Every finding on record at Living Stones Hospice Care LLC

Based on interview and record review, the agency failed to participate in a full-scale community-based disaster exercise, or a tabletop disaster exercise for two of two sampled years. As a result, the agency may have been less prepared for disasters. --- Findings: On 6/19/24 at 10:20 A.M., an interview was conducted with the Administrator Designee (AD). The AD stated, he had no documentation of the agency participating in any disaster exercises. The agency did not have a policy which directed them to annually participate in a full-scale community-based disaster exercise, or a tabletop disaster exercise.

Based on interview and record review, the hospice registered nurse failed to complete an initial comprehensive assessment within 48 hours of the election of hospice care (admission) for one of the 14 sampled patients (1). As a result, there was a potential for Patient 1's psychosocial, emotional, and spiritual needs to go unmet. --- Findings: Per the agency's Plan of Care for the certification period 10/19/23 through 1/16/24, Patient 1 was admitted to the agency on 10/19/23 with diagnoses to include heart disease. A review of Patient 1's clinical record was conducted on 6/17/24. There was no evidence that the Registered Nurse (RN) 's initial assessment was completed. The registered nurse was not available for interview. On 6/19/24 at 9:50 A.M., an interview with the Director of Patient Care Services Designee (DPCSD). The DPCSD stated the initial comprehensive assessment was not completed yesterday (6/18/24). The DPCSD further stated the registered nurse should have completed the initial comprehensive assessment on time.Per the agency's policy and procedure dated 2009, titled Initial Assessment, "...An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care..."

Based on interview and record review, the agency failed to complete a comprehensive assessment within five days of admission for two of 14 sampled patients (5, 11). As a result, the interdisciplinary group (IDG) did not know about Patient 5's and Patient 11's psychosocial/emotional needs. --- 2. Per the agencys Plan of Care for the certification period 2/13/24 through 5/12/24, Patient 11 was admitted to the agency on 2/13/24 with diagnoses to include Parkinsons disease (a nerve and movement disorder). The agencys Spiritual Assessment for Patient 11 was dated 2/26/24 (13 days after admission). On 6/19/24 at 10:20 A.M., an interview was conducted with the Administrator Designee (AD). The AD stated, the initial visits of the Social Worker and Spiritual Counsellor should have been completed within five days of admission. The agency did not have a policy on comprehensive assessments. Findings: 1. Per the agency's Plan of Care (POC) for the certification period 2/6/24 through 5/5/24, Patient 5 was admitted to the agency on 2/6/24 with diagnoses to include senile degeneration of the brain (decline in mental health). A review of Patient 5's clinical record was conducted. The Spiritual Assessment was created on 2/13/24 (7 days after the admission) and was not completed. In addition, the Medical Social Worker Assessment was dated 2/15/24 (9 days after the admission). The spiritual coordinator and medical social worker were not available for the interview. On 6/19/24 at 10:20 A.M., an interview was conducted with the Administrator Designee (AD). The AD stated the initial visits of the social worker and spiritual counselor should have been completed within five days of admission.

Based on interview and record review, the agency failed to ensure a physician attended all InterDisciplinary Group (IDG) meetings for four of 14 sampled patients (8, 9, 10, 14). As a result, there was no physician input when discussing patient care. --- Findings: 1. Per the agencys POC for the certification period 4/30/24 through 6/28/24, Patient 8 was admitted to the agency on 7/5/23 with diagnoses to include Parkinson's disease (a nerve and movement disorder). A review of Patient 8s clinical record was conducted on 6/18/24. There were no physician signatures on any of their IDG notes during the certification period. 2. Per the agencys POC for the certification period 5/16/23 through 8/13/23, Patient 9 was admitted to the agency on 5/16/23 with diagnoses to include Alzheimers disease (a disorder of physical and mental decline). A review of Patient 9s clinical record was conducted on 6/18/24. There were no physician signatures on any of their IDG notes during the certification period. 3. Per the agencys POC for the certification period 4/19/24 through 6/17/24, Patient 10 was admitted to the agency on 8/23/23 with diagnoses to include heart disease. A review of Patient 10s clinical record was conducted on 6/18/24. There were no physician signatures on the IDG notes on 5/10/24 or 5/24/24. 4. Per the agencys POC for the certification period 3/7/24 through 6/4/24, Patient 14 was admitted to the agency on 12/8/23 with diagnoses to include heart disease. A review of Patient 14s clinical record was conducted on 6/18/24. There was no physician signature on the IDG note on 3/15/24. On 6/19/24 at 10 A.M., an interview was conducted with the Director of Patient Care Designee (DPCSD). The DPCSD stated, the IDG team should include the physician, and all attending staff should have signed the IDG notes. Per the agencys policy, titled Interdisciplinary Group Membership and Responsibilities, dated 2018, ";...The hospice interdisciplinary team/group members will include, at a minimum: A. Physician..."

Based on interview and record review, the agency failed to ensure the interdisciplinary group (IDG) meeting was conducted not less frequently than every 15 calendar days for 7 of 14 sampled patients (2, 4, 6, 8, 11, 12, 13).As a result, the IDG did not address the patient's care needs or possible changes. --- 4. Per the agencys POC for the certification period 4/30/24 through 6/28/24, Patient 8 was admitted to the agency on 7/5/23 with diagnoses to include Parkinson's disease (a nerve and movement disorder). A review of Patient 8s clinical record was conducted on 6/18/24. The latest IDG note was on 5/10/24. (39 days without an IDG note.) 5. Per the agencys POC for the certification period 2/13/24 through 5/12/24, Patient 11 was admitted to the agency on 2/13/24 with diagnoses to include Parkinson's disease (a nerve and movement disorder), and was discharged on 4/3/24. A review of Patient 11s clinical record was conducted on 6/18/24. Patient 11s last IDG note before discharge was on 3/1/24. (33 days without an IDG note.) 6. Per the agencys POC for the certification period 2/6/24 through 4/5/24, Patient 12 was admitted to the agency on 2/6/24 with diagnoses to include senile degeneration of brain (brain failure), and was discharged on 3/17/24. A review of Patient 12s clinical record was conducted on 6/18/24. Patient 12 did not have any further IDG notes after admission on 2/6/24. (40 days without an IDG note.) 7. Per the agencys POC for the certification period 1/9/24 through 4/7/24, Patient 13 was admitted to the agency on 1/9/24 with diagnoses to include heart disease, and was discharged on 3/14/24. A review of Patient 13s clinical record was conducted on 6/18/24. Patient 13 did not have any IDG notes while on service. (65 days without an IDG note.) On 6/19/24 at 10:20 A.M., an interview was conducted with the Administrator Designee (AD). The AD stated he could not explain why there were missing IDG notes. The AD further stated the IDG should have been held every 15 days and documented in the patient's clinical record. Per the agency's policy and procedure, dated 2018, titled Interdisciplinary Group Membership and Responsibility, "...The interdisciplinary group will:...B. Participate in the periodic review and updating of the plan of care for each patient and family receiving hospice services..." Per the agency's policy and procedure, dated 2009, titled The Plan of Care, "...assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days..." Findings: 1. Per the agency's Plan of Care (POC) for the certification period 7/10/23 through 10/7/23, Patient 2 was admitted to the agency on 7/10/23 with diagnoses to include Parkinson's disease (a nerve and movement disorder). A review of Patient 2's clinical record was conducted on 6/17/24. The first IDG was conducted on 7/10/23, and the second IDG was documented on 8/23/23, 43 days without IDG. 2. Per the agency's Plan of Care (POC) for the certification period 2/7/24 through 4/6/24, Patient 4 was admitted to the agency on 12/9/23 with diagnoses to include heart disease.A review of Patient 4's clinical record was conducted on 6/18/24. The last IDG was conducted on 1/19/24. Patient 4 was discharged from the agency on 3/29/24, which meant there was no documented evidence that the IDG happened during the entire certification period. 3. Per the agency's Plan of Care (POC) for the certification period 1/24/24 through 4/22/24, Patient 6 was admitted to the agency on 1/24/24 with diagnoses to include heart disease. A review of Patient 6's clinical record was conducted on 6/18/24. There was no documented evidence that the IDG meetings were conducted for Patient 6. Patient 6 was discharged on 2/23/24. No IDG happened during the certification period.

Based on interview and record review, the agency failed to complete the home visits per the plan of care for 12 of 14 sampled patients (1, 2, 3, 4, 6, 8, 9, 10, 11, 12, 13, 14 ). As a result, there was a potential for the patients not to receive the care needed. --- 6a. Per the agencys POC for the certification period 4/30/24 through 6/28/24, Patient 8 was admitted to the agency on 7/5/23 with diagnoses to include Parkinson's disease (a nerve and movement disorder). Per the POC, the SN was to visit the patient one time per week. On 6/18/24 a review was conducted of Patient 8s clinical record. There were no documented SN visits on the week of 6/2/24 through 6/8/24. There was no documentation to explain the missed visit. 6b. Per the agencys POC for the certification period 4/30/24 through 6/28/24, Patient 8 was admitted to the agency on 7/5/23 with diagnoses to include Parkinson's disease (a nerve and movement disorder). Per the POC, the HA was to visit the patient three times per week. On 6/18/24 a review was conducted of Patient 8s clinical record. There were no documented HA visits on the week of 6/9/24 through 6/15/24. There was no documentation to explain the missed visits. 7a. Per the agencys POC for the certification period 5/16/23 through 8/13/23, Patient 9 was admitted to the agency on 5/16/23 with diagnoses to include Alzheimers disease (a disorder of physical and mental decline). Per the POC, the HA was to visit the patient three times per week. On 6/18/24 a review was conducted of Patient 9s clinical record. There was documentation of one instead of three HA visits on the week of 5/14/23 through 5/20/23. There was no documentation to explain the missed visits. 7b. Per the agencys POC for the certification period 5/16/23 through 8/13/23, Patient 9 was admitted to the agency on 5/16/23 with diagnoses to include Alzheimers disease (a disorder of physical and mental decline). Per the POC, the Spiritual Counselor (SC) was to visit the patient one time. On 6/18/24 a review was conducted of Patient 9s clinical record. There was no documentation of an SC visit for Patient 9 and there was no documentation to explain the missed visit. 8. Per the agencys POC for the certification period 4/19/24 through 6/17/24, Patient 10 was admitted to the agency on 8/23/23 with diagnoses to include heart disease. Per the POC, the Social Worker (SC) was to visit the patient one time. On 6/18/24 a review was conducted of Patient 10s clinical record. There was no documentation of an SW visit for Patient 10 and there was no documentation to explain the missed visit. 9. Per the agencys POC for the certification period 2/13/24 through 5/12/24, Patient 11 was admitted to the agency on 2/13/24 with diagnoses to include Parkinson's disease (a nerve and movement disorder). Per the POC, the HA was to visit the patient two times per week. On 6/18/24 a review was conducted of Patient 11s clinical record. There were no documented HA visits on the week of 2/11/24 through 2/17/24. There was no documentation to explain the missed visits. 10a. Per the agencys POC for the certification period 2/6/24 through 4/5/24, Patient 12 was admitted to the agency on 2/6/24 with diagnoses to include senile degeneration of brain (brain failure). Per the POC, the SN was to visit the patient one time per week. On 6/18/24 a review was conducted of Patient 12s clinical record. There were no documented SN visits on the week of 2/11/24 through 2/17/24. There was no documentation to explain the missed visit. 10b. Per the agencys POC for the certification period 2/6/24 through 4/5/24, Patient 12 was admitted to the agency on 2/6/24 with diagnoses to include senile degeneration of brain (brain failure). Per the POC, the HA was to visit the patient two times per week. On 6/18/24 a review was conducted of Patient 12s clinical record. There were no documented HA visits on the week of 2/4/24 through 2/10/24. There was no documentation to explain the missed visits. 11a. Per the agencys POC for the certification period 1/9/24 through 4/7/24, Patient 13 was admitted to the agency on 1/9/24 with diagnoses to include heart disease. Per the POC, the SN was to visit the patient one time per week. On 6/18/24 a review was conducted of Patient 13s clinical record. There were no documented SN visits on the weeks of 1/14/24 through 1/20/24 or 2/11/24 through 3/14/24 (six weeks total without SN visits) There was no documentation to explain the missed visits. 11b. Per the agencys POC for the certification period 1/9/24 through 4/7/24, Patient 13 was admitted to the agency on 1/9/24 with diagnoses to include heart disease. Per the POC, the HA was to visit the patient two times per week. On 6/18/24 a review was conducted of Patient 13s clinical record. There were no documented HA visits on the weeks of 1/7/24 through 1/13/24 and 1/14/24 through 1/20/24. On the week of 1/21/24 through 1/27/24 there was only one HA visit instead of two. There was no documentation to explain the missed visits. 12. Per the agencys POC for the certification period 3/7/24 through 6/4/24, Patient 14 was admitted to the agency on 12/8/23 with diagnoses to include heart disease. Per the POC, the HA was to visit the patient three times per week. On 6/18/24 a review was conducted of Patient 14s clinical record. On the week of 3/17/24 through 3/23/24 there was only one HA visit documented instead of three. There was no documentation to explain the missed visits. On 6/19/24 at 10:25 A.M., a joint interview and record review was conducted with the Administrator Designee (AD). The AD confirmed the missed visits. The AD further stated that the staff should have documented the missed visits in the clinical record if they could not follow the order. Per the agency's policy and procedure, dated 2018, titled Missed Visits "...Missed visits will be documented in the clinical record..." Findings: 1. Per the agency's Plan of Care (POC) for the certification period 10/19/23 through 1/16/24, Patient 1 was admitted to the agency on 10/19/23 with diagnoses to include heart disease. Per the POC, the Skilled Nurse (SN) was to visit the patient twice a week. A review of Patient 1's clinical record was conducted. During the week of 10/29/23 through 11/4/23, the SN did not make a visit, and on the week of 11/5/23 through 11/11/23, the SN made only one visit instead of two. There was no documentation about the missed visit in the patient's clinical records. 2. Per the agency's Plan of Care (POC) for the certification period 7/10/23 through 10/7/23, Patient 2 was admitted to the agency on 7/10/23 with diagnoses to include Parkinson's disease (a nerve and movement disorder). Per the POC, the Skilled Nurse (SN) was to visit the patient once a week. A review of Patient 2's clinical record was conducted. The week of:7/16/23 through 7/22/23, 7/23/23 through 7/29/23,8/20/23 through 8/26/23,9/3/23 through 9/9/23,9/17/23 through 9/23/23, and10/1/23 through 10/7/23. The SN made no visit, and there was no documentation about the missed visit. 3. Per the agency's Plan of Care (POC) for the certification period 8/25/23 through 11/22/23, Patient 3 was admitted to the agency on 8/25/23 with diagnoses to include Parkinson's disease (a nerve and movement disorder). Per the POC, the Health Aide (HA) was to visit the patient twice a week. A review of Patient 3's clinical record was conducted. The HA did not visit during the week of 8/27/23 through 9/2/23, and there was no documentation of the missed visit. During the week of 10/22/23 through 10/28/23, the HA made two visits instead of three. 4. Per the agency's Plan of Care (POC) for the certification period 2/7/24 through 4/6/24, Patient 4 was admitted to the agency on 12/9/23 with diagnoses to include heart disease. Per the POC, the Skilled Nurse (SN) was to visit the patient once a week. A review of Patient 4's clinical record was conducted. The week of:2/11/24 through 2/17/24,2/25/24 through 3/1/24,3/10/24 through 3/16/24, and3/17/24 through 3/23/24. The SN made no visits, and there was no documentation of the missed visits. 5a. Per the agency's Plan of Care (POC) for the certification period 1/24/24 through 4/22/24, Patient 6 was admitted to the agency on 1/24/24 with diagnoses to include heart disease. Per the POC, the Skilled Nurse (SN) was to visit the patient once a week. A review of Patient 6's clinical record was conducted. The SN did not make any visits, and there was no documentation of the missed visits. 5b. Per the agency's Plan of Care (POC) for the certification period 1/24/24 through 4/22/24, Patient 6 was admitted to the agency on 1/24/24 with diagnoses to include heart disease. Per the POC, the Health Aide would visit the patient twice weekly. A review of Patient 6's clinical record was conducted. The HA visited the patient once from 2/11/24 through 2/17/24, but there was no documentation of the missed visits.

Based on interview and record review, the agency failed to complete a supervisory visit every 14 days for patients receiving care from a Home Health Aide (HHA) for one of 14 sampled patients (13). As a result, the HHA may have provided inadequate care. --- Findings: Per the agencys Plan of Care for the certification period 1/9/24 through 4/7/24, Patient 13 was admitted to the agency on 1/9/24 with diagnoses to include heart disease. On 6/19/24 at 10:20 A.M., an interview and record review was conducted with the Administrator Designee (AD). The HHA visits were provided to Patient 13 from 2/7/24 through 3/13/24. The last documented supervisory visit was on 2/6/24 (30 days before the last HHA visit.) The AD stated, a supervisory visit should have been completed every 14 days. Per the facilitys policy, titled Responsibilities/Supervision of Clinical Services, dated 2018, ";...Hospice aide supervisory visits will be conducted on-site at least every 14 days by a hospice registered nurse..."

Based on interview and record review, the agency failed to ensure the volunteer services provided a minimum of five percent of the total patient care hours of all paid hospice employees and contracted staff for five of the 12 months reviewed. As a result, there was a potential for the volunteer service to not be available for the patients, families, and hospice program's needs. --- On 6/19/24 a review was conducted of the Agency's Volunteer Savings Report dated from May 2023 through May 2024. The months of 7/23, 8/23, 10/23, 1/24, and 6/24, indicated that the volunteer hours were less than five percent of the total patient care hours. On 6/19/24 at 10:50 A.M., an interview and record review were conducted with the Administrator Designed (AD). The AD stated the volunteer hours needed to meet the requirement. The agency could not provide a policy for volunteer hours.

Based on interview and record review, the agency failed to ensure the clinical records were complete, authenticated, and dated for 11 of 14 sampled patients (1, 2, 3, 4, 8, 9, 10, 11, 12, 13, 14). As a result, there was a potential for patient care records to be uncompleted and missing patient information. --- 5. Per the agencys POC for the certification period 4/30/24 through 6/28/24, Patient 8 was admitted to the agency on 7/5/23 with diagnoses to include Parkinson's disease (a nerve and movement disorder). The POC was not signed by the physician. On 6/18/24 a review was conducted of Patient 8s clinical record. All Skilled Nurse (SN) notes during the certification period were unsigned. The SN was not available for interview. 6. Per the agencys POC for the certification period 5/16/23 through 8/13/23, Patient 9 was admitted to the agency on 5/16/23 with diagnoses to include Alzheimers disease (a disorder of physical and mental decline). The POC was not signed by the physician. 7. Per the agencys POC for the certification period 4/19/24 through 6/17/24, Patient 10 was admitted to the agency on 8/23/23 with diagnoses to include heart disease. The POC was not signed by the physician. On 6/18/24 a review was conducted of Patient 10s clinical record. SN notes were unsigned for the dates of 3/12/24, 3/26, 4/30, 5/7, 5/14, 5/15, 5/21, and 5/30. The SN was not available for interview. 8. Per the agencys POC for the certification period 2/13/24 through 5/12/24, Patient 11 was admitted to the agency on 2/13/24 with diagnoses to include Parkinson's disease (a nerve and movement disorder). The POC was not signed by the physician. On 6/18/24 a review was conducted of Patient 11s clinical record. Social Worker (SW) notes were unsigned for the dates 2/26/24 and 3/15. All SN notes were unsigned from 2/23/24 through 4/1. Health Aide (HA) notes were unsigned on 3/5/24, 3/8, 3/12, 3/22, 3/26, and 3/29. The SW, SN, and HA were not available for interview. 9. Per the agencys POC for the certification period 2/6/24 through 4/5/24, Patient 12 was admitted to the agency on 2/6/24 with diagnoses to include senile degeneration of brain (brain failure). The POC was not signed by the physician. On 6/18/24 a review was conducted of Patient 12s clinical record. SN notes were unsigned for the dates 2/20/24, 3/1, 3/6, and 3/13. The SN was not available for interview. 10. Per the agencys POC for the certification period 1/9/24 through 4/7/24, Patient 13 was admitted to the agency on 1/9/24 with diagnoses to include heart disease. The POC was not signed by the physician. On 6/18/24 a review was conducted of Patient 13s clinical record. A SW visit note was unsigned for the date 1/11/24. SN notes were unsigned for the dates 2/2/24 and 2/6. The SW and SN were not available for interview. 11. Per the agencys POC for the certification period 3/7/24 through 6/4/24, Patient 14 was admitted to the agency on 12/8/23 with diagnoses to include heart disease. The POC was not signed by the physician. On 6/18/24 a review was conducted of Patient 14s clinical record. An HA note was unsigned for the date 3/18/24. The HA was not available for interview. On 6/19/24 at 10:20 A.M., a joint interview and record review was conducted with the Administrator Designee (AD). The AD stated many signatures and dates in the patient's medical record were not completed. The AD further stated the clinical record should have been complete and signed.Per the agency's policy and procedure, dated 4/21, titled Clinical/Service Data Collection, "...Signature authorization of clinical/service documentation will include the staff member's name and credentials...All entries will reflect the date care was provided, including the month, day, year..." Findings:1. Per the agency's Plan of Care (POC) for the certification period 10/19/23 through 1/16/24, Patient 1 was admitted to the agency on 10/19/23 with diagnoses to include heart disease. A record review of Patient 1's clinical record was conducted on 6/17/24. The following visit notes were not signed and dated by the skilled nurses to indicate the completion of hospice service on 10/23/23, 10/24/23, 10/25/23, 10/27/23, 10/28/23, 10/30/23. 11/8/23. 11/10/23, and 11/13/23. The skilled nurses were not available for interviews. 2a. Per the agency's Plan of Care (POC) for the certification period 7/10/23 through 10/7/23, Patient 2 was admitted to the agency on 7/10/23 with diagnoses to include Parkinson's disease (a nerve and movement disorder). A record review of Patient 2's clinical record was conducted on 6/17/24. The medical social worker did not sign and date the following Psychosocial Assessment notes conducted on 7/14/23 and 10/1/23. 2b. Per the agency's Plan of Care (POC) for the certification period 7/10/23 through 10/7/23, Patient 2 was admitted to the agency on 7/10/23 with diagnoses to include Parkinson's disease (a nerve and movement disorder). A record review of Patient 2's clinical record was conducted on 6/17/24. The following visit notes were not signed and dated by the skilled nurses to indicate the completion of hospice service on 10/28/23, 10/30/23, 11/4/23, 11/9/23, 11/11/23, 11/12/23, 11/13/24, and 11/14/23. The medical social worker and the skilled nurses were not available for interview. 3. Per the agency's Plan of Care (POC) for the certification period 8/25/23 through 11/22/23, Patient 3 was admitted to the agency on 8/25/23 with diagnoses to include Parkinson's disease (a nerve and movement disorder). A record review of Patient 3's clinical record was conducted on 6/18/24. The skilled nurse did not sign and date the discharge summary note. The skilled nurse was not available for the interview. 4. Per the agency's Plan of Care (POC) for the certification period 2/7/24 through 4/6/24, Patient 4 was admitted to the agency on 12/9/23 with diagnoses to include heart disease.A record review of Patient 4's clinical record was conducted on 6/18/24. The skilled nurse did not sign and date the discharge summary note. The skilled nurse was not available for the interview.

Based on interview and record review, the agency failed to ensure the discharge summary was complete and accurate, and to make attempts at resolution before discharging a patient for non-compliance for two of 14 sampled patients (6, 13). As a result, there was a potential for an inability to provide continuity of care, and discharging a patient who still needed services. --- 2. Per the agencys Plan of Care for the certification period 1/9/24 through 4/7/24, Patient 13 was admitted to the agency on 1/9/24 with diagnoses to include heart disease. Per the agencys Discharge Summary for Patient 13, dated 3/14/24, ";...Patient was Revocated from Hospice on 03/14/2024. Patient was non-compliant with Plan of care and treatment..." The document did not explain what Patient 13 was non-compliant with or if any attempts were made to resolve the problem. On 6/19/24 at 9:55 A.M., an interview was conducted with the Director of Patient Care Services Designee (DPCSD). The DPCSD stated, Patient 13 was discharged due to staff being unable to conduct visits, but the staff did not document when those situations occurred. The agency did not have a policy on discharging for cause. Findings:1. Per the agency's Plan of Care (POC) for the certification period 1/24/24 through 4/22/24, Patient 6 was admitted to the agency on 1/24/24 with diagnoses to include heart disease.On 6/17/24, a review of the agency's discharge list was conducted. Per the discharge list, Patient 6 revoked (patient chose to stop) hospice service on 2/23/24. There was no documented evidence that Patient 6 revoked hospice service. Per the Discharge Summary, "...it was discussed during IDG [interdisciplinary group] that patient will be discharge due to improvement of clinical status...] The document was not signed or dated. On 6/19/24 at 10:50 A.M., an interview was conducted with the Administrator Designee (AD). The discharge summary should be accurate, signed, and dated. Per the agency's policy and procedure, dated 2009, titled Clinical/Service Data Collection, "...Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided..."

Based on interview and record review, the agency failed to treat the hallucinations of one of two sampled patients (1). As a result, Patient 1 was at risk of increased distress. --- Findings: Per the agencys Comprehensive Nursing Assessment, dated 5/16/23, Patient 1 was admitted with diagnosis of Alzheimers disease (a mental and physical decline), she was having hallucinations, and, ";...I have discussed patients status with the Physician...the Physician has issued an order to admit this patient to hospice..." Per the agencys POC (Plan of Care) Summary, signed 6/19/23, Patient 1 had an order on 5/16/23 (the day of admission) for CBD (a medication derived from marijuana). Per the agencys undated Communication Log, there was a note on 7/25/23, ";...Informed (Patient 1s Responsible Party) the doctor said he will not place her on loreazpam (a medication for anxiety), Haldol (a medication to treat hallucinations). She will need to be off CBD..." Per the agencys Visit Note RN (Registered Nurse) dated 7/26/23, ";...Per the caregivers (Patient 1) is still hallucinating...Had conversation with (Patient 1s responsible party) concerning adding medication for hallucination...She wants to keep (Patient 1) on CBD medication...The decision was the patient had to come off CBD...(Patient 1s responsible party) adamant or not starting new pain regimen. Informed her nothing can be given for anxiety. Still not happy with this decision..." On 1/11/24 at 2:45 P.M., a telephone interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated, the agencys Medical Director (MD) was not comfortable treating patients who took CBD, and the agency should not have admitted Patient 1 because she was taking CBD. The DPCS further stated, once Patient 1 developed hallucinations, the MD said they would not treat Patient 1s symptoms unless they stopped taking CBD. On 2/26/24 at 4 P.M., a telephone interview was conducted with the Medical Director (MD). The MD stated, he was not comfortable treating patients who took CBD because he was not familiar with how it could interact with other medications. The MD further stated, he did not know Patient 1 was taking CBD at the time of admission, and the agency should not have admitted Patient 1 for that reason. The agency did not have a policy to restrict admissions for patients who take CBD.