Every finding on record at Intelicare Hospice Services II, LLC

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient 5: On the initial comprehensive assessment the RN documented, "patient has pain 10/10 at rest and with movement. Patient reports pain in her back and hip, she is taking Norco 10/325 and only sleeps 4 hours a night due to pain". There was no evidence of effective pain management and responses to pain control during visit.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1,2,3,4,5,6,7,8,9,10: There is no evidence that the RN took into consideration the imminence of death on the comprehensive assessment.

Upon patient record review, 3 of 14 (Patient #2,3,4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 2: On the patient medication profile the hospice agency has Acetaminophen 120mg rectal suppository, Bisacodyl 10mg rectal suppository, Compazine 10mg tablet, Flonase nasal spray, Hyoscyamine 0.125mg tablet, Miralax 17 gram oral powder, these medications are not on the SNF medication profile. On the SNF medication profile there is Milk of Magnesia 30ml every 72 hours, this medic ation is not on the hospice agency medication profile. Corrected on site. Patient 3: In the patient record there is Acetaminophen 325mg 2 tablets every 4 hours as needed and Acetaminophen 650mg rectal suppository every 6 hours as needed for mild pain or fever. There is not a daily limit of 4,000mg for Acetaminophen. In addition, on the patient medication profile there is an order for Bactrim DS 800 MG-160 tablet and Loratadine 10mg tablet, these medications are not in the patient's home, the patient caregiver stated these medications have been discontinued. Corrected on site Patient 4: On the medication profile there is an order for Miralax 17g oral powder, there is no diluent listed for this medication. Corrected on site.

Upon patient record review, 2 of 14 (Patient #3,4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 3: On the plan of care there is medication Acetaminophen 325mg 2 tablets every 4 hours as needed and Acetaminophen 650mg rectal suppository every 6 hours as needed for mild pain or fever. There is not a daily limit of 4000mg for the Acetaminophen. Corrected on site. Patient 4: On the plan of care there is an order for Miralax 17g oral powder, there is no diluent listed for this medication. Corrected on site.

Upon patient record review, 7 of 14 (Patient #1,3,4,5,6,9,10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: On the initial comprehensive assessment there is documentation of a wheelchair, the wheelchair is not on the DME list or the plan of care. Corrected on site. Patient:3: On the RN assessment 7/8/25 there is documentation, "patient is sitting at the edge of the hospital bed", the hospital bed is not listed on the plan of care. Corrected on site Patient 4: On the RN comprehensive assessment there is documentation that the patient has a wheelchair, the wheelchair is not listed on the plan of care. Corrected on site. Patient 5: The RN documented "patent has wheeled walker, hospital bed, wheelchair, cane, bedside commode, oxygen concentrator", these equipment items are not listed on the plan of care. Corrected on site. Patient 6: On the RN comprehensive assessment there is documentation, "patient has oxygen concentrator, oxygen cylinder, walker standard and wheeled walker and a cane", the equipment items are not listed on the plan of care. Corrected on site. Patient 9: In the patient record there is evidence that the patient has a wheeled walker and gait belt medical these items are not listed on the plan of care. Corrected on site. Patient 10: In the patient record there is evidence of a wheeled walker, this equipment is not listed on the plan of care. Corrected on site.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 2: During the home visit the RN did not follow the hospice agency policy for hand washing and did not wash hands prior to administering care, RN cleaned equipment and did not wash hands prior to returning the clean equipment to the bag.

Upon patient record review, 2 of 14 (Patient #2,3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 2: In the RN comprehensive assessment there is documentation, “patient was able to ambulate independently and now requires to use 2WW”, "Patient has COA that comes in twice weekly”. COA and 2WW are not an approved abbreviations. Patient 3: On the RN assessment 6/17/25 the nurse documented “AJD acting out” this sentence is not clear and complete. On the medication profile there is an order for Tolnaftate 1% topical powder 3 times daily, instructions are “ apply topically to Panis and under breast” It is unclear what Panis is.

Upon personnel record review, 1 of 14 (Personnel #11) did not have evidence of criminal background checks being obtained in accordance with the state of Michigan only, Michigan state Act of 2006 state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #11: There is no evidence in the personnel record that there is a state and federal background check.

Based on record review and interview, the hospice agency failed to ensure the patient was involved in the plan of care in 1 of 12 (P-4, 9) sample records, resulting in a lack of inclusion in planning and potential unmet care needs. Findings include: --- P-4: The Start of Care (SOC) was dated 2/27/24. The Plan of Care (POC) identified a terminal diagnosis of Chronic Obstructive Pulmonary Disease. During record review on 3/20/24, it was noted that the signed consent dated 2/27/24 documented, ";RN, Hospice Aide, Social Worker, Chaplain and Volunteer." There was no documentation that volunteer services were provided or that the patient declined volunteer services. The agency failed to provide volunteer services as ordered. P-9: The Start of Care (SOC) was dated 2/5/24. The Plan of Care (POC) identified a terminal diagnosis of Chronic Obstructive Pulmonary Disease. During record review on 3/20/24, it was noted that the signed consent dated 2/5/24 documented, ";RN, Hospice Aide, Social Worker, Chaplain and Massage Therapy." There was no documentation that massage therapy services were provided or that the patient declined massage therapy services. The agency failed to provide massage therapy services as ordered. These findings were reviewed with and acknowledged by the Staff A (Administrator) and Staff B (Director of Hospice Services) during an interview on 3/21/24 at 12:30 pm.

Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed by all members of the interdisciplinary team within 5 calendar days after the election of benefit in 1 (P-12) of 15 sample records reviewed resulting in assessment delay for a terminal patients care needs. Findings include: --- Agency policy titled ";Patient Assessments", PE.1, (undated), was reviewed on 3/20/24. On page 1., it stated ";II. The Hospice will conduct and document in writing a patient-specific comprehensive assessment that identifies the patients need for hospice care and services... A. The Interdisciplinary Group (IDG)... will complete the comprehensive assessment no later than (5) calendar days after the election of the hospice benefit..." On page 3., it stated ";D. ... The assessment... will be gathered and documented on the appropriate disciplines assessment form(s)." P-12: This 88-year-old patient was admitted to the agency on 2/6/24 with a terminal diagnosis of senile degeneration of the brain. The medical record was reviewed on 3/19/24. During review of the record, it was noted the patient's election of benefit was dated 2/6/24. The comprehensive assessment was completed on 2/6/24 by the nurse and documented the need for the medical social worker (MSW) and Chaplain to evaluate the needs of the patient. The evaluation visit by the MSW occurred on 2/13/24, 7 calendar days after the election of benefit. There was no documentation indicating why there was a delay in the MSW evaluation. The first Chaplain visit took place on 3/13/24 (after the patient had been on hospice for over 4 weeks). During review of the IDG plan of care updates dated 2/22/24 and 3/7/24, the Chaplain included documentation that the patient declined Chaplain services. There were no documented phone calls or visits by the Chaplain and no other documentation by another clinician in the medical record to support the declined Chaplain services. There was only one patient/family contact (visit note) in the medical record at the time of the survey that was entered by the Chaplain on 3/13/24 and included documentation that during the visit, the patient shared his fondness for the visit and invited the Chaplain to return. There was no documentation found by the Chaplain or other clinician indicating that the patient had made a new request for Chaplain services. This finding was reviewed and acknowledged during interview with the Administrator (Staff A) and the Clinical Manager (Staff B) on 3/21/24 at 1 p.m. Staff A stated that the expectation and policy of the hospice is that all IDG members including MSW and Chaplain evaluate the patient/family within the first 5 calendar days after election of benefit and document their encounters in the medical record. Staff A also stated that this patient was admitted with another team Chaplain who no longer works with this hospice. No further evidence to support that the patient or family delayed the MSW visit, or initially declined Chaplain services was provided.

Based on record review, interview, and policy it was determined that the hospice failed to ensure the plan of care included patient specific measurable goals in 10 (P-1, 2, 3, 4, 5, 6, 9) of 12 records reviewed out of a total sample of 10 records, resulting in the potential for unmet patient goals. Findings include: ** Agency Policy: Plan of Care Process (Policy No. PC.30) states, "The POC includes, but is not limited to: ... C. Measurable outcomes anticipated from implementing and coordinating the POC." --- P-1: The Start of Care (SOC) was dated 12/17/22. The Plan of Care (POC) identified a terminal diagnosis of Parkinsons. During record review on 3/18/24, it was noted the goals were not measurable. Examples of goals on this patient's POC included: "Pain will be managed at a level acceptable to the patient. Appropriate level of care will be established based on the identified needs of the patient/caregiver. Patent/Caregiver will understand measures to cope with depression. Patients depression will be reduced." The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal. P-2: The Start of Care (SOC) was dated 4/23/23. The Plan of Care (POC) identified a terminal diagnosis of Dementia. During record review on 3/18/24, it was noted the goals were not measurable. Examples of goals on this patient's POC included: "Pain will be managed at a level acceptable to the patient. Patient/caregiver will verbalize/demonstrate understanding of care required secondary to bowel incontinence. Changes in neurologic status will be addressed appropriately." The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal. P-3: The Start of Care (SOC) was dated 8/11/22. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 3/19/24, it was noted the goals were not measurable. Examples of goals on this patient's POC included: "Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Indwelling urinary catheter will remain patent. Medications will be managed appropriately as evidenced by steady symptom control." The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal. P-4: The Start of Care (SOC) was dated 2/27/24. The Plan of Care (POC) identified a terminal diagnosis of Chronic Obstructive Pulmonary Disease. During record review on 3/20/24, it was noted the goals were not measurable. Examples of goals on this patient's POC included: "Pain will be managed at a level acceptable to the patient. Medications will be managed appropriately as evidenced by steady symptom control. Verbalize/demonstrate compliance with medication regimen." The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal. P-5: The Start of Care (SOC) was dated 12/28/22. The Plan of Care (POC) identified a terminal diagnosis of Cerebrovascular Disease. During record review on 3/20/24, it was noted the goals were not measurable. Examples of goals on this patient's POC included: "Pain will be managed at a level acceptable to the patient. Patient/caregiver will verbalize/demonstrate appropriate pain management. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms." The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal. P-6: The Start of Care (SOC) was dated 3/22/23. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 3/20/24, it was noted the goals were not measurable. Examples of goals on this patient's POC included: " Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Patient/caregiver will verbalize/demonstrate understanding of managing cardiopulmonary symptoms within constraints of the disease. Patient/caregiver will verbalize/demonstrate understanding of how to use oxygen safely and effectively." The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal. P-9: The Start of Care (SOC) was dated 2/5/24. The Plan of Care (POC) identified a terminal diagnosis of Chronic Obstructive Pulmonary Disease. During record review on 3/20/24, it was noted the goals were not measurable. Examples of goals on this patient's POC included: "Medications will be managed appropriately as evidenced by steady symptom control. Caregiver will verbalize/demonstrate compliance with medication regimen. Pain will be managed at a level acceptable to the patient." The goals in this plan of care were not objectively measurable to determine if the patient was progressing toward meeting each goal. These findings were reviewed with and acknowledged by the Staff A (Administrator) and Staff B (Director of Hospice Services) during an interview on 3/21/24 at 12:30 pm.

Based on policy review, observation, record review and interview, the hospice failed to ensure the IDG (interdisciplinary group) revised and updated the plans of care in 4 (P-1, 3, 5, 6) of 12 records reviewed, resulting in potential unmet patient and family/caregiver needs. Findings include: Agency policy: Plan of Care Process (Policy: PC.30) states, "VI. The POC includes, but is not limited to: A. Interventions to manage pain and symptoms and identified issues/problems; D. Drugs and treatments necessary to meet the needs of the patient; E. Medical supplies, equipment, and appliances necessary to meet the needs of the patient... VII. The Hospice IDG/IDT (in collaboration with the individuals Attending Physician, if any) will review, revise, and document the individualized plan as frequently as the patients condition requires, but no less than every 15 calendar days. A. A revised POC will include information from the patients updated comprehensive assessment and will note the patients progress toward outcomes and goals specified in the plan of care." --- P-1: The Start of Care (SOC) was dated 12/17/22. The Plan of Care (POC) identified a terminal diagnosis of Parkinsons. During record review on 3/18/24, it was noted that the recertification POC dated 2/10/24, was missing DME (Durable Medical Equipment) and Supplies, Functional Limitations, Safety Measures, Activities Permitted, Nutritional Requirements, Advance Directives, Mental Statuses, and Allergies that were documented on the original POC dated 12/17/22. The agency failed to review and updated the POC resulting in potential patient and caregiver unmet needs. P-3: The Start of Care (SOC) was dated 8/11/22. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 3/19/24, it was noted that the recertification POC dated 2/2/24, was missing DME (Durable Medical Equipment) and Supplies, Functional Limitations, Safety Measures, Activities Permitted, Nutritional Requirements, Advance Directives, Mental Statuses, and Allergies that were documented on the original POC dated 8/11/22. Additionally, the POC stated, ";Calendar Frequency: SN (Skilled Nurse) effective 2/2/24 1every2wk2 (1 visit every 2 weeks 2 times), 1wk7 (1 visit weekly for 7 weeks), 3PRN (As Needed). CH (Chaplin) effective 2/2/24 1M3 (1 time a month for 3 months), 4PRN." The ";Orders" section documented, ";Medical Social Worker to evaluate social, emotional and financial factors related to the patient's illness, need for additional care/resources, adjustment to care and develop a plan of care. Home Health Aide service for assistance with personal care, hygiene and activities of daily living." The agency failed to review and updated the POC resulting in potential patient and caregiver unmet needs. P-5: The Start of Care (SOC) was dated 12/28/22. The Plan of Care (POC) identified a terminal diagnosis of Cerebrovascular Disease. During record review on 3/20/24, it was noted that the recertification POC dated 2/21/24, was missing DME (Durable Medical Equipment) and Supplies, Functional Limitations, Safety Measures, Activities Permitted, Nutritional Requirements, Advance Directives, Mental Statuses, and Allergies that were documented on the original POC dated 12/28/22. The agency failed to review and updated the POC resulting in potential patient and caregiver unmet needs. P-6: The Start of Care (SOC) was dated 3/22/23. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 3/20/24, it was noted that the recertification POC dated 3/16/24, was missing DME (Durable Medical Equipment) and Supplies, Functional Limitations, Safety Measures, Activities Permitted, Nutritional Requirements, Advance Directives, Mental Statuses, and Allergies that were documented on the original POC dated 3/22/23. Additionally, the POC stated, ";Calendar Frequency: SN effective 3/16/24 1every2wk2, 1wk7, 3PRN." The ";Orders" section documented, ";Medical Social Worker to evaluate social, emotional and financial factors related to the patient's illness, need for additional care/resources, adjustment to care and develop a plan of care." The agency failed to review and updated the POC resulting in potential patient and caregiver unmet needs. These findings were reviewed with and acknowledged by the Staff A (Administrator) and Staff B (Director of Hospice Services) during an interview on 3/21/24 at 12:45 pm.

Based on observation, interview, and record review, the agency failed to ensure the home health aide followed accepted standards of practice per agency policy and procedure for 1 (P-12) of 1 patients in which a bed bath was observed during a home visit potentially resulting in the spread of infectious agents from one part of the body to another part of the body, and to areas of the home where others may have contact. Findings include: --- Agency policy titled ";Implementing Care and Treatment", PC.7, (undated) was reviewed on 3/20/24. On page 1., it stated ";1. The Agency staff providing patient care and treatment will be competent to the level of care/treatment needed." Agency procedure titled ";P-140 Bed Bath" (undated), was reviewed on 3/21/24. On the first page of the procedure, it stated ";Applies to ...Health Aides...". On the second page of the procedure, it stated ";16. ... and change the bath water. 17. Remove gloves, wash hands, and put on new gloves... 19. Bathe, rinse, and dry back and buttocks... 21. Remove gloves, wash hands, change bath water, put on clean gloves... 22. Bathe the genital area... 23. Remove gloves, wash hands and assist the patient with dressing...". P-12: This 88-year-old patient was admitted to the agency on 2/6/24 with a terminal diagnosis of senile degeneration of the brain. The medical record was reviewed on 3/19/24. On 3/19/24 a joint home visit was conducted with the home hospice aide and a patient bed bath was observed. During the observation, the hospice aide prepared the bath basin with warm water, donned clean gloves for the bath, and cleansed the patients body including genitals, foley catheter care, and buttocks without changing the bath water or changing gloves during care. It was also observed after the bath that the aide touched the bed controls with the same gloves. The aide then took the bath basin to the family bathroom to dump/rinse and touched the toilet, sink, and shower with the same gloves used to wash the patient before removing the dirty gloves. This finding was reviewed and acknowledged during interview with the Administrator (Staff A) and the Clinical Manager (Staff B) on 3/21/24 at 1 p.m. Staff A stated that the expectation for staff performing a bed bath is that water and gloves are changed as described in agency procedure.

Based on record review and interview, the Registered Nurse failed to ensure the written plan of care for the assigned Hospice Aide provided specific guidance and care instructions on the needs of the patient, for 5 (P-1, 2, 4, 5, 9) of 9 records with Hospice Aide services ordered from a total of 12 records reviewed resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Agency Policy: "Implementing Care and Treatment" (Policy: PC.7) stated, "Procedure II. The assigned discipline(s) will be provided with information needed to provide care/treatment including, but not limited to, the plan of care. III. The Hospice RN (Registered Nurse), who is a member of the IDG, will oversee the assignment of a hospice aide to a particular patient, initiating hospice aide services within time frame to meet identified patients needs as identified in the plan of care and per physician orders." --- P-1: The Start of Care (SOC) was dated 12/17/22. The Plan of Care (POC) identified a terminal diagnosis of Parkinsons. During record review on 3/18/24, it was noted that the "Aide Care Plan" dated 2/10/24 completed by the Registered Nurse (RN) contained no safety precautions. The Aide Care Plan failed to include the necessary safety measure and precautions to alert the aide of the patient's health concerns. P-2: The Start of Care (SOC) was dated 4/23/23. The Plan of Care (POC) identified a terminal diagnosis of Dementia. During record review on 3/18/24, it was noted that the "Aide Care Plan" dated 4/23/23 completed by the Registered Nurse (RN) contained no safety precautions. The Aide Care Plan failed to include the necessary safety measure and precautions to alert the aide of the patient's health concerns. P-4: The Start of Care (SOC) was dated 2/27/24. The Plan of Care (POC) identified a terminal diagnosis of Chronic Obstructive Pulmonary Disease. During record review on 3/20/24, it was noted that the "Aide Care Plan" dated 2/27/24 completed by the Registered Nurse (RN) contained no safety precautions. The Aide Care Plan failed to include the necessary safety measure and precautions to alert the aide of the patient's health concerns. P-5: The Start of Care (SOC) was dated 12/28/22. The Plan of Care (POC) identified a terminal diagnosis of Cerebrovascular Disease. During record review on 3/20/24, it was noted that the "Aide Care Plan" dated 2/21/24 completed by the Registered Nurse (RN) contained no safety precautions. The Aide Care Plan failed to include the necessary safety measure and precautions to alert the aide of the patient's health concerns. P-9: The Start of Care (SOC) was dated 2/5/24. The Plan of Care (POC) identified a terminal diagnosis of Chronic Obstructive Pulmonary Disease. During record review on 3/20/24, it was noted that the "Aide Care Plan" dated 2/5/24 completed by the Registered Nurse (RN) contained no safety precautions. The Aide Care Plan failed to include the necessary safety measure and precautions to alert the aide of the patient's health concerns. These findings were reviewed with and acknowledged by the Staff A (Administrator) and Staff B (Director of Hospice Services) during an interview on 3/21/24 at 12:30 pm.

Based on record review and interview, the agency failed to ensure the supervising nurse provided an accurate assessment of a hospice aides performance in 1 (P-10) of 13 sample records reviewed with patients receiving hospice aid services, resulting in documentation of staff/family relationship and assessment of care that had not occurred. Findings include: --- P-10: This 96-year-old patient was admitted to the agency on 8/23/23 with a terminal diagnosis of chronic osteomyelitis (bone infection) of the right foot and ankle. The medical record was reviewed on 3/20/24. During review, it was noted that hospice aide services were ordered for the patient on 12/18/23 at a frequency of 2 times weekly for 5 weeks. The hospice aide documented 2 missed visits on 12/21/23 and 12/22/23 both with a note which stated that the owner of the facility that the patient resided stated that hospice aide services were not needed at that time. The following week, the registered nurse (RN) made a patient visit on 12/27/23 and completed a hospice nursing visit with a hospice aide supervisory note. The RN documented in the ";Supervisory Functions" section of the visit note that the hospice aide follows the care plan; the patient/family are satisfied with the care delivered by the hospice aide; the services are meeting the needs of the patient; the hospice aide was observing infection control protocols during care; no changes needed to be made to the plan of care relating to hospice aide services; and, the hospice aide was respectful of the patients rights, privacy, dignity, confidentiality, personal belongings, and property. The RN also documented in the narrative that the hospice aide was not present for the assessment. At the time of the above RN supervisory visit note, no hospice aide visit or service had been documented as provided. This finding was reviewed and acknowledged during interview with the Administrator (Staff A) and the Clinical Manager (Staff B) on 3/21/24 at 1 p.m.

Based on record review and interview, the agency failed to ensure the clinical record contained timely clinical notes per agency policy in 3 (P-10, 12, and 13) of 17 sample records reviewed potentially resulting in a delay in updated patient information accessible for other hospice staff to utilize during care management. Findings include: --- Agency policy titled ";Clinical Documentation- All Disciplines", Revised: 11/08/2021, was reviewed on 3/20/24. On page 1., it stated ";... A clinical note will be completed for each visit made to a patients home... within 24 hours of the visit." P-10: This 96-year-old patient was admitted to the agency on 8/23/23 with a terminal diagnosis of chronic osteomyelitis (bone infection) of the right foot and ankle. The medical record was reviewed on 3/20/24. During review, it was noted the Medical Social Worker (MSW) made an initial evaluation visit on 8/25/23 but did not complete documentation until 9/8/23 (14 days later). The registered nurse (RN) made a visit on 11/21/23 and completed the documentation on 11/30/23 (9 days later). The RN made a visit on 1/15/24 and completed the documentation on 1/21/24 (6 days later). P-12: This 88-year-old patient was admitted to the agency on 2/6/24 with a terminal diagnosis of senile degeneration of the brain. The medical record was reviewed on 3/19/24. During review, it was noted the MSW made a visit on 2/14/24 and completed documentation on 2/25/24 (11 days later). The RN made a visit on 3/15/24 and completed documentation on 3/17/24 (2 days later). P-13: This 82-year-old patient was admitted to the agency on 6/7/23 with a terminal diagnosis of heart disease. The medical record was reviewed on 3/18/24. During review, it was noted the RN made a visit on 2/2/24 and completed documentation on 2/5/24 (3 days later). The RN made a visit on 2/9/24 and completed documentation on 2/15/24 (6 days later). The hospice aide made a visit on 3/1/24 and completed documentation on 3/4/24 (3 days later). The MSW made a visit on 6/12/23 and completed documentation on 6/18/23 (6 days later). These findings were reviewed and acknowledged during interview with the Administrator (Staff A) and the Clinical Manager (Staff B) on 3/21/24 at 1 p.m. Staff A stated that late documentation has been an ongoing issue with staff.

Based on record review and interview, the agency failed to ensure the hospice discharge summary was forwarded to the receiving facility in 2 (P-2, 14) of 2 sample live discharge records reviewed potentially resulting in a lack of continuity of care and unmanaged patient care needs. Findings include: --- P-14: This 77-year-old patient was admitted to the agency on 2/8/23 with a terminal diagnosis of cancer of the pancreas. The medical record was reviewed on 3/20/24. The patient was transferred to a hospice medical facility on 7/20/23 per patient/family request. A discharge visit was completed by the registered nurse (RN) on 7/20/23 and documented conversation which occurred with the daughter regarding the move. The RN answered the following question on the discharge summary ";was a verbal report given?", and the RN wrote ";NO" which indicated that the RN did not call the facility with a report. No documentation was found in the medical record indicating that a discharge summary had been sent to the receiving hospice medical facility. During interview with the Administrator (Staff A) and the Clinical Manager (Staff B) on 3/21/24 at 1 p.m., Staff A was queried to whether a discharge summary was forwarded to receiving facility for this patient. Staff A stated that they (the agency) usually fax them but that they were not able to find this patients discharge summary fax report because the timeframe was too long ago. No other evidence was provided that a discharge summary was sent. P-2: The Start of Care (SOC) was dated 4/23/23. The Plan of Care (POC) identified a terminal diagnosis of Dementia. During record review on 3/18/24, it was noted that the patient was transferred to another hospice agency on 6/7/23. There was no identifiable documentation that a discharge summary was sent to the receiving hospice agency. The agency failed to verify that the discharge summary was sent to the accepting hospice agency. These findings were reviewed with and acknowledged by the Staff A (Administrator) and Staff B (Director of Hospice Services) during an interview on 3/21/24 at 12:30 pm.

Based on document review and interview, the agency failed to ensure the clinical record contained a discharge summary concerning a patient's revocation of hospice services in 1 (P-2) of 2 records reviewed, in which hospice services were revoked, from a total sample of 12 records reviewed, resulting in an incomplete clinical record for this patient. Findings include: Agency Policy: "Patient Discharge" (Policy PE.20) stated, "IV. The discharge summary will include: A. The date and reason for discharge, B. Any instructions or referral information given to the patient or family, C. Patient identifying information, D. Patients physician, E. Hospice diagnosis, F. Significant health history, G. Discharge orders, instructions, medication profile and allergies if discharge is other than patient death, H. A brief description of services provided and ongoing needs that cannot be met, I. Status of patient at the tie of discharge, J. Presence of Advance Directives, K. End of life decisions, L. Any third-party revocation or termination, M. A summary of the patients stay, including treatments, symptoms, and pain management, N. The patients current plan of care, O. The patients latest physician orders, and P. Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility. --- P-2: The Start of Care (SOC) was dated 4/23/23. The Plan of Care (POC) identified a terminal diagnosis of Dementia. During record review on 3/18/24, it was noted that the patient was transferred to another hospice agency on 6/7/23. On 6/7/23, a ";Visit Type: RN (Registered Nurse) hospice discharge data collection only – No visit made" note was completed that documented, ";Indicate who discharge was initiated by: Family. Reason for discharge: Revoked. Death/discharge location: Residential care setting. Indicate election date of revocation: Date of revocation. Indicate election date of revocation: 6/7/23. Was a verbal report given? No." The clinical record failed to contain documentation of discharge summary per agency policy. These findings were reviewed with and acknowledged by the Staff A (Administrator) and Staff B (Director of Hospice Services) during an interview on 3/21/24 at 12:30 pm.