Every finding on record at Parrish Home Healthcare

Based on observations, interviews, record review, and agency policy review, the agency failed to provide the patient and/or representative with written notice of the patient's rights and responsibilities for three patients (Patients (P) 6, P8, and P9) of three patient home binders reviewed during home visits. This failure had the potential to affect the patients and/or their representatives ability to be aware of and understand their rights under the hospice benefit.Findings included: --- 1. Review of P6's  "Face Sheet" located in the "Intake" tab of the electronic medical record (EMR) revealed a "Start of Care" (SOC) date of 08/22/23 and a diagnosis of Crohn's disease (a digestive disorder).During a home visit observation at a Skilled Nursing Facility (SNF) on 04/16/26 at 9:00 AM, the hospice agency binder was reviewed. The binder did not contain information regarding the patient's rights and responsibilities under the hospice benefit.During an interview on 04/16/26 at 10:15 AM, the Director of Nursing (DON) stated, "I have only been here for two weeks and was not aware that the patient's rights and responsibilities were not included in the hospice binder."During an interview on 04/16/26 at 2:24 PM, the Hospice Administrator stated, "I don't know why that information was not there, we have all the signed documents at the office."2. Review of P8's  "Face Sheet" located in the "Intake" tab of the EMR revealed a SOC date of 10/08/20 and a diagnosis of Alzheimer's diseaseOn 04/16/26 at 10:45 AM, a visit was made to P8's home. The hospice binder was reviewed with[TP1] [SH2] [SH3]  Caregiver 1. There was no documentation to show that P8 or his/her representative was provided with a written copy of the rights and responsibilities under the hospice benefit.During an interview on 04/16/26 at 11:00 AM, Caregiver 1 stated, "That book has not been updated in six years."During an interview on 04/16/26 at 2:59 PM, the Administrator stated, "I don't know why that information was not included in the binder."3. Review of P9's "Face Sheet" located in the "Intake" tab of the EMR revealed a SOC date of 12/05/25 and a diagnosis of Alzheimer's disease.On 04/16/26 at 12:00 PM, a visit was made to P9's group home. A hospice binder could not be located in the group home. The owner of the group home was contacted on the telephone and confirmed no binder was ever received and the home did not have information regarding P9's rights and responsibilities under the hospice benefit.During an interview on 04/16/26 at 2:52 PM, the Administrator stated, "I don't know why she does not have a binder with this information in it."Review of an undated agency policy titled, "Hospice Policy and Procedures" revealed, "Rights Policy... Hospice protects and promotes patient rights...Provide written notice of rights...Ensure confidentiality, dignity, and right to refuse care... Maintain grievance process documentation..."

Based on observations, interviews, record reviews, and  policy review, the Hospice agency failed to ensure three patient (Patients (P) 6, P8, P9) hospice binders reviewed during home visit observations had received information about all hospice services and non-covered services. In addition, the binders did not include documentation of the Hospice Election of Benefits or physician signed "Do Not Resuscitate" (DNR) order. This failure placed the residents and caregivers at risk of not fully knowing information about hospice services.Findings included: --- 1. Review of P6's "Face Sheet" located in the "Intake" tab of the electronic medical record (EMR) revealed a "Start of Care (SOC)" date of 08/22/23, and a diagnosis of Crohn's disease (a digestive disorder).Review of P6's hospice binder during a home visit on 04/16/26 at 9:00 AM, at a Skilled Nursing Facility (SNF), revealed the binder did not include the following signed documents: Election of Hospice Benefit, a physician signed copy of the DNR, or the non-covered hospice services form.During an interview on 04/16/26 at 2:24 PM, the Hospice Administrator stated, "They[TP1] [SH2]  [nursing home staff] have a binder and after the forms are signed, they are to put them into that binder. All forms are turned over to the nursing home administrator after signing. I don't know why the information is not there, we have the signed documents at the office."2. Review of P8's  "Face Sheet" located in the "Intake" tab of the EMR revealed, a SOC date of 10/08/20, and a diagnosis of Alzheimer's disease.Review of P8's hospice binder during a home visit on 04/16/26 at 10:45 AM, revealed no front cover which contained the hospice's 24-hour phone number or the name and phone number of the Registered Nurse Case Manager (RN/CM). In addition, the following items were not located in the binder: Certification of Terminal Illness, Signed copy of the DNR.During an interview on 04/16/26 at 2:59 PM, the Administrator was asked why the signed documents had not been placed in P8's home binder. The Administrator stated, "I don't know why they are not in there; they were signed a while ago."3. Review of P9's "Face Sheet" located in the "Intake" tab of the EMR revealed a SOC date of 12/02/25, and a diagnosis of Alzheimer's disease.During a home visit on 04/16/26 at 12:00 PM, no hospice binder was located at the group home where P9 resides.The group home staff confirmed there was no documentation regarding P9's Election of Benefits, Certification of Terminal Illness, non-covered hospice services, or a DNR/Code Status at the group home.During an interview on 04/16/26 at 2:52 PM, the Administrator stated, "[P9] moved to this new house and those are standard forms that should have been in the binder. I don't know why the group home does not have a binder."Review of the agency policy titled, "Care to Residents in a SNF/NF [skilled nursing facility/nursing facility] and ICF/MR [intermediate care facility/mentally retarded]" dated 2016, revealed, "...Hospice will provide to the SNF/NF or ICF/MR the following information...Hospice election form and any advanced directives specific to each patient...Physician certification and recertification of the terminal illness specific to each patient...Names and contact information for Hospice personnel involved in Hospice care of each patient..."

Based on interviews, record review, and policy review, the Hospice agency failed to ensure that the "Spiritual Counselor" and "Social Services" comprehensive assessments were completed within five days of the Hospice Election of Benefits (EOB) for four of 14 patients (Patient (P)1, P2, P3, P4). Failure to complete a spiritual assessment and/or social services assessment had the potential to miss the identification of the patient or their caregivers' needs.Findings included: --- 1. Review of P1's "Face Sheet" located in the "Intake" tab of the electronic medical record (EMR) revealed a "Start of Care" (SOC) date and an EOB date of 03/25/26, with a diagnosis of bone cancer.Review of the P1's "Social Service" assessment in the "Assessments" tab in the EMR revealed the assessment was completed on 04/04/26, which was not within the required timeframe.2. Review of P2's "Face Sheet" located in the "Intake" tab of the EMR revealed a SOC date and an EOB date of 08/08/25, with a diagnosis of colon cancer.Review of P2's "Social Services" assessment located in the "Assessments" tab in the EMR revealed the assessment was completed on 08/29/25, which was not within the required timeframe.3. Review of P3's "Face Sheet" located in the "Intake" tab of the EMR revealed a SOC date and an EOB date of 01/27/26 for a diagnosis of Alzheimer's disease.Review of P3's "Assessments" tab in the EMR revealed that no evidence of a comprehensive social services assessment was completed for P3 within five days, as required.4. Review of P4's "Face Sheet" located in the "Intake" tab of the EMR revealed a SOC date and an EOB date of 03/10/26, for a diagnosis of a cerebral vascular accident (CVA-stroke).Review of P4's "Spiritual Counselor" assessment located in the "Assessments" tab in the EMR revealed the assessment was completed on 04/01/26, which was not within the required timeframe.Review of P4's "Social Services" assessment located in the "Assessments" tab in the EMR revealed the assessment was completed on 03/27/26, which was not within the required timeframe.During an interview on 04/17/26 at 1:52 PM, the Administrator stated, "It is my expectation that assessments are to be completed within five days, as required."Review of the agency policy titled, "Coordination of Patient Care," dated 2013, revealed, "...Ensure that all care and services are provided in accordance with the plan of care and are based on all assessments of the patient and family needs..."

Based on interviews, record review, and agency policy review, the hospice agency failed to ensure the interdisciplinary group (IDG) developed a plan of care (POC) for spiritual needs and/or social service needs for four of 14 patients (Patients (P)1, P3, P4, P5). This failure had the potential to affect the planning of anticipated needs for the 12 patients who are currently receiving hospice services.Findings included: --- 1. Review of P1's "Face Sheet" located in the "Intake" tab of the electronic medical record (EMR) revealed a "Start of Care (SOC)" date of 03/25/26 with a diagnosis of bone cancer.Review of P1's POC located in the "Care Plan" tab in the EMR did not show the Licensed Medical Social Worker (LMSW) had developed a "Social Services" POC despite having completed an assessment and made visits.2. Review of P3's "Face Sheet" located in the "Intake" tab of the EMR revealed a "SOC" of 01/27/26 with a diagnosis of Alzheimer's disease.Review of P3's POC located in the "Care Plan" tab in the EMR did not show the LMSW had developed a "Social Services" POC despite having completed an assessment and made visits.3. Review of P4's  "Face Sheet" located in the "Intake" tab of the EMR revealed a "SOC" date of 03/10/26 with a diagnosis of cerebral vascular accident (CVA-stroke).Review of P4's POC located in the "Care Plan" tab in the EMR did not show the Spiritual Advisor had developed a "Spiritual Services" POC despite having completed an assessment and made visits.4. Review of P5's "Face Sheet" located in the "Intake" tab of the EMR revealed a "SOC" date of 07/07/23 with a diagnosis of CVA.Review of P5's POC in the "Care Plan" tab in the EMR did not show documentation that a "Spiritual Counselor" and "Social Services" had developed a POC despite having completed an assessment and made visits.During an interview on 04/17/26 at 1:47 PM, the Administrator stated, "I don't know why they did not develop a care plan, we discuss it in IDG [interdisciplinary group]." The Administrator further stated, "My expectation is the care plan is developed when the assessment is completed."

Based on interview, record review, and policy review, the Hospice agency failed to obtain a signed "Certification of Terminal Illness (CTI)" which included a physician narrative indicating a life expectancy of six months or less for one patient (Patient (P) 11) in a total sample of 14. This failure had the potential for fraud.Findings include: --- Review of P11's "Face Sheet" located in the "Intake" tab of the electronic medical record revealed a "Start of Care (SOC)" date on 01/15/26 with a diagnosis of end-stage heart failure.Review of the "Certifications" tab in the EMR revealed a verbal order dated 01/15/26, to admit to hospice was received from an on-call physician and was documented in the EMR by Registered Nurse (RN) 2. There was no signed CTI which included a narrative by the Medical Director (MD) to indicate P11 had a life-expectancy of six months or less since admission to hospice.During an interview on 04/17/26 at 12:37 PM, the Administrator stated, "I don't know why it [CTI] wasn't done. It was missed."Review of an undated agency policy titled, "Patient Eligibility & Admission Policy" revealed, "...Patients must meet CMS [Center for Medicare and Medicaid] hospice eligibility criteria...Physician certification of terminal illness...Document diagnosis and related conditions..."

Based on interview, record review, and policy review, the Hospice agency failed to send a discharge summary to the attending physician who assumed the patient's care for one patient (Patient (P) 11) in a total sample of 14 patients' who had revoked hospice services The failure to provide the current provider information regarding the services the patient received while on hospice had the potential to affect the patient's continuity of care.Findings include: --- Review of P11's "Face Sheet" located in the "Intake" tab of the electronic medical record (EMR) revealed a "start of care (SOC)" date of 01/15/26 and a diagnosis of end-stage heart failure.Review of information in the "Discharge" tab in the EMR revealed that on 03/06/26, P11 and his/her family had revoked hospice services. A discharge summary was completed, however, there was no indication that the discharge summary was provided to the attending physician.During an interview on 04/17/26 at 12:09 PM, the Administrator was asked if a copy of the discharge summary was provided to the attending physician. The Administrator stated, "No, I was not aware that I needed to do this."Review of the agency policy titled, "Coordination of Patient Care," dated 2013 revealed, "... Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions."

Observed in Record Review. In 1 of 4 patient records reviewed, the organization failed to ensure the interdisciplinary group (IDG) updated the comprehensive assessment as frequently as the patient condition requires but no less than every 15 days. For example in review of RRD/C# 1's IDG/plan of care update dated four days prior to RRD/C# 1's discharge revealed no documentation of goals, interventions, or updates, as it was blank with a RN signature the same date of the IDG/plan of care meeting. This was reviewed and validated with the Administrator.

Observed in Record Review. In 2 of 4 patient records reviewed, During RRNHV# 1 and RRNHV# 2's patient record review it was noted the organization had not ensured the patient records were complete and accurately documented. For example: review of RRNHV# 1's patient record revealed a recertification Certificate of Terminal Illness (CTI), and a recertification plan of care order dated the last date of the certification period. Further review of the recertification CTI and recertification plan of care order revealed a RN verbal order signed and dated 13 days after the date of the physician order. Review of the electronic medical record audit trail provided by the Administrator revealed both documents were created the date of the RN signature with no documentation to indicated this was a late entry into the record. Review of RRNHV# 2's patient record revealed an initial CTI, and an initial plan of care order dated the date of the election of benefit (EOB). Further review of the initial CTI and initial plan of care order revealed a RN verbal order signed and dated four days after the election of benefit with no indication this was a late entry into the record. Further review of RRNHV# 2's revealed RRNHV# 2 was admitted 30 days prior to the surveyor review of the record. Review of RRNHV# 2's patient record revealed no documentation of a Consent, EOB, Advanced Directives, Patient Bill of Rights, Attending Physician, or Patient Notification of Hospice Non-covered Items, Services, and Drugs. The Administrator shared the admission RN had RRNHV# 2's documents and had not brought them to the office yet. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 1 of 1 patient records review with transfer to hospital, During RRD/C# 1's patient record review it was noted the organization had not ensured the hospice discharge summary was provided to the receiving facility/hospital. For example: review of RRD/C# 1's patient record revealed RRD/C# 1 was discharged to the hospital, yet there was no documentation that the discharge summary was provided to the receiving facility/hosptal. This was reviewed, discussed and validated with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, where patient revoked hospice services, the organization failed to respect the patient's right to elect and revoke hospice care, in accordance with Medicare hospice regulations. For example: In review of HSRRDC#11 the patient went to the hospital seeking aggressive treatment for pain in the groin, yet the patient or family did not sign a revocation form. Per conversation with the Administrator the patient went to the hospital but the revocation form was not presented for signature to the patient/caregiver.

Observed in Record Review. In 2 of 10 patient records reviewed, for active records, the organization failed to ensure the hospice registered nurse complete an initial assessment within 48 hours after the election of hospice care. For example: on review of HSRRHV#2 the election of benefits was signed on 7/18/23 however the initial comprehensive assessment with not documented as completed until 7/24/23 6 days after election. In HSRRNHV#4 the admission consent was signed on 4/18/23 with a SOC of 4/18/23 noted yet the initial admission assessment occurred on 4/22/23, and the start of care per the POC is noted to be 4/22/23. There was no documentation noted in the record explaining the delay in assessment of the patients. These observations were reviewed with the Administrator.

Observed in Record Review. In 8 of 10 patient records reviewed, for active patients, the organization failed to ensure the comprehensive assessment was completed no later that 5 calendar days after the election of hospice care. For example: on review of HSRRHV#1 the MSW assessment occurred on day 6. In HSRRHV#2 the MSW assessment occurred on day 20 and the spiritual assessment on day 6. In HSRRHV#3 the MSW assessment was documented on day 9. In HSRRNHV#10 the MSW assessment was on day 25 and the spiritual on day 23. In HSRRNHV#8 the MSW assessment was on day 6. In HSRRNHV#5 the MSW assessment was on day 9. In HSRRNHV#9 the MSW assessment was documented on day 12. HSRRNHV#4 was also noted to not have documentation of the comprehensive assessment to be completed withing 5 calendar days after admission. These observations were reviewed with the Administrator.

Observed in Record Review. In 4 of 10 patient records reviewed, for active patients, the organization failed to conduct and document a patient specific assessment and reassessment that identifies that patient's need for hospice care and services. For example: on review of HSRRNHV#10 the patient's wound was not assessed and documented each week per the policy as the Administrator noted policy is to assess and document all wounds weekly. In HSRRNHV#8 the patient's wounds were also not assessed and documented per organization policy. There was no skin assessment noted on the initial comprehensive assessment. Further, the patient was on oxygen yet there was no documentation of a respiratory assessment on admission. On HSRRNHV#9 there was no documentation on admission of a respiratory assessment or shortness of breath screening, no comprehensive pain assessment, and the patient was noted in documentation to have a neck mass yet there was no documentation of an assessment of the mass/lesion. In review of HSRRNHV#7 the wounds were no documented per policy as every other week the assessment lacked measurements, and how the patient tolerated the wound care. These observations were reviewed with the Administrator.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the interdisciplinary group update the comprehensive assessment as frequently as the patient condition requires but no less than every 15 days. For example in review of HSRRHV#3 the IDG documentation for 8/1/23 did not note any updates to the comprehensive assessment considering changes that have taken place since the initial assessment. On interview with hospice and facility staff it was noted there had been marked improvement in the patient's conditions since admission yet these changes were not reflected in the updated comprehensive assessment. In HSRRNHV#8 the documentation notes that the patient was hospitalized while on hospice service from 6/16/23 to 6/20/23 yet the changes in patient status were not reflected in the comprehensive assessment and IDG updates. In HSRRNHV#9 the IDG meeting documentation for 6/20/23, 7/18/23, and 8/1/23 were incomplete and blank showing no updates to the comprehensive assessment by the IDG team. HSRRNHV#6 also had multiple IDG meeting notes that were incomplete and blank showing no updates to the comprehensive assessment. These observations were reviewed with the Administrator.

Observed in Record Review. In 2 of 10 patient records reviewed, for active records, the organization failed to ensure education and training, based on the patient's assessed needs, was provided. For example: on review of HSRRHV#2 and HSRRNHV#10 the patients had wounds with dressing changes, yet there was no documentation noted in the record that the patient/caregiver was provided education on how to care for the wounds, their response to the education, and their proficiency at providing the care as ordered. This observation was reviewed with the Administrator.

Observed in Record Review. In 10 of 10 patient records reviewed, for active patients, the organization failed to ensure the plan of care reflect the patient and family goals and the time frames, settings, and services required to meet the goals that were specific, measurable, achievable, realistic, and time bound. Throughout all records reviewed the goals established were not noted to be measurable, with various time frames that did not reflect the patient needs. For example: in HSRRHV#1 a goals read patient will maintain optimal mobility during care within 18 day period, and patient will remain at comfortable level during care within 18 day period of time. In HSRRHV#3 a goal reads promote optimal nutrition/hydration during care within 64-day period of time, and skin will be maintained at optimal level during care within 64 day period of time. Further there are interventions for Respiratory but no goals established. Similar non-measurable goals can be seen throughout all records reviewed. This observation was reviewed with the Administrator. Observed in Record Review. In 10 of 10 patient records reviewed, for active patients, the organization failed to ensure the plan of care reflect the patient and family goals and the time frames, settings, and services required to meet the goals that were specific , measurable, achievable, realistic, and time bound. Throughout all records review the goals established were not noted to be measurable with various time frames that did not reflect the patient needs. For example: in HSRRHV#1 a goals read patient will maintain optimal mobility during care within 18 day period, and patient will remain at comfortable level during care within 18 day period of time. In HSRRHV#3 a goal reads promote optimal nutrition/hydration during care within 64-day period of time, and skin will be maintained at optimal level during care within 64 day period of time. Further there are interventions for Respiratory but no goals established. Similar non-measurable goals can be seen throughout all records reviewed. This observation was reviewed with the Administrator.

Observed in Record Review. In 8 of 10 patient records reviewed, for active records, the organization failed to ensure the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions. For example: on all active records reviewed the hospice medical director was noted to document visits to the patient, however frequency orders for MD visits were not noted to be included in the patient plan of care. In HSRRHV#1 the patient was seen by the MD in May, June, and August. In HSRRNHV#5a the patient was seen by the MD in May and July but the visits were not reflected in the plan of care. On conversation with the Administrator it was stated that the MD visit patients approximately monthly.

Observed in Record Review. In 2 of 10 patient records reviewed, for active records, the organization failed to ensure plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of HSRRHV#2 and HSRRNHV#7 the patient were being seen by the physical therapist yet the physical therapy was not reflected in the plan of care. This observation was reviewed with the Administrator.

Observed in Record Review. In 3 of 10 patient records reviewed, for active records, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of HSRRHV#2 there was an order for Tramadol that stated Tramadol 50mg PRN for pain but it did not specify how often it could be used PRN. In HSRRNHV#8 the documentation noted multiple wounds yet there were no specific wound care orders for each wound. In HSRRNHV#7 the patient had a suprapubic catheter that the initial orders noted only to be changes by the urologist, yet the plan of care noted the catheter to be changed PRN. These observations were reviewed with the Administrator.

Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to ensure that care and services were provided in accordance with the plan of care. For example: on review of HSRRHV#1 the hospice aide was scheduled 2 times a week yet was seeing the patient 3 times a week. In HSRRHV#2 the plan of care ordered wound dressing changes with Medihoney, yet documentation noted dressing changes using Santyl and another dressing change using Dakins. Further, the HA was ordered 3 times a week but week 2 had 1 visit and week 3 had only 2 visits documented. In HSRRHV#3 the SN was ordered 1time a week per the plan of care yet there were no visits for wk 5, and 2 visits for weeks 4 and 6. In HSRRNHV#10 the MSW was ordered 2-4 times a month but was seeing the patient monthly. The aide was ordered 3 times a week but there were no visits documented week 7, and only 2 visits documented weeks 5,8,9,10,11. In HSRRNHV#5 the RN was scheduled 1xweek in the 1st BP there were no documented visits week 4, 6, 9, and 12. In BP#2 the RN was increased to 2x week, yet in week 3,4,and 5 only 1x a week visits were documented. These observations were reviewed with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it has planned. For example: on home observation for HSRRHV#1 the nurse was observed to place the hospice bag on a pillow in the patient's room, and not on a clean surface as required by policy. After using equipment the nurse wiped the equipment with a Clorox wipe, but failed to wipe all surfaces such as only wiping the outside of the surfaces. There was no allowance for wet time per manufacturers guidelines, as the equipment was lightly wiped and immediately placed back in the nurses bag. In home observation for HSRRHV#3 the hospice aide was noted to be carrying a tote bag that did not include a clean and dirty side, and was unable to close as it had an open top. The organization's policy notes separation of clean and dirty and that bags should be closed. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, For patients discharged for death, the organization failed to develop a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. For example: on review of HSRRBR#13 the bereavement plan of care noted the bereavement wanted mailings only however it did not specify how many mailings and the frequency of the mailings to be sent. This observation was reviewed with the Chaplain/BC and the Administrator.

Observed in Tracer Activities. On review of the volunteer program and interview with the Director of Nursing who serves as the Volunteer Coordinator, it was noted that the organization is not currently recruiting volunteers and therefore have no documentation of recruitment and retention efforts.

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.104, 418.54, and 418.56, were met per policy as determined through observations, documentation, and staff interviews.

Observed in Record Review. In 2 of 8 patient records reviewed, of active records where aide services were provided, the organization failed to ensure the patient record reflect the patient's care, treatment and services. For example: on review of HSRRNHV#10 the aide visit notes failed to populate the tasks assigned and therefore the aide's documentation failed to specify what type of bath was given to the patient. Similar issues with not specifying the type of bath given as the tasks did not populate can be seen in HSRRNHV#5. These observations were reviewed with the Administrator. Observed in Patient Home. In 5 of 14 patient records reviewed, the organization failed to ensure the patient record contain information that reflects the patient's care, treatment, and services. For example: on review of HSRRBR#13 and HSRRBR#14 the patient was discharge for death and the death visit documentation conducted by the RN was incomplete as it lacked a summary of care provided, no documentation of the caregivers reaction to the death. Further there was a notation that specific discharge instructions given to the son yet there was no documentation of what those instructions included. Example 2: on review of HSRRNHV#8 the patient's start of care was 6/8/23 and admission paperwork was signed by the staff on 6/8/23, but the family signed the admission documents on 6/13/23. There was no documentation noted in the clinical record detailing why the delay in the family signature for consent. Example 3: on review of HSRRNHV#9 the RN visit documentation for 7/21/23, 7/28/23, and 8/1/23 was noted to have a time in and time out and patient signature but the remainder of the documentation was incomplete as the notes were blank. In review of HSRRNHV#6 also had multiple nursing visit notes that had a time in and out yet the remainder of the documentation was blank. These observations were reviewed with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, where the patient was discharged live, the organization failed to ensure the hospice discharge summary provided to the receiving facility with a copy of the hospice discharge summary and, if requested, a copy of the patient's clinical record. On review of HSRRDC#11 the patient was discharged to the hospital, and HSRRDC#12 was transferred to another hospice per the revocation form, yet there was no documentation that the discharge summary was provided to the receiving facility. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, where the patient was discharged live, the organization failed to ensure the hospice discharge summary included all required element to include a summary of the patient's stay including treatments, symptoms, and pain management. On review of HSRRDC#11 and HSRRDC#12 the discharge summary did not include a summary of the patient's care, current plan of care or the lastest physicians orders. This observation was reviewed with the Administrator.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure the patient record was complete, promptly and accurately documented. For example: on review on HSRRHV#3 the nursing documentation noted multiple aide supervisory visits documented prior to the first documented aide visit. The aide's first visit was on 7/14/23, yet there were supervisory visits documented on 6/10, 6/14, 6/16, and 6/26. Similar documentation on aide supervisory visits prior to the 1st aide visit can be seen in HSRRNHV#8. Further in HSRRNHV#8 the medication profile orders oxygen 2 lts/min per nc continuous, yet the plan of care notes the oxygen at 2-3 lts/min. In HSRRBR#13 the spiritual assessment is dated to had occurred on 5/26/23, 2 weeks prior to the patient start of care on 6/8/23. These observations were reviewed with the Administrator.