all the medications the patients were currently taking for 3 of 11 samples patients (Patients 2, 4, and 8). This deficient practice the patients at risk for medication errors and adverse actions that could affect the patient's medical status and wellbeing. Findings: 1. A review of Patient 2's "Patient Intake" indicated the patient was admitted to Hospice Agency (HA) on 9/18/2020 with a primary diagnosis of Neoplasm of unspecified behavior of brain (brain tumor). A review of Patient 2's "Recertification Comprehensive Hospice Assessment" dated 7/10/2022 indicated Patient 2 was receiving routine care and is very dependent on Activities of Daily Living (ADLs). Patient 2 was oriented to person and place and on a regular soft diet. Patient 2 was provided Skilled Nursing (SN) visits 1-3 visits per week for 60-day(s) starting on 7/10/2022, Chaplain/Clergy & Medical Social Worker (MSW) visits 1 visit(s) month for 60-day(s) starting on/10/2022, and hospice aide visits 2 visit(s) week for 60-day(s) starting 7/10/2022. A review of Patient 2's "Medication Profile" for certification period of 7/10/2022 to 9/7/2022 indicated Patient 2 had no known allergies (NKA) and was prescribed: Miralax 7 gm capful powder oral once a day Senna 8.6 mg 1 tablet oral once a day Vitamin D 1.25 mg 1 tablet oral once a day During a concurrent observation and interview on 9/1/2022, at 11 a.m., with Registered Nurse 1 (RN1) and review of Patient 2's medication reconciling with the medication profile revealed inconsistent in formation of the following medications: Senna 8.6 mg 1-2 tablets oral twice a day filled 7/20/22 Vitamin D2 50,000IU 1 cap oral once a week filled 8/17/22 Miralax 7 gm capful powder oral once a day PRN filled 5/24/22 RN1 stated, "All medication that they are taking, I tell them to give me all the medications they are taking. Look at dose frequency, name, time, dose. If there is medication not being used, we need to discontinue and inform the team." 2. A review of Patient 4's profile indicated a start of care date of 11/2/21, with diagnoses including hypertensive heart disease with heart failure (the heart cannot pump blood effectively to the body). During a home visit at Patient 4's residence on 9/1/22, at 9:34 a.m., Registered Nurse 1 (RN 1) was observed reviewing the medications Patient 4 was taking. The following medications were observed at home, but not listed in the medication profile: Triple antibiotic cream Benzocaine 7.5 mg/Dextromethorphan 5 mg (cough drops) Lubricant eye drops During an interview on 9/1/22, at 9:34 a.m., RN 1 stated "all these medications are over the counter (OTC). Yes, we are supposed to list OTC medications in the medication profile". A review of Patient 4's record titled, "Medication Profile", the period of 6/30/22-8/28/22, did not list Triple antibiotic cream, Benzocaine, and lubricant eye drops in the list. 3. A review of Patient 8's "Patient Intake" indicated the patient was admitted to Hospice Agency (HA) on 11/4/21, with a primary diagnosis of Alzheimer's Disease (the most common cause of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life). A review of Patient 8's "Plan of Care" (POC) dated 7/2/22, the patient was receiving routine care and required maximum assistance on all Activities of Daily Living (ADLs). Patient 8 was oriented to person and place and on a regular soft diet. The POC included Skilled Nursing (SN) visits 1-2 visits per week for 60-day(s) starting on 7/2/22, Chaplain/Clergy & Medical Social Worker (MSW) visits 1 visit(s) month for 60-day(s) starting 7/2/22. Patient 8 refused hospice Aide starting 7/2/22. Patient 8 lived at home with a 24 hour caregiver. A review of Patient 8's "Medication Profile" for certification period of 7/2/22 to 8/30/22 indicated the patient had no known allergies (NKA) and was prescribed Ambien 10 Mg daily at bedtime. During a joint home visit with Registered Nurse 1 (RN1), it was noted Patient 8 had no Ambien available at home. It was also noted Patient 8 had Lorazepam 0.5 Mg 1 tablet every 4 hours as needed and Methadone HCl 5 Mg, 0.5 tablet twice daily routinely. Both Lorazepam 0.5 Mg and Methadone HCl 5 Mg were not found in the patient's medication profile. During an interview with Caregiver 1 (CG1) on 9/1/22 at 1:30 p.m., CG1 stated she used to give Patient 8's Ambien medication in the evening, but it ran out. CG1 stated the medication helped Patient 8 to sleep. During an interview with RN1 on 9/1/22, at 1:35 p.m., RN1 stated the visiting nurse should review patient's medications on each visit. RN1 further stated the nurse should check the medication dose, expiration date, if patient had stopped taking a certain medication, and if medications are effective. During an interview on 9/2/2022, at 11:10 a.m. with Administrator (ADM), ADM stated, "Every time there is a new order, we update the medication profile". ADM stated if the medication profile is not reconciled, "It will result with a problem for whoever is taking care of the patient. It can cause pain and suffering to the patient. The medication profile needs to be reviewed at every visit". A review of facility's police titled, "Medication Reconciliation" dated 4/1/2022, indicated "Medication reconciliation consist of a comparison of those medications ordered for, administered to, or dispensed to the patient while under the care of the organization to those on the list and any discrepancies are resolved. The RN assigned as the coordination of the patient's care is responsible for medication reconciliation. The medication profile or list is updated and kept current throughout the patient's stay on hospice. New orders are added, and discontinued medications are deleted".

4. A review of Patient 4's profile indicated a start of care date of 11/2/21, with diagnoses including hypertensive heart disease with heart failure (the heart cannot pump blood effectively to the body). Further review of the record did not indicate an initial bereavement assessment was done. 5. A review of Patient 5's profile indicated a start of care date on 6/27/2020, with diagnoses including hypertensive heart disease with heart failure (the heart is unable to effectively pump blood and oxygen to the body). Further review of the record did not indicate an initial bereavement assessment was done. 6. A review of Patient 6's profile indicated a start of care date on 3/7/2021, with diagnoses including malignant neoplasm of colon (colon cancer). Further review of the record did not indicate an initial bereavement assessment was done. 7. A review of Patient's 7 profile indicated a start of care date of 3/26/22, with diagnoses including unspecified cirrhosis of the liver (liver failure). Further review of the record did not indicate an initial bereavement assessment was done. Based on interview and record review the Hospice Agency (HA) failed to ensure the comprehensive assessment included bereavement assessment of the needs of the patient's family for 11 of 11 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, and Patient 11). This deficient practice had the potential for the patients families not being provided social, spiritual, and cultural support in anticipation of the patients prior and after death. Findings: 1. A review of Patient 1's "Patient Intake" indicated an admission date of 3/22/2022 with a primary diagnosis of heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood). A review of Patient 1's "Physician Certification for Medicare Hospice Benefit" for certification period of 6/20/22 to 9/17/22 indicated Medical Director 1 (MD1) certified the patient was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. 2. A review of Patient 2's "Patient Intake" indicated an admission date of 9/18/2020 with a primary diagnosis of neoplasm of unspecified behavior of brain (brain tumor). A review of Patient 2's "Physician Certification for Medicare Hospice Benefit" for certification period of 7/10/22 to 9/7/22 indicated Medical Director 1 (MD1) certified the patient was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. 3. A review of Patient 3's "Patient Intake" indicated an admission date of 10/19/2021 with a primary diagnosis of Protein calorie malnutrition, unspecified (a nutritional status in which reduced availability of nutrients leads to changes in body). A review of Patient 3's "Physician Certification for Medicare Hospice Benefit" with certification period dates 1/17/2022 to 4/16/2022 indicated Medical Director 1 (MD1) certified Patient 3's was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 3's "Discharge/Transfer Summary" dated 2/7/2022 indicated Patient 3's expired and case was transferred to bereavement. A concurrent interview and record review on 9/2/2022, at 1:40 p.m., with Administrator (ADM), of Patients 1, 2, and 3's electronic medical record indicated the initial bereavement assessment was conducted on 9/1/2022. ADM stated, "We did it yesterday, I thought it was done post death". 8. A review of Patient 8's "Patient Intake" indicated an admission date of 11/4/21 with a primary diagnosis of Alzheimer's Disease (the most common cause of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life). A review of Patient 8's "Physician Certification for Medicare Hospice Benefit" with certification period dated 7/2/22 to 8/30/22 indicated Medical Director 1 (MD1) certified that Patient 8's was terminally ill with a life expectancy of six months or less if the terminal illness ran its normal course. A review of Patient 8's medical records indicated the HA staff never conducted an initial bereavement assessment. 9. A review of Patient 9's "Patient Intake" indicated an admission date of 6/28/19 with a primary diagnosis of Alzheimer's Disease (the most common cause of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life). A review of Patient 9's "Physician Certification for Medicare Hospice Benefit" with certification period dated 10/15/21 to 12/13/21 indicated Medical Director 1 (MD1) certified Patient 9 was terminally ill with a life expectancy of six months or less if the terminal illness ran its normal course. A review of Patient 9's "Discharge/Transfer Summary" dated 12/13/21 indicated Patient 9 was no longer terminally ill and was discharged from the HA. A review of Patient 9's medical records indicated the HA staff never conducted an initial bereavement assessment. 10. A review of Patient 10's "Patient Intake" indicated an admision date of 10/26/21 with a primary diagnosis of chronic obstructive pulmonary disease/COPD (a group of diseases that cause airflow blockage and breathing-related problems). A review of Patient 10's "Physician Certification for Medicare Hospice Benefit" with certification period dated 6/23/22 to 8/21/22 indicated Medical Director 1 (MD1) certified Patient 10 was terminally ill with a life expectancy of six months or less if the terminal illness ran its normal course. A review of Patient 10's "Discharge/Transfer Summary" dated 7/4/22 indicated Patient 10's was seeking active treatment and therefore was discharged from the HA. A review of Patient 10's medical records indicated the HA never conducted an initial bereavement assessment. 11. A review of Patient 11's "Patient Intake" indicated Patient 11's was admitted to Hospice Agency (HA) on 9/3/19 with a primary diagnosis of Chronic Obstructive Pulmonary Disease/COPD (a group of diseases that cause airflow blockage and breathing-related problems). A review of Patient 11's "Physician Certification for Medicare Hospice Benefit" with certification period dated 2/19/22 to 4/19/22 indicated Medical Director 1 (MD1) certified Patient 11 was terminally ill with a life expectancy of six months or less if the terminal illness ran its normal course. A review of Patient 11's "Discharge/Transfer Summary" dated 4/18/22 indicated Patient 11 was seeking active treatment and therefore was discharged from the HA. A review of Patient 11's medical records indicated the HA never conducted an initial bereavement assessment. During an interview with Administrator (ADM) on 9/2/22, at 9:35 a.m., ADM confirmed the initial bereavement assessments were not conducted for Patients 8, 9, 10, and 11. ADM stated, "I thought it is done once a patient has passed away." ADM also stated, "I informed the chaplain yesterday to conduct one on every patient upon admission." A review of the Hospice Agency's policy and procedure titled, "Bereavement Program", dated 4/1/11, indicated "Procedures: Upon admission or within 5 days thereafter, the patient/family ...will be evaluated by the social worker or designee focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. That assessment along with input from other disciplinary team members will be discussed at the firs IDT conference following the patient's admission and an "Initial Bereavement Assessment" will be completed."

5. A review of Patient 8's "Patient Intake" indicated the patient was admitted to Hospice Agency (HA) on 11/4/21, with a primary diagnosis of Alzheimer's Disease (the most common cause of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life). A review of Patient 8's "Physician Certification for Medicare Hospice Benefit" with certification period dated 7/2/22 to 8/30/22 indicated Medical Director 1 (MD1) certified the patient was terminally ill with a life expectancy of six months or less if the terminal illness ran its normal course. A review of Patient 8's "IDG (Interdisciplinary) Note/Update to Plan of Care (POC)" dated 8/17/2022, indicated there was no Medical Director 1 (MD1) and no Chaplain (CHAP) signature. A concurrent interview and record review on 9/2/2022 at 1:40 p.m. with Administrator (ADM) regarding Patient 8's "IDG Note/Update to Plan of Care," ADM stated, "On 8/17/22 Interdisciplinary Meeting the Medical Director 1 (MD1) did not sign. I will remind the doctor to sign today, he should have signed. Once they signed the IDG meeting notes, means they participated". A review of the Hospice Agency's undated policy and procedure titled, "Plan of Care", indicated "It is the policy of Western Care Hospice, Inc. to conduct an interdisciplinary care plan development, review and update of the comprehensive assessment for every hospice patient no less frequently than every 14 days ...The interdisciplinary team includes ...hospice and attending physicians, RN case manager, Spiritual counselor, Social Worker ..." A review of facility's police titled, "Plan of Care - Interdisciplinary Group, Care Planning and Coordination of Services" undated, indicated "All information specified on the Interdisciplinary Care plan must be completed and required signatures obtained". 3. A review of Patient 4's profile indicated a start of care date of 11/2/21, with diagnoses including hypertensive heart disease with heart failure (the heart cannot pump blood effectively to the body). A review of Patient 4's record titled, "IDG Conference note/Update to Plan of Care", dated 8/3/22, did not indicate the doctor and chaplain participated in the meeting. 4. A review of Patient's 7 profile indicated a start of care date of 3/26/22, with diagnoses including unspecified cirrhosis of the liver (liver failure). Further review of the record indicated the patient was discharged from the agency on 7/4/22. A review of Patient 7's record titled, "IDG Conference note/Update to Plan of Care", dated 5/25/22, indicated an IDG meeting was held. Further review of the record did not indicate subsequent IDG meetings at least every 15 days. During an interview on 9/2/22, at 1:49 a.m., the administrator (ADM) stated the interdisciplinary group (IDG) were supposed to sign the IDG form on the day of the meeting/attendance as this was the evidence they participated in the discussion of the patient's care. Based on interview and record review, the agency failed to ensure the interdisciplinary group (IDG) met and updated the comprehensive assessment at least every 15 days for 5 of 11 sampled patients (Patients 1, 2, 4, 7, and 8). This deficient practice has the potential for the patients progress or decline of their health status will not be identified promptly for further treatment and intervention to meet the patients hospice needs. Findings: A review of Patient 1's "Patient Intake" indicated the patient was admitted to Hospice Agency (HA) on 3/22/2022 with a primary diagnosis of heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood). 1. A review of Patient 1's "Physician Certification for Medicare Hospice Benefit" with certification period dates 6/20/22 to 9/17/22 indicated Medical Director 1 (MD1) certified Patient 1 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 1's "IDG (Interdisciplinary) Note/Update to Plan of Care (POC)" dated 8/17/2022, indicated there was no Medical Director 1 (MD1) signature. A review of Patient 1's "IDG (Interdisciplinary) Note/Update to Plan of Care (POC)" dated 8/31/2022, indicated there was no MD signature. 2. A review of Patient 2's "Patient Intake" indicated Patient 2 was admitted to Hospice Agency (HA) on 9/18/2020 with a primary diagnosis of neoplasm of unspecified behavior of brain (brain tumor/cancer). A review of Patient 2's "Physician Certification for Medicare Hospice Benefit" with certification period dates of 7/10/22 to 9/7/22 indicated Medical Director 1 (MD1) certified that Patient 2 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 2's "Recertification Comprehensive Hospice Assessment" dated 7/10/2022 indicated Patient 2 was receiving routine care and is very dependent on Activities of Daily Living (ADLs). Patient 2 was oriented to person and place and on a regular soft diet. The POC included Skilled Nursing (SN) visits 1-3 visits per week for 60-day(s) starting on 7/10/2022, Chaplain/Clergy & Medical Social Worker (MSW) visits 1 visit(s) month for 60-day(s) starting 7/10/2022, and Aide visits 2 visit(s) week for 60-day(s) starting on 7/10/2022. A review of Patient 2's "IDG (Interdisciplinary) Note/Update to Plan of Care (POC)" dated 7/20/2022, indicated there was no Chaplain signature. A review of Patient 2's "IDG (Interdisciplinary) Note/Update to Plan of Care (POC)" dated 8/3/2022, indicated there was no Chaplain or Medical Doctor 1 (MD1) signature.

3. A review of Patient 4's profile indicated a start of care date of 11/2/21, with diagnoses including hypertensive heart disease with heart failure (the heart cannot pump blood effectively to the body). A review of Patient 4's record titled, "Plan of Care", for certification period 6/20/22-8/28/22 indicated, to provide hospice aide services 2-3 visit(s) per week for 60 day(s) starting on 6/30/22. Further review of the record disclosed no hospice aide visits during the week of 8/21/22. 2. A review of Patient 11's "Patient Intake" indicated Patient 11 was admitted to Hospice Agency (HA) on 9/3/19 with a primary diagnosis of Chronic Obstructive Pulmonary Disease/COPD (a group of diseases that cause airflow blockage and breathing-related problems). A review of Patient 11's "Physician Certification for Medicare Hospice Benefit" with certification period dated 2/19/22 to 4/19/22 indicated Medical Director 1 (MD1) certified that P10 was terminally ill with a life expectancy of six months or less if the terminal illness ran its normal course. A review of Patient 11's "Plan of Care" (POC) dated 2/19/22 with a certification period of 2/19/22 to 4/19/22 indicated Patient 11 had Skilled Nursing (SN) visits 1-2 visits per week for 60-day(s) starting on 2/19/22, Chaplain/Clergy & Medical Social Worker (MSW) visits 1 visit(s) month for 60-day(s) starting on 2/19/22, and Aide visits 2 visit(s) week for 60-day(s) starting on 2/19/22. The POC also indicated Patient 11 was bedbound and requires maximum assistance on all Activities of Daily Living (ADLs). A review of Patient 11's "Nursing Clinical Note" for the certification period of 2/19/22 to 4/19/22 indicated there were no SN visits for the week of 4/10/22 to 4/16/22. No communication notes were documented regarding the missed visits. A review of facility's police titled, "Plan of Care - Interdisciplinary Group, Care Planning and Coordination of Services" undated, indicated "All hospice care and services furnished to patients and their families must follow an individualized written plan of care ...". Based on interview and record review, the Hospice Agency (HA) failed to ensure care and services were furnished according to the plans of care for 3 of 11 sampled patients (Patients 2, 11, and 4). This deficient practice has the potential in not meeting the patient's needs identified in the plan of care that could affect their already compromised health status. Findings: 1. A review of Patient 2's "Patient Intake" indicated patient was admitted to Hospice Agency (HA) on 9/18/2020 with a primary diagnosis of neoplasm of unspecified behavior of brain (brain tumor). A review of Patient 2's "Physician Certification for Medicare Hospice Benefit" with certification period dates 7/10/22 to 9/7/22 indicated Medical Director 1 (MD1) certified patient was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 2's "Plan of Care" dated 7/10/2022 with a certification period of 7/10/2022 to 9/7/2022 indicated Patient 2 had Skilled Nursing (SN) visits 1-3 visits per week for 60-day(s) starting on 7/10/2022, Chaplain/Clergy & Medical Social Worker (MSW) visits 1 visit(s) month for 60-day(s) starting 7/10/2022, and Aide visits 2 visit(s) week for 60-day(s) starting on 7/10/2022. It also indicated Patient 2 was alert and oriented to self and place, was receiving routine care, and was bed to chair bound and totally dependent on all Activity of Daily Living (ADLs). A concurrent interview and record review on 9/2/2022 at 1:40 p.m. with Administrator (ADM) of Patient 2's electronic medical record, ADM stated that Registered Nurse 1 (RN1) was behind with her notes. ADM stated, "notes are supposed to be uploaded within 7 days". ADM was not able to locate any Skilled Nursing (SN) notes for the month of August 2022. A review of facility's police titled, "Medical Record - Entries into Medical Records" undated, indicated "Documentation shall be placed in the patient's medical record within 7 days ...".

Based on interview and record review, the hospice agency failed to ensure the medical director and/or physician designee CTI (Certificate of Terminal Illness) included a written clinical information necessary for the patient's certification to receive hospice services for 1 of 11 sampled patients (Patient 6). This deficient practice has the potential to result in the provision of hospice services to the patient not clinically eligible to receive hospice care benefits. Findings: A review of Patient 6's profile indicated a start of care date on 3/7/2021, with diagnoses including malignant neoplasm of colon (colon cancer). During an interview on 9/2/22, at 2:00 p.m., the administrator (ADM) stated the certificate of terminal illness (CTI) needed to have a narrative describing the patient's prognosis and review of clinical records to make sure patient is meeting the eligibility for hospice. The ADM stated Patient 6's CTI did not include a narrative that the patient's life expectancy is 6 months or less if the illness runs its normal course. A review of Patient 6's clinical record titled, "Physician's Certification for Medicare Hospice Benefit" for certification period 3/7/21-6/24/21, did not indicated a narrative that the patient's life expectancy is 6 months or less if the illness runs its normal course. A review of the Hospice Agency's (HA)'s policy and procedures titled, "Initial Certification of Terminal Illness for Medicare or Medical Hospice Beneficiaries", dated 4/1/11, indicated, "Procedure ...5) A brief narrative, written by the certifying physician, explaining the clinical findings that support a patient's life expectancy of six months or less if the terminal illness runs its normal course."