Access Hospice Care

“Based on policy review, employee file review, and interview, the hospice provider failed to ensure employees received the providers emergency preparedness training during orientation in one of five employee files reviewed (Employee #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medical Director,” dated 05/01/2024, showed the medical director directly employed by the hospice provider shall follow the personnel file guidelines for employees. The policy failed to include that contracted employees should follow the personnel file guidelines. Review of employee files showed: EMPLOYEE #1:-Date of hire: 04/01/2024; and -No evidence of emergency preparedness training at orientation. During an interview on 08/28/2024 at 1:30 PM, the administrator stated that he/she would expect emergency preparedness training to be completed during orientation and then annually for all employees.”

“Based on policy review, record review, and interview the hospice provider failed to ensure staff maintained an accurate/updated medication profile in two of five full records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;Monitoring Medications,” revised 11/01/2017, showed in part that a drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all nurses will participate in medication review and reconciliation throughout the benefit period. The physician is contacted immediately if any discrepancies between agency information and patients’ medications are found; - A comprehensive medication review will be completed on admit and at every interdisciplinary group (IDG) meeting in conjunction with all comprehensive assessments; - Compare medication list to actual medications the patient is taking. If the patient resides in a facility, compare medication list to the facilitys medication administration record (MAR) rather than reviewing actual medications; and - Review over the counter medications, vitamins, herbs and herbal products, creams, and topical ointments. RECORD/PATIENT #2: Review of the record showed the patient elected hospice care on 08/02/2023. Diagnoses included senile degeneration of the brain (a type of dementia) and dementia. The patient resided in a skilled nursing facility (SNF). Review of the SNF’s most recent medication orders and the hospice medication profile showed the following discrepancies: -The medication profile showed an order dated 11/26/2023, for lorazepam (anti-anxiety) 0.5 milligrams (mg) every six hours as needed for anxiety. The SNF’s orders failed to include this medication; -The medication profile showed an order dated 11/16/2023, for haloperidol lactate (antipsychotic) 2 mg/ml (milliliter) 0.5 ml every six hours as needed for agitation. The SNF’s orders failed to include this medication; -The medication profile showed an order dated 07/29/2024, for tizanidine (muscle relaxer) 2 mg as needed every eight hours for muscle spasms. The IDG (interdisciplinary group) note dated 07/31/2024, showed a recommendation for baclofen (muscle relaxer). The record showed no documented follow up regarding the baclofen. The SNF’s orders failed to include an order for tizanidine or baclofen; and -The SNF’s orders showed an order dated 07/11/2024, for Voltaren (pain relief gel) gel 1% apply to bilateral knees topically every 12 hours as needed for OA (osteoarthritis). The medication profile did not include this medication. During an interview on 08/28/2024, beginning at 3:10 PM, the administrator stated that during each visit, the nurse asked if there were any new physician orders. If there were, they printed out the new order. Once a month, the nurse printed out the facility orders. If the facility had a new order, the nurse updated that on their tablet when they finished their visit or when they finished their charting that night. The patients physician at the facility would not take orders from the hospice physician. The nurses write a recommendation in the physicians communication book at the facility and the physician addresses it at some time. All new orders come from the facility physician. The nurse probably put the recommendation for baclofen in the communication book and the physician probably did not answer it. He/she would expect the nurse to be checking on it to see if it had been ordered. RECORD/PATIENT #3: Review of the record showed the patient elected hospice care on 08/10/2024. Diagnoses included malignant neoplasm (cancer) of the right breast. The patient lived at home with a caregiver. Observation and interview on 08/27/2024, beginning at 11:30 AM, during the patients home visit, showed the following medication discrepancies with the providers medication profile: - The patient had a box labeled and dated 08/09/2024, of atropine 1% three drops sublingual (under the tongue) every four hours as needed for excess secretions. The medication profile failed to include this medication. The family member stated that they had not had to use this, but could if the patient needed it; - The medication profile showed an order dated 08/10/2024, of senna with docusate sodium (laxative plus stool softener) 8.6-50 mg one tablet two times a day. The patient had a bottle of stimulant laxative 8.6-50 one tablet two times a day as needed for constipation for 14 days while taking pain medication. The patients family member stated that he/she administered it about every other day. He/she was not aware the patient was to take it twice a day regularly; - The patient had a bubble packed package of diphenhydramine (Benadryl) 25 mg laying inside the box with the patients medications. The family member stated that the patient used it for itching. The patient had not been itching lately but thought he/she could take that if needed. The medication profile failed to include this medication; and -The patient had a bottle of daily relax evening formula (contained melatonin (used for sleep) and tryptophan (an amino acid)). The family member stated that the patient had taken this about once a week. The medication profile failed to include this medication. During an interview on 08/28/2024, beginning at 3:10 PM, the administrator stated that the nurse should check the medication list on their tablets with what the patient had in the home, and they should match. The nurse should clarify any discrepancies with the physician. The nurse should reconcile medications at every visit.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure staff completed an initial bereavement assessment (an assessment of the patient’s caregivers, family members, and/or significant others to assess risks and concerns related to grief and loss) in two of five full records reviewed (Records/Patients #3 and #5). This deficient practice has the potential to affect the families and other bereaved individuals of all patients served by the provider. Findings included: Review of the provider’s policy titled, “Bereavement Counseling,” revised 02/01/2022, showed in part that a bereavement risk assessment will be completed at the time of admission to hospice as part of the comprehensive assessment. RECORD/PATIENT #5: Review of the record showed the provider admitted the patient to service on 07/29/2024. Diagnoses included COPD (chronic obstructive pulmonary (lung) disease and atrial fibrillation (irregular heartbeat). The patient lived at home with his/her spouse who was his/her primary caregiver. Review of the record failed to include an initial bereavement risk assessment. Review of the chaplain spiritual assessment dated 08/01/2024, showed the patient lived with his/her spouse. The caregiver was willing and able to care for the patient. There was substantial family involvement who were supportive of the patient and one another. The patient and spouse were still processing the accidental death of a grandson in 2019. During an interview on 08/27/2024, at 3:15 PM, the administrator stated that he/she did not have a bereavement assessment for patients #3 and #5. One chaplain had left and they hired another chaplain. The bereavement assessments were not completed. The assessments were missed during this time. Could this be added to the DPS? and failed to incorporate factors that may impact coping with the patient’s death, into the hospice plan of care. Findings included: RECORD/PATIENT #3: Review of the provider’s policy titled, “Bereavement Counseling”, revised 02/01/2022, showed in part that a bereavement risk assessment will be completed at the time of admission to hospice as part of the comprehensive assessment. Review of the record showed the provider admitted the patient to service on 08/10/2024. Diagnoses included metastatic breast cancer to the brain, leptomeninges (the membrane surrounding the brain and spinal cord) and bone (sacral area), and chronic kidney disease. The patient lived at home with his/her son and the caregiving is shared with the son, the daughter, and the patients finance who lived next door. Review of the record failed to include an initial bereavement risk assessment. Review of the chaplain spiritual assessment given to the patient dated 08/12/2024, showed the patient grieving the loss of independence and the patient viewed him/herself as a “;burden” to his/her caregivers. The patient reported anxiety and fear about need for care, fear of disease progression, fear of the dying process, and concern for family members. The patient reported grief over the “;shock regarding the diagnosis and prognosis” of his/her condition. The patient reported excessive crying in anticipation of mourning and separation from his/her family. The emotional assessment indicated the patient has moderate to server anxiety, fears, and excessive worries. The chaplain comments showed the patient was quick to cry when he/she talked about his/her diagnosis and the impact on the people he/she loves and the patients finance wants the patient to “;deny” his/her feelings. The patient indicated that he/she has unresolved issues or tasks such as a sense of meaning and purpose and ongoing desire to care for his/her loved ones. Review of the chaplain spiritual assessment given to the patients fiancé on 08/12/2024 showed the caregiver was willing and able to take care of the patient, the caregiver is “;struggling” physically, mentally, and emotionally to take care of the patient. Review of the social worker psycho-social assessment given to the patient on 08/13/2024 showed the patient “;does not want to die” and his/her coping mechanisms are denial, pets, or supportive relationships. The patient reported the nature of anxiety and fear was fear of the dying process and unmourned grief and loss. The patient reported that he/she was depressed about his/her diagnosis. The assessment showed the social worker did not complete the bereavement assessment and gave the reason that “;the chaplain to do”. The narrative indicated that the social worker “;will” visit weekly. The social worker failed to follow up with the patient after 08/13/2024. Review of the record showed the hospice provider failed to incorporate the grief issues, that impacted the anticipation of the patient’s death, into the patients plan of care. During an interview on 08/27/2024 at 12:30 PM, the patient stated that he/she had trouble sleeping at night. The patient stated that nights were “hard” because his/her mother died at night. The patient stated that he/she had not really talked to anyone about his/her feelings. The patient stated that he/she could talk to the hospice aide. During an interview on 08/27/2024 at 12:45 PM, the patient’s fiancé stated that the pastor from the local church had come one time, the social worker two times, and the chaplain two times. During an interview on 08/27/2024, at 3:15 PM, the administrator stated that he/she did not have a bereavement assessment for patients #3 and #5. One chaplain left and they hired another chaplain. The bereavement assessments were not completed. The assessments were missed during this time.”

“Based on policy review, record review, and interview, the hospice provider failed to obtain a respite discharge summary of care from the skilled nursing facility (SNF) in one of one respite records reviewed (Record/Patient #6). This deficient practice has the potential to affect all the providers patients receiving respite care. Findings included: Review of the providers policy titled, “Interdisciplinary Group (IDG) Membership and Responsibilities,” dated 11/01/2021, showed the IDG is responsible for “;providing for and ensuring the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement”. RECORD/PATIENT #6: Review of the medical record showed the patient had a respite stay in the SNF on 05/08/2024 through 05/12/2024. The record showed the provider failed to obtain a summary of care upon discharge from the SNF. During an interview on 08/27/2024 at 3:30 PM, the administrator stated that they (the provider) did not have a discharge summary of care from the patients respite stay. They have a lot of trouble getting the SNF or hospitals to give them any kind of discharge summary when their patients are admitted for respite care.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to assess and measure wounds in two of five full records reviewed (Records/Patients #3 and #4) and failed to ensure timely follow-up and assessment in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #5: Review of the record showed the provider admitted the patient to service on 07/29/2024. Diagnoses included COPD (chronic obstructive pulmonary (lung) disease and atrial fibrillation (irregular heartbeat). Review of the RN (registered nurse) visit report dated 08/08/2024, showed the patient complained of constipation and having to strain and pass hard stool. The nurse instructed the patient to increase the senna (laxative) dose to three tablets daily and increase to a maximum of four in (unsure if this meant “;for”) several days if constipation continued. The record showed no follow up to the patients constipation until 08/12/2024 (four days later), when the social worker visited. Review of a social worker (SW) visit dated 08/12/2024, showed the patient had a rough night due to constipation. The patient reported not feeling well or sleeping well. The patients oxygen tubing caused discomfort to the left ear. The SW notified the RN of the patients complaint. Review of the RN visit report dated 08/13/2024, showed the patient complained of constipation to the SW yesterday. The spouse was contacted and told to give the patient a suppository with plans to give enema/disimpact (manual removal of hard stool from the rectum) today if constipation continued. On arrival, the patient had not had a bowel movement. A saline (salt water) enema was administered but the patient was unable to pass any stool. Digital rectal assessment revealed a bulky and hard mass of stool low in the rectal vault. The patient was manually disimpacted. The patient tolerated the procedure poorly, but expressed relief of constipation. The nurse failed to document an assessment of the patients left ear. During an interview on 08/28/2024, the administrator stated that he/she would expect follow up at the next visit if they were going to give a few days to see if the increased dose was going to work. He/she agreed that the patient may have not gotten to that point if earlier follow up had taken place. He/she would expect the nurse to document an assessment of the left ear. RECORD/PATIENT #4: Review of the providers policy titled, “;Wound Assessment, Documentation, and Photography,” dated 03/01/2021, showed in part, the following: - The purpose was to ensure the accurate and consistent assessment and documentation of wounds; - Upon initial visit and subsequently as applicable, all wounds will be assessed with appropriate documentation within the medical record; and - Document in the medical record treatment and condition of the wound each visit, the appearance of the wound bed, and weekly wound measurements including the length, depth, and width of the wound in centimeters. Review of the clinical record showed the patient was admitted to hospice services on 03/12/2024 with a terminal diagnosis of Alzheimers disease (a disease marked by progressive loss of mental capacity). The patient was bedbound and required maximum to total assistance with activities of daily living (ADLs). He/she had a suprapubic catheter and was incontinent of stool. He/she lived with his/her spouse, who was the primary caregiver. The patient also had adult children who assist with care as well as a part-time paid in-home caregiver. Review of the skilled nurse (SN) notes showed, in part, the following: - On 08/09/2024, the SN note showed that a stage two pressure ulcer (a lesion caused by unrelieved pressure resulting in damage of underlying tissue) was present on the patients “;coccyx” (tailbone). The SN failed to document an assessment of the wound or obtain measurements of the wound; - On 08/13/2024, the SN note showed that the wound was a reactivation of a previously healed pressure ulcer (healed on 07/08/2024) and was identified as “;Wound #3” and the location was the left upper buttock. The wound was assessed to have a small amount of purulent (puss filled) drainage, contained zero to 25% of “;yellow” necrotic (dead tissue cells) tissue and the surrounding skin was bright red. The SN failed to measure the wound and the reason given was “;unable”. The SN documented wound care was provided to the “;coccyx” and a foam dressing was applied. The note failed to indicate why the SN was unable to measure the wound; - On 08/16/2024, the SN note showed the nurse failed to assess or measure the wound and the reason given was because the caregiver completed wound care; - On 08/20/2024, the SN note showed no necrotic tissue, and the surrounding skin was bright red. The SN failed to measure the wound and the reason was “;unable” (no reason given for why the SN was unable to measure the wound). The SN documented that the patients “;coccyx” wound had not progressed. Wound was cleansed with wound cleanser, pat dry, applied barrier cream and covered with a foam dressing; and - On 08/23/2024, the SN note showed the wound had scant serosanguinous (watery bloody) drainage and the wound was cleansed and a dressing was applied. The SN failed to measure the wound and the reason was “;unable” (no documented reason why the nurse was unable to measure). Observation on 08/27/2024 at 1:00 PM, during the patients home visit, showed registered nurse D (RN-D) and the paid caregiver rolled the patient on his/her side and removed the patients dressing. The patient was compliant with being rolled side to side with some coaching from spouse and caregiver. This surveyor observed the patients buttocks and noted two pressure injuries on the patients right upper buttock. The superior wound was the approximate size of a dime, and the inferior wound was the approximate size of a quarter. Also observed the left mid- buttock with two pressure injuries: The superior wound was the approximate size of a quarter, and the inferior wound was the approximate size of a dime. The skin surrounding wounds on both buttocks was red. The patient was incontinent of stool. RN-D provided incontinence care and wound care. During the wound care, RN-D stated that the wounds on the right buttock were new. RN-D failed to obtain measurements of the patients wounds. Per an interview conducted during observation, the patients spouse stated that he/she cant always get help to clean the patient when incontinent, so he/she had to lay in it until someone can help. Review of the SN visit note, dated 08/27/2024 (the observation home visit), showed wound #3 was not measured and the reason was “;unable” (this nurse observed wound care no attempt to measure wounds was made). The SN documented “;Coccyx wound was cleansed, zinc oxide cream applied to periwound (the skin surrounding a wound), foam dressing placed. Increased purulent drainage noted and a new opening in the skin.” The SN failed to assess and measure the second wound on the left buttock. The SN failed to assess and measure the two wounds on the right buttock. During an interview on 08/27/2024 at 2:30 PM, the administrator stated that the expectation is for weekly wound measurements. Maybe the nurse couldnt get the patient to turn over and thats why they documented they were unable to measure them but he/she would have expected the nurse to document the reason they were unable to measure the wound. Agreed that it would be hard to determine if the wound was improving or worsening without measurements. During an interview on 08/28/2024 at 3:31 PM, the administrator stated that the nurse should have assessed and measured the wounds. Findings included: RECORD/PATIENT #3 Review of the providers policy titled, “;Wound Assessment, Documentation, and Photography,” dated 03/01/2021, showed in part, the following: - The purpose was to ensure the accurate and consistent assessment and documentation of wounds; - Upon initial visit and subsequently as applicable, all wounds will be assessed with appropriate documentation within the medical record; and - Document in the medical record treatment and condition of the wound each visit, the appearance of the wound bed, and weekly wound measurements including the length, depth, and width of the wound in centimeters. Review of the clinical record showed the patient was admitted to hospice services on 08/10/2024 with metastatic breast cancer to the brain, leptomeninges (the membrane surrounding the brain and spinal cord) and bone (sacral area). The patient has chronic kidney disease and has bilateral nephrostomy (a tube that lets urine drain from the kidney through an opening in the skin on the back) sites. The patient was chairfast and required assistance with two or more activities of daily living (ADLs). He/she lived with his/her son and his/her fiancé lived next door. The patient also had an adult daughter who assists with care. - On 08/10/2024, SN “;Start of Care” notes showed a wound assessment for a nephrostomy tube on the left side (Wound #1) and right side (Wound #2) of the patient. The SN wound assessment for the left and right side showed the wound was assessed and no measurements were taken. The SN note showed that wound care was not provided by the SN and the caregiver completed the wound care. - On 08/10/2024, SN “;Start of Care” notes showed the genitourinary status description of size, date placed, stoma appearance as “;changed every three months, drainage bags on each tubes, and sutured to Stat Lock (an effective alternative to medical tape for the stabilization of tubing without restricting strap) and covered with four by four tape. - On 08/12/2024, SN supervisory visit note showed the genitourinary status was assessed; and description of size, date placed, and stoma appearance as “;unknown”. - On 08/15/2024, SN supervisory visit note showed the genitourinary status was assessed; and the description of size, date placed, and stoma appearance as “;not assessed this visit”. - On 08/23/2024 SN supervisory visit note showed the genitourinary status was assessed; and description of size, date placed, and stoma appearance as “;covered with dry dressing”. - On 08/24/2024, the SN supervisory note showed the genitourinary status was assessed and the description of size, date placed, stoma appearance as “;UTA” (urinary tract abnormalities). On 08/10/24, 08/12/2024, 08/15/2024, 08/23/2024, and 08/24/2024, the SN failed to document an assessment of the wounds identified as Wound #1 and Wound #2, obtain measurements of the wounds, and provide wound care. - On 08/23/2024, the SN note showed a wound identified as “Wound #3” at the coccyx (tail bone) with stage 2 pressure ulcer (a wound that extends into the bottom layers of the skin). The SN failed to assess, measure or provide care for the wound and the reason given was the caregiver completed wound care. During an interview on 08/27/2024 at 2:30 PM, the administrator stated that the expectation is for weekly wound measurements. Maybe the nurse couldnt get the patient to turn over and thats why they documented they were unable to measure them but he/she would have expected the nurse to document the reason they were unable to measure the wound. Agreed that it would be hard to determine if the wound was improving or worsening without measurements. During an interview on 08/28/2024 at 3:31 PM, the administrator stated that the nurse should have assessed and measured the wounds.”

“Based on policy review, record review, observation, and interview the hospice provider failed to provide the hospice aide written instructions for patient care that were patient specific in, but not limited to, one of four records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the provider’s patients. Findings included: Review of the hospice provider’s policy titled, “Hospice Aide Supervision: Management of Human Resources,” dated 11/01/2022 showed in part, the aides are assigned to patients based on the assessment made by the staff registered nurse (RN). Review of the hospice provider’s policy titled, “Home Health Aide: Effective Communication and Care Coordination Tip Sheet,” dated 01/19/2018 showed in part, the home health aide is responsible for the following: - Report and document any changes that need to be made to the aide plan of care (POC); - Only provide services listed on the POC; and - If the plan of care does not meet the patient’s needs, contact the patient care manager to discuss the changes. RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice care on 08/10/2024. Diagnoses included, metastatic breast cancer to the brain, leptomeninges (the membrane surrounding the brain and spinal cord), and bone (sacral area). The patient also had chronic kidney disease and had bilateral nephrostomy (a tube that lets urine drain from the kidney through an opening in the skin on the back) sites. The patient was chairfast and required assistance with two or more activities of daily living (ADLs). The patient lived at home with a caregiver. Review of the patient’s POC dated 08/10/2024 showed in part, the activities permitted as transfer between the bed and chair and use of a walker. Review of the start of care assessment dated 08/10/2024 showed in part, the following assessment: - Chairfast; - No mobility limitations and made major and frequent changes in position without assistance; - Transfers bed to chair with maximal assistance; and - Cleanse nephrostomy (a tube that lets urine drain from the kidney through an opening in the skin on the back) site with soap and water daily and apply four by four seal with tape. Review of the registered nurse (RN) supervisory visit note dated 08/12/2024 showed in part, the following: - Chairfast; and - Very limited mobility and unable to make frequent or significant changes independently. Review of the RN supervisory visit note dated 08/15/2024 showed in part, the following: - Walks occasionally; and - Slightly limited mobility and makes frequent though slight changes in body or extremity position independently. Review of the hospice aide (HA) care plan dated 08/16/2024 showed in part, the following: - Stand-by assistance with ambulation at every visit; - Bathing (chair) at every visit; - Ambulate with use of walker at every visit; and - The aide care plan failed to show frequency of visits for the home health aide. Review of the RN supervisory visit note dated 08/23/2024 showed in part, the following: - Bedfast and confined to bed; and - Very limited mobility and unable to make frequent or significant changes independently. Review of the RN supervisory visit note dated 08/24/2024 showed, mobility assessment as bedbound. Review of the HA visit note dated 08/16/2024, 08/23/2024, and 08/26/2024 showed in part, the following: - Completed stand-by assistance with ambulation; - Completed bathing (chair); - Completed ambulation with use of walker; and - Completed cleaning of nails. Observation on 08/27/2024 at 11:30 AM showed the hospice aide (HA)-A completed a bed bath for the patient. HA-A told the patient that the patient seemed cold “yesterday” during the bed bath, so today he/she will warm a blanket or towels in the dryer. The patient was not able to reposition him/herself and mentioned it was uncomfortable when HA-A adjusted the bed. The patient told HA-A to look at the patient’s legs and moved his/her feet but was unable to move his/her legs. HA-A stated that the patient’s legs were making him/her “nervous, because when I go to move you, it hurts.” Review of the HA visit note dated 08/27/2024 at 12:43 PM showed in part, the following: - Did not complete stand-by assistance with ambulation with note that patient unable to stand; - Did not complete bathing (chair) with note that patient bed bath was given, and RN was notified; - Did not complete ambulate use of walker with note that client refused, patient bed bound, and RN was notified; and - Did not complete clean nails with note of one time per week. The hospice provider failed to update the care plan to reflect the patient’s current status. The hospice provider failed to provide nephrostomy care instructions on the care plan. The HA-A failed to follow the care plan. During an interview on 08/28/2024 at 3:00 PM, the administrator stated that a new order should have been written if the frequency of visits changed. The aide should have recorded changes in the patient in the coordination notes after the home visit. The clinical coordinator reviews the notes and if there are abnormal issues the coordinator would call the nurse. The administrator stated that there is confusion whether to put “yes or no” on the care plan for each ADL services, but he/she stated that “yes” indicated that the service was provided. The administrator stated that if there were changes in the patient’s abilities to complete the ADLs, then the nurse should be notified, and the care plan adjusted. The administrator stated that the care instructions for the nephrostomy should be on the care plan.”

“Based on policy review, record review, observation, and interview the hospice provider failed to ensure the skilled nursing facility (SNF) had the most recent physician recertification of terminal illness (the physician certifies that life expectancy is six months or less) in one of one patient record that resided in a SNF (Record/Patient #2). This deficient practice has the potential to affect all patients that reside in a SNF. Findings included: Review of the providers policy titled, “;Hospice Care in the Nursing Home/Skilled Nursing Facility Setting,” revised 06/01/2018, showed in part, that the hospice agency will provide the nursing home/skilled facility with the physician certification and recertification. RECORD/PATIENT #2: Review of the record showed the patient elected hospice care on 08/02/2023. Diagnoses included senile degeneration of the brain and dementia. The patient resided in a SNF. During a home visit observation at the SNF on 08/27/2024, beginning at 2:00 PM, showed the facility hospice binder failed to contain the most recent physician recertification. The last recertification was dated 03/06/2024. The hospice nurse stated that he/she could not find the recertification in the binder. During an interview on 08/28/2024, beginning at 3:10 PM, the administrator stated that the office manager printed the recertification and put them in the nurse’s mailbox for the nurses to put in the facility binders.”