Survey Report for 341576

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	341576	A. BUILDING __________ B. WING ______________	12/12/2019
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
COMMUNITY HOME CARE & HOSPICE	2800 BREEZEWOOD AVENUE, SUITE 100, FAYETTEVILLE, NC, 28303
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0545
L0545	28783 Based on clinical record review, policy review and staff interview the agency failed to develop plans of care that addressed interventions, goals and/or parameters for 2 of 2 patients with Diabetes [#1 and 2]. The findings include: The "PLAN OF CARE" policy provided by the Regional Director of Clinical Operations on 12/12/19 at 6:15 p.m. revealed "... Policy No. 4-027 ... An individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program ... PROCEDURE ... 4. The plan of care will identify the patient's needs and services to meet those needs ... 8. Care decisions and services to be provided will be made as a result of the care planning process ...13. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions ... October 2019 ..." 1. Patient #1 had a start of care date of 7/31/19. The Hospice Election Statement was signed by the daughter of Patient #1 on 7/31/19. The Plan of Care [POC] for the Certification Period 7/31/2019 to 9/28/19 included diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 Unspecified Chronic Kidney and Diabetes. Services ordered on this plan of care included SN [skilled nursing]. Medications on the POC included, Lantus Solostar U-100 Insulin 20 units subcutaneous at bedtime for blood glucose. The Hospice Recertification orders for the Certification Period 9/29/2019 to 11/27/2019 revealed, "... CONTINUE WITH PLAN OF CARE." The POC for Patient #1 did not include interventions and goals in regards to the patient's Diabetes and did not include parameters for glucose monitoring. Review of the SN visit notes from 7/31/19 to 11/6/19 revealed the following entries: -07/31/19 "... INDICATE ANY SECONDARY CONDITIONS ... INSULIN DEPENDENT DIABETES MELLITUS ... HOW FREQUENTLY ARE BLOOD SUGARS CHECKED ... THREE TIMES DAILY ... WHAT ARE THE PATIENT'S USUAL BLOOD SUGAR READINGS? ... High .... High range 200 ..." -08/02/19 "... WHAT ARE THE PATIENT'S USUAL BLOOD SUGAR READINGS? ... High ... High range 200 ..." -08/09/19 "... WHAT ARE THE PATIENT'S USUAL BLOOD SUGAR READINGS? ... High ... High range 200's ..." -08/12/19 "... WHAT ARE THE PATIENT'S USUAL BLOOD SUGAR READINGS? ... High ... High range 200's ..." -08/21/19 "... WHAT ARE THE PATIENT'S USUAL BLOOD SUGAR READINGS? ... High ... High range 150-200 ..." -08/26/19 "... WHAT ARE THE PATIENT'S USUAL BLOOD SUGAR READINGS? ... High ... High range 200's ..." -09/03/19 "... Narrative ... BLOOD SUGAR OBTAINED BY PATIENT'S DAUGHTER. READING 594 DR ... MADE AWARE ... ORDERS GIVEN TO ADMINISTER 5 UNITS REGULAR INSULIN NOW... BLOOD GLUCOSE WILL BE CHECKED 3 TIMES DAILY BEFORE MEALS AND 7 UNITS REGULAR INSULIN WILL BE ADMINISTERED WITH MEALS. PT WILL ALSO DISCONTINUE PREDNISONE ..." -09/11/19 "Narrative ... DAUGHTER INFORMED PTS BLOOD GLUCOSE HAS REMAINED ELEVATED WITH READING OF 303 THIS AM. DR. ... NOTIFIED. NEW ORDERS GIVEN ..." -09/18/19 "... WHAT ARE THE PATIENT'S USUAL BLOOD SUGAR READINGS? ... High ... High range 150's ..." -09/25/19 "... WHAT ARE THE PATIENT'S USUAL BLOOD SUGAR READINGS? ... High ... High range 208 TODAY ..." -09/30/19 "... WHAT ARE THE PATIENT'S USUAL BLOOD SUGAR READINGS? ... High ... High range 200's ..." -10/07/19 "... WHAT ARE THE PATIENT'S USUAL BLOOD SUGAR READINGS? ... High ... High range 150 ..." -10/17/19 "... WHAT ARE THE PATIENT'S USUAL BLOOD SUGAR READINGS? ... High ... High range 150-200 ..." -10/24/19 "... WHAT ARE THE PATIENT'S USUAL BLOOD SUGAR READINGS? ... High ... High range 200 ..." -10/31/19 "... WHAT ARE THE PATIENT'S USUAL BLOOD SUGAR READINGS? ... High ... High range 200 ..." and -11/06/19 "WHAT ARE THE PATIENT'S USUAL BLOOD SUGAR READINGS? ... High ... High range 150 ..." An interview was conducted on 12/12/19 at 10:20 a.m. with the RN [#1E] who developed the POC and was also the Case Manager for Patient #1. Interview revealed, "Her primary diagnosis was not related to her Diabetes ... I guess that was an oversight on my part ... The plan of care should have included interventions, goals and parameters ... No, I didn't ask the doctor for parameters ..." Interview confirmed the POC for Patient #1 was incomplete for interventions, goals and parameters. 2. Patient #2 had a start of care date of 6/24/19. The Plan of Care [POC] for the Certification Period 6/24/2019 to 9/21/19 included diagnoses of Chronic Obstructive Pulmonary Disease and Type 2 Diabetes. Services ordered on this plan of care included SN [skilled nursing]. The Hospice Recertification orders for the Certification Period 9/22/2019 to 12/20/2019 revealed, "... CONTINUE WITH PLAN OF CARE." Medications for Diabetes listed on the POC included the following: -Glipizide 2.5 milligrams by mouth two times per day, -Levemir FlexTouch U-100 Subcutaneous [injection] 100 units per milliliter give 30 units at bedtime, and -Novolog FlexPen U-100 Subcutaneous before meals and at bedtime as needed for blood sugar readings 151 to 200 give 2 units, 201 to 251 give 3 units, 251 to 300 give 4 units, 301 to 350 give 5 units, 351 to 400 give 6 units and blood sugar greater than 400 give 7 units. The POC for Patient #2 did not include interventions and goals regarding the patient's Diabetes. There was no evidence that the patient's blood sugars were assessed/monitored by SN for 12 of 14 visits between 9/25/19 and 11/25/19. The patient's blood sugar on 11/24/19 was 300 and on 11/25/19 the blood sugar ranged beween 150-300. Interview on 12/12/16 at 4:36 p.m. with the Director [#5E], who was also a registered nurse, confirmed the plan of care "did not have" interventions and goals regarding Diabetes. Interview revealed, the plan of care "should have" included interventions and goals for the Diabetes.
L0591
L0591	28783 Based on clinical record review, policy review and staff interview the agency failed to re-assess in a timely manner, uncontrolled blood sugar for 1 of 1 patient [#1]; failed to thoroughly and consistently assess the feet of 1 of 1 Diabetic patient who developed a pressure ulcer on the heel for 1 of 1 patient [#2]; failed to measure newly developed wound for 1 of 1 patient [#2]; and failed to assess/monitor blood sugar readings of insulin dependent patient for 1 of 1 patient [#2]. The findings include: The "ONGOING ASSESSMENTS" policy provided by the Regional Director of Clinical Operations on 12/12/19 at 6:15 p.m. revealed "... Policy No. 4-043 ... The scope and intensity of ongoing hospice assessments will be determined by the patient's prognosis, diagnoses, condition, desire for care, response to previous care ... PROCEDURE ... During each home visit the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment ... 2. The nurse may assess each patient on each visit for ... B. Secondary symptoms related to the terminal illness ... and patient's response to medications and other interventions ... 4. Based on the assessments, the plan of care-including problems, needs, goals and outcomes-will be reviewed and updated by the interdisciplinary group members responsible for care ... December 2018 ..." 1. Patient #1 had a start of care [SOC] date of 7/31/19. The Hospice Election Statement was signed by the daughter of Patient #1 on 7/31/19. The Plan of Care [POC] for the Certification Period 7/31/2019 to 9/28/2019 included diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 Unspecified Chronic Kidney and Diabetes. Services ordered on this plan of care included SN [skilled nursing]. The Hospice Recertification orders for the Certification Period 9/29/2019 to 11/27/2019 revealed, "... CONTINUE WITH PLAN OF CARE." Medications on the POC included, Lantus Solostar U-100 Insulin 20 units subcutaneous at bedtime for blood glucose. Review of the SN visit notes from 7/31/19 to 11/6/19 revealed the RN Case Manager [#1E] conducted a visit to Patient #1 on 9/03/19 and documented, "... Narrative ... BLOOD SUGAR OBTAINED BY PATIENT'S DAUGHTER. READING 594 DR ... MADE AWARE ... ORDERS GIVEN TO ADMINISTER 5 UNITS REGULAR INSULIN NOW... BLOOD GLUCOSE WILL BE CHECKED 3 TIMES DAILY BEFORE MEALS AND 7 UNITS REGULAR INSULIN WILL BE ADMINISTERED WITH MEALS. PT WILL ALSO DISCONTINUE PREDNISONE ..." There was no evidence that the SN re-assessed the status of the patient's blood sugar until 9/11/19. The RN Case Manager documented on the visit conducted 9/11/19, "... Narrative ... DAUGHTER INFORMED ... BLOOD GLUCOSE HAS REMAINED ELEVATED WITH READING OF 303 THIS AM. DR.______ [Name of Medical Director] ... NOTIFIED ... NEW ORDERS GIVEN ..." Order dated 9/12/19 revealed the patient was started on Metformin 500 milligrams 2 times daily for hyperglycemia [high blood sugar]. An interview was conducted on 12/12/19 at 10:23 a.m. with the RN [#1E]. The DOO was present during this interview. Interview revealed, "I [#1E] was in contact with _______ [Name of Daughter of Patient #1] prior to another visit [9/11/19] and she didn't see a need for me to come out." Interview with the DOO during this interview revealed, "Yes she should have seen the patient sooner." Interview confirmed the agency failed to reassess Patient #1 in a timely manner. 2a. Patient #2 was a 76-year-old female who resided in and assisted living facility [ALF]. She was admitted to Hospice on 6/24/19. The Plan of Care [POC] for the Certification Period 6/24/2019 to 9/21/2019 included diagnoses of Chronic Obstructive Pulmonary Disease, Alzheimer's Disease and Type 2 Diabetes. Services ordered on this plan of care included SN [skilled nursing]. The Hospice Recertification orders for the Certification Period 9/22/2019 to 12/20/2019 revealed, "... CONTINUE WITH PLAN OF CARE." The ordered SN visit frequency was 1 time per week for 13 weeks and 4 PRN [as needed]. Review of the complaint log revealed a complaint report regarding Patient #2 was called in by the administrator from the ALF. The administrator was "upset" because the aide and RN [registered nurse/#6E] had not discovered a pressure ulcer on patient's right heel. Between 9/22/19 to 11/20/19 SN conducted 10 visits without evidence that the feet of this Diabetic patient [#2] had been assessed by SN. #8E, a registered nurse, conducted 7 of 10 visits between 9/22/19 and 11/20/19 [9/25, 10/9, 10/14, 10/22, 10/28, 11/5 and 11/12/19]. #8E documented on each of the 7 visits, "WAS INTEGUMENTARY [skin] ASSESSED ... YES ... INDICATE INTEGUMENTARY ASSESSMENT FINDINGS ... POOR TURGOR [skin checked for signs of fluid loss/dehydration]." There was no indication that the patient's feet were assessed on any of the 7 visits. #6E conducted 3 of 10 visits [10/01, 10/12 and 11/20/19]. The RN case manager [#6E] conducted a scheduled SN visit to Patient #2 on 11/20/19 at 11:09 a.m. The RN case manager [#6E] documented on 11/20/19, "WAS INTEGUMENTARY [skin] ASSESSED ... YES ... NO PROBLEMS IDENTIFIED ... Narrative ... SKIN INTACT ..." There was no evidence that the feet of Patient #2 were assessed and there was no evidence that the Patient refused assessment of her feet on 11/20/19. On the evening of 11/20/19 the on-call nurse [#7E] received a call from the ALF requesting a visit to evaluate a wound discovered to the right heel. The RN [#7E] conducted a PRN visit on 11/20/19 at 6:28 p.m. and documented, "NEW PRESSURE WOUND TO RIGHT HEEL." The wound was described as round with bright red tissue surrounding the wound. No wound care was performed and there were no measurements taken of the wound at that time. There was no evidence prior to the PRN visit conducted on 11/20/19 by #7E, that the Hospice nursing staff assessed the feet of this Diabetic patient, until, the wound was discovered by the ALF staff. SN PRN visit was conducted by the RN case manager [#6E] on 11/21/19. #6E documented "SN ASSESSED HEEL ..." There were no wound measurements noted, nor description of the wound noted. On 11/22/19 #6E conducted a PRN visit and documented, "NARRATIVE RIGHT HEEL ... LOOKS BLACK IN COLOR TODAY ... 3.5 x 3.75 x 0CM [centimeters]." Subsequent SN visits were conducted on 11/24/19 and 11/25/19. The patient was discharged from Hospice services on 11/25/19, per request of the patient's daughter, to seek aggressive treatment for the wound. Interview with #6E conducted on 12/12/19 at 3:22 p.m. to 3:28 p.m. revealed, "Yes ... I was the case manager [for patient #2] ... It's not that I assessed it [assessed skin on 10/1/19] ... that was what was reported to me [reported by ALF staff] ... She was in an assisted living facility ... in memory care ... I took her to the room because I wrote she was finishing lunch ... I would have looked at her feet [10/1/19] ... It [skin intact on 11/20/19] was reported to me ... She [Patient #2] had refused for me to check her skin [11/20/19] ...Yes, you would assess the feet of a Diabetic each visit if they let you. She refused assessment of skin that time [11/20/19]. If she was in bed I would assess [assess feet] and she was on that visit [11/20/19], but she refused ... if's she's up in the chair I would assess her feet." Interview conducted with #8E on 12/12/19 at 3:54 p.m. to 4:14 p.m. revealed, "I would have checked her skin ... what I was able to see ... Generally speaking, I would have checked her feet but I don't remember it was so long ago [9/25/19] ... That visit I saw her entire body [10/9/19] ... She's in the dining room this visit I doubt that I wound have taken her shoes off that visit [10/14/19] ... I would have likely taken her shoes off this visit, but it doesn't say that [10/22/19] ... If I saw her sacral area, I would have seen her entire body, but it's not documented that I looked at her feet [10/28/19] ... I can see why documenting about feet would be important [11/5/19-response when asked about patient being diabetic] ... On this visit I can't accurately answer if I looked at her feet [11/12/19] ..." Interview with #7E conducted on 12/12/19 at 4:27 p.m. revealed, "I don't have a reason why I didn't measure the wound [11/20/19] ... Negligence on my part." 2b. Medications for Diabetes listed on the POC for Patient #2 included the following: -Glipizide 2.5 milligrams by mouth two times per day, -Levemir FlexTouch U-100 Subcutaneous [injection] 100 units per milliliter give 30 units at bedtime, and -Novolog FlexPen U-100 Subcutaneous before meals and at bedtime as needed for blood sugar readings 151 to 200 give 2 units, 201 to 251 give 3 units, 251 to 300 give 4 units, 301 to 350 give 5 units, 351 to 400 give 6 units and blood sugar greater than 400 give 7 units. There was no evidence that the patient's blood sugars were assessed/monitored by SN for 15 of 17 visits between 9/25/19 and 11/25/19. #8E conducted 8 of the 17 visits. The patient's blood sugar on 11/24/19 was 370 and on 11/25/19, the day of discharge, the blood sugar ranged between 150-300. Interview on 12/12/16 at 4:20 p.m. with #8E revealed, "No, we were not monitoring her blood sugars. It was my understanding that her blood sugars were controlled. No I did not ask about her blood sugars."
L0642
L0642	28783 Based on clinical record review, policy review, caregiver interview and staff interview the agency failed to provide requested volunteer services to 1 of 1 patient [#1]. The findings include: The "COMPREHENSIVE ASSESSMENT" policy provided by the Regional Director of Clinical Operations on 12/12/19 at 6:15 p.m. revealed "... Policy No. 4-042 ... PURPOSE ... To provide guidelines for the comprehensive assessment ... PROCEDURE ... W. An assessment of the need for volunteer services to offer support or respite to the patient and family/caregiver ... May 2019 ..." The "Organization and Administration" policy provided by the Regional Director of Clinical Operations on 12/12/19 at 6:15 p.m. revealed "... Policy No. 1-027 ... PURPOSE ... To establish the scope and services and requirements for patients eligible under the Medicare hospice benefit program ... A Summary of the Medicare Hospice Benefit ... Hospice care, which emphasizes comfort and palliative management ... for patients who have been given a diagnosis, of a life limiting illness of 6 months or less ... Hospice also specializes in a coordinated team approach that includes addressing, physician, psychosocial ... needs of the individual patient and his/her family, however family is defined ... The benefit is available to patients who 1. Are eligible for Medicare Part A ... 2. Are terminally ill and have a life expectancy of six ... months or less confirmed by the attending physician and the hospice Medical Director ...4. Are willing to sign an election statement that identifies the hospice ... services to be provided in goals and interventions ... The following services may also be provided by hospice ... medical supplies including drugs ... In addition, hospice provides a variety of volunteer services ... Home Care Coverage ... To be provided by hospice as needed by patient ... 6. Medication related to the terminal diagnosis ... 9. Volunteers as requested ... December 2018 ..." Patient #1 had a start of care [SOC] date of 7/31/19. The Hospice Election Statement was signed by the daughter of Patient #1 on 7/31/19. Review of the Hospice certifications [CTI] revealed, "HOSPICE PHYSICIAN ... ________ [Name of Hospice Medical Director] ... CLIENT ... ________ [Name of Patient #1] ... CERT: 7/31/2019 to 9/28/2019 ... I CERTIFY THAT THE PATIENT'S PROGNOSIS IS SIX MONTHS OR LESS ... Page 1 of 2 ... BRIEF NARRATIVE STATEMENT (REVIEW THE INDIVIDUAL'S CLINICAL CIRCUMSTANCES AND SYNTHESIZE THE MEDICAL INFORMATION TO PROVIDE CLINICAL JUSTIFICATION FOR HOSPICE SERVICES) 90 YEAR OLD FEMALE PATIENT ADMITTED TO HOSPICE WITH DIAGNOSIS OF HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE WITH HEART FAILURE AND STAGE 1-4 UNSPECIFIED CHRONIC KIDNEY. HER COMORBIDITIES INCLUDE ... DIABETES ... PATIENT IS APPROPRIATE FOR HOSPICE SERVICES ... VERBAL CERTIFICATION TAKEN BY ... ______ [Name of RN/#2E] ... DATE: 07/31/2019 ... CERTIFICATION FROM HOSPICE PHYSICIAN ... __________[Name of Medical Director] ... DATE 08/09/2019 ... Page 2 of 2." A CTI for the Certification Period 9/29/2019 to 11/27/2019 was signed by the Medical Director on 9/21/2019. The Plan of Care [POC] for the Certification Period 7/31/2019 to 9/28/2019 included diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 Unspecified Chronic Kidney and Diabetes. Services ordered on this plan of care included SN, [skilled nursing], MSW [medical social worker], HHA [home health aide], and CH [chaplain]. There was no indication that volunteer services were ordered. The SN SOC visit was conducted by a RN [#1E] on 7/31/19. #1E documented on 7/3/19, "INDICATE WHICH VOLUNTEER SERVICES THE PATIENT/FAMILY IS OPEN TO RECEIVE (MARK) ALL THAT APPLY ... VISITATION ... ERRANDS ... EMOTIONAL SUPPORT (TELEPHONE) ..." Review of the clinical notes from 7/31/19 to 11/8/19 revealed no evidence that volunteer services were provided to Patient #1. There was no evidence that the patient/caregiver declined volunteer services. Interview with the caregiver of Patient #1 conducted on 12/11/19 from 7:12 p.m. to 8:30 p.m. revealed, "They did not provide volunteer services. Yes ... I asked for a volunteer ..." Interview with the RN [#1E] conducted on 12/12/19 at 10:42 a.m. revealed, "She [caregiver of patient #1] wanted an aide to sit there with her 7 or 8 hours a day ... The volunteer wasn't an aide and she wanted aide ... I referred her to our social worker to see what she was eligible for ... I explained to her that a volunteer could sit with her ... I spoke with the volunteer coordinator [#3E] about her ... The volunteer coordinator was willing to have someone to go and sit with her, but _______ [Name of Patient's Daughter] wanted PCS [personal care services] ..." Interview with the Volunteer Coordinator [#3E] on 12/12/19 at 11:11 a.m. revealed, #3E had dual roles, she was also a LPN [licensed practical nurse]. Interview further revealed, "I talked to _______ [Name of RN/#1E] about this patient [#1] ... No, I don't have documentation of the conversations ... I never went to see her as a Volunteer Coordinator, but I went as a nurse. We did discuss the Volunteer role on that visit [10/31/19]. She wanted PCS services. There wasn't a volunteer referral done after _______ [Name of RN/#1E] talked with her and learned that she wanted PCS services ... we didn't know that we should make the referral since we realized that volunteer services was not what she was looking for." Interview conducted on 12/12/19 at 11:15 a.m. with the Director, who was also a RN [#2E] revealed, "I had a new volunteer coordinator [#3E] and a new nurse [#1E] when the patient [#1] was admitted." Interview confirmed that volunteer services were not provided for Patient #1.
L0652
L0652	28783 Based on clinical record review, policy review, caregiver interview and staff interview the agency failed to take financial responsibility for covered medication related to the Hospice diagnosis for 1 of 1 patient [#1]. The findings include: The "PHARMACY SERVICES" policy provided by the Regional Director of Clinical Operations on 12/12/19 at 6:15 p.m. revealed "... POLICY ... Drugs and biologicals related to the palliation and management of the terminal illness and related conditions, as identified in the hospice plan of care, are provided by the hospice while the patient is under hospice care ..." The "Organization and Administration" policy provided by the Regional Director of Clinical Operations on 12/12/19 at 6:15 p.m. revealed "... Policy No. 1-027 ... PURPOSE ... To establish the scope and services and requirements for patients eligible under the Medicare hospice benefit program ... A Summary of the Medicare Hospice Benefit ... Hospice care, which emphasizes comfort and palliative management ... for patients who have been given a diagnosis, of a life limiting illness of 6 months or less ... The benefit is available to patients who 1. Are eligible for Medicare Part A ... 2. Are terminally ill and have a life expectancy of six ... months or less confirmed by the attending physician and the hospice Medical Director ...4. Are willing to sign an election statement that identifies the hospice ... services to be provided in goals and interventions ... medical supplies including drugs ... December 2018 ..." Patient #1 had a start of care [SOC] date of 7/31/19. The Hospice Election Statement was signed by the daughter of Patient #1 on 7/31/19. Review of the Hospice certifications [CTI] revealed, "HOSPICE PHYSICIAN ... ________ [Name of Hospice Medical Director] ... CLIENT ... ________ [Name of Patient #1] ... CERT : 7/31/2019 to 9/28/19 ... I CERTIFY THAT THE PATIENT'S PROGNOSIS IS SIX MONTHS OR LESS ... Page 1 of 2 ... BRIEF NARRATIVE STATEMENT (REVIEW THE INDIVIDUAL'S CLINICAL CIRCUMSTANCES AND SYNTHESIZE THE MEDICAL INFORMATION TO PROVIDE CLINICAL JUSTIFICATION FOR HOSPICE SERVICES) 90 YEAR OLD FEMALE PATIENT ADMITTED TO HOSPICE WITH DIAGNOSIS OF HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE WITH HEART FAILURE AND STAGE 1-4 UNSPECIFIED CHRONIC KIDNEY. HER COMORBIDITIES INCLUDE ... DIABETES ... PATIENT IS APPROPRIATE FOR HOSPICE SERVICES ... VERBAL CERTIFICATION TAKEN BY ... ______ [Name of RN/#2E] ... DATE: 07/31/2019 ... CERTIFICATION FROM HOSPICE PHYSICIAN ... __________[Name of Medical Director] ... DATE 08/09/2019 ... Page 2 of 2." A second CTI for the Certification Period 9/29/2019 to 11/27/2019 was signed by the Medical Director on 9/21/2019. The Plan of Care [POC] for the Certification Period 7/31/2019 to 9/28/2019 included diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 Unspecified Chronic Kidney [heart and kidney disease caused by high blood pressure]. Review of the medications on the medication profile indicated that Cartia XT 240 milligrams 1 capsule daily used for blood pressure was not the "Financial Responsibility" of the Hospice agency but was the "Financial Responsibility" of the patient [#1]. Interview with the caregiver of Patient #1 conducted on 12/11/19 from 7:12 p.m. to 8:30 p.m. revealed, "I don't know what all they paid for ... They paid for the Percocet ... I don't think they were paying for everything they were supposed to pay for ... the day [11/7/19] that I went to the office to talk to ______ [Name of Director/#2E] ... I wanted to talk about ... the medications they were supposed to provide ..." Interview with the RN [#1E] conducted on 12/12/19 at 11:18 a.m. revealed, "Medications are covered that are related to the Hospice diagnosis ... the Cartia should have been covered. It just got overlooked." Complaint Intake Number NC 00158108/cmw