Every finding on record at Mary of Joy Hospice, Inc.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed for patients that revoked the hospice benefit revealed the agency did not ensure a copy of the hospice discharge summary had been forwarded to the patient's attending physician. CLINICAL RECORD 6: The patient called for a revocation of the hospice benefit on 05/14/2025 to pursue a scheduled surgery. The record lacked evidence that the agency forwarded the hospice discharge summary to the patient's attending physician. CLINICAL RECORD 7: The patient's daughter called for a revocation of the patient hospice benefit on 01/10/2025 because the patient was deemed to be an unlawful resident. The record lacked evidence that the agency forwarded the hospice discharge summary to the patient's attending physician. The Administrator and Administrator Designee/Director of Patient Care Services/Registered Nurse/Volunteer Coordinator stated in an interview while performing joint clinical record reviews on 02/05/2026 that they both agreed the clinical records for the patients that revoked the hospice benefit were missing the evidence that showed the discharge summary had been forwarded to the patient's attending physician.

Upon patient record review, 3 of 11 (Patient #2,#5,#7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2: The patient is no longer taking cipro eye drops ordered 11/33/22 for 7 days, Bactroban for wound care ordered 9/22/22, Santyl for wound care ordered 11/4/22, and Calmoseptine ordered 8/16/22 and these remained on the medication profile. Patient #5: The patient is taking Aleve for pain management. The medication profile did not include Aleve as a medication the patient was taking. Patient #7: The patient is no longer taking diclofenac sodium, docusate, ferrous sulfate, and Olanzapine 5mg, and these remain on the medication profile. There is documentation from a face to face by the physician dated 12/13/22 to increase the Olanzapine to 10 mg, the medication profile does not reflect the change in dosage.

Upon patient record review, 1 of 11 (Patient #5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #5: The patient was admitted on 5/2/22. There was no evidence of a bereavement risk assessment at the time of survey.

Upon patient record review, 1 of 11 (Patient #8) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #8: The medical record contained documentation on 11/25/22 that the caregiver called the nurse to report "blood in the patient's diaper". The medical record did not contain evidence of an assessment by the nurse.

Upon patient record review, 2 of 11 (Patient 5, 10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/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. Patient #5: The medical record contained documentation on the comprehensive assessment and the updated comprehensive assessment visit notes that the patient is depressed and continues to have depression at the time of survey. The patient has been on Lexapro 5 mg daily since 5/2/22 with no updates to the plan of care to manage depression. Patient #10: The plan of care did not include any problems, goals, and interventions initiated or updates on the plan of care review for dates 4/20/22, 5/4/22, and 5/18/22. For each of these they were blank, no problems for nursing spiritual care, or psychosocial.

Upon patient record review, 2 of 11 (Patient #5,#7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #5: There is documentation in the medical record that the patient is taking Aleve for pain. The medical record did not contain evidence of an order for Aleve. Patient #7: There is documentation from a face to face by the physician dated 12/13/22 to increase the Olanzapine to 10 mg. There is no physician order to increase Olanzapine 10 mg by mouth at bedtime.

Upon patient record review, 5 of 11 (Patient #3,#5,#6,#8,#10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #3: The medical record contained documentation on 12/7/22 that the patient had a hospital bed and was up in the wheelchair. No evidence of an order for the DME. Patient #5: The medical record contained documentation that the patient had a wheelchair and rollator walker in the home. No evidence of an order for the DME. Patient #6: The medical record contained documentation on 12/16/22 that the patient was waiting for ted hose to be delivered. No evidence of an order for TED hose. Patient #8: The medical record contained ongoing documentation that the patient uses a crutch for assistance with ambulating. No evidence of an order for the DME. Patient #10: The medical record contained documentation on 4/13/22 that the patient uses a walker for ambulation. No evidence of an order for the DME.

Upon client record review, 1 of 11 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8: The medical record contains documentation on the plan of care that the RN visit frequency will be 1 visit every 14 days. The medical record did not contain evidence of RN visits from 9/27/22-10/25/22 and 10/27/22-11/18/22.

Upon patient record review 1 of 12 (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3: The aide visit frequency was indicated at 2x/week. The week of 11/27/22-12/3/22, the aide only visited once on 11/29/22 and the week of 12/4/22-12/10/22 the aide only visited once on 12/8/22.

Upon patient client record review, 1 of 11 (Patient #3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #3: The Hospice Medicare Election statement does not have a signature by the patient or the patient's representative. The signature line is blank.

Upon patient client record review, 4 of 11 (Patient #1,#3,#4,#10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: Documentation on the plan of care dated 12/14/22 and the update to the comprehensive assessment dated 12/8/22 did not contain signatures by the registered nurse. Patient #3: Documentation on the update to the comprehensive assessment dated 11/9/22 did not contain a signature by the nurse. There is documentation by the physician that the patient was using antibiotics for a UTI. Upon staff interview the nurse stated the physician documented on the wrong patient and provided evidence of orders for the correct patient. Patient #4: Documentation on the plan of care dated 12/14/22 and the update to the comprehensive assessment dated 12/7/22 did not contain signatures by the nurse. Patient #10: Documentation on the nursing comprehensive assessment dated 4/13/22 did not contain a signature by the registered nurse.