Every finding on record at Triangle Care Hospice LP

It is required that the hospice designate a registered nurse member of the Interdisciplinary group (IDG) to: Provide coordination of care; Ensure continuous assessment of each patient’s and family’s needs; Ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidence by clinical record review and interview. In 1 of 14 (7%) clinical record review with hospice aide services revealed the agency did not ensure the implementation of the IDG plan of care by the registered nurse (RN). CLINICAL RECORD 11: The Plan of Care (POC)Order dated 03/15/2024 identified that the clinical record did not include an order for hospice aide services that included a frequency. During a joint record review and interview on 03/07/2025, the Director of Nursing/Registered Nurse confirmed no documented evidence of physician order that included the aide frequency.

It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, under the direction of a physician. The psychosocial assessment addresses the patient’s and the family’s adjustment to the terminal illness, the social and emotional factors related to the terminal illness, the presence or absence of adequate coping mechanisms, family dynamics and communication patterns, financial resources and any constraints, the caregiver’s ability to function effectively, obstacles and risk factors that may affect compliance with the plan of care, family support systems to facilitate coping with end-of-life issues. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed revealed the agency did not ensure that medical social services were provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services. CLINICAL RECORD 5: The patient's date of election was 10/13/2023. The Plan of Care Order dated 10/13/2023 documented medical social worker (MSW) frequency 1/mo. (once a month) and prn. The MSW missed visit form dated 02/02/2024 stated, "SW (social worker) attempted to complete routine visit via telephone. Pt did not respond or call back. SW will follow up next month." There was no further attempt for February 2024. CLINICAL RECORD 7: The patient's date of election was 12/20/2023. The IDT Meeting note dated 03/01/2024 documented "MSW frequency 1/mo. and prn." The MSW visit dated 03/01/2024 had a status of "not started," and there was no other documented evidence for the March 2024 visit. CLINICAL RECORD 8: The patient's date of elections was 01/31/2024. The IDT Meeting note dated 07/05/2024 documented "MSW frequency 1/mo. and prn." The MSW missed visit form dated 07/31/2024 stated, "Attempt to reach to schedule visit, no answer to phone or return call from patient's family." There was no documented evidence of an attempt for July 2024. CLINICAL RECORD 9: The patient's date of election was 07/04/2023. The IDG Meeting note dated 10/27/2023 documented Medical Social Worker frequency 1/mo. (once a month) and prn. There was no documented evidence for a MSW visit for November 2023. The IDT Meeting notes dated 03/01/2024, 07/05/2024, 08/02/2024, 09/27/2024, and 11/08/2024 documented "MSW frequency 1/mo. and prn." The MSW Visit dated 03/01/2024 had a status of "not started," and there was no other documented evidence for the March 2024 visit. The MSW missed visit form dated 07/31/2024 stated, "Attempt to make monthly visit. No answer to phone to schedule visit. No MSW visit this month. Will attempt visit again next month and PRN (as needed)." The MSW missed visit form dated 08/30/2024 stated, "Attempt to make monthly visit. No answer to phone to schedule visit. No MSW visit this month. Will attempt visit again next month and PRN (as needed)." The MSW missed visit form dated 10/25/2024 stated, "No answer to phone calls to patient to schedule visit. Will attempt visit again next month and PRN patient request." There was documented evidence of further attempts for July, August, and October 2024 MSW visits. CLINICAL RECORD 11: The patient's date of election was 08/15/2022. The IDT Meeting note dated 07/05/2024 documented "MSW frequency 1/mo. and prn." The MSW visit dated 03/01/2024 had a status of "not started," and there was no other documented evidence for the March 2024 visit. During a joint record review and interview on 03/07/2025, the Administrator/Director of Nursing/Registered Nurse/Chaplain/Bereavement Coordinator/Volunteer Coordinator confirmed that there was no documented evidence that social work services were provided during the times identified

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 Physician order. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure physician orders were included in the clinical record. CLINICAL RECORD 5: The patient's date of discharge was 08/07/2024. There was no documented evidence of a physician's order to discharge the patient due to no longer being terminally ill. CLINICAL RECORD 11: The Plan of Care (POC)Order dated 03/15/2024 identified that the clinical record did not include an order to establish the hospice aide services. During a joint record review and interview on 03/07/2025, the Director of Nursing/Registered Nurse confirmed no documented evidence of physician orders for the discharge and for the aide services.

It is required that all entries must be legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice This standard was not met as evidence by clinical record review and interview. In 1 of 14 (7%) records reviewed revealed the agency did not ensure that all physician orders were complete. CLINICAL RECORD 2: The patient's date of election was 12/12/2024. The Plan of Care dated 12/12/2024 stated in part, "Patient with unstageable pressure areas to bilateral hips, left shoulder blade and mid back on her spine. All areas cleansed with wound cleanser, pat dry, Dakin's wet to dry dressings applied and covered with dry dressing." The Physician Order dated 12/12/2024 documented "Dakins (1/4 strength) External Solution 0.125%... apply to necrotic wound bed with scheduled wound care and prn dressing change - do not apply to healthy skin." There was no documented evidence in the clinical record for the frequency for the wound care. During a joint record review and interview on 03/07/2025, the Director of Nursing confirmed the physician’s orders for the above wound care was incomplete.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 4 of 5 (80%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 5: The patient's date of discharge was 08/07/02024. There was no documented evidence that a discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 7: The patient's date of discharge was 07/12/2024. There was no documented evidence that a discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 8: The patient's date of discharge was 11/02/2024. There was no documented evidence that a discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 9: The patient's date of discharge was 12/05/02024. There was no documented evidence that a discharge summary was forwarded to the patient's attending physician. During a joint record review and interview on 03/07/2025, the Administrator/Director of Nursing/Registered Nurse/Chaplain/Bereavement Coordinator/Volunteer Coordinator confirmed that the records lacked evidence that the discharge summary was forwarded to the patient’s attending physician.

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; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 4 of 5 (80%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to 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; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. CLINICAL RECORD 5: The patient's date of discharge was 08/07/2024. There was no documented evidence that the discharge summary included the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care to the patient’s attending physician. CLINICAL RECORD 7: The patient's date of discharge was 07/12/2024. There was no documented evidence that the discharge summary included the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care to the patient’s attending physician. CLINICAL RECORD 8: The patient's date of discharge was 11/02/2024. There was no documented evidence that the discharge summary included the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care to the patient’s attending physician. CLINICAL RECORD 9: The patient's date of discharge was 12/05/2024. There was no documented evidence that the discharge summary included the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care to the patient’s attending physician. During a joint record review and interview on 03/07/2025, the Administrator/Director of Nursing/Registered Nurse/Chaplain/Bereavement Coordinator/Volunteer Coordinator confirmed that the record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care to the patient’s attending physician.

It is required that patient care instructions for a hospice aide are prepared by a RN who is a member of the clinical team. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interview. In 1 of 5 (20%) records reviewed with hospice aide services the hospice aide plan of care did not include specific instructions for Foley care Record #38718: The patient elected the hospice benefit on 10/15/21 with a primary diagnosis of cirrhosis of the liver. The clinical record includes an order for Foley catheter insertion on 4/3/22. The aide POC was last updated on 3/22/22 with an end date of 5/20/22 (beginning and end dated of the current certification period). For this period to date the aide POC instructs “Incontinent Care – every visit.” The aide POC was not updated to include instructions related to Foley care. On 4/4/22 the aide POC states, in part, as comment to instruction of incontinent care to be completed every visit, “Complete (catheter care done as well, RNCM notified).” On 4/5/22, 4/6/22, 4/7/22, and 4/8/22 the aide states in comments “Complete” in response to “Incontinent care to be completed every visit.” On 4/9/22 the clinical record includes an order to remove the Foley catheter. The aide POC was not updated to include catheter care during the period of 4/3/22 through 4/9/22, when the Foley was inserted. On 4/28/22 during review of survey findings, the Administrator, Director of Clinical Services and Alternate Director of Clinical Services agreed the aide POC was not updated to include instructions for Foley care.

It is required that if a patient revokes the election of hospice care the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by a review of a document, clinical record and interview. 1 of 1 (100%) record reviewed with a revocation from hospice services lacked a discharge summary and documentation that a discharge summary was forwarded to the patient’s attending physician. Record #16371: The patient elected the hospice benefit on 8/5/21 with a primary diagnosis of Heart Disease. Documentation in the clinical record dated 2/25/22 includes a signed revocation statement and a signed order from the Medical Director stating, “Patient discharge due to patient/cg choice to revocate for aggressive treatment.” Review of the clinical record revealed a hospice discharge summary and documentation of a discharge summary was forwarded to the patient’s attending physician was not in the record. Hospice policy PE.7 titled “Patient Revocation” states, in part, “The patient’s attending physician is notified by the Hospice of the patient’s intent to revoke the hospice benefit. The Hospice will forward copies of the following information to the patient's attending physician: the hospice discharge summary that includes but is not limited to: A summary of the patient's care (pain management, symptoms, and treatments); the patient's current plan of care, including the current medication profile; the latest physician orders; and any other documentation requested or that may assist with the patient's post-discharge continuity of care.” On 4/28/22 during review of survey findings, the Administrator, Director of Clinical Services and Alternate Director of Clinical Services agreed the clinical record did not include documentation of a discharge summary or that a discharge summary was forwarded to the patient’s attending physician.