Concho Hearts Hospice, LLC

“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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed that the hospice did not ensure an initial bereavement risk assessment was completed. THIS IS A NEW FINDING Document 1: Policy # PC.130 stated in part “ The hospice will perform an initial assessment of the patient’s family and other care individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death as part of the Initial Comprehensive Assessment.” Clinical Record 2: The patient elected hospice care on 01/05/2024. The Registered Nurse initial comprehensive assessment was dated 01/05/2024. A chaplain refusal visit was documented on 01/07/2024. A Social Worker initial assessment was done on 01/09/2023. A review of the visit notes did not include a bereavement assessment. A review of the record revealed there was no initial bereavement assessment documented as of 01/31/2024. During an interview on 01/31/2024 the Director of Nursing confirmed the finding and stated that the initial bereavement assessment had not been completed. No further information was provided.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed with hospice aide services, revealed the agency did not ensure the hospice aide provided services as ordered in the plan of care (POC). CONTINUING REQUIRED ACTION. Clinical Record 2: The aide plan of care dated 01/05/2024 assigned the aide to provide visits “three times a week.” A review of the clinical record review revealed the hospice aide provided one visit for the week of 01/07/2024 to 01/13/2024. The Director of Nursing was interviewed on 01/31/2024 and confirmed that the aide did not follow the plan of care for visit frequency. No further information was provided. PRIOR REQUIRED ACTION.”

“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; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical record review with discharge/transfer/revocation, the agency did not ensure that a discharge summary was sent to the receiving Medicare/Medicaid Certified Facility. CONTINUING REQUIRED ACTION. Clinical Record 4: Clinical record review revealed the patient revoked to seek aggressive treatment at a hospital on 12/28/2023. A discharge summary was completed but there was no documented evidence that the discharge summary was sent to the receiving Medicare/Medicaid Certified Facility. The Director of Nursing was interviewed on 01/31/2024 and confirmed that there was no documented evidence that the discharge summary was sent to the receiving facility. No further information was provided. PRIOR REQUIRED ACTION.”

“It is required that the hospice and its staff operate and provide care and services, in compliance with local, state, and federal law and regulation related to the health and safety of patients, and as a licensed entity if state or local law provides for hospice licensing. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by document review, personnel record reviews, clinical record reviews, and interviews with the Administrator and the Director of Nursing which revealed issues with the organization’s compliance with local, state, and federal law and regulation related to the health and safety of patients, and as a licensed entity if state or local law provides for hospice licensing in the following areas: Failure of the hospice to ensure hospice physicians providing care at alternative delivery sites functioned under the supervision of the hospice medical director [HCDT.5.I/L590]; Failure of the hospice to ensure alternative delivery sites were approved by Medicare as a multiple locations before providing hospice care and services to Medicare patients [HSLG.17.I/L656]; Failure to ensure alternative delivery sites shared administration, supervision, and services with the hospice issued the certification number [HSLG.17.I/G657]; and Failure of the hospice to ensure the hospice continually monitors and manages all services provided at each of its multiple locations to ensure services are delivered in a safe and effective manner [HSLG.18.I/L660]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.116: Compliance with Federal, State, Local Laws & Regulations related to the health and safety of patients. 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 the written Patient Bill of Rights includes the right to choose his or her attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the patient’s right to choose their attending physician was documented. Clinical Record 11: The patient elected the hospice benefit on 11/09/2023. The consent form, signed by the patient and dated 11/09/2023, had a space for the patient’s choice of attending physician and a check box to decline physician designation, but the space and box were left blank. The Administrator confirmed in an interview on 12/19/2023 that the consent was incomplete and did not include if the patient declined or chose an attending physician.”

“It is required that the hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG [interdisciplinary group] in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure hospice care and services provided to patients and families followed the individualized plan of care. Clinical Record 5: Clinical record review revealed the plan of care dated 05/23/2023 included an order for “Medical Social Worker [MSW] frequency for one time a month and prn [as needed].” The clinical record contained no documented evidence that the MSW provided visits for May, June, and August 2023. Clinical Record 13: The IDG plan of care reviews dated from 11/22/2022 to 12/06/2023 documented Medical Social Worker “1x monthly and two prn monthly to provide support as needed.” The clinical record contained documentation that the MSW attempted one call for February, March, and May 2023 and no documented evidence of MSW visits or missed visit documentation for January, April, June, and July 2023. The IDG plan of care reviews dated from 11/22/2022 to 12/06/2023 stated Spiritual Counselor [SC] “1x month effective 11/28/2022.” A SC progress note dated 05/25/2023 documented “Patient unavailable.” The clinical record contained no documentation of another attempted contact for May and no documented evidence of SC visits or missed visit documentation for February, March, April, and September 2023. Clinical Record 15: A physician’s order dated 01/29/2023 ordered “SW frequency will be 1x month and two prn to provide social emotional support for the patient and assess needs.” The IDG plan of care reviews dated from 01/31/2023 to 02/14/2023 documented “Social Worker will continue to provide support and assess needs at each monthly visit.” The clinical record contained no documented evidence of MSW visits or missed visit documentation for February, June, and July 2023. The IDG plan of care reviews dated from 01/31/2023 to 02/14/2023 documented SC “ 1x month and 2x PRN.” The clinical record contained no documented evidence of SC visits or missed visit documentation for January, February, March, May, and June 2023. During a joint record review and interview on 12/21/2023, the Director of Nursing confirmed that the records lacked evidence of missed visits documented Medical Social Worker and Spiritual Counselor visits according to the plan of care.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, observation, and interview. In 3 of 4 (75%) home visit observations, the organization did not ensure staff followed the agency’s hand hygiene policy. Agency policy IC.3 Hand Hygiene (11/01/2020) stated in part, “With hands held upright, staff will dry hands and wrists thoroughly with a clean paper towel. They will use a paper towel to turn off the faucet. If hands are not visibly soiled, staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: prior to initial entry into the supply bag and after removing gloves.” Home Visit 1: During home visit observation on 12/20/2023, the hospice aide was observed removing gloves and putting on a clean pair of gloves without washing the hands. The hospice aide was observed handling the trash and resuming patient care without changing gloves or washing hands. Home Visit 2: During home visit observation on 12/20/2023, the Registered Nurse (RN) was observed putting gloves on the hands and then checking the skin for a “rash.” The RN then used the phone without removing gloves and washing hands. Without removing the gloves or washing the hands, the RN was observed to enter the bag and removed a pulse oximeter, thermometer, blood pressure cuff, and a stethoscope on two occasions. The nurse was observed to not disinfect hands before returning the equipment to the bag. The RN did not disinfect hands each time the bag was entered. The RN was observed to perform wound care on three different wounds. The RN changed the gloves during each wound care procedure but did not wash hands each time gloves were changed. The RN was observed to wash hands between caring for each wound. Home Visit 3: During home visit observation 12/20/2023, the hospice aide was observed after washing hands to dry hands with a cloth hand towel on the towel holder in the patient’s bathroom and then turned off the faucet with the cloth hand towel. The Director of Nursing confirmed in an interview on 12/21/2023 that the staff did not follow the hand hygiene policy.”

“It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. All physician employees, and those under contract, must function under the supervision of the hospice medical director. This standard was not met as evidenced by document review, clinical record review, personnel record review, and interview which revealed that the hospice failed to ensure that hospice physicians providing care at alternative delivery sites functioned under the supervision of the hospice medical director. The agency provided the following list of Locations/Alternate Delivery Sites (ADS) and the active census for each site: Parent Location with 41 active patients. Location 1 with 42 active patients, the date the first patient elected the hospice benefit 09/01/2021. Location 2 with 2 active patients, the date the first patient elected the hospice benefit was 10/01/2023. Location 3 with 20 active patients, the date the first patient elected the hospice benefit was 01/03/2022. Location 4 with 14 active patients, the date the first patient elected the hospice benefit was 08/02/2021. Location 5 with 11 active patients, the date the first patient elected the hospice benefit was 09/27/2023. Location 6 with 30 active patients, the date the first patient elected the hospice benefit was 10/01/2022. Location 7 with 9 active patients, the date the first patient elected the hospice benefit was 06/01/2022. Location 8 with 24 active patients, the date the first patient elected the hospice benefit was 04/28/2021. Location 9 with 9 active patients, the date the first patient elected the hospice benefit was 05/01/2023. Location 10 with 66 active patients, the date the first patient elected the hospice benefit was 10/01/2022. Location 11 with 11 active patients, the date the first patient elected the hospice benefit was 03/17/2023. Location 12 with 58 active patients, the date the first patient elected the hospice benefit was 04/27/2021. Location 13 with 4 active patients, the date the first patient elected the hospice benefit was 06/01/2023. Location 14 with 7 active patients, the date the first patient elected the hospice benefit was 03/20/2023. Location 15 with 3 active patients, the date the first patient elected the hospice benefit was 10/16/2023. Location 16 with 2 active patients, the date the first patient election for the hospice benefit was 10/01/2023. Location 17 with 0 active patients. Clinical Record 4: Clinical record review revealed the Initial Certification of Terminal Illness dated 08/16/2023 to 11/13/2023 and the Recertification Physician Statement of Eligibility dated 11/14/2023 to 01/12/2024 were signed by the Hospice Physician/Staff 11. Clinical Record 5: Clinical record review revealed the Initial Certification of Terminal Illness dated 05/13/2023 to 08/10/2023 and the Recertification Physician Statement of Eligibility dated 08/11/2023 to 11/08/2023 were signed by the Hospice Physician/Staff 25. Clinical Record 6: Clinical record review revealed the Initial Certification of Terminal Illness dated 11/22/2023 to 02/19/2024 was signed by the Hospice Physician/Staff 24. Clinical Record 7: Clinical record review revealed the Initial Certification of Terminal Illness dated 04/06/2022 to 07/04/2022 and the Recertification Physician Statement of Eligibility dated 01/31/2023 to 03/31/2023, 12/02/2022 to 01/30/2023, 09/28/2023 to 11/26/2023, 07/05/2022 to 10/02/2022, 04/01/2023 to 05/30/2023, 07/30/2023 to 09/27/2023, 05/31/2023 to 07/29/2023, 10/03/2022 to 12/01/2022, and 11/27/2023 to 01/25/2024 were signed by the Hospice Physician/Staff 25. Clinical Record 9: Clinical record review revealed the Initial Certification of Terminal Illness dated 09/08/2023 to 11/06/2023 and the Recertification Physician Statement of Eligibility dated 11/07/2023 to 01/05/2024 were signed by the Hospice Physician/Staff 25. Clinical Record 10: Clinical record review revealed the Initial Certification of Terminal Illness dated 03/28/2023 to 06/25/2023 and the Recertification Physician Statement of Eligibility dated 06/26/2023 to 09/23/2023, 09/24/2023 to 11/22/2023, and 11/23/2023 to 01/21/2024 were signed by the Hospice Physician/Staff 25. Clinical Record 12: Clinical record review revealed the Initial Certification of Terminal Illness dated 10/30/2023 to 12/28/2023 and the Recertification Physician Statement of Eligibility dated 12/29/2023 to 02/26/2024 were signed by the Hospice Physician/Staff 25. Clinical Record 13: Clinical record review revealed the Initial Certification of Terminal Illness dated 12/01/2022 to 01/29/2023 and the Recertification Physician Statement of Eligibility dated 01/30/2023 to 03/30/2023, 03/23/2023 to 05/29/2023, 05/30/2023 to 07/28/2023, 07/29/2023 to 09/26/2023, 09/27/2023 to 11/25/2023 were signed by the Hospice Physician/Staff 25. Clinical Record 16: Clinical record review revealed the Recertification Physician Statement of Eligibility dated 09/28/2023 to 12/26/2023 was signed by the Hospice Physician/Staff 25. Clinical Record 17: Clinical record review revealed the Initial Certification of Terminal Illness dated 11/10/2022 to 02/07/2023 was signed by the Hospice Physician/Staff 24. Clinical Record 19: Clinical record review revealed the Initial Certification of Terminal Illness dated 04/10/2023 to 07/08/2023 was signed by the Hospice Physician/Staff 25. During an interview on 12/21/2023, the Administrator stated the Hospice Medical Director (Staff 10) oversees the parent location and locations 2, 7, 11, and 15. Hospice Physician (Staff 11) oversees location 12, Hospice Physician (Staff 24) oversees locations 1 and 14, and Hospice Physician (Staff 25) oversees locations 3, 4, 5, 6, 9, 10, 13, and 16. The Hospice Medical Director (Staff 10) was interviewed on 12/22/2023 and stated that she oversees the parent location and some other offices (locations 2, 7, 11, and 15). The Hospice Medical Director stated that she was “the main medical director” for the organization and oversees IDG (interdisciplinary group) for her locations. The Hospice Medical Director stated that she is available to the other medical directors (hospice physicians) remotely, but they make the decisions for patient care and certifications. The Hospice Medical Director stated, I don’t get involved all are physicians and can make their own decisions about care. I don’t need to babysit them. Hospice Physician (Staff 11), who also stated they were the Alternate Medical Director was interviewed on 12/22/2023 and stated she was the “Medical Director” for location 12. The Hospice Physician reported overseeing the medical treatment for patients, reviewing nurse practitioner assessments, and documenting in the electronic medical record. The Hospice Physician stated she handles the orders and frequently communicates with the leadership team at location 12 office, attends the IDG meetings every other week via Zoom, and oversees the medical management, discusses social needs, and reviews the patient notes. The Clinical Manager/Director of Nursing (Staff 2) for location 10 was interviewed on 12/22/2023 and stated that Hospice Physician (Staff 25) was the Medical Director for this location. The Clinical Manager/Director of Nursing for locations 6 and 16 was interviewed on 12/22/2023 and stated that Hospice Physician (Staff 25) was the Medical Director for these locations. Review of personnel records for Hospice Medical Director (Staff 10), Hospice Physician (Staff 11), Hospice Physician (Staff 24), and Hospice Physician (Staff 25) revealed all hospice physician contracts were identical and contained the same verbiage and did not designate the physician who assumed the responsibilities as the Medical Director for the hospice agency and did not include that hospice physicians’ function under the supervision of the hospice medical director. The agency did not ensure the Hospice Medical Director contract (Staff 10) included the designation and role responsibilities for the Medical Director of the hospice and did not ensure the Hospice Physician contracts for Staff 11, Staff 24, and Staff 25 included the designation that hospice physicians’ function under the supervision of the hospice medical director. The Administrator confirmed during an interview on 12/21/2023 that all physician contracts were identical and were titled, “Hospice Medical Director Contract Agreement.” Parent Location: 41 active patients. Location 1: 42 active patients. The date of the first patient election for the hospice benefit was 9/1/2021. Location 2: 2 active patients. The date of the first patient election for the hospice benefit was 10/1/2023. Location 3: 20 active patients. The date of the first patient election for the Hospice benefit was 1/3/2022. Location 4: 14 active patients. The date of the first patient election for the Hospice benefit was 8/2/2021. Location 5: 11 active patients. The date of the first patient election for the Hospice benefit was 9/27/2023. Location 6: 30 active patients. The date of the first patient election for the Hospice benefit was 10/1/2022. Location 7: 9 active patients. The date of the first patient election for the Hospice benefit was 6/1/2022. Location 8: 24 active patients. The date of the first patient election for the Hospice benefit was 4/28/2021. Location 9: 9 active patients. The date of the first patient election for the Hospice benefit was 5/1/2023. Location 10: 66 active patients. The date of the first patient election for the Hospice benefit was 10/1/2022. Location 11: 11 active patients. The date of the first patient election for the Hospice benefit was 3/17/2023. Location 12: 58 active patients. The date of the first patient election for the Hospice benefit was 4/27/2021. Location 13: 4 active patients. The date of the first patient election for the Hospice benefit was 6/1/2023. Location 14: 7 active patients. The date of the first patient election for the Hospice benefit was 3/20/2023. Location 15: 3 active patients. The date of the first patient election for the Hospice benefit was 10/16/2023. Location 16: 2 active patients. The date of the first patient election for the Hospice benefit was 10/1/2023. Location 17: 0 active patients.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN (Registered Nurse) who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 16 (12%) clinical records review with hospice aide services, the agency did not ensure the Registered Nurse prepared complete written patient care instructions for a hospice aide. Clinical Record 9: Review of the hospice aide plan of care dated 04/11/2023 assigned the aide visit frequency “two times a week.” A physician’s order dated 10/02/2023 ordered aide visit frequency increased and stated, “hospice aide three times a week.” The hospice aide frequency was not updated on the hospice aide plan of care. Clinical Record 10: The initial hospice aide plan of care assigned the hospice aide visit frequency “two times a week.” A physician’s order dated 08/15/2023 ordered aide visit frequency increased and stated hospice aide “three times a week.” The hospice aide frequency was not updated on the hospice aide plan of care. During a joint record review and interview on 12/21/2023, the Director of Nursing confirmed that the aide plans of care had not been updated with the most current visit frequency order.”

“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 4 of 16 (25%) clinical records reviewed with hospice aide services, the agency did not ensure the hospice aide provided services as ordered in the plan of care. Clinical Record 4: The hospice aide plan of care dated 08/16/2023 assigned the aide to provide visits “three times a week.” Clinical record review revealed the hospice aide provided two visits for the weeks of 10/01/2023 to 10/07/2023, 10/15/2023 to 10/21/2023, and 10/29/2023 to 11/04/2023, and the hospice aide did not provide visits the week of 10/22/2023 to 10/28/2023. Clinical Record 9: The hospice aide plan of care dated 04/11/2023 assigned the aide visit frequency “two times a week.” For the week of 05/14/2023 to 05/20/2023 an extra aide visit was completed on 05/19/2023, and for the week of 09/24/2023 to 9/30/2023 an extra aide visit was completed on 09/29/2023. A physician’s order dated 10/02/2023 ordered, “hospice aide three times a week.” Clinical record review revealed the hospice aide provided two visits for the weeks of 11/26/2023 to 12/02/2023 and 12/03/2023 to 12/09/2023, and one visit for the weeks of 11/05/2023 to 11/11/2023 and 11/12/2023 to 11/18/2023. Clinical Record 10: A physician’s order dated 08/15/2023 ordered, “hospice aide three times a week.” Clinical record review revealed the hospice aide provided one visit for the weeks of 09/03/2023 to 09/09/2023, 11/12/2023 to 11/18/2023, and 11/19/2023 to 11/25/2023. For the week of 08/27/2023 to 09/02/2023 an extra aide visit was completed on 09/01/2023. Clinical Record 12: The hospice aide plan of care dated 10/10/2023 assigned the hospice aide “frequency five times a week.” Clinical record review revealed the hospice aide provided four visits for the weeks of 11/19/2023 to 11/25/2023 and 12/03/2023 to 12/09/2023 and two visits for the week of 11/12/2023 to 11/18/2023. The hospice aide did not provide visits for the week of 11/05/2023 to 11/11/2023. The Director of Nursing confirmed in a joint record review and interview on 12/21/2023 that the hospice aides did not follow the plan of care for visit frequency.”

“It is required that a hospice operating multiple locations, also known as alternative delivery sites (ADS), ensures that each location is approved by Medicare as a multiple location before providing hospice care and services to Medicare patients. This standard was not met as evidenced by document review, observation, and interview that revealed the hospice failed to provide documents needed to prove the ADS was approved by CMS (Centers for Medicare and Medicaid Services). The [state] Health and Safety Code stated, HEALTH AND SAFETY CODE, TITLE 2. HEALTH. SUBTITLE G. LICENSES AND OTHER REGULATION. CHAPTER 142. HOME AND COMMUNITY SUPPORT SERVICES. SUBCHAPTER A. HOME AND COMMUNITY SUPPORT SERVICES LICENSE Sec. 142.001. DEFINITIONS. In this chapter: (2) “Alternate delivery site” means a facility or site, including a residential unit or an inpatient unit: (A) that is owned or operated by a hospice; (B) that is not the hospice’s principal place of business; (C) that is located in the geographical area served by the hospice; and (D) from which the hospice provides hospice services.” The [state] Administrative Code stated in part, “26 [state] Admin. Code §XXX.856. Section XXX.856 - Hospice Alternate Delivery Sites (a) If a hospice operates an ADS, the hospice must comply with this section. (b) A Medicare-certified hospice agency must have an ADS approved by CMS before providing Medicare-reimbursed hospice services to Medicare clients from the ADS. (c) An ADS must be part of the hospice and must share administration, supervision, and services with the parent agency. (d) In addition to the requirements in §XXX.242 of this chapter (relating to Organizational Structure and Lines of Authority), the lines of authority and professional and administrative control must be clearly delineated in the hospice’s organizational structure and in practice and must be traced to the parent agency. (e) The hospice must continually monitor and manage all services provided by its ADS to ensure that services are delivered in a safe and effective manner and to ensure that a client and the client’s family receives the necessary care and services outlined in the plan of care. 26 [state] Admin. Code §XXX.856. The provisions of this §XXX.856 adopted to be effective October 1, 2013, 38 [state] Reg 6628; Transferred from Title 40, Chapter 97 by [state] Register, Volume 44, Number 15, April 12, 2019, [state] Reg 1893, eff. May 1, 2019; Amended by [state] Register, Volume 46, Number 15, April 9, 2021, [state] Reg 2434, eff. April 25, 2021.” The Centers for Medicaid and Medicare Services Regulation and Guidance stated in section 2088 - Multiple locations, “When an existing hospice intends to add a multiple location, it must notify CMS, the SA, and, if deemed, it should notify its’ approved national AO, in writing, of the proposed location if it expects this location to participate in Medicare or Medicaid. The hospice must also submit a Form CMS-855A Change of Information Request (including all supporting documentation) to its MAC before CMS approval can be granted. The provider must obtain CMS approval of the new location before it is permitted to bill Medicare for services provided from the new location. There was no documented evidence that the agency notified CMS through the 855A and the state agency of the 17 ADS that are in operation as required by federal and state requirements. The surveyor visited the ADS office on 12/20/2023 and observed signage on the door with the contact information for deliveries. During home visit 4 to the ADS Location 12 review of the patient folder contained local phone numbers for contact and did not include contact information for the parent location. An interview was conducted with the Administrator on 12/18/2023. The Administrator stated that the agency included a parent location and 17 alternate delivery sites (ADS). The Administrator stated that each ADS location was fully functional and included an Executive Director, Clinical Manager, Interdisciplinary Group Meetings, and staffing. The Administrator then also stated that the seventeen ADS locations with active patient census are “drop sites,” and used to mail patient supplies and office supplies like name badges. The Administrator stated the locations do not have signage but can be used for meetings. The Administrator stated they considered making some of the more prominent locations “alternative delivery sites” but reported the 17 ADS locations have not been reported to CMS [Centers for Medicare and Medicaid Services] and they were unaware of the need to do so. The administrator provided a document of the agency’s ADS locations and current census but provided no documented evidence each ADS location had been approved by Medicare as a multiple location before providing hospice care and services to Medicare hospice patients. Document review revealed the following list of locations and active census: Parent Location with 41 active patients. Location 1 with 42 active patients, the date the first patient elected the hospice benefit 09/01/2021. Location 2 with 2 active patients, the date the first patient elected the hospice benefit was 10/01/2023. Location 3 with 20 active patients, the date the first patient elected the hospice benefit was 01/03/2022. Location 4 with 14 active patients, the date the first patient elected the hospice benefit was 08/02/2021. Location 5 with 11 active patients, the date the first patient elected the hospice benefit was 09/27/2023. Location 6 with 30 active patients, the date the first patient elected the hospice benefit was 10/01/2022. Location 7 with 9 active patients, the date the first patient elected the hospice benefit was 06/01/2022. Location 8 with 24 active patients, the date the first patient elected the hospice benefit was 04/28/2021. Location 9 with 9 active patients, the date the first patient elected the hospice benefit was 05/01/2023. Location 10 with 66 active patients, the date the first patient elected the hospice benefit was 10/01/2022. Location 11 with 11 active patients, the date the first patient elected the hospice benefit was 03/17/2023. Location 12 with 58 active patients, the date the first patient elected the hospice benefit was 04/27/2021. Location 13 with 4 active patients, the date the first patient elected the hospice benefit was 06/01/2023. Location 14 with 7 active patients, the date the first patient elected the hospice benefit was 03/20/2023. Location 15 with 3 active patients, the date the first patient elected the hospice benefit was 10/16/2023. Location 16 with 2 active patients, the date the first patient election for the hospice benefit was 10/01/2023. Location 17 with 0 active patients. An interview was conducted with the Administrator on 12/18/2023. The Administrator stated that the agency included a parent location and 17 alternate delivery sites (ADS). The Administrator further stated that these ADS locations were fully functioning locations complete with an Executive Director, Clinical Manager, Interdisciplinary Group Meetings, and staffing. The administrator provided documentation of the ADS location’s current census, which is as follows: Parent Location: 41 active patients. Location 1: 42 active patients. The date of the first patient election for the hospice benefit was 9/1/2021. Location 2: 2 active patients. The date of the first patient election for the hospice benefit was 10/1/2023. Location 3: 20 active patients. The date of the first patient election for the Hospice benefit was 1/3/2022. Location 4: 14 active patients. The date of the first patient election for the Hospice benefit was 8/2/2021. Location 5: 11 active patients. The date of the first patient election for the Hospice benefit was 9/27/2023. Location 6: 30 active patients. The date of the first patient election for the Hospice benefit was 10/1/2022. Location 7: 9 active patients. The date of the first patient election for the Hospice benefit was 6/1/2022. Location 8: 24 active patients. The date of the first patient election for the Hospice benefit was 4/28/2021. Location 9: 9 active patients. The date of the first patient election for the Hospice benefit was 5/1/2023. Location 10: 66 active patients. The date of the first patient election for the Hospice benefit was 10/1/2022. Location 11: 11 active patients. The date of the first patient election for the Hospice benefit was 3/17/2023. Location 12: 58 active patients. The date of the first patient election for the Hospice benefit was 4/27/2021. Location 13: 4 active patients. The date of the first patient election for the Hospice benefit was 6/1/2023. Location 14: 7 active patients. The date of the first patient election for the Hospice benefit was 3/20/2023. Location 15: 3 active patients. The date of the first patient election for the Hospice benefit was 10/16/2023. Location 16: 2 active patients. The date of the first patient election for the Hospice benefit was 10/1/2023. Location 17: 0 active patients. The Administrator further stated that these 17 ADS locations have not been reported to CMS, the agency is not in the process of the 855A application, and they were unaware of the need to do so.”

“It is required that a hospice operating multiple locations, also known as alternative delivery sites (ADS), shares administration, supervision, and services with the hospice issued the certification number. This standard was not met as evidenced by document review, clinical record review, and interview that revealed the hospice failed to ensure that the alternative delivery sites shared administrative, supervision, and services with the hospice issued the certification number. The [state] Health and Safety Code stated, HEALTH AND SAFETY CODE, TITLE 2. HEALTH. SUBTITLE G. LICENSES AND OTHER REGULATION. CHAPTER 142. HOME AND COMMUNITY SUPPORT SERVICES. SUBCHAPTER A. HOME AND COMMUNITY SUPPORT SERVICES LICENSE Sec. 142.001. DEFINITIONS. In this chapter: (2) “Alternate delivery site” means a facility or site, including a residential unit or an inpatient unit: (A) that is owned or operated by a hospice; (B) that is not the hospice’s principal place of business; (C) that is located in the geographical area served by the hospice; and (D) from which the hospice provides hospice services.” The [state] Administrative Code stated in part, “26 [state] Admin. Code §XXX.856. Section XXX.856 - Hospice Alternate Delivery Sites (a) If a hospice operates an ADS, the hospice must comply with this section. (c) An ADS must be part of the hospice and must share administration, supervision, and services with the parent agency. (d) In addition to the requirements in §XXX.242 of this chapter (relating to Organizational Structure and Lines of Authority), the lines of authority and professional and administrative control must be clearly delineated in the hospice’s organizational structure and in practice and must be traced to the parent agency. (e) The hospice must continually monitor and manage all services provided by its ADS to ensure that services are delivered in a safe and effective manner and to ensure that a client and the client’s family receives the necessary care and services outlined in the plan of care. 26 [state] Admin. Code §XXX.856. The provisions of this §XXX.856 adopted to be effective October 1, 2013, 38 [state] Reg 6628; Transferred from Title 40, Chapter 97 by [state] Register, Volume 44, Number 15, April 12, 2019, [state] Reg 1893, eff. May 1, 2019; Amended by [state] Register, Volume 46, Number 15, April 9, 2021, [state] Reg 2434, eff. April 25, 2021.” Document review revealed the following list of locations/Alternate Delivery Sites (ADS) and the active census for each site: Parent Location with 41 active patients. Location 1 with 42 active patients, the date the first patient elected the hospice benefit 09/01/2021. Location 2 with 2 active patients, the date the first patient elected the hospice benefit was 10/01/2023. Location 3 with 20 active patients, the date the first patient elected the hospice benefit was 01/03/2022. Location 4 with 14 active patients, the date the first patient elected the hospice benefit was 08/02/2021. Location 5 with 11 active patients, the date the first patient elected the hospice benefit was 09/27/2023. Location 6 with 30 active patients, the date the first patient elected the hospice benefit was 10/01/2022. Location 7 with 9 active patients, the date the first patient elected the hospice benefit was 06/01/2022. Location 8 with 24 active patients, the date the first patient elected the hospice benefit was 04/28/2021. Location 9 with 9 active patients, the date the first patient elected the hospice benefit was 05/01/2023. Location 10 with 66 active patients, the date the first patient elected the hospice benefit was 10/01/2022. Location 11 with 11 active patients, the date the first patient elected the hospice benefit was 03/17/2023. Location 12 with 58 active patients, the date the first patient elected the hospice benefit was 04/27/2021. Location 13 with 4 active patients, the date the first patient elected the hospice benefit was 06/01/2023. Location 14 with 7 active patients, the date the first patient elected the hospice benefit was 03/20/2023. Location 15 with 3 active patients, the date the first patient elected the hospice benefit was 10/16/2023. Location 16 with 2 active patients, the date the first patient election for the hospice benefit was 10/01/2023. Location 17 with 0 active patients. During an interview on 12/18/2023, the Administrator stated that the agency included a parent location and 17 alternate delivery sites (ADS). The Administrator stated that each ADS location was fully functional and included an Executive Director, Clinical Manager, Interdisciplinary Group Meetings, and staffing. The Administrator then also stated that the seventeen ADS locations with active patient census were “drop sites,” and are used to mail patient supplies and office supplies like name badges. During an interview on 12/22/2023, the Administrator was asked how the agency provides operational oversight of the parent location and the seventeen associated ADS (Locations 1 through 17). The Administrator stated the Alternate Administrator/Registered Nurse visits all the ADS locations monthly to provide education and has done this since the inception of the agency. The Administrator stated the visits were documented on the agency’s shared drive but did not have evidence of sign-in sheets or verification of the education provided. The Administrator was unable to provide evidence that the organization shared administration and supervision of services with all locations operating under the certification number of the parent agency. Review of the agency’s organizational chart included the “drop sites” within the responsibility of the Administrator and Director of Nursing. However, the agency was unable to demonstrate evidence of shared administrative oversight and supervision with the parent office and the ADS locations 1 through 17. During an interview on 12/22/2023, the Clinical Manager for Location 10 stated her job duties included conducting on-site visits, performing case management, preparing for the Interdisciplinary Group meetings every two weeks for the site, and auditing charts for Location 10. The Clinical Manger also stated that Hospice Physician (Staff 25) was the Medical Director for Location 10 and was unable to explain how the parent location provided administrative oversight and supervision for this location. During an interview on 12/22/2023, the Clinical Manager for Locations 6 and 16 stated her job duties included performing case management, ensuring the Interdisciplinary Group meetings were conducted every two weeks for the site, and conducting clinical supervisory visits for Locations 6 and 16. The Clinical Manger also stated that Hospice Physician (Staff 25) was the Medical Director for Locations 6 and 16 and was unable to explain how the parent location provided administrative oversight and supervision for this location. The Hospice Medical Director (Staff 10) was interviewed on 12/22/2023 and stated that she oversees the parent location and some other offices (Locations 2, 7, 11, and 15). The Hospice Medical Director stated that she was “the main medical director” for the organization and oversees IDG (interdisciplinary group) for her locations. The Hospice Medical Director stated that she is available to the other medical directors (hospice physicians) remotely, but they make the decisions for patient care and certifications. The Hospice Medical Director stated, I do not get involved all are physicians and can make their own decisions about care. I do not need to babysit them. Hospice Physician (Staff 11), who also stated she was the Alternate Medical Director was interviewed on 12/22/2023 and stated she was the “Medical Director” for Location 12. The Hospice Physician reported overseeing the medical treatment for patients, reviewing nurse practitioner assessments, and documenting in the electronic medical record. She stated she manages the physician orders for this location and frequently communicates with the leadership team at Location 12. The Hospice Physician attends the IDG meetings every other week via Zoom and oversees the medical management, discusses social needs, and reviews the patient notes. The Hospice Physician stated that the Hospice Medical Director (Staff 10) would be available if a question related to care came up, but that the Medical Director did not provide routine administrative oversight for this location (Location 12). The agency was unable to provide evidence that the parent agency with certification number shared administrative and supervisory oversight of ADS/Locations 1 through 17 at the conclusion of the site visit on 12/22/2023. Parent Location: 41 active patients. Location 1: 42 active patients. The date of the first patient election for the hospice benefit was 9/1/2021. Location 2: 2 active patients. The date of the first patient election for the hospice benefit was 10/1/2023. Location 3: 20 active patients. The date of the first patient election for the Hospice benefit was 1/3/2022. Location 4: 14 active patients. The date of the first patient election for the Hospice benefit was 8/2/2021. Location 5: 11 active patients. The date of the first patient election for the Hospice benefit was 9/27/2023. Location 6: 30 active patients. The date of the first patient election for the Hospice benefit was 10/1/2022. Location 7: 9 active patients. The date of the first patient election for the Hospice benefit was 6/1/2022. Location 8: 24 active patients. The date of the first patient election for the Hospice benefit was 4/28/2021. Location 9: 9 active patients. The date of the first patient election for the Hospice benefit was 5/1/2023. Location 10: 66 active patients. The date of the first patient election for the Hospice benefit was 10/1/2022. Location 11: 11 active patients. The date of the first patient election for the Hospice benefit was 3/17/2023. Location 12: 58 active patients. The date of the first patient election for the Hospice benefit was 4/27/2021. Location 13: 4 active patients. The date of the first patient election for the Hospice benefit was 6/1/2023. Location 14: 7 active patients. The date of the first patient election for the Hospice benefit was 3/20/2023. Location 15: 3 active patients. The date of the first patient election for the Hospice benefit was 10/16/2023. Location 16: 2 active patients. The date of the first patient election for the Hospice benefit was 10/1/2023. Location 17: 0 active patients.”

“It is required that a hospice continually monitors and manages all services provided at each of its multiple locations to ensure services are delivered in a safe and effective manner, each patient and family receives the necessary care and services outlined in the plan of care, and the scope of care and services is the same as offered directly or under contract at the location with the certification number. This standard was not met as evidenced by document review and interview revealed the agency failed to ensure that the hospice continually monitors and manages all services provided at each of its multiple locations to ensure services are delivered in a safe and effective manner. The [state] Administrative Code stated in part, “26 [state] Admin. Code §XXX.856 Section XXX.856 - Hospice Alternate Delivery Sites (a) If a hospice operates an ADS, the hospice must comply with this section. (e) The hospice must continually monitor and manage all services provided by its ADS to ensure that services are delivered in a safe and effective manner and to ensure that a client and the client’s family receives the necessary care and services outlined in the plan of care. 26 [state] Admin. Code §XXX.856. The provisions of this §XXX.856 adopted to be effective October 1, 2013, 38 [state] Reg 6628; Transferred from Title 40, Chapter 97 by [state] Register, Volume 44, Number 15, April 12, 2019, [state] Reg 1893, eff. May 1, 2019; Amended by [state] Register, Volume 46, Number 15, April 9, 2021, [state] Reg 2434, eff. April 25, 2021.” There was no documented evidence that the parent agency was involved in communication, coordination of care, the Interdisciplinary Group, and oversight with the ADS as related to the safe and effective delivery of care. Document review revealed the following list of locations/Alternate Delivery Sites (ADS) and the active census for each site: Parent Location with 41 active patients. Location 1 with 42 active patients, the date the first patient elected the hospice benefit 09/01/2021. Location 2 with 2 active patients, the date the first patient elected the hospice benefit was 10/01/2023. Location 3 with 20 active patients, the date the first patient elected the hospice benefit was 01/03/2022. Location 4 with 14 active patients, the date the first patient elected the hospice benefit was 08/02/2021. Location 5 with 11 active patients, the date the first patient elected the hospice benefit was 09/27/2023. Location 6 with 30 active patients, the date the first patient elected the hospice benefit was 10/01/2022. Location 7 with 9 active patients, the date the first patient elected the hospice benefit was 06/01/2022. Location 8 with 24 active patients, the date the first patient elected the hospice benefit was 04/28/2021. Location 9 with 9 active patients, the date the first patient elected the hospice benefit was 05/01/2023. Location 10 with 66 active patients, the date the first patient elected the hospice benefit was 10/01/2022. Location 11 with 11 active patients, the date the first patient elected the hospice benefit was 03/17/2023. Location 12 with 58 active patients, the date the first patient elected the hospice benefit was 04/27/2021. Location 13 with 4 active patients, the date the first patient elected the hospice benefit was 06/01/2023. Location 14 with 7 active patients, the date the first patient elected the hospice benefit was 03/20/2023. Location 15 with 3 active patients, the date the first patient elected the hospice benefit was 10/16/2023. Location 16 with 2 active patients, the date the first patient election for the hospice benefit was 10/01/2023. Location 17 with 0 active patients. During an interview on 12/18/2023, the Administrator stated that the agency included a parent location and 17 alternate delivery sites (ADS). The Administrator stated that each ADS location was fully functional and included an Executive Director, Clinical Manager, Interdisciplinary Group Meetings, and staffing, independent of the parent office. During an interview on 12/22/2023, the Administrator was asked how the agency monitors and manages all services provided at the parent location and the seventeen associated ADS (Locations 1 through 17) to ensure services are delivered in a safe and efficient manner. The Administrator stated the Alternate Administrator/Registered Nurse visits all the ADS locations monthly to provide education and has done this since the inception of the agency. The Administrator stated the visits were documented on the agency’s shared drive but did not have evidence of sign-in sheets or verification of the education provided. The Administrator was unable to provide evidence that the organization monitored and managed the delivery of patient services provided at all locations. The Hospice Medical Director (Staff 10) was interviewed on 12/22/2023 and stated that she oversees the parent location and some other offices. The Hospice Medical Director stated that she was “the main medical director” for the organization and oversees IDG (interdisciplinary group) for her locations. The Hospice Medical Director stated that she is available to the other medical directors (hospice physicians) remotely, but they make the decisions for patient care and certifications. The Hospice Medical Director stated, I don’t get involved all are physicians and can make their own decisions about care. I don’t need to babysit them. During an interview on 12/22/2023, the Clinical Manager for Location 10 stated her job duties included conducting on-site visits, performing case management, preparing for the Interdisciplinary Group meetings every two weeks for the site, and auditing charts for Location 10. The Clinical Manger also stated that Hospice Physician (Staff 25) was the Medical Director for Location 10 and was unable to explain how the parent location monitored and managed the services provided at this location. During an interview on 12/22/2023, the Clinical Manager for Locations 6 and 16, and stated her job duties included performing case management, ensuring the Interdisciplinary Group meetings were conducted every two weeks for the site, and conducting clinical supervisory visits for Locations 6 and 16. The Clinical Manger also stated that Hospice Physician (Staff 25) was the Medical Director for Locations 6 and 16 and was unable to explain how the parent location monitored and managed the services provided at this location. During the site visit the agency was unable to provide documented evidence that the parent location monitored and managed the services delivered by employees or contract staff at the ADS/Locations 1 through 17. The agency was unable to provide documented evidence of clinical record reviews or chart audits that included review of the outcomes of care provided at each ADS. The agency was unable to provide evidence that the Hospice Medical Director provided oversight of the care and services provided at ADS/Locations 1 through 17. There was no documented evidence that the agency’s Director of Nursing provided oversight for the field staff at each ADS/Locations 1 through 17. A review of the hospice’s current state license revealed that the agency is licensed for the state of Texas. Parent Location: 41 active patients. Location 1: 42 active patients. The date of the first patient election for the hospice benefit was 9/1/2021. Location 2: 2 active patients. The date of the first patient election for the hospice benefit was 10/1/2023. Location 3: 20 active patients. The date of the first patient election for the Hospice benefit was 1/3/2022. Location 4: 14 active patients. The date of the first patient election for the Hospice benefit was 8/2/2021. Location 5: 11 active patients. The date of the first patient election for the Hospice benefit was 9/27/2023. Location 6: 30 active patients. The date of the first patient election for the Hospice benefit was 10/1/2022. Location 7: 9 active patients. The date of the first patient election for the Hospice benefit was 6/1/2022. Location 8: 24 active patients. The date of the first patient election for the Hospice benefit was 4/28/2021. Location 9: 9 active patients. The date of the first patient election for the Hospice benefit was 5/1/2023. Location 10: 66 active patients. The date of the first patient election for the Hospice benefit was 10/1/2022. Location 11: 11 active patients. The date of the first patient election for the Hospice benefit was 3/17/2023. Location 12: 58 active patients. The date of the first patient election for the Hospice benefit was 4/27/2021. Location 13: 4 active patients. The date of the first patient election for the Hospice benefit was 6/1/2023. Location 14: 7 active patients. The date of the first patient election for the Hospice benefit was 3/20/2023. Location 15: 3 active patients. The date of the first patient election for the Hospice benefit was 10/16/2023. Location 16: 2 active patients. The date of the first patient election for the Hospice benefit was 10/1/2023. Location 17: 0 active patients. There was no evidence presented during the site visit that the parent location monitored any services delivered by employees or contract staff at the ADS. There was no documented evidence of clinical record reviews or contract reviews conducted at the ADS. There was no documented evidence of visits to the ADS nor documentation of participation by the medical director’s oversight or involvement in any ADS (except Locations 11, 2, 7, and 15) IDG meetings. There was no evidence of any QAPI documentation for the individual ADS locations. The field staff reported to the ADS location’s Clinical Manager, not the Director of Nursing. There was no documented evidence of state-wide meetings or in-service training (per the individual ADS sites).”

“It is required that a hospice may contract for medical director services with either a self-employed physician or a physician employed by a professional entity or physician group. The contract specifies the physician who assumes the medical director responsibilities and obligations. This standard was not met as evidenced by interview and personnel record review. Document review revealed the following list of locations/Alternate Delivery Sites (ADS) and the active census for each site: Parent Location with 41 active patients. Location 1 with 42 active patients, the date the first patient elected the hospice benefit 09/01/2021. Location 2 with 2 active patients, the date the first patient elected the hospice benefit was 10/01/2023. Location 3 with 20 active patients, the date the first patient elected the hospice benefit was 01/03/2022. Location 4 with 14 active patients, the date the first patient elected the hospice benefit was 08/02/2021. Location 5 with 11 active patients, the date the first patient elected the hospice benefit was 09/27/2023. Location 6 with 30 active patients, the date the first patient elected the hospice benefit was 10/01/2022. Location 7 with 9 active patients, the date the first patient elected the hospice benefit was 06/01/2022. Location 8 with 24 active patients, the date the first patient elected the hospice benefit was 04/28/2021. Location 9 with 9 active patients, the date the first patient elected the hospice benefit was 05/01/2023. Location 10 with 66 active patients, the date the first patient elected the hospice benefit was 10/01/2022. Location 11 with 11 active patients, the date the first patient elected the hospice benefit was 03/17/2023. Location 12 with 58 active patients, the date the first patient elected the hospice benefit was 04/27/2021. Location 13 with 4 active patients, the date the first patient elected the hospice benefit was 06/01/2023. Location 14 with 7 active patients, the date the first patient elected the hospice benefit was 03/20/2023. Location 15 with 3 active patients, the date the first patient elected the hospice benefit was 10/16/2023. Location 16 with 2 active patients, the date the first patient election for the hospice benefit was 10/01/2023. Location 17 with 0 active patients. During an interview on 12/21/2023, the Administrator stated the Hospice Medical Director (Staff 10) oversees the parent location and locations 2, 7, 11, and 15. Hospice Physician (Staff 11) oversees location 12, Hospice Physician (Staff 24) oversees locations 1 and 14, and Hospice Physician (Staff 25) oversees locations 3, 4, 5, 6, 9, 10, 13, and 16. During an interview on 12/22/2023, the Hospice Medical Director (staff 10) confirmed he/she was “the main Medical Director” for the hospice. Review of personnel records for Medical Director (staff 10), Hospice Physician (staff 11), Hospice Physician (staff 24), and Hospice Physician (staff 25) revealed all hospice physician contracts were identical and contained the same verbiage and did not designate the physician who assumed the responsibilities as the Medical Director for the hospice agency. The agency did not ensure the Hospice Medical Director contract (staff 10) included the designation and role responsibilities for the Medical Director of the hospice and did not ensure the Hospice Physician contracts for staff 11, staff 24, and staff 25 included the designation of hospice physician with roles and responsibility for the hospice physician role. Contracts for Hospice Medical Director and Alternates were reviewed, and it revealed that all contracts lacked identification of the Medical Director who assumes the Medical Director’s responsibilities and obligations as all contracts contain identical verbiage. Staff 10: Hospice Medical Director, Staff 11: Alternate Medical Director, Staff 24 Alternate Medical Director, and Staff 25 Alternate Medical Director”

“It is required that 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 1 of 19 (5%) clinical records reviewed, the agency did not ensure the signed consent included the date of election. Clinical Record 11: The patient elected the hospice benefit on 11/09/2023. The consent form signed and dated 11/09/2023, had a space for the date of election, but the space and box were left blank. The Administrator confirmed in an interview on 12/19/2023 that the patient’s signed consent did not include the hospice date of election.”

“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 and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed with discharged/transfer, the agency did not ensure the discharge summary was sent to the receiving Medicare/Medicaid certified facility. Clinical Record 16: Clinical record review revealed the patient was transferred to another hospice provider on 12/01/2023. The clinical record contained no documented evidence that the discharge summary was forwarded to the receiving hospice. During a joint record review and interview on 12/21/2023, the Director of Nursing confirmed that the record lacked evidence that the discharge summary was sent to the receiving hospice provider.”

“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 1 of 2 (50%) clinical records reviewed with live discharge, the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 16: Clinical record review revealed no documented evidence that the discharge summary dated 12/01/2023 was forwarded to the patient’s attending physician. During a joint record review and interview on 12/21/2023, the Director of Nursing confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.”