Every finding on record at Aspen Hospice Care Inc

Based on record review and interview, the agency interdisciplinary group in collaboration with the attending physician, (if any), failed to revise the plan of care every 15 days, to include the identified issue/problem of dysphagia (problem swallowing foods or liquid) in 1 (#1) of 2 client records reviewed where swallowing issues were identified. The failure placed the patients at risk of negative outcomes and possible aspiration (choking on food, liquids, and/or pills), --- Patient #1:Record review of Patient #1's clinical record revealed an Initial Plan of Care dated 1/19/2024 to 4/17/2024. The Plan of Care indicated that Patient #1 started on the agency's services on 1/19/2024. The Plan of Care listed Parkinson's Disease (brain disorder causing unintended or uncontrollable movements; shaking, stiffness, and difficulty with balance and coordination which worsen over time) as the terminal diagnosis. The Plan of Care contained an order for diet to be as tolerated. Registered Nurse D conducted a Start of Care Comprehensive Assessment on 1/19/2024. Registered Nurse D documented that Patient #1 had Parkinson's Disease with Dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs or trunk) with fluctuations. Registered Nurse D documented Patient #1 did not have pain; had garbled speech; was never short of breath; Lung sounds diminished at bases; Current Diet was regular, as tolerated; able to eat normal diet/no dysphagia (also documented dysphagia as a comorbidity/secondary condition - a medical condition that is a complication of or occurs as a result of the primary condition); Family/Caregiver felt patient not eating and/or drinking enough; incontinent of bladder (involuntary loss of urine); at risk for malnutrition, falls, infections; and total assistance with activities of daily living. Registered Nurse C conducted skilled nurse visits on 1/22/2024 and 1/25/2024. Registered Nurse C documented dysphagia in the Digestive Nutrition portion of the clinical note. Registered Nurse C documented dysphagia as Secondary/Comorbidity condition. Registered Nurse E conducted skilled nurse visits on 1/30/2024 and 1/31/2024. Registered Nurse E documented dysphagia as a Secondary/Comorbidity condition. Registered Nurse C conducted skilled nurse visits on 2/6/2024, 2/9/2024, 2/13/2024, 2/15/2024, 2/21/2024, and 2/23/2024. Registered Nurse C documented dysphagia as a Secondary/Comorbidity condition. Registered Nurse C conducted a skilled nurse visit on 2/28/2024. Registered Nurse C documented that Patient #1 had a new onset of difficulty swallowing medications. Registered Nurse C documented dysphagia as a Secondary/Comorbidity condition. Registered Nurse C conducted a skilled nurse visit on 3/1/2024. Registered Nurse C documented that Patient #1's medications were having to be crushed. Registered Nurse C documented dysphagia as a Secondary/Comorbidity condition. Registered Nurse C conducted skilled nurse visits on 3/4/2024 and 3/6/2024. Registered Nurse C documented dysphagia as a Secondary/Comorbidity condition. Registered Nurse C conducted a skilled nurse visit on 3/11/2024. Registered Nurse C documented Patient #1 was in the dining room being feed by staff. Patient #1 was coughing and had a runny nose and eyes. Registered Nurse C instructed the assisted living facility staff to give Patient #1 smaller bites and not to use straws when coughing. Registered Nurse C documented dysphagia as a Secondary/Comorbidity condition. Registered Nurse C conducted a skilled nurse visit on 3/12/2024. Registered Nurse C documented receipt of a call that the assisted living facility called that Patient #1 had a change in condition. Registered Nurse C documented that Patient #1's oxygen saturation level (amount of oxygen in the blood) was fluctuating between 85-90% on room air. Registered Nurse C documented "Keeping patient on oxygen, suspects aspiration (when food, liquid, saliva, stomach contents, or other substances are inhaled into the lungs instead of being swallowed) MD (Medical Doctor) contacted. New orders received for ABT (antibiotic) and nebs (nebulizer treatments) ...Mediation (sic) and equipment ordered...Staff made aware patient to remain NPO (nothing by mouth) except medications IF [Patient #1] can swallow..." Registered Nurse C documented dysphagia as a Secondary/Comorbidity condition. Registered Nurse C conducted a skilled nurse visit on 3/13/2024. Registered Nurse C documented Morphine (pain medication), Ativan (used for anxiety and agitation), Nebulizer, and Levaquin (antibiotic) were administered. Registered Nurse C documented attempting to give Patient #1 thickened water using a "G-tube syringe" that was unsuccessful. Registered Nurse C documented that Patient #1 continued to cough even with thicken fluids; Registered Nurse C documented that Levaquin was administered crushed in pudding, which Patient #1 swallowed but coughed shortly afterwards; Registered Nurse C documented that Patient #1 was to remain nothing by mouth until more alert and a suction machine was ordered stat (without delay). Patient #1 was transferred to hospital via ambulance. Plan of Care orders: The Initial Plan of Care dated 1/19/2024 did not include dysphagia. The Plan of Care order dated 1/30/2024 was not revised to include dysphagia.The Plan of Care order dated 2/13/2024 was not revised to include dysphagia.The Plan of Care order dated 2/27/2024 was not revised to include dysphagia.The Plan of Care order dated 3/11/2024 was not revised to include dysphagia. Hospice services were revoked by Patient #1's family on 3/13/2024 and Patient #1 was transported to the hospital via ambulance for aspiration pneumonia (lung infection that occurs when food, liquid, saliva, stomach contents, or other substances are inhaled into the lungs instead of being swallowed). During an interview on 8/28/2024 at 9:11 a.m. with the Administrator/Alternate Supervising Nurse, the Alternate Administrator, and the Supervising Nurse the surveyor discussed Patient #1's Plan of Care. The surveyor discussed that the agency's staff were documenting Patient #1 was having issues with swallowing and that it was not included as a problem in the Plan of Care. The Administrator/Alternate Supervising Nurse informed the surveyor that the Plan of Care, "Didn't have dysphagia." During an interview on 8/28/2024 at 12:50 p.m. with Registered Nurse C, the surveyor discussed Patient #1 problems with swallowing and having medications crushed. The surveyor discussed that dysphagia was not in the Plan of Care and not included in the interdisciplinary team meetings. Registered Nurse C informed the surveyor that it was part of the hospice diagnosis. Agency policies were given to the surveyor by the agency's Administrator or the Supervising Nurse. Review of the agency's policy titled "Plan of Care Process," labeled PC.30, and was undated. The policy read in part; " Purpose To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient's and family's specific needs. Policy...II. The Hospice will develop an individualized written POC for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. Procedure...VI. The POC includes, but is not limited to: A. Interventions to manage pain and symptoms and identified issues/problems...VII. The Hospice IDG/IDT (In collaboration with the individual's attending physician, if any, will review, revise, and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 days..."

Based on record review and interview, the agency failed to include a physician order in the clinical record, where facility staff were instructed to give nothing by mouth except for medications if the patient could swallow for 1 (#1) of 2 patient records reviewed where swallowing issues were identified. The failure placed the patients at risk of a negative outcome and aspiration (choking on food, liquids, and/or pills). --- Patient #1:Record review of Patient #1's clinical record revealed an Initial Plan of Care dated 1/19/2024 to 4/17/2024. The Plan of Care indicated that Patient #1 started on the agency's services on 1/19/2024. The Plan of Care listed Parkinson's Disease (brain disorder causing unintended or uncontrollable movements; shaking, stiffness, and difficulty with balance and coordination which worsen over time) as the terminal diagnosis. The Plan of Care contained an order for diet to be as tolerated and the hospice nurse may add or change nutritional supplements as needed. Registered Nurse D conducted a Start of Care Comprehensive Assessment on 1/19/2024. Registered Nurse D documented that Patient #1 had Parkinson's Disease with Dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs or trunk) with fluctuations. Registered Nurse D documented Patient #1 did not have pain; had garbled speech; was never short of breath; Lung sounds diminished at bases; Current Diet was regular, as tolerated; able to eat normal diet/no dysphagia; Family/Caregiver felt patient not eating and/or drinking enough; incontinent of bladder (involuntary loss of urine); at risk for malnutrition, falls, infections; and total assistance with activities of daily living. Registered Nurse C conducted a skilled nurse visit on 2/28/2024 documented that Patient #1 had new onset of issues swallowing medications. Registered Nurse C conducted a skilled nurse visit on 3/1/2024. Registered Nurse C documented that Patient #1's medications were having to be crushed. Registered Nurse C conducted a skilled nurse visit on 3/11/2024. Registered Nurse C documented that Patient #1 was coughing, had runny nose and eyes. Registered Nurse C advised the staff to give smaller bites and no straws when Patient #1 was coughing. Registered Nurse C conducted an as needed skilled nurse visit on 3/12/2024. Registered Nurse C documented that Patient #1's oxygen saturation level (amount of oxygen in the blood) was 87% on room air. Registered Nurse C documented that Patient #1's oxygen saturation levels fluctuated between 85-90% and suspected aspiration (accidentally inhaling food or liquid into the airway, instead of swallowing food through the food pipe, or esophagus, and into the stomach). Registered Nurse C documented receipt of orders for an antibiotic and nebulizer treatments. Registered Nurse C documented that staff were made aware that Patient #1 was to remain NPO (nothing by mouth) except medications if Patient #1 could swallow. An order for Patient #1 to have nothing by mouth except for medications if Patient #1 could swallow was not in the clinical record. During an interview on 8/28/2024 at 9:11 a.m. with the Administrator/Alternate Supervising Nurse, the Alternate Administrator, and the Supervising Nurse, the surveyor discussed Patient #1 and that Registered Nurse C documented telling the assisted living facility staff that Patient #1 was to be nothing by mouth except for medications if Patient #1 can swallow. The surveyor asked who gave the order for Patient #1 to be nothing by mouth except for medications if Patient #1 could swallow. The Administrator/Alternate Supervising Nurse stated, "I don't believe there is an order for NPO. I believe it was a suggestion. There was no order." During an interview on 8/28/2024 at 12:26 p.m. with Physician X, the surveyor discussed Patient #1. The surveyor asked Physician X if Physician X gave an order for Patient #1 to have nothing by mouth except medications if Patient #1 could swallow. Physician X stated, "I will have to check my records." During an interview on 8/28/2024 at 12:50 p.m. with Registered Nurse C, the surveyor asked who gave the order that Patient #1 could have nothing by mouth except for medications if Patient #1 could swallow. Registered Nurse C stated, "Nothing by mouth came into play because he could not swallow and it wasn't nothing by mouth, [Patient #1] was still receiving medications by mouth and pleasure feeds." Registered Nurse C was asked if Registered Nurse C had informed the assisted living facility staff that Patient #1 was to have nothing by mouth except for medications if Patient #1 could swallow. Registered Nurse C stated, "I don't recall, I'll have to look at my documentation." Registered Nurse C's documentation on 3/12/2024, "Staff made aware patient to remain NPO except medications IF [Patient #1] can swallow." The surveyor received an email on 8/29/2024 at 2:42 p.m. from the agency's Administrator with the response from Physician X. The email read:"I just spoke with [Physician X] regarding Levaquin order for Patient #1. [Physician X] states he instructed the nurse, [Registered Nurse C], to only give Levaquin if patient was able to swallow, as patient had been having small amounts of food that day and to discuss goals of care with family if patient became unable to swallow." Review of the agency's policy titled "Timelines," labeled IM.40, and dated 10/1/2021 read in part; "Purpose To establish timely parameters for all medical record information. Policy The Hospice will ensure timely provision of care to meet patient's needs in compliance with all federal and state laws and regulations. Procedure...G. Supplemental verbal orders may be obtained before care is provided and are written within 24 hours of receiving the orders..."

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, 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 clinical record review, document review and interview. In 1 of 6 (17%) clinical records reviewed revealed the agency did not ensure the patient's medication (drug) profile contained all the prescribed medications, specifically the oxygen. Document 12: Agency policy titled: Medication List and Monitoring PC.85 (last reviewed 10/01/2021) stated in relevant part, "The hospice will maintain a current list of all prescription and over the counter (OTC) medications taken by the patient. The medication will be documented on the medication profile." Clinical Record 6: The patient elected the hospice benefit on 01/19/2024 with a diagnosis of Parkinson's disease. The initial plan of care orders, dated 01/19/2024, contained an order for "Respiratory Distress: Oxygen 1-4 liters/minute PRN (as needed). May titrate to level of patient discomfort or to keep oxygen saturation above greater than/equal to 95% as needed." Nursing assessment, dated 03/12/2024, documented oxygen saturation of 87% and oxygen was initiated and was being titrated per order. The medication profile, effective from 01/19/2024 to date of discharge (03/13/2024), did not list oxygen as one of the patient's prescription medications. Personnel Record 2: The director of nursing, on 07/31/2024, confirmed the oxygen was not included on the medication profile and stated, "we had a performance improvement plan (PIP) on this and have been educating the nurses."

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed revealed the agency did not ensure the plans of care included specific interventions based on the problems identified within the comprehensive assessments. Clinical Record 3: The hospice benefit was elected on 06/12/2024 for the terminal diagnosis of hypertensive heart disease. The patient resided in an assisted living facility throughout the course of the hospice stay. Initial nursing assessment documented a fall risk assessment score of "8" and per the assessment tool a "score of 4 or greater is considered at risk for falling." The physician narrative, on the initial certification signed 06/16/2024, stated "The patient has also experienced several falls recently." Nursing assessment, dated 06/20/2024, documented that a PRN (as needed) visit was made because the facility reported the patient fell on 06/19/2024. The nursing note stated the staff was "educated on fall precautions" and that a fall matt was ordered. The plan of care, effective from 06/12/2024 until 07/22/204, did not include any problems, goals, or interventions specific to falls, fall prevention, or safety. Effective 07/22/2024 a fall care plan was added which included fall safety precautions, low bed, and the fall matt. The administrator (personnel record #1) reported on 07/31/2024 that the plan of care did not address the fall precautions or interventions until it was added on 07/22/2024. Clinical Record 6: The hospice benefit was elected on 01/19/2024 and the diagnoses included Parkinson's disease with dyskinesia and dementia. A face-to-face visit by a nurse practitioner was documented on 01/18/2024 which stated, "He is at risk for falls, aspiration, skin breakdown, malnutrition, and respiratory failure." The nursing narrative on the initial nursing assessment (01/19/2024) reported the patient had dysphagia and required assistance with feeding. The physician narrative dated 01/19/2024 listed dysphagia as a secondary condition. On the 03/01/2024 nursing comprehensive assessment the RN documented that the patient's "medications needing to be crushed, family made aware." During a visit on 03/11/2024 the RN documented, "Patient noted in dining room being fed by staff. Coughing noted with runny nose and eyes. Advised staff to do smaller bites and no straws when patient coughing, will continue to monitor." On 03/12/2024 the patient was started on antibiotics for symptoms of an upper respiratory infection and "possible aspiration." On 03/13/2024 the patient was admitted to the hospital for possible aspiration pneumonia. The plan of care, effective from 01/19/2024 to date of discharge (03/13/2024) did not include any problems goals or interventions related to dysphagia or aspiration precautions. On 07/31/2024 the director of nursing (personnel record #2) and the administrator (personnel record #1) both stated that the plan of care did not contain any interventions related to the documented dysphagia or aspiration precautions.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed, in which a patient was transferred to a Medicare/Medicaid certified facility, revealed the agency did not ensure that a discharge summary was provided to the receiving institution. Clinical Record 6: The clinical record review revealed the patient's family revoked hospice services on 03/13/2024 seeking aggressive treatment. The nursing assessment from 03/13/2024 documented the ambulance was called and arrived at the facility at 1500, the hospice nurse was present and provided verbal report to the ambulance personnel. The hospice nurse documented at 1530 that the patient was transferred to (name of hospital) and verbal report was called to the triage nurse. The record did not include evidence that the discharge summary had been sent to the receiving institution or detail what components were provided in the phone report. Personnel Record 1: On 07/31/2024 the administrator stated that they (the administrator and director of nursing) had reviewed the record and confirmed with the business office personnel that there was no evidence a discharge summary was faxed to the hospital.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed, in which a discharge summary was required, revealed the agency did not ensure the discharge summary was provided to the patient's attending physician. Clinical Record 5: During a nursing visit, on 07/03/2024, the patient stated that he thought he wanted to come off hospice services because, "I don't think I am sick and doesn't want to waste peoples time." The patient was going to see his attending physician to discuss. On 07/05/2024 the patient signed the revocation form. The record did not include evidence that the primary care physician had been provided a copy of the discharge summary. Personnel Record 1: On 07/31/2024 the administrator reported that there was no evidence the discharge summary had been sent and stated, "I think since the nurse knew he (the patient) had met with the attending physician they didn't need to send one.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure that the patient's Plans of Care included interventions based on information obtained from the Comprehensive and updated Comprehensive Assessments. Clinical Record 4: The patient elected the hospice benefit on 10/17/2023. The nurse noted on 10/20/2023 that the patient had 2+ edema to his left lower extremity. The Plan of Care (POC) dated 10/17/2023 - 1/14/2024 included the diuretic medication orders for Furosemide 40mg by mouth twice a day and Spironolactone Powder 1 tab by mouth daily. There was no documented evidence included on the POC that included patient/family goals related to diuretic therapy and no specific skilled interventions for the patient's edema. Clinical Record 9: The patient elected the hospice benefit on 7/12/2023. There was a physician order dated 10/13/2023 for Levaquin 500mg by mouth daily for seven days for a suspected upper respiratory infection. The Registered Nurse documented on the skilled nurse (SN) visit note dated 10/16/2023 that the patient's right lung fields had crackles on auscultation. The patient was on 4 liters per minute of oxygen continuously and had a productive cough. There was no documented evidence in the clinical record that the POC was updated to include any new problems, interventions, or goals related to the prescribed antibiotic. It was confirmed during a joint interview with the Director of Nursing (Staff 3) and the Administrator (Staff 1) on 12/1/2023 that the patient's Care Plans had not been updated to provide pertinent interventions identified in the Comprehensive and Updated Comprehensive Assessments.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure that the visit frequencies of all disciplines ordered by the Interdisciplinary Group in the Plan of Care were followed as ordered. Clinical Record 3: The patient elected the hospice benefit on 6/23/2022. The Plan of Care orders dated 6/18/23 – 8/16/23, 8/17/23 – 10/15/23, AND 10/16/23 – 12/14/23 included an order for weekly Chaplain visits. During the months of August, September and October, there was only one visit documented per month in the clinical record. There was no documented evidence of why the visits were not completed as ordered. Clinical Record 5: The patient elected the hospice benefit on 7/13/2023. The Plan of Care order dated 8/27/2023 stated Chaplain frequency as once a month. There was no documented evidence of a chaplain visit for the month of September. During a joint interview with the Administrator (Staff 1) and the Director of Nursing (Staff 3) on 12/1/2023 confirmed that there was a discrepancy between the ordered Chaplain visits and the frequency in which the Chaplain was making visits to the patients. It was confirmed during a joint interview with the Director of Nursing (Staff 3) and the Administrator (Staff 1) on 12/1/2023 that there was a discrepancy between the ordered Chaplain visits and the frequency in which the Chaplain was making visits to the patients.

It is required that Hospice Aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 17 (24%) clinical records reviewed in which Hospice Aide services were accepted revealed that the agency did not ensure that specific instructions were provided to the Hospice Aide by the RN for specific Aide intervention frequency. Clinical Record 4: The patient elected the hospice benefit on 10/17/2023. The Plan of Care (POC) Order dated 10/17/2023 - 1/14/2024 included an order for Hospice Aide visits three times weekly. A physician POC update order dated 10/25/2023 decreased the hospice aide frequency to twice a week. The Hospice Aides plan of care dated 10/18/2023 included an intervention for a complete bed bath to be performed by the Aide three times a week and a partial bath/shower to be done twice a week. Additionally, there are instructions to shampoo the patient's hair, shave his face, and change his linen three times a week. There is no documented evidence that the aide plan of care was updated when the frequency was changed to twice a week. Clinical Record 9: The patient elected the hospice benefit on 7/12/2023. The POC dated 9/ 7/12/2023 - 10/9/2023 and 10/10/2023 - 1/7/2024 included an order for Hospice Aides visits five times a week. The Aide plans of care dated 9/27/2023 and 10/2/2023 included an intervention for a complete shower to be performed by the Aide three times a week and a partial bath/shower to be done twice a week. The Aide visit notes dated 9/27/2023, 9/28/2023, 10/9/2023, 10/10/2023, 10/13/2023, and 10/26/2023 included documentation that both the complete shower and the partial bath/shower were completed during the visits. Clinical Record 13: The patient elected the hospice benefit on 5/25/2023. The POC dated 8/23/2023 - 11/20/2023 included an order for Hospice Aide visits five times a week. The Registered Nurse documented on the visit note dated 8/28/2023 that the patient was alert and oriented to self only. The patient resides at a long-term care facility/SNF. The Aide plan of care dated 8/31/2023 included an intervention for the Hospice Aides to shampoo the patient's hair as needed. There was no documented evidence that the RN included specific instructions for the patient's hair shampoo frequency. Clinical Record 15: The patient elected the hospice benefit on 8/11/2022. The POC dated 4/8/2023 - 6/6/2023 included orders for the Hospice Aides to perform visits five times a week. The POC dated 3/30/2023 included instructions for the aide to perform a complete bed bath three times weekly and a partial bath/shower twice weekly. The Aide documented both type of baths completed on the Aide visits dated 4/10/2023, 4/11/2023, 4/12/2023, 4/13/2023, 4/14/2023, 4/17/2023, 4/18/2023, 4/21/2023 ,4/25/2023, 4/26/2023, 4/27/2023, 5/2/2023, 5/3/2023, 5/4/2023, 5/5/2023, 5/8/2023, 5/9/2023 ,5/10/2023, 5/11/2023 ,5/12/2023, 5/15/2023, 5/16/2023, 5/17/2023, 5/18/2023 ,5/19/2023, 5/22/2023 ,5/23/2023, 5/24/2023, 5/25/2023, 5/26/2023, 5/29/2023, 5/30/2023, 5/31/2023, 6/2/2023. During a joint interview with the Administrator (Staff 1) and Director of Nursing (DON) (Staff 3) on 12/1/2023, Staff 1 and Staff 2 confirmed that the Hospice Aide Care Plans were developed in such a way as to be unclear about when some of the interventions were to be completed when two types of showers/baths were included. Additionally, discussion developed in regard to tasks being assigned specific days of the week versus a generic "three times a week. Staff 1 and Staff 2 confirmed that the nurses needed further education regarding developing Aide Care Plans and the Hospice Aides needed instructions on how to complete documentation when there is more than one intervention of the same type included on the Care Plan (for example two types of baths).

It is required that Volunteer services are noted in the Plan of Care and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed in which Volunteer services were accepted revealed that the agency did not ensure that the Volunteer visit documentation matched the Volunteer visit frequency order. Clinical Record 2: The patient elected the hospice benefit on 3/10/2023. The Plan of Care order dated 7/30/2023 included a volunteer visit frequency of three times monthly. The Interdisciplinary Group Meeting (IDG)/Plan of Care Updates for 8/4/2023 through 11/10/2023 continued to include a volunteer visit frequency of three times monthly. A review of the clinical record revealed one volunteer visit for the months of August and September, and two volunteer visits for the month of October. There was no documented evidence of reason or notification to the physician of the missed volunteer visits. Additionally, there were no notations in the IDG Meetings from 8/4/2023 through 11/10/2023. During a joint interview with the Administrator (Staff 1) and the Director of Nursing (Staff 3) on 11/30/2023, it was confirmed that there was a misunderstanding regarding this patient's Volunteer order frequency and the previous Volunteer visit schedule.

It is required if the care of the patient is transferred to a Medicare/Medicaid certified facility, the hospice must forwards to the receiving facility a copy of the discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which the hospice patient was discharge from the hospice, it was revealed that the agency did not ensure that the discharge summary was sent to the facility receiving the patient for care. Clinical Record 18: The patient elected the hospice benefit on 1/28/2023 and revoked the hospice benefit on 3/26/2023 and admitted to the hospital to seek aggressive treatment. There was no documented evidence that the discharge summary was sent to the receiving facility. It was confirmed during a joint interview with the Director of Nursing (Staff 3) and the Administrator (Staff 1) on 12/1/2023 that the discharge summary was not sent to the facility.

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 a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which the patient was discharged from the hospice agency revealed that the agency did not ensure that the patient's Discharge Summary included all the required elements. The patient elected the hospice benefit on 1/28/2023 and revoked the hospice benefit on 3/26/2023 and was admitted to the hospital to seek aggressive treatment. There was no documented evidence that the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, current plan of care, and the patient’s latest physician orders. There was no documented evidence in the clinical record that a discharge summary with all the required elements was sent to the attending physician or the receiving facility. During a joint interview with the Director of Nursing (Staff 3) and the Administrator (Staff 1) on 12/1/2023 that the patient's discharge summary didn't include important information about the patient's pain management the Plan of Care, or any physician orders.