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
551638 A. BUILDING __________
B. WING ______________ 		03/23/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
COMPCARE HOSPICE, INC 4305 TORRANCE BLVD SUITE 200, TORRANCE, CA, 90503
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)
L0500      
25997 The agency failed to ensure the Condition of Participation: Patient Rights was in compliance when it failed to: 1. Ensure the patient's family was given the opportunity to participate in the development of the plan of care for Patient 1. (refer to L 513) 2. Ensure Patient 1's right to choose her attending physician was granted. Patient 1 stated she would like to keep her primary care physician (PCP) but was told her PCP would have to be hired by the agency in order to provide her care. (refer to L 515) The cumulative effect of these systemic practices resulted in the hospice's inability to be in compliance with the Condition of Participation: Patient Rights, 42 CFR 418.52.
L0513      
25997 Based on interview and record review the hospice agency failed to ensure the patient's family was given the opportunity to participate in the development of the plan of care for Patient 1. This deficient practice resulted in the patient's family being unaware the patient was under hospice care and the hospice staff having a significant lack of knowledge regarding the patient's care needs. Findings: On 6/6/19, at 1 PM, an unannounced on-site visit was made to investigate complaint allegations that the agency had not contacted Patient 1's family or her Primary Care Physician (PCP) to coordinate the patient's care. A review of the initial "Physician's Certification For Hospice Benefit" dated 9/22/18, indicated Patient 1, an 80 year old female, had been admitted to the hospice with a diagnosis of atheriosclerotic heart disease (a buildup of cholesterol plaque in the walls of the arteries that can cause decreased blood flow). The hospice Medical Director certification indicated Patient 1 had, "a life expectancy of six months or less, if the terminal illness runs its normal course." On 6/6/19, during intervew at 8:53 AM, Patient 1's PCP stated on 2/28/19 he had been informed his patient was under hospice care since September 2018. The PCP was attempting to get home health care for multiple falls possibly due to medication non-compliance, but was unable to enroll her in home health because the patient was listed as a hospice patient. The PCP stated Patient 1 had been under his care for many years, and he had continued to see the patient approximately every two weeks during the time she was under hospice care. The PCP further stated he called the patient's son to find out why the patient was in hospice, but the son was also unaware his mother was being seen by the hospice staff. On 6/5/19, at 11 AM, during an interview, the patient's son stated his mother had dementia and had no memory of hospice visiting her. The son stated he was aware hospice agencies had been knocking on some of the neighboring apartment doors, and acknowledged there was a possibility his mother may have signed up for hospice without understanding what hospice involved. Patient 1's son asserted his mother did not need hospice, he had never met any of the hospice staff, and he had not signed any paperwork to have her enrolled in hospice. During the on-site visit on 6/6/19, at 4 PM, the Director of Patient Care Services (DPCS) stated Patient 1 had informed the hospice she had a PCP when she was initially admitted to hospice care. The DPCS stated Patient 1 had been referred to the hospice agency by her son and the son had signed all of the consents. A concurrent review of the consents with the DPCS indicated all of the consents had been signed by the patient, not her son. A review of the Interdisciplinary Group (IDG) meetings, comprehensive assessments, and plans of care, dated 9/22/18 to 6/12/19 indicated RN 1 had documented discussing the plan of care with the patient's son. On 7/1/19, at 11 AM, the hospice registered nurse (RN 1) acknowledged she had documented and signed the initial and comprehensive assessments and IDG notes indicating she had met and performed teaching with Patient 1's son on multiple occasions. During the same interview, after being told the patient's son stated he had never met anyone from the hospice, RN 1 stated she had never met, nor spoken with the patient's son.
L0515      
25997 Based on observation and interview the hospice agency failed to ensure Patient 1's right to choose her attending physician was granted. Patient 1 stated she would like to keep her primary care physician (PCP) but was told her PCP would have to be hired by the agency in order to provide her care. This deficient practice resulted in the patient's primary care physician (PCP) being unaware the patient was under hospice care, the hospice staff being unaware the patient was receiving treatment from her PCP, and medication duplications, ineffectiveness, and non-compliance. Findings: On 6/6/19, at 1 PM, an unannounced on-site visit was made to investigate complaint allegations that the agency had not contacted Patient 1's family or her Primary Care Physician (PCP) to coordinate the patient's care, and the agency had committed fraud by admitting a patient to hospice that did not meet hospice criteria. A review of the initial "Physician's Certification For Hospice Benefit" dated 9/22/18, indicated Patient 1, an 80 year old female, had been admitted to the hospice with a diagnosis of atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of the arteries that can cause decreased blood flow). The physician's certification indicated Patient 1 had, "a life expectancy of six months or less, if the terminal illness runs its normal course." On 6/6/19, at 8:53 AM, Patient 1's PCP stated on 2/28/19 he was informed his patient had been under hospice care since September 2018. The PCP was attempting to get home health care for multiple falls possibly due to medication non-compliance, but was unable to enroll her in home health because the patient was listed as a hospice patient. The PCP stated Patient 1 had been under his care for many years, and he had continued to see the patient approximately every two weeks during the time she was under hospice care. The PCP further stated he did not understand how the hospice staff diagnosed the patient as having terminal heart disease. The patient had a history of asymptomatic atherosclerosis (a disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls). During the on-site visit on 6/6/19, at 4 PM, the Director of Patient Care Services (DPCS) acknowledged Patient 1 had notified the hospice she had an attending primary care physician (PCP) upon initial admission. The DPCS stated the hospice notified the patient's PCP on 2/28/19, four months after the patient was admitted for hospice care. The DPCS stated the agency attempted calling the PCP on 10/8/18 and the call would be documented in their communication book. Review of all September 2018 and October 2018 entries in the communication book with the DPCS indicated there was no documentation of the agency attempting to contact the PCP. The DPCS then acknowledged the agency had no contact with the PCP until February 2019. During the same interview, the DPCS stated the agency's policy indicated the PCP was to be notified when a patient was admitted. During an interview on 7/1/19, at 11 AM, a hospice registered nurse, (RN 1) stated she was aware the patient had a PCP. The RN further stated she explained to Patient 1 the hospice's attending physician would take care of her and if she wanted to continue seeing her personal PCP he would need to be hired by the hospice. The RN indicated she told the patient that because that is the hospice's policy. During an interview with Patient 1's PCP on 6/6/19, at 9:30 AM, he stated he received a call from the hospice's medical director apologizing for not contacting him when the patient was admitted to the agency. A review of the agency's undated "Physician Services--Primary Physician's Role" Policy No. 2-015.1 indicated: "The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from the patient's attending physician (if any)." "If a patient chooses to have Primary Care Physician to follow up medical management of the patient under the Hospice Benefit Program, Primary Care Physician will be contacted by hospice prior to admitting patient." "If patient...declines to have primary care physician as his/her attending MD, hospice will contact Primary Care Physician of patient admission to hospice and request medical records for hospice to provide medical justifiable care of patient approved by the hospice attending MD, Interdisciplinary Team, under the supervision of the hospice Medical Director."
L0520      
25997 The agency failed to ensure the Condition of Participation: Initial and Comprehensive Assessment of the Patient was in compliance when it failed to: 1. Ensure a member of the Interdisciplinary Group (IDG) consulted with Patient 1's primary care physician (PCP) to ensure the plan of care addressed all of the patient's care needs. (refer to L 524) 2. Conduct an initial and comprehensive assessment that accurately evaluated Patient 1's appropriateness for hospice care based on the patient's history, current status, patient complaints and objective data. (refer to L 525) 3. Ensure the initial and comprehensive assessments accurately reflected all medications the patient was taking to identify: the effectiveness of the drug therapy, actual or potential drug interactions, and duplicate drug therapies. (refer to L 530) The cumulative effect of these systemic practices resulted in the hospice's inability to be in compliance with the Condition of Participation: Initial and Comprehensive Assessment of the Patient, 42 CFR 418.54
L0524      
25997 Based on interview and record review, the hospice agency failed to ensure a member of the Interdisciplinary Group (IDG) consulted with Patient 1's primary care physician (PCP) to ensure the plan of care addressed all of the patient's care needs. This deficient practice resulted in Patient 1's physical, psychosocial, and emotional needs not being met. Findings: On 6/6/19, at 1 PM, an unannounced on-site visit was made to investigate complaint allegations that the agency had not contacted Patient 1's family or her Primary Care Physician (PCP) to coordinate the patient's care, and the agency had committed fraud by admitting a patient to hospice that did not meet hospice criteria. A review of the initial "Physician's Certification For Hospice Benefit" dated 9/22/18, indicated Patient 1, an 80 year old female, had been admitted to the hospice with a diagnosis of atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of the arteries that can cause decreased blood flow). The physician's certification indicated Patient 1 had, "a life expectancy of six months or less, if the terminal illness runs its normal course." On 6/6/19, at 8:53 AM, Patient 1's PCP stated on 2/28/19 he was informed his patient had been under hospice care since September 2018. The PCP was attempting to get home health care for multiple falls possibly due to medication non-compliance, but was unable to enroll her in home health because the patient was listed as a hospice patient. The PCP stated Patient 1 had been under his care for many years, and he had continued to see the patient approximately every two weeks during the time she was under hospice care. A review of post visit documents dated 9/4/18 through 2/1/19, indicated Patient 1 was seen by her PCP approximately every two weeks for sciatica pain (pain caused by pressure on the nerve that runs down the legs from the lower back), dementia (a disorder of the mental processes that results in memory loss, personality changes, and impaired reasoning), anorexia (loss of appetite for food), abdominal pain with diarrhea, and suicidal ideation (no plan) for which she had started seeing a psychiatrist on 9/25/18. In addition, the post visits indicated she had exhibited no signs and symptoms of cardiac problems. A concurrent review of the hospice's initial and comprehensive assessments, nursing notes, plans of care, and physician orders dated 9/22/18 through 2/16/19 for Patient 1 indicated the patient occasionally complained of leg pain which was controlled by medication, expressed no complaints of chest pain or shortness of breath, was alert and oriented at all times, was prescribed a medication for constipation, and exhibited no indication of depression or sadness. The hospice documents indicated the hospice staff were unaware the patient had been referred to a psychiatrist for suicidal ideation. A review of post visit documents dated 9/4/18 through 2/1/19, indicated the PCP made several medication changes during the period of time the patient was also under hospice care. The PCP was not aware the patient was receiving hospice care, therefore the hospice was unaware of the medication changes. (refer to L 530) A review of the agency's undated Comprehensive Assessment Policy No. 2-030.1 indicated during the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record including: Current treatment and patient response to that treatment. Complications and risk factors that affect care planning. Patient's past and present medical and psychosocial history including pertinent diagnosis and any co-morbid conditions. Name and address of the patient's attending physician.
L0525      
25997 Based on interview and record review the hospice agency failed to conduct an initial and comprehensive assessment that accurately evaluated Patient 1's appropriateness for hospice care based on the patient's history, current physical, emotional, and psychosocial status. This resulted in the hospice agency admitting a patient that did not have a terminal illness based on objective data or subjective complaints. Findings: On 6/6/19, at 1 PM, an unannounced on-site visit was made to investigate complaint allegations the agency had not contacted Patient 1's family or her Primary Care Physician (PCP) to coordinate the patient's care, and the agency had committed fraud by admitting a patient to hospice that did not meet hospice criteria. A review of the initial "Physician's Certification For Hospice Benefit" dated 9/22/18, indicated Patient 1, an 80 year old female, had been admitted to the hospice with a diagnosis of atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of the arteries that can cause decreased blood flow). The hospice medical director's certification indicated Patient 1 had, "a life expectancy of six months or less, if the terminal illness runs its normal course." On 6/6/19, at 8:53 AM, Patient 1's PCP stated he had not been informed his patient was under hospice care until 2/28/19. The PCP stated, "She has been my patient for a long time, and she was my patient during the time she was listed as a hospice patient. The PCP further stated he did not understand how the hospice staff diagnosed the patient as having terminal heart disease. The patient had a history of asymptomatic atherosclerosis (a diagnosis of a build up of cholesterol in the arteries that the patient was not exhibiting any symptoms of concern). On 7/1/19, at 11 AM, an agency registered nurse, (RN 1) stated Patient 1's terminal disease diagnosis was based on an interview she had with the patient, because the patient was taking one-half aspirin each day, and some leg swelling she observed on the first visit, but not on subsequent visits. A review of the hospice's initial and comprehensive assessments, nursing notes, plans of care, and physician orders dated 9/22/18 through 2/16/19 for Patient 1 indicated the patient occasionally complained of leg pain which was controlled by medication, expressed no complaints of chest pain or shortness of breath. During an interview on 6/6/19, at 8:53 AM, Patient 1's PCP stated he would have known if his patient was exhibiting any signs of terminal heart disease. The PCP stated Patient 1 did not exhibit any symptoms of heart disease until he ordered an Echocardiograph (a diagnostic test in which ultrasound waves are used to investigate the action of the heart) in January 2019, four months after the patient was admitted to hospice. The PCP stated the echocardiograph showed only delayed ejection (measurement of the percentage of blood leaving the heart each time the heart contracts). A review of the hospice agency's undated Physician Services-Primary Physician's role, Policy No. 2-015.1 indicated as of October 1, 2009, the physician's brief narrative explanation of the clinical findings supports a life expectancy of 6 months or less as part of the certification and recertification. The narrative shall include a statement directly above the physician's signature attesting that by signing, the physician confirms that he/she composed the narrative based on his review of the patient's medical record or, if applicable, his or her examination of the patient. On 6/6/19, at 4 PM, the agency's Director of Patient Care Services (DPCS) stated the agency did not attempt to obtain any medical records or diagnostic tests to confirm Patient 1 had a terminal illness. The DPCS stated this was not an uncommon practice.
L0530      
25997 Based on interview and record review, the hospice agency failed to ensure the initial and comprehensive assessments accurately reflected all medications Patient 1 was taking. This deficient practice resulted in Patient 1 being placed at the risk of great harm due to lack of drug therapy effectiveness, actual or potential drug interactions, and duplicate drug therapies. Findings: On 6/6/19, at 1 PM, an unannounced on-site visit was made to investigate complaint allegations the agency had not contacted Patient 1's family or her Primary Care Physician (PCP) to coordinate the patient's care, and the agency had committed fraud by admitting a patient to hospice that did not meet hospice criteria. A review of the initial "Physician's Certification For Hospice Benefit" dated 9/22/18, indicated Patient 1, an 80 year old female, had been admitted to the hospice with a diagnosis of atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of the arteries causing obstruction of blood flow). On 6/6/19, at 8:53 AM, Patient 1's PCP stated he had not been informed his patient was under hospice care until 2/28/19. The PCP stated, "She has been my patient for a long time, and she was my patient during the time she was listed as a hospice patient. The hospice agency never contacted me." The PCP stated he was concerned the patient was being non-compliant with his medication orders due to multiple falls, new on-set diarrhea and abdominal pain, and a lack of expected response to multiple medication changes he made. A review of Patient 1's post PCP visit notes, dated 9/18/18 through 2/19/19, indicated the patient was allergic to the following medications: Lisinopril (a high blood pressure medication), Clemastine (an allergy relief medication), Iodine solution and antibiotics from the penicillin family). A review of a comprehensive assessment performed by RN 1, dated 9/22/18, indicated Patient 1 had no food or medication allergies. A comparison review of the medications ordered by the hospice medical director, dated 9/22/18 and medication orders written by PCP 1 over the 4 month period the patient was under hospice care indicated the following: 1. Hospice order dated 9/22/18 -Lyrica (a medication for pain) 100milligrams (mg) at bedtime -Lyrica 50 mg morning and lunch PCP 1 order dated 3/20/18: - Lyrica 100 mg. Take one capsule every night at bedtime. Do not take 50 mg capsule previously prescribed. Review of PCP 1's orders indicated Patient 1 was only to have the medication at night. 2. Hospice order dated 9/22/18: Amiodipine 5mg every day for high blood pressure. Review of PCP 1's medication orders 9/4/18 through 1/18/19 indicate he did not order this medication and was not aware Patient 1 was receiving the medication. 3. Hospice order dated 9/22/18: Colace 100mg every day for constipation Review of PCP 1's medication orders indicated he did not order this medication and was not aware Patient 1 was receiving it. 4. Hospice order dated 9/22/18: Mirtazapine (a medication for depression) 15 mg every day for insomnia PCP 1 order dated 9/4/18: Mirtazapine 15 mg at night for 30 days A review of PCP 1's medication orders indicated he increased the dose of this medication to 30 mg once a day on 10/15/18, then increased the dose again on 12/19/18 to 45 mg once a day. A review of the hospice discharge Plan of Care (POC), dated 1/23/19, revealed the medication dose was not changed from the original 15 mg every day. During an interview with RN 1 on 7/1/19, at 11 AM, the RN stated she determined what medications the patient was taking on admission, 9/22/18, by holding up the bottles and asking the patient if she was currently taking the medication and she reviewed the medications every week during her visit. Lastly, RN 1 stated there were no medication changes while the patient was under hospice care. A review of the discharge Plan of Care (POC) dated 2/16/19, also indicated during the time Patient 1 was under the care of the hospice, there were no changes in the medication orders. Patient 1's PCP made several medication changes during that time period. On 6/6/19, at 8:43 AM, Patient 1's PCP stated due to the patient's dementia the PCP and family were unable to determine which medication orders the patient was following. A further review of the post visit notes indicated Patient 1 was seen in PCP 1's office on four occasions between 9/22/18 and 1/23/19 complaining of abdominal pain and diarrhea. During a concurrent interview PCP 1 stated Patient 1's complaints and medication non-compliance were possibly due to the medication discrepancies between his orders and those ordered by the hospice Medical Director. Messages were left requesting a call back from the hospice Medical Director on 6/6/19, 7/1/19, and 7/31/19. On 6/6/19, at 8:53 AM PCP 1 stated he contacted the agency on 2/28/19 when he found out his patient had been enrolled with the hospice since 9/23/18. The PCP requested the hospice medical records because he was concerned Patient 1 had not been taking the medications he ordered. The PCP stated immediately after that call the hospice Medical Director called him to apologize. A review of the agency's undated "Physician Services-Primary Physician's Role" Policy No. 2-015.1 indicated: "The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from the patient's attending physician (if any)." "If a patient chooses to have Primary Care Physician to follow up medical management of the patient under the Hospice Benefit Program, Primary Care Physician will be contacted by hospice prior to admitting patient." "If patient...declines to have primary care physician as his/her attending MD, hospice will contact Primary Care Physician of patient admission to hospice and request medical records for hospice to provide medical justifiable care of patient approved by the hospice attending MD, Interdisciplinary Team, under the supervision of the hospice Medical Director." "Section 1814(a)(7) of the Social Security Act specifies that certification of terminal illness for hospice benefits shall be based on the clinical judgment of the hospice medical director or physician member of the interdisciplinary group (IDG) and the individual's attending physician..." A review of the agency's undated "Medication Monitoring" policy No. 3-015.1 indicated: "The ongoing medication monitoring will be used to: Evaluate the continued use of a medication in the current regimen and evaluate patient adherence to the prescribed medication regimen. "The clinician will assess the effect of medications on the patient. The assessment will identify drug interactions, duplicate drug therapy, and non-compliance with drug therapy."
L0664      
25997 The agency failed to ensure the Condition of Participation: Medical Director was in compliance when it failed to: Ensure the medical director obtained and reviewed all relevant clinical information, to include related diagnoses, subjective and objective medical findings, and current medications and treatment orders in order to certify the patient had an anticipated life expectancy of six months or less. (refer to L 667) The cumulative effect of these systemic practices resulted in the hospice's inability to be in compliance with the Condition of Participation: Medical Director, 42 CFR 418.102.
L0667      
25997 Based on interview and record review, the hospice failed to ensure the medical director obtained and reviewed all relevant clinical information, related diagnoses, current medications and treatment orders in order to accurately certify Patient 1 had an anticipated life expectancy of six months or less. This deficient practice resulted in the patient being an inappropriate candidate for hospice care and a decline in the patient's physical, psychosocial, and emotional wellbeing. Findings: On 6/6/19, at 1 PM, an unannounced on-site visit was made to investigate complaint allegations that the agency had not contacted Patient 1's family or her Primary Care Physician (PCP) to coordinate the patient's care, and the agency had committed fraud by admitting a patient to hospice that did not meet hospice criteria. A review of the initial "Physician's Certification For Hospice Benefit" dated 9/22/18, indicated Patient 1, an 80 year old female, had been admitted to the hospice with a diagnosis of atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of the arteries that can cause decreased of blood flow). On 6/6/19, at 8:53 AM, Patient 1's PCP stated on 2/28/19 he was informed his patient had been under hospice care since September 2018. The PCP was attempting to get home health care for multiple falls possibly due to medication non-compliance, but was unable to enroll her in home health because the patient was listed as a hospice patient. The PCP stated Patient 1 had been under his care for many years, and he had continued to see the patient approximately every two weeks during the time she was under hospice care. The PCP further stated Patient 1 was not a candidate for hospice care because at the time of her admission to the hospice the only cardiac diagnosis Patient 1 had asymptomatic atherosclerosis (a diagnosis of a build up of cholesterol in the arteries that the patient was not exhibiting any symptoms of concern). During the same interview, Patient 1's PCP stated the patient was not diagnosed as having any impediments to the blood flow from her heart until he ordered an echocardiograph (a diagnostic test that uses ultrasound to determine a patient's percentage of blood flow from the heart). The result of that test showed the patient only had delayed ejection (blood flow). The PCP stated this was not unexpected in an 80 year old patient. A review of post visit documents dated 9/4/18 through 2/1/19, indicated Patient 1 was seen by her PCP approximately every two weeks for sciatica pain (pain caused by pressure on the nerve that runs down the legs from the lower back), dementia (a disorder of the mental processes that results in memory loss, personality changes, and impaired reasoning), anorexia (loss of appetite for food), abdominal pain with diarrhea, and suicidal ideation (no plan) for which she had started seeing a psychiatrist on 9/25/18. In addition, the post visits indicated she had exhibited no signs and symptoms of cardiac problems. A concurrent review of the hospice's initial and comprehensive assessments, nursing notes, plans of care, and medical director orders dated 9/22/18 through 2/16/19, indicated the patient occasionally complained of leg pain which was controlled by medication, expressed no complaints of chest pain or shortness of breath, was alert and oriented at all times, was prescribed a medication for constipation, and exhibited no indication of depression or sadness. The hospice documents indicated the hospice staff were unaware the patient had been referred to a psychiatrist for suicidal ideation. (refer to L524 and L525) A review of post visit documents dated 9/4/18 through 2/1/19, indicated the PCP made several medication changes during the period of time the patient was also under hospice care. The PCP was not aware the patient was receiving hospice care, therefore the hospice was unaware of the medication changes. (refer to L530) The PCP stated immediately after he called the hospice requesting copies of his patient's records, the hospice Medical Director called him to apologize for not notifying him his patient was receiving care from her hospice. Messages were left requesting a call back from the hospice Medical Director on 6/6/19, 7/1/19, and 7/31/19. A review of the agency's undated "Physician Services-Primary Physician's Role" Policy No. 2-015.1 indicated: "The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from the patient's attending physician (if any)." "If a patient chooses to have Primary Care Physician to follow up medical management of the patient under the Hospice Benefit Program, Primary Care Physician will be contacted by hospice prior to admitting patient." "If patient...declines to have primary care physician as his/her attending MD, hospice will contact Primary Care Physician of patient prior to admission to hospice and request medical records for hospice to provide medical justifiable care of patient approved by the hospice attending MD, Interdisciplinary Team, under the supervision of the hospice Medical Director." "Section 1814(a)(7) of the Social Security Act specifies that certification of terminal illness for hospice benefits shall be based on the clinical judgment of the hospice medical director or physician member of the interdisciplinary group (IDG) and the individual's attending physician..." "A review of the hospice agency's undated Physician Services-Primary Physician's role, Policy No. 2-015.1 indicated as of October 1, 2009, the physician's brief narrative explanation of the clinical findings supports a life expectancy of 6 months or less as part of the certification and recertification. The narrative shall include a statement directly above the physician's signature attesting that by signing, the physician confirms that he/she composed the narrative based on his review of the patient's medical record or, if applicable, his or her examination of the patient." A review of the Physician's Certification For Hospice Benefit, dated 9/28/18, and signed by the hospice medical director, indicated the certification was based on Patient 1's medical history, record, and the hospice team assessment. On 6/6/19, at 4 PM, the agency's Director of Patient Care Services (DPCS) stated the agency did not attempt to obtain any medical records or diagnostic tests to confirm Patient 1 had a terminal illness. The DPCS stated this was not an uncommon practice. On 7/1/19, at 11 AM, an agency registered nurse, (RN 1) stated Patient 1's terminal disease diagnosis was based on an interview she had with the patient, because the patient was taking one-half aspirin each day, and some leg swelling she observed on the first visit, but not on subsequent visits.