Every finding on record at Our Sacred Heart Hospice, LLC

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 14 (29%) clinical records reviewed for patients receiving services revealed that the hospice did not ensure a registered nurse provided coordination of care, continuous assessment of each patient's and family's needs, and ensure the implementation of the interdisciplinary plan of care. Hospice Policy 013115 Hospice-CHAP, Assessments, stated in part: the hospice will ensure the update of the comprehensive assessment be accomplished by the hospice interdisciplinary group, consider changes that have taken place since the initial assessment, and as frequently as the condition of the patient requires, but no less frequently than every 15 days. Clinical Record 1: The election of hospice was 11/29/2023 with a diagnosis of Alzheimer’s Disease. The initial plan of care dated 11/29/2023 ordered skilled nursing visits for one time a week. The registered nurse visited on 02/28/2024. The licensed vocational nurse made visits on 03/06/2024 and 03/12/2024. The next scheduled registered nurse visit was on 03/21/2024. A registered nurse had not completed a comprehensive assessment for twenty-one (21) days. Clinical Record 2: The election of hospice was 11/28/2023 with a diagnosis of Senile Degeneration of the Brain. The recertification plan of care dated 02/26/2024-05/25/2024 ordered skilled nursing visits for one time a week. The registered nurse visited on 02/27/2024. The licensed vocational nurse visited on 03/05/2024 and 03/12/2024. The next scheduled registered nurse visit was on 03/21/2024. A registered nurse had not completed a comprehensive assessment for more than twenty-two (22) days. Clinical Record 3: The election of hospice benefit was 01/05/2024 with a diagnosis of Alzheimer’s Disease. The initial plan of care dated 01/05/2024-04/03/2024 ordered skilled nursing visits for one time a week. The registered nurse visited on 02/26/2024. The licensed vocational nurse made visits to the patient on 03/04/2024 and 03/11/2024. The next scheduled registered nurse visit was on 03/21/2024. A registered nurse had not completed a comprehensive assessment for twenty-three (23) days. Clinical Record 4: The election of hospice benefit was 11/10/2023 with a diagnosis of Senile Degeneration of Brain. The initial plan of care dated 11/10/2023-02/07/2024 ordered skilled nursing visits for one time a week. The registered nurse visited on 12/22/2023. There were documented missed visits on 12/25/2023 and 01/01/2024. The licensed vocational nurse made visits on 12/27/2023 and 12/29/2023. The next completed registered nurse visit was on 01/18/2024. A registered nurse had not completed a comprehensive assessment for more than twenty-six (26) days. During an interview on 03/20/2024, the Administrator/Director of Nursing agreed that the patients had not had a visit by a registered nurse for more than fifteen days. He agreed that the licensed vocational nurse had made visits for two weeks in a row.

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 described in HCDT 40.I This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 1 (100%) clinical record reviewed for patients who were live discharges while on services revealed that the hospice did not ensure that a copy of the hospice discharge summary was forwarded to the receiving Medicare/Medicaid-certified facility where the patient was transferred. Agency Policy: 3115 Hospice-CHAP, stated in part, that the registered nurse will notify the attending physician about the transfer and document notification and input on the discharge summary, obtain a written order from the hospice medical director, and complete the discharge summary to include a summary of patient's stay including treatments, symptoms, and pain management, current plan of care, latest physician orders and any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility. Clinical Record 5: The election of hospice was 02/18/2024 with a live discharge date of 02/20/2024. The Interdisciplinary team (IDG) documented on 02/23/2024 that the patient was transferred to another hospice due to agency not having a contract at the skilled nursing facility where patient was to live. There was no documented evidence that a discharge summary was forwarded to the receiving Medicare/Medicaid-certified facility where the patient was transferred. During an interview on 03/22/2024, the Administrator/Director of Nursing agreed that a discharge summary had not been completed or forwarded to the receiving agency.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed for patients who were live discharges while on services revealed that the hospice did not ensure that the discharge summary was provided to the patient's community attending physician upon hospice discharge. Clinical Record 5: The election of hospice was 02/18/2024 with a live discharge date of 02/20/2024. There was no documented evidence that a discharge summary was completed upon the live discharge of the patient on 02/20/2024 or sent to the physician. During an interview on 03/22/2024, the Administrator/Director of Nursing stated that he missed that and had forgotten to complete the discharge summary.