Every finding on record at Newman Memorial Health Care Hospice

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility 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 document review. In 3 of 10 (30%) clinical records reviewed of patients transferred to the hospital revealed the agency did not ensure that a copy of the discharge summary was forwarded to the receiving facility. CLINICAL RECORD 13: The patient elected hospice benefit on 07/17/2022. The live discharge dated 07/27/2024 documented the patient was admitted to a hospital to seek aggressive treatment. There was no evidence that a discharge summary was forwarded to the receiving hospital as of 01/15/2025. CLINICAL RECORD 14: The patient elected hospice benefit on 06/08/2022. The live discharge dated 07/02/2024 documented the patient was admitted to a hospital to seek aggressive treatment. There was no evidence that a discharge summary was forwarded to the receiving hospital as of 01/15/2025. CLINICAL RECORD 7: The patient elected hospice benefit on 06/01/2024. The live discharge dated 06/08/2024 documented the patient was admitted to a hospital to seek aggressive treatment. There was no evidence that a discharge summary was forwarded to the receiving hospital as of 01/15/2025. During an interview 01/15/2025, the licensed vocational nurse (LVN)(Personnel Record 8) confirmed that the clinical records did not include documentation of information provided to the receiving facilities.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management; The patient’s current plan of care; The patient’s latest physician orders; Any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 3 of 10 (30%) clinical records reviewed of discharged patients revealed the agency did not ensure the discharge summary included a summary of the patient's hospice stay, current plan of care, and latest physician orders. CLINICAL RECORD 14: The patient elected hospice benefit on 06/08/2022. The live discharge dated 07/02/2024 documented the patient was admitted to a hospital to seek aggressive treatment. A clinical record review revealed no evidence that a discharge summary was completed as of 01/15/2025 that included the treatments, symptoms, and pain management; the patient’s current plan of care; or the patient’s latest physician orders. CLINICAL RECORD 13: The patient elected hospice benefit on 07/17/2022. The live discharge dated 07/27/2024 documented the patient was admitted to a hospital to seek aggressive treatment. A clinical record review revealed no evidence that a discharge summary was completed as of 01/15/2025 that included the treatments, symptoms, and pain management; the patient’s current plan of care; or the patient’s latest physician orders. CLINICAL RECORD 7: The patient elected hospice benefit on 06/01/2024.The live discharge dated 06/08/2024 documented the patient was admitted to a hospital to seek aggressive treatment. A clinical record review revealed no evidence that a discharge summary was completed as of 01/15/2025 that included the treatments, symptoms, and pain management; the patient’s current plan of care; or the patient’s latest physician orders. During an interview 01/15/2025, the licensed vocational nurse (LVN)(Personnel Record 8) confirmed that the clinical records did not include documentation of information sent to the receiving facility and confirmed that the clinical record did not contain documentation that any of the required elements (plan of care, physician orders, summary of hospice stay) were provided in any other method.