Home Hospice

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed revealed that the agency did not ensure an initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. CLINICAL RECORD 3: The patient’s election of benefit was dated 04/01/2024. The initial nursing comprehensive assessment was dated 04/01/2024, the initial psychosocial assessment completed on 04/02/2026, and the initial spiritual assessment completed on 04/10/2026 (a total of 9 days from the election of benefit). CLINICAL RECORD 10: The patient’s election of benefit was dated 02/03/2026. The initial nursing comprehensive assessment was dated 02/03/2026, the initial psychosocial assessment completed on 02/03/2026, and the initial spiritual assessment completed on 02/14/2026 (a total of 11 days from the election of benefit). CLINICAL RECORD 11: The patient’s election of benefit was dated 10/22/2025. The initial nursing assessment completed on 10/23/2025, the initial psychosocial assessment completed on 10/23/2025, and the initial spiritual assessment completed on 10/28/2025 (a total of 6 days from the election of benefit). During an interview with the Executive Director (Personnel Record 6) on 07/23/2026, she stated they will be providing education to clinical staff about completing the comprehensive assessment no later than 5 days after admission.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by personnel record review, document review, and interview. In 3 of 9 (33%) personnel records reviewed of clinical staff, the agency did not ensure the skills and competencies of all individuals providing care were assessed. Document 1: The agency policy titled Competency of Clinical Staff, effective date 02/20/2002, revision date 03/22/2013, stated in part, “Clinical competency evaluations are performed at time of hire and annually to assess the basic skills levels for all Home Hospice staff who provide patient/family care.” PERSONNEL RECORD 4: The personnel record review of the spiritual counselor, with a date of hire 10/05/2011, did not include documented evidence that the hospice assessed the skills and competencies annually for the year 2025, as required by agency policy. PERSONNEL RECORD 5: The personnel record review of the Volunteer Coordinator, with a date of hire 07/21/2025, did not include documented evidence that the hospice assessed the skills and competencies of all individuals providing care at hire as required by agency policy. PERSONNEL RECORD 7: The personnel record review of the alternate Bereavement Coordinator, with a date of hire 02/10/2015, did not include documented evidence that the hospice assessed the skills and competencies at hire and annually as required by agency policy, During an interview with the Executive Director (Personnel Record 6) on 07/22/2026, she stated that she was not aware that the competency needed to be completed for the volunteer coordinator or the bereavement coordinator and doesn’t know why the spiritual counselor was missed in 2025. However, they would review and update the process as soon as possible.”

“It is required that the hospice medical director, physician-designee, or physician member of the IDG provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 12 of 13 (92%) clinical records reviewed of patients who have been recertified for hospice benefit revealed that the agency did not ensure that a recertification of terminal illness was present in the patient’s clinical record as required. CLINICAL RECORD 1: A review of the clinical record for the recertification benefit periods 02/28/2026 to 04/28/2026, 04/29/2026 to 06/27/2026 and 06/28/2026 to 08/26/2026 revealed no documented evidence of a recertification of terminal illness for these benefit periods. The Face-to-face documentation was completed on 02/17/2026, 04/21/2026 and 06/19/2026, however, no recertification of terminal illness was completed as required. CLINICAL RECORD 3: A review of the clinical record for the recertification benefit periods 03/11/2026 to 05/09/2026, 05/10/2026 to 07/08/2026 and 07/09/2026 to 09/06/2026 revealed no documented evidence of a recertification of terminal illness for these benefit periods. Face-to-face was completed on 03/05/2026, 05/01/2026 and 06/30/2026, however, no recertification of terminal illness was completed as required. CLINICAL RECORD 4: A review of the clinical record for the recertification benefit periods 04/13/2026 to 07/11/2026 and from 07/12/2026 to 09/09/2026 revealed no documented evidence of a recertification of terminal illness for these benefit periods. A Face-to-face was dated 07/09/2026, however, no recertification of terminal illness was completed as required. CLINICAL RECORD 5: A clinical record review for the recertification benefit periods 02/21/2026 to 04/21/2026, 04/22/2026 to 06/20/2026, and 06/21/2026 to 08/19/2026 revealed no documented evidence of a recertification of terminal illness for these benefit periods. A Face-to-face was completed on 02/17/2026, 04/07/2026, and 06/21/2026, however, no recertification of terminal illness was completed as required. CLINICAL RECORD 6: A clinical record review for the recertification benefit periods 03/29/2026 to 05/27/2026 and 05/28/2026 to 07/26/2026 revealed no documented evidence of a recertification of terminal illness for these benefit periods. A Face-to-face was completed 03/29/2026 and 05/20/2026, however, no recertification of terminal illness was completed as required. CLINICAL RECORD 7: A clinical record review for the benefit period 07/09/2026 to 10/06/2026 revealed no documented evidence of a recertification of terminal illness for this benefit period as required. CLINICAL RECORD 8: A clinical record review for the recertification benefit periods for 03/18/2026 to 05/16/2026, 05/17/2026 to 07/15/2026, and 07/16/2026 to 09/13/2026 revealed no documented evidence of a recertification of terminal illness for these benefit periods. A Face-to-face was completed on 03/09/2026, 05/04/2026 and 07/13/2026, however, no recertification of terminal illness was completed as required. CLINICAL RECORD 9: A clinical record review for the recertification benefit periods for 04/05/2026 to 06/03/2026 and 06/04/2026 to 08/02/2026 revealed no documented evidence of a recertification of terminal illness for these benefit periods. A Face-to-face was completed on 03/26/2026 and 05/29/2026, however, no recertification of terminal illness was completed as required. CLINICAL RECORD 10: A clinical record review for the recertification benefit periods for 04/04/2026 to 06/02/2026 and 06/03/2026 to 08/01/2026 revealed no documented evidence of a recertification of terminal illness for these benefit periods. A Face-to-face was completed on 03/30/2026 and 06/03/2026, however, no recertification of terminal illness was completed as required CLINICAL RECORD 11: A clinical record review for the recertification benefit periods for 04/20/2026 to 06/18/2026 and 06/19/2026 to 08/17/2026 revealed no documented evidence of a recertification of terminal illness for these benefit periods. A Face-to-face was completed on 04/14/2026 and 06/23/2026, however, no recertification of terminal illness was completed as required. CLINICAL RECORD 12: A review of the benefit period 07/10/2026 to 09/07/2026 revealed a written recertification without the hospice medical director’s signature as of 07/23/2026, 13 days after the start of the benefit period. There was no documented evidence that the clinical record included a signed recertification of terminal illness by the medical director as of the record review date 07/23/2026. CLINICAL RECORD 14: A clinical record review for the recertification benefit periods for 03/18/2026 to 06/15/2026 and 06/16/2026 to 08/14/202 revealed no documented evidence of a recertification of terminal illness for these benefit periods. A Face-to-face was completed on 06/10/2026, however, no recertification of terminal illness was completed as required. During an interview with the Executive Director (Personnel Record 6) on 07/22/2026, she stated she was aware and that they are actively working on a process to have the recertifications completed in a timely manner.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients who were live discharge from hospice services, the agency did not ensure a copy of the patient’s hospice discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 18: A review of the clinical record revealed that the patient elected the hospice benefit on 05/23/2025 and revoked on 01/24/2026. The hospice discharge summary was dated 01/24/2026, however, there was no documented evidence that the discharge summary was forwarded the patient’s attending physician. CLINICAL RECORD 19: A review of the clinical record revealed that the patient elected the hospice benefit on 06/10/2025 and was discharged on 10/21/2025 for being out of the service area. The discharge summary was dated 10/21/2025, however, there was no documented evidence that the discharge summary was forwarded the patient’s attending physician. During an interview with the Executive Director (Personnel Record 6) on 07/22/2026, she stated that they will be reviewing the policy and updating the staff on this requirement.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: the most recent hospice plan of care; hospice election form; physician certification and recertification of the terminal illness; and hospice physician and attending physician (if any) orders. This standard was not met as evidenced by interview and observation. In 3 of 3 (100%) observation visits of patients living in a skilled nursing facility (SNF) revealed that the agency did not ensure the designated IDG member provided the SNF/NF with the physician certification and recertification of the terminal illness. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 09/01/2025 with diagnosis of chronic systolic (congestive) heart failure. The patient resided in a skilled nursing facility (SNF). During the home visit observation with the hospice aide (Personnel Record 2) on 07/21/2026 at the SNF, a review of the documents provided to the facility revealed there was no documented evidence that the physician certification and recertification of terminal illness was included in the documents provided to the facility. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit on 06/10/2026 with diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. The patient resided in a skilled nursing facility (SNF). During the home visit observation with the registered nurse (RN) (Personnel Record 1) on 07/21/2026 at the facility, a review of the documents provided to the facility revealed there was no documented evidence that the physician certification and recertification of terminal illness was included in the documents provided to the facility. CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 01/13/2026 with diagnosis of Alzheimer’s disease with late onset. The patient resided in a skilled nursing facility (SNF). During the home visit with the Medical Social Worker (Personnel Record 3) on 07/21/2026 at the SNF, a review of the documents provided to the facility revealed there was no documented evidence that the physician certification and recertification of terminal illness was included in the documents provided to the facility During an interview with the Executive Director (Personnel Record 6) on 07/21/2026, she stated that all the documents are sent to the facility after the interdisciplinary team meeting; however, it is true that the recertification of terminal illness was missing, but they would review and strengthen the process.”