We Care Hospice, Inc.

“It is required that a hospice aide provides services Included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed for patients that elected aide services revealed the agency did not ensure the hospice aide provided services as ordered on the aide care plan. CONTINUING REQUIRED ACTION CLINICAL RECORD 2: The patient elected the hospice benefit 01/14/2025 with diagnosis of Cerebral atherosclerosis. The plan of care for 01/14/2025 included an order for the hospice aide three times a week. The aide care plan dated 01/14/2025 included the tasks “Change Linen”, “Light Housekeeping”, “Make Bed”, and “Turn or Position” every visit. The aide visit notes dated 04/09/2025 and 04/11/2025, the aide documented “NA” for the ordered tasks “Change Linen”, “Light Housekeeping”, “Make Bed”, and “Turn or Position”. The record lacked evidence of supportive documentation as to the reason “Change Linen”, “Light Housekeeping”, “Make Bed”, and “Turn or Position” were not “Done” when the task was ordered. CLINICAL RECORD 3: The patient elected the hospice benefit 03/13/2025 with diagnosis of Cerebral atherosclerosis. The plan of care dated 03/13/2025-06/10/2025 included an order for hospice aide two times a week. The aide care plan dated 03/13/2025 included the tasks “Foot Care”, “Light Housekeeping”, and “Range of Motion” every visit. The aide visit notes dated 04/09/2025 and 04/14/2025, the aide documented “NA” for the ordered tasks “Foot Care”, “Light Housekeeping”, and “Range of Motion”. The record lacked evidence of supportive documentation as to the reason “Foot Care”, “Light Housekeeping”, and “Range of Motion” were “NA” and not “Done” when the task was ordered. CLINICAL RECORD 4: The patient elected the hospice benefit 03/04/2025 with diagnosis of Chronic obstructive pulmonary disease. The plan of care dated 03/04/2025 - 04/10/2025 included an order for the hospice aide two times a week. The aide care plan dated 03/04/2025 included the task “Incontinent Care” every visit. The aide visit note dated 03/05/2025, the aide documented “NA” for the ordered tasks “Incontinent Care”. The record lacked supportive documentation as to the reason “Incontinent Care” was “NA” and not “Done” when the task was ordered. The Director of Patient Care Services stated in an interview on 04/15/2025 that the agency did not ensure that the aide provided services included on the aide care plan. She also stated the “NA” meaning not applicable is being utilized and the answer should be either “Done” or “Not Done” with a supportive reason for “Not Done”. CONTINUATION OF REQUIRED ACTION”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed for patients that elected hospice aide services revealed the agency did not ensure the aide reported changes in the patient’s medical needs to the RN as the changes related to the aide care plan. CONTINUING REQUIRED ACTION CLINICAL RECORD 2: The patient elected the hospice benefit 01/14/2025 with diagnosis of Cerebral atherosclerosis. The plan of care for 01/14/2025 included an order for the hospice aide three times a week. The aide care plan dated 01/14/2025 included the tasks “Change Linen”, “Light Housekeeping”, “Make Bed”, and “Turn or Position” every visit. The aide visit notes dated 04/09/2025 and 04/11/2025, the aide documented “NA” for the ordered tasks “Change Linen”, “Light Housekeeping”, “Make Bed”, and “Turn or Position”. The record lacked documented evidence that the aide notified the RN of the above changes in the patient’s medical needs as related to the ordered tasks “Change Linen”, “Light Housekeeping”, “Make Bed”, and “Turn or Position”. CLINICAL RECORD 3: : The patient elected the hospice benefit 03/13/2025 with diagnosis of Cerebral atherosclerosis. The plan of care dated 03/13/2025-06/10/2025 included an order for hospice aide two times a week. The aide care plan dated 03/13/2025 included the tasks “Foot Care”, “Light Housekeeping”, and “Range of Motion” every visit. The aide visit notes dated 04/09/2025 and 04/14/2025, the aide documented “NA” for the ordered tasks “Foot Care”, “Light Housekeeping”, and “Range of Motion”. The record lacked documented evidence that the aide notified the RN of the above changes in the patient’s medical needs as related to the ordered tasks “Foot Care”, “Light Housekeeping”, and “Range of Motion”. CLINICAL RECORD 4: The patient elected the hospice benefit 03/04/2025 with diagnosis of Chronic obstructive pulmonary disease. The plan of care dated 03/04/2025 - 04/10/2025 included an order for the hospice aide two times a week. The aide care plan dated 03/04/2025 included the task “Incontinent Care” every visit. The aide visit note dated 03/05/2025, the aide documented “NA” for the ordered tasks “Incontinent Care”. The record lacked documented evidence that the aide notified the RN of the above changes in the patient’s medical needs as related to the ordered tasks “Incontinent Care”. The Director of Patient Care Services stated in an interview on 04/15/2025 that the agency did not ensure that the aide reported changes in the patient’s medical needs to the RN as the changes related to the aide care plan. CONTINUATION OF REQUIRED ACTION”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by document review and interviews with the Volunteer Coordinator and Clinical Supervisor, which revealed the hospice: Failed to provide day-to-day administrative or direct patient services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff [HSLG.7.I/L647]. The cumulative effect of these deficiencies has resulted in the hospice agency’s inability to provide quality care for the Condition of Participation CFR 418.76: Volunteers. The collective deficient practice illustrated not having a process to ensure the provision of volunteer services to all patients.”

“It is required that the hospice registered nurse completes an initial assessment within 48 hours of the patient’s election of hospice care. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure an initial assessment was completed within 48 hours of the patient’s election of hospice care. Agency Policy No C: 3-1062, Documentation (no date), stated in relevant part: “3. All documentation shall be completed and submitted within forty-eight hours of the visit.” CLINICAL RECORD 2: The patient elected the hospice benefit on 02/26/2025 for a diagnosis of cerebral atherosclerosis. As of 03/06/2025 the clinical record lacked documented evidence of the initial nursing assessment, making it 6 days outstanding. CLINICAL RECORD 6: The patient elected the hospice benefit on 03/01/2025 for a diagnosis of Alzheimer’s disease. As of 03/06/2025 the clinical record lacked documented evidence of the initial nursing assessment, making it 4 days outstanding. An interview and joint record review were conducted with the Clinical Supervisor on 03/06/2025 and the Clinical Supervisor stated, “the assessments had not been entered as he was not finished charting.””

“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. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure the comprehensive assessment included an initial bereavement assessment. Agency Policy No C: 3-1062, Documentation Policy No C; 3:1062 (no date), stated in relevant part, “3. All documentation shall be completed and submitted within forty-eight hours of the visit.” CLINICAL RECORD 2: The patient elected the hospice benefit on 02/26/2025. The clinical record lacked evidence of a completed initial bereavement assessment as of the date of review on 03/06/2025. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/17/2025. The clinical record lacked evidence of a completed initial bereavement assessment as of the date of review on 03/06/2025. An interview and joint record review were conducted with the Clinical Supervisor on 03/06/2025 and the Clinical Supervisor stated, “the assessments had not been entered as he was not finished charting.””

“It is required that a hospice aide provides services ordered by the interdisciplinary group and included in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 5 of 8 (63%) clinical records reviewed, in which hospice aide services were accepted, revealed the agency did not ensure the aide provided services included in the plan of care as ordered by the Interdisciplinary Group. Clinical Record 1/Home Visit 1: The hospice aide care plan (POC) dated 02/12/2025 included the following tasks: “Bed bath, assistance with dressing, peri care, skin care, comb hair, shampoo hair, check pressure areas, light housekeeping, change linens, turn or position, incontinent care and vital signs.” These tasks were ordered to be completed every visit. The hospice aide visit frequency was three times per week. During the home visit conducted with the Hospice Aide (Personnel Record 5) on 03/06/2025, the aide did not complete the tasks of shampooing the hair or changing linens. After the visit, the aide advised the surveyor she had “asked the (RN/Clinical Supervisor) for the care plan to be changed multiple times to weekly for those two items but it hadn’t been changed yet.” The clinical record revealed a hospice aide visit note dated 02/14/2025 marked the tasks of light housekeeping and checking pressure areas every visit as “NA (not applicable).”There was no additional documentation as to why the tasks were not performed. CLINICAL RECORD 5: The hospice aide care plan dated 05/12/2024 included the tasks of light housekeeping, combing patient’s hair, shampoo hair, changing linens and make the bed every visit. The hospice aide visit note dated 12/10/2024 marked the tasks of comb hair and light housekeeping as “NA.” The hospice aide visit note dated 02/05/2025 marked the tasks of shampoo hair, changing linen, make bed, and light housekeeping as “NA”. There was no additional documentation as to why the tasks were not performed. CLINICAL RECORD 7: The hospice aide care plan dated 01/25/2025 included the task of assisting with ambulation every visit. However, the hospice aide visit notes dated 02/17/2025 and 02/26/2025 marked this task as “NA.” There was no additional documentation as to why the tasks were not performed. CLINICAL RECORD 9: The hospice aide care plan dated 02/17/2025 included the tasks of assist to dress, bed bath, skin care, shower, turn and position every visit. The hospice aide visit note dated 02/19/2025 noted “refused bed bath” and marked ‘NA’ for “turn and position.” The hospice aide visit note dated 02/26/2025 stated ‘NA’ for “bed bath, shower and turn and position.” The hospice aide visit note dated 03/03/2025 stated ‘NA’ for “assist to dress, bed bath, skin care, shower, turn and position.” There was no additional documentation as to why the tasks were not performed. CLINICAL RECORD 10: The hospice aide care plan dated 08/01/2024 included the tasks of light housekeeping and change linens every visit. The hospice aide visit notes dated 02/03/2025 and 03/03/2025 had a notation that a “shower was completed.” The aide had checked ‘NA’ to the tasks of “change linens and light housekeeping.” There was no additional documentation as to why the tasks were not performed. The task of shower was not listed on the hospice aide care plan. An interview and joint record review were conducted with the Clinical Supervisor on 03/06/2025 in which he confirmed “the aide care plans needed to be updated to reflect the care being provided currently.” He also confirmed he had previously “received notification from the aide about the care plans that needed to be changed.””

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (13%) clinical records reviewed, in which hospice aide services were accepted, revealed the agency did not ensure the aide reported changes in the patient’s medical, nursing, rehabilitative, and/or social need to a registered nurse as the changes related to the plan of care. CLINICAL RECORD 14: The hospice aide care plan dated 01/08/2025 included the task of showering patient every visit. The hospice aide visit note dated 01/09/2025 stated “Patient was seen. He refused shower/care. Stated he would rather sit outside for sun and then go back to bed.” The hospice aide visit note dated 01/11/2025 stated “Patient refused care. Complaint of not feeling well. Vitals done.” There was no documentation that the registered nurse (RN) was notified the patient was not feeling well or the refusal of cares. An interview and joint record review were conducted with the Clinical Supervisor on 03/06/2025 in which he confirmed there was no documentation of RN notification.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 8 (38%) clinical records reviewed revealed the agency did not ensure that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days CLINICAL RECORD 1: The Plan of Care (POC) effective as of 01/31/2025 ordered hospice aide visits twice weekly throughout the POC, beginning on 02/03/2025. The record lacked evidence of an aide supervisory visit to date, seventeen days outstanding. CLINICAL RECORD 7: The Plan of Care (POC) effective as of 01/25/2025 ordered hospice aide visits twice weekly throughout the POC. The last documented aide supervisory visit was on 02/04/2025. The record lacked evidence of an aide supervisory visit on 2/20/2025. CLINICAL RECORD 9: The Plan of Care (POC) effective as of 02/17/2025 ordered hospice aide visits twice weekly throughout the POC. The record lacked evidence of a Hospice Aide supervisory visit on 03/03/2025. An interview with the Clinical Supervisor on 03/07/2025 he stated, “he thinks he needs to document those visits still.””

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the volunteer program revealed the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview and document review were conducted with the Volunteer Coordinator and Clinical Supervisor on 03/06/2025 who reported that agency did not have any volunteer hours documented for the past year (February 2024 to February 2025) in either an administrative or patient care role, making the volunteer percentage 0%. Document review of the volunteer program revealed the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview and document review was conducted with the Volunteer Coordinator and Clinical Supervisor on 03/06/2025 The agency did not have any volunteer hours documented for the past year (February 2024 to February 2025) in either an administrative or patient care role, making the volunteer percentage 0%.”

“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. This standard was not met as evidenced by document review, interview and personnel record review. In 2 of 6 (33%) personnel records reviewed revealed the agency did not ensure the hospice assessed the skills and competencies of all individuals providing care. Agency Policy No C:3-023-1, Competency Program (no date), stated in relevant part, “1. The organization will establish and annually re-evaluate its job-specific competency-based orientation checklist which reflects duties commonly required in the performance of patient contact positions.” Personnel Record 2: A Registered Nurse with date of hire 08/06/2020 providing direct patient care lacked documentation of a skills competency for 2022, 2023, 2024. The last documented skills competency was dated in 2021. Personnel Record 3: A Social Worker with date of hire 11/25/2019 providing direct patient care lacked documentation of a skills competency for 2022, 2023, 2024. The last documented skills competency was dated in 2019. A joint record review was conducted with the Office Coordinator on 03/06/2025 and the competencies were unable to be located for the missing years.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 2 of 7 (29%) clinical records reviewed, that required recertification of terminal illness, revealed the agency did not ensure written and signed recertification to meet the hospice care benefit requirement was completed. CLINICAL RECORD 3: The clinical record lacked documentation of the recertification of terminal illness for the third benefit period, which began on 11/29/2024. CLINICAL RECORD 10: The clinical record lacked documentation of the recertification of terminal illness for the second benefit period, which began on 01/27/2025. In an interview conducted on 03/06/2025 the Administrator/Medical Director advised he “thought they had all been completed in a timely manner.” At the time of the exit conference the agency was unable to produce these documents.”

“It is required that a patient clinical record patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 14 (21%) clinical records reviewed, it was revealed that the agency did not ensure the clinical record included physician orders for the hospice patient’s medication. Agency Policy No C:3-1062, Documentation (no date), stated in relevant part: “3. All documentation shall be completed and submitted within forty-eight hours of the visit.” CLINICAL RECORD 2: The patient elected the hospice benefit on 02/26/2025 for the diagnosis of cerebral atherosclerosis. A review of the clinical record on 03/06/2025 revealed no evidence of medication orders identified in the plan of care. The clinical record only contained the scanned hospital discharge medication list received with the referral but did not include physician orders for the medications the patient was taking while on hospice services. CLINICAL RECORD 6: The patient elected the hospice benefit on 03/01/2025 for the diagnosis of Alzheimer’s disease. A review of the clinical record on 03/06/2025 revealed there were no medication orders documented in the clinical record or identified in the plan of care; however, the nursing visit notes indicated the patient was taking medications. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/17/2025 for the diagnosis of heart failure. A review of the clinical record on 03/06/2025 revealed the only medication documented in the clinical record or identified in the plan of care was oxygen. An interview with the Clinical Supervisor on 03/06/2025 indicated the patient was on “more medications but these had not been entered in the clinical record yet.” The clinical record did not include physician orders for the medications the patient was taking while on hospice services. An interview and joint record review were conducted with the Clinical Supervisor on 03/06/2025 and the Clinical Supervisor stated, “the medications had not been entered as he was not finished charting.””

“It is required that information management policies and procedures (P&P) address how the hospice documents, collects, retrieves, protects, shares, and retains information in accordance with state and federal law and regulation. This standard was not met as evidenced by clinical record review, document review, and interview. In 14 of 14 (100%) clinical records reviewed revealed the agency did not ensure the documents were stored in accordance with hospice policy. Agency Policy C:2-031.1, Safeguarding/Retrieval of Clinical/Service Record (no date), stated in relevant part, “1. All patient clinical/service records will be maintained in a locked, waterproof file cabinet in a record room: A. The files will be locked at night. B. The clinical/service record room will be locked at night… 3. The original clinical/service record for active patients will remain in the office at all times… 8. Organization personnel will return any and all clinical/service record contents or copies of such to the office for destruction no later than the time of discharge.” A clinical record review was conducted on 03/05/2025 with the Clinical Supervisor. During the review, the notice of elections, the advance directives, and informed consents were requested for Clinical Records 1 through 14. In an interview the Clinical Supervisor stated these documents were “stored at his house in the garage.” He further went on to state he “lived approximately 1 1/2 hours from the office and didn’t come to the office that often to turn in paperwork.” It was requested he produce the documents; the next day he brought them to the office in a banker’s box for review. They were then scanned into the clinical records. A clinical record review was conducted on 03/05/2025 with the Clinical Supervisor. During the review, the notice of election, the advance directive, and informed consent were requested for Clinical Records 1 through 14. The Clinical Supervisor stated these documents were “stored at his house in the garage.” He further went on to state he “lived approximately 1 1/2 hours from the office and didn’t come to the office that often to turn in paperwork.” It was requested he produce the documents the next day and he brought them to the office in a banker’s box for review. They were then scanned into 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 a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed which required a discharge summary, it was revealed that the agency did not ensure the discharge summary included at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. CLINICAL RECORD 11: The patient was discharged on 03/22/2024. The discharge summary dated 03/22/2024 stated in its entirety “patient relocated to {name of city} and discharged.” It did not include at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. CLINICAL RECORD 12: The patient elected to revoke their hospice benefit on 04/05/2024. The discharge summary dated 04/05/2024 stated in its entirety “The patient was transferred to the hospital to seek aggressive treatment.” It did not include at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. An interview and joint record review were conducted with the Clinical Supervisor on 03/06/2025 in which he stated, “I did not know to include all of that information.””

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. THIS IS A CONTINUING PRIOR REQUIRED ACTION. In 2 of 2 (100%) clinical records reviewed of patients who expired revealed the hospice did not ensure a completed post death bereavement plan of care. Clinical Record 4: The patient’s benefit election was dated 6/2/2023. The patient’s death was dated 7/12/2023. There was no evidence of a post death bereavement assessment or a bereavement plan of care. Clinical Record 5: The patient’s benefit election was dated 12/15/2022. The patient’s death was dated 1/9/2023. There was no evidence of a post death bereavement assessment or a bereavement plan of care. Document 1: The agency policy titled Bereavement Services Policy No. H:2-008.1 (revised 4/2018) stated in relevant parts “After a death has occurred, the bereavement assessment will be updated..” and “Within 2 weeks after the death of a patient, a sympathy card will be sent to the bereaved.” and “After 3 weeks, a bereavement letter with be sent to the bereaved” and “Within 3-5 weeks after the patient’s death, a bereavement assessment will be completed by the bereavement counselor.” An interview with the DPCS who reviewed records with this site visitor on 12/5/2023 confirmed this finding. THIS IS A CONTINUING PRIOR REQUIRED ACTION. In 2 of 2 (100%) clinical records reviewed of patients who expired revealed the hospice did not ensure a completed post death bereavement plan of care.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. THIS IS A CONTINUING PRIOR REQUIRED ACTION. In 2 of 3 (67%) clinical records reviewed of patients requiring recertification revealed the hospice did not ensure a verbal or written recertification was completed. In 1 of 1 (100%) clinical record reviewed of patients requiring a face-to-face encounter revealed the hospice did not ensure a face-to-face encounter was completed. Clinical Record 2: The patient’s benefit election was dated 4/21/2023. Benefit period #12 was dated 4/21/2023-6/19/2023. There was no evidence of a written certification of terminal illness. The face-to-face encounter was documented on 5/31/2023. Benefit period #13 was dated 6/20/2023-8/18/2023. There was no evidence of a verbal or written certification of terminal illness. There was no evidence of a face-to-face encounter prior to the start of the benefit period. Benefit period #14 was dated 8/19/2023-10/17/2023. There was no evidence of a written certification of terminal illness. There was no evidence of a face-to-face encounter prior to the start of the benefit period. Benefit period #15 was dated 10/18/2023-12/16/2023. There was no evidence of a face-to-face encounter prior to the start of the benefit period. Clinical Record 3: The patient’s benefit election was dated 11/24/2023. The was no evidence of a written certification of terminal illness. An interview with the DPCS who reviewed records with this site visitor on 12/5/2023 confirmed this finding. THIS IS A CONTINUING PRIOR REQUIRED ACTION. In 2 of 3 (67%) clinical records reviewed of patients requiring recertification revealed the hospice did not ensure a verbal or written recertification was completed. In 1 of 1 (100%) clinical record reviewed of patients requiring a face-to-face encounter revealed the hospice did not ensure a face-to-face encounter was completed.”