Holistic Hospice Care Services, Inc.

“It is required that the written Patient Bill of Rights includes the right to be informed about the scope of services the hospice provides and any specific limitations on those services; and the right to receive effective pain management and symptom control for conditions related to the terminal illness. This CONDITION was not met as evidenced by clinical record review, document review and interview. The hospice agency failed to ensure the following: that patients received information about the scope of services that the hospice will provide and specific limitations on those services [HPFC.2.D/L519]; that patients received effective pain management and symptom control for conditions related to the terminal illness [HPFC.2.D/L512] and that care and services provided to hospice patients followed the individualized plan of care established by the hospice interdisciplinary group as related to ongoing monitoring of patients’ pain [HCPC.19.I/L543]. The cumulative effect of these systemic problems resulted in the inability of the hospice to ensure safe, quality patient care. This is a CMS CONDITION level finding at CFR 418.52.”

“It is required that the hospice policies and procedures address the minimum information provided to facilitate patient evacuation and transportation including if the patient is mobile or not; if the patient has life-dependent equipment, and if so, is it able to be transported (e.g. battery operated, size, condition, etc.); and any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g. deaf, non-English speaking, etc.). This standard was not met as evidenced by clinical record review, document review and interview. In 8 of 8 (100%) clinical records reviewed from the start of care, the organization did not ensure that all information necessary to facilitate patient evacuation and transportation was documented in each patient’s emergency plan. Document 2: Document titled Emergency Plan includes items to be completed as follows: Patient name, diagnosis, allergies, in case of medical emergency contact Holistic Hospice Care Services; Physician name/telephone; Closest relative/friends name/telephone; name of Pharmacy/telephone; and Name of DME provider/telephone. Clinical Record 1: The patient was admitted to hospice services on 8/23/2023 with a primary terminal diagnosis of Alzheimer’s Disease. The patient’s initial RN Assessment documented on 8/23/2023 indicates that the patient is totally bedbound, nonverbal, and on oxygen at 2 liters/minute per nasal cannula continuously. The patient’s documented emergency plan does not include the patient’s lack of mobility, dependence on oxygen, or that she has Alzheimer’s dementia. Clinical Record 2: The patient was admitted to hospice services on 7/26/23 and recertified into the second benefit period on 10/24/23-1/21/24 with a primary terminal diagnosis of liver cell carcinoma. The RN recertification assessment indicates that the patient is sometimes bed and sometimes chair-bound and on oxygen at 2 liters/minute per nasal cannula continuously. The patient’s documented emergency plan does not include the patient’s lack of mobility, dependence on oxygen, or that he primarily speaks Armenian. Clinical Record 3: The patient was admitted to hospice services on 7/31/2023 and recertified into the second benefit period on 10/29/23-1/26/24 with a primary terminal diagnosis of heart failure and secondary diagnoses of Alzheimer’s and Dementia. The RN recertification assessment indicates that the patient is sometimes bed and sometimes chair-bound and on oxygen at 2 liters/minute per nasal cannula continuously. The patient’s documented emergency plan does not include the patient’s lack of mobility, dependence on oxygen, or that she primarily speaks Armenian and that she has Alzheimer’s with Dementia. Clinical Record 4: The patient was admitted to hospice services on 6/19/2023 and recertified into the second benefit period on 9/17/23-12/15/23 with a primary terminal diagnosis of acute on chronic combined systolic and diastolic (congestive) heart failure. The RN recertification assessment indicates that the patient is on oxygen at 2 liters/minute per nasal cannula continuously. The patient’s documented emergency plan did not include the patient’s dependence on oxygen. Clinical Record 5: The patient was admitted to hospice services on 2/1/2023 and was recertified into benefit period 2 effective 5/2/2023-7/30/2023. On 7/29/23, the day prior to the end of the second benefit period, the patient was live discharged due to a move out of the hospice’s service area. The patient’s primary terminal diagnosis is acute on chronic combined systolic and diastolic (congestive) heart failure. The RN recertification assessment dated 5/3/2023 indicates that the patient is unable to ambulate more than 2-3 steps and is on oxygen at 2 liters/minute per nasal cannula continuously. The patient’s documented emergency plan did not include his limited mobility, dependence on oxygen, or that he primarily speaks Armenian. Clinical Record 6: The patient was admitted to hospice services on 2/6/2023 and was recertified into benefit period 2 effective 5/7/2023-8/4/2023. On 8/2/2023, two days prior to the end of the second benefit period, the patient was live discharged to a hospital with respiratory distress. The patient’s primary terminal diagnosis is Alzheimer’s Disease with Dementia. The patient’s RN recertification assessment indicates that the patient is totally bedbound, and on oxygen at 2 liters/minute per nasal cannula continuously. The patient’s documented emergency plan did not include the patient’s lack of mobility, dependence on oxygen, or that he has Alzheimer’s dementia. Clinical Record 7: The patient was admitted to hospice services on 3/7/2023 into the second benefit period. The patient was live discharged to a hospital on 4/5/2023. The patient’s primary terminal diagnosis is malignant neoplasm of the pylorum antrum. The RN initial assessment indicates that he is both totally bedbound and depends on a walker or cane, and that he is on oxygen at 2 liters/minute per nasal cannula continuously. The patient’s documented emergency plan did not include the patient’s lack of mobility, dependence on oxygen, or that he primarily speaks Armenian. Clinical Record 8: The patient was admitted to hospice services on 1/23/2023 and was discharged to a hospital on 3/3/2023. The patient’s primary terminal diagnosis is malignant neoplasm of the pylorum antrum. The RN initial assessment indicates that he is totally bedbound and that he is on oxygen at 2 liters/minute per nasal cannula continuously. The patient’s documented emergency plan did not include the patient’s lack of mobility, dependence on oxygen, or that he primarily speaks Armenian. During the Exit Conference on 11/4/2023, the Alternate Administrator/Alternate DPCS/RN stated, “It’s okay if the Emergency Plan does not include that the patient does not speak English or that they are on oxygen or they need a wheelchair or ambulance to leave home. We speak Armenian and our patients speak Armenian. If they have an emergency, we can tell [first responders] anything they need to know about the patient. We know them all.””

“It is required that the written Patient Bill of Rights includes the right to receive effective pain management and symptom control for conditions related to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 10 of 11 (91%) clinical records reviewed, the organization did not ensure that the patient’s pain and symptoms related to the terminal illness and related conditions were managed effectively 24 hours a day/7 days per week according to the patient’s plan of care. Clinical Record 1: The patient was admitted to hospice services on 8/23/2023 with a primary terminal diagnosis of Alzheimer’s Disease. The patient’s initial plan of care (POC) and POC updates included the following Pain Goal: “In 24-48 hours and throughout certification benefit period patient pain will be managed effectively by current pain medications as evidenced by increasing comfort with pain level 0-3/10.” Weekly skilled nursing visit notes documented 8/30, 9/6, 9/13, 9/20, 9/27, 10/4, 10/11, and 10/18/23 noted that the patient was experiencing “severe pain” of 8-9/10 at the onset of the skilled nursing visit and 3/10 by the end of the visit after pain medications and other non-pharmacologic interventions from the POC were implemented. Clinical Record 2: The patient was admitted to hospice services on 7/26/23 and recertified into the second benefit period on 10/24/23-1/21/24 with a primary terminal diagnosis of liver cell carcinoma. The patient’s initial plan of care (POC) and POC updates included the following Pain Goal: “In 24-48 hours and throughout certification benefit period patient pain will be managed effectively by current pain medications as evidenced by increasing comfort with pain level 0-3/10.” Weekly skilled nursing visit notes documented each week between 8/4/2023 through the week of 10/22/23 noted that the patient was experiencing “severe pain” of 8-9/10 at the onset of the skilled nursing visit and 3/10 by the end of the visit after pain medications and other non-pharmacologic interventions from the POC were implemented. Clinical Record 3: The patient was admitted to hospice services on 7/31/2023 and recertified into the second benefit period on 10/29/23-1/26/24 with a primary terminal diagnosis of heart failure and secondary diagnoses of Alzheimer’s and Dementia. The patient’s initial plan of care (POC) and POC updates included the following Pain Goal: “In 24-48 hours and throughout certification benefit period patient pain will be managed effectively by current pain medications as evidenced by increasing comfort with pain level 0-3/10.” The initial POC and POC updates also included the following Respiratory goal: “In 1-2 days and onward patient will experience decreased episodes of SOB at rest as evidenced by an 02 saturations at 95%.” Eleven (11) weekly skilled nursing visits reviewed between the weeks of 8/7/23 and 10/16/23 included documentation that the patient was experiencing severe back pain at start of each visit with a pain level of 8-9/10. Oxygen saturation levels were at 80-83%. Pain medication was administered, and oxygen tubing was adjusted, or 02@2L/nasal cannula was applied as ordered and at the end of each visit, the patient reported a pain level of 3/10 and had oxygen saturation levels of 86-88%. Clinical Record 4: The patient was admitted to hospice services on 6/19/2023 and recertified into the second benefit period on 9/17/23-12/15/23 with a primary terminal diagnosis of acute on chronic combined systolic and diastolic (congestive) heart failure. The patient’s recertification POC effective 9/17/23 and POC updates included the following Pain Goal: “In 24-48 hours and throughout certification benefit period patient pain will be managed effectively by current pain medications as evidenced by increasing comfort with pain level 0-3/10.” On 10/11/23, the patient was documented as “having pain, change in condition, Hydrocodone 5/Acetaminophen 325 every 6 hours DC’d and Hydrocodone 10/Acetaminophen 325 ordered every 8 hours.” The next skilled nursing documentation occurred following a nurse visit one week later on 10/19/23, “...called Dr. The patient has pain. Received new med order for Ibuprofen 800mg twice daily for moderate pain.” Clinical Record 5: The patient was admitted to hospice services on 2/1/2023 and was recertified into benefit period 2 effective 5/2/2023-7/30/2023 with a primary terminal diagnosis of acute on chronic combined systolic and diastolic (congestive) heart failure. The patient’s recertification plan of care (POC) and POC updates included the following Pain Goal: “In 24-48 hours and throughout certification benefit period patient pain will be managed effectively by current pain medications as evidenced by increasing comfort with pain level 0-3/10.” The recertification POC and POC updates also included the following Respiratory goal: “In 1-2 days and onward patient will experience decreased episodes of SOB at rest as evidenced by an 02 saturations at 95%.” The RN Recertification Assessment documented on 5/3/23, stated in part, “...Patient is uncomfortable because of pain. O2 Sat 83% on 2L of O2. ...Breathing labored, tachypneic, and crackles in lungs. Head of bed elevated and oxygen connections checked. Pt complained of back pain and left hand pain 9/10, given Hydrocodone/APAP. At the end of the visit, the patient had pain 3/10 and 02 saturation level of 88%.” The last skilled nursing visit prior to the live discharge due to a move (7/29/23) was documented on 7/25/23, “... SN reported to DPCS and MD that patient had pain in lower back and bilateral knees with pain scale 8/10. ...administered Hydrocodone, Lidocaine patch. SN left patient in comfort, pain was dropped to a tolerable level of 3/10 at end of visit. ...Will continue to monitor.” Clinical Record 6: The patient was admitted to hospice services on 2/6/2023 and was recertified into benefit period 2 effective 5/7/2023-8/4/2023. On 8/2/2023, two days prior to the end of the second benefit period, the patient was live discharged to a hospital with respiratory distress. The patient’s recertification plan of care (POC) and POC updates included the following Pain Goal: “In 24-48 hours and throughout certification benefit period patient pain will be managed effectively by current pain medications as evidenced by increasing comfort with pain level 0-3/10.” The recertification POC and POC updates also included the following Respiratory goal: “In 1-2 days and onward patient will experience decreased episodes of SOB at rest as evidenced by an 02 saturations at 95%.” The RN recertification assessment documented on 5/6/23 stated in part, “Pt uncomfortable because of pain; O2@2L 80%Sat, Patient has pain in bilateral knees 8/10. Tramadol HCL 50mg administered. In 35 minutes patient pain level 3/10 and O2 Sat 86%.” Skilled nursing visit documented on 7/25, “Pain 5/10, Tylenol given, decreased to 3/10”. Skilled nursing visit documented on 7/29, “SN contacted DPCS and MD regarding pain 7/10 in back. RN administered Tramadol. after 30 minutes pain decreased to tolerable level 3/10. Skilled nursing visit 8/1, “Pain 8/10. Tramadol given, 4/10 in 35 minutes” Clinical Record 7: The patient was admitted to hospice services on 3/7/2023 into the second benefit period with a primary terminal diagnosis of Malignant Neoplasms of the Pylorum Antrum. The patient was live discharged to a hospital on 4/5/2023. The patient’s initial plan of care (POC) and POC updates included the following Pain Goal: “In 24-48 hours and throughout certification benefit period patient pain will be managed effectively by current pain medications as evidenced by increasing comfort with pain level 0-3/10.” The initial POC and POC updates also included the following Respiratory goal: “In 1-2 days and onward patient will experience decreased episodes of SOB at rest as evidenced by an 02 saturations at 95%.” Initial RN assessment documented on 3/7/23 states in part, “Back pain 8/10, Norco given; pain reduced to 3/10. 02@2L sat 80%, head of bed elevated, in 40 minutes saturation elevated to 85%. Weekly skilled nursing visits 3/12, 3/19, 3/26 all noted that the patient’s pain level was 8-9/10 at the start of the visit, 02 saturation in the low 80%s, and after POC interventions the patient’s pain level was 3/10 and 02 saturation level was 86-88%. Clinical Record 8: The patient was admitted to hospice services on 1/23/2023 with a primary terminal diagnosis of Malignant Neoplasm of the Pylorum Antrum and live discharged to a hospital on 3/3/2023. The patient’s initial plan of care (POC) and POC updates included the following Pain Goal: “In 24-48 hours and throughout certification benefit period patient pain will be managed effectively by current pain medications as evidenced by increasing comfort with pain level 0-3/10.” The initial POC and POC updates also included the following Respiratory goal: “In 1-2 days and onward patient will experience decreased episodes of SOB at rest as evidenced by an 02 saturations at 95%.” Initial RN assessment documented on 1/23/23 states in part, “Pain 8/10; Tylenol 500mg 2 tabs not effective and Norco administered. 02@2L 83% on 2L; in 40 minutes O2 saturation was 87% and pain 3/10.” Skilled nursing visits documented the weeks of 1/29, 2/5, 2/12, 2/19, and 2/26 all noted that the patient’s pain level was 8-9/10 at the start of the visit, 02 saturation in the low 80%s, and after POC interventions the patient’s pain level was 3/10 and 02 saturation level was 87-89%. Clinical Record 9: The patient was admitted to hospice services on 10/6/2020 with a primary terminal diagnosis of benign neoplasm of the brain. The patient was live discharged to the hospital on 11/28/2020. Pain goal: “Bring down pain to less than 3 or stated comfort level of pain by patient after nursing intervention/education. Keep pain below SIT level for comfort. Comfort care for the patient.” Respiratory goal: “Lungs will be clear. Pt will verbalize and/or express decreased SOB during activities. No labor breathing. SNV note 11/21/2020-Pain level 9, 02 Sat 75% on RA with severe dyspnea. Summary note: “Patient was in severe pain. Pain scale was 9/10, pain location was bilateral knees and lower back, patient was also complaining of a headache. …administered Tramadol 50mg po. …comfort measures was provided, reassessed pain before end of the visit with result of 2/10. O2 saturation noted at 75%, Patient had difficulty breathing, refused to use oxygen at first then agreed to use 02@2L/nc continuously. …By the end of the visit the patient’s 02 saturation level was 84%. …” SNV note 11/24/23-“…pain was observed on patient’s bilateral knees, also patient complained of headache with pain level of 6/10. Instructed caregiver to administer Ibuprofen 600mg. …pain was dropped to 1/10 by the end of the visit. …O2 saturation was 82% on O2@2L/min continuously per nasal cannula. SN noted tube was not correctly connected, fixed. …In 20 minutes rechecked oxygen saturation with the result of 89%. …” SN visit note 11/26/23 “…Pt complaining of severe pain in her back. Asking skilled nurse to help, crying. Observed pain in patient’s back with scale of 8/10. Patient uncomfortable. …SN administered Tramadol 50mg PO. …Reassessment was done in 30 minutes with result of 3/10. …Oxygen saturation was 79% on oxygen 2L/min continuously via nasal cannula, patient was cyanotic, gasping for air, severe SOB noted, SN change patient’s oxygen to E-tank for 20 minutes. O2 saturation elevated to 88%. SN switched to concentrator.” Clinical Record 10: The patient was admitted to hospice services on 10/15/2020 with a primary terminal diagnosis of Unspecified combined systolic and diastolic congestive heart failure and was live discharged to the hospital on 12/30/2020. Pain goal: “Bring down pain to less than 3 or stated comfort level of pain by patient after nursing intervention/education. Keep pain below SIT level for comfort. Comfort care for the patient.” Pain goal: “In 24-28 hours patient will be managed effectively with current pain medications and non-pharmacological interventions. Respiratory goal: “Lungs will be clear. Pt will verbalize and/or express decreased SOB during activities. No labor breathing. Respiratory goal: “in 1-2 days patient will express or demonstrate decreased episodes of SOB at rest as evidenced by oxygen saturations maintain above 95%” 12/2 SNV note-“patient was cyanotic, gasping for air, had severe shortness of breathing. Patient was sweating. Oxygen saturation was 77%. SN gently applied oxygen to patient’s nasal cannula, elevated patient’s head. …before leaving reassessed patient oxygen saturation, O2 saturation at 83%. Patient was comfortable. All needs are met at this time.” Next visit 12/8 12/10 SNV note-“patient was in severe pain with pain scale 9;10 in her bilateral knees and shoulders. RN opened comfort kit and administered Tramadol 50mg po…. O2 sat was 75% on oxygen 2L/min continuously via nasal cannula. Pt had labored breathing, experiencing severe shortness of breath. RN checked the connections and noted that the nasal cannula tube was not connected. RN demonstrated right way of fixing the tubing to the caregiver. …Before leaving reassess patient’s comfort status, pain decreased to 4/10 and O2 saturation 81%. …” Next visit 12/16 12/16 SNV notes-“…Patient noted 7/10 pain in lower back and bilateral lower extremities. SN gave Tramadol 50mg PO. …Reassessed pain before leaving, pain intensity was 3/10. CM notified. …O2 sat 81%, provided comfort and rechecked O2 sat after 45 minutes with a reading of 89%. 12/18 severe pain in lower back 8/10, Tramadol administered, reassessed pain before end of visit 3/10. O2 sate 84%. Elevated patients head and opened windows. After 45 minutes oxygen saturation with a reading of 89%. 12/24 pain scale is 9/10 generalized body pain, aggravating with movement and alleviated with rest and medications. RN administered Morphine Sulfate 100mg/5ml 0.25ml sublingually. …02 saturation 83% on 2l/min O2 continuous. Tubing was dislodged. Replaced tubing and 02 saturation was 87%. By the end of the visit the patient appears comfortable, pain level drops 2/10.” 12/25 RN called patient daughter to get report on conditions. The daughter reports patient is comfortable, sitting on the sofa with legs elevated. During the wrap-up conference on 11/1/23 and 11/9/23, examples from the clinical records were reviewed with the Administrator/DPCS that revealed that pain levels and oxygen saturation goals were not being achieved or maintained 24 hours a day/7 day a week throughout the certification period according to each patient’s documented Pain and/or Respiratory POC goals. During the exit conference on 11/2/23, the Alternate Administrator/Alternate DPCS/RN stated, “We can only do what the family wants us to do. If they don’t want us to do other things or make any changes, we can’t do it without their permission.””

“It is required that the written Patient Bill of Rights includes the right to be informed about the scope of services the hospice provides and any specific limitations on those services. This standard was not met as evidenced by clinical record review, document review and interview. In 8 of 8 (100%) clinical records reviewed from the start of care, the organization did not ensure that patients were informed about the scope of services provided and any specific limitations on those services. Document 6: A document with the header “Payment Authorized and Assignment of Benefits” under the subheading “Hospice Services” included an explanation of Routine Home Care, Respite Care, Continuous Home Care, and Hospitalization available to patients in the format as follows: “Routine Home Care. I understand that hospice services are delivered primarily in the home by a team of hospice professionals, staff, and volunteers. A written plan of care will be established to include an assessment of the patient/family needs and the scope and frequency of services needed for the palliation and management of the terminal illness and related conditions. These services are available both on a scheduled basis and as needed. These services may include: nursing, physician care, social work, pastoral or other counseling, physical therapy, occupational therapy, speech-language pathology, home health aide/homemaker services, medical supplies, medications, and biological. Respite Care. This type of care is provided to offer relief and rest to caregivers who provide care to the hospice patient. Respite care allows caregivers this relief by providing trained workers (or in some cases a volunteer) to be with the patient when the caregivers need a break from the care-giving duties. This helps caregivers avoid burnout, stress, and fatigue. Respite care is available for five (5) days per certification period. Continuous Home Care. I understand that inpatient hospice care is provided in an inpatient bed when it is deemed necessary by the interdisciplinary team. I understand that general inpatient care intended for short-term stays required for pain control or acute or chronic symptom management. The hospice agrees to provide short-term hospice inpatient care for such a patient in SNF provided that the facility has a Registered Nurse (RN) available on the premises 25 hours a day. Hospitalization. May be required for certain procedures of care, and those will be arranged through a contracted facility of the hospice.” The form provided to patients/families did not include a complete explanation of Respite Care (missing setting/contracted facility), included an explanation of General Inpatient Care in the area labeled to include an explanation of Continuous Home Care; did not include an explanation of the Continuous Home Care, and indicated Hospitalization was one of the four levels of care. This form was included in all 8 patient records and observed in 2 of the 3 home visit patient folders (Home Visit 1 and Home Visit 3). Clinical Record 1: The patient was admitted to hospice services on 8/23/2023. The Administrator/DPCS provided a patient binder for review on 10/31/23 which included the “Payment Authorized and Assignment of Benefits” form, Hospice Services section, with an incomplete explanation of Respite Care, an inaccurate explanation of Continuous Care, and no explanation for General Inpatient level of care. Clinical Record 2: The patient was admitted to hospice services on 7/26/23. The Administrator/DPCS provided a patient binder for review on 10/31/23 which included the “Payment Authorized and Assignment of Benefits” form, Hospice Services section, with an incomplete explanation of Respite Care, an inaccurate explanation of Continuous Care, and no explanation for General Inpatient level of care. Clinical Record 3: The patient was admitted to hospice services on 7/31/2023. The Administrator/DPCS provided a patient binder for review on 10/31/23 which included the “Payment Authorized and Assignment of Benefits” form, Hospice Services section, with an incomplete explanation of Respite Care, an inaccurate explanation of Continuous Care, and no explanation for General Inpatient level of care. Clinical Record 4: The patient was admitted to hospice services on 6/19/2023. The Administrator/DPCS provided a patient binder for review on 10/31/23 which included the “Payment Authorized and Assignment of Benefits” form, Hospice Services section, with an incomplete explanation of Respite Care, an inaccurate explanation of Continuous Care, and no explanation for General Inpatient level of care. Clinical Record 5: The patient was admitted to hospice services on 2/1/2023. The Administrator/DPCS provided a patient binder for review on 10/31/23 which included the “Payment Authorized and Assignment of Benefits” form, Hospice Services section, with an incomplete explanation of Respite Care, an inaccurate explanation of Continuous Care, and no explanation for General Inpatient level of care. Clinical Record 6: The patient was admitted to hospice services on 2/6/2023. The Administrator/DPCS provided a patient binder for review on 10/31/23 which included the “Payment Authorized and Assignment of Benefits” form, Hospice Services section, with an incomplete explanation of Respite Care, an inaccurate explanation of Continuous Care, and no explanation for General Inpatient level of care. Clinical Record 7: The patient was admitted to hospice services on 3/7/2023 into the second benefit period. The Administrator/DPCS provided a patient binder for review on 10/31/23 which included the “Payment Authorized and Assignment of Benefits” form, Hospice Services section, with an incomplete explanation of Respite Care, an inaccurate explanation of Continuous Care, and no explanation for General Inpatient level of care. Clinical Record 8: The patient was admitted to hospice services on 1/23/2023. The Administrator/DPCS provided a patient binder for review on 10/31/23 which included the “Payment Authorized and Assignment of Benefits” form, Hospice Services section, with an incomplete explanation of Respite Care, an inaccurate explanation of Continuous Care, and no explanation for General Inpatient level of care. During the wrap-up conference on 10/31/23, the Hospice Services section of the “Payment Authorized and Assignment of Benefits” form was reviewed with the Administrator/DPCS. The Administrator/DPCS confirmed that this form had been provided to all patients whose records were reviewed. The Administrator/DPCS gave the form to the consultant, who stated, “I’ll get that fixed and print the corrected form for the patient folders going forward.””

“It is required that the documented assessment of the patient’s pain includes the use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 11 (18%) of clinical records reviewed, the organization did not ensure that an appropriate standardized pain assessment tool was used to document the assessment of the patient’s pain. Document 4: A document titled “[Organization Name] Pain Scale” was included in the patient admission folder and was observed in all clinical records reviewed; signed and dated in acknowledgment of receipt by each patient/family. The document indicated that the “Verbal” Pain Scale used by the organization is as follows: “0=No Pain. 1-3=Mild Pain. 4-5=Moderate Pain. 6-9=Severe Pain. 10=Worst Pain.” The “Non-Verbal (FACES PAIN RATING SCALE) or “Wong-Baker FACES Pain Rating Scale includes facial expressions with numbers indicating “0=No Hurt. 2=Hurts Little Bit. 4=Hurts Little More. 6=Hurts Even More. 8=Hurts Whole Lot. 10=Hurts Worst.” Clinical Record 1: The patient was admitted to hospice services on 8/23/2023 with a primary terminal diagnosis of Alzheimer’s Disease with Dementia. The patient was observed to be non-verbal during the home visit observation on 11/1/23 with Staff 4 MSW. On all documented nursing visits, including the nursing visit dated 10/25/23, the patient was documented as non-verbal, and the patient’s pain was documented according to the verbal pain scale. “Patient has pain low back 9/10. ...patient left in comfort 3/10 at the end of the visit.” The patient’s pain goal also used the verbal pain scale, “In 24-28 hours and through certification pain will be managed with pain level 0-3/10.” Clinical Record 6: The patient was admitted to hospice services on 2/6/2023 and was recertified into benefit period 2 effective 5/7/2023-8/4/2023. The patient’s primary terminal diagnosis was documented as Alzheimer’s Disease with dementia. On all documented nursing visits, including the Recertification Nursing Assessment dated 5/6/23, the patient was documented as non-verbal, and the patient’s pain was documented according to the verbal pain scale “Patient has pain in bilateral knees 8/10-Tramadol HCL 50mg administered. In 35 minutes, patient pain level 3/10.” The patient’s pain goal for both the first and second benefit period also used the verbal pain scale: “In 24-28 hours and through certification pain will be managed with pain level 0-3/10.” During the wrap-up conference on 11/1/2023, the Alternate Administrator/Alternate DPCS/RN stated, “Patients are different on every visit. Sometimes they can’t talk, and sometimes they are better and can.” It was explained that the patient’s/clinical records 1 and 6 included documentation to support that the two patients were non-verbal, and that Clinical Record 1 was observed to be non-verbal during a home visit observation in which the Administrator/Alternate DPCS/RN was present. She stated, “Some days they are better than others.””

“It is required hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 10 of 11 (91%) clinical records reviewed, the organization did not ensure that hospice care and services provided to patients and their families followed an individualized written plan of care established by the interdisciplinary group (IDG) in accordance with the patient’s needs. Clinical Record 1: The patient was admitted to hospice services on 8/23/2023 with a primary terminal diagnosis of Alzheimer’s Disease. The initial RN assessment documented on 8/23/23 indicates that the patient is experiencing general body pain “9/10”, Pain medication was administered per physician orders. At the end of the initial assessment visit the patient was “comfortable” with pain “3/10”. Weekly skilled nursing visits performed in the weeks of 8/27/23 through 10/22/23 all indicate that the patient was in severe pain, rated “8/10” or “9/10” at the start of each weekly RN visit and the patient was “comfortable” with pain “3/10” at the end of each weekly RN visit. The patient’s plan of care (POC) and POC updates between 8/27/23 and 10/22/23 included a goal and interventions for pain as follows: “In 24-48 hours and throughout certification benefit period patient pain will be managed effectively by current pain medications as evidenced by increasing comfort with pain level 0-3/10. Assess/monitor pain and severity every visit. Check pain status within 48 hours. Monitor effectiveness of current treatment.” There was no documented follow-up or skilled nursing visit in 24-48 hours of each weekly nursing visit as required by the POC in order to determine if the patient’s established comfort level of 0-3/10 was being maintained or achieved with the medication regimen and interventions. Clinical Record 2: The patient was admitted to hospice services on 7/26/23 and recertified into the second benefit period on 10/24/23-1/21/24 with a primary terminal diagnosis of liver cell carcinoma. The Recertification Nursing Assessment performed prior to the second benefit period effective 10/24/23 indicated that the patient was in “severe pain” at the start of the skilled nursing visit; Hydrocodone 5mg/APAP 325mg was administered by the RN per the patient’s POC, and by the end of the visit 35 minutes later the patient was comfortable with a pain level of 3/10. There was no documented follow-up or skilled nursing visit in 24-48 hours of the Recertification Nursing Assessment as required by the POC in order to determine if the patient’s established comfort level of 0-3/10 was being maintained or achieved with Hydrocodone 5mg/APAP 325mg. Clinical Record 3: The patient was admitted to hospice services on 7/31/2023 and recertified into the second benefit period on 10/29/23-1/26/24 with a primary terminal diagnosis of heart failure and secondary diagnoses of Alzheimer’s and Dementia. The Recertification Nursing Assessment indicated that the patient was in severe pain “8/10” not relieved with Tylenol 500mg 2 tablets po. Ibuprofen 600mg 2 tabs was administered by the RN at the start of the visit per the POC, and at the end of the skilled nursing visit the patient’s pain level was rated at 3/10 and “appeared comfortable”. There was no documented follow-up or skilled nursing visit in 24-48 hours of the Recertification Nursing Assessment as required by the POC in order to determine if the patient’s established comfort level of 0-3/10 was being maintained or achieved with the patient’s medication regimen or interventions. Clinical Record 4: The patient was admitted to hospice services on 6/19/2023 and recertified into the second benefit period on 9/17/23-12/15/23 with a primary terminal diagnosis of acute on chronic combined systolic and diastolic (congestive) heart failure. A skilled nursing visit note summary documented on 10/11/2023 indicated that the patient was “having pain, change in condition”, and that Hydrocodone 5mg/APAP 325mg PO every 6 hours was discontinued, and Hydrocodone 10mg/APAP 325mg PO every 8 hours was ordered by the patient’s attending physician. There was no documented follow-up or skilled nursing visit in 24-48 hours as required by the POC in order to determine if the patient’s established comfort level of 0-3/10 was being achieved with the change in medication. The next documented skilled nursing visit was on 10/19/23, during which the RN documented that the medical director was called because the “patient has pain”. A new medication order for Ibuprofen 800mg twice daily for moderate pain was documented. There was no documented follow-up or skilled nursing visit in 24-48 hours as required by the POC in order to determine if the patient’s established comfort level of 0-3/10 was being achieved with the change in medication. Clinical Record 5: The patient was admitted to hospice services on 2/1/2023 and was recertified into benefit period 2 effective 5/2/2023-7/30/2023 with a primary terminal diagnosis of acute on chronic combined systolic and diastolic (congestive) heart failure. The Recertification Nursing Assessment documented on 5/3/2023 included a nursing summary as follows, “Patient is uncomfortable because of pain. Complaining of low back and left hand pain 9/10, given Hydrocodone 10mg/APAP 325mg PO. ...At end of the visit patient reporting comfort and pain 3/10.” There was no documented follow-up or skilled nursing visit in 24-48 hours of the Recertification Nursing Assessment as required by the POC in order to determine if the patient’s established comfort level of 0-3/10 was being maintained or achieved with the patient’s medication regimen or interventions. Clinical Record 6: The patient was admitted to hospice services on 2/6/2023 and was recertified into benefit period 2 effective 5/7/2023-8/4/2023 with a primary terminal diagnosis of terminal of Alzheimer’s disease. The Recertification Nursing Assessment documented on 5/6/2023 included a nursing summary as follows, “Patient has pain in bilateral knees 8/10”-Tramadol HCL 50mg administered. In 35 minutes, patient pain level 3/10”. There was no documented follow-up or skilled nursing visit in 24-48 hours of the Recertification Nursing Assessment as required by the POC in order to determine if the patient’s established comfort level of 0-3/10 was being maintained or achieved with the patient’s medication regimen or interventions. Clinical Record 7: The patient was admitted to hospice services into the second benefit period on 3/7/2023 with a primary terminal diagnosis of Malignant Neoplasm of Pylorum Antrum. The initial RN assessment documented on 3/7/2023 included a narrative note as follows; “Back pain 8/10, Norco given, pain reduced to 3/10 at the end of the visit. There was no documented follow-up or skilled nursing visit in 24-48 hours of the Initial RN Assessment as required by the POC in order to determine if the patient’s established comfort level of 0-3/10 was being maintained or achieved with the patient’s medication regimen or interventions. Clinical Record 8: The patient was admitted to hospice services on 1/23/2023 with a primary terminal diagnosis of Malignant Neoplasm of Pylorum Antrum. The initial RN assessment documented on 1/23/2023 included a narrative note as follows; “Pain 8/10, Tylenol 500mg 2 tabs not effective and Norco administered. In 40 minutes, patient’s pain is 3/10.” There was no documented follow-up or skilled nursing visit in 24-48 hours of the Initial RN Assessment as required by the POC in order to determine if the patient’s established comfort level of 0-3/10 was being maintained or achieved with the patient’s medication regimen or interventions. Clinical Record 9: The patient was admitted to hospice services on 10/6/2020 with a primary terminal diagnosis of benign neoplasm of the brain. The skilled nursing visit summary documented on 11/26/2020 stated in part, ““…Pt complaining of severe pain in her back. Asking skilled nurse to help, crying. Observed pain in patient’s back with scale of 8/10. Patient uncomfortable. …SN administered Tramadol 50mg PO. …Reassessment was done in 30 minutes with result of 3/10. ...” There was no documented follow-up or skilled nursing visit in 24-48 hours of the 11/26/2020 assessment as required by the POC in order to determine if the patient’s established comfort level of 0-3/10 was being maintained or achieved with the patient’s medication regimen or interventions. The patient was live discharged to a hospital on 11/28/2020 with no documented reason for the hospitalization. During an interview with the Administrator/DPCS on 11/9/2023 she stated, “Sometimes they just go because they want to be cured and there is no reason. I don’t see anything [in the clinical record] that says why the patient went to the hospital. There’s nothing that tells me if it was because of pain or something else.” Clinical Record 10: The patient was admitted to hospice services on 10/15/2020 with a primary terminal diagnosis of Unspecified combined systolic and diastolic congestive heart failure. The skilled nursing visit summary documented on 12/10/2020 stated in part, “...patient was in severe pain with pain scale 9/10 in her bilateral knees and shoulders. RN opened comfort kit and administered Tramadol 50mg po…Before leaving reassess patient’s comfort status, pain decreased to 4/10. The next documented intervention by a skilled nurse was on 12/16/23, 4 days later, and stated in part, “... Patient noted 7/10 pain in lower back and bilateral lower extremities. SN gave Tramadol 50mg PO. …Reassessed pain before leaving, pain intensity was 3/10. ...” There was no documented follow-up or skilled nursing visit within 24-48 hours of the 12/10/2020 assessment as required by the POC in order to determine if the patient’s established comfort level of 0-3/10 was being maintained or achieved with the patient’s medication regimen or interventions. During the wrap-up conference on 11/2/23, it was addressed that all patients had the same Pain POC goal: “In 24-48 hours and throughout cert period patient pain will be managed effectively as evidenced by verbalizations of increased comfort with pain level within 0-3/10”; and the same pain POC interventions: “Assess/monitor pain and severity every visit. Check pain status within 48 hours. Monitor effectiveness of current treatment. Instruct on non-pharmacological methods of pain and symptom relief of repositioning, music therapy, and/or calm quiet environment.” Examples were provided of instances in the clinical records in which it was revealed that the written plan of care established by the interdisciplinary group (IDG) was not followed in order to meet the patient’s needs for pain management. Clinical records were discussed that indicated that patients had severe pain rated at 8-9/10 at the start of the visit, and after skilled nurse intervention according to each patient’s Pain POC, the patients had pain most often rated at 3/10 by the end of the visit. When asked why there was no follow-up in 24-48 hours, no increase in nursing visits, or no change to individual POCs to address patient pain issues, the Alternate Administrator/Alternate DPCS/RN stated, “The patients and families don’t want us to come more than once a week. ...Sometimes patients act worse when the nurse visits than they do for the family. ...I do know we follow up within a day or two, and I do agree that we should write it down every time when we do follow up.””

“It is required that 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, document review and interview. In 2 of 11 (18%) of clinical records reviewed the organization did not ensure that clinical notes were documented in the clinical records according to organizational policy. Document 5: Policy titled “Timely Submission of Patient Documentation” states itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding three (3) business days. All patient visit reports from contract personnel must be submitted within three (3) business days from the date of the visit, e.g, PT, SLP, etc. Clinical Record 2: The patient was admitted to hospice services on 7/26/2023 and was recertified into benefit period 2 effective 10/24/23-1/21/24 with a primary terminal diagnosis of Liver Cell Carcinoma. An order for weekly RN visits was included on both the plan of care (POC) effective 7/26/23 and the POC effective 10/24/23. During clinical record review on 10/31/23, it was observed that the last documented skilled nursing visit was on 10/17/2023, 14 days prior. There was no documentation of a missed visit. When asked the Administrator/DPCS stated, “She is not available today, but I’ll tell her to do it [document]. I know she went to see the patient last week. She sees the patients every week.” Clinical Record 3: The patient was admitted to hospice services on 7/31/2023 and was recertified into benefit period 2 effective 10/29/23-1/26/24 with a primary terminal diagnosis of heart failure. An order for weekly RN visits included on both the plan of care (POC) effective 7/31/23 and the POC effective 10/29/23. During clinical record review on 10/31/23, it was observed that the last documented skilled nursing visit was on 10/18/2023, 13 days prior. There was no documentation of a missed visit. When asked the Administrator/DPCS stated, “She is not available today, but I’ll tell her to do it [document]. I know she sees all patients every week.” During an interview on 10/31/2023, the Administrator/DPCS stated that organizational policy requires that clinicians turn in documentation from patient visits every seven (7) days. “I’ll print it [the policy] for you.” Upon providing the policy, when asked again, the Administrator/DPCS stated, “Oh yes, it is three days.””

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each record contains signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review, document review and interview. In 6 of 8 (75%) clinical records reviewed from the start of care, the organization did not ensure that patients were informed of non-covered items, services, and drugs determined by the hospice to be unrelated to their terminal illness and related conditions. Clinical Record 1: The patient was admitted to hospice services on 8/23/2023 with a primary terminal diagnosis of Alzheimer’s Disease. The “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” document was marked at the start of care on 8/23/23 by the patient’s representative to indicate that the patient elected to receive the addendum which was to include in writing those conditions, items, services, and drugs not covered by the hospice because the hospice has determined that they are unrelated to the patient terminal illness and related conditions. Under the section of the Addendum form titled, Diagnoses unrelated to the terminal illness and related conditions, “Severe Pain” was listed as not covered. The section that was to include non-covered items, services, and drugs was blank. Clinical Record 2: The patient was admitted to hospice services on 7/26/23 with a primary terminal diagnosis of liver cell carcinoma. The “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” document was not check-marked at the start of care on 7/26/23 to indicate whether the patient did or whether the patient did not elect to receive the addendum which was to include in writing those conditions, items, services, and drugs not covered by the hospice because the hospice determined that they were unrelated to the patient terminal illness and related conditions. Under the section of the Addendum form titled, Diagnoses unrelated to the terminal illness and related conditions, “Generalized weakness, Ascites, Bed/Chair bound, incontinence” were listed as not covered. The section that would include non-covered items, services, and drugs was blank. Clinical Record 5: The patient was admitted to hospice services on 2/1/2023 with a primary terminal diagnosis of acute on chronic combined systolic and diastolic (congestive) heart failure. The “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” document was marked at the start of care on 2/1/23 by the patient to indicate that the patient elected to receive the addendum which was to include in writing those conditions, items, services, and drugs not covered by the hospice because the hospice has determined that they are unrelated to the patient terminal illness and related conditions. Under the section of the Addendum form titled, Diagnoses unrelated to the terminal illness and related conditions, “recent weight loss, decreased oral intake, and unsteady gait” were listed as not covered. The section that was to include non-covered items, services, and drugs was blank. Clinical Record 6: The patient was admitted to hospice services on 2/6/2023 with a primary terminal diagnosis of Alzheimer’s Disease and secondary diagnoses of hypertensive heart disease with heart failure, dementia, and history of a brain tumor. The “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” document was marked at the start of care on 2/6/23 by the patient’s representative to indicate that the patient elected to receive the addendum which was to include in writing those conditions, items, services, and drugs not covered by the hospice because the hospice has determined that they are unrelated to the patient terminal illness and related conditions. Under the section of the Addendum form titled, Diagnoses unrelated to the terminal illness and related conditions, “hypertensive heart disease with heart failure” was listed as not covered. The section that was to include non-covered items, services, and drugs was blank. Clinical Record 7: The patient was admitted to hospice services on 3/7/2023 into the second benefit period with a primary terminal diagnosis of Malignant neoplasm of the pylorum antrum and secondary diagnoses of end-stage heart failure. The “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” document was marked at the start of care on 3/7/23 by the patient’s representative to indicate that the patient elected to receive the addendum which was to include in writing those conditions, items, services, and drugs not covered by the hospice because the hospice has determined that they are unrelated to the patient terminal illness and related conditions. Under the section of the Addendum form titled, Diagnoses unrelated to the terminal illness and related conditions, “generalized pain and shortness of breath” were listed as not covered. The section that was to include non-covered items, services, and drugs was blank. Clinical Record 8: The patient was admitted to hospice services on 1/23/2023 with a primary terminal diagnosis of Malignant neoplasm of the pylorum antrum and secondary diagnoses of end-stage heart failure. The “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” document was marked at the start of care on 1/23/23 by the patient’s representative to indicate that the patient elected to receive the addendum which was to include in writing those conditions, items, services, and drugs not covered by the hospice because the hospice has determined that they are unrelated to the patient terminal illness and related conditions. Under the section of the Addendum form titled, Diagnoses unrelated to the terminal illness and related conditions, “end-stage heart failure, severe constipation, severe pain” were listed as not covered. The section that was to include non-covered items, services, and drugs was blank. During an interview with the Administrator/DPCS on 11/1/2023, she was asked to review the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” documents completed for Clinical Records 1, 2, 5, 6, 7, and 8. She stated, “Yes, these things are not covered by us, not covered by the hospice.” The consultant was present and stated, “I think they didn’t understand. I’ll explain that they don’t need to provide this form unless the patient requests it.” It was pointed out that 5 of the 6 patients whose documents were reviewed did request the addendum. The consultant stated, “I’ll work with them on [understanding] how this form is used.””

“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 a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review, document review and interview. In 7 of 7 (100%) discharged clinical records reviewed revealed that the organization did not ensure the discharge summary provided to the patient’s attending physician included a summary of the patient’s hospice stay including treatments, symptoms, and pain management. Clinical Record 5: The patient was admitted to hospice services on 2/1/2023 and was recertified into benefit period 2 effective 5/2/2023-7/30/2023. On 7/29/23, the day prior to the end of the second benefit period, the patient was live discharged due to a move out of the hospice’s service area. The nursing visit note documented 7/29/2023 stated in part, “Written discharge instructions on patient safe medication administrations, current plan of care and current medication list provided to primary doctor and patient/family.” There was no documented evidence in the record of a discharge summary that included a summary of the patient’s hospice stay including treatments, symptoms, and pain management. Clinical Record 6: The patient was admitted to hospice services on 2/6/2023 and was recertified into benefit period 2 effective 5/7/2023-8/4/2023. On 8/2/2023, two days prior to the end of the second benefit period, the patient was live discharged to a hospital with respiratory distress. The nursing communication note documented on 8/2/2023 stated in part, “Patient is having respiratory distress, labored breathing, restless. Family wants to transfer patient to nearest hospital. DPCS notified. HMD notified. Due to the law (right to refuse treatment), patient being discharged on 8/2/23 due to hospitalization. Discharge instructions, current medications list, and care plan provided to the doctor and will be available upon request.” There was no documented evidence in the record of a discharge summary that included a summary of the patient’s hospice stay including treatments, symptoms, and pain management. Clinical Record 7: The patient was admitted to hospice services on 3/7/2023 into the second benefit period. The patient was live discharged to a hospital on 4/5/2023. It was documented that “the patient refused treatment” offered by the hospice. A fax cover sheet dated 4/5/23 with stapled documents that included the nursing communication note dated 4/5/23 that the patient was “discharged to the hospital”, and a checklist indicating that discharge instructions, current medication list, and care plan were provided to the doctor. There was no documented evidence in the record of a discharge summary that included a summary of the patient’s hospice stay including treatments, symptoms, and pain management. Clinical Record 8: The patient was admitted to hospice services on 1/23/2023 and live discharged to a hospital on 3/3/2023. It was documented that “the patient refused treatment” offered by the hospice. A fax cover sheet dated 3/3/23 with stapled documents that included the nursing communication note dated 4/5/23 that the patient was “discharged to the hospital”, and a checklist indicating that discharge instructions, current medication list, and care plan were provided to the doctor. There was no documented evidence in the record of a discharge summary that included a summary of the patient’s hospice stay including treatments, symptoms, and pain management. Clinical Record 9: The patient was admitted to hospice services on 10/6/2020 with a primary terminal diagnosis of benign neoplasm of the brain. The patient was live discharged to the hospital on 11/28/2020. The reason for hospitalization was not documented. A nursing summary note dated 11/28/2020 stated in part, “...Medical record of the patient, plan of care, and medication sheet was faxed to the hospital, to the charge nurse and the attending physician. There was no documented evidence in the record of a discharge summary that included a summary of the patient’s hospice stay including treatments, symptoms, and pain management. Clinical Record 10: The patient was admitted to hospice services on 10/15/2020 with a primary terminal diagnosis of Unspecified combined systolic and diastolic congestive heart failure and was live discharged to the hospital on 12/30/2020. The reason for hospitalization was not documented. A nursing summary note dated 12/30/20 states in part, “...Medical record of the patient was faxed to the MD office and hospital nurse.” There was no documented evidence in the record of a discharge summary that included a summary of the patient’s hospice stay including treatments, symptoms, and pain management. Clinical Record 11: The patient was admitted to hospice services on 10/27/2020 with a primary terminal diagnosis of Alzheimer’s Disease, and live discharged/moved out of the area on 12/1/2020. A nursing summary note dated 12/1/2020 states in part, “...”RN provided discharge instruction on safe patient care and safe medications administrations to family and faxed to MD. DPCS notified. Current care plan and medication lists provided to family/provider.” There was no documented evidence in the record of a discharge summary that included a summary of the patient’s hospice stay including treatments, symptoms, and pain management. During an interview with the Administrator/DPCS on 11/2/23, she stated, “We do a discharge summary in the system [electronic medical record] and send it to the doctor. The Administrator/DPCS provided documents as proof of sending discharge-related information to the attending physician which included the last nursing visit note summary with reason for the patient discharge and the patient’s last IDT plan of care update/orders. The documentation provided did not include a summary of treatments, symptoms, and pain management throughout the patient’s course of care and did not include a summary of the patient’s hospice stay from admission to discharge. “I’m sure we did do that, we include everything. I don’t have a document, but we do it.” During an interview with the Administrator/DPCS on 11/9/23, she stated, “That was back at the beginning. Our records would be the same, same information, as the other discharges that we discussed last week.””