Every finding on record at Blue Water Hospice, LLC

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, document review and interview. In 1 of 2 (50%) clinical records reviewed in which the patient was a live discharge revealed that that agency did not ensure that a complete discharge summary was completed and provided to the attending physician. Document 1: The agency's policy titled Discharge summary states in part, "If a patient revokes the election of Hospice care, or is discharged from Hospice, Hospice will forward to the patient's attending physician, a copy of the Hospice discharge summary." CLINICAL RECORD 13: The patient elected hospice on 05/09/2024 and signed a revocation of hospice services on 06/07/2024. The clinical record contained no evidence of a documented discharge summary, a discharge summary sent to the alternate hospice, or any care coordination with the alternate hospice. During an interview on 01/08/2025 with the owner she stated that they were generating a discharge summary, but the process was not followed through to send it to the patient's attending physician.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review and staff interview. 2 of 5 (40%) clinical records reviewed revealed the agency failed to meet the individualized visit frequency orders as established by the IDG. Record #27810 (election of benefit 1/12/2022): Social work (SW) plan of care order (effective 1/12/22) was for one visit per month, for the months of January and February there were two routine visits documented as made. Chaplain plan of care order (effective 1/12/22) was for one visit per week; the weeks of 2/20/2022, 3/13/2022 and 3/20/2022 there were two routine visits documented as made. There were no PRN (as needed) orders written for the SW or the Chaplain. Record #76786 (election of benefit 1/26/2022): SW plan of care order (effective 1/26/22) was for one visit per month, during the month of February two routine visits were documented as made. Chaplain plan of care order (effective 1/26/22) was for one visit per week, there were two routine visits documented as made during the weeks of 2/20/22, 3/13/2022 and 3/20/2022. There were no PRN (as needed) orders written for the SW or the Chaplain. An interview with the Administrator in Training (Staff ID: 50236) and Administrator/RN (Staff ID: 71347) on 3/24/2022 acknowledged that the documented visits for the SW and Chaplain did not follow the current plan of care and they were unable to provide physician orders for the changes in the visits made.

It is required that a hospice aide provide services ordered by the Interdisciplinary group. This standard was not met as evidenced by joint clinical record review and staff interview. 3 of 4 (75%) applicable records, in which the hospice aide was accepted, revealed the agency failed to provide documented evidence that the hospice aide was compliant with visits as assigned in the hospice plan of care and/or physician’s orders. Record #11600 (election of benefit 1/13/2022): Hospice aide plan of care order, (effective 1/13/22) was for two visits per week, the week of 2/13/2022 there were three (3) visits documented as completed and for the week of 2/20/2022 only one visit was documented. Record #34469 (election of benefit 1/7/2022): Hospice aide plan of care order (effective 1/7/22) was for two visits per week, the week of 2/13/2022 there were three (3) visits documented as made. Record #84746 (election of benefit 2/11/2022): Hospice aide plan of care order (effective 2/11/22) was for two visits per week, the week of 2/13/2022 there were three (3) visits documented. An interview with the Administer in Training (Staff ID: 50236) and Administrator/RN (Staff ID: 71347) on 3/24/2022 acknowledged that the documented aide visits did not follow the plan of care orders and they were unable to provide documentation for missed visits or changes to the aide plan of care orders.