Every finding on record at N S I Hospice, L L C

Based on record review and interview, the agency failed to maintain a system of communication to ensure that coordination of care was provided as evidenced by the SN (skilled nurse) failing to inform the physician of changes in a patient’s condition for 1 (#3) out of 14 (#1- #14) sampled patients. --- Patient #3.  Review of the patient’s electronic clinical record revealed the start of care date was 09/10/2024.  The patient’s admitting diagnosis included Alzheimer’s disease.  The benefit period reviewed was 09/29/2025 to 11/27/2025. Review of the patient’s POC for benefit period 09/29/2025 to 11/27/2025 revealed an order for SN 1wk1, 2wk7, 1wk1, 3 prn (skilled nurse visit one time a week for one week, two visits a week for seven weeks, one visit a week for one week, three visits as needed.  Review of the patient’s SN visit note dated 09/30/2025 revealed, “…+2 pitting BLE (bilateral lower extremity) edema.  Also, noted ascites (abnormal accumulation of fluid in the abdominal cavity- swollen abdomen).  (Caregiver) report that pt (patient) was not able to button pants this morning due to ascites…”  There was no evidence the skilled nurse informed the physician concerning the patient’s +2 pitting edema to bilateral lower extremities and ascites.   On 11/05/2025 at 9:53 a.m., an interview was conducted with S1ADON (Acting Director of Nursing).  S1ADON reviewed the patient’s electronic clinical record and confirmed there was no evidence the SN informed the physician concerning the patient’s +2 pitting edema to bilateral lower extremities and ascites.  S1ADON stated the SN should have informed the physician and should have documented the notification in the patient’s clinical record.   On 11/05/2025 at 10:05 a.m., a telephone interview was conducted with S2RN (Registered Nurse).  S2RN confirmed she did not document the physician was notified concerning the patient’s +2 pitting edema and ascites and confirmed she should have.

Based on record review and interview, the agency failed to coordinate care as evidenced by failing to provide an ongoing sharing of information with the patient’s non-hospice provider for 1 (#3) out of 14 (#1-#14) sampled patients. --- Review of the agency’s document titled, Coordination of Patient Care with an effective date of 10/01/2022, read in part… 5. Care will be coordinated with other involved external organizations, e.g., home medical equipment providers, infusion therapy/pharmacy companies and community agencies.  Staff will: Share relevant information to facilitate appropriate continuity and care coordination. Review of Patient #3’s electronic clinical record revealed the start of care date was 09/10/2024.  The patient’s admitting diagnosis included Alzheimer’s disease.  The benefit period reviewed was 09/29/2025 to 11/27/2025.   On 11/04/2025 at 10:01 a.m., a home visit was conducted at Patient #3’s place of residence at an assisted living facility.  During the home visit, the surveyor asked the staff for the information that the hospice agency provide to them regarding the patient’s services being provided by hospice.  The staff stated the Executive Director would have that information.    On 11/04/2025 at 11:00 a.m., an interview was conducted with the Executive Director at Patient #3’s place of residence.  The Executive Director stated she could not provide any documents regarding the patient’s services being provided by hospice. On 11/05/2025 at 10:30 a.m., an interview was conducted with S1ADON (Acting Director of Nursing).  S1ADON confirmed that information regarding Patient #3’s hospice services were not shared with his place of residence at the assisted living facility.