Every finding on record at Suncrest Hospice Illinois LLC

Based on interview and record review, the Hospice agency failed to provide volunteer services in an amount equal to five percent of the total patient care hours. This had the potential to affect 502 of the 502 active patients receiving services from the agency who may have benefited from volunteer services. Findings include: Review of the Quality Assessment Performance Improvement (QAPI) documentation, provided by the agency and dated for 2025, revealed the agency's monthly volunteer percentages were: January – 1.95 percent (%)February – 1.94%March – 2.18%April – 1.83%May – 1.25%June – 0.95%July – 0.95%August – 1.47%September – 0.84%October – 1.32%November – 1.3%December – 0.55% During a home visit observation on 02/19/26 at 9:30 AM, Family Member (F1), P9's spouse/caregiver, stated, "I didn't know volunteers were available. No one told me about that. I think that could be helpful at times."  During an interview on 02/20/26 at 12:30 PM, the Executive Director (ED) confirmed the agency had not been able to reach the volunteer services minimum of five percent of the total patient care hours of paid and contracted hospice personnel and that a performance improvement project (PIP) was a part of the agency's QAPI program to achieve the goal. The ED also stated the Volunteer Coordinator was out of the state on vacation and was not available for an interview.  Review of the Hospice agency policy titled, "Volunteer Services," dated December 2025, revealed, "Patient care volunteers provide personal care or emotional support and practical assistance which enhance the comfort and quality of life for patients and family/caregivers. These services include being available for companionship, listening, simply 'being there,' and preparing meals. Patient care volunteers may also provide relief for caregivers or assist them with household chores . . . The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel . . ."

It is required that the documented comprehensive assessment include a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met, as evidenced by a review of the clinical records, interviews, and observations. In 1 of 2 (50%) observed home visits in which a medication profile was obtained from the assisted living, the agency did not ensure that they had reviewed all medications for potential side effects. HOME VISIT 1/CLINICAL RECORD 4: During the observed home visit with the Registered Nurse (RN) (Personnel Record 1) on 08/25/2025, a medication profile was reviewed at the assisted living facility (ALF). The ALF medication profile listed medications that were not listed on the hospice medication profile and/or the plan of care. The following medication was listed on the facility's medication profile but was not included in the hospice plan of care: Guaisorb DM 100mg/5ml, 20ml, administered orally every 4 hours as needed. The order date was 09/17/2024, and continued on the facility's medication profile. Additionally, a Melatonin, 5 mg at bedtime, was documented as received on 11/13/2023 and continued on the facility's medication profile. The hospice did not review these medications for potential medication interactions. During an interview with the RN (Personnel Record 1) on 08/25/2025, the RN stated that medications were reviewed by their software from the medication profile. During an interview on 08/26/2025 with the Vice President of Compliance, who jointly reviewed records and stated that their process will be changed related to medication collaboration, as the facility pharmacy profiles print differently and have caused some confusion about the accuracy of medications.

It is required that each patient’s individualized written plan of care: include all services necessary for the palliation and management of the terminal illness, including the following: Drugs and treatment necessary to meet the needs of the patient. This standard was not met, as evidenced by a review of the clinical record, interview, and observation. In 2 of 5 (40%) clinical records and home visit observations reviewed, the agency did not ensure that the medications listed on the plan of care were accurate when compared to the assisted living medication profile. HOME VISIT 1/CLINICAL RECORD 4: The election of the Hospice Benefit was documented as effective 06/17/2025 with a primary diagnosis of Senile Degeneration. During the observed home visit on 08/25/2025, with the Registered Nurse (RN) (Personnel Record 1), a medication profile from the facility was reviewed. The discrepancies between the facility's medication profile and the current plan of care were as follows: Guaisorb DM 100mg/5ml, 20ml, administered orally every 4 hours as needed, and Melatonin, 5mg at bedtime. These medications had not been listed on the current plan of care. HOME VISIT 2/CLINICAL RECORD 5: The election of the Hospice Benefit was documented as effective 07/20/2025 with a primary diagnosis of Parkinson's. During the observed home visit on 08/25/2025, the RN (Personnel Record 1) reviewed a medication profile from the facility. The facility's medication profile documented that the medication midodrine 10mg oral tablet was taken 3 times a day for hypotension and to be held for a systolic blood pressure greater than 120. This medication was not on the current plan of care. During an interview on 08/26/2025 with the Vice President of Compliance, who jointly reviewed records and stated that their process will be changed related to medication collaboration, as the facility pharmacy profiles print differently and have caused some confusion.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #2-004, "Medication Profile" (revised June 2022) sub-section seven (7) stated in part, "A drug regimen review will be performed at the time of the initial and comprehensive assessment when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication." In 4 of 6 (67%) home visits observed, the hospice did not ensure that the comprehensive assessment included a drug profile that included the patient's current medications. Home Visit 1/Clinical Record 2: The patient elected hospice care on 5/25/2023 and resided in a skilled nursing facility (SNF). During the home visit with the Assistant Director of Clinical Services [Personnel Record 9] on 10/10/2023, a medication reconciliation was performed, comparing the hospice medication profile to the SNF medication profile. The hospice medication profile documented, "Guaifenesin 100 milligrams (mg) per 5 milliliters (ml), give 5 ml oral every 6 hours as needed (PRN) for cough. The SNF medication profile documented, "Guaifenesin 100 mg per 5 ml, give 10 ml oral every 6 hours as needed (PRN) for cough." The hospice medication profile documented, "Pantoprazole 20 mg, give 1 tablet 1 time a day; Oxybutynin 5 mg, give 1 tablet 2 times a day for muscle weakness; Atorvastatin 2o mg, give 1 tablet 1 time a day for hyperlipidemia; and Carvedilol 3.125 mg, take 1 tablet 2 times a day for hypertension. The SNF medication profile did not include documentation of Pantoprazole, Oxybutynin, Carvedilol, and Atorvastatin. The Assistant Director of Clinical Services confirmed that the hospice medication profile did not match the patient's SNF medication regimen. Home Visit 2/Clinical Record 1: The patient elected hospice care on 5/30/2023 and resided at a SNF. During the home visit with the Assistant Director of Clinical Services [Personnel Record 9] on 10/10/2023, a medication reconciliation was performed, comparing the hospice medication profile to the SNF medication profile. The hospice medication profile documented, "Escitalopram 5 mg, take 1 tablet daily for depression." The SNF medication profile documented, "Escitalopram 10 mg, take 1 tablet daily for depression." The hospice medication profile stated, "Nystatin powder 100,000 units per gram (g), application 3 times a day for rash." The SNF medication profile documented, "Nystatin powder 100,000 units per gram, apply to skin folds topically as needed (PRN)." The Assistant Director of Clinical Services confirmed that the hospice medication profile did not match the patient's SNF medication regimen. The Registered Nurse (RN) [Personnel Record 8] stated in a joint interview that they perform a medication reconciliation "about every three (3) weeks." Home Visit 4/Clinical Record 5: The patient elected hospice care on 6/8/2023. During the home visit with the Assistant Director of Clinical Services on 10/11/2023, a medication reconciliation was performed, comparing the hospice medication profile to the patient's medication regimen. The patient's caregiver (husband) reported the patient is taking Senna liquid 8.8 milligrams (mg) per 5 milliliters (ml), take 2 teaspoons 2 times daily for constipation. In addition, the patient takes Polyethylene Glycol 17 grams (g) 1 time a day as needed (PRN) for constipation. The patient's caregiver reported the patient takes the Polyethylene Glycol two (2) times per week. The hospice medication profile did not include documentation of Senna Liquid or Polyethylene Glycol. There was no evidence that the comprehensive assessment included a review of Senna Liquid and Polyethylene Glycol. The Assistant Director of Clinical Services confirmed the medication profile, and the plan of care did not include the medications. Home Visit 5/Clinical Record 6: The patient elected hospice care on 3/5/2023 and resided in an assisted living facility (ALF). During the home visit with the Assistant Director of Clinical Services on 10/11/2023, a medication reconciliation was performed, comparing the hospice medication profile to the patient's medication regimen. The hospice medication profile documented, "Gabapentin 100 mg, take 1 capsule by mouth 3 times a day." The ALF medication profile documented, "Gabapentin 100 mg take 1 capsule 2 times a day." The ALF medication profile documented, "Ibuprofen 200 mg, take 1 tablet by mouth every 6 hours as needed (PRN) for pain. Tums (Calcium Carbonate) 200 mg, take 1 to 2 tablets every 4 hours as needed (PRN)." The hospice medication profile did not include documentation of Ibuprofen and Tums. There was no evidence that the comprehensive assessment included a review of Ibuprofen and Tums. The Assistant Director of Clinical Services confirmed the medication profile, and the plan of care did not include the Ibuprofen and Tums.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: all drugs and treatments necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, document review, and observation. Agency Policy# 9-017, "The Plan of Care" (revised June 2022) sub-section twelve (12), stated in part, "The written plan of care will contain, but will not be limited to the following, (S) drugs and treatments." In 2 of 6 (33%) home visits observed, the hospice did not ensure that all drugs and treatments necessary to meet the needs of the patient were included in the written plan of care. Home Visit 4/Clinical Record 5: The patient elected hospice care on 6/8/2023. During the home visit with the Assistant Director of Clinical Services on 10/11/2023, a medication reconciliation was performed, comparing the hospice medication profile to the patient's medication regimen. The patient's caregiver (husband) reported the patient is taking Senna liquid 8.8 milligrams (mg) per 5 milliliters (ml), take 2 teaspoons 2 times daily for constipation. In addition, the patient takes Polyethylene Glycol 17 grams (g) 1 time a day as needed (PRN) for constipation. The patient's caregiver reported the patient takes the Polyethylene Glycol two (2) times per week. The plan of care did not include documentation of the medications Senna Liquid or Polyethylene Glycol. The Assistant Director of Clinical Services confirmed the medication profile, and the plan of care did not include the medications. Home Visit 5/Clinical Record 6: The patient elected hospice care on 3/5/2023 and resided in an assisted living facility (ALF). During the home visit with the Assistant Director of Clinical Services on 10/11/2023, a medication reconciliation was performed, comparing the hospice medication profile to the patient's medication regimen. The ALF medication profile documented, "Ibuprofen 200 mg , take 1 tablet by mouth every 6 hours as needed (PRN) for pain. Tums (Calcium Carbonate) 200 mg, take 1 to 2 tablets every 4 hours as needed (PRN)." The plan of care did not include documentation of the medications did not include documentation of the medications Ibuprofen and Tums. The Assistant Director of Clinical Services confirmed the medication profile, and the plan of care did not include the Ibuprofen and Tums.

It is required that counseling services include spiritual counseling to meet spiritual needs and is provided in accordance with the patient’s and family’s acceptance of the services. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy # 9-017, "The Plan of Care" (revised June 2022), stated in part, "Care provided to the patient will be in accordance with the plan of care." Clinical Record 3: The patient elected hospice care on 6/29/2023 and accepted Chaplain services. On 6/30/2023, the physician ordered, "Chaplain one (1) to two (2) times per month for four (4) months and as needed (PRN)." In addition, the interdisciplinary team (IDT) notes dated 7/12/2023, 7/26/2023, 8/9/2023, and 8/23/2023 documented, "Chaplain visit frequency orders one (1) to two (2) times per month for four (4) months and as needed (PRN)." There was documented evidence that the patient received a Chaplain visit on 6/30/2023 and a phone call from the Chaplain on 9/29/2023. A clinical record review revealed no evidence of Chaplain visits for the months of 7/2023 or 8/2023 and no evidence of documented missed visits. During the joint record review and interview on 10/10/2023, the Senior Director of Clinical Quality confirmed the record did not contain evidence of a Chaplain visit for the month of 8/2023. They confirmed the record did not include documentation of a missed Chaplain visit for the month of 8/2023. The Senior Director of Clinical Quality stated, "It looks like the visit never got scheduled for August (2023)."

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy# 9-017, "The Plan of Care" (revised June 2022), stated in part, "Care provided to the patient will be in accordance with the plan of care." In 1 of 22 (5%) clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure the hospice aide provided services included in the plan of care. Clinical Record 7: The patient elected hospice care on 3/1/2023. The plan of care dated 5/30/2023 through 8/24/2023 ordered hospice aide services four (4) times weekly. During the home visit on 10/11/2023 with the Chaplain [Personnel Record 11] and the Assistant Director of Clinical Services [Personnel Record 4], a review of the patient's home folder revealed the paper document labeled "hospice aide communication," which documented the hospice aide shaved the patient on 10/2/2023, 10/5/2023, and 10/6/2023. The Assistant Director of Clinical Services confirmed the hospice aide documented on a paper chart in the patient's home that they shaved the patient on 10/2/2023, 10/5/2023, and 10/6/2023. The hospice aide was not assigned the task of shaving in the hospice aide care plan dated 3/2/2023 through 10/11/2023. During the joint record review and interview on 10/11/2023, the Senior Director of Clinical Quality confirmed the finding and stated that there was a paper form created " a long time ago" to communicate with facilities and families the tasks completed by the hospice aide during the visit. The Senior Director of Clinical Quality stated, "I didn't even know they were still using that form we created many years ago.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 22 (5%) clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure the hospice aide documented services provided in the patient's electronic medical record. Clinical Record 7/Home Visit 6:The patient elected hospice care on 3/1/2023. The plan of care dated 5/30/2023 through 8/24/2023 ordered hospice aide services four (4) times weekly. During the home visit on 10/11/2023 with the Chaplain [Personnel Record 11] and the Assistant Director of Clinical Services [Personnel Record 4], a review of the patient's home folder revealed the paper document labeled "hospice aide communication," which documented the hospice aide shaved the patient on 10/2/2023, 10/5/2023, and 10/6/2023. The Assistant Director of Clinical Services confirmed the hospice aide documented on a paper chart in the patient's home that they shaved the patient on 10/2/2023, 10/5/2023, and 10/6/2023. The hospice aide did not document that they shaved the patient on 10/2/2023, 10/5/2023, or 10/6/2023 in the patient's electronic medical record (EMR). The EMR did not contain all tasks and services the hospice aide provided during the visits on 10/2/2023, 10/5/2023, and 10/6/2023. During the joint record review and interview on 10/11/2023, the Senior Director of Clinical Quality confirmed the finding and stated that there was a paper form created " a long time ago" to communicate with facilities and families the tasks completed by the hospice aide during the visit. The Senior Director of Clinical Quality stated, "I didn't even know they were still using that form we created many years ago.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Human Resources Charting Timeline Policy" (revised 4/1/2021) stated in part, "Effective February 1, 2014, it is the policy of (Hospice) that all charting is completed within twenty-four (24) hours of the applicable visit." In 2 of 27 (7%) clinical records reviewed, the hospice did not ensure that documentation was completed within twenty-four (24) hours per hospice policy. Clinical Record 7: The patient elected hospice care on 3/1/2023. The Registered Nurse (RN) performed a patient assessment on 6/2/2023. The RN completed and signed the assessment documentation on 6/6/2023, with four days outstanding. Clinical Record 14: The patient elected hospice care on 12/27/2023. The RN performed a patient assessment on 9/6/2023. The RN completed and signed the assessment documentation on 9/11/2023, with five (5) days outstanding. During a joint record review and interview on 10/11/2023, the Senior Director of Clinical Quality confirmed the visit documentation was late and did not comply with the hospice policy of twenty-four (24) hours.

A. Based on a review of the complaint log, clinical record review, Hospice policies and staff interview, it was determined the Hospice failed to ensure medication was delivered promptly, and administered appropriately. This was found in 2 of 3 (Pts. #1 and 3) clinical records reviewed. Findings include: 1. The Hospice's complaint log for 2021 was reviewed on 3/31/22 at 10:50 AM and record contained the complaint log for 2021 which included an investigation concerning Pt. #1. The Pt. did not receive pain medication in a timely manner. 2. Pt. #1. SOC 10/20/21. Hospice Diagnosis: Malignant Neoplasm of the Prostate. The clinical record was reviewed on 3/31/22 at 1:00 PM. The clinical record contained a Physician order received on 11/4/21 (8:09 AM) for the Pt. to receive the medication "Pyridium" for inability to urinate, pain and burning. The RN visit note (4:00 PM) included: "Patient remains in terrible pain ..." The medication was delayed, scheduled to arrive at 6:00 PM. The SN visit note dated 1/4/22 (4:00 PM) contained documentation the RN had to obtain an emergency supply of the medication, deliver to the Pt./caregiver. 3. Pt. #3. SOC 12/14/21. Hospice Diagnosis: Senile Degeneration of Brain Not Elsewhere Classified. The clinical record was reviewed on 3/31/22 at 1:00 PM. The record contained the RN visit note dated 12/20/21 which included documentation the patient's POA contacted the patient's neurologist concerning the Pt. receiving Lorazepam, and the POA requested not to use Lorazepam. The RN visit note dated 1/3/22 included the Pt. received Lorazepam twice with little or no relief. The Hospice Physician was contacted and the dose was increased to 2 milligrams every 2 hours as needed. The RN visit note dated 1/4/22 included the Pt. was very agitated and not responding to the increased dose of Lorazepam. 4. The Interdisciplinary Group Meeting minutes dated 12/23/21 contained: "use of lorazepam- per spouse prefer not to use lorazepam due to patient reacting to it very strongly and taking several days to recover." The Interdisciplinary Group Meeting minutes dated 1/6/22 lacked documentation that the POA requested not to give the Pt. Lorazepam, but included, " ...severe agitation treated with PRN lorazepam and morphine." The Hospice failed to discontinue the Lorazepam, as requested by the POA. 5. The policy titled, "Bill of Rights" was reviewed on 3/31/22 at 2:15 PM and included: " ...A patient, who has not been judged to lack legal capacity, may designate someone (surrogate decision maker), to act as his/her representative. This representative, on behalf of the patient may exercise any of rights provided ... F. Refuse care or treatment. 6. During an interview with the Director of Clinical Services and the Office Manager on 3/31/22 at 3:15 PM, the Director of Clinical Services stated the pharmacy was supposed to deliver the medication to Pt. #1 during the "noon run (12:00 PM to 2:00 PM)", but the medication was delivered on the evening run (scheduled to arrive at 6:00 PM). During the same interview the Director of Clinical Services confirmed the Hospice failed to ensure medication was delivered promptly, and administered appropriately.

A. Based on a clinical record review, Hospice policies and staff interview, it was determined the Hospice failed to document the POA's disagreement with the POC, as required by the Hospice's policy. This was found in 1 of 3 (Pt. #3) clinical records reviewed. Findings include: 1. Pt. #3. SOC 12/14/21. Hospice Diagnosis: Senile Degeneration of Brain Not Elsewhere Classified. The clinical record was reviewed on 3/31/22 at 1:00 PM. The record contained the "Discharge Summary" completed by a RN and dated 1/31/22. The Summary contained, "Discussion with ... (POA) who expressed that she had concerns patient has been over medicated ..." As of 3/31/22, the complaint log for 2022 lacked documentation, investigation and resolution of this concern/complaint. 2. The hospice policy titled, "Complaint/Grievance Process" was reviewed on 3/31/22 at 2:15 PM and included: " ...Any difference of opinion, dispute or controversy between a patient or family/caregiver or patient representative and ... Hospice concerning any aspect of services ... will be considered a grievance ... Procedure ... 4. Complaints and any action taken will be documented on a complaint form ..." 3. The hospice policy titled, "Bill of Rights" was reviewed on 3/31/22 at 2:30 PM and included: "1. The Bill of Rights statement defines the right of the patient to ...Q. Receive an investigation by ... Hospice of complaints made by the patient or the patient's family or guardian regarding treatment or care that is (or fails to be) furnished... and that... Hospice will document the existence of the complaint and the resolution of the complaint. 4. During an interview with the Director of Clinical Services and the Office Manager on 3/31/22 at 3:15 PM, the Director of Clinical Services confirmed the Hospice failed to document the POA's disagreement with the POC, as required by the Hospice's policy.

A. Based on review of a clinical record, Interdisciplinary Group meeting minutes, Agency policy and staff interview, it was determined that the Interdisciplinary Group failed to review the POC as frequently as patient's condition required. This was found in 1 of 3 (Pt. #3) clinical records reviewed. Findings include: 1. Pt. #3. SOC 12/14/21. Hospice Diagnosis: Senile Degeneration of Brain Not Elsewhere Classified. The clinical record was reviewed on 3/31/22 at 1:00 PM. The record contained the RN visit note dated 1/29/22 which included documentation the Pt. yelled and screamed loudly for duration of the RN visit. The POA was convinced the Pt. was being over-medicated, and that the Hospice RN "agreed that a "medication evaluation by MD(s) would be warranted and will take place early next week. However, nurse pointed out that clearly ... is suffering right now ... 5 mg Roxanol given ..." The RN failed to notify the hospice Medical Director immediately that a medication evaluation was needed for this Pt. 2. The Interdisciplinary Group meeting minutes dated 1/6/22 included documentation of the patient's falls on 12/28/21, 1/15/22 and 1/20/22 with injury; and ongoing issues with pain, agitation and anxiousness of Pt. #3. Based on the skilled nursing assessments, the Interdisciplinary Group failed to meet the patient's needs, re-evaluate the level of care provided to this Pt., considering inpatient care for diagnostic testing and/or symptom management. 3. The hospice policy titled, "Comprehensive Assessment" was reviewed on 3/31/22 at 1:20 PM and contained: " ...5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient's condition requires..." 4. The hospice policy titled, "Interdisciplinary Group Coordination of Care" was reviewed on 3/31/22 at 1:30 PM and contained: The type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient ... The exact combination of services and the level of care will be unique to each patient ... and will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice. 5. The hospice's policy titled, "Monitoring Patient's Response/Reporting to Physician" was reviewed on 3/31/22 at 1:45 PM and included: " ...3. The patient's physician and/or the hospice Medical Director will be contacted on the same day when any of the following occur, or as applicable .... E. Changes in the patient's expected response to hospice care or medications ..." 6. During an interview with the Director of Clinical Services and the Office Manager on 3/31/22 at 3:15 PM, the Director of Clinical Services confirmed the Hospice failed to review Pt. #1's POC, as frequently as patient's condition required.

A. Based on a clinical record review, Interdisciplinary Group meeting minutes, Agency policy and staff interview, it was determined the Hospice failed ensure effective correspondence between disciplines was conducted, information communicated to others and contained in the clinical record was accurate. This was found in 1 of 3 (Pt. #3) clinical records reviewed. Findings include: 1. Pt. #3. SOC 12/14/21. Hospice Diagnosis: Senile Degeneration of Brain Not Elsewhere Classified. The clinical record was reviewed on 3/31/22 at 1:00 PM. The record contained the Hospice RN visit note dated 1/11/22 which included the FN reported earlier that morning, the Pt. was given Haldol due to screaming. Pt. also received Morphine and Lorazepam PRN. The RN visit note also included the Hospice RN spoke with the Primary Care Physician's Nurse Practitioner and requested a medication review. The clinical record lacked documentation of whether a medication review was conducted and if so, the outcome of the review. The record included the Hospice's Discharge Summary completed by a RN and dated 1/31/22. The Summary included documentation the POA had concerns of the Pt. being over medicated. The POA revoked hospice and had the Pt. sent to the hospital. The same Discharge Summary included documentation the patient's discharge condition was "stable" and the reason for the hospice discharge was the Pt. had " Moved Outside Service Area". The clinical record was inaccurate and lacked documentation the Pt. was unstable, and reason for discharge was that hospice was revoked and Pt. was sent to the hospital. 2. The hospice's policy titled, "Interdisciplinary Group Coordination of Care" contained: " ...6. Written evidence of care coordination will be found ...in the patient's clinical record, and will involve the hospice patient's attending physician." 3. The hospice policy titled, "Clinical/Service Data Collection" was reviewed and included: " ...Documentation in the clinical/service record will be ...accurate ...3. Entries into the clinical/service record will be ... concise, and specific statements of fact ..." 4. During an interview with the Director of Clinical Services and the Office Manager on 3/31/22 at 3:15 PM, the Director of Clinical Services confirmed the above findings.