Every finding on record at Carefor Hospice, LLC

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide reported changes in the patient’s condition to the Registered Nurse. CLINICAL RECORD 5: The patient elected the hospice benefit on 04/29/2025 with a diagnosis of Alzheimer’s disease. The Hospice Aide was ordered three times per week. The Hospice Aide documented on the aide visit note dated 07/11/2025 that the patient "...appears to be confused and agitated. I observed while giving a shower a bruise on the left side of [the patient’s] forehead." There was no documented evidence in the clinical record that the Hospice Aide reported the patient’s confusion, agitation, and the bruise to the left side of forehead to the Registered Nurse. During a review of the record and interview on 07/24/2025, the Alternate Administrator (Personnel Record 5) stated that she could not find any documentation that the nurse was notified, but that they would send out an update this evening. She was sure that it was reported, but she understood it needed to be documented, and she would be working on some education for the clinical staff.

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 and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient live discharge, the agency did not ensure the discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 6: The patient elected the hospice benefit on 05/30/2025 and chose to revoke hospice care on 06/19/2025. Clinical record review revealed no documented evidence that the discharge summary was sent to the patient's attending physician. During a review of the record and interview on 07/24/2025, the Alternate Administrator (Personnel Record 5) stated that she was unable to find documentation that the attending physician was sent the discharge summary but ensured the process would be reviewed with the clinical staff.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient live discharged, the agency did not ensure the discharge summary included the patient's treatments, symptoms, pain management, current plan of care, and the patient’s latest physician orders. CLINICAL RECORD 6: The patient elected the hospice benefit on 05/30/2025 and chose to revoke the hospice benefit on 06/19/2025. Clinical record review revealed that the discharge summary did not include the patient's treatments, symptoms, pain management, current plan of care, and latest physician orders. The sections of the discharge summary labeled Care Plan, Medications, and Summary where left blank. During a review of the record and interview on 07/24/2025, the Alternate Administrator (Personnel Record 5) stated the required fields were left blank, but that she would be providing additional education to staff. She also stated that all the staff were new to the current electronic medical record.