Every finding on record at Legacy Health Care Inc. D/B/A Atlas Hospice

Based on interviews and record review, it was determined the hospice agency failed to meet the Condition of Participation for Patient Rights. Specifically, the hospice agency failed to report and investigate violations of patient rights. --- Findings include: The agency failed to immediately investigate all alleged violations of patients' rights and take immediate action to prevent further potential violations while the alleged violation was being verified. (Refer to tag L509) The agency failed to ensure that violations were reported to state and local bodies having jurisdiction. (Refer to tag L511)

Based on interviews and record review, it was determined that the hospice agency did not immediately investigate all alleged violations of patients rights and immediately take action to prevent further potential violations while the alleged violation was being verified. Specifically, the agency did not do its own investigation into 2 out of 2 incidents and did not immediately take action to prevent further violations. (Patient identifiers: 20 and 21) --- Findings include: 1. It was documented on an incident report dated 3/4/2024 that patient 21s bottle of morphine went missing. The follow-up regarding the incident report stated the assisted living facility notified the police and opened an investigation, but there was not enough evidence, so the incident was closed. No further documented evidence of an investigation/follow-up was provided. 2. An incident report dated 7/10/2024 regarding patient 20 was reviewed and revealed the following: The incident report was filed by an aide (staff 1) of the hospice agency who observed the incident. Staff 1 stated she was having difficulty convincing patient 20 to shower, so she requested the assistance of two aides from the assisted living where patient 20 resides. Staff 1 documented the two aides from the assisted living ";forced patient out of her bed by grabbing her by her arms and hands forcing her against her will. Patient was screaming/yelling to stop youre hurting me." Staff 1 documented that she noticed new bruises from where the aides grabbed patient 20. Staff 1 submitted pictures with the incident report that showed bruising around patient 20s arm and wrist. The follow-up section of the incident report documented that the hospice agency met with the administrator of the assisted living facility to discuss the incident. The administrator stated they would check the camera footage and talk to the patient about the incident. In a follow-up communication note dated 7/12/2024, the assisted living administrator assured the hospice case manager that the cameras were reviewed, and no foul play was witnessed. The note further stated that education was provided to the assisted living staff and that patient 20 was safe at that time. On 12/19/2024 at 3:34 PM, an interview was conducted with the hospice director of nursing (staff 2). Staff 2 stated they do not do their own investigation if the incident does not involve their own staff. Staff 2 stated the incident investigation was left up to the assisted living facility. Staff 2 was asked if they do not investigate an incident on their own, how would they determine if a patient was safe or not. Staff 2 stated that the patient and family both felt that patient 20 was safe and that they did not want to report the incident. Staff 2 stated she was not sure if the aides from the incident continued to provide care to patient 20 after the incident but stated those aides no longer work at the assisted living facility. On 12/23/2024 at 1:53 PM, an interview was conducted with patient 20s emergency contact (patient 20s sister). The emergency contact stated she was never told of any incident involving staff being forceful with patient 20, causing bruising, or regarding the patient being forced to shower. The emergency contact was asked if patient 20 was cognitive enough to express whether she felt safe or not. Patient 20s sister replied, ";no, she does not know what is going on." Patient 20 resided in the memory care unit of the assisted living facility. There was no documented evidence that the hospice agency took immediate action to prevent further incidents. Patient 20 was discharged from the hospice agency on 7/16/2024.

Based on interview and record review, it was determined the hospice agency did not ensure that violations were reported to State and local bodies having jurisdiction (including the state survey and certification agency) within 5 working days of becoming aware of the violation. Specifically, the agency did not report 2 out of 2 incidents reviewed. --- Findings include: Two incidents were selected from the incident log to review. One involved an observation of mistreatment/abuse, the other involved a patients bottle of morphine going missing. On 12/19/2024 at 3:34 PM, an interview was conducted with the agencys Director of Nursing (staff 2). Staff 2 stated they did not report either incident to the Department of Health, police, or Adult Protective Services. When asked why the incidents were not reported, she stated they did not want to hurt their relationship with assisted living and only reported confirmed cases. (Note: The abuse allegation incident was directly observed by hospice staff.) During the survey, on 12/19/2024, the hospice agency notified the Department of Health of both incidents, as well as notified Adult Protective Services and the police of the abuse allegation.

Based on interview and record review, it was determined that a drug profile was not accurate and completed timely for 3 of 13 sample patients who had a full medical record review completed by the survey team. Specifically, a review of all prescription and over-the-counter-drugs, containing all medications and treatments, and was not updated when new medications were added. (Patient identifiers: 3, 8, and 10.) Findings include: 1. Patient 3 was admitted to the agency on 4/15/2021 with a terminal diagnosis of heart disease. Patient 3's medical record was reviewed on 12/21/2021. On 11/19/2021, patient 3 was seen by a massage therapist (MT). The MT documented in a progress note that somba pain cream was applied to patient 3. A review of patient 3's drug profile revealed that there was no order for the use of the somba pain cream. 2. Patient 8 was admitted to the agency on 9/29/2021 with a terminal diagnosis of respiratory failure with hypoxia post Covid-19. Patient 8's medical record was reviewed on 12/21/2021. On 10/19/2021, an order was received to discontinue Amitriptyline and Metformin. A review of patient 8's drug profile revealed the Metformin had not been listed as a medication that patient 8 was taking and that the Amitriptyline was discontinued on 10/1/2021. On 12/21/2021 at 3:57 PM, an e-mail was sent to the administrator, who also acted as the director of nursing, related to the Amitriptyline and Metformin order. The Administrator stated that the nurse "inadvertently omitted putting the Metformin on the med list" and that the Amitriptyline was discontinued on 10/1/2021 without a physician's order. 3. Patient 10 was admitted to the agency on 5/7/2021 with a terminal diagnosis of Parkinson's disease. Patient 10's medical record was reviewed on 12/21/2021. On 11/9/2021, an order was received to administer Ondansetron 4 mg (milligrams) every 8 hours as needed. The medication profile was reviewed. Ondansetron 4 mg every 4 hours as needed was listed. On 12/21/2021 at 12:58 PM, an email was sent to the Administrator related to the Ondansetron order. The administrator stated that patient 10 was to receive Ondansetron 4 mg every 8 hours and that the nurse inadvertently typed as needed instead of leaving it as scheduled.

Based on interview and record review, the hospice agency failed to meet the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services. Findings include: 1. The hospice failed to ensure all hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. Refer to tag L0543. 2. The hospice failed to ensure the plan of care reflected patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Refer to tag L0545. 3. The hospice failed to ensure the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Refer to tag L0547. 4. The hospice failed to ensure the IDG (in collaboration with the individual's attending physician, (if any)) reviewed, revised and documented the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. Refer to tag L0552. 5. The hospice failed to provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services were provided directly or under arrangement. Refer to tag L0557.

Based on interview and record review, it was determined the hospice agency did not ensure care and services were provided as identified in the plan of care (POC) for 6 of 13 sample patients who had a full medical record review completed by the survey team. Specifically, social work (SW), aide, music therapy, massage therapy, and volunteer visits were not provided as identified in the POC. (Patient identifier's: 1, 3, 5, 8, 9, and 10.) Findings include: 1. Patient 9 was admitted to the agency on 3/2/2021 with a terminal diagnosis of protein calorie malnutrition. A review of patient 9's medical record was completed on 12/22/2021. Music therapy visit notes were documented in patient 9's medical record on 11/12/2021 and 12/13/2021. A review of IDG (interdisciplinary group) meeting documentation for 11/11/2021, 11/25/2021, and 12/9/2021 did not contain evidence that music therapy visits were to be completed. 2. Patient 1 was admitted to the agency on 8/4/2021 with a terminal diagnosis of Alzheimer's disease. A review of patient 1's medical record was completed on 12/22/2021. A review of IDG meeting documentation for 11/11/2021, 11/23/2021, and 12/8/2021, was completed. Aide visits were documented to occur three times a week in each note. In an email from the administrator, who was also acting as the director of nursing, on 12/21/2021 at 2:10 PM, she stated the aide visit frequency was changed on 11/10/2021 but that the documentation indicating this did not save in the electronic medical record. 3. Patient 5 was admitted to the agency on 9/27/2021 with a terminal diagnosis of dementia with Lewy Bodies. Patient 5's medical record was reviewed on 12/21/2021. On the plan of care order, dated 9/27/2021, a frequency for the volunteer was not documented. The visits for patient 5 were reviewed. A volunteer documented completing visits on 9/28/2021 and 10/4/2021. 4. On 12/22/2021 at 12:45 PM, a telephone interview was conducted with the Administrator. The Administrator stated the orders for volunteers and music therapy should be on the IDG meeting notes under the section titled other. She then stated the IDG meeting notes were not being updated due to a glitch in the electronic charting system. 5. Patient 3 was admitted to the agency on 4/15/2021 with a terminal diagnosis of heart disease. Patient 3's medical record was reviewed on 12/21/2021. The IDG meeting notes for 10/14/2021, 10/25/2021, 11/11/2021, 11/25/2021 and 12/9/2021 were reviewed. The frequency documented for the skilled nurse was 1-7 times a week, the hospice aide was 3 times a week and the Chaplin was once a month. A frequency for the social worker, volunteer and massage therapist was not documented. The IDG did document that volunteer services were offered and declined. The visits for patient 3 were reviewed. A volunteer documented that visits were completed on 10/26/2021 and 11/23/2021. The massage therapist documented a visit was completed on 11/19/2021. The social worker documented a visit was completed on 12/16/2021. On 12/21/2021 at 2:45 PM, an e-mail correspondence was sent to the administrator related to the above visits without orders. On 12/21/2021 at 4:05 PM, the administrator stated that interventions were added to the care plan but "the frequency was neglected to be added to the POC." 6. Patient 8 was admitted to the agency on 9/29/2021 with a terminal diagnosis of respiratory failure with hypoxia post Covid-19. Patient 8's medical record was reviewed on 12/21/2021. Review of the IDG meeting note completed on 9/30/2021 was blank and did not include the frequency for the disciplines that were providing services to patient 8. Review of the IDG meeting notes, dated 10/14/2021, 10/28/2021, 11/11/2021 and 11/23/2021 indicated the following frequencies: social worker once a week for one quarter, hospice aide 3 times a week for one quarter and the Chaplain once week for one quarter. There were no orders for the volunteer to visit patient 8. The visits completed for patient 8 were reviewed. There was one missing aide visit from 9/29/2021 to 10/2/2021, one missing aide visit from 10/3/2021 to 10/8/2021, one missing aide visit from 10/17/2021 to 10/23/2021, and one missing aide visit from 10/24/2021 to 10/30/2021. There were no social work visits completed for the weeks of 10/3/2021, 10/10/2021, 10/17/2021, 11/7/2021, 11/21/2021, 11/28/2021, 12/5/2021 and 12/12/2021. An agency volunteer documented visiting patient 8 on 10/26/2021 and 11/29/2021 without orders. On 12/21/2021 at 3:57 PM, an e-mail correspondence was sent to the administrator related to the visits missed and completed for patient 8. On 12/22/2021 at 10:13 AM the administrator stated, "The nurse intended for the HHA (hospice aide) frequency to be 2-3x per week, the plan of care was documented 3 x wk (week), but the admission summary reported to staff indicated 2x wk. Also the aide care plan was documented as 2x wk. The plan of care defaults to a weekly frequency under all disciplines, we usually start with a monthly frequency on MSW (medical social worker) and Chaplain unless the patient is identified as high risk. The nurse did not adjust the week to month on the plan of care. We have identified the Plan of care as an area of QAPI (Quality Assurance Performance Improvement) improvement due to issues with discipline frequency." 7. Patient 10 was admitted to the agency on 5/7/2021 with a terminal diagnosis of Parkinson's disease. Patient 10's medical record was reviewed on 12/21/2021. Review of the IDG meeting notes, dated 10/14/2021, 10/28/2021, 11/11/2021 and 11/23/2021 did not document a frequency for an agency volunteer to visit patient 10. An agency volunteer documented visiting patient 10 on 11/15/2021 and 12/13/2021. On 12/21/2021 at 12:58 PM, an e-mail correspondence was sent to the administrator related to the hospice visits made without orders. On 12/21/2021 at 2:08 PM, the administrator responded stating, "Volunteers were declined on initial admit 5/7/21, however, there is a note from the volunteer coordinator dated 5/12/21 that documents that she did request a volunteer. The adjustment to the coordination of care portion of the POC was missed."

Based on interview and record review, it was determined the hospice agency did not develop an individualized written plan of care (POC) for each patient. Specifically, the hospice agency did not develop a POC that reflected patient and family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments for 3 of 13 sample patients who had a full medical record review completed by the survey team. (Patient identifiers: 1, 3, and 10.) Findings include: 1. Patient 1 was admitted to the agency on 8/4/2021 with a terminal diagnosis of Alzheimer's disease. A review of patient 1's medical record was completed on 12/22/2021. a. The following information was documented in nursing notes: i. On 11/29/2021, "...left foot and ankle appear to be swollen, red, and hot to touch." The physician was notified and an order for an antibiotic and steroid was placed. ii. On 12/8/2021 patient 1 continued to take an antibiotic for her swollen left foot. The foot was no longer red or warm to the touch. A review of IDG (interdisciplinary group) meeting documentation, which the agency considered their plan of care updates, for 11/25/2021 and 12/9/2021, was completed. There was no documented evidence patient 1's foot status or antibiotic and steroid use was discussed or addressed. On 12/21/2021 at 2:10 PM, in an email from the administrator who was also acting as the director of nursing, she stated the POC's were updated to show the progress with antibiotic and status of ankle on 11/10/2021 but this information did not save in the medical record. b. On 8/4/2021 in the initial assessment note the nurse documented patient 1's first comorbidity was a "Personal history of urinary (tract) infections." The nurse also documented, " ...Pt (patient) has gets (sic) UTI (urinary tract infection) frequently, she ended up in the hospital for an infection ...Pt is incontinent with bladder and bowels ..." The following was documented in the initial physician certification of terminal illness for the 8/4/2021 to 11/1/2021 certification period, " ...She has a h/o (history of) recurrent UTIs ..." The physician also documented that patient 1 had "frequent" urinary tract infections on the recertification of terminal illness dated 11/1/2021. The care plans developed for patient 1 were reviewed. A care plan related to urinary incontinence and history of UTI's was not found in the medical record. 2. Patient 3 was admitted to the agency on 4/15/2021 with a terminal diagnosis of heart disease. Patient 3's medical record was reviewed on 12/21/2021. On 10/14/2021, a hospice interdisciplinary group (IDG) meeting note documented that patient 3's daughter reported that she (patient 3) occasionally saw blood in the catheter tubing but that the urine was straw colored without redness noted. The data collected for the IDG that was completed on 10/14/2021 was from 8/18/2021. On 11/2/2021, a skilled nurse documented that patient 3's catheter was changed on 10/22/2021. The care plans developed for patient 3 were reviewed. A care plan related to the use and care of the urinary catheter was not found in the medical record. On 12/21/2021 at 2:45 PM, an e-mail correspondence was sent to the administrator, who also functioned as the director of nursing, related to the missing urinary catheter care plan. On 12/21/2021 at 4:05 PM, the administrator responded with "the catheter is referred to in the POC but there is not a specific urinary care plan for the catheter..." 3. Patient 10 was admitted to the agency on 5/7/2021 with a terminal diagnosis of Parkinson's disease. Patient 10's medical record was reviewed on 12/21/2021. The following references to the use of a urinary catheter and wound care were documented by a skilled nurse: a. On 10/14/2021, "...Foley catheter is patent and draining clear yellow urine..." b. On 10/18/2021, "Foley catheter is patent and draining clear yellow urine..." The nurse further documented the catheter was changed on 9/23/2021 c. On 10/21/2021, "Foley catheter is patent and draining clear yellow urine. SN (skilled nurse) performed catheter change using sterile technique." d. On 10/28/2021, Wound to the right buttocks was an open Stage II pressure ulcer that measured 0.5 cm (centimeters) X (by) 0.5 cm X 0 cm. There was pink tissue without drainage. The nurse documented the area was cleansed with a wound cleaner and a padded dressing with medihoney was applied to the site. The nurse further documented, "...Her catheter is patent and draining yellow urine. She denies any s/s (signs or symptoms) of dysuria..." There was no documentation that the hospice physician was notified of the stage II pressure ulcer. On 11/3/2021 a skilled nurse documented in a POC order, "Plan of care reviewed with IDT (interdisciplinary team) and physician. Plan of care order created." However, a care plan related to the urinary catheter and stage II pressure ulcer was not found in the medical record. On 12/21/2021 at 12:58 PM, an e-mail correspondence was sent to the administrator related to the missing care plans. On 12/21/2021 at 2:08 PM, the administrator responded stating that the initial assessment summary documented that patient 8 had an indwelling foley catheter related to a neurogenic bladder but that the actual "problem" on the plan of care was missed. The administrator did not respond to why a care plan related to the wound had not been developed.

Based on interview and record review, it was determined the plan of care did not include all services necessary for the palliation and management of the terminal diagnosis for 4 of 13 sample patients who had a full medical record review and 1 of 5 sample patients who had a focused medical record review completed by the survey team. Specifically, the agency documented visit ranges that were not individulized for each patient with 1-7 visits being commonly documented. (Patient identifiers: 2, 3, 4, 9, and 18.) Findings include: 1. Patient 3 was admitted to the agency on 4/15/2021 with a terminal diagnosis of heart disease. The IDG (interdisciplinary group) meeting, dated 10/14/2021 indicated that a skilled nurse was to visit patient 3 "1-7W (times a week for)90 (90 days)." 2. Patient 2 was admitted to the agency on 9/1/2021 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris A review of patient 2's medical record was completed on 12/22/2021. The visit frequency for the skilled nurse (SN) listed on the 10/28/2021, 11/11/2021, 11/25/2021 and 12/9/2021 IDG meeting notes was 1 to 7 visits per week with 5 as needed (PRN). 3. Patient 4 was admitted to the agency on 10/21/2021 with a terminal diagnosis of unspecified cirrhosis of the liver. A review of patient 4's medical record was completed on 12/22/2021. The visit frequency for the SN listed on the 10/28/2021, 11/11/2021, 11/25/2021 and 12/9/2021 IDG meeting notes was 1 to 7 visits per week. 4. Patient 18 was admitted to the agency on 8/16/2021 with a terminal diagnosis of Parkinson's disease. Patient 18's medical record was reviewed on 12/22/2021. The plan of care, dated 10/15/2021 indicated that a SN was to visit patient 18 2-7 times per week with 3 PRN visits. 5. Patient 9 was admitted to the agency on 3/2/2021 with a terminal diagnosis of protein-calorie malnutrition. A review of patient 9's medical record was completed on 12/22/2021. The visit frequency for the SN listed on the 11/11/2021, 11/25/2021, and 12/9/2021 IDG meeting notes was 2 to 7 visits per week. 6. In an email on 12/21/2021 at 12:06 PM, when asked why the agency used large intervals such as 1 to 7 or 2 to 7 visits per week, the administrator stated agency nurses would input visit frequencies of 1 to 7 or 2 to 7 a week when patients were declining in anticipation of increasing to daily visits.

Based on interview and record review it was determined the hospice agency did not ensure the interdisciplinary group (IDG) reviewed, revised and documented the individualized plan as frequently as the patient's condition required, but no less frequently than every 15 calendar days. Specifically, the documentation in the individualized plans was not accurate or updated for 6 of 13 sample patients who had a complete medical record review and 2 of 5 focused medical record reviews completed by the survey team. (Patient identifiers: 1, 3, 6, 7, 8, 10, 17 and 18.) Findings include: 1. Patient 3 was admitted to the agency on 4/15/2021 with a terminal diagnosis of heart disease. Patient 3's medical record was reviewed on 12/21/2021. There was a POC (plan of care) order, dated 10/12/2021 to 12/10/2021. An agency skilled nurse documented, "2 week summary- IDT (interdisciplinary team) REVIEW 08/18/2021 PPS (palliative performance scale):40% FAST (functional assessment staging):6B WT (weight): 113 MAC (mid-arm circumference):22.5ccm (cubic centimeters) RA (room air) SATS:95% MED CHANGES: none at this time CHANGE IN PT (patient) CONDITION: ...pleasant female on Hospice service under the care of (name of medical director). Admitting Diagnosis:Hypertensive heart disease with heart failure, Non Rheumatic Aortic Stenosis, and AFIB (atrial fibrillation). Pt has a PMH (patient medical history) of A-fib, long term use of anticoagulants, HTN (hypertension), CAD (coronary artery disease), Osteoarthritis, PUD (peptic ulcer disease), PVC's (preventricular contractions), HLD (high-density lipoprotein), Aortic stenosis, GERD (gastroesophageal reflux disease), anemia, peripheral vascular disease, multiple falls, L (left) femur fx (fracture), fx to L ulna, kyphosis, and macular degeneration which she receives R (right) eye injection from opthalmist q (every) 12 weeks, which she believes is helping to keep macular degeneration from progressing to R eye, she is legally blind and has min (minimal) eyesight to her L eye. Pts lower limbs are red and glossy, no edema present. Pt does appear to be declinging (sic) physically as well as mentally as evidenced by her more challenging transfers and by her inability to know the day or time, she struggles to find the right words frequently and it is frustrating to her when she is unable to state what she is thinking. She has a foley catheter that is patent and draining. Her daughter reports that she occasionally see blood in the catheter tubing, however, urine is straw colored with no redness noted. She denies any other s/s (signs or symptoms) of UTI (urinary tract infection). SHe (sic) recently had MOHS (a surgical procedure) surgery for 2 cancerous spots on her face that are healing appropriately. Her L ankle has 1+ pitting edema and was painful for a time, however, she denies pain this day. She has no areas of impaired skin integrity at this time." The summary/comments section of the IDT meeting note had "IDT meeting held, all disciplines present. All patients discussed. Eligibility discussed, patient needs reviewed, plan of cares updated. Pt medications review for effectiveness, hospice coverage, and pt/pcg (patient caregiver) ability to safely administer. Discussed new admissions, recertifications, discharges and deaths." The IDG meetings completed on 10/14/2021, 10/28/2021, 11/11/2021, 11/25/2021 and 12/9/2021 documented, "2 week summary- IDT REVIEW 08/18/2021" and was an exact duplicate of the documentation that was on the POC order dated 10/12/2021 to 12/10/2021. The IDG documentation did not accurately reflect patient 3's care that was received for the prior two weeks. Additionally, the summary/comments section of the IDT meeting notes had "IDT meeting held, all disciplines present. All patients discussed. Eligibility discussed, patient needs reviewed, plan of cares updated. Pt medications review for effectiveness, hospice coverage, and pt/pcg (patient caregiver) ability to safely administer. Discussed new admissions, recertifications, discharges and deaths" which are not specific to patient 3. The SW (social worker) and SN (skilled nurse) did not document a two week summary for the cares provided. Additionally, the IDG did not ensure that a care plan was developed related to patient 3's urinary catheter care. On 12/21/2021 at 2:45 PM, an e-mail correspondence was sent to the administrator related to the duplicate IDG meeting notes. On 12/21/2021 at 4:05 PM the administrator responded with "Noted". 2. Patient 6 was admitted to the agency on 10/5/2021 with a terminal diagnosis of malignant neoplasm of the brain. Patient 6's medical record was reviewed on 12/21/2021. The IDG meeting note, dated 10/14/2021, did not have the discipline frequencies documented or a summary of patient 6's status from 10/5/2021 to 10/14/2021. The IDG meeting note, dated 10/28/2021, had "Admission: PPS:40% FAST:3 WT: 161 BMI: MAC:36cm RA SATS:89% MED CHANGES:NONE CHANGE IN PT CONDITION: hospice admission." The Chaplain documented an update, but there were no summaries from the other disciplines. Additionally, the summary/comments section of the IDT meeting note had "IDT meeting held, all disciplines present. All patients discussed. Eligibility discussed, patient needs reviewed, plan of cares updated. Pt medications review for effectiveness, hospice coverage, and pt/pcg ability to safely administer. Discussed new admissions, recertifications, discharges and deaths" and was not specific to patient 6. The IDG meeting notes, dated 11/11/2021 and 11/25/2021, had "Admission: PPS:40% FAST:3 WT: 161 BMI: MAC:36cm RA SATS:89% MED CHANGES:NONE CHANGE IN PT CONDITION: hospice admission" which was an exact duplicate of what was documented on 10/28/2021. 3. Patient 8 was admitted to the agency on 9/29/2021 with a terminal diagnosis of respiratory failure with hypoxia post Covid-19. Patient 8's medical record was reviewed on 12/21/2021. The IDG meetings completed on 10/14/2021 and 10/28/2021 had a note from the Chaplain. There was no documentation from other disciplines that were seeing patient 8. The summary/comments section of the IDT meeting note had "IDT meeting held, all disciplines present. All patients discussed. Eligibility discussed, patient needs reviewed, plan of cares updated. Pt medications review for effectiveness, hospice coverage, and pt/pcg ability to safely administer. Discussed new admissions, recertifications, discharges and deaths," which are not topics specific to the care and treatment of this patient. The IDG meeting completed on 10/14/2021, did not address that patient 8 was started on Macrobid on 10/4/2021. The IDG meeting completed on 10/28/2021, did not address that patient 8's Amitriptyline and Metformin was discontinued on 10/29/2021 or that patient 8 was started on Lorazepam and Haldol on 10/28/2021. An IDG meeting note, dated 11/11/2021, documented "...2 week summary- IDT REVIEW PPS: 40% FAST: 7a WT: 123 BMI (body mass index): MAC: RA SATS: 90% MED CHANGES: Haldol for agitation CHANGE IN PT CONDITION: Pt mood has improved with the haldol." The summary/comments section of the IDT meeting note had "IDT meeting held, all disciplines present. All patients discussed. Eligibility discussed, patient needs reviewed, plan of cares updated. Pt medications review for effectiveness, hospice coverage, and pt/pcg ability to safely administer. Discussed new admissions, recertifications, discharges and deaths," which are not specific to the care and treatment for this patient. The IDG meetings completed on 11/25/2021 and 12/9/2021 documented, "...2 week summary- IDT REVIEW PPS: 40% FAST: 7a WT: 123 BMI: MAC: RA SATS: 90% MED CHANGES: Haldol for agitation CHANGE IN PT CONDITION: Pt mood has improved with the haldol." The summary/comments section of the IDT meeting notes had "IDT meeting held, all disciplines present. All patients discussed. Eligibility discussed, patient needs reviewed, plan of cares updated. Pt medications review for effectiveness, hospice coverage, and pt/pcg ability to safely administer. Discussed new admissions, recertifications, discharges and deaths" and were not specific to patient 8. The SW and SN did not document a two week summary for the cares provided. On 12/21/2021 at 3:57 PM, an e-mail correspondence was sent to the Administrator related to the duplicate documentation on the IDG meeting notes. The administrator responded on 12/22/2021 at 10:13 AM with "I spoke with the RN (registered nurse) regarding the PoC, she stated that she did update her documentation prior to the IDG meeting. We have found that an update to our EMR (electronic medical record) has cause (sic) some of our IDT update notes to not save. We have been trying to proactively audit and catch any missed updates." 4. Patient 10 was admitted to the agency on 5/7/2021 with a terminal diagnosis of Parkinson's disease. Patient 10's medical record was reviewed on 12/21/2021. The IDG meeting, dated 11/3/2021, documented a recertification and 2 week summary as, "IDT REVIEW 11/3/21 PPS:30% FAST:6d WT: 131 BMI:23 MAC:25cm RA SATS: mid 80s MED CHANGES: none CHANGE IN PT CONDITION: Patient's hospice is being recertified for a Parkinson's diagnosis under (the name of the physician and nurse practitioner redacted). She is an 87-year-old female with (sic) lives at (the name of the ALF redacted). PPS: 30% and FAST: 6e. Assessment completed and vital signs obtained, Respirations are even and unlabored at rest with bilateral breath sounds clear and equal throughout but diminished in the bases. She requires oxygen continuously to maintain therapeutic saturations. Distant heart sounds auscultated apically without acute cardiac distress noted. Bowel sounds are present and normal with abdomen soft and nontender. Patient denies any concerns r/t (related to) her bowels or bladder. Foley catheter is patent and draining clear yellow urine. Patient reports for continued left hip pain stating it has not been very well managed and she is utilizing ekit morphine at least daily to help better control it. SN reviewed pain management including the use of non-pharmacological interventions. Patient has a new stage 2 pressure ulcer to her left buttock that is requiring wound care from SN. She spends all day in bed or in her chair and has a poor functional status requiring assistance with all transfers and mobility. She states that she is tolerating her mechanical soft diet without added sputtering / choking incidents. She has had quite a decreased appetite and is often refusing meals. Patient is generally only eating 20-40% of one meal a day. Her MAC has decreased 1cm this certification period with her weight dropping 8 pounds. Patient often presents with a rigid body regardless of whether she is in bed or in her chair. She has frequent bilateral arm and head tremors that are prominently noted. She is sleeping much more frequently throughout the day and night and is often hard to arouse. Patient remains weak and has not been spending as much time in her chair as she is sleeping more and staying in bed. Patient requires assistance with all activities d/t akinesia and paralysis. Patient continues to qualify for hospice services." The summary/comments section of the form had "IDT meeting held, all disciplines present. All patients discussed. Eligibility discussed, patient needs reviewed, plan of cares updated. Pt medications review for effectiveness, hospice coverage, and pt/pcg ability to safely administer. Discussed new admissions, recertifications, discharges and deaths" and was not specific for patient 10. The IDG did not identify that a care plan related to the urinary catheter or the stage II pressure sore had not been developed. The IDG meetings completed on 11/11/2021, 11/25/2021 and 12/9/2021 documented, "recertification & 2 week summary-IDT REVIEW 11/3/2021..." and was an exact duplicate of the recertification documentation on 11/3/2021. The IDG note did not reflect an accurate two week summary. Additionally, the summary/comments section of the IDT meeting notes had "IDT meeting held, all disciplines present. All patients discussed. Eligibility discussed, patient needs reviewed, plan of cares updated. Pt medications review for effectiveness, hospice coverage, and pt/pcg ability to safely administer. Discussed new admissions, recertifications, discharges and deaths" and were not specific to patient 10. The IDG meeting completed on 11/11/2021, did not document that patient 10 had a left hip x-ray completed on 10/31/2021, had an eye exam on 11/9/2021 or had a medication error related to the use of the Ondansetron. On 12/21/2021 at 12:58 PM, an e-mail correspondence was sent to the administration related to the duplicate documentation in the IDG meetings. The Administrator responded on 12/21/2021 at 2:08 PM with "The plan of care was updated and a new POC order created on 11/5/21 per worklog. Plan of care was also updated again on 11/10/21 per worklog. We were unaware of the severity of this issue within (the computer program)." 5. Patient 17 was admitted to the agency on 5/28/2021 with a terminal diagnosis of heart failure. Patient 17's medical record was reviewed on 12/21/2021. The IDG meeting note, dated 11/11/2021 had "2 week summary- IDT REVIEW 06/24/21 PPS: 40% FAST: 4 WT: 129 BMI: 25 MAC: 21.5 RA SATS: 86% MED CHANGES: No CHANGE IN PT CONDITION: Pt was admitted to Hospice for heart failure. She is now living at (name of the ALF). She is requiring supplemental oxygen more frequently throughout the day. She has a fair appetite and has no current complaints of pain. 2 week summary- IDT REVIEW PPS: 50% FAST: 5 WT: BMI: MAC: RA SATS: 86% MED CHANGES: no changes- need order for ibuprofen, her shoulder is still bothering her from her fall CHANGE IN PT CONDITION: no changes 2 week summary- IDT REVIEW PPS: 50% FAST: 4 WT: 134 BMI: MAC: RA SATS: 83% MED CHANGES: cough medicine, abx (antibiotic), tessalon pearls, albuterol inhaler CHANGE IN PT CONDITION: Pt has a cold with cough causing her oxygen needs to be increased 2 week summary- IDT REVIEW PPS: 40% FAST: 6D WT: 134 BMI: MAC: 23 RA SATS: 88% MED CHANGES: no changes CHANGE IN PT CONDITION: no changes, feeling better after having a cold 2 week summary- IDT REVIEW PPS: 40% FAST: 6 WT: 144 BMI: MAC: 23 RA SATS: 90% MED CHANGES: no changes CHANGE IN PT CONDITION: no changes 2 week summary- IDT REVIEW PPS: 50% FAST: WT: 136 BMI: MAC: 23 RA SATS: 88% MED CHANGES: no changes CHANGE IN PT CONDITION: no changes." Additionally, the summary/comments section of the IDT meeting note had "IDT meeting held, all disciplines present. All patients discussed. Eligibility discussed, patient needs reviewed, plan of cares updated. Pt medications review for effectiveness, hospice coverage, and pt/pcg ability to safely administer. Discussed new admissions, recertifications, discharges and deaths" and was not specific to patient 17. The survey team was unable to determine which two week summary accurately reflected patient 17's condition. The IDG meeting note, dated 11/23/2021 had "2 week summary-IDT REVIEW 06/24/2021" and was an exact duplicate of the IDG meeting note dated 11/11/2021. The IDG did not mention that patient 17 was discharged on 11/23/2021. On 12/21/2021 at 5:42 PM, an e-mail correspondence was sent to the Administrator related to the IDG meeting notes. The Administrator responded on 12/22/2021 at 10:15 AM with "The IDT summaries were updated each week, but as previously identified, (the computer system) has not been saving all updates. ..." The Administrator documented that patient 17's discharge was verbally discussed with the "ADON (assistant director of nursing), physician, family and CM (case manager) on the day of discharge." 6. Patient 18 was admitted to the agency on 8/16/2021 with a terminal diagnosis of Parkinson's disease. Patient 18's medical record was reviewed on 12/22/2021. Patient 18's skilled nurse noted on 11/10/2021 the following: "patient continues yes(sic) to show s/sc (sic)(signs/ Symptoms) of decline. Patient requiring more assistance with adls (activities of daily living) and ongoing edema in BLE (bilateral lower extremities). She continues to have quite a bit of weakness noted and spends nearly all day in bed or in WC (wheel chair). Pt continues to show decline fo (sic) decreased appetite, worsening cognitive status, and increased edema in BLE with poor response to treatment. Staff reports pt has become weaker,.... staff v/u (verified understanding) and was encouraged to reach out to SN with any changes or concerns". The IDT for patient 18 on 11/18/2021 contained only one comment from the Chaplain and part of his note documented "After review the IDG team as (sic) determined that hospice eligibility is still being met. Chaplain will continue to provide support with no changes to current plan of care." The SN did not document a two week summary for the cares provided in the IDT notes. The IDG comments for 10/28/2021, 11/11/2021 and 11/25/2021 all read as: "2 week summary- IDT REVIEW PPS:30% FAST:7D WT: 132 BMI: MAC:21.2cm RA SATS:88% MED CHANGES: PT STARTED ON CEFUROXIME FOR CDIFF/UTI. CHANGE IN PT CONDITION:PT WAS READMITTED TO HOSPICE ON 8/16/2021. SHE HAD BEEN ADMITTED TO (local hospital) ER FOR DEHYDRATION, UTI, AND SHE DEVELOPED CDIFF. NOW TAKING VANCO WHICH WILL BE COMPLETE AS OF TODAY. " The IDG did not included updated information on patient's 2 week progression and patients response to care. 7. Patient 7 was admitted to the agency on 8/18/2021 with a terminal diagnosis of Corticobasal degeneration with hemiplegia, unspecified affecting right dominant side. Patient 7's medical records were reviewed on 12/22/2021. The IDG comments for 11/16/2021, 11/24/2021 and 12/18/2021 were all documented as: "2 week summary- IDT REVIEW 9/15/21 PPS:40% FAST: WT: BMI: MAC: RA SATS: 95% MED CHANGES: Baclofen prn CHANGE IN PT CONDITION: Pt having increased depression d/t disease process." The IDG did not include updated information on patient 7's two week progression or response to care. On 12/22/2021 at 11:13 AM, in email with the administrator she stated the following: "They are required to input their IDG notes. The IDT summaries were updated each week, but as previously identified; (the computer program) has not been saving all updates. This is also verbally discussed at the IDT meeting." 8. Patient 1 was admitted to the agency on 8/4/2021 with a terminal diagnosis of Alzheimer's disease. A review of patient 1's medical record was completed on 12/22/2021. A review of IDG meeting documentation for 11/11/2021, 11/23/2021, and 12/8/2021, was completed. The documentation in the comments section was an exact duplicate for all three meetings, as listed below: "2 week summary- IDT REVIEW PPS: 50% FAST: 6 WT: 147 BMI: MAC: RA SATS: 90% MED CHANGES: Family would like to discontinue medication except for her antidepressant CHANGE IN PT CONDITION: 2 week summary- IDT REVIEW PPS: 50% FAST: 6 WT: 149 BMI: MAC: 23.5 RA SATS: 97% MED CHANGES: no changes CHANGE IN PT CONDITION: Pt has good day (sic) and bad days, she reports feeling tired and just wants to stay in bed and sleep. She did come out of her room to see the RN to report that her skin changed within mins (minutes) of her looking at it. 2 week summary- IDT REVIEW PPS: 50% FAST: 6d WT: 149 BMI: MAC: 23.5 RA SATS: 94% MED CHANGES: D/C eliquis,restasis per family request, started aspirin 81mg CHANGE IN PT CONDITION: no change- upper thighs have multiple sores from her picking at her skin, she co (sic) that it was from a MD injection 2 week summary- IDT REVIEW PPS: 50 FAST: 7a WT: 156 BMI: MAC: 23 RA SATS:97% MED CHANGES: no changes CHANGE IN PT CONDITION: no changes." 9. On 12/21/2021 at 12:06 PM, in an email from the administrator, she confirmed they had identified that some patients plans were not being updated as the software system the agency used for their electronic medical records had been updating their software and, " ...it has caused some issues with saving and signing documents. ..."

Based on interview and record review, it was determined the hospice agency did not ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services were provided directly or under arrangement for 3 of 13 sample patients who had a full medical record review and 1 of 5 patients who had a focused medical record review completed by the survey team. Specifically, the Registered Nurse (RN) did not document coordination with the other members of the interdisciplinary team (IDT). (Patient identifiers: 2, 10, 12 and 16.) Findings include: 1. Patient 2 was admitted to the agency on 9/1/2021 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris. A review of patient 2's medical record was completed on 12/22/2021. The following information was documented in nursing notes from 9/7/2021 to 12/15/2021: a. On 9/7/2021, "Patient has bruising to bilateral upper and lower extremities. Facility aide Isn't not (sic) sure where it all came from as she said it was not like that yesterday ..." b. On 10/18/2021, "Patient continues to have bruising to bilateral upper and lower extremities. Facility does not often know where they come from ..." c. On 11/10/2021, "Patient continues to have bruising to bilateral upper extremity's and bilateral lower extremity's ..." d. On 11/17/2021, "Pt (patient) cont (continues) to have bruising to BUE (bilateral upper extremities) and BLE (bilateral lower extremities) ..." e. On 11/24/2021, "Pt cont to have brushing(sic) to BUE and BLE, likely from transfers." f. On 11/25/2021, "Pt has bruising to BUE and BLE, unknown the origin of them ..." g. On 12/1/2021, "Pt cont to have bruising to BUE and BLE ..." h. On 12/3/2021, "Pt cont to have bruising to BUE and BLE ..." i. On 12/6/2021, "Pt has bruising to BUE and BLE, no one knows where it comes from ...." j. On 12/10/2021, "Pt cont to have bruising to BUE and BLE, no one knows where it comes from ...." k. On 12/15/2021, "Patient has bruising to bilateral upper and lower extremities, nobody knows where the bruising comes from though." No documented evidence could be found to indicate the bilateral upper and lower extremity bruising information was shared or discussed with the IDT. On 12/22/2021 in email with Administrator who was also acting as the director of nursing, she stated the following: "Per the RN the bruising has been consistently present since 9/7/21." The bruising was reported to the MD/NP (medical director/nurse practitioner) during IDT and it was determined that the bruising was related to poor circulation and use of Coumadin (a blood thinner). The nurse was instructed to continue to monitor. No adjustments were made in the orders or POC (plan of care). Note: No evidence of the discussion with the MD/NP mentioned by the Administrator could be found in patient 2's medical record. 2. Patient 10 was admitted to the agency on 5/7/2021 with a terminal diagnosis of Parkinson's disease. Patient 10's medical record was reviewed on 12/21/2021. An agency nurse documented on 10/28/2021 that patient 10 developed a stage II pressure ulcer on the right buttocks that measured 0.5 cm (centimeters) X (by) 0.5 cm. The wound bed was pink without drainage and the surrounding tissue was erythematous. The nurse cleansed the pressure ulcer with a wound cleanser, applied medihoney and placed a padded dressing over the area. The nurse documented that the case manager was notified, but did not notify the physician to obtain treatment orders and did not update the care plan. On 12/21/2021 at 12:58 PM, an e-mail correspondence was sent to the Administrator related to the development of the stage II pressure ulcer, no wound care orders and no care plan. The Administrator responded on 12/21/2021 at 2:08 PM with "On the RN recertification that (the RN) did dated 11/1/21 it noted on the recert (recertification) about the wound with the wound care orders." The Administrator did not provide documented evidence that the physician was notified of the stage II pressure ulcer on 10/28/2021 or that a care plan had been developed. 3. Patient 12 was admitted to the agency on 12/3/2021 with a terminal diagnosis of malignant neoplasm of the kidney. Patient 12 was discharged from the agency on 12/10/2021. A review of patient 12's medical record was completed on 12/22/2021. On 12/10/2021, a discharge note was written by an agency nurse. The nurse documented that patient 12 was admitted on 12/3/2021, and had received nursing visits on the day of admit and the day after. The nurse further documented that nursing visits were then attempted each day from 12/5/2021 to 12/10/2021 with no success due to patient not answering the door or his phone. The following was also documented, " ...Multiple disciplines attempted to make contact with the pt or his roommate without success. Pt is being discharged d/t (due to) cause of non compliance, and our inability to provide the necessary care this pt needs ..." The IDT meeting documentation for 12/9/2021 included information regarding patient 1's current health status, but did not include any information about missed visits or a possible discharge. The only documentation regarding his compliance with care was the following, "Pt agreed to hospice care and DNR (do not resuscitate). It (sic) is unsure if pt will be compliant or allow services. SN (skilled nurse) 2 x (times) weekly, SW (social work) and chaplain welcome." On 12/8/2021, a visit by the chaplain was completed. The chaplain documented his conversation with patient 12. He did not document any concerns with other staff members not being able to make contact with patient 12 or his roommate. Missed visit notes documented by agency nurses were as follows: a. On 12/6/2021, two missed visit notes were documented indicating the patient was not home during the first attempt, and there was no answer at the door or when a phone call was attempted later in the day. The nurse documented, "No" next to the section titled medical doctor (MD) notification. b. On 12/7/2021, the patient did not answer the door or his phone. The nurse documented the MD was notified of this missed visit. c. On 12/8/2021, the patient did not answer the door or his phone. The nurse documented, "No" next to the section titled MD notification. d. On 12/9/2021, the patient did not answer the door or his phone. The nurse documented, "No" next to the section titled MD notification. e. On 12/10/2021, the patient did not answer the door or his phone. The nurse documented the MD was notified of this missed visit and that the patient would be discharged due to non-compliance. Note: Per documentation the MD was only notified of two of the missed nursing visits. Additionally, there was no documented evidence that the IDT discussed the patient's non-compliance prior to his discharge. On 12/22/2021 at 9:02 AM, in an email from the administrator she stated patient 12's non-compliance was "verbally discussed" during the IDT meeting. The administrator further stated the nursing missed visit note on 12/7/2021 was evidence that the MD was notified, "of all missed visits." 4. Patient 16 was admitted to the agency on 10/21/2021 with a terminal diagnosis of gastrointestinal hemorrhage. She was discharged from the agency on 12/1/2021. A review of patient 16's medical record was completed on 12/22/2021. Nursing documentation for November 2021 revealed the following: a. On 11/22/2021, "...Pt will be moving to a daughters home in (name of city) Utah some time in Dec.(December)" b. On 11/29/2021, "... Pt is going to be moving to another daughters home in (name of city) Ut (Utah) some time (sic) this week at families request, a transfer to another agency has been arranged..." A discharge note dated 12/1/2021 revealed the following, "Pt is moving to her daughters house in (name of city) she will be transferring to another hospice." The IDT meeting documentation on 11/25/2021 included information regarding patient 16's current health status, but did not include any information about her upcoming discharge. On 12/22/2021 at 9:51 AM, in an email from the administrator she stated, "The potential move was discussed verbally in IDT, but not documented on the note because there was no concrete move date, per the case manager."

Based on interview and medical record review, it was determined the agency failed to maintain clinical records which contained pertinent past and current findings in accordance with accepted professional standards. Findings include: 1. The hospice failed to ensure that when a patient was transferred to another Medicare/Medicaid-certified facility, the hospice forwarded, to the receiving facility, a copy of the hospice discharge summary. Refer to tag L0682. 2. The hospice failed to ensure that when a patient revoked the election of hospice care, or was discharged from hospice in accordance with §418.26, the hospice forwarded to the patient's attending physician, a copy of the hospice discharge summary. Refer to tag L0683.

Based on interview and record review, it was determined the agency did not complete a discharge summary for patients that were transferred to another Medicare/Medicaid certified facility for 2 of 13 sampled patient who had a full medical record review and 3 of 5 focused record reviews completed by the survey team. The discharge summary was to include, a summary of the patient's stay including treatments, symptoms and pain management; the patient's current plan of care; the patient's latest physician orders; and any other document that would assist in post-discharge continuity of care. (Patient identifiers: 13, 14, 15, 16, and 18.) Findings include: 1. Patient 14 was admitted to the agency on 10/27/2021 with a terminal diagnosis of chronic respiratory failure with dementia and behavioral disturbances. Patient 14's medical record was reviewed on 12/21/2021. On 11/3/2021, a revocation statement was documented as "Pt was moved from ALF (assisted living facility) to SNF (skilled nursing facility) for increased level of care. Family opted to revoke hospice at that time." On 11/3/2021, a communication note documented that patient 14 was transferred to a skilled nursing facility due to an increased level of care that the assisted living facility was unable to provide. The agency documented that patient 14's hospice benefit was revoked. A discharge summary was not located in patient 14's medical record. On 12/21/2021 at 4:33 PM, an e-mail correspondence was sent to the Administrator related to the discharge summary. On 12/22/2021 at 9:48 AM, the Administrator responded with "Revocation statement and communication note collectively is our version of a discharge order (and summary)..." 2. Patient 15 was admitted to the agency with a terminal diagnosis of acute diastolic congestive heart failure. Patient 15's medical record was reviewed on 12/21/2021. On 10/18/2021 a facility nurse completed a revocation statement that included, "Pt was noted to have severe abdominal pain, coffee ground emesis and abdominal distention. Her family wished to revoke hospice and send her to the hospital for evaluation and possible treatment." It should be noted that the reason for hospital evaluation was not related to the hospice diagnosis. A discharge summary was not located in patient 15's medical record. On 12/21/2021 at 5:00 PM, an email correspondence was sent to the administrator related to the discharge summary. On 12/22/2021 at 9:49 AM, the administrator responded stating, "We don't have credentials in the hospital that the patient went to and the family, in an abundance of caution, they requested to revoke so that if any concerns came up with the aspect of her health that the hospital would be free to treat it. ... " The administrator further stated the revocation form served as the discharge summary. 3. Patient 16 was admitted to the agency on 10/21/2021 with a terminal diagnosis of gastrointestinal hemorrhage. She was discharged from the agency on 12/1/2021. A review of patient 16's medical record was completed on 12/22/2021. A live discharge form dated 12/1/2021, and completed by the nurse, revealed the following, "Pt is moving to her daughters house in (name of city) she will be transferring to another hospice." A discharge summary was not located in patient 16's medical record. On 12/22/2021 the administrator was notified a discharge summary could not be located for patient 16. At 9:51 AM, she emailed the following response, " ...(The) Live Discharge form serves as order and communication documentation." Note: The live discharge form did not include all required information for a discharge summary. 4. Patient 13 was admitted to the agency on 11/4/2021 with a terminal diagnosis of Parkinson's disease. Patient 13's medical record was reviewed on 12/22/2021. The following information was documented in nursing note on 11/20/2021: "Patient is actively dying, RN (registered nurse) educated his family on decline and that patient would probably not make it more than a few days." They agreed to the current care plan of keeping the patient comfortable. The RN educated family on use of E (emergency) kit medications, a schedule of when to give along with signs and symptoms to watch for. They were told to call the RN if they had any concerns or issues or if they did not feel their dad was comfortable. The family verbalized their understanding. On 11/21/2021, a revocation statement was documented as "Patients family decided to revoke hospice care to seek treatment at (local hospital)." A discharge summary was not located in patient 13's medical record. On 12/22/2021 12:13 PM, in an email the administrator stated: "In speaking to the nurse, the decision to send the patient to the hospital was made by the children of the patient in the early hours of the morning on 11/21/21. They made this decision since one of the siblings was out of town, and they were not ready for him to pass. They did not call our On Call service, and only notified our nurse through a phone call during business hours. The IDT was updated via email and in the IDT 11/24/21." Note: There was no evidence or documentation of an IDT for patient 13 on 11/24/2021. 5. Patient 18 was admitted to the agency on 8/16/2021 with a terminal diagnosis of Parkinson's disease. Patient 18's medical record was reviewed on 12/22/2021. Patient 18 was discharged on 11/29/2021 and transferred to another hospice agency. A discharge summary was not located in patient 18's medical record. On 12/22/2021 at 11:13 AM, in email the administrator stated the following: The discharge note and summary are included as part of the RN discharge note.

Based on interview and record review, it was determined the agency did not complete a discharge summary for patients who were discharged for 1 of 13 sampled patients who had a full medical record review and 1 of 5 focused record reviews completed by the survey team. The discharge summary was to include, a summary of the patient's stay including treatments, symptoms and pain management; the patient's current plan of care; the patient's latest physician orders; and any other documents that would assist in post-discharge continuity of care. (Patient identifiers: 12 and 17.) Findings include: 1. Patient 17 was admitted to the agency on 5/28/2021 with a terminal diagnosis of heart failure. Patient 17's medical record was reviewed on 12/21/2021. The hospice physician completed a face-to-face visit for patient 17 on 11/21/2021, which was not documented until 12/21/2021. The hospice physician documented, "...She has been not declining recently, therefore have been evaluating her for possible live discharge from hospice. ...will be discharged from hospice, for lack of progression towards death..." On 11/23/2021, a hospice nurse documented in a live discharge note that patient 17 was discharged home and was no longer terminally ill. The nurse documented that the discharge was discussed with the patient and family. A discharge summary that was sent to patient 17's primary care physician was not located in patient 17's medical record. On 12/21/2021 at 5:42 PM, an e-mail correspondence was sent to the administrator, who also functioned as the director of nursing, related to the discharge summary. On 12/22/2021 at 10:15 AM, the administrator responded stating the hospice physician documentation had been sitting in a "hot box" awaiting signature. The physician was asked to sign the face-to-face by the assistant director of nursing on 12/21/2021. The administrator did not respond as to why a discharge summary had not been completed. 2. Patient 12 was admitted to the agency on 12/3/2021 with a terminal diagnosis of malignant neoplasm of the kidney. Patient 12 was discharged from the agency on 12/10/2021. A review of patient 12's medical record was completed on 12/22/2021. On 12/10/2021 a discharge note was written by an agency nurse. The nurse documented that patient 12 was admitted on 12/3/2021 and had received nursing visits on the day of admit and the day after, 12/4/2021. The nurse further documented that nursing visits were then attempted each day from 12/5/21 to 12/10/21 with no success due to patient not answering the door or his phone. The following was also documented, " ...Multiple disciplines attempted to make contact with the pt (patient) or his roommate without success. Pt is being discharged d/t (due to) cause of non compliance, and our inability to provide the necessary care this pt needs ..." A discharge summary could not be found in patient 12's medical record.