Every finding on record at Wyoming Home Health Inc

Based on record review, staff interview, and Performance Improvement Plan (PIP) review, the agency failed to ensure volunteers were used in administrative and/or direct patient care roles (refer to L644) and failed to demonstrate ongoing efforts to recruit volunteers (refer to L645). In addition, the facility failed to document the cost savings achieved through the use of volunteers (refer to L646). Further, the facility failed to ensure volunteers provided administrative and/or direct patient care hours in an amount that equaled, at a minimum, 5 percent of the total patient care hours of all paid employees and contract staff (refer to L647). This system failure resulted in the inability of the facility to meet the Condition of Participation for Volunteers.

Based on record review, staff interview, policy review, and Performance Improvement Plan (PIP) review the agency failed to ensure volunteer services were provided. The findings were: --- 1. Review of the active staff list hand delivered on 3/3/26 at 2:30 PM showed no volunteers were included. 2. Interview with the Executive Director (ED) on 3/5/26 at 10 AM revealed the agency just hired their first volunteer. The person had committed to 1 to 2 hours weekly. She revealed the agency had not had any volunteers prior to that time.  3. Review of the policy "Volunteer Services" hand delivered on 3/5/26 at 10:15 AM by the ED showed "...Hospice uses volunteers in administrative or direct patient care roles under the supervision of Volunteer Coordinator. Volunteers are considered Hospice employees to facilitate compliance with core services..."4. Review of the PIP showed a start date of 2/6/26. The problem statement/opportunity for improvement showed "Through ongoing QAPI review, internal audit, or census and utilization monitoring, the agency identified a deficiency in meeting the CMS hospice volunteer requirement..." The Identified Discrepancies showed "...Volunteer hours below the required 5% threshold. Inadequate recruitment and retention of hospice volunteers. Volunteer services not integrated into patient care plans. Lack of volunteer program."

Based on staff interview, policy review, and review of a Performance Improvement Plan (PIP), the agency failed to ensure an ongoing effort for recruitment and retention of volunteers. The findings were: --- 1. Interview with the Executive Director (ED) on 3/5/26 at 10 AM revealed the agency just hired their first volunteer. She revealed the agency had not had any volunteers prior to that time. She also revealed the agency had gone to a high school, and a community center to try and recruit. 2. Review of the policy "Volunteer Services" hand delivered on 3/5/26 at 10:15 AM by the ED showed "...Hospice uses volunteers in administrative or direct patient care roles under the supervision of Volunteer Coordinator. Volunteers are considered Hospice employees to facilitate compliance with core services..." "...6.The Coordinator is responsible for planning, organizing, documenting and direction the comprehensive volunteer services program. Coordination duties include, but are not limited to: On-going recruiting and training of sufficient numbers of volunteers to meet the needs of patients/families regardless of race, gender, ..." 3. Review of the PIP showed a start date of 2/6/26. The problem statement/opportunity for improvement show "Through ongoing QAPI review, internal audit, or census and utilization monitoring, the agency identified a deficiency in meeting the CMS hospice volunteer requirement..." The Identified Discrepancies showed "...Volunteer hours below the required 5% threshold. Inadequate recruitment and retention of hospice volunteers. Volunteer services not integrated into patient care plans. Lack of volunteer program."

Based on staff interview, policy review, and review of a Performance Improvement Plan (PIP), the agency failed to document cost savings through the use of volunteers. The findings were: --- 1. Interview with the Executive Director (ED) on 3/5/26 at 10 AM revealed the agency just hired their first volunteer. The person had committed to 1 to 2 hours weekly. She revealed the agency had not had any volunteers prior to that time. Therefore, the agency could not document cost savings. 2. Review of the policy "Volunteer Services" hand delivered on 3/5/26 at 10:15 AM by the ED showed "...Hospice uses volunteers in administrative or direct patient care roles under the supervision of Volunteer Coordinator. Volunteers are considered Hospice employees to facilitate compliance with core services..." 3. Review of the PIP showed a start date of 2/6/26. The problem statement/opportunity for improvement show "Through ongoing QAPI review, internal audit, or census and utilization monitoring, the agency identified a deficiency in meeting the CMS hospice volunteer requirement..." The Identified Discrepancies showed "...Volunteer hours below the required 5% threshold. Inadequate recruitment and retention of hospice volunteers. Volunteer services not integrated into patient care plans. Lack of volunteer program."

Based on staff interview, policy review, and Performance Improvement Plan (PIP) review, the agency failed to ensure volunteer services were provided to equal at least 5% of the total patient care hours. The findings were: --- 1. Interview with the Executive Director (ED) on 3/5/26 at 10 AM revealed the agency just hired their first volunteer. The person had committed to 1 to 2 hours weekly. She revealed the agency had not had any volunteers prior to that time. Therefore, the volunteer services did not meet the 5% total patient care hours.  2. Review of the policy "Volunteer Services" hand delivered on 3/5/26 at 10:15 AM by the ED showed "...Hospice uses volunteers in administrative or direct patient care roles under the supervision of Volunteer Coordinator. Volunteers are considered Hospice employees to facilitate compliance with core services..." 3. Review of the PIP showed a start date of 2/6/26. The problem statement/opportunity for improvement show "Through ongoing QAPI review, internal audit, or census and utilization monitoring, the agency identified a deficiency in meeting the CMS hospice volunteer requirement..." The Identified Discrepancies showed "...Volunteer hours below the required 5% threshold. Inadequate recruitment and retention of hospice volunteers. Volunteer services not integrated into patient care plans. Lack of volunteer program."

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 2 of 4 (50%) applicable records reviewed there was no documented evidence of Licensed Practical Nurse supervision completed by the Registered Nurse. The agency's policy, "C:30 Nursing/Clinical Services/Delegation", stated in part: "All LPN staff will provide care, under the supervision of the RN, within the state Nurse Practice Act. The RN shall supervise and evaluate the client's ongoing care." Clinical Record 2 - The patient was admitted to hospice services on 7/18/2022 with a diagnosis of hypertensive heart and chronic kidney disease with heart failure. The LPN made a patient visit on 12/23/2022. There was no documented evidence of LPN supervision noted in the subsequent RN notes dated 1/06/2023, 1/20/2023, or 2/3/2023. Clinical Record 3 - The patient was admitted to hospice services on 7/15/2022 with a diagnosis of pan lobular emphysema. The LPN made a visit to the patient on 12/23/2022. There is no documented evidence of LPN supervision noted in the subsequent RN notes dated 1/6/2023, 1/9/2023, 1/20/2023 or 1/25/2023. In an interview with the Administrator, she stated that the Registered Nurse is required to review and supervise the LPN's work. Agency policy C:30 Nursing/Clinical Services/Delegation states in part, "All LPN staff will provide care, under the supervision of the RN, within the state Nurse Practice Act. The RN shall supervise and evaluated the client's ongoing care." In an interview with the Administrator, she stated that the Registered Nurse is required to review and supervise the LPN's work.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. This standard was not met as evidenced by review of personnel records and interviews. In 2 of 9 (22%) personnel records reviewed it was identified that there was no documentation of the completion of initial hospice emergency preparedness training. Staff HMD: The personnel record was reviewed and identified that the date of hire/contract was 7/8/2022. There was no documentation of initial hospice Emergency Preparedness training documented in the personnel file. Staff SPEECH THERAPY: The personnel record was reviewed and identified that the date of hire/contract was 9/14/2016. There was no documentation of initial hospice Emergency Preparedness training documented in the personnel file. The Alternate Administrator was interviewed on 10/13/2022 and agreed that this information was not present in the personnel file. he

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over-the-counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interviews. In 5 of 7 (71%) clinical records reviewed it was identified that the drug profiles were not updated to include all of the medications used by the patients. Clinical Record 2 was reviewed and identified the patient elected the hospice benefit on 7/18/2022 with a primary hospice diagnosis of Chronic Heart and Kidney Failure. The admission nurse documentation stated the patient required "Oxygen @2LPM". Orders for oxygen were not documented on the medication profile. Clinical Record 5 was reviewed and identified the patient elected the hospice benefit on 7/19/2022 with a primary hospice diagnosis of Parkinson's Disease. The admission nurse documentation stated the patient required "Oxygen @2LPM". Orders for oxygen were not documented on the medication profile. Clinical Record 6 was reviewed and identified the patient elected the hospice benefit on 9/12/2022 with a primary hospice diagnosis of End Stage Heart Failure. The admission nurse documentation stated the patient required "Oxygen @2LPM". Orders for oxygen were not documented on the medication profile. Clinical Record 7 was reviewed and identified the patient elected the hospice benefit on 9/12/2022 with a primary hospice diagnosis of Pulmonary Fibrosis. The admission nurse documentation stated that the patient required "Oxygen @12L High Flow/NC". Orders for oxygen were not documented on the medication profile. Clinical Record 1 was reviewed and identified the patient elected the hospice benefit on 8/1/2022 with a primary hospice diagnosis of Pneumonia. The admission nurse documentation stated the patient required "Oxygen @2LPM". Orders for oxygen were not documented on the medication profile. The Alternate Administrator was interviewed on 10/13/2022 and agreed that O2 was not present on the medication profile.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 7 of 7 (100%) clinical records reviewed it was identified that an initial bereavement assessment was not completed. Clinical Record 7 was reviewed and identified the patient elected the hospice benefit on 9/12/2022 with a primary hospice diagnosis of Pulmonary Fibrosis. There was no documentation in the record that an initial bereavement assessment was completed. Clinical Record 5 was reviewed and identified the patient elected the hospice benefit on 7/19/2022 with a primary hospice diagnosis of Parkinson's Disease. There was no documentation in the record that an initial bereavement assessment was completed. Clinical Record 2 was reviewed and identified the patient elected the hospice benefit on 7/18/2022 with a primary hospice diagnosis of Chronic Heart and Kidney Failure. There was no documentation in the record that an initial bereavement assessment was completed. Clinical Record 4 was reviewed and identified the patient elected the hospice benefit on 7/19/2022 with a primary hospice diagnosis of Centrilobular Emphysema. There was no documentation in the record that an initial bereavement assessment was completed. Clinical Record 1 was reviewed and identified the patient elected the hospice benefit on 8/1/2022 with a primary hospice diagnosis of Pneumonia. There was no documentation in the record that an initial bereavement assessment was completed. Clinical Record 6 was reviewed and identified the patient elected the hospice benefit on 9/12/2022 with a primary hospice diagnosis of End Stage Heart Failure. There was no documentation in the record that an initial bereavement assessment was completed. Clinical Record 3 was reviewed and identified the patient elected the hospice benefit on 7/15/2022 with a primary hospice diagnosis of Pan Lobular Emphysema. There was no documentation in the record that an initial bereavement assessment was completed. The Alternate Administrator and the Bereavement Coordinator were interviewed on 10/13/2022 and both agreed that an initial bereavement assessment was not completed in the medical record.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 7 (29%) clinical records reviewed it was identified that the plans of care did not include orders for interventions to address all of the patients' care and service needs that were identified in the comprehensive assessment. Clinical Record 2 was reviewed and identified the patient elected the hospice benefit on 7/18/2022 with a primary hospice diagnosis of Chronic Heart and Kidney Failure. The admission assessment completed on 7/18/2022 identified that the patient required "Oxygen @ 2lpm". The use of oxygen therapy was not identified as a respiratory problem on the plan of care. Clinical Record 5 was reviewed and identified the patient elected the hospice benefit on 7/19/2022 with a primary hospice diagnosis of Parkinson's Disease. The initial spiritual assessment completed on 7/22/2022 identified a visit frequency need of one visit every two weeks. There was no documentation related to the patient's spiritual care problems, goals or interventions identified on the plan of care. The Alternate Administrator was interviewed on 12/12/2022 and agreed that the identified elements were missing on the plans of care.

It is required that Hospice care and services provided to patients and families follow the individualized plan of care established by: The hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 7 (14%) clinical records reviewed it was identified that visits were not made by all ordered services in accordance with the patient's plan of care. Clinical Record 5 was reviewed and identified the patient elected the hospice benefit on 7/19/2022 with a primary hospice diagnosis of Parkinson's Disease. The initial Social Work Assessment was completed on 7/22/2022 and the plan of care included orders for visits to be conducted "1x each month". There was no documentation of a social work visit made during the month of August. In addition, the record contained evidence that a spiritual assessment was completed on 7/22/2022 and the plan of care included orders for the chaplain to conduct visits two times each month. There was no documented evidence of a second chaplain visit made during the month of July and no visits made during the month of August. The Alternate Administrator was interviewed on 10/12/2022 and agreed that visits were not completed as ordered.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by a review of clinical records and interviews. In 4 of 7 (57%) clinical records reviewed it was identified there was no documented evidence that an initial spiritual care assessment was completed and that spiritual counselling services were offered to the patient and/or family. Clinical Record 2 was reviewed and identified the patient elected the hospice benefit on 7/18/2022 with a primary hospice diagnosis of Chronic Heart and Kidney Failure. There was no documented evidence that a spiritual assessment was completed or that spiritual counselling services were offered and declined. Clinical Record 1 was reviewed and identified the patient elected the hospice benefit on 8/1/2022 with a primary hospice diagnosis of Pneumonia. There was no documented evidence that a spiritual assessment was completed or that spiritual counselling services were offered and declined. Clinical Record 4 was reviewed and identified the patient elected the hospice benefit on 7/19/2022 with a primary hospice diagnosis of Centrilobular Emphysema. There was no documented evidence of a completed spiritual assessment, however orders were present on the plan of care for spiritual care visits to be provided two times each month. Clinical Record 7 was reviewed and identified the patient elected the hospice benefit on 9/12/2022 with a primary hospice diagnosis of Pulmonary Fibrosis. There was no completed spiritual assessment and no documentation that the services were declined. The Alternate Administrator was interviewed on 10/12/2022 and agreed that the records were missing documentation of completed spiritual care assessments offers of chaplain services.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: The needs and concerns of patients and families coping with a terminal illness; and education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by document review, interview, and personnel record reviews. In 3 of 9 (33%) personnel records reviewed it was identified that an initial hospice orientation was not completed. The agency's policy, "Number P:25 Orientation", with and effective date of 1/13/2018, stated in part: "All personnel, inclusive of direct care contract agency personnel, are required to attend an orientation program upon employment. Staff DIRECTOR OF CLINICAL SERVICES/QUALITY ASSURANCE - The personnel record was reviewed and identified the date of hire was 6/5/2018. There was no documentation of a completed hospice orientation present in the personnel record. Staff HMD - The personnel record was reviewed and identified the date of hire/contract was 7/8/2022. There was no documentation of a completed hospice orientation present in the personnel record. Staff SPEECH THERAPY - This personnel record was reviewed and identified the date of hire/contract was 9/14/2016. There was no documentation of a completed hospice orientation present in the personnel record. The Alternate Administrator was interviewed on 10/13/2022 and agreed that this information was not present in the personnel record.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and: Maintains a written description of the in-service training provided during the previous months. This standard was not met as evidenced by document review, interview and personnel record reviews. In 3 of 9 (33%) personnel records reviewed it was identified that assessment of skills and competencies was not documented as completed. The agency's policy, "Number P:3 Competency Testing: Clinical Staff Effective Date: 1/13/1018", stated in part: "Policy: It is the policy of (agency name) to provide skills competency evaluations at the time of hire and annually thereafter, and as needed based on performance, for clinical professional and paraprofessional staff to ensure the highest quality of Client care. Staff SOCIAL WORKER/BEREAVEMENT COORDINATOR/VOLUNTEER COORDINATOR: The personnel record was reviewed and identified the date of hire was 7/5/2022. There was no documentation of a completed competency assessment for the roles of hospice Social Worker, Bereavement Coordinator or Volunteer Coordinator present in the personnel record. Staff HMD: The personnel record was reviewed and identified the date of hire/contract was 7/8/2022. There was no documentation of a completed competency assessment for the role of Hospice Medical Director present in the personnel record. Staff SPEECH THERAPY: The personnel record was reviewed and identified the date of hire/contract was 9/14/2016. There was no documentation of a completed competency assessment for the role of Speech Therapist present in the personnel record. The Alternate Administrator was interviewed on 10/13/2022 and agreed that this information was not present in the personnel records.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: The primary terminal condition; Related diagnosis(es), if any; Current subjective and objective medical findings; Current medication and treatment orders; and Information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by a review of clinical records, document review and interviews. In 7 of 7 (100%) clinical records reviewed it was identified that the certification of terminal illness documentation did not include all of the required elements in the narrative statement as described in agency policy. The agency's policy, "Physician Services and Medical Director Roles and Responsibilities-Revised June 2019", stated in part: "6. The Medical Director or physician designee reviews the clinical information for each Hospice patient and provides written certification that it is anticipated that the patient's life expectancy is 6 moths of less if the illness runs its normal course. The physician must consider the following when making this determination: The primary terminal condition; Related diagnosis(es), if any; Current subjective and objective findings; Current medication and treatment order; and Information about the medical management of any of the patient's conditions unrelated to the terminal illness." Clinical Record 4 was reviewed and identified the patient elected the hospice benefit on 7/19/2022 with a primary hospice diagnosis of Panlobular Emphysema. The Certification of Terminal Illness (CTI) document did not contain verbiage that the patient had a prognosis of 6 months or less if the illness runs it normal course and did not include a narrative statement that contained information related to the review of the patient's clinical information. Clinical Record 1 was reviewed and identified the patient elected the hospice benefit on 8/1/2022 with a primary hospice diagnosis of Pneumonia. The Certification of Terminal Illness (CTI) document did not contain verbiage that the patient had a prognosis of 6 months or less if the illness runs it normal course and did not include a narrative statement that contained information related to the review of the patient's clinical information. Clinical Record 7 was reviewed and identified the patient elected the hospice benefit on 9/12/2022 with a primary hospice diagnosis of Pulmonary Fibrosis. The Certification of Terminal Illness (CTI) document did not contain verbiage that the patient had a prognosis of 6 months or less if the illness runs it normal course and did not include a narrative statement that contained information related to the review of the patient's clinical information. Clinical Record 6 was reviewed and identified the patient elected the hospice benefit on 9/12/2022 with a primary hospice diagnosis of End Stage Heart Failure. The Certification of Terminal Illness (CTI) document did not contain verbiage that the patient had a prognosis of 6 months or less if the illness runs it normal course and did not include a narrative statement that contained information related to the review of the patient's clinical information. Clinical Record 2 was reviewed and identified the patient elected the hospice benefit on 7/18/2022 with a primary hospice diagnosis of Chronic Heart and Kidney Disease. The Certification of Terminal Illness (CTI) document did not contain verbiage that the patient had a prognosis of 6 months or less if the illness runs it normal course and did not include a narrative statement that contained information related to the review of the patient's clinical information. Clinical Record 3 was reviewed and identified the patient elected the hospice benefit on 7/15/2022 with a primary hospice diagnosis of Panlobular Emphysema. The Certification of Terminal Illness (CTI) document did not contain verbiage that the patient had a prognosis of 6 months or less if the illness runs it normal course and did not include a narrative statement that contained information related to the review of the patient's clinical information. Clinical Record 5 was reviewed and identified the patient elected the hospice benefit on 7/19/2022 with a primary hospice diagnosis of Parkinson's Disease. The Certification of Terminal Illness (CTI) did not contain the verbiage that the patient had a prognosis of 6 months or less if the illness runs it normal course. It also did not contain a narrative statement containing information from the review of clinical information. The Alternate Administrator and the Medical Director were interviewed on 10/13/2022 and agreed that the CTI documents did not contain information to address all of the required elements.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 7 (29%) clinical records reviewed it was identified that all entries in the clinical record were not appropriately authenticated. Clinical Record 2 was reviewed and identified the patient elected the hospice benefit on 7/18/2022 with a primary hospice diagnosis of Chronic Heart and Kidney Failure. An initial Chaplain assessment was present in the record but there was no documentation of the clinician's signature or the date the assessment was completed on the document. Clinical Record 4 was reviewed and identified the patient elected the hospice benefit on 7/19/2022 with a primary hospice diagnosis of Centrilobular Emphysema. An initial Chaplain assessment was present in the record but there was no documentation of the clinician's signature or the date the assessment was completed on the document. The Alternate Administrator was interviewed on 10/13/2022 and agreed that the signatures and dates completed were not present.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 2 (100%) applicable clinical records reviewed of live discharges identified that there was no evidence that the discharge summary was sent the patients' attending physician. Clinical Record 5 was reviewed and identified the patient elected the hospice benefit on 7/19/2022 with a primary hospice diagnosis of Parkinson's Disease. The patient revoked the hospice benefit on 8/29/2022. There was no documentation that the discharge summary was forwarded to the patient's attending physician. Clinical Record 7 was reviewed and identified the patient elected the hospice benefit on 9/12/2022 with a primary hospice diagnosis of Pulmonary Fibrosis. The patient revoked the hospice benefit on 9/23/2022. There was no documentation that the discharge summary was forwarded to the patient's attending physician. The Alternate Administrator was interviewed on 10/13/2022 and agreed that documentation of the discharge summary being sent to the Attending Physician was missing from the clinical record.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management; The patient’s current plan of care; The patient’s latest physician orders; Any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 2 (100%) applicable clinical records reviewed of patients who were discharged alive from hospice, it was identified that the discharge summaries did not include all of the required information. Clinical Record 5 was reviewed and identified the patient elected the hospice benefit on 7/19/2022 with a primary hospice diagnosis of Parkinson's Disease. The patient revoked the hospice benefit on 8/29/2022. A discharge summary was initiated on 8/29/2022 but was not completed to include a summary of the hospice stay, physician's orders, and the current plan of care. Clinical Record 7 was reviewed and identified the patient elected the hospice benefit on 9/12/2022 with a primary hospice diagnosis of Pulmonary Fibrosis. The patient revoked the hospice benefit on 9/23/2022. A discharge summary was initiated on 9/23/2022 but was not completed to include a summary of the hospice stay, physician's orders, and the current plan of care. The Alternate Administrator was interviewed on 10/13/2022 and agreed that the discharge summaries were missing documentation of all the required information.

It is required that a physician is a Doctor of Medicine or Osteopathy legally authorized to practice medicine by the state in which he or she practices, and who is acting within the scope of his or her license. This standard was not met as evidenced by document reviews, interviews and personnel record reviews. In 1 of 1 (100%) personnel record for the Hospice Medical Director (HMD), there was no documented evidence of physician licensure. Record HMD - The personnel record for the Hospice Medical Director was reviewed and identified that the initial date of hire/contract was 7/8/2022. There was no documentation in the personnel record of validation of the physician's licensure. The agency's policy, "Licensure, Registration or Certification Requirements, Reviewed June 12019", stated in part: "2. When current licensure, certification and/or registration are required by law and/or regulation to practice a profession, Hospice verifies such credentials with the primary source at time of hire and prior to or upon expiration of credentials. Primary source verification will occur through the applicable state board of practice for: Medical Director. The Alternate Administrator was interviewed on 10/13/2022 and agreed that this information was not available in the personnel file.