Every finding on record at Morning Calm Hospice Inc

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 5(40%) clinical records reviewed, with aide services provided, revealed the agency did not ensure the RN provided the hospice aides with specific written patient care instructions. CONTINUING PRIOR REQUIRED ACTION. Clinical Record 3: The patient elected hospice benefit on 10/03/2024, with a diagnosis of malignant neoplasm of unspecified part of right bronchus or lung. The aide care plan dated 10/03/2024, by the RN, included the frequency of PRN (as needed) for the task of assist with bedpan, assist with feeding, and to change linen when necessary. The "PRN" task frequency assigned was not specific. Clinical Record 4: The patient elected hospice benefit on 07/31/2024, with a diagnosis of senile degeneration of brain. The aide care plan dated 07/31/2024 by the RN included the frequency of PRN for the task of feeding assist. The "PRN" task frequency assigned was not specific. During an interview on 10/07/2024, the DON stated the PRN task frequencies were not specific and have since been corrected. CONTINUING PRIOR REQUIRED ACTION.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the drug profile contained the patient's current prescription and over the counter drugs. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 10/03/2023, with a terminal diagnosis of pulmonary fibrosis. During the home visit observation with the Registered Nurse, the patient was observed using oxygen at 5 liters per minute via nasal cannula. Oxygen was not included on the plan of care and medication profile dated 10/03/2023, as of the date of the home visit and record review on 10/24/2023. During an interview on 10/26/2023, the Alternate Director of Patient Care Services reviewed the associated records and stated oxygen had inadvertently been excluded from the medication profile and had since been added.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. Clinical Record 2: The patient elected the hospice benefit on 04/30/2023, with a terminal diagnosis of Parkinson’s disease. Clinical record review revealed the initial bereavement assessment was dated 09/12/2023 and was not completed as part of the initial comprehensive assessment at the start of care. Clinical Record 4: The patient elected the hospice benefit on 09/21/2023, with a terminal diagnosis of congestive heart failure. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed as part of the comprehensive assessment at the start of care, as of the date of record review on 10/25/2023. During an interview on 10/26/2023, the Alternate Director of Patient Care Services reviewed the associated records and stated that the missing documentation was inadvertently missed at start of care and had since been completed.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the individualized plan of care included a detailed statement of the scope and frequency of services provided. Clinical Record 6: The patient elected the hospice benefit on 05/05/2023, with a terminal diagnosis of Lupus. The hospice plan of care dated 10/02/2023 included a visit frequency order that stated, MSW [medical social worker] 3 prn [as needed] visits and SC [spiritual counselor] 1 prn. The plan of care did not include routine visit orders for the MSW or SC. During an interview on 10/26/2023, the Alternate Director of Patient Care Services reviewed the associated record and stated that the frequency should have read monthly in addition to the prn visits and had since been corrected.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, observation, and interview. In 8 of 19 (42%) clinical records reviewed, the agency did not ensure the individualized written plan of care included drugs and treatments necessary to meet the needs of the patient. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 10/03/2023, with a terminal diagnosis of pulmonary fibrosis. During the home visit observation with the Registered Nurse (RN), the patient was observed using oxygen at 5 liters per minute via nasal cannula. The hospice plan of care dated 10/03/2023 did not include an order for oxygen. Clinical Record 4/Home Visit 4: The patient elected the hospice benefit on 09/21/2023, with a terminal diagnosis of congestive heart failure. During the home visit observation with the Social Worker, the caregiver stated the patient had a catheter. The hospice plan of care dated 09/21/2023 and the comprehensive assessment dated 09/21/2023 included documentation that the patient experienced urinary incontinence. The Licensed Practical Nurse documented the patient had a foley catheter for urinary elimination on skilled nurse visit notes dated 10/10/2023, 10/13/2023 and 10/17/2023 nursing. The interdisciplinary team meeting dated 10/11/2023 included documentation that stated, “patient has a foley catheter and plan of care updated.” The hospice plan of care /updates to the plan of care did not include an order for the foley catheter or catheter care, as of the date of record review on 10/24/2023. Clinical Record 7: The patient elected the hospice benefit on 07/30/2023, with a terminal diagnosis of respiratory failure. The hospice plan of care dated 07/30/2023 included an order that stated, “Hospice nurse to insert/maintain indwelling catheter 16Fr 10cc balloon, may irrigate with 40 cc, change catheter every 30 days as needed.” The order did not include the type of solution to be used to irrigate the catheter, how often the catheter should be irrigated, and did not include directions or parameters for when to insert the catheter for the “as needed” order. Clinical Record 11: The patient elected the hospice benefit on 07/03/2023, with a terminal diagnosis of prostate cancer. The Registered Nurse entered a physician’s verbal order dated 10/03/2023 that stated, “SN [skilled nurse] irrigate wound with 30cc NS [normal saline], pat dry with sterile gauze, apply crushed Flagyl and place Medihoney on wound, cover with Mepilex dressing. Perform wound care 2 times/week.” The order did not include the location of the wound. On the comprehensive assessment dated 07/03/2023 the Registered Nurse documented the patient had a 16Fr suprapubic foley catheter. The hospice plan of care did not include orders related to a suprapubic foley. Clinical Record 15: The patient elected the hospice benefit on 06/01/2023, with a terminal diagnosis of Parkinson’s disease. The hospice plan of care dated 06/01/2023 included an order that stated, “Hospice nurse to insert/maintain indwelling catheter 18Fr 10cc balloon, may irrigate with 5-10 cc, change catheter every 30 days or as needed.” The order did not include the type of solution to be used to irrigate the catheter, how often the catheter should be irrigated, and did not include directions or parameters for when to insert the catheter for the “as needed” order. The hospice plan of care also included an order that stated, “Hospice nurse to perform wound care to right buttock stage IV pressure wound utilizing clean technique cleanse with wound cleanser, pat dry, insert wet gauze with normal saline into wound, cover with Hydrofera blue 4x4 foam dressing, change every visit and prn [as needed].” The wound care order did not include directions or parameters for when to provide the “as needed” wound care. Clinical Record 16: The patient elected the hospice benefit on 09/06/2023, with a terminal diagnosis of lymphoma. The hospice plan of care dated 09/06/2023 included an order that stated, “Hospice nurse to insert/maintain indwelling catheter 18Fr 10cc balloon, may irrigate with 5-10 cc, change catheter every 30 days or as needed.” The order did not include the type of solution to be used to irrigate the catheter, how often the catheter should be irrigated, and did not include directions or parameters for when to insert the catheter for the “as needed” order. Clinical Record 18: The patient elected the hospice benefit on 09/06/2023, with a terminal diagnosis of protein calorie malnutrition. The Registered Nurse documented on the comprehensive assessment dated 08/02/2023 that the patient had a feeding (PEG-percutaneous endoscopic gastrostomy) tube. The hospice plan of care dated 08/02/2023 did not include orders related to PEG tube care. Clinical Record 19: The patient elected the hospice benefit on 06/02/2023, with a terminal diagnosis of senile degeneration of the brain. The hospice plan of care dated 06/02/2023 included an order that stated, “hospice nurse to monitor and perform wound care to 1 cm scabbed stage 1 wound to coccyx utilizing clean technique cleanse with wound cleanser and leave OTA [open to air] if wound does not digress, change/monitor every visit and prn [as needed].” The wound care order did not include directions or parameters for when to provide the “as needed” wound care. During an interview on 10/26/2023, the Alternate Director of Patient Care Services reviewed the associated records and stated that the care plans have since been corrected.

It is required that the policies and procedures ensure that care and services provided are in accordance with the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that care and services were provided in accordance with the plan of care. Clinical Record 19: The patient elected the hospice benefit on 06/02/2023, with a terminal diagnosis of senile degeneration of the brain. The plan of care dated 06/02/2023 included an order for skilled nursing (SN) visit frequency that stated SN three times a week for one week, then twice a week for twelve weeks. Clinical record review revealed two SN visits were completed for week 1, the week of 06/02/2023. SN visit notes were dated 06/02/2023 and 06/03/2023. The clinical record contained no documented evidence to explain why services were not provided as per the ordered frequency. During an interview on 10/26/2023, the Alternate Director of Patient Care Services reviewed the associated record and stated the missed visit entry had since been completed.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed with aide services provided, the agency did not ensure the written patient care instructions included patient specific care instructions for the hospice aide. Clinical Record 11: The patient elected the hospice benefit on 07/03/2023, with a terminal diagnosis of prostate cancer. On the comprehensive assessment dated 07/03/2023 the RN documented the patient had a suprapubic catheter. The hospice aide plan of care instructions did not include instructions or precautions related to the patient’s suprapubic catheter. The clinical record included a physician order dated 10/03/2023 for the skilled nurse (SN) to provide wound care to the patient. The order stated, “SN irrigate wound with 30 cc NS [normal saline], pat dry with sterile gauze, apply crushed Flagyl and place Medihoney on wound, cover with Mepilex dressing, perform wound care two times per week.” The aide plan of care instructions did not include instructions or precautions for the aide related to how to care for the patient’s wound and wound dressing while providing care to the patient. The aide plan of care instructions assigned the tasks of bed bath, perineal care, and skin care but did not include the frequency the aide should provide the tasks. During an interview on 10/26/2023, the Alternate Director of Patient Care Services reviewed the associated record and stated the aide instructions had inadvertently been omitted form the aide assignment and had since been corrected.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 12 of 19 (63%) clinical records reviewed with aide services provided, the agency did not ensure the hospice aide provided services as ordered by the Interdisciplinary Group and included in the plan of care. Clinical Record 1: The patient elected the hospice benefit on 10/03/2023, with a terminal diagnosis of pulmonary fibrosis. The 10/10/2023 aide care plan instructions created by the Registered Nurse (RN) assigned the task to obtain the patient’s weight weekly. Review of the aide visit notes dated 10/16/2023 and 10/20/2023 revealed the aide obtained the patient’s weight at both visits for the week of 10/16/2023. Clinical Record 2: The patient elected the hospice benefit on 04/30/2023, with a terminal diagnosis of Parkinson’s disease. The hospice plan of care dated 09/27/2023 included an order for aide frequency three times a week for one week, then five times a week for eight weeks. The week of 10/09/2023, the aide provided four visits dated 10/09/2023, 10/10/2023, 10/11/2023 and 10/12/2023. The clinical record contained no documented evidence to explain why 5 aide visits were not completed as ordered for the week. On the aide care plan instructions dated 05/05/2023 the RN assigned the tasks of ear care, foot care, nail care, shampoo, and linen change to be provided weekly. The RN also assigned showers on Monday, Wednesday, Friday, and bath Tuesday and Thursday. The aide visits dated 10/02/2023 through 10/06/2023 included documentation that ear care, foot care, nail care, and linen change was completed at each visit and not weekly as assigned. The aide visits dated 10/02/2023, 10/04/2023 and 10/06/2023 included documentation that patient shampoo completed at each visit and not weekly as assigned. The aide visit note dated 10/06/2023 documented a bath on Friday when a shower was assigned. Clinical Record 4: The patient elected the hospice benefit on 09/21/2023, with a terminal diagnosis of congestive heart failure. The hospice plan of care dated 09/21/2023 included an order for aide frequency of visits once a week for one week, then three times a week for 12 weeks. Clinical record review revealed two aide visits were completed the week of 10/09/2023 on 10/09/2023 and 10/11/2023. There was no documented evidence of a missed visit or explanation of why aide services were not provided three times per week as ordered. On the aide care plan instructions dated 09/21/2023 the RN assigned the tasks of shower and shampoo weekly. The aide visits dated 09/25/2023 through 10/20/2023 included completion of shower and shampoo at each visit and not weekly as assigned. Clinical Record 5: The patient elected the hospice benefit on 09/17/2023, with a terminal diagnosis of cerebral artery occlusion. On the aide care plan instructions dated 09/17/2023 the RN assigned shampoo three times per week. The aide visits dated 09/18/2023 through 10/20/2023 documented a shampoo was completed at each visit and not three times a week as assigned. Clinical Record 6: The patient elected the hospice benefit on 05/05/2023, with terminal diagnosis of Lupus. On the aide care plan instructions dated 10/02/2023 the RN assigned foot care, nail care, and shampoo weekly. The aide visits dated 10/02/2023 through 10/19/2023 documented foot care, nail care and shampoo were completed at each visit and not weekly as assigned. Clinical Record 9: The patient elected the hospice benefit on 04/04/2023, with a terminal diagnosis of Pulmonary Fibrosis. On the aide care plan instructions dated 10/01/2023 the RN assigned nail care weekly. The aide visits dated 10/02/2023 through 10/20/2023 documented that nail care was completed at each visit and not weekly as assigned. Clinical Record 10: The patient elected the hospice benefit on 09/20/2023, with a terminal diagnosis of Pulmonary Fibrosis. The hospice plan of care dated 09/20/2023 included an order for aide frequency two times a week for one week, then five times a week for eight weeks. The week of 09/22/2023, the aide provided one visit dated 09/22/2023. The clinical record contained no documentation to explain why 2 aide visits were not completed for the week as ordered. Clinical Record 11: The patient elected the hospice benefit on 07/03/2023, with a terminal diagnosis of prostate cancer. On the aide care plan instructions dated 10/01/2023 the RN assigned linen change and shampoo weekly. The aide visits dated 10/09/2023 through 10/19/2023 documented linen change and shampoo were completed at each visit and not weekly as assigned. Clinical Record 13: The patient elected the hospice benefit on 09/19/2023, with a terminal diagnosis of acute kidney failure. On the aide care plan instructions dated 09/19/2023 the RN assigned nail care weekly. The aide visits dated 09/20/2023 through 10/20/2023 documented nail care was completed at each visit and not weekly as assigned. Clinical Record 14: The patient elected the hospice benefit on 07/31/2023, with a terminal diagnosis of congestive heart failure. On the aide care plan instructions dated 07/31/2023 the RN assigned nail care and shampoo weekly. The aide visits dated 07/31/2023 through 10/20/2023 documented nail care and shampoo were completed at each visit and not weekly as assigned. Clinical Record 18: The patient elected the hospice benefit on 08/02/2023, with a terminal diagnosis of protein calorie malnutrition. On the aide care plan instructions dated 08/02/2023 the RN assigned nail care weekly. The aide visits dated 08/07/2023 through 09/01/2023 documented nail care was completed at each visit and not weekly as assigned. Clinical Record 19: The patient elected the hospice benefit on 06/02/2023, with a terminal diagnosis of senile degeneration of the brain. The hospice plan of care dated 06/02/2023 included an order for aide frequency of visits once a week for one week, then three times a week for 12 weeks. Clinical record review revealed no documented evidence of an aide visit for the week of 06/02/2023 and no documentation of a missed visit. During an interview on 10/26/2023, the Alternate Director of Patient Care Services reviewed the associated records and stated further education was needed for nurses and aides regarding care planning, following the care plan and missed visit documentation.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed with aide services provided, the agency did not ensure a Registered Nurse made an on-site aide supervisory visit to the patient’s home every 14 days. Clinical Record 9: The patient elected the hospice benefit on 04/04/2023, with a terminal diagnosis of Pulmonary Fibrosis. The Registered Nurse documented a Hospice Aide supervisory visit on 10/06/2023, the next supervisory visit was dated 10/25/2023, 19 days after the 10/06/2023 supervisory visit. The RN did not document aide supervisory visits every 14 days. During an interview on 10/26/2023, the Alternate Director of Patient Care Services reviewed the associated record and stated that the supervisory visit was inadvertently made outside of the 14-day requirement and remedial education would be provided to staff.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review and interview. In 6 of 19 (32%) clinical records reviewed, the agency did not ensure that entries in the patient record were appropriately authenticated and dated by the person performing the care/service. Clinical Record 4: Review of the Hospice Aide visit note dated 10/16/2023 revealed the note was signed and dated by the aide but did not include the aide’s credentials with the signature. Clinical Record 5: Review of the Hospice Aide visit notes dated 10/05/2023 and 10/13/2023 revealed the notes were signed and dated by the aide but did not include the aide’s credentials with the signatures. The 10/12/2023 aide visit note included the credentials and date but did not include a signature of the aide who completed the documentation. Clinical Record 8: Review of the Hospice Aide visit notes dated 08/24/2023, 09/05/2023, and 09/07/2023 revealed the notes were signed and dated by the aide but did not include the aide’s credentials with the signatures. Clinical Record 14: Review of the Hospice Aide visit note dated 10/05/2023 revealed the note was signed and dated by the aide but did not include the aide’s credentials with the signatures. The 10/12/2023 and 10/13/2023 aide visit notes included the credentials and date but did not include a signature of the aide who completed the documentation. Clinical Record 17: The 08/12/2023 aide visit note included the credentials and date of the aide that completed the visit but did not include the signature of the aide. Clinical Record 19: The 06/19/2023 aide visit note included the credentials and date of the aide that completed the visit but did not include the signature of the aide. During an interview on 10/26/2023, the Alternate Director of Patient Care Services reviewed the associated records and stated the signatures and credentials had since been corrected.

It is required that the hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed for patients that reside in a skilled nursing facility (SNF), the agency did not ensure the hospice plan of care specified which provider was responsible for performing the functions that are agreed upon and included in the plan of care. Clinical Record 5: The patient elected the hospice benefit on 09/17/2023, with a terminal diagnosis of cerebral artery occlusion. The nursing visit notes dated 09/18/2023 through 10/20/2023 included documentation that the patient resided in a SNF. The plan of care dated 09/17/2023 and the updated plans of care dated 09/20/2023, 10/04/2023, and 10/18/2023 contained no documented evidence specifying which provider, the hospice, or the facility, was responsible for performing the functions of care provided to the patient. Clinical Record 15: The patient elected the hospice benefit on 06/01/2023, with a terminal diagnosis of Parkinson’s disease. The Registered Nurse documented on the comprehensive assessment dated 06/01/2023 that the patient resided in a SNF. The plan of care dated 06/01/2023 and the updated plans of care dated 06/14/2023 and 06/28/2023 contained no documented evidence specifying which provider, the hospice, or the facility, was responsible for performing the functions of care provided to the patient. During an interview on 10/26/2023, the Alternate Director of Patient Care Services reviewed the associated records and was unable to located delineation of care form the agency utilizes to document care assignments provided to patient’s that reside in a facility.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial comprehensive assessments and intervention to manage pain and symptoms. measurable outcomes anticipated from implementing and coordinating the plan of care. THIS IS A CONTINUED PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure all problems, interventions, and measurable outcomes were included in the Plan of Care. Clinical Record 4: The initial Plan of Care dated 10/13/2022-11/10/2022 listed a primary diagnosis of Chronic Systolic Congestive Heart Failure. There was no documented evidence that the Plan of Care included all problems, interventions, and treatments based on the initial comprehensive assessment dated 10/13/2022. The Initial Comprehensive Assessment and the Admitting Diagnosis listed the reason for the terminal illness as Congestive Heart Failure. There was no documented evidence of any Congestive Heart Failure, cardiac-related interventions, or patient/family goals identified on the Plan of Care. The Director of Nurses stated on 12/2/2022, " there are no interventions or goals for congestive heart failure." THIS IS A CONTINUED REQUIRED ACTION

It is required that Hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure the aide reported changes to the Registered Nurse related to changes in patient needs. Clinical Record 1: EOB 10/29/2022. Hospice Aide Care Plan dated 10/29/2022, Under the Section titled “Interventions- Personal Care Oral Hygiene Denture Care stated this task was to be done every visit. Under the Section titled, “Activity” Assist with ambulation and Assist in Transfer stated this was to be done every visit. The Section titled “Additional Comments” stated "Notify RN if patient refuses care/no personal care provided per family/caregiver request. Notify Facility Nurse/Caregiver if no care provided. Notify RN for no BM longer than 3 days. Notify RN for any changes with the patient". The aide documented on visits 11/3/2022 and 11/17/2022 the patient declined Oral Hygiene. There was no documented evidence in the chart, the RN was notified. The aide documented on visits dated 11/15/2022 and 11/22/2022 the patient declined assist with ambulation/transfer. There was no documented evidence in the chart the RN was notified. During joint record review with the Director of Nurses (DON) on 12/2/2022, the DON stated, “the aide didn’t notify the RN when the patient declined the task assigned.” Clinical Record 3: EOB 8/10/22 Hospice Aide Care Plan dated 8/10/22, Under the Section titled “Interventions- Personal Care Shave, Oral Hygiene, stated this task was to be done every visit. Under the Section titled, “Household” change linen and make bed stated these were to be done every visit. The Section titled “Additional Comments” stated "Notify RN if patient refuses care/no personal care provided per family/caregiver request. Notify Facility Nurse/Caregiver if no care provided. Notify RN for no BM longer than 3 days. Notify RN for any changes with the patient." The Aide documented on visits dated 8/24/2022, 8/26/2022, 9/2/2022, 9/12/2022, 9/19/22, 9/23/2022 and 9/26/2022, the patient declined a shave. Documentation for aide visit on 9/6/2022, states, " the patient declined the linen change and making bed." Documentation for aide visits 9/19/2022, 9/26/2022, 9/28/2022, 9/30/2022, and 10/13/2022 the patient declined linen change. There is no documented evidence in the chart the aide notified the RN when the patient declined a shave, linen change or making of the bed. During joint record review with the Director of Nurses (DON) on 12/2/22, the DON stated, “the aide didn’t notify the RN when the patient refused the task assigned."

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, or the patient's record if requested. This standard was not met, as evidenced by a review of clinical records and interviews. In 1 of 2 (50%) patients revoked hospice services and were discharged from the agency, the Agency did not ensure the Discharge Summary was sent to the attending physician. Clinical Record 5: Election of Hospice Benefit was signed on 9/29/2022. The primary Hospice Diagnosis was Chronic Obstructive Pulmonary Disease; the Co-morbidity diagnosis was End Stage Renal Disease. The Discharge note dated 10/6/2022 stated, "the patient's daughter called the Hospice Agency to inform the Agency she took her mother to the hospital to receive dialysis." The Revocation Statement signed by the daughter was dated 10/6/2022. The Discharge Summary had a "faxed stamp," but there was no documented evidence as to whom the Discharge Summary was faxed. During the joint record review with the Director of Nurses, they stated, "it doesn't show who the fax was sent to." THIS IS A CONTINUED REQUIRED ACTION