Every finding on record at Enchanted Sky Hospice, LLC

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes, at a minimum, the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes, including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that the patient's record included clinical notes that included the care and services provided. Clinical Record 1: The date of the election was 1/6/2023. Wounds were Initially documented on 9/5/2023 stated, "Wound 1: mid spine pressure injury stage III onset date 7/17/2023; wound 2: sacrum pressure injury stage IV, onset date 8/14/2023; wound 3: right buttock skin tear, onset date 8/14/2023; wound 4: left elbow pressure injury stage III, onset date 8/14/2023. Wound care orders started on 9/5/2023. The skilled nursing notes lacked adequate wound documentation, including how many, locations, conditions, and wound care provided. Minimally skilled nursing notes that state, "Wound care done, pt tolerated well after morphine give prior," "Deep tissue pressure sores. Wound care to be performed. Wound care performed per physician orders," or "Pressure ulcers on the sacrum, right sit bone, left elbow and spine. Pre-medicated with morphine sulfate. Wound care performed per physician order." During an interview on 1/10/2023, the Director of Nursing confirmed that there was not sufficient wound documentation in the record for the four wounds. The Director of Nursing stated that there is a wound worksheet in the visit notes, but the nurse has to enter data for it to appear on the completed visit note.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure the patient's signed consents included the date of election. Clinical Record 16: The patient elected the hospice benefit on 7/1/2022. The consent forms, signed and dated 7/1/2022, had a space for the date of election, but the space was left blank. The Director of Nursing confirmed in an interview on 1/12/2024 that the patient's signed consent lacked the hospice date of election. The Administrator confirmed in an interview on 1/12/2024 that the patient's signed consent lacked the hospice date of election.

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 and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was sent to the receiving Medicare/Medicaid certified facility. Clinical Record 15: The patient was transferred to another Medicare/Medicaid-certified facility on 3/7/2023. The record lacks evidence that the discharge summary was forwarded to the receiving facility. During a joint record review and interview on 1/12/2024, the Director of Nursing confirmed that the record lacked evidence that the discharge summary was sent to the receiving Medicare/Medicaid-certified facility. No additional documentation was presented prior to the conclusion of the site visit.

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 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 16: The patient revoked the hospice benefit on 4/17/2023. The record lacks evidence of the discharge summary being sent to the patient's attending physician. During a joint record review and interview on 1/12/2024, the Director of Nursing confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.