Bellerose Hospice Care Inc.

“Upon patient record review, 10 of 14 (Patient #1-#10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1-10: The record indicated there were no ongoing reviews during the IDG meetings to include the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and or drug therapy currently associated with laboratory monitory. The review for this was left blank for all IDG meetings. Patient #3: Upon home visit the Chaplain interpreted for surveyor. All medications were written in English. The medication bottle was handed to the caregiver and asked how was the medication being given she stated to the Chaplain she was giving the Icosapent Ethyl 1g 2 Tabs twice a day. The medication was ordered for one tablet 4 times a day.”

“Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #6: The record indicated the patient was a full code at the time of hospice admission. There was no individualized care plan to reflect the patient/family goals and interventions based on the problem identified in the initial comprehensive assessment. COS.”

“Upon patient record review 3 of 14 (Patient #4, #6, #8) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #4: The record indicated an aide supervisory visit was due on 4/22/25 and it was not completed. Patient #6: The record indicated an aide supervisory visit was due on 07/18/24 and it was not completed. Patient #8: The record indicated an aide supervisory visit was due on 06/24/25 and it was not completed.”

“Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participations regarding Initial and Comprehensive Assessments of Patients was met as evidenced by: 1. The Hospice Agency (HA) failed to ensure the comprehensive assessment of patients included the identified physical, psychosocial, emotional, and spiritual needs related to their terminal illness for three of 14 patients (Patient 3, Patient 8 and Patient 9). This failure had the potential to result in patients not provided appropriate hospice care services that could impact the hospice patient’s well-being, comfort, and dignity throughout the dying process. (Refer to L524). 2. The HA failed to review all medications and update the medication profiles with the currently used medications for two of 14 sample selected patients (Patient 8 and Patient 9). The patients were at risk for medication errors and adverse drug reactions. (Refer to L 530). 3. The Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG) met and updated the comprehensive assessment at least every 15 days for one out of 14 sample selected patients (Patient 9). This deficient practice had potential for the hospice patient’s identified needs will not be evaluated that included accurate information about patient’s response to the care, treatment and services provided, and progress toward desired outcomes. (Refer to L533). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated Federal compliance for Initial & Comprehensive Assessment of Patients to ensure highest quality of care are provided for patients certified to receive Medicare Hospice benefits.”

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Medical Director was met as evidenced by: 1. The HA failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) had the responsibility for the medical component of the hospice’s patient care program, including initial certification of terminal illness for four of 14 sample patients (Patient 3, Patient 8, Patient 9, and Patient 14). (Refer to L 667). 2. The HA failed to ensure the medical director and/or physician designee conducted a review and verified the patient’s clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services four of 14 sample patients (Patient 3, Patient 8, Patient 9, and Patient 14). (Refer to L 668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure the highest quality of patient care are provided to the patients certified to receive hospice services.”

“Based on interview, observation, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation on Clinical Records was met as follows: 1. The HA failed to ensure the clinical records included advance directives for one of 14 sampled patients (Patient 2). (Refer to L677). 2. The HA failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for 3 of 14 sampled patients (Patient 1, Patient 3, Patient 4). (Refer to L679). 3. The HA failed to ensure contents and information in the patients’ medical records were safeguarded from unauthorized access by HA staff to make alterations or modifications for one of 14 sampled patients (Patient 3). (Refer to L680). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients’ medical records are safeguarded from unauthorized access by any individuals or hospice staff.”

“Based on interview, observation, and record review the Hospice Agency (HA) failed to ensure the comprehensive assessment of patients included the identified physical, psychosocial, emotional, and spiritual needs related to their terminal illness for three of 14 patients (Patient 3, Patient 8 and Patient 9). This failure had the potential to result in patients not provided appropriate hospice care services that could impact the hospice patient’s well-being, comfort, and dignity throughout the dying process. During an interview on 7/17/2025 at 3:52 p.m., with the DPCS, stated psychosocial assessments are to be done monthly to assess the patients’ living condition, how they are coping with their disease, placement and any other issues found. The DPCS stated patients’ needs could be missed and not assessed when the psychosocial assessment was not done. The DPCS stated “I also know that if it is not documented, it didn’t happen.”1. During a record review of Patient 3’s Personal Information sheet, indicated a start of care date of 3/8/2024, with a terminal diagnosis of Alzheimer’s disease (a brain disease that affects memory and other body functions).During a concurrent interview and record review on 7/16/2025, at 11:31 a.m., the Director of Patient Care Services (DPCS) reviewed Patient 3’s records and stated the last Psychosocial Assessment was on 1/2/2025. The DPCS stated the Medical Social worker visited the patient on 6/19/2025 and this visit could be considered the recertification assessment for the period 7/1/2024 to 8/29/2025. Patient 3’s record titled, “Psychosocial Assessment”, dated 1/2/2025, indicated blank sections on the document. The DPCS stated the areas that were not filled out were psychosocial circumstances, patient-psychosocial distress, and family-psychosocial distress. The DPCS stated if there were no changes with the patient’s psychosocial status, as long as the narrative said there was no changes, then that was “okay”. 2. During a record review of Patient 8’s medical record form titled “Patient Information” undated, indicated a start of care date of 2/2/2025 with a primary diagnosis of cerebral infarction (lack of blood supply to brain causing death to tissue). During a record review of Patient 8’s medical record form titled “Comprehensive Nursing Assessment” dated 2/25/2025, indicated Patient 8’s weight was 170 pounds, had a primary disease of stroke and coma with comorbidities including COPD (chronic obstructive pulmonary disease – long term lung disease that makes it hard to breathe), hyperlipidemia (high cholesterol levels in the blood), and depression. The Comprehensive Nursing Assessment indicated Patient 8 was referred to social work, spiritual care, and bereavement care. In the narrative section it indicated that Patient 8 was taking Warfarin (blood thinner medication).During a record review of Patient 8’s medical record form titled “Re-Cert Assessment” dated 7/11/2025, indicated Patient 8’s weight was 170 pounds, had a primary disease of stroke and coma with comorbidities including COPD, and depression. Lastly, the Comprehensive Nursing Assessment indicated Patient 8’s was referred to social work, spiritual care, and bereavement care. During a record review of Patient 8’s medical record form titled “Current Treatment/Medication/DME List” undated, indicated there was a physician’s order for the Medical Social Worker and Spiritual Care Coordinator to assess Patient 8 monthly. During a concurrent observation and interview on 7/15/2025 at 11:10 a.m., with Patient 8 at her home, Patient 8 was noted sitting up on bed. Patient 8 stated she has been receiving hospice services since March 2025 and has not seen a hospice doctor since then. Patient 8 stated she did not have heart issues. Patient 8 stated she had one of her heart valves replaced in 1984 and has been taking Warfarin (blood thinning medication). Patient 8 stated she had back surgery in 2002 which was due to blood leaking from her spine because of taking Warfarin and not having blood levels checked. Patient 8 stated her vertebra T4 to L5 (mid back to low back) were removed and that was the reason she was unable to walk. Patient 8 stated she has not seen a hospice spiritual counselor and was unsure if she saw a hospice social worker. Patient 8 stated she had not been told by a doctor that she had 6 months or less to live. During an interview on 7/17/2025 at 12:22 p.m., with the Medical Director 1 (MD1), MD1 stated Patient 8’s hospice diagnosis was CVA (cerebral vascular accident – stroke). The MD1 stated Patient 8 was hospice eligible due to being bedbound and Patient 8’s gradual decrease in life and functional status. The MD1 stated he was told by HA nurses that Patient 8 had a 10-pound weight loss. During a concurrent interview and record review on 7/17/2025 at 12:38 p.m., with the DPCS, stated Patient 8 informed MD1 and the admitting nurse that Patient 8 had a stroke. The DPCS stated the HA did not have Patient 8’s history and physical confirming or indicating Patient 8’s current medical conditions which included CVA. The DPCS stated Patient 8 referred herself for hospice services. The DPCS stated there was no documentation the HA had any contact with Medical Doctor 2 (MD2). During an interview on 7/17/2025 at 1:25 p.m., with the MD1, stated he could not recall why Patient 8 was taking Warfarin. MD1 stated the HA needs to reassess Patient 8 as soon as possible, and if indicated MD1 will discharge Patient 8. MD1 stated he did not speak with MD2. 3. During a record review of Patient 9’s medical record form titled “Patient Information” undated, indicated a start of care date of 6/8/2024 with a primary diagnosis of heart failure. Section “Secondary DX (diagnosis)” was left blank. During a record review of Patient 9’s medical record form titled “Updated Assessment” dated 7/3/2025, indicated a primary diagnosis/disease of heart failure. Section “Secondary DX (diagnosis)” was left blank. During a concurrent observation and interview on 7/15/2025 at 12:30 p.m., with Patient 9 at her home, Patient 9 was noted sitting in a wheelchair. Patient 9 stated has been receiving hospice services since Marh 2024. Patient 9 stated she had breast surgery due to cancer on 9/2024. It was observed Patient 9 had a right breast scar. Patient 9 stated she had a provider (PV1) at the Veterans Affairs, which she saw last on 5/2025. Patient 9 stated she received a “shot” on her back due to sciatic pain in 2017, which caused a bubble of medication to lie dormant until it burst in 2022 after slipping off a sitting stool. Patient 9 stated she developed CHF (congestive heart failure – chronic/progressive condition where the heart muscle is unable to pump enough blood) in 2024 and that was the reason for receiving hospice services. Patient 9 stated she spoke to a “gal” from the hospice agency and was told that the only way to get rid of CHF was to have a heart transplant. Patient 9 stated she has not heard from a doctor that she was going to die within 6 months, “I don’t know when I am going to die”. During a phone interview on 7/17/2025 at 1:32 p.m., with the Medical Director 1 (MD1), MD1 stated Patient 9’s primary diagnosis was heart failure. MD1 stated Patient 9 was receiving hospice services due to her CHF diagnosis and co morbidities of high blood pressure, sciatica, and gout. MD1 stated Patient 9 was self-referred. MD1 stated the HA did not have a history and physical (H&P) for Patient 9 to confirm her CHF diagnosis. MD1 stated “when it’s self-referral, we don’t have and H&P, we go by what the patient tells us.” During a concurrent interview and record review on 7/17/2025 at 3:52 p.m., with the DPCS of Patient 9’s medical record, the DPCS stated Patient 9’s last psychosocial assessment was conducted on 2/2/2025. The DPCS there was no documentation in Patient 9’s medical record indicating why the psychosocial assessment was not conducted since 2/2/2025. During a record review of the agency’s record titled “Admission Criteria and Process” revised 4/2020, indicated “The patient must desire hospice services, and be aware of the diagnosis and prognosis. During a record review of the agency’s record titled “Psychosocial Assessment” revised 4/2020, indicated “A thorough psychosocial assessment will be initiated at the time of admission and continued throughout the course of care. After the assessment is performed, ongoing contact will be maintained by phone and/or home visit by the hospice social worker.” During a record review of the agency’s record titled “Psychosocial Services” revised 4/2020, indicated “A social worker will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient.””

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to review all medications and update the medication profiles with the currently used medications for two of 14 sample selected patients (Patient 8 and Patient 9). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. 1. During a record review of Patient 8’s medical record form titled “Patient Information” undated, indicated a start of care date of 2/2/2025 with a primary diagnosis of cerebral infarction (lack of blood supply to brain causing death to tissue). During a record review of Patient 8’s medical record form titled “Current Treatment/Medication/DME List” undated, indicated Patient 8 was prescribed Morphine (narcotic pain medication), Atropine (medication for secretions), and lorazepam (anti-anxiety medication).During a concurrent interview and record review on 7/15/2025 at 11:10 a.m., with Registered Nurse 1 (RN1) at Patient 8’s home, RN1 was noted reconciling Patient 8’s medication with the HA’s medication list. RN1 was observed picking up medication bottles and placing them back down without verifying medication expiration dates. RN1 was not observed to reconcile Patient 8’s emergency medications, which included Morphine, Atropine, and Lorazepam.During a concurrent observation and record review on 7/15/2025 at 11:10 a.m., with Patient 8’s care giver (CV1) of Patient 8’s medications and list, CV1 was requested to provide all Patient 8’s medications including the emergency medications. CV1 provided Patient 8’s medications, including Morphine, Atropine, and Lorazepam. During an interview on 7/17/2025 at 11:10 a.m., with RN1, RN1 stated patients’ medications are reconciliated during every skilled nurse visit to ensure patients are taking the appropriate medications. RN1 stated she did not check Patient 8’s medication expiration dates. RN1 stated it was important to check the expiration dates to ensure the medications are doing what they are supposed to do. RN1 stated she did not check Patient 8’s emergency medications. RN1 stated “I don’t know if they are being used or not and I don’t know if they are expired.” 2. During a record review of Patient 9’s medical record form titled “Patient Information” undated, indicated a start of care date of 6/8/2024 with a primary diagnosis of heart failure. Section “Secondary DX (diagnosis)” was left blank. During a record review of Patient 9’s medical record form titled “Current Treatment/Medication/DME List” undated, indicated Patient 9 was prescribed Allopurinol (medication to reduce high levels of uric acid in the blood), Colace (medication for constipation), Nexium (medication to reduce stomach acid), Senna (medication for constipation), Norco (pain medication), and Atropine. During a concurrent observation, interview, and record review on 7/15/2025 at 12:30 p.m. with Patient 9 at her home of her medication and medication list, Patient 9 stated she only takes five medications, which included Benadryl (allergy medication), Metoprolol (high blood pressure medication), multivitamin, valsartan (high blood pressure medication), and Lasix (water medication). Patient 9 stated that she has not taken the rest of the medications listed on the HA medication list since 9/2024.During a concurrent interview and record review on 7/15/2025 at 12:30 p.m., with RN1 of Patient 9’s medications and medication list, RN1 stated she did not check Patient 9’s medication expiration dates or her emergency medications. RN1 stated “We leave the medication listed on their medication list to give them time to make sure they really want to stop taking them. I need to talk with the nurses, if that was me, I would have taken those medications off the list since October of last year, 2024.”During an interview on 7/16/2025 at 2:53 p.m., with Registered Nurse 2 (RN2), stated she was not allowed to make any changes to the patients’ medication list. During an interview on 7/16/2025 at 2:17 p.m., with the Director of Patient Care Services (DPCS), stated nurses check patients’ medications during every visit, check the expiration dates, if they are taking their medications, and if they need to be refilled to ensure the patients are taking their medications. During a review of the agency’s record titled “Medication Profile” revised 4/2020, indicated “The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.””

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG) met and updated the comprehensive assessment at least every 15 days for one out of 14 sample selected patients (Patient 9). This deficient practice had potential for the hospice patient’s identified needs will not be evaluated that included accurate information about patient’s response to the care, treatment and services provided, and progress toward desired outcomes. During an interview on 7/16/2025 at 11:51 a.m., with the Spiritual Counselor 1 (SC1), stated he was part the HA’s IDG. SC1 stated that the HA conducts IDG meetings every two weeks either in person or over the phone. SC1 stated he (SC1) signs his (SC1) participation in the meeting the same day or within 24 hours of the meeting. SC1 stated that he attended the IDG meeting on 7/4/2025 in person and signed on a sign in sheet. During an interview on 7/16/2025 at 12 p.m., with the DPCS, stated the HA has a sign in sheet where the disciplines sign during the IDG meetings. The DPCS stated she (DPCS) does not keep the sign in sheets and throws them away. During an interview on 7/16/2025 at 2:17 p.m., with the DPCS, stated the HA conducts IDG meetings every other Friday in the office or electronically to discuss and update the patients’ care plans. The DPCS stated the HA does not usually do not invite the patients to their IDG meeting because “it would be a HIPPA (Health Insurance Portability and Accountability – a law that protects patients’ information) violation” because other patients are being discussed. The DPCS stated all disciplines sign their involvement in the IDG meeting on their electronic medical record (EMR) system with 2-3 hours of meeting. During an interview on 7/17/2025 at 12:15 p.m., with MD1, stated he was the HA’s Medical Director for about three years now. MD1 stated the IDG team conducts IDG meetings every 2 weeks. MD1 stated he has 48 hours to assess a patient’s condition, primary and secondary diagnosis, and the medication list is reviewed. During an interview on 7/17/2025 at 9:12 a.m., with Medical Social Worker 2 (MSW2), stated she visited patients and their families to provide resources, emotional support and whatever else they need. MSW2 stated she was an IDG member. MSW2 stated the HA holds IDG meetings every other Friday at 6 p.m. MSW2 stated she attended HA’s IDG meetings via an electronic forum because she lives in a different town. MSW2 stated she logs into the HA’s EMR system before or during the IDG meeting to input her discussion and signature. MSW2 stated she completed the discussion section and confirms those were her findings. MSW2 stated she attended the IDG meeting on 7/4/2025 via an electronic forum. MSW2 stated she sometimes has issues with the HA’s EMR system. During a record review of Patient 9’s medical record form titled “Patient Information” undated, indicated a start of care date of 6/8/2024 with a primary diagnosis of heart failure. Section “Secondary DX (diagnosis)” was left blank. During a record review of Patient 9’s medical record form titled “POC (plan of care)/IDG (interdisciplinary group) Review” dated 7/4/2025, did not indicate it was signed by a Registered Nurse. The POC/IDG Summary also indicated it was signed by the Medical Director (MD1), the Spiritual Counselor (SC), and the Medical Social Worker (MSW) on 7/4/2025.During a record review of Patient 9’s medical record form titled “POC (plan of care) Summary” dated as of 7/14/2025, indicated “IDT (interdisciplinary team) to review patients’ status every 14 days and as needed to evaluate changes in condition”. During a record review of Patient 9’s medical record form titled “Audit Log” dated from 7/14/2025 to 7/17/2025, indicated MD1, the SC, and the MSW signed Patient 9’s interdisciplinary group (IDG) meeting dated 7/4/2025 on 7/14/2025. The Audit Log also indicated that the Director of Patient Care Services (DPCS) signed Patient 9’s IDG meeting dated 7/4/2025 on 7/15/2025.During a concurrent interview and record review on 7/16/2025 at 2:17 p.m. with the DPCS of Patient 9’s medical record, the DPCS stated that all the disciplines signed Patient 9’s POC/IDG Summary dated 7/4/2025 on 7/14/2025. The DPCS was informed of Patient 9’s Audit Log. The DPCS stated that maybe the HAs EMR (electronic medical record) did not capture the disciplines signatures on 7/4/2025. During a record review of the agency’s record titled “Admission Criteria and Process” revised 4/2020, indicated “Eligibility criteria will be continually reviewed on an ongoing basis by the interdisciplinary team to assure appropriateness of hospice care. During a record review of the agency’s record titled “Interdisciplinary Group Membership and Responsibilities” revised 4/2020, indicated “The hospice interdisciplinary group membership includes as a minimum: Physician, Registered Nurse, Social Worker, Pastoral or other counselor.”During a record review of the agency’s record titled “Interdisciplinary Group Meeting” revised 4/2020, indicated “Each patient’s plan of care will be updated… no less frequently than every 15 days or more… The hospice Medical Director and all hospice interdisciplinary members will be present… Members at the interdisciplinary group meeting will sign an attendance from that will be kept by the hospice Clinical Supervisor.””

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) had a responsibility for the medical component of the hospice’s patient care program, including initial certification of terminal illness for four of 14 sample patients (Patient 3, Patient 8, Patient 9, and Patient 14), to support diagnoses of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient’s pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. These deficient practices resulted in the continued certification of patients for hospice by the medical director and/or physician designee without written clinical evidence anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. During an interview on 7/17/2025 at 12:15 p.m., with Medical Director 1 (MD1), stated he was the HA’s Medical Director for about three years. MD1 stated he sees patients himself but that it was not always possible because he also works at a hospital and has other responsibilities. MD1 stated he has 48 hours to assess the patient’s condition, primary and secondary diagnosis, and the medication list. MD1 stated the HA receives patients’ referrals from hospitals, doctors, and community outreach. MD1 stated referrals are sent to the HA, then he was informed by the HA that there is a new patient.During a phone interview on 7/17/2025 at 2:05 p.m., with MD1, stated his signature on patients Certification of Terminal Illness (CTI) indicates that he (MD1) justifies and agrees it was dictated by him. MD1 stated he dictates his findings to the Director of Patient Care Services (DPCS) to be documented on patients CTI. At 2:12 p.m., MD1 stated he had to end the call and could not answer any more questions.During an interview on 7/17/2025 at 3:52 p.m., with the DPCS, stated that a face-to-face assessment is conducted every two months by the medical director or the nurse practitioner, starting before the 3rd benefit period to evaluate if a patient continues to qualify for hospice benefits. 1. During a record review of Patient 3’s Personal Information sheet, indicated a start of care date of 3/8/2024, with a terminal diagnosis of Alzheimer’s disease (a brain disease that affects memory and other body functions).During a concurrent interview and record review on 7/16/2025 at 11:59 a.m., the DPCS reviewed Patient 3’s documents titled Physician’s Certification for Hospice Benefit-CTI, for certification period 3/8/2024 to 5/6/2024 and the Audit Log (a document that indicates all the entries in a medical record) dated 3/8/2024 to 7/16/2024. The CTI document did not indicate that a verbal authorization to hospice care was given by MD 1. During a review of the audit log, the document indicated that the physician narrative on the CTI for the initial certification period of 3/8/2024 to 5/6/2024, was documented by the DPCS on 4/8/2024 and MD 1 signed the CTI on 4/29/2024. The DPCS stated the certification was not supposed to be delayed this much. The DPCS stated the reason for the delay was an electronic medical record (EMR) issue. Most likely the previous CTI was deleted. The DPCS stated whenever a user makes a mistake, the CTI is deleted. The date on the audit log of 4/8/2024, showed when the agency corrected the CTI. Most likely this is what happened. During a record review of Patient 3’s CTI, dated 3/8/2024 to 7/16/2024, indicated, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The document indicated MD 1 had documented a signature date of 3/9/2024. 2. During a record review of Patient 8’s medical record form titled “Patient Information” undated, indicated a start of care date of 2/2/2025 with a primary diagnosis of cerebral infarction (lack of blood supply to brain causing death to tissue). During a record review of Patient 8’s medical record form titled “Comprehensive Nursing Assessment” dated 2/25/2025, indicated Patient 8’s weight was 170 pounds, had a primary disease of stroke and coma with comorbidities including COPD (chronic obstructive pulmonary disease – long term lung disease that makes it hard to breathe), hyperlipidemia (high cholesterol levels in the blood), and depression. During a record review of Patient 8’s medical form titled “Physician’s Certification for Hospice Benefits (CTI) – Certification #2” dated 2/25/2025 to 5/25/2025, indicated “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The Physician’s Certification for Hospice Benefits form also indicated the MD1 signed the form on 2/25/2025.During a record review of Patient 8’s medical record form titled “Audit Log” dated from 1/29/2025 to 7/17/2025, indicated MD1 composed the “Physician Narrative Certifying Physician Summary” of Patient 8’s CTI dated 2/25/2025 on 3/25/2025. The Audit Log also indicated MD1 signed Patient 8’s CTI dated 2/25/2025 on 3/25/2025. During a record review of Patient 8’s medical record form titled “Audit Log” dated from 1/29/2025 to 7/17/2025, indicated the DPCS composed section “RN (Registered Nurse) Assessment Narrative” of Patient 8’s CTI dated 2/25/2025 on 5/15/2025. The Audit Log also indicated the DPCS composed section “Physician Narrative Face to Face Summary” of Patient 8’s CTI dated 2/25/2025 on 5/25/2025.During a record review of Patient 8’s medical form titled “LCD (local coverage determination) Hospice Eligibility Determination” dated 2/25/2025, indicated Patient 8 was made eligible for hospice benefits based on a “Stroke and Coma”. The LCD Hospice Eligibility Determination form also indicated for a stroke 1 and 2 should be met. The LCD Hospice Eligibility Determination form indicated a “Yes” was placed under: 1. Impairment of functional status: Is KPS (Karnofsky Performance Status of 40 – a patient is disabled and requires special care and assistance) or PPS (Palliative Performance Scale of 40% - a patient is mainly bed-bound and requires extensive assistance) less than 40% and 2. Weight loss >10% in the last 6 months or >7.5% in the last 3 months?During a record review of Patient 8’s medical record form titled “F2F (face to face) Visit Note” dated 5/10/2025, indicated “I confirm that I had a face – to – face encounter with this patient on the date noted above and that the clinical findings of that encounter were provided to the certifying physician, for use in determining whether the patient continues to have a life expectance of 6 months or less, should the illness run its normal course. The F2F Visit Notes was signed by MD1 on 5/10/2025.During a concurrent observation and interview on 7/15/2025 at 11:10 a.m. with Patient 8 at her home, Patient 8 was noted sitting up on bed. Patient 8 stated she has been receiving hospice services since March 2025 and has not seen a hospice doctor since then. Patient 8 stated she was informed by the HA nurse that she was not allowed to continue seeing her primary physician (MD2) once she started hospice services. Patient 8 stated she had not been told by a doctor that she had 6 months or less to live. Patient 8 stated she was aware of what hospice is but that a nurse from the HA told her the hospice also provided palliative care. Patient 8 stated she did not have heart issues. Patient 8 stated she had one of her heart valves replaced in 1984 and has been taking Warfarin (blood thinning medication) since then. Patient 8 stated she had back surgery in 2002 which was due to blood leaking from her spine because of taking Warfarin and not having blood levels checked. Patient 8 stated her vertebra T4 to L5 (mid back to low back) were removed and that is the reason she was unable to walk.On 7/15/2025 at12:16 p.m., MD2 was called at the phone number provided by Patient 8. Machine answered, message left with call back number. During an interview on 7/17/2025 at 12:22 p.m., with the MD1, stated Patient 8’s hospice diagnosis was CVA (cerebral vascular accident – stroke). The MD1 stated Patient 8 was hospice eligible due to being bedbound and Patient 8’s gradual decrease in life and functional status. The MD1 stated he (MD1) was told by HA nurses that Patient 8 had a 10-pound weight loss. During a concurrent interview and record review on 7/17/2025 at 12:38 p.m., with the DPCS of Patient 8’s medical record, the DPCS stated Patient 8 informed MD1 and the admitting nurse that Patient 8 had a stroke. The DPCS stated the HA did not have Patient 8’s history and physical confirming or indicating her current medical conditions. The DPCS stated Patient 8 referred herself for hospice services. The DPCS stated there was no documentation that the HA had any contact with Patient 8’s medical provider (MD2). The DPCS stated the HA did not offer palliative care and did not know who told Patient 8 that the HA also offers palliative care. The DPCS stated some patients graduate from hospice. The DPCS stated Patient 8’s diagnosis and comorbidities make Patient 8 eligible for hospice. During a concurrent interview and record review on 7/17/2025 at 12:38 p.m., with the DPCS of Patient 8’s medical record, the DPCS stated the HA uses the LCD to determine if a patient qualifies for hospice services. The DPCS stated that there were no objective findings that Patient 8 had a weight loss of 10%. The DPCS stated that since Patient 8 referred herself for hospice services, MD1 signs the referral. During an interview on 7/17/2025 at 1:25 p.m., with the MD1, stated he does not recall why Patient 8 is taking Warfarin. MD1 stated the HA needs to reassess Patient 8 as soon as possible, and if indicated he will discharge her (Patient 8). MD1 stated he did not speak with MD2. 3. During a record review of Patient 9’s medical record form titled “Patient Information” undated, indicated a start of care date of 6/8/2024 with a primary diagnosis of heart failure. Section “Secondary DX (diagnosis)” was left blank. During a record review of Patient 9’s medical record form titled “F2F Visit Note” dated 6/8/2024, indicated “Patient is appropriate for hospice admission due to the progression of her heart failure. The F2F Visit Note was signed by MD1 on 6/8/2024.During a record review of Patient 9’s medical record form titled “Audit Log – MD Visit Note” dated from 6/8/2024 to 7/17/2024, indicated MD1 created and signed the “MD Visit Note” dated 6/8/2024 on 7/3/2024 and 3/15/2024.During a record review of Patient 9’s medical record form titled “Physician’s Certification for Hospice Benefits (CTI) – Certification #3” dated 6/8/2024 to 8/6/2024, indicated “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The Physician’s Certification for Hospice Benefits form also indicated the MD1 signed the form on 6/8/2024.During a record review of Patient 9’s medical record form titled “Audit Log – Certification MD” dated from 6/8/2024 to 7/17/2024, indicated MD1 composed the “Physician Narrative Certifying Physician Summary” and signed Patient 9’s CTI dated 6/8/2024 on 8/12/2024.During a record review of Patient 9’s medical form titled “LCD Hospice Eligibility Determination” dated 6/8/2024, indicated Patient 9 was made eligible for hospice benefits based on “heart disease”. The LCD Hospice Eligibility Determination form also indicated “Patient does not qualify per LCD guidelines”.During a concurrent observation and interview on 7/15/2025 at 12:30 p.m., with Patient 9 at her home, Patient 9 was noted sitting in a wheelchair. Patient 9 stated has been receiving hospice services since Marh 2024. Patient 9 stated she had breast surgery due to cancer on 9/2024. Patient 9’s right breast scar was observed. Patient 9 stated she had a provider (PV1) at Veterans Affairs, which she saw last on 5/2025. Patient 9 stated she received a “shot” on her back due to sciatic pain in 2017, which caused a bubble of medication to lie dormant until it burst in 2022 after slipping off a stool. Patient 9 stated she developed CHF (congestive heart failure – chronic/progressive condition where the heart muscle is unable to pump enough blood) in 2024 and that is the reason for receiving hospice services. Patient 9 stated she spoke to a “gal” from the hospice agency and was told that the only way to get rid of CHF was to have a heart transplant. Patient 9 stated she has not heard from a doctor that she was going to die within 6 months, “I don’t know when I am going to die”. During an interview on 7/17/2025 at 1:04 p.m., with Patient 9’s medical provider (PV1)’s nurse (PV2) stated there was no documentation in Patient 9’s medical record that stated she was referred to hospice in the past 2-3 years. PV2 stated Patient 9 had a video consultation with PV1 in May 2025 and was seen face to face in April 2025. PV2 stated that there was nothing in Patient 9’s medical record to indicate Patient 9 was receiving hospice services. During a phone interview on 7/17/2025 at 1:32 p.m., with the MD1, stated Patient 9’s primary diagnosis is heart failure. MD1 stated Patient 9 is receiving hospice services due to CHF diagnosis and co morbidities of high blood pressure, sciatica, and gout. MD1 stated Patient 9 was self-referred. MD1 stated the HA did not have a history and physical (H&P) for Patient 9 to confirm Patient 9’s CHF diagnosis. MD1 stated “when it’s self-referral, we don’t have and H&P, we go by what the patient tells us.” 4. During a record review of Patient 14’s medical record form titled “Patient Information” undated, indicated a start of care date of 1/13/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (plaque buildup inside the heart arteries) w/o (without) angina pectoris (chest pain/discomfort). Section “Secondary DX (diagnosis)” was left blank. During a record review of Patient 14’s medical record form titled “Physician’s Certification for Hospice Benefits (CTI) – Certification #4” dated 1/13/2025 to 3/13/2025, indicated “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The Physician’s Certification for Hospice Benefits form also indicated the MD1 signed the form on 1/13/2025.During a record review of Patient 14’s medical record form titled “Audit Log – Certification MD” dated from 1/13/2025 to 7/17/2024, indicated MD1 composed the “Physician Narrative Certifying Physician Summary” and signed Patient 14’s CTI dated 1/13/2025 on 2/19/2025.During a record review of Patient 14’s medical form titled “LCD Hospice Eligibility Determination” dated 1/13/2025, indicated Patient 14 was made eligible for hospice benefits based on “heart disease”. The LCD Hospice Eligibility Determination form indicated a “YES” was selected on sections 1b – has patient declined surgical procedures? 1c – Is patient optimally treated for heart disease with diuretics and vasodilators? and 2a – Does this CHF or angina patient meet the criteria for NYHA (New York Heart Association) Class IV (severe limitations in physical activity die to heart failure) level?During an interview on 7/16/2025 at 5:17 p.m., with Patient 14, stated he has been receiving hospice services for about a year. Patient 14 stated he (Patient 14) has care providers that visit him (Patient 14) and provide assistance. Patient 14 stated one of his ex-providers told him about the hospice program. Patient 14 stated Medical Doctor 3 (MD3) was his primary physician, which he saw last on 7/9/2025. Patient 14 stated he has not seen the hospice MD. Patient 14 stated he was not told by a physician that he has 6 months or less to live. Patient 14 stated “If someone told me I had six months or less to live, I would not be at home. I would be out partying with women.” Patient 14 stated he went to the IHHS (in home supportive services) office on Monday 7/14/2025 to find a new care provider. Patient 14 stated he needs a care provider because it takes him all day to mop the floor at his home. Patient 14 stated the HA provides two nurses. One of the nurses visits him twice a week and assists him in showering because he has one arm. The other nurse comes twice a week to fill in his medication pill container but does not stay long. On 7/16/2025 at 5:46 p.m., Patient 14’s MD3 was called at number provided by Patient 14. Message with the call back number was left. On 7/17/2025 at 8:05 a.m., Patient 14’s MD3 was called again at number provided by Patient 14. Message with the call back number was left. During a phone interview on 7/17/2025 at 1:44 p.m., with the MD1, stated Patient 14 was receiving hospice services due to Patient 14’s functioning declined status. MD1 stated NYHA is usually an ejection fraction of less than 20% (1/3 of hearts ability to pump blood) and difficult ambulating. MD1 stated he (MD1) does not have supporting documents for Patient 14’s medical conditions. MD1 stated Patient 14 is receiving hospice services due to his diagnosis and decline in health status. MD1 had to stop the phone interview at 1:48 p.m. and stated he will return call.During a concurrent interview and record review on 7/17/2025 at 1:48 p.m., with DPCS, stated Patient 14 did not have H&P on file. The DPCS stated there has not been any communication with Patient 14’s primary physician (MD3). During a record review of the agency’s record titled “Admission Criteria and Process” revised 4/2020, indicated “(HA) will admit a patient only on recommendation of the medical director in consultation with, or input from, the patient’s attending physician, if any. If the request for services is not made by the patient’s physician, he/she will be consulted prior to the evaluation visit/initiation of services. During a record review of the agency’s record titled “Admission Criteria and Process” revised 4/2020, indicated “The patient’s life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary’s Local Coverage Determination (LCD).”During a record review of the agency’s record titled “Physician Services – Medical Director” revised 4/2020, indicated “Purpose – To ensure qualified medical direction and consultation for the delivery of hospice services and programs. To demonstrate that the Medical Director/hospice tam physician (Physician designee) has overall responsibility for patient care through documentation that demonstrates interaction/communication with the attending physician as necessary for appropriate medical care.” The Physician Services – Medical Director record also indicated “The duties and responsibilities of the Medical Director will include… Reviewing patients medical eligibility for hospice services… Providing written certification and narrative of the terminal illness for all subsequent benefit periods, will perform home visits, patient assessment and provide intervention as requested… May provide a face to face encounter visit with the patient prior to 3rd and subsequent benefit periods. Documenting care provided in the patients’ clinical record, providing evidence of progression of the end stage disease process. During a record review of the agency’s record titled “Certification of Terminal Illness” revised 4/2020, indicated “At the time a patient and family/caregiver chooses hospice care, the hospice Medical Director and the patients attending physician, in 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.” During a record review of the agency’s record titled “Certification of Terminal Illness” revised 4/2020, indicated “At the time of admission to hospice, the hospice Medical Director or the patients attending physician will complete a certification narrative that reflects the patients’ induvial circumstances based on: his/her review of the patient’s medical record or, if applicable, examination of the patients. If written certification cannot be obtained within two (2) calendar days following the start of care, verbal certification must be obtained and documented in the clinical record within two (2) days following initiation of care and written certification must be obtained before the hospice submits a claim for payment.” During a record review of the agency’s record titled “Certification of Terminal Illness” revised 4/2020, indicated “Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification.””

“Based on interview and record review the Hospice Agency (HA) failed to ensure the medical director and/or physician designee conducted a review and verified the patient’s clinical information to determine recertification of terminal illness and continued hospice care and services four of 14 sample patients (Patient 3, Patient 8, Patient 9, and Patient 14). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential of the patients not receiving appropriate hospice healthcare services that could affect their quality of life. During an interview on 7/17/2025 at 12:15 p.m. with Medical Director 1 (MD1), stated he was the HA’s Medical Directo for about three years. MD1 stated that he sees patients himself but that it was not always possible because he also works at a hospital and has other responsibilities. MD1 stated he has 48 hours to assess a patient’s condition, primary and secondary diagnosis, and the medication list. MD1 stated the HA receives patients’ referrals from hospitals, doctors, and community outreach. MD1 stated referrals are sent to the HA then he is informed by the HA office that there is a new patient.During a phone interview on 7/17/2025 at 2:05 p.m. with MD1, stated his signature on patients Certification of Terminal Illness (CTI) indicates that he justifies and agrees it was dictated by him. MD1 stated he dictates his findings to the DPCS to be documented on patients CTI. MD1 had to end the call, at 2:12 p.m.During an interview on 7/17/2025 at 3:52 p.m. with the Director of Patient Care Services (DPCS), stated that a face-to-face assessment is conducted every two months by the medical director or the nurse practitioner, before the 3rd benefit period to evaluate if a patient continues to be certified for hospice benefits. 1. During a record review of Patient 3’s Personal Information sheet, indicated a start of care date of 3/8/2024, with a terminal diagnosis of Alzheimer’s disease (a brain disease that affects memory and other body functions).During a concurrent interview and record review on 7/16/2025 at 12:09 p.m., the DPCS reviewed Patient 3’s documents titled Physician’s Certification for Hospice Benefit-CTI, for certification period 5/2/2025 to 6/30/2025 and the Audit Log (a document that indicates all the entries in a medical record) dated 3/8/2024 to 7/16/2024. The CTI document did not indicate that a verbal authorization to hospice care was given by MD 1. During a review of the audit log, the document indicated that the physician narrative on the CTI for the recertification period of 5/2/2025 to 6/30/2025, was documented by the Licensed Vocational Nurse (LVN 1) on 5/31/2025 and MD 1 signed the CTI on 6/3/2024. The DPCS stated most likely LVN 1 did not log off her computer and MD 1 documented the recertification under the LVN 1’s username. During a record review of Patient 3’s CTI, dated 5/2/2025 to 6/30/2025, indicated, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The document indicated MD 1 had documented a signature date of 5/2/2025. 2. During a record review of Patient 8’s medical record form titled “Patient Information” undated, indicated a start of care date of 2/2/2025 with a primary diagnosis of cerebral infarction (lack of blood supply to brain causing death to tissue). During a record review of Patient 8’s medical record form titled “Comprehensive Nursing Assessment” dated 2/25/2025, indicated Patient 8’s weight was 170 pounds.During a record review of Patient 8’s medical record form titled “Re-Cert Assessment” dated 7/11/2025, indicated Patient 8’s weight was 170 pounds, had a primary disease of stroke and coma with comorbidities including COPD (chronic obstructive pulmonary disease – long term lung disease that makes it hard to breathe), hyperlipidemia (high cholesterol levels in the blood), and depression.During a record review of Patient 8’s medical form titled “Physician’s Certification for Hospice Benefits (CTI) – Certification #3” dated 5/26/2025 to 7/24/2025, indicated “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The Physician’s Certification for Hospice Benefits form also indicated that the Medical Director 1 (MD1) signed the form on 5/26/2025.During a record review of Patient 8’s medical form titled “LCD (local coverage determination) Hospice Eligibility Determination” dated 7/11/2025, indicated Patient 8 was made eligible for hospice benefits based on a “Stroke and Coma”. The LCD Hospice Eligibility Determination form also indicated for a stroke 1 and 2 should be met. The LCD Hospice Eligibility Determination form indicated a “Yes” was placed under: 1. Impairment of functional status: Is KPS or PPS less than 40% and 2. Weight loss >10% in the last 6 months or >7.5% in the last 3 months?”.During a record review of Patient 8’s medical record form titled “F2F (face to face) Visit Note” dated 7/5/2025, indicated “I confirm that I had a face – to – face encounter with this patient on the date noted above and that the clinical findings of that encounter were provided to the certifying physician, for use in determining whether the patient continues to have a life expectance of 6 months or less, should the illness run its normal course. The F2F Visit Note was signed by MD1 on 7/5/2025.During a concurrent observation and interview on 7/15/2025 at 11:10 a.m. with Patient 8 at her home, Patient 8 was noted sitting up on bed. Patient 8 stated she has been receiving hospice services since March 2025 and has not seen a hospice doctor since then. Patient 8 stated she was informed by the HA nurse that she was not allowed to continue seeing her primary physician (MD2) once she started hospice services. Patient 8 stated she had not been told by a doctor that she had 6 months or less to live. Patient 8 stated she was aware of what hospice is but that a nurse from the HA told her hospice also provided palliative care. Patient 8 stated she did not have heart issues. Patient 8 stated she had one of her heart valves replaced in 1984 and has been taking Warfarin (blood thinning medication) since then. Patient 8 stated she had back surgery in 2002 which was due to blood leaking from her spine because of taking Warfarin and not having blood levels checked. Patient 8 stated her vertebra T4 to L5 (mid back to low back) were removed and that was the reason why she was unable to walk.On 7/15/2025 at12:16 p.m. MD2 was called at the phone number provided by Patient 8. Machine answered, message left with a call back number. During an interview on 7/17/2025 at 12:22 p.m. with MD1, stated Patient 8’s hospice diagnosis was CVA (cerebral vascular accident – stroke). MD1 stated Patient 8 was hospice eligible due to being bedbound and Patient 8’s gradual decrease in life and functional status. MD1 stated he was told by HA nurses that Patient 8 had a 10-pound weight loss. During a concurrent interview and record review on 7/17/2025 at 12:38 p.m. with the DPCS of Patient 8’s medical record, the DPCS stated Patient 8 informed MD1 and the admitting nurse Patient 8 had a stroke. DPCS stated the HA did not have Patient 8’s history and physical confirming or indicating her current medical conditions. DPCS stated Patient 8 referred herself for hospice services. DPCS stated there was no documentation that the HA had any contact with MD2. DPCS stated the HA does not offer palliative care and does not know who told Patient 8 that the HA also offers palliative care. DPCS stated some patients graduate from hospice. DPCS stated Patient 8’s diagnosis and comorbidities (co-existing conditions) made her eligible for hospice. During a concurrent interview and record review on 7/17/2025 at 12:38 p.m. with the DPCS of Patient 8’s medical record, the DPCS stated the HA uses the LCD to determine if a patient qualifies for hospice services. The DPCS stated that there were no objective findings that Patient 8 had a weight loss of 10%. The DPCS stated that since Patient 8 referred herself for hospice services, MD1 signs the referral. DPCS stated there was no documentation of any interactions or communication with Patient 8’s primary physician (MD2).During an interview on 7/17/2025 at 1:25 p.m. with the MD1, stated he could not recall why Patient 8 was taking Warfarin. MD1 stated the HA needs to reassess Patient 8 as soon as possible, and if indicated Patient 8 will be discharged. MD1 stated he (MD1) did not speak with MD2. 3. During a record review of Patient 9’s medical record form titled “Patient Information” undated, indicated a start of care date of 6/8/2024 with a primary diagnosis of heart failure. Section “Secondary DX (diagnosis)” was left blank. During a record review of Patient 9’s medical record form titled “Updated Assessment” dated 7/3/2025, indicated Patient 9’s primary diagnosis was heart failure and primary disease was heart disease. Section “Secondary DX (diagnosis)” was left blank. During a record review of Patient 9’s medical record form titled “F2F Visit Note” dated 7/23/2024, indicated “I confirm that I had a face to face encounter with this patient on the date noted above and that the clinical findings of the encounter were provided to the certifying physician, for use in determining whether the patient continues to have a life expectancy of 6 months or less, should the illness run its normal course”. The F2F Visit Note was signed by Registered Nurse 1 (RN1) on 7/23/2024.During a record review of Patient 9’s medical record form titled “Audit Log – MD Visit Note” dated from 6/8/2024 to 7/17/2024, indicated RN1 created and signed the “MD Visit Note” dated 7/23/2024 on 8/7/2024.During a record review of Patient 9’s medical record form titled “Physician’s Certification for Hospice Benefits (CTI) – Certification #4” dated 8/7/2024 to 10/5/2024, indicated “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The Physician’s Certification for Hospice Benefits form also indicated the Medical Director 1 (MD1) signed the form on 8/7/2024.During a record review of Patient 9’s medical record form titled “Audit Log – Certification MD” dated from 6/8/2024 to 7/17/2024, indicated MD1 composed the “Physician Narrative Certifying Physician Summary” and signed Patient 9’s CTI dated 8/7/2024 on 10/4/2024.During a record review of Patient 9’s medical form titled “LCD Hospice Eligibility Determination” dated 8/7/2024, indicated Patient 9 was made eligible for hospice benefits based on “heart disease”. The LCD Hospice Eligibility Determination form also indicated “Patient does not qualify per LCD guidelines”.During a record review of Patient 9’s medical record form titled “F2F Visit Note” dated 9/15/2024, indicated “I confirm that I had a face to face encounter with this patient on the date noted above and that the clinical findings of the encounter were provided to the certifying physician, for use in determining whether the patient continues to have a life expectancy of 6 months or less, should the illness run its normal course”. The F2F Visit Note was signed by RN1 on 9/15/2024.During a record review of Patient 9’s medical record form titled “Audit Log – MD Visit Note” dated from 6/8/2024 to 7/17/2024, indicated RN1 created and signed the “MD Visit Note” dated 9/15/2024 on 9/16/2024.During a record review of Patient 9’s medical record form titled “Physician’s Certification for Hospice Benefits (CTI) – Certification #5” dated 10/6/2024 to 12/4/2024, indicated “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The Physician’s Certification for Hospice Benefits form also indicated the Medical Director 1 (MD1) signed the form on 10/6/2024.During a record review of Patient 9’s medical record form titled “Audit Log – Certification MD” dated from 6/8/2024 to 7/17/2024, indicated MD1 composed the “Physician Narrative Certifying Physician Summary” and signed Patient 9’s CTI dated 10/6/2024 on 11/5/2024.During a record review of Patient 9’s medical form titled “LCD Hospice Eligibility Determination” dated 10/10/2024, indicated Patient 9 was made eligible for hospice benefits based on “heart disease”. The LCD Hospice Eligibility Determination form indicated a “YES” was selected on sections 1a – has patient been ruled out as a candidate for surgical procedures? and 2a – Does this CHF or angina patient meet the criteria for NYHA (New York Heart Association) Class IV (severe limitations in physical activity die to heart failure) level?”. During a record review of Patient 9’s medical record form titled “F2F Visit Note” dated 11/9/2024, indicated “I confirm that I had a face to face encounter with this patient on the date noted above and that the clinical findings of the encounter were provided to the certifying physician, for use in determining whether the patient continues to have a life expectancy of 6 months or less, should the illness run its normal course”. The F2F Visit Note was signed by RN1 on 11/9/2024. During a record review of Patient 9’s medical record form titled “Audit Log – MD Visit Note” dated from 6/8/2024 to 7/17/2024, indicated RN1 created the “MD Visit Note” dated 11/9/2024 on 11/11/2024. The Audit Log also indicates RN1 signed the “MD Visit Note” dated 11/9/2024 on 11/20/2024.During a record review of Patient 9’s medical record form titled “Physician’s Certification for Hospice Benefits (CTI) – Certification #6” dated 12/5/2024 to 2/2/2025, indicated “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The Physician’s Certification for Hospice Benefits form also indicated the MD1 signed the form on 12/5/2024.During a record review of Patient 9’s medical record form titled “Audit Log – Certification MD” dated from 6/8/2024 to 7/17/2024, indicated MD1 composed the “Physician Narrative Certifying Physician Summary” and signed Patient 9’s CTI dated 12/5/2024 on 1/14/2025.During a record review of Patient 9’s medical form titled “LCD Hospice Eligibility Determination” dated 12/5/2024, indicated Patient 9 was made eligible for hospice benefits based on “heart disease”. The LCD Hospice Eligibility Determination form indicated a “YES” was selected on sections 1a – has patient been ruled out as a candidate for surgical procedures? and 2a – Does this CHF or angina patient meet the criteria for NYHA Class IV level?”.During a record review of Patient 9’s medical record form titled “F2F Visit Note” dated 1/25/2025, indicated “I confirm that I had a face to face encounter with this patient on the date noted above and that the clinical findings of the encounter were provided to the certifying physician, for use in determining whether the patient continues to have a life expectancy of 6 months or less, should the illness run its normal course”. The F2F Visit Note was signed by MD1 on 1/25/2025.During a record review of Patient 9’s medical record form titled “Audit Log – MD Visit Note” dated from 6/8/2024 to 7/17/2024, indicated MD1 created the “MD Visit Note” dated 1/25/2025 on 2/12/2025. The Audit Log also indicates MD1 signed the “MD Visit Note” dated 1/25/2025 on 3/18/2025.During a record review of Patient 9’s medical record form titled “Physician’s Certification for Hospice Benefits (CTI) – Certification #7” dated 2/3/2025 to 4/3/2025, indicated “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The Physician’s Certification for Hospice Benefits form also indicated the MD1 signed the form on 2/3/2025.During a record review of Patient 9’s medical record form titled “Audit Log – Certification MD” dated from 6/8/2024 to 7/17/2024, indicated MD1 composed and signed the “Physician Narrative Certifying Physician Summary” Patient 9’s CTI dated 2/3/2025 on 3/18/2025.During a record review of Patient 9’s medical form titled “LCD Hospice Eligibility Determination” dated 1/30/2025, indicated Patient 9 was made eligible for hospice benefits based on “heart disease”. The LCD Hospice Eligibility Determination form indicated a “YES” was selected on sections 1a – has patient been ruled out as a candidate for surgical procedures? and 2a – Does this CHF or angina patient meet the criteria for NYHA Class IV level?”.During a record review of Patient 9’s medical record form titled “F2F Visit Note” dated 3/15/2025, indicated “I confirm that I had a face to face encounter with this patient on the date noted above and that the clinical findings of the encounter were provided to the certifying physician, for use in determining whether the patient continues to have a life expectancy of 6 months or less, should the illness run its normal course”. The F2F Visit Note was signed by RN3 on 3/15/2025.During a record review of Patient 9’s medical record form titled “Audit Log – MD Visit Note” dated from 6/8/2024 to 7/17/2024, indicated RN3 signed the “MD Visit Note” dated 3/15/2025 on 7/14/2025.During a record review of Patient 9’s medical record form titled “Physician’s Certification for Hospice Benefits (CTI) – Certification #8” dated 4/4/2025 to 6/2/2025, indicated “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The Physician’s Certification for Hospice Benefits form also indicated the MD1 signed the form on 4/4/2025.During a record review of Patient 9’s medical record form titled “Audit Log – Certification MD” dated from 6/8/2024 to 7/17/2024, indicated MD1 composed and signed the “Physician Narrative Certifying Physician Summary” Patient 9’s CTI dated 4/4/2025 on 5/27/2025.During a record review of Patient 9’s medical form titled “LCD Hospice Eligibility Determination” dated 4/10/2025, indicated Patient 9 was made eligible for hospice benefits based on “heart disease”. The LCD Hospice Eligibility Determination form indicated a “YES” was selected on sections 1a – has patient been ruled out as a candidate for surgical procedures? and 2a – Does this CHF or angina patient meet the criteria for NYHA Class IV level?”.During a record review of Patient 9’s medical record form titled “F2F Visit Note” dated 5/10/2025, indicated “I confirm that I had a face to face encounter with this patient on the date noted above and that the clinical findings of the encounter were provided to the certifying physician, for use in determining whether the patient continues to have a life expectancy of 6 months or less, should the illness run its normal course”. The F2F Visit Note was signed by MD1 on 5/10/2025.During a record review of Patient 9’s medical record form titled “Audit Log – MD Visit Note” dated from 6/8/2024 to 7/17/2024, indicated RN3 signed the “MD Visit Note” dated 5/10/2025 on 6/9/2025.During a record review of Patient 9’s medical record form titled “Physician’s Certification for Hospice Benefits (CTI) – Certification #9” dated 6/3/2025 to 8/1/2025, indicated “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The Physician’s Certification for Hospice Benefits form also indicated the MD1 signed the form on 6/3/2025.During a record review of Patient 9’s medical record form titled “Audit Log – Certification MD” dated from 6/8/2024 to 7/17/2024, indicated MD1 composed and signed the “Physician Narrative Certifying Physician Summary” Patient 9’s CTI dated 6/3/2025 on 6/9/2025.During a record review of Patient 9’s medical form titled “LCD Hospice Eligibility Determination” dated 6/5/2025, indicated Patient 9 was made eligible for hospice benefits based on “heart disease”. The LCD Hospice Eligibility Determination form indicated a “YES” was selected on sections 1a – has patient been ruled out as a candidate for surgical procedures? and 2a – Does this CHF or angina patient meet the criteria for NYHA Class IV level?”. During a concurrent observation and interview on 7/15/2025 at 12:30 p.m. with Patient 9 at her home, Patient 9 was noted sitting in a wheelchair. Patient 9 stated has been receiving hospice services since Marh 2024. Patient 9 stated she (Patient 9) had breast surgery due to cancer on 9/2024. Right breast scar was observed on Patient 9. Patient 9 stated she had a provider (PV1) at Veterans Affairs, which she saw last on 5/2025. Patient 9 stated she received a “shot” on her back due to sciatic pain in 2017, which caused a bubble of medication to lie dormant until it burst in 2022 after slipping off a stool. Patient 9 stated she developed CHF (congestive heart failure – chronic/progressive condition where the heart muscle is unable to pump enough blood) in 2024 and that is the reason for receiving hospice services. Patient 9 stated she (Patient 9) spoke to a “gal” from the hospice agency and was told that the only way to get rid of CHF was to have a heart transplant. Patient 9 stated she had not heard from a doctor that she was going to die within 6 months, “I don’t know when I am going to die”. During a phone interview on 7/17/2025 at 1:04 p.m. with Patient 9’s medical provider (PV1)’s nurse PV2, PV2 stated there was no documentation in Patient 9’s medical record that Patient 9 was referred to hospice in the past 2-3 years. PV2 stated Patient 9 had a video consultation with PV1 in May 2025 and was seen face to face in April 2025. PV2 stated that there was nothing in Patient 9’s medical record to indicate Patient 9 was receiving hospice services. During a phone interview on 7/17/2025 at 1:32 p.m. with the MD1, stated Patient 9’s primary diagnosis was heart failure. MD1 stated Patient 9 was receiving hospice services due to Patient 9’s CHF diagnosis and comorbidities of high blood pressure, sciatica, and gout. MD1 stated Patient 9 was self-referred. MD1 stated the HA did not have a history and physical (H&P) for Patient 9 to confirm Patient 9’s CHF diagnosis. MD1 stated “when it’s self-referral, we don’t have H&P, we go by what the patient tells us.” MD1 had to disconnect phone and ended the interview. 4. During a record review of Patient 14’s medical record form titled “Patient Information” undated, indicated a start of care date of 1/13/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (plaque buildup inside the heart arteries) w/o (without) angina pectoris (chest pain/discomfort). Section “Secondary DX (diagnosis)” was left blank. During a record review of Patient 14’s medical record form titled “Physician’s Certification for Hospice Benefits (CTI) – Certification #5” dated 3/14/2025 to 5/12/2025, indicated “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The Physician’s Certification for Hospice Benefits form also indicated the MD1 signed the form on 3/14/2025.During a record review of Patient 14’s medical record form titled “Audit Log – Certification MD” dated from 1/13/2025 to 7/17/2024, indicated MD1 composed the “Physician Narrative Certifying Physician Summary (Module ID 2357768)” and signed Patient 14’s CTI (Module ID 2357768) dated 3/14/2025 on 3/25/2025. The Audit Log also indicated that the DPCS deleted the Physician Narrative Certifying Physician Summary (Module ID 2357768) dated 3/14/2025 on 4/3/2025.The Audit Log also indicated the DPCS composed the Physician Narrative Certifying Physician Summary (Module ID 2443619) dated 3/14/2025 on 4/3/2025 and 6/25/2025 and MD1 signed Patient 14’s CTI (Module ID 2443619) dated 3/14/2025 on 4/4/2025. During a record review of Patient 14’s medical form titled “LCD Hospice Eligibility Determination” da ted 3/10/2025, indicated Patient 14 was made eligible for hospice benefits based on “heart disease”. The LCD Hospice Eligibility Determination form indicated a “YES” was selected on sections 1b – has patient declined surgical procedures? 1c – Is patient optimally treated for heart disease with diuretics and vasodilators? and 2a – Does this CHF or angina patient meet the criteria for NYHA (New York Heart Association) Class IV (severe limitations in physical activity die to heart failure) level?”.During an interview on 7/16/2025 at 5:17 p.m. with Patient 14 stated, he was receiving hospice services for about a year. Patient 14 stated he had care providers that visited him and provided assistance. Patient 14 stated one of his ex-providers told him about the hospice program. Patient 14 stated Medical Doctor 3 (MD3) was his primary physician, which he saw last on 7/9/2025. Patient 14 stated he had not seen the hospice MD. Patient 14 stated he was not told by a physician that he had 6 months or less to live. Patient 14 stated “If someone told me I had six months or less to live, I would not be at home. I would be out partying with women.” Patient 14 stated he went to the IHHS (in home supportive services) office on Monday 7/14/2025 to find a new care provider. Patient 14 stated he needs a care provider because it takes him (Patient 14) all day to mop the floor at his home. Patient 14 stated the HA provided two nurses. One of the nurses visited him twice a week and assists him in showering because he has one arm. The other nurse comes twice a week to fill in his medication pill container but does not stay long. On 7/16/2025 at 5:46 p.m. Patient 14’s MD3 was called at number provided by Patient 14. Message left with the call back number. On 7/17/2025 at 8:05 a.m. Patient 14’s MD3 was called at number provided by Patient 14. Message left with the call back number. During a phone interview on 7/17/2025 at 1:44 p.m. with the MD1, stated Patient 14 was receiving hospice services due to his functioning declined status. MD1 stated NYHA is usually an ejection fraction of less than 20% (1/3 of hearts ability to pump blood) and difficult ambulating. MD1 stated he does not have supporting documents for Patient 14’s medical conditions. MD1 stated Patient 14 was receiving hospice services due to Patient 14’s diagnosis and decline in health status. MD1 stopped the phone interview at 1:48 p.m. MD1 stated he will return call.During a concurrent interview and record review on 7/17/2025 at 1:48 p.m. with DPCS, stated Patient 14 did not have H&P on file. DPCS stated there has not been any communication with Patient 14’s primary physician (MD3). During a record review of the agency’s record titled “Admission Criteria and Process” revised 4/2020, indicated “(HA) will admit a patient only on recommendation of the medical director in consultation with, or input from, the patient’s attending physician, if any. If the request for services is not made by the patient’s physician, he/she will be consulted prior to the evaluation visit/initiation of services. During a record review of the agency’s record titled “Admission Criteria and Process” revised 4/2020, indicated “The patient’s life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary’s Local Coverage Determination (LCD).”During a record review of the agency’s record titled “Physician Services – Medical Director” revised 4/2020, indicated “Purpose – To ensure qualified medical direction and consultation for the delivery of hospice services and programs. To demonstrate that the Medical Director/hospice team physician (Physician designee) has overall responsibility for patient care through documentation that demonstrates interaction/communication with the attending physician as necessary for appropriate medical care.” The Physician Services – Medical Director record also indicated “The duties and responsibilities of the Medical Director will include… Reviewing patients medical eligibility for hospice services… Providing written certification and narrative of the terminal illness for all subsequent benefit periods, will perform home visits, patient assessment and provide intervention as requested… May provide a face to face encounter visit with the patient prior to 3rd and subsequent benefit periods. Documenting care provided in the patients’ clinical record, providing evidence of progression of the end stage disease process. During a record review of the agency’s record titled “Certification of Terminal Illness” revised 4/2020, indicated “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.” During a record review of the agency’s record titled “Certification of Terminal Illness” revised 4/2020, indicated “A subsequent recertification, at the beginning of each new benefit period… The Hospice Medical Director must compose and sign the narrative based on a review of the patient’s medical record, or if applicable, examination of the patient. A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than fifteen (15) calendar days prior or two (2) calendar days after the first day of each period.”During a record review of the agency’s record titled “Certification of Terminal Illness” revised 4/2020, indicated “The hospice physician or nurse practitioner must have a face-to-face encounter with the patient within the 30 days prior to the 3rd benefit period recertification and within 30 days prior to each subsequent benefit period recertification. During a record review of the agency’s record titled “Certification of Terminal Illness” revised 4/2020, indicated “Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification.””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the clinical records included advanced directives for one of 14 sampled patients (Patient 2). This failure resulted in an incomplete medical record and potential for violation of patient rights by not having the advanced directive included in the medical record, to be aware of the patient’s wishes. During a record review of Patient 2’s Personal Information sheet indicated the start of care date of 6/11/2025, with a terminal diagnosis of Alzheimer’s disease (a brain disease that affects memory and other body functions).During an interview at the home visit on 7/15/2025, at 12:05 p.m., Patient 2’s caregiver (CV 2) stated she had the Power of Attorney for Patient 2. During an interview on 7/16/2025, at 10:45 a.m., with the Director of Patient Care Services (DPCS) stated that she reviewed Patient 2’s medical records and the copy of the Power of Attorney (POA) was not in the medical record. The DPCS stated the importance of having a copy of the POA was to know who the decision maker and what the patient’s wishes were. During a record review of the agency’s record titled “Patient Bill of rights/Responsibilities” revised 4/2020, indicated “A patient may designate someone to act as his/her representative.” During a record review of the agency’s record titled “Clinical/Service Data Collection” revised 4/2020, indicated “A clinical/service record will be initiated and maintained for each patient receiving care or services according to organization policies… and will include at a minimum: Patient…authorization…”. During a record review of the agency’s record titled “Contents of Clinical Record” revised 4/2020, indicated “The following information will be available in the clinical record as applicable to care and services provided: G. Name, address, and telephone number of: 1. Contact person for emergencies and/or notification of death. 2. Legal representative for fiscal and health care decisions (power of attorney), when applicable.” During a record review of agency’s record titled “Advance Directives” revised 4/2020, indicated “(HA) recognizes that all adult persons have a fundamental right to make decisions relating to their own medical treatment, including the right to accept or refuse medical care. It is the policy of (HA) to encourage individuals and their family/caregivers to participate in decisions regarding care, treatment and services… During the admission/evaluation visit, the admitting clinician/technician will ask the patient or his/her representative whether or not he/she has completed and Advance Directive, Durable Power of Attorney (DPOA)… If an Advance Directive has been completed, the clinician/technician will ask for a copy of the Advance Directive so it will be placed in the clinical/service record.””

“Based on interview and record review the hospice agency (HA) failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for three of 14 sampled patients (Patient 1, Patient 3, Patient 4). This failure resulted in an unauthorized and inaccurate patient information or assessment entered into the patients’ clinical record that could affect the patient’s quality of care and well-being. During a phone interview on 7/17/2025 at 2:05 p.m., the Medical Director (MD1) stated his signature on patients Certification of Terminal Illness (CTI) indicated that he justified and agreed it was dictated by him (MD1). MD1 stated he dictates his findings to the Director of Patient Care Services (DPCS) to be documented on patients CTI. MD1 stated he had to end the call at 2:12 p.m. and could no longer answer any questions.During an interview on 7/17/2025, at 3:15 p.m., the Medical Social Worker (MSW 1) stated he documents the psychosocial discussion in the POC/IDG document after every meeting.During an interview on 7/17/2025, at 3:29 p.m., the Spiritual Counselor (SC 1) stated he documents the update of the spiritual assessment on the POC/IDG document after every meeting. The SC 1 stated he types the note himself. 1. During a record review of Patient 1’s document titled, Personal Information, indicated a start of care date of 6/13/2025, with a terminal diagnosis of cerebrovascular (brain) disease. During a concurrent interview and record review on 7/16/2025 at 11:40 a.m., the DPCS reviewed Patient 1’s documents titled Physician’s Certification for Hospice Benefit-CTI, for certification period 6/13/2025 to 8/11/2025 and the Audit Log (a document that indicates all the entries in a medical record) dated 6/11/2025 to 7/16/2024. During a review of the audit log, the document indicated that the physician narrative on the CTI for the recertification period of 6/13/2025 to 8/11/2025, was documented by the DPCS on 6/13/2025. The audit log further indicated that the DPCS had documented the physician narrative on 6/13/2025 at 12:04 p.m. and MD 1 signed it on 6/13/2025 at 12:05 p.m. The DPCS stated MD 1 was most likely in the office and had asked the DPCS to help document the CTI physician narrative. MD 1 then logged in to sign the document. The DPCS further stated that the document was not considered a doctor’s note because the MD 1 was next to her. If MD 1 was next to her and telling her (DPCS) what to type, she (DPCS) was not working outside her scope of practice because MD 1 would review, edit, and sign the document. The DPCS further stated that sometimes staff do not realize they are documenting under another person’s name. It was possible MD 1 logged in under the DPCS’s name and accidentally documented under the DPCS name.During a record review of Patient 1’s document titled, Physician’s Certification for Hospice Benefit-CTI, for certification period 6/13/2025 to 8/11/2025, indicated, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The record further indicated MD 1 documented a signature date of 6/14/2025.During a record review of Patient 1’s audit log dated 6/11/2025 to 7/17/2025, indicated the MSW 1 signed the POC/IDG documents for 7/4/2025 and 6/20/2025, but the psychosocial discussion documentation was entered by the DPCS. Further review of the record indicated SC 1 had signed the POC/IDG documents for 7/4/2025 and 6/20/2025, but the DPCS had documented the spiritual discussion for 7/4/2025 and Licensed Vocational Nurse 1 (LVN 1) had documented the spiritual discussion for 6/20/2025. 2. During a record review of Patient 3’s Personal Information sheet, indicated a start of care date of 3/8/2024, with a terminal diagnosis of Alzheimer’s disease (a brain disease that affects memory and other body functions).During a concurrent interview and record review on 7/16/2025 at 11:59 a.m., the DPCS reviewed Patient 3’s documents titled Physician’s Certification for Hospice Benefit-CTI, for certification period 3/8/2024 to 5/6/2024 and the Audit Log (a document that indicates all the entries in a medical record) dated 3/8/2024 to 7/16/2024. During a review of the audit log, the document indicated that the physician narrative on the CTI for the initial certification period of 3/8/2024 to 5/6/2024, was documented by the DPCS on 4/8/2024 and MD 1 signed the CTI on 4/29/2024. The DPCS stated MD 1 told her what to write.During a record review of Patient 3’s CTI, dated 3/8/2024 to 7/16/2024, indicated, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The document indicated MD 1 had documented a signature date of 3/9/2024.During a concurrent interview and record review on 7/16/2025 at 12:09 p.m., the DPCS reviewed Patient 3’s documents titled Physician’s Certification for Hospice Benefit-CTI, for certification period 5/2/2025 to 6/30/2025 and the Audit Log (a document that indicates all the entries in a medical record) dated 3/8/2024 to 7/16/2024. During a review of the audit log, the document indicated that the physician narrative on the CTI for the recertification period of 5/2/2025 to 6/30/2025, was documented by the Licensed Vocational Nurse (LVN 1) on 5/31/2025 and MD 1 signed the CTI on 6/3/2024. The DPCS stated most likely LVN 1 did not log off her computer and MD 1 documented the recertification under the LVN 1’s username.During a record review of Patient 3’s CTI, dated 5/2/2025 to 6/30/2025, indicated, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The document indicated MD 1 had documented a signature date of 5/2/2025. 3. During a record review of Patient 4’s Personal Information sheet indicated a start of care date on 10/15/2024, with a terminal diagnosis of Alzheimer’s disease (a brain disease that affects memory and other body functions).During a concurrent interview and record review on 7/16/2025 at 12:15 p.m., the DPCS reviewed Patient 4’s documents titled Physician’s Certification for Hospice Benefit-CTI, for certification period 6/12/2025 to 8/10/2025 and the Audit Log (a document that indicates all the entries in a medical record) dated 10/14/2024 to 7/16/2024. During a review of the audit log, the document indicated that the physician narrative on the CTI for the initial certification period of 6/12/2025 to 8/10/2025, was documented by the DPCS on 6/18/2025 and MD 1 signed the CTI on 6/18/2025. The DPCS stated MD 1 told her what to write.During a record review of Patient 4’s CTI, dated 6/12/2025 to 8/10/2025, indicated, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The document indicated a signature date of 6/12/2025. During a record review of the hospice agency’s record titled “Person or Entry Authentication” revised 4/2020, indicated “(HA) will use appropriate authentication methods to confirm that only properly authenticated and authorized persons or entities access ePHI. Appropriate access methods may include- Unique user identifiers (user IDs), Security identifiers (password)…Digital signatures.” During a record review of the hospice agency’s record titled “Clinical/Service Data Collection” revised 4/2020, indicated “All entries will reflect the date care was provided, including the month, day, and year.””

“Based on interview and record review the Hospice Agency (HA) failed to ensure contents and information in the patients’ clinical records were safeguarded from unauthorized access by HA staff to make any alterations or modifications for one of 14 sampled patients (Patient 3).This failure has the potential to result in unauthorized and inaccurate patient information or assessment entered into the patients’ clinical record that could affect the patient’s quality of care and well-being. During a phone interview on 7/17/2025 at 2:05 p.m., the Medical Director (MD1) stated his signature on patients Certification of Terminal Illness (CTI) indicated that he justified and agreed it was dictated by him. MD1 stated he dictates his findings to the Director of Patient Care Services (DPCS) to be documented on patients CTI. MD1 stated “the people in the office might know my EMR (electronic medical record) access”. MD1 stated the DPCS might know his (MD1) log in information because they (MD1 and DPCS) do notes together. MD1 stated the DPCS scribes for him. MD1 stated he had to end the call at 2:12 p.m. and could no longer answer any questions.During a record review of Patient 3’s Personal Information sheet, indicated a start of care date of 3/8/2024, with a terminal diagnosis of Alzheimer’s disease (a brain disease that affects memory and other body functions).During a concurrent interview and record review on 7/16/2025 at 12:09 p.m., the Director of Patient Care Services (DPCS) reviewed Patient 3’s documents titled Physician’s Certification for Hospice Benefit-CTI, for certification period 5/2/2025 to 6/30/2025 and the Audit Log (a document that indicates all the entries in a medical record) dated 3/8/2024 to 7/16/2024. During the review of the audit log, the document indicated that the physician narrative on the CTI for the recertification period of 5/2/2025 to 6/30/2025, was documented by the Licensed Vocational Nurse (LVN 1) on 5/31/2025 and MD 1 signed the CTI on 6/3/2024. The DPCS stated most likely LVN 1 did not log off her computer and MD 1 documented the recertification under the LVN 1’s username. During a record review of Patient 3’s CTI, dated 5/2/2025 to 6/30/2025, indicated, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” The document indicated MD 1 had documented a signature date of 5/2/2025. During a record review of the agency’s record titled “Person or Entry Authentication” revised 4/2020, indicated “(HA) will use appropriate authentication methods to confirm that only properly authenticated and authorized persons or entities access ePHI. Appropriate access methods may include: Unique user identifiers (user IDs), Security identifiers (password)…Digital signatures.” During a record review of the agency’s record titled “Clinical/Service Data Collection” revised 4/2020, indicated “All entries will reflect the date care was provided, including the month, day, and year.””