Every finding on record at Regency IHS Hospice Services LLC

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. 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 nursing services were provided as per the plan of care. CLINICAL RECORD 18: The patient elected the hospice benefit 12/25/2024 with a terminal diagnosis of malignant neoplasm of the cecum. The patient was pronounced deceased on 01/16/2025. The plan of care dated 12/25/2024 included an order for skilled nursing frequency of 1XD [one time per day]. Clinical record review revealed the skilled nurse documented nursing visit notes on 12/25/2024, 12/26/2024, 12/29/2024, 12/31/2024, 01/01/2025, 01/03/2025, 01/06/2025, 01/08/2025, and 01/16/2025. There was no documented evidence in the clinical record that the skilled nurse provided visits to the patient on the following dates: 12/27/2024, 12/28/2024, 12/30/2024, 01/02/2025, 01/04/2025, 01/05/2025, 01/07/2025, 01/09/2025, 01/10/2025, 01/11/2025, 01/12/2025, 01/13/2025, 01/14/2025, and 01/15/2025. The clinical record did not include documentation of the missed visits or a physician order to change the frequency of nursing visits. During an interview and review of findings on 06/13/2025, the Regional Director of Nursing stated that the frequency order for skilled nursing once a day was not followed and there were no updated orders or missed visit documentation present in the clinical record.

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 40.1. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed with patient revocation and discharge, the agency did not ensure the hospice discharge summary was forwarded to the receiving facility. CLINICAL RECORD 15: The patient elected the hospice benefit on 02/17/2023 with a terminal illness of cerebral atherosclerosis and was discharged to a skilled nursing facility on 02/11/2025 as the patient was no longer hospice appropriate. There was no documented evidence in the clinical record that the discharge summary was sent to the receiving facility. During an interview and review of findings with the Regional Director of Nursing on 06/13/2025, there was an extensive search for documentation that the discharge summaries were sent to the receiving provider. The Regional Director of Nursing explained the agency’s policy was to provide the discharge summary to the receiving facility, but there was no evidence present in the clinical record, or fax reports that the summary had been sent to the provider. The Regional Director of Nursing stated that the agency had recently changed the EMR [electronic medical record] software, and it was noted at this time that the new EMR did not include a discharge summary process, and this was the determining factor as to why the discharge summary was not forwarded to the facility. The prior EMR had a discharge summary mechanism that was initiated electronically when a patient was discharged.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (8%) records reviewed revealed that the agency did not ensure the comprehensive assessment, including the psychosocial assessment was completed no later than five (5) calendar days after the election of hospice care. Record #12 was reviewed and identified the patient elected hospice care on 7/1/2022. The missed visit note completed by the Medical Social Worker (MSW) on 7/1/22 documented, “unable to coordinate with patient.” The communication note completed by the MSW dated 7/4/22 documented, “MSW made contact with responsible person (RP) to assess needs for caregiver services. MSW educated family on respite care services, provider services and volunteer services. Family was receptive to referral for provider services. MSW facilitated request.” The record did not include evidence the MSW completed a comprehensive assessment during the month of July 2022.There was no evidence that a psychosocial assessment was completed within 5 days of the patient's election of hospice care. Staff #2 confirmed during an interview and a joint review of the clinical record on 8/10/22 that the MSW did not complete a comprehensive assessment within 5 days of the election of the hospice benefit.