Jomel Palliative and Hospice Care, Inc.

“Based on records reviewed and interviews, the hospice comprehensive assessments of 5 of 8(patients 4, 5, 6, 7, and 8) patients failed to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be met in order to promote the hospice patients’ and families’ well-being throughout the dying process. In that, the hospice failed to ensure that the content of the initial comprehensive assessments accurately reflected the patients’ current health status. The physical assessments of IDG members (the age, MAC, FAST and other parameters), completed within a few days of each other, contained discrepancies in the patients’ age, weight, mid-arm circumference measurements, functional abilities, and diagnosis. The assessment did not provide an accurate baseline from which to provide appropriate care and services to meet each patient’s needs. This failure placed the patients at risk of not receiving appropriate care and services due to the inconsistencies of the assessments not giving an adequate picture of the patients’ decline, stability or improvement. Findings include: Patient #4benefit period 06/02/2023 – 08/30/2023.Review of patient #4’s electronic clinical records (ECR) for the above benefit period revealed the following clinical records amongst others: a physician order, RN recertification assessment, Nurse Practitioner Face-to-face assessment, and written Certification of terminal illness documents. Review of the physician orders dated 05/31/2023 revealed patient #4’s terminal diagnosis as Chronic Obstructive Pulmonary Disease (COPD) - A common lungs disease that causes restricted airflow and breathing problems. Review of recertification assessment visit document conducted by RN C on 08/30/2023 revealed patient’s terminal diagnosis as COPD along with other comorbidities that consisted of Essential Hypertension (elevated blood pressure), bipolar disorder ( A mental illness that causes unusual mood swings that range from extreme high moods (known as mania or manic) to extremely low moods (depression or depressive), and chronic pain (This refers to persisted pain that lasts for more than three months). RN C also recorded in the recertification assessment document patient #4’s oxygen saturation level as 96% on room air and patient’s mid arm circumference (MAC) as 22cm. RN C also indicated in the recertification assessment record that patient #4 was able to be weighed, but there was no record that RN C weighed the patient during the visit. However, RN C stated in the assessment narrative on page 24 of recertification assessment document, that patient #4 had a 2-5lbs weight loss within the recent month, and a mid-arm circumference decrease from 26cm to 22cm within the past 6 months. RN C further reported that patient #4 had a Karnofsky performance status rate (KPS- a clinical tool used to assess a patient’s functional status and ability to perform daily activities or tasks) of 40% which means patient was disabled and required special care and assistance in performing activities of daily living such as eating, bathing, dressing, and personal grooming activities. The RN C also assessed patient #4 and assigned him a FAST rating of 7C on a Functional assessment staging (a tool used to assess the functional capability of dementia (is group of conditions that cause a decline in the cognitive abilities, memory, and thinking skills that interfere with daily life). Review of patient #4’s clinical records does not show that patient had a dementia diagnosis. Review of the Nurse Practitioner’s F2F assessment document dated 08/12/2023 revealed the following clinical information about patient #4: NP stated that patient had episodes of confusion and memory loss and assigned patient KPS score of 50% which means that the patient required considerable assistance and frequent medical care. The NP also noted that the patient lost 5lbs of body weight within the past month. Review of written certificate of terminal illness dated 08/30/2023, the hospice medical director stated that patient lost 5lbs in the last 30 days and assigned a KPS score of 50% which meant patient required considerable assistance and frequent medical care. However, few lines down the same narrative the hospice medical director assigned patient #4 another KPS Score of 40% (which means patient was disabled and required special care and assistance in performing activities of daily living such as eating, bathing, dressing, and personal grooming activities.) and a FAST score of 7C which means patient had lost ambulatory abilities and needed personal assistance to walk. The hospice Medical Director also noted patient #’s MAC as 30cm. Benefit Period: 08/31/2023 – 10/29/2023 Review of patient #4’s ECR for benefit period 08/31/2023 – 10/29/2023 revealed the following conflicting assessment documentation from hospice Nurses, the Nurse Practitioner, and hospice medical director: Review of RN C recertification assessment document dated 10/25/2023, the RN recorded patient #4’s O2 Sat as 96% on room air and patient’s MAC as 23cm, but review of the visit Summary narrative, the nurse recorded that patient’s O2 saturations ranged from low 80’s – low 90s during the benefit period and also noted the patient’s MAC as 22cm. Review of patient #4’s Nursing visits notes dated 08/04/2023 and 10/20/2023 noted patient’s O2 Sat of 95% and other nurses’ visit notes dated 08/14/23, 08/25/23 and 08/30/23 all recorded patient’s oxygen saturations of 96% on room air. Further review of patient #4’s nursing visits notes during this benefit period showed no records of patient’s oxygen saturation in the 80s. The nurse further rated patient’s Karnofsky (KPS) as 40% (which means patient was disabled and required special care and assistance in performing activities of daily living such as eating, bathing, dressing, and personal grooming activities.). Review of NP’s face-to-face assessment document dated 08/12/2023 the Nurse partitioner assigned patient a KPS rating of 50% which meant patient required considerable assistance and frequent medical care. The NP further noted that patient #6 lost 5lbs in the last month. Further review of the F2F document had no record that the NP weighed the patient during the visit or prior weights on record. Review of the Hospice Medical Director Recertification CTI dated 10/25/2023, the hospice personnel stated in part, “…Over the past six months, she has faced challenges with multiple medication adjustments, hospitalizations, and visits to the emergency department. These experiences had significantly impacted on her 6-month prognosis, elevating her risk of mortality. Her appetite is poor, resulting in a weight loss of 13 pounds in the past 2 months…” Review of Patient’s clinical records from start of care date 03/04/2023 to 10/29/2023 showed no documentation that patient had any ER visit or hospital admissions. benefit period 10/30/23 – 12/28/23:Review of patient #4’s ECR for benefit period 10/30/23 – 12/28/23 revealed the following conflicting assessment documentation from hospice Nurses, the Nurse Practitioner, and hospice medical director: Review of the NP’s F2F assessment document conducted on 12/23/23 the NP documented that in the last six months patient had multiple hospitalizations and ER visits that had adversely affected patient’s 6 months prognoses which had increased patient’s mortality risk. The NP also stated that patient #6 had lost 5 pounds within the last month. Review of the RN recertification document dated 12/26/23 the Nurse recorded patient’s O2 saturation as 92% on room air at the beginning of the document and 96% on room air on page 13 of the same document.On page 15 of the recertification assessment document the RN recorded 12/27/23 as the date of the last bowel movement for a visit that was supposedly conducted on 12/26/23. On page 21 of the recertification document the RN wrote that Patient needs assistance with 0/6 ADLS and 0/8 IADLS, but few lines down the same document the nurse wrote that patient needs assistance with ADLS and ambulation due to unsteady gait and poor balance/endurance and chronic pain. The RN also stated that patient’s oxygen saturation ranged from mid-80’s to low 90s as patient has history of COPD and still continues to smoke. Review of all nursing visits notes during the benefit period had no visit notes with patient’s Oxygen saturation in the 80’s but there was one visit note – the recertification visit note dated 12/26/2023 the nurse recorded that patient’s oxygen saturation was 92% on room air. Review of complaint #573493 general intake document states in part, “The XXXX found a pattern of instances where documentation from the provider failed to align with the beneficiaries’ true clinical conditions, which raises quality concerns. The documentation was found to be conflicting, repetitive, and often inaccurate…The quality-of-care concerns for hospice services are multifaceted and stem from various inconsistencies and inaccuracies in beneficiary documentation. Specific examples include conflicting measurements, inconsistent oxygen saturation levels, weight discrepancies, and inconsistent discharge documentation. The certifying physician and FNP repeatedly documented multiple hospitalizations and emergency department visits that were not supported by the beneficiary’s’ Medicare billing history. There were discrepancies in the documentation of the beneficiary’s mid-arm circumference measurements and weights. The documentation also showed conflicting information regarding the beneficiary’s New York Heart Association (NYHA) classification, which is essential for assessing the severity of cardiac disease. These inconsistencies made it difficult to determine an accurate clinical status of the beneficiary… However, according to the beneficiary’s Medicare billing history, from admission to hospice services, the beneficiary only had one visit to theemergency department on February 25, 2024, for dyspnea and osteoarthritis of the knee…” Patient #5 Benefit Period: 10/07/2022 – 12/05/2022 Review of the physician written certificate of terminal illness signed by Hospice Medical director on 10/07/2022 revealed patient’s terminal diagnosis as Heart failure (a heart condition that weakens the heart muscle and makes the heart unable to pump blood as it should) along with other comorbidities such as Hypertension(also known as high blood pressure), PVD(Peripheral vascular disease – a conditions where the arteries of the limbs – arms legs, and feet become narrow or blocked thereby reducing the blood flow to these areas), Hypertension (High blood pressure), chronic fatigue (Extreme exhaustion), anxiety (Feelings of fear or worry that interferes with one’s daily activities). The hospice physician also rated patient’s Karnofsky Score as 30% (Severely disabled; hospital admission is indicated although death not imminent) and Fast is 7C (Ambulatory ability is lost (cannot walk without personal assistance). Review of patient’s CTI further revealed that patient’s left foot was amputated after patient was hospitalized for sepsis (A life threatening condition that happens when one’s body reacts to an infection) and necrotic (dead body tissues that result from decreased or no blood flow to the area, infection or injury) left foot and that patient’s health status had rapidly declined since his hospitalization. The hospice physician also reported that the patient had New York’s Heart Association CHF functional scale rating of class IV (meaning physical activity causes discomfort to the patient). RN Initial comprehensive assessment: Review of patient #5’s initial comprehensive Nursing assessment conducted on 10/07/22 by RN B revealed the following information:- O2 SAT on admission was 94%.- That patient #5’s Karnofsky Performance Status Scale 30% (meaning patient was Severely disabled; hospital admission is indicated although death not imminent)- Functional Assessment Staging (FAST) was rate at 7C (Ambulatory ability is lost, patient cannot walk without personal assistance)- Patient #5 was recently hospitalized for sepsis and underwent surgery to have a necrotic left foot amputated.- The patient was dependent on 0/6 ADLS and 0/8 IADLS- Patient is bed-confined with stage 3 nonhealing open wound on the left heel.- Patient is a class IV of NYHA (physical activity causes discomfort). Review of NP F2F dated 10/07/2022 by NP revealed the following information:- Patient was 68y/o male admitted for hospice services for terminal heart failure. - After being hospitalized for sepsis and necrotic right foot, the patient’s right foot was amputated. Since he was hospitalized, his health has deteriorated drastically. - An open wound on the right plantar side of the right foot is at stage 3 and not healing. - The patient is bed-confined The patient has been hospitalized several times over the past 6 to 12 months and has frequented the Emergency Department. Patient #6 Benefit Period: 09/13/22 – 10/18/2022 Review of patient #4’s ECR for benefit period 09/13/22 – 10/18/2022 revealed the following conflicting and sometimes repetitive patient’s assessment documentation from hospice Nurses, the Nurse Practitioner, and hospice medical director: Review of patient’s written certificate of terminal illness signed and dated by hospice medical director on 09/13/2022 revealed patient was admitted to hospice services with the terminal diagnoses of congestive heart failure (a chronic condition which makes the heart not pump blood as it should) with other comorbidities of PVD(Peripheral vascular disease – a conditions where the arteries of the limbs – arms legs, and feet become narrow or blocked thereby reducing the blood flow to these areas), Hypertension (High blood pressure), chronic fatigue (Extreme exhaustion), anxiety (Feelings of fear or worry that interferes with one’s daily activities), depression (A common mental health disorder that is characterized by persistent feelings of sadness, hopelessness, and loss of interest, or pleasure in activities), and insomnia (refers to trouble falling asleep, staying asleep usually through the night or waking too early in the morning). The medical director also rated patient class IV on the New York Heart Association functional ability assessment which means any form of physical activity causes discomfort to the patient. The hospice medical director also stated that the patient had memory deficits and impairment, loss of ability to carry out everyday tasks, continuous decline in thinking, and behavioral and social skills that disrupt patient’s ability to function independently. The physician assigned patient the Palliative Performance Score or Karnofsky ability to function independently. Palliative Performance Score or Karnofsky score of 40% (meaning patient was totally disabled). Review of patient #6’s initial RN comprehensive assessment conducted by RN A on 09/13/2022 revealed the following information: Patient had 2+ edema(swelling) on the lower extremities. Patient weighed 166lbs. MAC was 28cm. That patient had low o2 saturation and was short of breath on exertion. Also, that patient had frequent ER visits and hospitalizations in the past 6-12 months. Review of complaint general intake document stated that per patient #6’s MEDICARE billing records patient did not have any ER visits or hospitalization from the inception of patient’s admission to the hospice care Review of the RN A’s recertification assessment dated 10/18/2022 document, the nurse recorded patient’s O2 saturation as 96% on room air, patient’s actual weight as 175lbs, patient’s MAC as 37.3cm.RN A also stated that patient #6 had frequent ER visits and hospitalization in the past regarding his signs and symptoms of heart failure. However, the Review of complaint general intake document stated that per patient #6’s MEDICARE billing records patient did not have any ER visits or hospitalization since patient got admitted to the hospice service. Review of NP’s F2F dated 10/03/2022 the NP documented that patient #6 had multiple ER visits and hospitalizations in the past 6 12 months.The NP also stated in the record review that patient #6 had lost 10lbs in the last two months and patient was eating 50% of two out of 3 meals. The NP also stated that patient #6 was qualified for hospice services due to his continued decline in cognitive and bodily fitness. Benefit period 10/19/2022 -12/17/2022 Review of the NP’s F2F assessment document dated 11/17/22 the NP stated that patient had frequently visited the ER and had been hospitalized several times within the past 6 to 12months.Review of patient clinical records showed no report of patient’s frequent visits to the ER or multiple hospitalizations from the initial benefit period which started on 09/13/22 to this benefit period and patient was a transfer admit from another provider with no prior clinical records in the hospice ECR for review. Review of patient #6’s ECR from initial benefit period 09/13/22 -12/17/2022 had no record of patient’s ER visits or hospital admissions. Review of RN Recertification assessment document dated 12/17/22 conducted by (DON), the RN documented patient’s weight as 171lbs and MAC as 17cm.The RN also noted that patient #6 resided in an apartment and not in a Personal care homeA review of MSW A’s initial assessment dated 11/07/2022 revealed that the patient resided in a PCH. Review of CTI written on 12/17/22 by Medical Director, the doctor stated that patient was admitted to the Hospice/Palliative Care services on 04/22/2022. Review of patient’s clinical records revealed patients were admitted to hospice agency on 09/13/22 as a transfer patient. The Physician also documented that patient had an unintentional weight loss of 15lbs in the last 4 months. Review of the patient’s Nursing initial comprehensive assessment dated 09/13/2022 noted patient’s weight as 166lbs and the nursing recertification assessment dated 10/18/2022 recorded the patient’s weight as 175lbs and the 12/17/2022 nursing reassessment document recorded that the patient weighed 171lbs respectively. Benefit Period 12/18/2022 -02/15/2023Review of the NP’s face-to-face assessment document dated 01/19/2023, the NP stated in her narrative that patient had significant functional decline that had caused him to frequently visit the ER and to be admitted in the hospital several times in the last 6 to 12months. However, review of patient’s clinical records since his admission on 09/13/2022 to the hospice agency to 02/15/2023 benefit period showed no record(s) of patient visiting the ER or being admitted to the hospital. Review of patient #6’s recertification dated 02/13/2023 conducted by RN B, the Nurse recorded patient’s O2 Sat as 96% on room air, patient’s MAC as 24 cm, and the patient’s weight as 160lbs. Review of patient’s CTI dated 02/13/2023 the Medical Director stated that patient was admitted to the Hospice and Palliative Care services on 09/13/2022. The Physician further stated that patient #6 had unintentional weight loss of 15 lbs over the past 6months. However, review of patient’s initial nursing comprehensive assessment document dated 09/13/2022 the nurse recorded patient’s weight on admission as 166lbs, and the nursing recertification assessment dated 02/13/23 RN B reported patient #6’s weight as 160lbs. Review of the complaint #573493 general intake document regarding patient’s hospice benefit report reads in part, “The quality-of-care concern for hospice services revolves around several critical discrepancies in the documentation and clinical evaluations. There were conflicting records regarding the beneficiary’s hospitalizations and emergency department visits, with no adequate follow-up or clinical concern documented. There were inconsistencies in the recorded weight loss amounts, making it difficult to determine the accuracy of the beneficiary’s actual weight loss. Lastly, there were contradictory notes about the beneficiary’s living situation and caretaker status, raising questions about the accuracy of the documentation and the clinical staff’s firsthand knowledge of the beneficiary’s circumstances. These discrepancies suggested a lack of thorough evaluation and reliable documentation… Per the beneficiary’s Medicare billing history, from admission to hospice services, the beneficiary did not have any inpatient nor outpatient hospitalizations throughout the dates of service on review…” Patient #7 Hospice Benefit Period 09/18/22 – 12/14622: Record review of the patient clinical record showed a SOC date of 09/18/22 with hospice benefit period of 09/18/22 – 12/16/22 with a terminal diagnosis of Alzheimer’s disease (a disease that affects the brain). The record revealed that the patient elected hospice services on 09/18/22 and was 89 years old upon admission based on the patient date of birth on the clinical record. Further review of the clinical record showed that RN-A documented on the SOC assessment that the patient was a 79-year-old female with a different last name (#other identifier). further review of the patient’s assessment showed that the RN-A documented that the patient weighed 142 pounds, a FAST (Functional Assessment Staging Test) score of 6D (urinary incontinence), a MAC (Mid-Arm Circumference) measurement of 26 centimeters, and a weight loss of 5 pounds over last month. The clinical record also showed a POC dated 09/18/22 with a documentation that the patient was a 90-year-old female with a FAST score of 6E (meaning patient was fecal incontinence). A review of the MSW Assessment note dated 09/20/22 showed that MSW-A documented that patient #7 was an 89-year-old female. A review of the physician written certification dated 09/18/22 showed the hospice Medical Director documented that the patient was a 69-year-old female who had a weight loss of over 10 pounds in the last 2 months, a MAC measurement of 21.5 centimeters, a Palliative Performance Scale (PPS) score of 40%, (meaning patient was disabled), and a FAST score of 6E (meaning patient was fecal incontinence). A review of the RN recertification note dated 12/12/22 showed that the RN-A documented that the patient was a 79-year-old female with a different last name, which was the same last name that was documented in the start of care assessment (#another identifier). the RN-A also documented that the patient had a recent weight loss of 5 pounds over the past 60 days. A review of the entire benefit period 09/18/22 – 12/16/22 revealed inconsistent and conflicting documentation regarding patients’ clinical condition and assessments. Hospice Benefit Period 05/16/23 – 07/14/23: Record review of the patient #7 hospice benefit period 05/16/23 – 07/14/23 revealed a POC dated 06/08/23 with a documentation that the patient was a 90-year-old female with a terminal diagnosis of Alzheimer’s disease (Brain disease). Further review of the same benefit period showed a Face-to-Face assessment note dated 4/18/23 where the NP documented that the patient was a 69-year-old female who lost over 10 pounds in the last 2 months and reported intermittent numbness and tingling in her legs and feet with pain worsening upon movement, reaching, and turning. The NP documented a FAST scale of 6D (meaning the patient was urinary incontinence). Further review of the same benefit period 05/16/23 - 07/14/23 revealed a physician written recertification dated 7/15/23 where the hospice Medical Director documented that the patient was 69-year-old female, had weight loss of more than 10 pounds, a MAC measurement of 20 centimeters and a FAST scale of 6E. A review of the IDG meetings held for the entire hospice benefit period 05/16/23 – 07/14/23 revealed documentations that patient was 90-year-old female with a FAST scale of 6E. Further review of the same benefit period showed an RN Recertification note dated 7/14/23 where the Alternate Administrator/DON documented that the patient was a 90-year-old female with a MAC measurement of 24 centimeters and a FAST score of 7C (meaning the patient has lost her ambulatory ability, that is, the patient cannot walk without personal assistance). This review revealed inconsistent and conflicting documentation regarding patients’ assessments. Hospice Benefit Period 07/15/23 – 09/12/23: Record review of the patient #7 hospice benefit period 07/15/23 – 09/12/23 revealed a POC dated 07/06/23 with a documentation that the patient was a 90-year-old female with a terminal diagnosis of Alzheimer’s disease (Brain disease), lived with family, and had a FAST score of 6E (meaning patient has fecal incontinence). A review of the MSW Assessment note dated 07/28/25 showed the MSW documented that the patient lived alone. Further review of the same benefit period showed a Face-to-Face assessment note dated 6/14/23 and the NP documented that the patient was a 69-year-old female who lost over 20 pounds in 2 months and reported intermittent numbness and tingling in her legs and feet with pain worsening upon movement, reaching, and turning. The NP documented a FAST scale of 6D (meaning the patient was urinary incontinence). This NP Face-to-Face assessment visit note was the same assessment that was written in prior Face-to-Face assessment (benefit period 05/16/23 – 07/14/23). A review of the physician written certification dated 07/15/23 showed the hospice Medical Director documented that the patient was a 69-year-old female who had a weight loss of over 10 pounds in the past 2 months, a MAC measurement of 20 centimeters, and a FAST score of 6E (meaning patient was fecal incontinence). A review of the RN recertification note dated 09/12/23 showed that the RN-A documented that the patient was a 90-year-old female, was seen for initial assessment today, patient lived in a care-assisted home and provided admission teaching and instructed patient/caregiver on admission criteria to hospice.This was not an admission visit but a recertification visits which revealed further conflicting documentation regarding patients’ assessments. Hospice Benefit Period 11/12/23 – 12/18/23: Record review of the patient #7 hospice benefit period 11/12/23 – 12/18/23 revealed a Face-to-Face visit note written by an external Medical Provider’s office dated 10/14/23. The external Medical Provider documented that the patient lived by herself with the help of a caretaker and the only reason she was able to stay by herself was because a provider provided the patient care at home as far as cooking, cleaning, making her bed, and putting her to bed before the provider leave. This revealed further conflicting documentation regarding patients’ assessments in terms of living alone, living with family, or living in a care-assisted home. A review of a communication note written and dated 12/18/23 by the Alternate Administrator/DON that the patient was transported to emergency room (ER) and remained in observation unit for further evaluation. The Alternate Administrator/DON further documented that the patient has not admitted at the time the note was written. A review of a discharged note dated 12/18/23 and signed by the Alternate Administrator/DON documented that the patient was discharged to home or self-care with a reason that the patient moved out of hospice service area with a comment to discharge the patient from all hospice services because patient relocated and was not available for continued care. Further review of the discharge summary dated 12/18/23 stated discharge instruction was given to patient’s caregiver. Review of the IDG meeting note dated 12/28/23 and signed by the Alternate Administrator/DON documented that the patient was discharged from hospice care on 12/18/23 because the patient moved or relocated out of the agency’s service area. This review further revealed conflicting documentation regarding patients’ assessments in terms of the patient being transferred to the ER and the patient being discharge from all hospice services because the patient relocated and was not available for continued care. Hospice Benefit Period 02/15/24 – 04/14/24: Record review of the patient #7 hospice benefit period 02/15/24 – 04/14/24 revealed a Face-to-Face visit note written by an external NP from the Medical Provider’s office dated 02/15/24. The external NP documented the patient was a 91-year-old woman currently receiving hospice with end-stage congestive heart failure (the final stage of heart failure, where the heart is severely weakened and unable to pump blood effectively). The external NP further documented that the patient had a recent fall and was seen in the emergency room with no evidence of acute fracture, but the patient had issues with fractures in the past and suffered a C1 (first cervical vertebra located at the very top of the neck) fracture at one time related to her fall. The external NP documented that the patient lives alone with a provider and had weight loss of at least 2 pounds per caregiver. A review of the RN initial assessment note dated 02/15/24 showed a narrative documentation that the patient was a 91-year-old female admitted to routine hospice with a primary diagnosis of Chronic diastolic (congestive) heart failure (a condition where the heart muscle becomes stiff and cannot relax properly, leading to reduced blood flow and congestion). The RN initial assessment note revealed further documentation that the patient had a recent hospitalization following an episode of syncope(fainting) and collapse(fall), sustaining a displaced fracture of first cervical vertebrae. The documentation continued that the patient was hospitalized and then transferred to a skilled nursing facility for continued rehabilitation. Further review of the RN’s initial assessment showed that the patient fell on 12/18/23 and was discharged to her home on 02/02/24 and no longer a candidate for aggressive treatments because her condition was rapidly declining. A review of the physician written certification dated 02/15/24 showed the hospice Medical Director documented that the patient was a 91-year-old female with primary diagnosis of chronic diastolic (congestive) heart failure (a condition where the heart muscle becomes stiff and cannot relax properly, leading to reduced blood flow and congestion), a MAC measurement of 22 centimeters, and a FAST score of 6E (meaning patient was fecal incontinence). A review of the RN recertification note dated 04/02/24 showed documentation that the patient was a 91-year-old female with a terminal diagnosis of chronic diastolic (congestive) heart failure (a condition where the heart muscle becomes stiff and cannot relax properly, leading to reduced blood flow and congestion). This review revealed conflicting documentation regarding patients’ assessments in terms of the patient’s diagnosis where the external NP had a diagnosis of end-stage congestive heart failure (the final stage of heart failure, where the heart is severely weakened and unable to pump blood effectively) which was different from the RN initial assessment, RN recertification assessment, and the hospice physician’s written diagnosis of chronic diastolic (congestive) heart failure (a condition where the heart muscle becomes stiff and cannot relax properly, leading to reduced blood flow and congestion). The review revealed further conflicting documentation regarding the patient in terms of the discharge note from December 18, 2023, where it was documented that the patient was discharged from hospice services due to relocation “patient moved out of hospice service area.” The Alternate Administrator/DON documented on the physician’s discharge order for December 18, 2023, that the patient was discharged from all hospice services, has relocated and was not available for continued care. However, the RN initial assessment narrative for the start of care assessment on 02/15/24, documented that the patient had a syncopal episode, collapsed, and fell on December 18, 2023, and was transferred to the hospital and had a displaced fracture of the first cervical vertebrae. Hospice Benefit Period 04/15/24 – 06/13/24: Record review of the patient #7 hospice benefit period 04/15/24 – 06/14/24 revealed a Face-to-Face visit note written by an external NP from the Medical Provider’s office dated 03/18/24. The external NP documented the patient was a 91-year-old woman being seen for hospice Face-to-Face and currently on hospice with end-stage congestive heart failure (the final stage of heart failure, where the heart is severely weakened and unable to pump blood effectively). A review of the physician written certification dated 04/02/24 showed the hospice Medical Director documented that the patient was a 91-year-old female with primary diagnosis of chronic diastolic (congestive) heart failure (a condition where the heart muscle becomes stiff and cannot relax properly, leading to reduced blood flow and congestion), a MAC measurement of 21 centimeters, a PPS has decreased from previous 40% to 30% (meaning patient was severely disabled; hospital admission was indicated although death not imminent), and a FAST score of 6E (meaning patient was fecal incontinence). A review of the POC order dated 04/18/24 showed a comment read in part; “…IDT team met on 04/18/24 to discuss POC of 91 y/o AA female with primary diagnosis of Chronic diastolic (congestive) heart failure…” A review of the physician’s order dated 05/26/24 and signed by both the Alternate Administrator/DON showed that the physician ordered that the patient be discharged from all hospice services, patient has moved out of service area and is not available for continued care. A review of a communication note written and dated 05/26/24 by the Alternate Administrator/DON contained a discharge summary that patient was discharge on 05/26/24 reason being that the patient moved out of service area. Further review of the discharge summary stated that patient was not available, and discharge instruction was given to the caregiver. A review of a discharge-Live note dated 05/26/24 and signed by the Alternate Administrator/DON documented that the patient was discharged to home or self-care with a reason that the patient moved out of hospice service area with a comment that the patient has moved out of service area and was not available for continued care. There was no documentation that supported what happened that led to the patient being discharge or how the patient was discharged. This review further revealed conflicting documentation regarding patients’ assessment in terms of the patient’s diagnosis where the external NP have a diagnosis for the patient that was different from the physicians. Patient #8 Hospice Benefit Period 09/12/22 – 12/04/22: Record review of patient #8 clinical record showed a SOC date of 09/12/22 with hospice benefit period of 09/12/22 – 12/04/22 with a terminal diagnosis of hypertensive heart disease with congestive heart failure (a condition where long standing blood pressure causes the heart to weaken which the results in the heart’s inability to pump blood effectively). The record revealed that the patient elected hospice services on 09/12/22. The patient was 71 years old upon admission based on the patient date of birth on the clinical record. Further review of the clinical record showed the RN-A narrative note on the SOC assessment that the patient was a 70-year-old alert and oriented times three, patient recently discharged from the hospital for chest pain and Altered Mental Status (AMS). Further review of the patient’s assessment showed that the RN-A documented a FAST (Functional Assessment Staging Test) score of 6E (fecal incontinence), a PPS score of 40% (meaning the patient was disabled and required special care and assistance), and a weight loss of 10 pounds over 2 months. A review of the physician written certification dated 09/12/22 showed the hospice Medical Director documented that the patient was a 70-year-old male admitted to Hospice/Palliative care services for terminal illness of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), a PPS score of 40% (disabled), and documented that “According to the FAST scale, the patient is at stage 6E or higher. A review of the RN recertification note dated 12/02/22 showed that the RN-A documented that the patient was a 71-year-old male, alert and oriented time two with a terminal illness of hypertensive heart disease with congestive health failure (a condition where long standing blood pressure causes the heart to weaken which the results in the heart’s inability to pump blood effectively). This review revealed a conflicting documentation regarding the patient’s diagnosis where the physician’s narrative of the patient’s diagnosis was different from the RN narrative and conflicting in the patient’s age. The physician documented that the patient was a 70-year-old in his written certification, the RN documented that the patient was a 70-year-old in the SOC, and documented the patient was 71-year-old in the RN recertification (the patient was 71 years old on admission and still within the same benefit period). Hospice Benefit Period 12/05/22 – 02/02/23: A review of the RN recertification narrative note dated 02/02/22 showed that the RN-B documented that the patient was a 72-year-old male, alert and oriented to person and place with a terminal illness, specifically hypertensive heart disease with congestive heart failure (a condition where long standing blood pressure causes the heart to weaken which the results in the heart’s inability to pump blood effectively) . Hospice Benefit Period 02/03/23 – 04/03/23: A review of the physician written certification narrative note dated 02/02/23 showed the hospice Medical Director documented that the patient was a 70-year-old male admitted to Hospice/Palliative care services for terminal illness of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). A review of the RN recertification narrative note dated 04/03/23 showed that the RN-B documented that the patient was a 72-year-old male, alert and oriented to person and place with a terminal illness of hypertensive heart disease with congestive heart failure (a condition where long standing blood pressure causes the heart to weaken which the results in the heart’s inability to pump blood effectively).Hospice Benefit Period 04/04/23 – 06/02/23: A review of the physician written certification narrative note dated 04/03/23 showed the hospice Medical Director documented that the patient was a 70-year-old male admitted to Hospice/Palliative care services due to a terminal illness of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). A review of the IDG meeting narrative note dated 04/13/23 revealed a documentation that the patient was 72-year-old male, alert and oriented times two with a terminal illness of hypertensive heart disease with congestive heart failure. Further review of the same benefit period showed an RN Recertification narrative note dated 05/31/23 where the Alternate Administrator/DON documented that the patient was a 72-year-old African American male with a MAC measurement decreased to 23 centimeters. A review of the entire benefit period 04/04/23 – 06/02/23 revealed inconsistent and conflicting documentation regarding patient’s age and diagnosis. Hospice Benefit Period 06/03/23 – 08/01/23: A review of the physician written certification narrative note dated 05/31/23 showed the hospice Medical Director documented that the patient was a 70-year-old male admitted to Hospice/Palliative care services due to a terminal illness of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), and now confined to a wheelchair and was ambulatory with a walker previously. A review of the IDG meeting narrative note dated 06/08/23 revealed a documentation that the patient was 72-year-old male, alert and oriented times two with a terminal illness of hypertensive heart disease with congestive heart failure. The narrative documentation revealed that the patient dependent upon walker, furniture and walls for support during ambulation. A review of the RN skilled nursing visit narrative note dated 06/27/23 showed documentation that the patient was a 72-year-old male with a terminal diagnosis of hypertensive heart disease and patient was dependent upon walker during ambulation and standby assistance. A review of the RN recertification narrative note dated 07/24/23 showed that the NP documented that the patient was a 72-year-old male with a terminal illness of hypertensive heart disease with congestive heart failure, with a MAC measurement of 22 centimeters. The NP further documented that the patient was dependent upon a walker with standby assistance for ambulation, and only able to walk a few steps before needing to stop and rest. A review of the entire benefit period 06/03/23 – 08/01/23 revealed inconsistent and conflicting documentation regarding patient’s age, diagnosis, and mobility status. Hospice Benefit Period 08/02/23 – 09/30/23:Findings include: Patient #8 Hospice Benefit Period 09/12/22 – 12/04/22: Record review of patient #8 clinical record showed a SOC date of 09/12/22 with hospice benefit period of 09/12/22 – 12/04/22 with a terminal diagnosis of hypertensive heart disease with heart failure (heart disease). The record revealed that the patient elected hospice services on 09/12/22. A review of the physician written certification narrative note dated 09/12/22 showed the hospice Medical Director documented that the patient was a 70-year-old male admitted to Hospice/Palliative care services for terminal illness of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), a PPS score of 40% (patient was disabled). The hospice Medical Director documented that “According to the FAST scale, the patient is at stage 6E or higher and has lost 10 pounds over the past two months. The Hospice physician also documented that the patient was recently released from the hospital after suffering from chest pain and AMS (Altered Mental Status). A review of the initial IDG meeting narrative note dated 09/15/22 showed a documentation that the patient was a 70-year-old, alert and oriented times three, and was recently discharged from the hospital for chest pain and AMS with a stage 6E or higher on the FAST scale. The narrative note stated that the patient has a continued progressive slowing of mental functions and has a recent weight loss of 10 pounds over the last 2 months. A review of IDG meeting narrative note dated 09/24/22 showed a documentation that the patient was a 70-year-old, alert and oriented times three, and was recently discharged from the hospital for chest pain and AMS with a stage 6E or higher on the FAST scale. The narrative note stated that the patient has a continued progressive slowing of mental functions and has a recent weight loss of 10 pounds over the last 2 months. This note was a verbatim of the initial IDG meeting note dated 09/15/22. Hospice Benefit Period 12/05/22 – 02/02/23: Record review of the patient #8 hospice benefit period 12/05/22 – 02/02/2 3revealed a Face-to-Face narrative visit note dated 11/04/2022 which was shown to be for 12/05/22 – 02/02/22 benefit period. The NP documented that the patient was released from the hospital earlier this year after suffering from chest pain and AMS, and that the patient has lost 10 pounds over the last past 2 months. The NP further documented that according to the FAST scale, the patient was at stage 6E or higher. Hospice Benefit Period 02/02/23 – 04/03/23: Record review of the patient #8 hospice benefit period 02/02/23 – 04/03/23revealed a Face-to-Face narrative visit note dated 01/06/23 which was shown to be a Face-to-Face assessment for 02/02/23 – 04/03/23 benefit period. The NP documented that the patient was released from the hospital earlier this year after suffering from chest pain and AMS, and that the patient has lost 10 pounds over the last past 2 months. The NP further documented that according to the FAST scale, the patient was at stage 6E or higher. This narrative note was verbatim with the last hospice benefit period 12/05/22 – 02/02/23. A review of the physician written certification narrative note dated 02/02/23 showed the hospice Medical Director documented that the patient was a 70-year-old male admitted to Hospice/Palliative care services for terminal illness of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), a PPS score of 40% (patient was disabled). The hospice Medical Director documented that “According to the FAST scale, the patient is at stage 6E or higher and has lost 10 pounds over the past two months. The Hospice physician also documented that the patient was recently released from the hospital after suffering from chest pain and AMS (Altered Mental Status). This narrative note was verbatim with the last hospice benefit period 12/05/22 – 02/02/23. Hospice Benefit Period 04/04/23 – 06/02/23: Record review of the patient #8 hospice benefit period 04/04/23 – 06/02/23revealed a Face-to-Face narrative visit note dated 03/08/23 which was shown to be a Face-to-Face assessment for 04/04/23 – 06/02/23 benefit period. The NP documented that earlier this year, the patient was released from the hospital after experiencing chest pain and AMS and has lost 10 pounds over the last 2 months. A review of the physician written certification narrative note dated 04/03/23 showed the hospice Medical Director documented that the patient was a 70-year-old male admitted to Hospice/Palliative care services due to a terminal illness of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), a PPS score of 40% (patient was disabled) and a MAC measurement of 26 centimeters. The Hospice Medical Director documented that the patient was now confined to a wheelchair and was ambulatory with a walker previously. The Hospice Medical Director further documented that the patient was released from the hospital recently after suffering from chest pain and AMS. Hospice Benefit Period 06/03/23 – 08/01/23: Record review of the patient #8 hospice benefit period 06/03/23 – 08/01/23revealed a Face-to-Face narrative visit note dated 05/03/23 which was shown to be a Face-to-Face assessment for 06/03/23 – 08/02/23 benefit period. The NP documented that the patient was discharged from the hospital after presenting chest pain and Altered Mental Status (AMS), a PPS of 40%, indicating total disability, with a weight loss of 10 pounds over the past two months. A review of the physician written certification narrative note dated 05/31/23 showed the hospice Medical Director documented that the patient was a 70-year-old male admitted to Hospice/Palliative care services due to a terminal illness of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), a PPS score of 40% (patient was disabled) and a MAC measurement of 26 centimeters. The Hospice Medical Director documented that the patient was now confined to a wheelchair and was ambulatory with a walker previously. The Hospice Medical Director further documented that the patient was released from the hospital recently after suffering from chest pain and AMS. This narrative note was verbatim with the same narrative note from last benefit period. During interviews with the Administrator with Hospice license holder/owner in attendance on 08/28/2025 at 2:31p.m., the administrator was asked who was responsible for conducting initial comprehensive assessments and the recertification assessments of the agency’s patients and how the hospices agency verify that the patients were being seen by agency’s staff as planned. The administrator looked surprised by the inquiry but did not respond immediately. The license holder responded that all their staff visit the patients as scheduled and the patients or patients’ families do call if the assigned staff did not show up for a scheduled visit. The hospice personnel were then asked how they verify that the hospice staff visited the patients who are bed bound and not able to call to report to agency when a staff member does not visit a patient as scheduled. The Administrator then replied, “We may have to start visiting the patient from time to time (speaking to the agency owner), but we do have administrative staff call to check on our patients sometimes.” The Administrator then responded that the Supervising Nurse and the alternate Supervising Nurse usually conduct the initial comprehensive assessments and the recertification assessments of the hospice patients, and the Supervising Nurse also assigns the agency’s registered Nurses to conduct the initial comprehensive assessments and the recertification assessments of the hospice patient. The surveyor then asked if the Supervising Nurse and the Alternate Supervising Nurse usually review the hospice Nurses’ visits notes including the Nurse Practitioner’s Face-to-Face assessment document and the Hospice Medical Director’s certificate of terminal illnesses for the agency’s patients because there are so many conflicting documentations that make it difficult to ascertain hospice patients’ true health statuses at the time the assessments were performed from 2022 when you began operations after you bought the agency. The Administrator stated that she was not the hospice Administrator when the agency began operations in 2022 that she was designated as the administrator of the agency toward the end of 2024. The Administrator also stated that she was not sure if the Supervising Nurse reviews the other Nurses’ visits notes, but the Supervising Nurse also visits the patients too. The surveyor then asked if the hospice agency had a quality assurance Nurse that reads through the agency’s clinical staff home visits documentations. The Administrator looked confused but did not respond to the inquiry. The agency license holder who was sitting in during the interview suddenly broke down crying and stated, “I hired all these people who are supposed to be professionals in what they do to run my company, but they did not do what they were supposed to do and now I’m in this mess and they have all gone away…” During interview with the medical director on 09/10/23 at 3:52p.m the physician was asked if any of the hospice patients were his direct patients he said, “No, none of the patients are my direct patients. I don’t know any of them.” The Hospice physician was asked if he had ever interacted/visited any of the patients either in person or via Tele-Med. The Physician stated that he had never visited with any of the agency’s patients in person or via Tele-Med. The physician was then asked how he came about the information he used to write certificates of terminal illnesses for these hospice patients. The Physician stated that he used the clinical assessment records of the agency’s Nurse Practitioner to write the certificates of terminal illnesses for the patients. The Physician was then asked why some of his clinical narratives were sometimes conflicting with those of the NP. The physician asked, “are my narratives different from the NP’s, then I’m sorry, that’s my mistake let me log in to my computer to see my notes on each of the patients.” Surveyors waited for the doctor to log in to his computer and after some time the physician apologized again and said he could not access his computer in the office, but he would call surveyors back when he was able to log on to his personal computer at home. The physician did not call back until surveyors exited the agency. During an interview with the NP on 09/10/25 at 4:37p.m, the NP was asked if she had worked for Jomel Palliative and Hospice. The NP stated that she did not know or ever worked for the hospice before. The Surveyors then informed the NP that agency had a personnel file on her and read out the NP hire date to her. The NP then accepted knowledge of the agency. The NP was asked if she actually visited the agency’s hospice patients during her face-to-face assessments. The NP replied, “Yes, I do visit the patients during my face-to-face assessments. The NP was then asked why her reports had numerous conflicting patients’ information from the agency’s nurses. The NP quickly stated, “Those are not my notes, maybe someone had tampered with my notes and changed my documentations.” And she quickly excused herself and hung up the phone. Surveyors were unable to contact RN A, RN C, LVN A, DON/Supervising Nurse, and Alternate Supervising Nurse after many attempted calls on 09/09/2025 and 09/10/2025; the agency staff did not call back until surveyors exited the agency. Record review of the undated agency Administrative Policy titled “Assessment” read in part; “... The comprehensive assessment will: Accurately reflect the patient’s health status at the time of the comprehensive assessment and include information to establish and monitor a plan of care…””

“It is required that hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by personnel record review and interviews with the Owner, Administrator and the Director of Nurses which revealed issues with the agency’s ability to provide core services in the following areas: Failure to ensure the core services were provided directly by hospice employees. Core services for nursing services, medical social services, and counseling was not being provided by hospice employees. These core services were being provided by 1099 employees {HCDT.2. I/L587}. The cumulative effect of this deficiency has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.64: Core Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from 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 clinical record may be maintained electronically. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records, documents, and interviews revealed the hospice: Failed to ensure the clinical record included documentation of a written and signed recertification of the terminal illness completed by the medical director no later than two (2) calendar days after the first day of each benefit period and no more than 15 days before the next benefit period began{HCPC.6.I/L676}; Failed to ensure that a complete discharge summary was completed and provided to the attending physician {HCDT.39.I/L683}; and Failed to ensure that a discharge summary was provided to the hospice receiving the patient or the community attending physician{HCDT.40.I/L684}. 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 the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure that each patient had a comprehensive assessment within 5 days of the date of election. Clinical Record 2: The patient elected hospice on 08/29/2024, an initial nursing assessment was done on 08/29/2024 and the chaplain was declined. The Medical Social Worker’s initial assessment was completed on 09/13/2024, which was 15 days after the date of the election. Clinical Record 3: The patient elected hospice on 11/17/2023 an initial nursing assessment was done on 11/17/2023 and the initial spiritual assessment was done on 11/22/2023. The Psychosocial assessment was not completed until the social worker assessment done on 11/27/2023 which was 10 days after the date of the election. Clinical Record 6: The patient elected hospice on 11/21/2023 an initial nursing assessment was done on 11/21/2023 and the initial spiritual assessment was on 11/24/2023. The Psychosocial assessment was not completed until the social worker assessment done on 11/27/2023 which was 6 days after the date of the election. Clinical Record 8: The patient elected hospice on 06/07/2024 an initial nursing assessment was done on 06/07/2024 and the initial spiritual assessment was done on 06/10/2024. The Psychosocial assessment was not completed until the social worker assessment done on 06/14/2023 which was 7 days after the date of the election. Clinical Record 12: The patient elected hospice on 07/11/2023 an initial nursing assessment was done on 07/11/2023 and an initial spiritual assessment was done on 07/12/2023. The Psychosocial assessment was not completed until the social worker assessment done on 07/17/2023 which was 6 days after the date of the election. During an interview with the administrator and Director of Nurses on 10/09/2024, they stated that they have a new scheduler and are planning on doing additional education with the scheduler and the social worker.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: Prescription and over-the-counter (OTC) drugs; Supplements; Herbal remedies; and Other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by interview and observation. In 1 of 3 (33%) home visits, it was revealed the agency did not ensure the drug profile was updated with changes in the medication profile. Home Visit 2: During a joint visit with the Social Worker (personnel record 3) on 10/09/2024, the patient stated that she was taking her new medication due to a burning sensation when she had the urge to urinate. A closer examination of the medication revealed that the Mybretriq 25 mg, ordered on 09/26/2024, was not on the medication list, not documented in a comprehensive assessment, dated 10/02/2024 and not discussed in the Interdisciplinary Group meeting, dated 10/03/2024. During an interview with the Director of Nurses on 10/09/2024 she stated that it should have been included in the comprehensive assessment, also stated that it was a documentation issue, and she would do more education with the staff.”

“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, document review and interview. In 2 of 2 (100%) clinical records reviewed revealed the agency did not ensure that the bereavement plan of care included the frequency of service delivery. Document 1: The agency’s policy titled Hospice Policy and Procedure Manual Bereavement Counseling Services states in part “j. Maintain documentation of all bereavement interventions or attempts, which will include: i. A bereavement progress note, and ii. An update to the bereavement plan of care, and iii. If applicable, a copy of the mailing (or name of mailing on a progress note with a master copy kept in binder), invitation, funeral service notice, or other material provided to or by the bereaved”. Clinical Record 11: The patient elected hospice on 04/02/2023, an initial bereavement assessment was completed. The date of death was 01/12/2024, a bereavement plan of care was present in the electronic medical record but did not contain a frequency of services offered or documentation that a bereavement plan of care was followed. There was no documented evidence of the bereavement progression in the clinical record. Clinical Record 12: The patient elected hospice on 07/11/2023, an initial bereavement assessment was completed. The date of death was 05/09/2024, a bereavement plan of care was present in the electronic medical record but did not contain a frequency of services offered or documentation that a bereavement plan of care was followed. There was no documented evidence of the bereavement progression in the clinical record. During an interview with the Director of Nurses on 10/10/2024, she stated that the bereavement program recently changed to the EMR, and more education is needed.”

“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, document review and interview. In 2 of 12 (17%) clinical records reviewed for patients requiring a physician’s recertification of terminal illness revealed that the agency did not ensure that the hospice medical director completed the recertification of terminal illness. Document 3: The agency’s policy titled Hospice Policy and Procedure Manual Certification of Terminal Illness states in part “The narrative associated with the 3rd benefit period recertification and every subsequent recertification will include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of 6 months or less. Followed by the Physician attesting that by signing, the Physician confirms that he/she composed the narrative based on his/her review of the patient’s medical record. Followed by the Physician’s signature. . Clinical Record 1: The patient elected hospice services on 09/20/2022. The clinical record review revealed that a Recertification of Terminal Illness for periods 11/19/22 to 1/17/23, 1/18/23 to 3/18/23, 3/19/23 to 5/17/2023, 5/18/23 to 7/16/23, 7/17/23 to 9/14/23, 9/15/23 to 11/13/23, 11/14/23 to 1/12/24, 1/13/24 to 3/12/24, 3/13/24 to 5/11/24, and 5/12/24 to 7/10/24 included all required narrative, yet lacked evidence of a physician signature. Clinical Record 9: The patient elected hospice services on 09/12/2022. A review of the clinical record revealed there was no documented evidence of the written Recertification of Terminal Illness for the benefit period 06/03/2023 to 08/01/2023. During an interview with the administrator on 10/09/2024, she stated that she does not know why the recertification is missing.”

“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: copy of the hospice discharge summary; The patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) clinical record reviewed in which the patient was a live discharge revealed that that agency did not ensure that a complete discharge summary was completed and provided to the attending physician. Document 2: The agency’s policy titled Hospice Policy and Procedure Manual Discharge from Hospice Care stated in part “Clinical Record J. If a patient is discharged from hospice, the hospice must forward to the patient’s attending physician, a copy of each of the following: 1. The hospice Discharge Summary, which includes: a. A summary of the patient’s stay including treatments, symptoms and pain management. b. The patient’s current plan of care. c. The patient’s latest physician orders and d. Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility”. Clinical Record 13: The patient elected hospice on 04/12/2024. The patient signed a revocation of hospice services on 08/29/2024. There was no documented evidence in the clinical record of a discharge summary or that a discharge summary sent to the attending physician. During an interview with the Director of Nurses on 10/10/2024 regarding the discharge summary, she stated that they have identified that the discharge summary was not being generated and have a new process in place to implement with the next discharge.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review, document review and interview. In 1of 1 (100%) clinical records reviewed in which the patient elected a transfer to another hospice revealed that the agency did not ensure that a discharge summary was provided to the hospice receiving the patient or the community attending physician. Document 2: The agency’s policy titled Hospice Policy and Procedure Manual Discharge from Hospice Care stated in part “Clinical Record J. If a patient is discharged from hospice, the hospice must forward to the patient’s attending physician, a copy of each of the following: 1. The hospice Discharge Summary, which includes: a. A summary of the patient’s stay including treatments, symptoms and pain management. b. The patient’s current plan of care. c. The patient’s latest physician orders and d. Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility”. Clinical Record 14: The patient elected hospice on 08/02/2023. The patient requested a transfer to another hospice on 12/20/2023. The clinical record contained no documented evidence of a discharge summary or coordination with the receiving hospice agency and the attending physician. During an interview with the Director of Nurses on 10/10/2024 regarding the discharge summary, she stated that they have identified that the discharge summary was not being generated and have a new process in place to implement with the next discharge.”