Sacred Hands Hospice Home Care, LLC

“Based on interview and record reviews the Hospice Agency’s failed to ensure its licensed nursing staff maintained comprehensive medical records (complete, accurate, and organized collection of all health‑related documentation about a patient during their care) for 2 of 8 sampled patients. (Patients 6 & 8) when their medical records had missing Interdisciplinary Group (IDG, a core clinical team responsible for planning, coordinating, and providing care to each hospice patient) and skilled nursing visit notes.This failure to maintain complete and accurate medical records resulted in a lack of coordinated and comprehensive care for Patients 6 and 8. Findings: Record review of Patient 8’s face sheet dated 5/28/26, indicated Patient 8’s start of care was 5/28/25 and had a diagnosis of Parkinson’s disease (A brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination. Symptoms usually begin gradually and worsen over time. As the disease progresses, people may have difficulty walking and talking. They may also have mental and behavioral changes, sleep problems, depression, memory difficulties, and fatigue.). During a concurrent interview and record review on 8/24/26, at 3:40 p.m., with ADM, Resident 8’s interdisciplinary Group (IDG) meeting notes were reviewed. ADM stated IDG meetings were required every 14 days and were documented in Patient’s charts. Patient 8’s chart indicated between May 2025 through August 2026 Patient 8 had five IDG meeting notes, which were dated 5/28/25, 6/11/25, 7/9/25, 7/22/26 and 8/19/26. ADM stated the rest of Resident 8’s IDG meeting notes were not in their electronic health record, their physical chart or in the office. ADM stated Patient 8’s complete IDG meeting notes were not available, and they should have had them. ADM stated IDG meetings were important to discuss the patient’s needs, medication management, symptoms, plan of care, nutrition, spiritual needs, psychosocial needs, family grief, recap visit frequencies, and any new issues. During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Group Meeting,” dated November 2020, the P&P indicated, “The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires.” A record review of the Agency’s document titled“Job Title/Position: Clinical Director/Director of Patient Care Services” (CDDPCS) dated 9/2022, CDDPCS indicated essential job duties included “Oversees the maintenance of patient clinical records…” and “Assures proper maintenance of clinical records in compliance with local, state and federal laws.”A record review of the Agency’s document titled “Job Title/Position: Registered Nurse” (JPRN) dated 9/2020, JPRN indicated the Registered Nurse “Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given.”A record review of the Agency’s Policy and Procedure (P & P) dated 11/2020, the P & P indicated the clinical record must include “Regular pain assessments, interventions, and outcomes.” It must also include “Interdisciplinary group meetings and individual patient and family/caregiver case conferences.”A record review of the document “POC/IDG Review” (POCIDG) dated 7/8/2026, POCIDG indicated Patient 6‘s start of care was 6/30/2026. Diagnoses included advanced lung cancer. Patient 6 was to receive a Registered Nurse visit every 14 days and as needed.During a concurrent interview and record review on 8/24/2026 at 3:15 p.m. with the Director of Nursing (DON), a review of Patient 6‘s clinical record showed no nursing visit notes. The DON stated she had taken manual handwritten notes during Patient 6’s visits and neglected to add them into the clinical record. The DON stated it was important to have a complete record with all nursing visit notes as it would enable continuity of care in the event another nurse is called in to care for the patient. A complete record provided needed information to care for the patient so staff would know “What was going on.” During an interview on 8/25/2026 at 2:13 p.m., the Agency’s Administrator (ADM) stated staff have 5 days to input their notes into the clinical record.”