Every finding on record at Holistic Touch Hospice LLC

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 in which a patient was discharged from the agency, it was revealed that the agency did not ensure that the patient's Discharge Summary included the minimum information required to facilitate continuity of care for the patient. Clinical Record 5: The patient elected the hospice benefit on 4/27/2023. The discharge summary included the patient's diagnosis, admission, discharge dates, and checkboxes for the types of visits: SN, MSW, and Chaplain visits received. The nurse's Summary of Care section documented that, "Patient got admitted to ....as per MD order, patient received SN, MSW, HHA, and Chaplain services. Received DME, all pharmacological management through hospice. Patient stayed free from injury, infection, hospitalization during the service. As patient got admitted in another agency we discharged him from service." It was signed by the RN on 6/19/2023. The Discharge Summary did not include any documentation describing the patient's specific treatments, symptoms, or pain management while on the hospice's service or the patient's plan of care to include DME needs and/or a list of the patient's current medications to facilitate a smooth continuity of care. During interview with the Director of Nursing on 7/19/2023, it was confirmed that the patient's Discharge Summary did not contain the required elements of the patient's treatments, symptom management, or the latest physician orders and plan of care. There was no documentation that these clinical record items were sent to the physician.