American Medical Hospice & Palliative Care

“It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its normal course. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed revealed that the agency did not ensure that the initial certification of terminal illness was completed and in the clinical record. CLINICAL RECORD 1: The patient was admitted on 04/08/2025 with a diagnosis of severe protein-calorie malnutrition. The clinical record was reviewed on 04/14/2025. The clinical record read, “not started” under physician written certification. The clinical record contained no evidence that the physician initial certification was completed for admission. The administrator confirmed in an interview on 4/14/2025 that the record did not contain a completed certificate of terminal illness from the physician.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed in which a patient was transferred to another Medicare provider revealed that the agency did not ensure that a discharge summary was sent to the alternate provider. CLINICAL RECORD 2: The patient was admitted on 03/09/2024. The clinical record noted that the agency received a fax memo from an alternate hospice agency on 04/10/2025 signed by the patient’s Medical Power of Attorney requesting that the patient be transferred to the alternate hospice agency. The SN note dated 04/10/2025 stated, “Transfer complete.” There was no documentation of a discharge summary and no documentation in the clinical record of any records being provided to the alternate agency. The administrator stated in an interview and review of the clinical records on 04/14/2025, “There should be another note after the discharge note showing the discharge summary and information sent to an alternate facility.” The administrator confirmed that the clinical record did not contain documentation of a discharge summary.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review and interview. Review of administrative documents, and interviews with leadership revealed the hospice : Failed to ensure volunteer services were used on a day to day basis in any roles. [HCDT.21.I/L644]; Failed to ensure that volunteers provided a minimum of 5% of the total patient care hours of all paid hospice employees and contract staff [HSLG.7.I/L647]; Failed to ensure that volunteer recruitment and retention efforts occurred. [HCDT.30.I/L645]; Failed to ensure that the hospice was engaged in providing volunteer services [HCDT.1.I/L652]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.78: Volunteers. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by document reviews, clinical record reviews, and interviews with the Administrator/Volunteer Coordinator and Director of Nurses, which revealed issues with the hospice organizing, managing and administering its resources to provide the hospice care and services to patients, families, and caregivers for managing palliation and the patient’s terminal illness in the following area: Failure of the governing body to assume responsibility for the organization’s ongoing performance improvement and patient safety [HSLG.2.I/L574/418.58(e)(1)]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation CFR 418.100: Organization and administration of services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and service from the agency.”

“It is required that a clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews revealed the hospice: Failed to ensure the clinical record contained a copy of the notice of patient rights and the hospice election statement.[HSIM.3.I/L673/ 418.104(a)(2)]; Failed to ensure the recertification of the terminal illness was completed by the physician no later than two calendar days after the first day of the benefit period and no more than 15 days before the next benefit period [HCPC.6.I/ 676/ 418.104(a)(5)]; Failed to ensure that a discharge summary was provided to the patient’s attending physician { HCDT.39.I/L683/ 418.104(e)(2)(i)}; and Failed to ensure that the patient’s discharge summary was provided to the facility [HCDT.38.I/L682/418.104(e)(1)(i)); and Failed to ensure that that the hospice medical director provided a written certification on admission that the patient’s life expectancy is six months or less if the illness runs its normal course [HCPC.4.I/L667/418.102(b)(1). The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.104: Clinical Records. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that during the initial assessment visit and in advance of providing care: The hospice provides the patient—or his or her representative—with verbal (meaning spoken) and written notice of the patient’s rights and responsibilities. This information is provided in a language and manner that the patient understands. The hospice obtains the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities statement. This standard was not met as evidenced by clinical record review and interview. In 5 of 9 (56%) clinical record review of patients electing the hospice benefit revealed the agency did not ensure that they obtained a signature confirming that the patient received a copy of the Bill of Rights and Responsibilities. CLINICAL RECORD 7: The hospice benefit was elected on 11/22/2024. The agency did not obtain a signature confirming that the patient received a copy of the Bill of Rights and Responsibilities, as evidenced by the lack of a signature or documentation that the Bill of Rights was provided before hospice services were provided. CLINICAL RECORD 9: The hospice benefit was elected on 02/04/2025. The agency did not obtain a signature confirming that the patient received a copy of the Bill of Rights and Responsibilities, as evidenced by the lack of a signature or documentation that the Bill of Rights was provided before hospice services were provided. CLINICAL RECORD 10: The hospice benefit was elected on 11/25/2024. The agency did not obtain a signature confirming that the patient received a copy of the Bill of Rights and Responsibilities, as evidenced by the lack of a signature or documentation that the Bill of Rights was provided before hospice services were provided. CLINICAL RECORD 13: The hospice benefit was elected on 02/05/2025. The agency did not obtain a signature confirming that the patient received a copy of the Bill of Rights and Responsibilities, as evidenced by the lack of a signature or documentation that the Bill of Rights was provided before hospice services were provided. CLINICAL RECORD 18: The hospice benefit was elected on 06/30/2023. The agency did not obtain a signature confirming that the patient received a copy of the Bill of Rights and Responsibilities, as evidenced by the lack of a signature or documentation that the Bill of Rights was provided before hospice services were provided. During an interview with the Administrator (Administrator personnel # 8) on 03/06/2025, he stated that he did not know why the consents were not uploaded into the system but that they would look into it.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) clinical record review revealed that the agency did not ensure that an initial bereavement assessment was included in the comprehensive assessment. CLINICAL RECORD 7: The hospice benefit was elected on 11/22/2024. A clinical record review revealed that the nursing initial assessment was completed on 11/22/2024, the social worker’s initial assessment was completed on 12/02/2024. There was no documented evidence that a completed initial bereavement assessment was a part of the comprehensive assessment through the date of this review. During an interview with the Administrator (personnel #8) on 03/06/2025 he stated that they have been providing bereavement services and did not know how that one was missed.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review, document review and interview. In 6 of 19 (32%) clinical record review revealed that the agency did not ensure the Interdisciplinary Group (IDG) reviewed, revised, and documented the care plan no less frequently than every 15 days. CLINICAL RECORD 2: The hospice benefit was elected on 04/19/2019. The clinical record review for the benefit period starting on 08/01/2022 and ending on 09/29/2022 and the benefit period starting on 03/29/2023 to 05/27/2023 revealed no evidence of an IDG being completed. During the benefit period starting on 05/22/2024 and ending on 07/20/2024, IDG was only done on 06/03/2024. CLINICAL RECORD 3: The hospice benefit was elected on 06/22/2022. The clinical record review for the benefit period starting on 06/22/2022 and ending on 09/19/2022 lacked evidence that the agency conducted an IDG at least every 15 days, no documentation of an IDG during that timeframe. CLINICAL RECORD 4: The hospice benefit was elected on 06/27/2023. The clinical record review for the benefit period starting on 06/27/2023 and ending on 09/19/2023 lacked evidence that the agency conducted an IDG at least every 15 days. The clinical record contained only one documented IDG on 09/01/2023 CLINICAL RECORD 5: The hospice benefit was elected on 09/26/2023. The clinical record review for the benefit period starting on 09/26/2023 and ending on 11/24/2023 lacked evidence that the agency conducted an IDG at least every 15 days. IDG was done on 09/29/2023, 10/23/2023 (24 days), 11/06/2023, and 11/20/2023. CLINICAL RECORD 6: The hospice benefit was elected on 01/11/2024. The clinical record review for the benefit period starting on 11/06/2024 and ending on 01/04/2025 lacked evidence that the agency conducted an IDG at least every 15 days. IDG was done on 12/02/2024 (26 days), 12/16/2024, and 12/31/2024. CLINICAL RECORD 18: The hospice benefit was elected on 06/30/2023. The clinical record review for the benefit period starting on 06/30/2023 and ending on 09/27/2023 lacked evidence that the agency conducted an IDG at least every 15 days. IDG was done on 08/04/2023 (35 days), 08/19/2023, 09/01/2023, and 09/15/2023. The Director of Nursing (DON Personnel record #4) stated in an interview on 03/06/2025 that she was not employed with the agency at the time that these IDG’s were not completed and acknowledges that these IDG’s were not held at least every 15 days.”

“It is required that the hospice’s governing body assumes legal authority and responsibility or the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by document review, clinical record review, observation and interview. A review of the clinical records, observation, and interviews with the Administrator/Volunteer Coordinator and Director of Nurses revealed that the governing body did not assume responsibility for the organization’ ongoing performance improvement and patient safety as evidenced by: A review of the Volunteer Program manual revealed there was no supporting evidence that the hospice was engaged in providing volunteer services. [HCDT.1.I/L652] During an interview with the administrator/volunteer coordinator on 03/04/2025 it was revealed through a review of the Volunteer Program that there were no active volunteers. He stated that they are currently looking for more volunteers. 1 of 19 (5%) clinical record reviewed revealed that the agency did not ensure that the hospice medical director provided a written certification on admission that the patient’s life expectancy is six months or less if the illness runs its normal course. [HCPC.4.I/L667] During an interview with the administrator (Administrator personnel # 8) on 03/06/2025, he stated that the physician was no longer the medical director for the agency. In 4 of 10 (40%) clinical records reviewed with recertification, the agency did not ensure the recertification of the terminal illness was completed. [HCPC.6.I/L676] During an interview with the Director of Nurses (DON Personnel record #4) a recent hire) on 03/06/2025, she stated that she is tracking CTIs and making sure they are completed in a timely manner. However, all she can do is ensure the process is being followed now; she was not here and cannot correct the past. In 1 of 3 (33%) clinical record reviewed for families requiring bereavement services post-death revealed the agency did not ensure bereavement services were provided. ]HCDT.22.I/L596] During an interview on 03/06/2025, the administrator (personnel #8) stated that they have been providing bereavement services and did not know how that one was missed. In 1 of 19 (5%) clinical record reviewed revealed that the agency did not ensure that an initial bereavement assessment was included in the comprehensive assessment. [HCPC.13.I/L531]. During an interview with the Administrator (personnel #8) on 03/06/2025 he stated that they have been providing bereavement services and did not know how that one was missed.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical record review for families requiring bereavement services post-death revealed the agency did not ensure bereavement services were provided. CLINICAL RECORD 17: The patient elected the hospice benefit on 06/27/2024.The patient’s date of death was 07/09/2024. A review of the clinical record lacked evidence of bereavement services post-death. Clinical documentation by the chaplain on 07/09/2024 stated “spouse stated that she would like to be contacted and check in on. Chaplain will follow and set up appropriately”. No evidence of bereavement follow-up is documented in the clinical record.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and Included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical record review revealed the agency did not ensure the hospice aide followed the aide plan of care as ordered by the interdisciplinary group. CLINICAL RECORD 5: The hospice aide plan of care dated 11/19/2024 included a complete bed bath and shampoo task ordered at two times a week. The clinical record review showed evidence that the patient was seen 12/09/2024, 12/11/2024, and 12/13/2024 and the complete bed bath and shampoo was given three times a week instead of two times a week as ordered on the aide plan of care. During an interview with the Director of Nurses (DON) Personnel record #4) on 03/06/2025, she stated that she just started and is attempting to educate the staff on documentation.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: Assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 9 (22%) clinical records reviewed, it was revealed that the agency did not ensure hospice aide supervisory visits were conducted no less frequently than every 14 days. CLINICAL RECORD 5: The patient elected the hospice benefit on 09/26/2023. The plan of care dated 09/20/2024 to 11/18/2024. The orders for hospice aide services two times per week were dated 09/20/2024. The clinical record included documented aide supervisory visits on 10/11/2024 with the next one documented on 11/08/2024, 28 days later and 14 days outstanding. The plan of care dated 11/19/2024 to 01/17/2025 included orders for the hospice aide visits three times per week. The clinical record included documented aide supervisory visits on 12/03/2024 with the next one not documented in the clinical record, 91 days later and 74 days outstanding. CLINICAL RECORD 6: The patient elected the hospice benefit on 01/11/2024. The plan of care dated 01/05/2025 to 03/05/2025 included orders for the hospice aide visits two times per week. The clinical record included documented aide supervisory visits on 01/09/2025 with the next one documented on 01/28/2025, 19 days later and 5 days outstanding. During an interview with the Director of Nurses (DON Personnel record #4) on 03/06/2025, she stated that she had just started and that she would be reviewing and providing additional education on supervisory visits.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. This standard was not met as evidenced by document review, interview and observation. 1 of 4 (25%) of home observation visit revealed that the agency did not ensure that volunteer services were used on a day to day basis in any roles. Document 1: The volunteer program was reviewed no evidence of a volunteer was evidence that a volunteer was available or had been hired. The Personnel Records did not contain evidence of a volunteer(s) on staff or any HR activity. The clinical records and the IDG documentation did not contain any evidence that volunteer services were provided. The volunteer percentage for year 2024 and year to date was zero. Home Visit 1 (Clinical Record 12): A home visit was completed on 03/05/2025 to observe the hospice aide (Personnel Record 2) for a patient that elected the hospice benefit on 02/27/2025. The clinical record lacked evidence that the patient was offered a volunteer. The daughter was interviewed during the home visit who stated that her mother was not offered a volunteer, but did not believe that she needed a volunteer at this time. During an interview with the administrator/volunteer coordinator [Administrator/volunteer coordinator personnel # 8) on 03/04/2025 stated that they do not have any volunteers at all. Stated that they are currently looking for more volunteers.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. During review of the Volunteer Program it was revealed that the agency had no documented evidence of volunteer recruitment and retention efforts. There was no additional documentation presented prior to the conclusion of the site visit. During an interview with the administrator/volunteer coordinator on 03/04/2025 he stated that they do not have any volunteers. Stated that they are currently looking for more volunteers. They were unable to provide documented evidence of any active ongoing volunteer recruitment activity.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by interview and document review. The agency did not ensure that volunteer were provided at a minimum of 5% of the total patient care hours of all paid hospice employees and contract staff. A review of the agency’s volunteer program/binder revealed hospice volunteer hours reported 0% of volunteer usage. During an interview on 03/04/2025, the volunteer coordinator stated that the agency did not currently have any active volunteers, so the volunteer percentage is 0%. He stated that they are currently looking for volunteers but have not been successful at this time. No additional documentation was presented prior to the conclusion of the site visit. During an interview with the volunteer coordinator, it was discovered that the agency did not have any active volunteers.”

“It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice for volunteer services. This standard was not met as evidenced by document review and interview. Review of the Volunteer Program manual revealed there was no supporting evidence that the hospice was engaged in providing volunteer services. Document 1: The volunteer program, was reviewed. There was no evidence of an available volunteer, The personnel records did not contain any evidence of a hired volunteer. A review of the clinical records and the IDG documentation did not reveal any volunteer activity or discussions. There was no evidence that a volunteer was available or had been hired for 2024 and year to date in 2025. During an interview with the administrator/volunteer coordinator on 03/04/2025 it was revealed through a review of the Volunteer Program that there were no active volunteers. He stated that they are currently looking for more volunteers.”

“It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its normal course. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical record review revealed the agency did not ensure that the hospice medical director provided a written certification on admission that the patient’s life expectancy is six months or less if the illness runs its normal course. CLINICAL RECORD 7: The hospice benefit was elected on 11/22/2024. The clinical record review lacked evidence of a written certification of terminal illness on admission. During an interview with the administrator (Administrator personnel # 8) on 03/06/2025, he stated that the physician was no longer the medical director for the agency.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical record review revealed the agency did not ensure each clinical record contained a copy of the notice of patient rights and the hospice election statement. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/22/2024. The clinical record review lacked evidence of the hospice election statement or a signed copy of the notice of patient rights, no consents were present in the clinical record. CLINICAL RECORD 9: The patient elected the hospice benefit on 02/04/2025. Clinical record review lacked evidence of the hospice election statement or a signed copy of the notice of patient rights, no consents were present in the clinical record. CLINICAL RECORD 10: The patient elected the hospice benefit on 11/25/2024. Clinical record review lacked evidence of the hospice election statement or a signed copy of the notice of patient rights, no consents were present in the clinical record. CLINICAL RECORD 13: The patient elected the hospice benefit on 02/05/2025. Clinical record review lacked evidence of the hospice election statement or a signed copy of the notice of patient rights, no consents were present in the clinical record. CLINICAL RECORD 18: The patient elected the hospice benefit on 06/30/2023. Clinical record review lacked evidence of the hospice election statement or a signed copy of the notice of patient rights, no consents were present in the clinical record. During an interview on 03/06/2025, the Administrator (Administrator personnel # 8) stated that he did not know why the hospice election statement was not uploaded into the electronic medical record but that he would look into it. No additional evidence was presented prior to the conclusion of the site visit.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 4 of 10 (40%) clinical records reviewed with recertification, the agency did not ensure the recertification of the terminal illness was completed by the physician no later than two calendar days after the first day of the benefit period and no more than 15 days before the next benefit period. CLINICAL RECORD 1: The clinical record review lacked evidence of a written recertification of terminal illness for benefit period 02/23/2025 to 04/23/2025. The clinical record contained a verbal certification for the benefit period but not a written certification. CLINICAL RECORD 4: The clinical record review lacked evidence of a written recertification of terminal illness for the benefit period 12/22/2023 to 02/19/2024. The clinical record contained a verbal certification for the benefit period but not a written certification. CLINICAL RECORD 5: The clinical record review lacked evidence of a written recertification of terminal illness for the benefit period 03/24/2024 to 05/22/2024, 05/23/2024 to 07/21/2024, and 11/19/2024 to 01/17/2025. The clinical record contained a verbal certification for the benefit period but not a written certification. CLINICAL RECORD 15: The clinical record review lacked evidence of a written recertification of terminal illness for the benefit period 10/05/2024 to 12/03/2024. The clinical record contained a verbal certification for the benefit period but not a written certification. During an interview with the Director of Nurses (DON Personnel record #4) a recent hire) on 03/06/2025, she stated that she is tracking CTIs and making sure they are completed in a timely manner. However, all she can do is ensure the process is being followed now; she was not here and cannot correct the past.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) clinical records reviewed of patients that transferred to another Medicare facility revealed that the agency did not ensure that the patient’s discharge summary was provided to the facility. CLINICAL RECORD 18: The hospice benefit was elected on 06/30/2023 and the patient was transferred to another hospice on 07/10/2024. The clinical record review lacked evidence that a discharge summary was sent to the facility upon discharge from the hospice agency. During an interview with the Director of Nurses on 03/06/2025, she confirmed that the discharge summary was not sent stating that she is a recent hire and is slowly educating the staff.”

“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. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) clinical records reviewed of discharged patients that revoked their election of hospice care revealed that the agency did not ensure that the patient’s discharge summary was provided to the patient’s attending physician. CLINICAL RECORD 19: The hospice benefit was elected on 12/09/2024 and the patient chose to revocate services on 12/20/2024. The clinical record review lacked evidence that a discharge summary was sent to the attending physician upon discharge from the hospice agency. During an interview with the Director of Nurses (DON Personnel record #4) on 03/06/2025, she confirmed that the discharge summary was not sent and stated that she is a recent hire and is slowly educating the staff.”