Every finding on record at Rising Sun Health Services, LLC.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), revises the individualized care plan. A revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by review of a clinical records and interview. In 1 of 5 (20%) clinical records reviewed it was revealed that the plan of care was not updated. Record #845553; A RN assessment note completed 12/29/21 states “began pureed diet as on 12/27/2021.” On review of the medical record, it was revealed the plan of care does not contain an order for a pureed diet. During an interview on 1/6/22 the administrator and DON stated no order was present.

It is required that each patient’s record includes, at a minimum, correct physician recertification of terminal illness as required. This standard was not met as evidenced by a review of clinical records and interview. In 4 of 5 (80%) clinical records it was revealed the recertification of terminal illness did not contain correct physician recertifications as required. CMS Condition of Participation 418.22 Certification of terminal illness (in part). (b) Content of certification. The certification must conform to the following requirements: (5) All certifications and recertifications must be signed and dated by the physician(s) and must include the benefit period dates to which the certification or recertification applies. Record #72929; Patient transferred to hospice on 11/22/21 in benefit period dated 10/17/21 to 12/15/21. Certification signed by the medical director documented benefit period dates as 11/22/21 to 1/20/22. Record #84553; Patient transferred to hospice on 11/23/21 in benefit period dated 10/17/21 to -12/15/21. Certification signed by the medical director documented benefit period dates as 11/23/21 to 1/21/22. Record #33675 Patient transferred to hospice on 11/24/21 in benefit period dated 10/26/21 to 12/25/22. Certification signed by the medical director states documented period dates as 11/24/21 to 1/22/22. Record #55032; Patient transferred to hospice on 11/23/21 in benefit period dated 11/6/21 to 1/4/22. Certification signed by the medical director states documented period dates as 11/23/21 to 1/21/22. The Administrator and DON acknowledge the benefit period dates are incorrect on the certification orders.