Symphony Hospice, Inc.

“Observed in Record Review. In 10 of 14 patient records reviewed, the initial bereavement assessment was not completed. In HOSRRDC #1 the son and one of the care givers did not have a bereavement assessment completed. In HOSRRDC #2 a bereavement assessment was not completed on the patient’s daughter or sister. In HOSRRBRV #1 the bereavement assessment was not completed on the patient’s wife. In HOSRRBRV #2 the son and daughter in law did not receive a bereavement assessment. In HOSRRHV #1 and HOSRRHV #3 one of the daughters did not have a bereavement assessment completed. In HOSRRNHV #1 a caregiver did not get a bereavement assessment. In HOSRRNHV #2 the patient’s wife did not receive a bereavement assessment. In HOSRRNHV #4 the stepdaughter was not assessed, and in HOSRRNHV #7 there was no assessment completed. Per the agency’s Bereavement Services Policy 2-010.1,, a bereavement assessment must be completed on all family members or caregivers involved in the patient’s care. This was reviewed and validated with the interim DCPS.”

“Observed in Record Review. In 12 of 14 patient records reviewed, the organization failed to ensure the goals established on the plan of care were measurable and individualized. In HOSRRDC #1 the patient had a pain level of 9 at admission but there was no patient specific pain goal assessed and the care plan was not individualized as it stated, Patient will report pain as manageable <4/10. The 4/10 pain goal was not assessed at start of care. In HOSRRDC #2 the patient had moderate pain at admission but no pain goal was assessed but the care plan stated, Patient will report pain as manageable <4/10. In HOSRRBRV #1 the patient had occasional pain to her left abdomen but a pain goal was not assessed and the pain care plan stated a pain goal of <4/10. in HOSRRBRV #2 the patient was assessed with generalized pain at admission but no patient specific pain goal assessment. The care plan states that the patient’s pain will be managed at < 4/10. In HOSRRHV #1 the patient’s pain goal in the assessment was <3/10 but the care plan stated a pain goal of < 4/10. In HOSRRHV #3 the paient’s pan goal was not assessed and the goal stated, pain will be managed. In HOSRRNHV #2, HOSRRNHV #3, and HOSRRNHV #6 the patient’s pain goal was not assessed. In HOSRRNHV #5 the patient had dementia and was nonverbal and an observational tool was used but the care plan did not include observational goals to reduce pain. Per the organization’s Pain Assessment Policy 2.032.2 which states that when a clinician assesses the patent for pain, that the patient’s specific pain goal is used. If an observational tool is utilized to assess pain then observational interventions must be added. This was reviewed and validated with the interim DCPS. In HOSRRDC#1 the patient was assessed by the RN to be a fall risk but there were no goals in the plan of care relating to fall risk prevention. In HOSRRHV #2 the patient was taking Keppra daily for seizures. The hospice surveyor discussed with the interim DCPS and she stated that the patient did have a history of seizures. In HOSRRNHV #1 the patient was on Eliquis daily and the RN did not include a care plan on bleeding precautions. The RN did not include a care plan in the POC addressing the seizures. This was reviewed and validated with the interim DCPS.”

“Observed in Record Review. In 14 of 14 patient records reviewed, the oxygen orders indication 2-5 liters per nasal cannula however there were no specific parameters provided for titration. In HOSRRDC #1, HOSRRBRV #1, HOSRRHV #1, HOSRRHV #3, HOSRRNHV #4, and HOSRRNHV #7 the patient’s had an order for O2 2-5 liters for shortness of breath with no clear indication when to titrate the oxygen from 2 to 3 to 4 to 5 liters. This was reviewed and validated with the interim DCPS. In HOSRRHV #1, HOSRRHV #2, HOSRRNHV #1, HOSRRNHV #2, HOSRRNHV #3, HOSRRNHV #4, HOSRRNHV #5, HOSRRNHV #6, HOSRRNHV #7, HOSRRDC #1, HOSRRDC #2, HOSRRBRV #1, HOSRRBR #2 the Chaplain and the MSW failed to include care plans in the Plan of Care. In HOSRRHV #3 the chaplain failed to include care plans in the Plan of Care. This was reviewed and validated with the interim DCPS. In HOSRRBRV #2 and HOSRRNHV #6 the patient had a foley catheter inserted with no documentation in the order as to the frequency of the catheter changes and there was no instruction as to the amount and type of fill for the balloon. This was reviewed and validated with the interim DCPS. In HOSRRHV #2 the patient had an order for Lidocaine 4% patches to be placed 12 hours on and 12 hours off and an order for Voltaren gel 1% every 6 hours. There was no documentation in the medication list where the patch or gel should be applied and when one should be used over the other. In HOSRRHV #3 this patient had an order for Voltaren 1% gel to affected area with no clear indication where it should be used. In HOSRRNHV #2 the patient had an order for Latanoprost 0.005% 1 drop at bedtime with no instruction on which eye to instill them. This patient also had an order for Hydrocortisone cream 1% twice a day as needed with no location entered. In HOSRRNHV #7 the patient had an order for Nystatin 100,000 cream twice a day as needed with no instruction as to where the patient should apply the cream. This was reviewed and validated with the interim DCPS.”

“Observed in Record Review. In 9 of 14 patient records reviewed, the organization failed to plan the patient’s care to include safety precautions specific to the Home Health Aide. In HOSRRDC #1 the patient was on Oxygen and the aide care plan did not give instructions to the aide of what she should do with the oxygen when bathing the patient. In HOSRRDC #2 the patient had a PEG tube and there were no instructions as to what the aide should do when bathing the patient. In HOSRRBRV #1 the aide care plan did not include fall risk precautions and what the aide should do with the oxygen when bathing the patient. In HOSRRBRV #2 the patient had both a foley catheter and wounds and the home health aide assignment did not include precautions for either. In HOSRRHV #1 the patient was on Eliquis daily and O2 and the aide care plan did not include bleeding precautions and or information on what the aide should do with the oxygen when bathing the patient. In HOSRRHV #3 the patient was on oxygen and the aide care plan did not give the aide instructions on what she should do with the oxygen when bathing the patient. This patient was also an aspiration risk and the aide care plan did not include this in the precautions. In HOSRRNHV #1 the home health aide care plan did not include fall risk or bleeding precautions. The patient also had a colostomy and there were instructions for the home health aide as to what to with the colostomy when bathing the patient. In HOSRRNHV #6 and HOSRRNHV #7 the home health aide assignment did not include fall risk precautions.This was reviewed and validated with the interim DCPS.”

“Observed in Patient Home. In 1 of 1 home visits conducted, where the home health aide provided direct patient care the hospice surveyor observed that the aide failed to follow the home health aide assignment. In HOSRRHV #2 the aide had the following orders for each visit: to comb the patient’s hair, apply lotion, brush teeth, and change linens, these were not offered and or refused. The aide shampooed the patient’s hair and sprayed whole body spray without specific orders on the aide assignment. This was reviewed and validated with the interim DPCS.”

“Observed in Patient Home. In 1 of 1 home visits conducted, where the RN conducted a medication reconciliation the hospice surveyor observed that the medication list in the home was inaccurate. In HOSRRHV #1 the medication list was missing the following medications: Centrum Men’s one tablet daily, Acetaminophen 325 mg 2 tablets by mouth daily, Ibuprofen 200 mg 1 tablet by mouth every 12 hours as needed for pain, Tramadol 50mg one tablet by mouth twice a day for pain, and Refresh eye drops one drop to each eye daily for dry eyes. This was reviewed and validated with the interim DCPS.”

“Observed in Record Review. In 2 of 2 patient records reviewed, where there was alive discharge the deemed hospice agency did not provide the hospital or receiving organization with the discharge summary. In HOSRRDC #1 the patient revoked hospice and then was transferred to a hospital. The receiving organization did not receive a discharge summary. In HOSRRDC #2 the patient was transferred to another hospice and the receiving organization did not receive a discharge summary. The organization did not follow its policy on Revocation of Hospice Benefit Election 2-068.1 or Transfer Information 2-070.1. This was reviewed and validated with the interim DCPS.”

“Based on interview and record review, the agency failed to ensure a medication reconciliation (the process of identifying the most accurate list of all medications that the patient is taking) was conducted during the initial and recertification assessment for two of five sampled patients (Patients 2 and 3) when: 1. For Patient 2: One of the medications the patient was taking was not listed on the Medication Profile (MP - a current list of all medications prescribed for a specific patient). 2. For Patient 3: Two medications that the patient had stopped taking were still listed on the MP. These failures had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy. 1. A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), indicated a start of care date of December 29, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of December 29, 2025, to February 26, 2026. Patient 2 had diagnoses that included malignant neoplasm (cancer is uncontrolled growth of abnormal) of prostate (tiny gland that only men have, located right below the bladder) and hypertension (high blood pressure).During a home visit on January 6, 2026, at 2:15 PM, with the Director of Patient Care Services (DPCS) Designee, an observation was conducted to compare Patient 2’s actual medications available in the home, in the presence of Patient 2’s wife, with Patient 2’s most current Medication Profile (MP).During an observation and interview on January 6, 2026, at 2:20 PM, with the DPCS Designee, the DPCS Designee checked a bottle of Amlodipine Besylate (a prescription medication used to manage heart conditions, primarily high blood pressure) 5 mg (milligram - unit of measurement). The DPCS Designee reviewed Patient 2’s MP and confirmed that there was no order for Amlodipine Besylate, and it was not included in Patient 2’s MP. During an interview on January 6, 2026, at 2:25 PM, with Patient 2, Patient 2 stated that he had been taking Amlodipine Besylate for years even before starting hospice care and that his doctor is aware of it. Furthermore, Patient 2 stated that he [Patient 2] took the medication this morning. During a further concurrent observation and interview on January 6, 2026, at 2:35 PM, with the DPCS Designee, the DPCS Designee stated that the medication reconciliation should have been completed, and the MP updated during each visit, but this had not been done. 2. A review of Patient 3’s face sheet, indicated a start of care date of February 13, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of December 10, 2025, to February 7, 2026. Patient 3 had diagnoses that included moderate protein-calorie malnutrition (body lacks enough protein and energy, leading to severe weight loss, muscle wasting, fatigue, slow heart rate, irritability, and impacting body function) and chronic obstructive pulmonary disease (COPD – is a term for lung and airway diseases that restrict your breathing).During a home visit on January 6, 2026, at 4:45 PM, with the Licensed Vocational Nurse 1 (LVN 1), an observation was conducted to compare Patient 3’s actual medications with the most current Medication Profile (MP), available in the home, in the presence of Patient 3’s daughter, During an observation and interview on January 6, 2026, at 4:50 PM, with LVN 1, LVN 1 confirmed that Patient 3’s medication profile listed Tramadol Hydrochloride (a prescription medication used to treat moderate to severe pain) 50 mg tablets and Norco (a prescription medication used to relieve moderate to severe pain) 5 mg/325 mg tablets as active orders. LVN 1 stated that neither medication was available from the patient’s home supply at the time of review.During an interview on January 6, 2026, at 5:00 PM with Patient 3’s daughter, Patient 3’s daughter was asked whether Tramadol or Norco were available in the home. She stated that her mother had taken Tramadol and Norco in the past but stopped taking them approximately six months ago, because they made her too sleepy. She further stated that the medications were no longer kept in the home.During an interview on January 8, 2026, at 3:30 PM, with the DPCS Designee, the Designee stated, “It was Visiting Nurse responsibility to update Medication Profile when there is any new order or changes. Nurses should have been reviewing and updating medication profile on their visits.” During a concurrent interview and record review on January 8, 2026, at 3:40 PM, with the DPCS Designee, the agency’s policy and procedure (P&P) titled “Medication Profile,” revised November 2024 was reviewed. The P&P indicated, “PURPOSE. To define the use of the medication profile in evaluating a patient’s current medication regimen. POLICY. Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. PROCEDURE… 3. A drug regimen review will be performed at the time of initial and comprehensive assessment. The review will assist in evaluating effectiveness and appropriateness, identify potential and actual drug/food interactions, adverse reactions, duplicative therapy and noncompliance issues, omissions and unclear information. 4. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen…”. The DPCS Designee stated the agency did not follow the policy. During a concurrent interview and record review on January 8, 2026, at 3:40 PM, with the DPCS Designee, the agency’s P&P titled “Comprehensive Assessment,” revised November 2024 was reviewed, indicated, “PURPOSE. To provide guidelines for the comprehensive assessment. Procedure… R. Review of current and related past medications, including prescription and over-the-counter medications, herbal remedies, other alternative treatments, allergy history and other medication information, including but not limited to identification of the following:1. Effectiveness drug therapy2. Unwanted side and toxic effects3. Drug interactions (actual or potential) that could affect drug therapy4. Duplicate drug therapy5. Drug therapy currently associated with laboratory monitoring6. Whether the medication is unrelated to the terminal illness or related conditions (ensure that there is clinical documentation to support unrelatedness)… “. The DPCS Designee stated the agency did not follow the policy.”

“Based on observation, interview, and record review, the agency failed to follow the policy and procedure (P&P) to develop and maintain a system of communication and integration for two out of four sampled patients (Patient 1 and Patient 2), when the patients’ home clinical record binders did not contain their current care plans (a guide that lists their medical and emotional needs, including treatments, medications, and personal wishes, to ensure their comfort and care). This failure had the potential to result in ineffective care coordination, unmanaged symptoms, which could place Patient 1 and 2’s safety, comfort, and overall well-being at serious risk in his end-of-life care. 1. A review of Patient 1’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of July 3, 2025 with a certification period (a specific timeframe during which a patient is eligible to receive hospice (medical care for people who are expected to live six months or less services) of December 30, 2025 to February 27, 2026. Patient 1 had primary diagnoses that included senile degeneration of brain (a decline in an individual’s memory, behavior, and cognitive abilities) and osteoporosis (a disease in which your bones become weak and are likely to fracture [break]).During a home visit on January 6, 2026, at 12:05 PM, with the Medical Social Worker (MSW), in the presence of Patient 1 and Patient 1’s daughter, a review of Patient 1’s home clinical record binder and the surrounding area was conducted. Patient 1’s current care plan was not found in the binder or anywhere in the house. Both MSW and Patient 1‘s daughter confirmed that this essential document was not available. 2. A review of Patient 2’s face sheet indicated a start of care date of December 29, 2025, with a certification period of December 29, 2025, to February 26, 2026. Patient 2 had diagnoses that included malignant neoplasm (cancer is uncontrolled growth of abnormal) of prostate (tiny gland that only men have, located right below the bladder) and hypertension (high blood pressure).During a home visit on January 6, 2026, at 2:10 PM, with the Director of Patient Care Services (DPCS) Designee, in the presence of Patient 2 and Patient 2’s wife, a review of Patient 2’s home clinical record binder and the surrounding area was conducted. Patient 2’s current care plan was not found in the binder or anywhere in the house. Both the DPCS Designee and Patient 2‘s wife confirmed that this essential document was not available.During an interview and record review on January 8, 2026, at 4:00 PM, with the DPCS Designee, the Designee stated, “It is the responsibility of the visiting nurse and case manager to ensure that the current care plan, and other essential documents are left at the patient’s location and are easily accessible.” The DPCS Designee further stated the current care plan was crucial for maintaining effective care coordination, timely clinical responses and to facilitate continuity of care.During a concurrent interview and record review on January 8, 2026, at 4:05 PM with the DPCS Designee, the Designee reviewed the agency’s P&P titled “Contents of the Clinical Records”, revised November 2024, the P&P indicated, “PURPOSE. To outline the requirements for and components of a clinical record. POLICY. A clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe patient problems/needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. PROCEDURE: … M. Record and findings of initial, comprehensive and updated comprehensive assessments. … S. Care planning activity {initial and updated POCs) based on the patient’s problem and needs …”. The DPCS Designee stated the agency did not follow the policy.”

“The agency failed to ensure the Condition of Participation: L 648 §418.100 Organization and administration of services was in compliance when:1. Based on interview and record review, the agency failed to provide the Hospice Election Statement (an explanation of hospice services, a life expectancy of six months or less to live, and an abandoning of curative treatments and acceptance of palliative care) Consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of the suggested medical care) and Notice of Rights and Responsibilities (Bill of Rights- a document that provides patients with information on how they can reasonably expect to be treated during their hospice care) in a language and manner the patients understood for one of four sampled patients (Patient 1) when Patient 1’s son, whose primary language was Spanish and who could not read and understand English, signed Patient 1’s English language Hospice Election Statement, Consents and Notice of Rights and Responsibilities on Patient 1’s behalf. (Refer to L 651)2. Based on interview and record review, the agency failed to ensure the Medical Director (MD) or Medical Director Designee (MDD) certified the patients’ terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for four of four sampled patients (Patients 1, 2, 3, and 4) when:2 a-b. For Patients 1 and 2: The MD or the MDD performed the face-to-face encounter (an in-person non-certifying physician’s or nurse practitioners’ clinical assessment of the patient) and certified both patients as terminally ill, despite the regulatory requirement for two separate clinicians to conduct these clinical assessments. In addition, the face-to-face encounter document did not contain a signed attestation statement (a formal declaration or confirmation that a statement, document, or set of facts is true and accurate) with the date of the visit, as mandated by the regulatory requirements. (Refer to L 651)2 c-d. For Patients 3 and 4: the CTI for the first and second 90-day benefit periods were not signed by two physicians, as mandated by the regulatory requirements. (Refer to L 651)3 a-d. Based on interview and record review, the MD or the MDD failed his responsibility for the medical component of the hospice program for four of four sampled patients (Patients: 1, 2, 3, and 4) when an attending physician’s confirmation of service needs, verification of the patients’ medical prognosis and supporting documentation was not obtained. The MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. (Refer to L 651)The cumulative effect of these systemic practices resulted in the potential to cause Patient 1 not to understand the meaning of hospice, a life expectancy of six months or less to live, an abandoning of curative treatments and acceptance of palliative care and her Bill of Rights. In addition, these failures had the potential to cause Patients 1, 2, 3, and 4 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and the Medical Director or designee not correctly evaluating Patients 1, 2, 3, and 4’s terminal diagnosis and prognosis of six months or less to live.”

“The agency failed to ensure that the Condition of Participation: L 664 §418.102 Medical director was in compliance as follows:1. Based on interview and record review, the agency failed to ensure the Medical Director (MD) or Medical Director Designee (MDD) certified the patients’ terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for four of four sampled patients (Patients 1, 2, 3, and 4) when:1a. For Patients 1 and 2: The MD or the MDD performed the face-to-face encounter (an in-person non-certifying physician’s or nurse practitioners’ clinical assessment of the patient) and certified both patients as terminally ill, despite the regulatory requirement for two separate clinicians to conduct these clinical assessments. In addition, the face-to-face encounter document did not contain a signed attestation statement (a formal declaration or confirmation that a statement, document, or set of facts is true and accurate) with the date of the visit, as mandated by the regulatory requirements. (Refer to L 667)1b. For Patients 3 and 4: the CTI for the first and second 90-day benefit periods were not signed by two physicians, as mandated by the regulatory requirements. (Refer to L 667)2. Based on interview and record review, the MD or the MDD failed his responsibility for the medical component of the hospice program for four of four sampled patients (Patients: 1, 2, 3, and 4) when an attending physician’s confirmation of service needs, verification of the patients’ medical prognosis and supporting documentation was not obtained. The MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services. (Refer to L 669)The cumulative effect of these systemic practices resulted in the potential to cause Patients 1, 2, 3, and 4 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and the Medical Director or designee not correctly evaluating Patients 1, 2, 3, and 4’s terminal diagnosis and prognosis of six months or less to live.”

“Based on interview and record review, the agency failed to provide the Hospice Election Statement (an explanation of hospice services, a life expectancy of six months or less to live, and an abandoning of curative treatments and acceptance of palliative care) Consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of the suggested medical care) and Notice of Rights and Responsibilities (Bill of Rights- a document that provides patients with information on how they can reasonably expect to be treated during their hospice care) in a language and manner the patients understood for one of four sampled patients (Patient 1) when Patient 1’s son, whose primary language was Spanish and who could not read and understand English, signed Patient 1’s English language Hospice Election Statement, Consents and Notice of Rights and Responsibilities on Patient 1’s behalf.This failure had the potential to cause Patient 1 and Patient 1’s son not to understand the meaning of hospice, a life expectancy of six months or less to live, an abandoning of curative treatments and acceptance of palliative care and the patient’s Bill of Rights. Findings:1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 12, 2024, with a benefit period of November 12, 2024, to January 10, 2025 (Benefit Period five). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age) and primary language Spanish.A review of Patient 1’s “INFORMED CONSENT AND TREATMENT AUTHORIZATION,” dated November 12, 2024, indicated, “This agreement is entered into by and between [name of hospice agency] (hereinafter called Agency) and [name of Patient 1] (hereinafter called Patient). This agreement is entered into under a desire by the Patient to obtain hospice services. I request admission to the Agency and understand and agree to the following conditions: I understand that the hospice program is palliative, not curative, in the goals and treatments. The program emphasizes the relief of symptoms such as pain and physical discomfort and addresses the spiritual needs and the emotional stress that may accompany a life-threatening illness. I understand I am encouraged to participate in the development and implementation of the approved plan of care that hospice services are not intended to take the place of care by family members or others who are important to the patient, but rather to support them in the care of the patient. With the help of hospice, the person designated the “caregiver” will provide around-the-clock care to the patient in their place of residence. If twenty-four-hour care is not available, the caregiver will arrange for another to provide it. The caregiver will also participate in decisions about the care provided to the patient. The Hospice Interdisciplinary Team supplements rather than replaces care provided by the family care or Care Center Staff. I accept the conditions of the Agency as described, understanding that I may choose not to remain in the program and that the hospice may discharge me from the program if hospice care is no longer appropriate. This means there will be no further liability for me or the Agency. I understand, however, that I may request to be readmitted later. I have been able to discuss the above conditions with a member of the hospice staff and have had my questions answered to my satisfaction” A review of Patient 1’s “INFORMED CONSENT AND TREATMENT AUTHORIZATION, MEDICARE/MEDI-CAL HOSPICE BENEFIT ELECTION,” dated November 12, 2024, indicated, “As a Medicare Part A or Medi-Cal beneficiary, I hereby elect [name of hospice agency] as my sole provider for hospice care effective (date) [November 12, 2024] I understand the hospice program to be palliative, not curative in its goals and treatment, the program emphasizes the alleviation of physical symptoms including pain, and the identification and meeting of emotional and spiritual needs that the patient and family may experience related to the terminal illness. … RECEIPT OF INFORMATION: Hospice services have been explained to me; I have been allowed to ask any questions I have concerning the hospice program, and my questions have been answered to my satisfaction. I have been provided with the following materials: A copy of the Patient’s Rights and Responsibilities, Written materials explaining a patient’s legal rights to accept or refuse medical treatments and to prepare and advance directives for health care. ACKNOWLEDGEMENT: I acknowledge and agree to the terms and conditions described in the following documents: Informed Consent and Treatment Authorization, Financial Agreement, Patient Rights & Responsibilities, Medicare/Medi-Cal Hospice Benefit Election, Advance Directives, Notice of Privacy Practices …” During an interview with Patient 1’s son on July 28, 2025, from 8:02 AM to 8:36 AM, Patient 1’s son stated he was the Responsible Party (RP) for Patient 1 and had signed all Patient 1’s hospice paperwork because Patient 1 could not. Patient 1’s son indicated that while he could communicate in English, his primary language was Spanish. Patient 1’s son stated he was unable to read and understand English, but he had initialed and signed the English language hospice paperwork at the nurse’s direction. Patient 1’s son reported that Patient 1’s Attending Physician (AP 1) had not discussed hospice services with him, but the staff in AP 1’s office informed him that a hospice agency would be contacting him. Patient 1’s son stated that the hospice agency informed him that Patient 1 qualified for hospice due to an inability to walk. Patient 1’s son was not aware of a terminal diagnosis, the prognosis of six months or less to live, or that Patient 1 would discontinue curative treatments upon admission to hospice, “If I had known I would not have signed up for hospice.” During an interview with a Registered Nurse (RN 1) and the Administrator/Director of Patient Care Services Designee (Admin/DPCSD) on July 30, 2025, at 11:54 AM, RN 1 stated she had conducted the Explanation of Benefits (EOB) and obtained Patient 1’s son’s initials and signatures on the English language Hospice Election Statement, Consents, and Notice of Rights and Responsibilities. RN 1 stated she did not speak or read the Spanish language, and no interpreter was present during the EOB. RN 1 stated Patient 1’s son communicated with her in English and did not mention any difficulties in reading or understanding English. RN 1 stated the agency did not provide her with Spanish language versions of the Hospice Election Statements, Consents, or Notice of Rights and Responsibilities. The Admin/DPCSD confirmed that the agency did not have Spanish language versions of these documents available for their Spanish-speaking patients and families.A review of the agency’s policy and procedure titled “Rights/Responsibilities,” undated, indicated, “PURPOSE: To encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. POLICY: Each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights and responsibilities as described. A patient may designate someone to act as his/her representative in accordance with state law. This representative, on behalf of the patient, may exercise any of the rights provided by the policies and procedures established by the organization. … PROCEDURE: … 3. Upon admission, each hospice patient and/or his/her representative will be given a written copy of the Patient Rights and Responsibilities. 4. Patient Rights and Responsibilities will be explained and distributed to the patient prior to the initiation of organization services. This explanation will be in a language that the patient and manager understand. 5. The patient and/or representative will sign the Patient Rights and Responsibilities form confirming that he/she has received a copy of the notice. The original will be kept in the patient’s clinical record. The patient will maintain a copy. A patient’s refusal to sign will be documented in the clinical record, including the reason for refusal. 6. The admitting clinician will document that the patient has received the copy of the Patient Rights and Responsibilities. A. If the patient is unable to understand his/her rights/responsibilities, documentation in the clinical note will be made. B. In the event a communication barrier exists, if possible, special devices or interpreters will be made available. C. Written information will be provided to patients in the predominant languages of the patient population served. …””

“Based on interview and record review, the Governing Body (GB) failed to operate and manage the agency from November 12, 2024, to July 31, 2025, for four of four sampled patients (Patients 1, 2, 3, and 4), when:1. The agency failed to provide the Hospice Election Statement (an explanation of hospice services, a life expectancy of six months or less to live, and an abandoning of curative treatments and acceptance of palliative care) Consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of the suggested medical care) and Notice of Rights and Responsibilities (Bill of Rights- a document that provides patients with information on how they can reasonably expect to be treated during their hospice care) in a language and manner the patients understood for one of four sampled patients (Patient 1) when Patient 1’s son, whose primary language was Spanish and who could not read and understand English, signed Patient 1’s English language Hospice Election Statement, Consents and Notice of Rights and Responsibilities on Patient 1’s behalf.This failure had the potential to cause Patient 1 and Patient 1’s son not to understand the meaning of hospice, a life expectancy of six months or less to live, an abandoning of curative treatments and acceptance of palliative care and the patient’s Bill of Rights.2. The agency failed to ensure the Medical Director (MD) or Medical Director Designee (MDD) certified the patients’ terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for four of four sampled patients (Patients 1, 2, 3, and 4) when:2 a-b. For Patients 1 and 2: The MD or the MDD performed the face-to-face encounter (an in-person non-certifying physician’s or nurse practitioners’ clinical assessment of the patient) and certified both patients as terminally ill, despite the regulatory requirement for two separate clinicians to conduct these clinical assessments. In addition, the face-to-face encounter document did not contain a signed attestation statement (a formal declaration or confirmation that a statement, document, or set of facts is true and accurate) with the date of the visit, as mandated by the regulatory requirements.2 c-d. For Patients 3 and 4: the CTI for the first and second 90-day benefit periods were not signed by two physicians, as mandated by the regulatory requirements.These failures had the potential to cause Patients 1, 2, 3, and 4 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to the MD not correctly evaluating Patients 1, 2, 3, and 4’s terminal diagnosis and prognosis of six months or less to live. Findings:1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 12, 2024, with a benefit period of November 12, 2024, to January 10, 2025 (Benefit Period five). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age) and primary language Spanish.A review of Patient 1’s “INFORMED CONSENT AND TREATMENT AUTHORIZATION,” dated November 12, 2024, indicated, “This agreement is entered into by and between [name of hospice agency] (hereinafter called Agency) and [name of Patient 1] (hereinafter called Patient). This agreement is entered into under a desire by the Patient to obtain hospice services. I request admission to the Agency and understand and agree to the following conditions: I understand that the hospice program is palliative, not curative, in the goals and treatments. The program emphasizes the relief of symptoms such as pain and physical discomfort and addresses the spiritual needs and the emotional stress that may accompany a life-threatening illness. I understand I am encouraged to participate in the development and implementation of the approved plan of care that hospice services are not intended to take the place of care by family members or others who are important to the patient, but rather to support them in the care of the patient. With the help of hospice, the person designated the “caregiver” will provide around-the-clock care to the patient in their place of residence. If twenty-four-hour care is not available, the caregiver will arrange for another to provide it. The caregiver will also participate in decisions about the care provided to the patient. The Hospice Interdisciplinary Team supplements rather than replaces care provided by the family care or Care Center Staff. I accept the conditions of the Agency as described, understanding that I may choose not to remain in the program and that the hospice may discharge me from the program if hospice care is no longer appropriate. This means there will be no further liability for me or the Agency. I understand, however, that I may request to be readmitted later. I have been able to discuss the above conditions with a member of the hospice staff and have had my questions answered to my satisfaction” A review of Patient 1’s “INFORMED CONSENT AND TREATMENT AUTHORIZATION, MEDICARE/MEDI-CAL HOSPICE BENEFIT ELECTION,” dated November 12, 2024, indicated, “As a Medicare Part A or Medi-Cal beneficiary, I hereby elect [name of hospice agency] as my sole provider for hospice care effective (date) [November 12, 2024] I understand the hospice program to be palliative, not curative in its goals and treatment, the program emphasizes the alleviation of physical symptoms including pain, and the identification and meeting of emotional and spiritual needs that the patient and family may experience related to the terminal illness. … RECEIPT OF INFORMATION: Hospice services have been explained to me; I have been allowed to ask any questions I have concerning the hospice program, and my questions have been answered to my satisfaction. I have been provided with the following materials: A copy of the Patient’s Rights and Responsibilities, Written materials explaining a patient’s legal rights to accept or refuse medical treatments and to prepare and advance directives for health care. ACKNOWLEDGEMENT: I acknowledge and agree to the terms and conditions described in the following documents: Informed Consent and Treatment Authorization, Financial Agreement, Patient Rights & Responsibilities, Medicare/Medi-Cal Hospice Benefit Election, Advance Directives, Notice of Privacy Practices …” During an interview with Patient 1’s son on July 28, 2025, from 8:02 AM to 8:36 AM, Patient 1’s son stated he was the Responsible Party (RP) for Patient 1 and had signed all Patient 1’s hospice paperwork because Patient 1 could not. Patient 1’s son indicated that while he could communicate in English, his primary language was Spanish. Patient 1’s son stated he was unable to read and understand English, but he had initialed and signed the English language hospice paperwork at the nurse’s direction. Patient 1’s son reported that Patient 1’s Attending Physician (AP 1) had not discussed hospice services with him, but the staff in AP 1’s office informed him that a hospice agency would be contacting him. Patient 1’s son stated that the hospice agency informed him that Patient 1 qualified for hospice due to an inability to walk. Patient 1’s son was not aware of a terminal diagnosis, the prognosis of six months or less to live, or that Patient 1 would discontinue curative treatments upon admission to hospice, “If I had known I would not have signed up for hospice.” During an interview with a Registered Nurse (RN 1) and the Administrator/Director of Patient Care Services Designee (Admin/DPCSD) on July 30, 2025, at 11:54 AM, RN 1 stated she had conducted the Explanation of Benefits (EOB) and obtained Patient 1’s son’s initials and signatures on the English language Hospice Election Statement, Consents, and Notice of Rights and Responsibilities. RN 1 stated she did not speak or read the Spanish language, and no interpreter was present during the EOB. RN 1 stated Patient 1’s son communicated with her in English and did not mention any difficulties in reading or understanding English. RN 1 stated the agency did not provide her with Spanish language versions of the Hospice Election Statements, Consents, or Notice of Rights and Responsibilities. The Admin/DPCSD confirmed that the agency did not have Spanish language versions of these documents available for their Spanish-speaking patients and families.A review of the agency’s policy and procedure titled “Rights/Responsibilities,” undated, indicated, “PURPOSE: To encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. POLICY: Each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights and responsibilities as described. A patient may designate someone to act as his/her representative in accordance with state law. This representative, on behalf of the patient, may exercise any of the rights provided by the policies and procedures established by the organization. … PROCEDURE: … 3. Upon admission, each hospice patient and/or his/her representative will be given a written copy of the Patient Rights and Responsibilities. 4. Patient Rights and Responsibilities will be explained and distributed to the patient prior to the initiation of organization services. This explanation will be in a language that the patient and manager understand. 5. The patient and/or representative will sign the Patient Rights and Responsibilities form confirming that he/she has received a copy of the notice. The original will be kept in the patient’s clinical record. The patient will maintain a copy. A patient’s refusal to sign will be documented in the clinical record, including the reason for refusal. 6. The admitting clinician will document that the patient has received the copy of the Patient Rights and Responsibilities. A. If the patient is unable to understand his/her rights/responsibilities, documentation in the clinical note will be made. B. In the event a communication barrier exists, if possible, special devices or interpreters will be made available. C. Written information will be provided to patients in the predominant languages of the patient population served. …”2. A review of “42 CFR [Code of Federal Regulation] § 418.22 - Certification of terminal illness, (4) Face-to-face encounter,” updated June 3, 2025, indicated, “(4) The physician or nurse practitioner who performs the face-to-face encounter with the patient described in paragraph (a)(4) of this section must attest in writing that he or she had a face-to-face encounter with the patient, including the date of that visit. The attestation of the nurse practitioner or a non-certifying hospice physician shall state that the clinical findings of that visit were provided to the certifying physician for use in determining continued eligibility for hospice care.”2a. A review of Patient 1’s face sheet, undated, indicated a start of care date of November 12, 2024, with a benefit period of November 12, 2024, to January 10, 2025 (Benefit Period five). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age).A review of Patient 1’s CTI dated November 12, 2024, to January 10, 2025 (Benefit Period five) indicated certification of Patient 1’s prognosis of six months or less life expectancy by the MD. A review of Patient 1’s physician’s “Progress Note,” dated November 12, 2024, by the MD, was conducted. There was no documented evidence to show an attestation statement that confirmed a face-to-face encounter with the patient, including the date of the visit and that the clinical findings were provided to the certifying physician for determining continued eligibility for hospice care.A review of Patient 1’s claims for payment, indicated a claim for payment was submitted on December 6, 2024, and January 6, 2025. During an interview with the MD and the Admin/DPCSD on July 31, 2025, at 10 AM, the MD confirmed Patient 1’s physician’s “Progress Note,” dated November 12, 2024, was his face-to-face encounter with Patient 1. The MD stated he was unaware of the regulatory requirement that one clinician must conduct the face-to-face encounter while a separate clinician certified the patient’s terminal illness. The MD stated he had known about the face-to-face attestation statement, “I just didn’t do it.” The Admin/DPCSD stated she was unaware that one clinician must conduct the face-to-face encounter while another certified the patient’s terminal illness. The Admin/DPCSD confirmed that the MD both certified Patient 1’s terminal illness and conducted the face-to-face encounter, which did not have the attestation statement.2b. A review of Patient 2’s face sheet, undated, indicated a start of care date of May 22, 2025, with a benefit period of May 22, 2025, to July 20, 2025 (Benefit Period three). Patient 2 had diagnoses that included senile degeneration of the brain.A review of Patient 2’s CTI dated May 22, 2025, to July 20, (Benefit Period three) indicated certification of Patient 2’s prognosis of six months or less life expectancy by the Medical Director Designee (MDD). A review of Patient 2’s CTI dated May 22, 2025, to July 20, (Benefit Period three), section “Face to Face Narrative,” by the MDD, was conducted. There was no documented evidence to show an attestation statement that confirmed a face-to-face encounter with the patient, including the date of the visit and that the clinical findings were provided to the certifying physician for determining continued eligibility for hospice care.A review of Patient 2’s claims for payment, indicated a claim for payment was submitted on June 4, 2025, and July 8, 2025. During an interview with the MDD and the Admin/DPCSD on July 31, 2025, at 9:30 AM, the MDD confirmed Patient 2’s CTI dated May 22, 2025, to July 20, 2025 (Benefit Period three), section “Face to Face Narrative,”, was his face-to-face encounter with Patient 2. The MDD stated he was unaware of the regulatory requirement that one clinician must conduct the face-to-face encounter while a separate clinician certified the patient’s terminal illness. The MDD stated he had not known about the face-to-face attestation statement. The Admin/DPCSD stated she was unaware that one clinician must conduct the face-to-face encounter while another certified the patient’s terminal illness. The Admin/DPCSD confirmed that the MDD both certified Patient 2’s terminal illness and conducted the face-to-face encounter, which did not have the attestation statement.A review of the agency’s policy and procedure titled “Face-To-Face Encounter,” undated, indicated, PURPOSE: To establish a process to comply with the Face-to-Face Encounter requirement. POLICY: A face-to-face encounter will be performed for patients entering the third and all subsequent benefit periods. PROCEDURE: 1. The hospice director (employed, volunteer, or under contract) or a hospice employed nurse practitioner (NP) will perform a face-to-face encounter within 30 days prior to the hospice recertification for the third and all subsequent benefit periods. 2. During the Face-to-Face encounter, the hospice medical director or NP must gather and document clinical findings to determine the patient’s continued hospice eligibility. 3. The physician/NP who performs the face-to-face encounter will attest in writing that he/she had the face-to-face encounter, including the date of the visit. The NP must also attest that the clinical findings were provided to the certifying physician. 4. The face-to-face attestation must be signed and dated by the individual who performed the visit. …”2. A review of “42 CFR § 418.22 - Certification of terminal illness, (c) Sources of certification,” updated June 3, 2025, indicated, “(1) For the initial 90-day period, the hospice must obtain written certification statements (and oral certification statements if required under paragraph (a)(3) of this section) from - (i) The medical director of the hospice or the physician member of the hospice interdisciplinary group; and (ii) The individual’s attending physician, if the individual has an attending physician. The attending physician must meet the definition of physician specified in § 410.20 of this subchapter.” 2c. A review of Patient 3’s face sheet, undated, indicated a start of care date of July 3, 2025, with a benefit period of July 3, 2025, to September 30, 2025 (Benefit Period one). Patient 3 had diagnoses that included senile degeneration of the brain.A review of Patient 3’s physician’s referral order, dated June 4, 2025, by Patient 3’s Attending Physician (AP 5), indicated to evaluate for hospice services. During an interview with Patient 3’s daughter on July 29, 2025, at 12:50 PM, Patient 3’s daughter stated AP 5 was Patient 3’s attending physician.A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated July 3, 2025, to September 30, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MD on July 5, 2025. A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated July 3, 2025, to September 30, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG [Interdisciplinary group - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient] Meetings and Plan of Care if I choose to follow the Patient,” the document indicated for AP 5 to sign, but it remained unsigned. There was no documented evidence to show AP 5 provided a signature verifying Patient 3’s prognosis of six months or less life expectancy.A review of Patient 3’s claims for payment indicated a claim for payment was pending submission in August 2025.During an interview with the MD and Admin/DPCSD on July 31, 2025, at 10:11 AM, the MD stated he knew about the requirement for two physician signatures certifying a patient’s terminal illness during the first and second benefit periods. The MD believed the agency was obtaining the second signature and did not know it was not being done. The Admin/DPCSD stated she knew about the requirement for two physician signatures certifying a patient’s terminal illness during the first and second benefit periods but was unaware that this had not been followed.2d. A review of Patient 4’s face sheet, undated, indicated a start of care date of April 4, 2025, with a benefit period of April 4, 2025, to July 2, 2025 (Benefit Period one). Patient 4 had diagnoses that included senile degeneration of the brain. A review of Patient 4’s physician’s referral order, dated April 3, 2025, by Patient 4’s AP 6, indicated to evaluate for hospice services. During an interview with Patient 4’s son on July 29, 2025, at 4:07 PM, Patient 4’s son stated AP 7 and AP 8 were Patient 4’s attending physicians.A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated April 4, 2025, to July 2, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MDD on April 6, 2025. A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated April 4, 2025, to July 2, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient,” the document indicated for the MDD to sign, but it remained unsigned. There was no documented evidence to show AP 6, AP 7, or AP 8 provided a signature verifying Patient 4’s prognosis of six months or less life expectancy.A review of Patient 4’s claims for payment indicated a claim for payment was submitted on May 8, 2025, June 4, 2025, and July 8, 2025. During an interview with the MDD and Admin/DPCSD on July 31, 2025, at 9:46 AM, the MDD stated he was not aware of the requirement for two physician signatures certifying a patient’s terminal illness during the first and second benefit periods. The Admin/DPCSD stated she knew about the requirement for two physician signatures certifying a patient’s terminal illness during the first and second benefit periods but was unaware that this had not been followed.A review of the agency’s policy and procedure titled “Certification of Terminal Illness,” undated, indicated, “PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient’s attending physician, if any, will certify the patient’s terminal illness. … Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. …”3. A review of “42 CFR § 418.25 – Admission to hospice care,” updated June 3, 2025, indicated, “(a) The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient’s attending physician (if any).”A review of “42 CFR § 418.3 – Definitions,” updated June 3, 2025, indicated, “Attending physician means a – … (2) Is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual’s medical care.”3a. A review of Patient 1’s face sheet, undated, indicated a start of care date of November 12, 2024, with a benefit period of November 12, 2024, to January 10, 2025 (Benefit Period five). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age).A review of Patient 1’s physician’s referral order dated November 12, 2024, by Patient 1’s Attending Physician (AP 2), indicated, “Please evaluate [name of Patient 1] for admission to Hospice. … Primary diagnosis supporting hospice referral – dementia [a general term for a decline in mental ability, severe enough to interfere with daily life, impacting memory, thinking, and reasoning] … Associated Diagnoses: Dementia, unspecified dementia severity [how severe the dementia symptoms are], unspecified dementia type, unspecified whether behavioral, psychotic [a mental health condition characterized by a loss of touch with reality], or mood disturbance or anxiety.”During an interview with Patient 1’s son on July 28, 2025, from 8:02 AM to 8:36 AM, Patient 1’s son stated he was the Responsible Party (RP) for Patient 1 and had signed all Patient 1’s hospice paperwork. Patient 1’s son reported that Patient 1’s AP 1 had not discussed hospice services with him, but the staff in AP 1’s office informed him that a hospice agency would be contacting him. Patient 1’s son stated that the hospice agency informed him that Patient 1 qualified for hospice due to an inability to walk. Patient 1’s son was not aware of a terminal diagnosis, the prognosis of six months or less to live, or that Patient 1 would discontinue curative treatments upon admission to hospice, “If I had known I would not have signed up for hospice.” Patient 1’s AP 1 was unavailable for interview.Patient 1’s AP 2 was unavailable for interview.A review of Patient 1’s CTI dated November 12, 2024, to January 10, 2025 (Benefit Period five) indicated certification of Patient 1’s prognosis of six months or less life expectancy by the MD. A review of Patient 1’s physician’s “Progress Note,” dated November 12, 2024, by the MD, indicated that AP 2 referred Patient 1 to hospice services. The MD assessed Patient 1 and recommended admission to hospice with palliative measures.During an interview with the MD and the Admin/DPCSD on July 31, 2025, at 10 AM, the MD confirmed Patient 1’s physician’s “Progress Note,” dated November 12, 2024, was his face-to-face encounter with Patient 1. The MD confirmed he had not obtained or considered clinical assessment information from a face-to-face encounter conducted by another clinician when certifying Patient 1’s terminal diagnosis. The MD stated he had not contacted AP 2 to clarify the primary diagnosis supporting the hospice referral for dementia. The MD stated he did not clarify the underlying disease or disorder causing the dementia, the severity of the dementia, or the type of dementia, whether it was behavioral, psychotic, mood disturbance, or anxiety related. The MD and Admin/DPCSD stated they were unaware of AP 1. The MD stated he did not reach out to AP 1 or AP 2 to consult about Patient 1’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services.3b. A review of Patient 2’s face sheet, undated, indicated a start of care date of May 22, 2025, with a benefit period of May 22, 2025, to July 20, 2025 (Benefit Period three). Patient 2 had diagnoses that included senile degeneration of the brain.A review of Patient 2’s physician’s referral order dated May 22, 2025, by Patient 2’s AP 3, indicated, “[Discharge] back on hospice today.” There was no documented evidence to show a terminal diagnosis.During an interview with Patient 2’s son on July 29, 2025, at 10:43 AM, Patient 2’s son stated Patient 2 had fallen, broke her hip and the hospital had discharged Patient 2 to a nursing home. Patient 2’s son stated the nursing home discharged Patient 2 with home health services (medical and therapeutic services delivered to a patient’s residence, rather than in a hospital or clinic) to an Assisted Living Facility (ALF-a living arrangement in which people with special needs, especially seniors, live in a facility that provides help with everyday tasks such as bathing, dressing, and taking medication) but Patient 2 kept falling so Patient 2 was transferred to a Board and Care Facility (B&C a licensed, non-medical facility providing room, board, and 24-hour care and supervision for individuals who need help with daily living activities but not 24-hour nursing care). Patient 2’s son stated a physician had not spoken with him about hospice services or a terminal diagnosis and Patient 2’s son thought the nursing home, or the home health agency might have mentioned hospice services. Patient 2’s son stated he did not know who AP 3 was and the doctor that knew Patient 2 best was AP 4. Patient 2’s AP 3 was unavailable for interview.During an interview with Patient 2’s AP 4 on July 30, 2025, from 9:11 AM to 9:36 AM, AP 4 stated he was not aware that Patient 2 had been admitted to hospice services and the hospice agency had not reached out to him. Patient 2’s AP 4 stated he had seen Patient 2 in February 2025, and she had been very thin following a hospitalization and nursing home stay. Patient 2’s AP 4 stated he had begun working with her and she slowly showed improvement in her weight. Patient 2’s AP 4 stated in April 2025, Patient 2’s son brought Patient 2 in for a heel wound and then Patient 2’s AP 4 received a phone call from an ALF requesting hospice services to care for Patient 2’s heel wound, “I told them you get nurses for wound care not hospice. I don’t agree with your hospice request; I don’t agree with hospice. I wrote in my notes, no hospice there is no terminal diagnosis.” Patient 2’s AP 4 stated he believed Patient 2 had some memory loss but not end stage dementia (dementia symptoms are severe, individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement), “I can’t support the diagnosis of senile degeneration of the brain, end stage.”A review of Patient 2’s CTI dated May 22, 2025, to July 20, (Benefit Period three) indicated certification of Patient 2’s prognosis of six months or less life expectancy by the Medical Director Designee (MDD). A review of Patient 2’s CTI dated May 22, 2025, to July 20, (Benefit Period three), section “Face to Face Narrative,” by the MDD, was conducted.During an interview with the MDD and the Admin/DPCSD on July 31, 2025, at 9:30 AM, the MDD confirmed Patient 2’s CTI dated May 22, 2025, to July 20, 2025 (Benefit Period three), section “Face to Face Narrative,”, was his face-to-face encounter with Patient 2. The MDD confirmed he had not obtained or considered clinical assessment information from a face-to-face encounter conducted by another clinician when certifying Patient 2’s terminal diagnosis. The MDD verified AP 3’s referral order did not indicate a terminal diagnosis for Patient 2 and the MDD and Admin/DPCSD stated they were unaware of AP 4. The MDD stated he did not reach out to AP 3 or AP 4 to consult about Patient 2’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services.3c. A review of Patient 3’s face sheet, undated, indicated a start of care date of July 3, 2025, with a benefit period of July 3, 2025, to September 30, 2025 (Benefit Period one). Patient 3 had diagnoses that included senile degeneration of the brain.A review of Patient 3’s physician’s referral order dated June 24, 2025, by Patient 3’s AP 5, indicated a hospice evaluation with a terminal diagnosis of dementia.During an interview with Patient 3’s daughter on July 29, 2025, at 12:50 PM, Patient 3’s daughter said she and her sister needed help with Patient 3’s care and she called the hospice agency for services but was told a physician’s order was required for an evaluation. Patient 3’s daughter then contacted AP 5, who provided the hospice referral order. Patient 3’s daughter stated AP 5 had not discussed hospice services, a terminal diagnosis for Patient 3, or any alternatives other than hospice care. Patient 3’s daughter confirmed AP 5 was the physician most familiar with Patient 3’s medical history. During an interview with Patient 3’s AP 5 on July 30, 2025, at 1:06 PM, AP 5 stated she saw Patient 3 and her daughter on March 13, 2025, requesting home physical therapy for Patient 3’s shoulder pain and AP 5 had been working on arranging outpatient therapy. AP 5 stated on May 27, 2025, Patient 3’s daughter wanted to speak with AP 5 about hospice services and AP 5 told Patient 3’s daughter she could not hospitalize Patient 3 if the daughter choose hospice. AP 5 stated she had to write some kind of diagnosis when she sent a hospice referral order but maybe dementia was not right because the patient was fine when AP 5 saw her in March 2025, “some memory loss but not end stage but the patient is 98 years old.” AP 5 stated the family just needed more help and hospice can give more help in caring for Patient 3. AP 5 stated she could not predict when someone was going to die so she would not sign certifying a life expectancy of six months or less. AP 5 stated the hospice did not contact her to discuss Patient 3 and hospice services.A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated July 3, 2025, to September 30, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MD on July 5, 2025. There was no documented evidence to show AP 5 had provided a second signature certifying a life expectancy of six months or less.During an interview with the MD and the Admin/DPCSD on July 31, 2025, at 10:11 AM, the MD and Admin/DPCSD confirmed there was no second physician signature certifying Patient 3’s life expectancy of six months or less and there should have been. The MD stated he did not reach out to AP 5 to consult about Patient 3’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services.3d. A review of Patient 4’s face sheet, undated, indicated a start of care date of April 4, 2025, with a benefit period of April 4, 2025, to July 2, 2025 (Benefit Period one). Patient 4 had diagnoses that included senile degeneration of the brain.A review of Patient 4’s physician’s referral order dated April 3, 2025, by Patient 4’s AP 6, indicated an evaluation for hospice services. There was no documented evidence to show a terminal diagnosis.During an interview with Patient 4’s son on July 29, 2025, at 4:07 PM, Patient 4’s son stated Patient 4 was living at an ALF and she began having a lot of falls some of which sent Patient 4 to the Emergency Room. Patient 4’s son stated he was approached by the ALF who informed him his mother either needed to be transferred to a nursing home or put Patient 4 on hospice services. Patient 4’s son stated he did not think Patient 4 would qualify for hospice because he believed Patient 4 would live far longer than 6 months, but the ALF indicated there was some kind of loophole which would allow Patient 4 to qualify, “I don’t know what the loophole was, but I didn’t want [Patient 4] in a nursing home.” Patient 4’s son stated the ALF recommended the hospice agency and he did not know how it happened, but the hospice agency came and admitted Patient 4 and he signed the paperwork. Patient 4’s son stated he did not know AP 6 and identified AP 7 and AP 8 as physician’s who knew and treated Patient 4. Patient 4’s son stated no physician had a conversation with him in regard to hospice services, a terminal diagnosis or giving up curative treatments. Patient 4’s AP 6 was unavailable for interview.Patient 4’s AP 7 was unavailable for interview.Patient 4’s AP 8 was unavailable for interview.A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated April 4, 2025, to July 2, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confi rm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MDD on April 6, 2025. There was no documented evidence to show AP 6, 7, or 8, had provided a second signature certifying a life expectancy of six months or less.During an interview with the MDD and the Admin/DPCSD on July 31, 2025, at 9:46 AM, the MDD and Admin/DPCSD confirmed there was no second physician signature certifying Patient 4’s life expectancy of six months or less and there should have been. The MDD stated he did not reach out to AP 6, 7, or 8 to consult about Patient 4’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services.A review of the agency’s policy and procedure titled “Certification of Terminal Illness,” undated, indicated, “PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient’s attending physician, if any, will certify the patient’s terminal illness. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. … PROCEDURE: … 3. Clinical information and other documentation that supports the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. Initially, the clinical information may be provided verbally and must be documented in the medical record and included as part of the hospice’s eligibility assessment.”A review of the agency’s policy and procedure titled “Physician Services-Medical Director,” undated, indicated, “To ensure qualified medical direction and consultation for the delivery of hospice services and programs. To demonstrate that the Medical Director/hospice team physician has overall responsibility for patient care through documentation that demonstrates interaction/ communication with the attending physician as necessary for appropriate medical care. … POLICY: … The duties and responsibilities of the Medical Director will include but not be limited to the following: … 3. Reviewing patients’ medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness. … Requirements to meet California Hospice Standards: … Medical Director services are provided in a manner consistent with the philosophy of hospice and palliative care and include but are not limited to: … 2. Consulting and coordinating care with hospice physicians and attending physicians. … 5. The responsibilities of the medical director, consistent with the organizational plan and structure of the program, shall include but are not limited to: a. Reviewing necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician. b. Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services. c. Assisting in developing and implementing the plan of care that is coordinated with the attending physician”During an interview with the Admin/DPCSD and Director of Operations (DOO) on July 21, 2025, at 12:30 PM, the Admin/DPCSD and DOO stated they were members of the GB and assumed full legal authority and responsibility for the operation of the agency, and for the quality of care and services provided. The Admin/DPCSD stated the GB had not identified:1. That the agency did not have Spanish language consents to provide to their Spanish speaking patients.2 a-b. That the certifying physician could not also conduct patients’ face to face encounters and the face to face encounters conducted did not contain the required attestation statement with signature.2 c-d. That two physician signatures were not obtained for patients in their 1st and 2nd benefit periods3 a-d. That an attending physician’s confirmation of service needs, verification of the patients’ medical prognosis and supporting documentation was not obtained. And the MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services.A review of the agency’s policy and procedure titled “Governing Body,’ undated, indicated, “PURPOSE: To outline the roles and responsibilities of the Governing Body. POLICY: The Governing Body will assume full legal authority and responsibility for the operation of [name of agency]. The Governing Body of [name of agency] will serve as the governing authority for the hospice program, which will function according to [name of agency] bylaws.””

“Based on interview and record review, the agency failed to ensure the Medical Director (MD) or Medical Director Designee (MDD) certified the patients’ terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for four of four sampled patients (Patients 1, 2, 3, and 4) when:1. For Patients 1 and 2: The MD or the MDD performed the face-to-face encounter (an in-person non-certifying physician’s or nurse practitioners’ clinical assessment of the patient) and certified both patients as terminally ill, despite the regulatory requirement for two separate clinicians to conduct these clinical assessments. In addition, the face-to-face encounter document did not contain a signed attestation statement (a formal declaration or confirmation that a statement, document, or set of facts is true and accurate) with the date of the visit, as mandated by the regulatory requirements.2. For Patients 3 and 4: the CTI for the first and second 90-day benefit periods were not signed by two physicians, as mandated by the regulatory requirements.These failures had the potential to cause Patients 1, 2, 3, and 4 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to the MD not correctly evaluating Patients 1, 2, 3, and 4’s terminal diagnosis and prognosis of six months or less to live. Findings:A review of “42 CFR [Code of Federal Regulation] § 418.22 - Certification of terminal illness, (4) Face-to-face encounter,” updated June 3, 2025, indicated, “(4) The physician or nurse practitioner who performs the face-to-face encounter with the patient described in paragraph (a)(4) of this section must attest in writing that he or she had a face-to-face encounter with the patient, including the date of that visit. The attestation of the nurse practitioner or a non-certifying hospice physician shall state that the clinical findings of that visit were provided to the certifying physician for use in determining continued eligibility for hospice care.”1a. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 12, 2024, with a benefit period of November 12, 2024, to January 10, 2025 (Benefit Period five). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age).A review of Patient 1’s CTI dated November 12, 2024, to January 10, 2025 (Benefit Period five) indicated certification of Patient 1’s prognosis of six months or less life expectancy by the MD. A review of Patient 1’s physician’s “Progress Note,” dated November 12, 2024, by the MD, was conducted. There was no documented evidence to show an attestation statement that confirmed a face-to-face encounter with the patient, including the date of the visit and that the clinical findings were provided to the certifying physician for determining continued eligibility for hospice care.A review of Patient 1’s claims for payment, indicated a claim for payment was submitted on December 6, 2024, and January 6, 2025. During an interview with the MD and the Administrator/Director of Patient Care Services Designee (Admin/DPCSD) on July 31, 2025, at 10 AM, the MD confirmed Patient 1’s physician’s “Progress Note,” dated November 12, 2024, was his face-to-face encounter with Patient 1. The MD stated he was unaware of the regulatory requirement that one clinician must conduct the face-to-face encounter while a separate clinician certified the patient’s terminal illness. The MD stated he had known about the face-to-face attestation statement, “I just didn’t do it.” The Admin/DPCSD stated she was unaware that one clinician must conduct the face-to-face encounter while another certified the patient’s terminal illness. The Admin/DPCSD confirmed that the MD both certified Patient 1’s terminal illness and conducted the face-to-face encounter, which did not have the attestation statement.1b. A review of Patient 2’s face sheet, undated, indicated a start of care date of May 22, 2025, with a benefit period of May 22, 2025, to July 20, 2025 (Benefit Period three). Patient 2 had diagnoses that included senile degeneration of the brain.A review of Patient 2’s CTI dated May 22, 2025, to July 20, (Benefit Period three) indicated certification of Patient 2’s prognosis of six months or less life expectancy by the Medical Director Designee (MDD). A review of Patient 2’s CTI dated May 22, 2025, to July 20, (Benefit Period three), section “Face to Face Narrative,” by the MDD, was conducted. There was no documented evidence to show an attestation statement that confirmed a face-to-face encounter with the patient, including the date of the visit and that the clinical findings were provided to the certifying physician for determining continued eligibility for hospice care.A review of Patient 2’s claims for payment, indicated a claim for payment was submitted on June 4, 2025, and July 8, 2025. During an interview with the MDD and the Admin/DPCSD on July 31, 2025, at 9:30 AM, the MDD confirmed Patient 2’s CTI dated May 22, 2025, to July 20, 2025 (Benefit Period three), section “Face to Face Narrative,”, was his face-to-face encounter with Patient 2. The MDD stated he was unaware of the regulatory requirement that one clinician must conduct the face-to-face encounter while a separate clinician certified the patient’s terminal illness. The MDD stated he had not known about the face-to-face attestation statement. The Admin/DPCSD stated she was unaware that one clinician must conduct the face-to-face encounter while another certified the patient’s terminal illness. The Admin/DPCSD confirmed that the MDD both certified Patient 2’s terminal illness and conducted the face-to-face encounter, which did not have the attestation statement.A review of the agency’s policy and procedure titled “Face-To-Face Encounter,” undated, indicated, PURPOSE: To establish a process to comply with the Face-to-Face Encounter requirement. POLICY: A face-to-face encounter will be performed for patients entering the third and all subsequent benefit periods. PROCEDURE: 1. The hospice director (employed, volunteer, or under contract) or a hospice employed nurse practitioner (NP) will perform a face-to-face encounter within 30 days prior to the hospice recertification for the third and all subsequent benefit periods. 2. During the Face-to-Face encounter, the hospice medical director or NP must gather and document clinical findings to determine the patient’s continued hospice eligibility. 3. The physician/NP who performs the face-to-face encounter will attest in writing that he/she had the face-to-face encounter, including the date of the visit. The NP must also attest that the clinical findings were provided to the certifying physician. 4. The face-to-face attestation must be signed and dated by the individual who performed the visit. …”A review of “42 CFR § 418.22 - Certification of terminal illness, (c) Sources of certification,” updated June 3, 2025, indicated, “(1) For the initial 90-day period, the hospice must obtain written certification statements (and oral certification statements if required under paragraph (a)(3) of this section) from - (i) The medical director of the hospice or the physician member of the hospice interdisciplinary group; and (ii) The individual’s attending physician, if the individual has an attending physician. The attending physician must meet the definition of physician specified in § 410.20 of this subchapter.” 2a. A review of Patient 3’s face sheet, undated, indicated a start of care date of July 3, 2025, with a benefit period of July 3, 2025, to September 30, 2025 (Benefit Period one). Patient 3 had diagnoses that included senile degeneration of the brain.A review of Patient 3’s physician’s referral order, dated June 4, 2025, by Patient 3’s Attending Physician (AP 5), indicated to evaluate for hospice services. During an interview with Patient 3’s daughter on July 29, 2025, at 12:50 PM, Patient 3’s daughter stated AP 5 was Patient 3’s attending physician.A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated July 3, 2025, to September 30, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MD on July 5, 2025. A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated July 3, 2025, to September 30, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG [Interdisciplinary group - a group of health care professionals who work in a coordinated fashion toward a common goal for a patient] Meetings and Plan of Care if I choose to follow the Patient,” the document indicated for AP 5 to sign, but it remained unsigned. There was no documented evidence to show AP 5 provided a signature verifying Patient 3’s prognosis of six months or less life expectancy.A review of Patient 3’s claims for payment indicated a claim for payment was pending submission in August 2025.During an interview with the MD and Admin/DPCSD on July 31, 2025, at 10:11 AM, the MD stated he knew about the requirement for two physician signatures certifying a patient’s terminal illness during the first and second benefit periods. The MD believed the agency was obtaining the second signature and did not know it was not being done. The Admin/DPCSD stated she knew about the requirement for two physician signatures certifying a patient’s terminal illness during the first and second benefit periods but was unaware that this had not been followed.2b. A review of Patient 4’s face sheet, undated, indicated a start of care date of April 4, 2025, with a benefit period of April 4, 2025, to July 2, 2025 (Benefit Period one). Patient 4 had diagnoses that included senile degeneration of the brain. A review of Patient 4’s physician’s referral order, dated April 3, 2025, by Patient 4’s AP 6, indicated to evaluate for hospice services. During an interview with Patient 4’s son on July 29, 2025, at 4:07 PM, Patient 4’s son stated AP 7 and AP 8 were Patient 4’s attending physicians.A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated April 4, 2025, to July 2, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MDD on April 6, 2025. A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated April 4, 2025, to July 2, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Referring Physician Attestation: It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient,” the document indicated for the MDD to sign, but it remained unsigned. There was no documented evidence to show AP 6, AP 7, or AP 8 provided a signature verifying Patient 4’s prognosis of six months or less life expectancy.A review of Patient 4’s claims for payment indicated a claim for payment was submitted on May 8, 2025, June 4, 2025, and July 8, 2025. During an interview with the MDD and Admin/DPCSD on July 31, 2025, at 9:46 AM, the MDD stated he was not aware of the requirement for two physician signatures certifying a patient’s terminal illness during the first and second benefit periods. The Admin/DPCSD stated she knew about the requirement for two physician signatures certifying a patient’s terminal illness during the first and second benefit periods but was unaware that this had not been followed.A review of the agency’s policy and procedure titled “Certification of Terminal Illness,” undated, indicated, “PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient’s attending physician, if any, will certify the patient’s terminal illness. … Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. …””

“Based on interview and record review, the Medical Director (MD) or the Medical Director Designee (MDD) failed his responsibility for the medical component of the hospice program for four of four sampled patients (Patients: 1, 2, 3, and 4) when an attending physician’s confirmation of service needs, verification of the patients’ medical prognosis and supporting documentation was not obtained. The MD failed to review data from a referral source in order to validate the diagnosis, life-limiting prognosis or appropriateness of hospice services.This failure had the potential to cause Patients 1, 2, 3, and 4 not to be given the opportunity to try curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon due to their attending physicians not identifying them as terminally ill and the Medical Director or designee not correctly evaluating Patients 1, 2, 3, and 4’s terminal diagnosis and prognosis of six months or less to live. Findings:A review of “42 CFR [Code of Federal Regulation] § 418.25 – Admission to hospice care,” updated June 3, 2025, indicated, “(a) The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient’s attending physician (if any).” A review of “42 CFR § 418.3 – Definitions,” updated June 3, 2025, indicated, “Attending physician means a – … (2) Is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual’s medical care.” 1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 12, 2024, with a benefit period of November 12, 2024, to January 10, 2025 (Benefit Period five). Patient 1 had diagnoses that included senile degeneration of the brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 1’s physician’s referral order dated November 12, 2024, by Patient 1’s Attending Physician (AP 2), indicated, “Please evaluate [name of Patient 1] for admission to Hospice. … Primary diagnosis supporting hospice referral – dementia [a general term for a decline in mental ability, severe enough to interfere with daily life, impacting memory, thinking, and reasoning] … Associated Diagnoses: Dementia, unspecified dementia severity [how severe the dementia symptoms are], unspecified dementia type, unspecified whether behavioral, psychotic [a mental health condition characterized by a loss of touch with reality], or mood disturbance or anxiety.” During an interview with Patient 1’s son on July 28, 2025, from 8:02 AM to 8:36 AM, Patient 1’s son stated he was the Responsible Party (RP) for Patient 1 and had signed all Patient 1’s hospice paperwork. Patient 1’s son reported that Patient 1’s AP 1 had not discussed hospice services with him, but the staff in AP 1’s office informed him that a hospice agency would be contacting him. Patient 1’s son stated that the hospice agency informed him that Patient 1 qualified for hospice due to an inability to walk. Patient 1’s son was not aware of a terminal diagnosis, the prognosis of six months or less to live, or that Patient 1 would discontinue curative treatments upon admission to hospice, “If I had known I would not have signed up for hospice.” Patient 1’s AP 1 was unavailable for interview. Patient 1’s AP 2 was unavailable for interview. A review of Patient 1’s CTI dated November 12, 2024, to January 10, 2025 (Benefit Period five) indicated certification of Patient 1’s prognosis of six months or less life expectancy by the MD. A review of Patient 1’s physician’s “Progress Note,” dated November 12, 2024, by the MD, indicated that AP 2 referred Patient 1 to hospice services. The MD assessed Patient 1 and recommended admission to hospice with palliative measures. During an interview with the MD and the Administrator/Director of Patient Care Services Designee (Admin/DPCSD) on July 31, 2025, at 10 AM, the MD confirmed Patient 1’s physician’s “Progress Note,” dated November 12, 2024, was his face-to-face encounter (an in-person non-certifying physician’s or nurse practitioners’ clinical assessment of the patient) with Patient 1. The MD confirmed he had not obtained or considered clinical assessment information from a face-to-face encounter conducted by another clinician when certifying Patient 1’s terminal diagnosis. The MD stated he had not contacted AP 2 to clarify the primary diagnosis supporting the hospice referral for dementia. The MD stated he did not clarify the underlying disease or disorder causing the dementia, the severity of the dementia, or the type of dementia, whether it was behavioral, psychotic, mood disturbance, or anxiety related. The MD and Admin/DPCSD stated they were unaware of AP 1. The MD stated he did not reach out to AP 1 or AP 2 to consult about Patient 1’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. 2. A review of Patient 2’s face sheet, undated, indicated a start of care date of May 22, 2025, with a benefit period of May 22, 2025, to July 20, 2025 (Benefit Period three). Patient 2 had diagnoses that included senile degeneration of the brain. A review of Patient 2’s physician’s referral order dated May 22, 2025, by Patient 2’s AP 3, indicated, “[Discharge] back on hospice today.” There was no documented evidence to show a terminal diagnosis. During an interview with Patient 2’s son on July 29, 2025, at 10:43 AM, Patient 2’s son stated Patient 2 had fallen, broke her hip and the hospital had discharged Patient 2 to a nursing home. Patient 2’s son stated the nursing home discharged Patient 2 with home health services (medical and therapeutic services delivered to a patient’s residence, rather than in a hospital or clinic) to an Assisted Living Facility (ALF-a living arrangement in which people with special needs, especially seniors, live in a facility that provides help with everyday tasks such as bathing, dressing, and taking medication) but Patient 2 kept falling so Patient 2 was transferred to a Board and Care Facility (B&C a licensed, non-medical facility providing room, board, and 24-hour care and supervision for individuals who need help with daily living activities but not 24-hour nursing care). Patient 2’s son stated a physician had not spoken with him about hospice services or a terminal diagnosis and Patient 2’s son thought the nursing home, or the home health agency might have mentioned hospice services. Patient 2’s son stated he did not know who AP 3 was and the doctor that knew Patient 2 best was AP 4. Patient 2’s AP 3 was unavailable for interview. During an interview with Patient 2’s AP 4 on July 30, 2025, from 9:11 AM to 9:36 AM, AP 4 stated he was not aware that Patient 2 had been admitted to hospice services and the hospice agency had not reached out to him. Patient 2’s AP 4 stated he had seen Patient 2 in February 2025, and she had been very thin following a hospitalization and nursing home stay. Patient 2’s AP 4 stated he had begun working with her and she slowly showed improvement in her weight. Patient 2’s AP 4 stated in April 2025, Patient 2’s son brought Patient 2 in for a heel wound and then Patient 2’s AP 4 received a phone call from an ALF requesting hospice services to care for Patient 2’s heel wound, “I told them you get nurses for wound care not hospice. I don’t agree with your hospice request; I don’t agree with hospice. I wrote in my notes, no hospice there is no terminal diagnosis.” Patient 2’s AP 4 stated he believed Patient 2 had some memory loss but not end stage dementia (dementia symptoms are severe, individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement), “I can’t support the diagnosis of senile degeneration of the brain, end stage.” A review of Patient 2’s CTI dated May 22, 2025, to July 20, (Benefit Period three) indicated certification of Patient 2’s prognosis of six months or less life expectancy by the Medical Director Designee (MDD). A review of Patient 2’s CTI dated May 22, 2025, to July 20, (Benefit Period three), section “Face to Face Narrative,” by the MDD, was conducted. During an interview with the MDD and the Admin/DPCSD on July 31, 2025, at 9:30 AM, the MDD confirmed Patient 2’s CTI dated May 22, 2025, to July 20, 2025 (Benefit Period three), section “Face to Face Narrative,”, was his face-to-face encounter with Patient 2. The MDD confirmed he had not obtained or considered clinical assessment information from a face-to-face encounter conducted by another clinician when certifying Patient 2’s terminal diagnosis. The MDD verified AP 3’s referral order did not indicate a terminal diagnosis for Patient 2 and the MDD and Admin/DPCSD stated they were unaware of AP 4. The MDD stated he did not reach out to AP 3 or AP 4 to consult about Patient 2’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. 3. A review of Patient 3’s face sheet, undated, indicated a start of care date of July 3, 2025, with a benefit period of July 3, 2025, to September 30, 2025 (Benefit Period one). Patient 3 had diagnoses that included senile degeneration of the brain. A review of Patient 3’s physician’s referral order dated June 24, 2025, by Patient 3’s AP 5, indicated a hospice evaluation with a terminal diagnosis of dementia. During an interview with Patient 3’s daughter on July 29, 2025, at 12:50 PM, Patient 3’s daughter said she and her sister needed help with Patient 3’s care and she called the hospice agency for services but was told a physician’s order was required for an evaluation. Patient 3’s daughter then contacted AP 5, who provided the hospice referral order. Patient 3’s daughter stated AP 5 had not discussed hospice services, a terminal diagnosis for Patient 3, or any alternatives other than hospice care. Patient 3’s daughter confirmed AP 5 was the physician most familiar with Patient 3’s medical history. During an interview with Patient 3’s AP 5 on July 30, 2025, at 1:06 PM, AP 5 stated she saw Patient 3 and her daughter on March 13, 2025, requesting home physical therapy for Patient 3’s shoulder pain and AP 5 had been working on arranging outpatient therapy. AP 5 stated on May 27, 2025, Patient 3’s daughter wanted to speak with AP 5 about hospice services and AP 5 told Patient 3’s daughter she could not hospitalize Patient 3 if the daughter choose hospice. AP 5 stated she had to write some kind of diagnosis when she sent a hospice referral order but maybe dementia was not right because the patient was fine when AP 5 saw her in March 2025, “some memory loss but not end stage but the patient is 98 years old.” AP 5 stated the family just needed more help and hospice can give more help in caring for Patient 3. AP 5 stated she could not predict when someone was going to die so she would not sign certifying a life expectancy of six months or less. AP 5 stated the hospice did not contact her to discuss Patient 3 and hospice services. A review of Patient 3’s “Physician’s Certification for Hospice Benefit,” dated July 3, 2025, to September 30, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MD on July 5, 2025. There was no documented evidence to show AP 5 had provided a second signature certifying a life expectancy of six months or less. During an interview with the MD and the Admin/DPCSD on July 31, 2025, at 10:11 AM, the MD and Admin/DPCSD confirmed there was no second physician signature certifying Patient 3’s life expectancy of six months or less and there should have been. The MD stated he did not reach out to AP 5 to consult about Patient 3’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. 4. A review of Patient 4’s face sheet, undated, indicated a start of care date of April 4, 2025, with a benefit period of April 4, 2025, to July 2, 2025 (Benefit Period one). Patient 4 had diagnoses that included senile degeneration of the brain. A review of Patient 4’s physician’s referral order dated April 3, 2025, by Patient 4’s AP 6, indicated an evaluation for hospice services. There was no documented evidence to show a terminal diagnosis. During an interview with Patient 4’s son on July 29, 2025, at 4:07 PM, Patient 4’s son stated Patient 4 was living at an ALF and she began having a lot of falls some of which sent Patient 4 to the Emergency Room. Patient 4’s son stated he was approached by the ALF who informed him his mother either needed to be transferred to a nursing home or put Patient 4 on hospice services. Patient 4’s son stated he did not think Patient 4 would qualify for hospice because he believed Patient 4 would live far longer than 6 months, but the ALF indicated there was some kind of loophole which would allow Patient 4 to qualify, “I don’t know what the loophole was, but I didn’t want [Patient 4] in a nursing home.” Patient 4’s son stated the ALF recommended the hospice agency and he did not know how it happened, but the hospice agency came and admitted Patient 4 and he signed the paperwork. Patient 4’s son stated he did not know AP 6 and identified AP 7 and AP 8 as physician’s who knew and treated Patient 4. Patient 4’s son stated no physician had a conversation with him in regard to hospice services, a terminal diagnosis or giving up curative treatments. Patient 4’s AP 6 was unavailable for interview. Patient 4’s AP 7 was unavailable for interview. Patient 4’s AP 8 was unavailable for interview. A review of Patient 4’s “Physician’s Certification for Hospice Benefit,” dated April 4, 2025, to July 2, 2025, indicated, “Certification [number one]: Statement for First 90-day period. … Medical Director … Certification, I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient,” signed by the MDD on April 6, 2025. There was no documented evidence to show AP 6, 7, or 8, had provided a second signature certifying a life expectancy of six months or less. During an interview with the MDD and the Admin/DPCSD on July 31, 2025, at 9:46 AM, the MDD and Admin/DPCSD confirmed there was no second physician signature certifying Patient 4’s life expectancy of six months or less and there should have been. The MDD stated he did not reach out to AP 6, 7, or 8 to consult about Patient 4’s terminal diagnosis, life-limiting prognosis or appropriateness of hospice services. A review of the agency’s policy and procedure titled “Certification of Terminal Illness,” undated, indicated, “PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patient’s attending physician, if any, will certify the patient’s terminal illness. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. … PROCEDURE: … 3. Clinical information and other documentation that supports the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. Initially, the clinical information may be provided verbally and must be documented in the medical record and included as part of the hospice’s eligibility assessment.” A review of the agency’s policy and procedure titled “Physician Services-Medical Director,” undated, indicated, “To ensure qualified medical direction and consultation for the delivery of hospice services and programs. To demonstrate that the Medical Director/hospice team physician has overall responsibility for patient care through documentation that demonstrates interaction/ communication with the attending physician as necessary for appropriate medical care. … POLICY: … The duties and responsibilities of the Medical Director will include but not be limited to the following: … 3. Reviewing patients’ medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness. … Requirements to meet California Hospice Standards: … Medical Director services are provided in a manner consistent with the philosophy of hospice and palliative care and include but are not limited to: … 2. Consulting and coordinating care with hospice physicians and attending physicians. … 5. The responsibilities of the medical director, consistent with the organizational plan and structure of the program, shall include but are not limited to: a. Reviewing necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician. b. Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services. c. Assisting in developing and implementing the plan of care that is coordinated with the attending physician.””