Every finding on record at Unicare Hospice Inc

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 10 (20%) clinical records reviewed for patients who received hospice aide services, the agency did not ensure that hospice aide supervision by a registered nurse occurred in the patient's home at least every 14 days. DOCUMENT 1: The agency policy HR.60, titled Employee Supervision, dated December 6, 2024, stated in part, "A registered nurse (RN) must make an on-site visit to the patient's home no less frequently than every 14 days." CLINICAL RECORD 2: The patient elected hospice benefit on 10/30/2025. The Interdisciplinary Group completed an updated plan of care on 04/28/2026, and ordered an aide visit five times a week. The aide plan of care was updated on 04/28/2026. The hospice aide completed and documented all visits as ordered. Registered nurse supervision was conducted on 04/14/2026, and again on 05/01/2026. The supervision visit was 17 days apart. CLINICAL RECORD 5: The patient elected hospice benefit on 05/02/2025. The Interdisciplinary Group completed on 04/27/2026 and ordered an aide visit three times a week. The aide plan of care was ordered on 02/26/2026. The hospice aide completed and document all visits as ordered. Registered nurse supervision was conducted on 04/09/2026, and then again on 04/24/2026. The supervision visit was 15 days apart. An interview was conducted on 05/06/2026, with the Clinical Manager and Hospice Director. The clinical records findings were discussed. They agreed that the aide supervision for both patients did not occur every 14 days.

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; 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, document review, and interview. In 1 of 1 (100%) clinical record review for a patient who revoked the hospice benefit, the agency did not ensure a discharge summary was created and sent to the patient's community attending physician. DOCUMENT 2: The agency's policy PE.20 titled Patient Discharge, dated September 1, 2024, stated in part, "The hospice will forward copies of the following to the patient's attending physician upon revocation and discharge from the hospice's services. The hospice discharge summary, which includes but is not limited to a summary of the patient's care, the patient's current POC, the latest physician orders, and any other documentation requested or that may assist with the patient's post-discharge continuity of care." CLINICAL RECORD 12: The patient elected hospice benefit on 04/04/2026. The patient revoked the hospice benefit on 04/18/2026, to seek curative treatment. There is no evidence that a discharge summary was created and sent to the community attending physician. An interview was conducted on 05/06/2026, with the Clinical Director and Hospice Director. They agreed the discharge summary was not created or sent to the community physician. Additionally, they stated, "Our EMR (electronic medical record) system does not create a discharge summary".

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. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 5 (20%) records reviewed it was revealed that the agency did not ensure that the medication profile contained the patient's current prescription medications. at initial and updated plan of care review. Document 6: The Administrative Policy Manual Medication List and Monitoring PC.17 read, "The Hospice will maintain a current, accurate Medication Profile of all prescription and over the counter medications taken by the patient." Clinical Record 4: The plan of care dated 06/06/2023 included an order for oxygen at 2-4 liters per minute via nasal cannula as needed for shortness of breath. The current medication profile read Oxygen 2-4 liters per minute via nasal cannula continuous. The interdisciplinary team meeting dated 06/12/2023 documented medication profile review and did not show evidence that the medication profile was used to reconcile the medications. During interview 06/22/2023, the Administrator stated the record had been reviewed and medication profile had been corrected.

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 and interview. In 2 of 5 (40%) records reviewed it was revealed that the agency did not ensure that all entries in the patient record were authenticated and dated by the person performing the care. Clinical Record 4: The registered nurse visit note dated 06/03/2023 lacked a date with the associated signature and credentials at the time of the review. Clinical Record 5: The bereavement assessment dated 05/29/2023 completed by the chaplain lacked a signature and date at the time of the review. During interview on 06/22/2023, the Administrator stated the records were reviewed and the missing credentials with dates had been corrected.