Nemaha County Home Health and Hospice

“Based on policy review, document review, record review, program review, and interview, the Hospice Agency (HA) failed to provide an initial bereavement assessment of the needs of the patient’s family and other individuals for 2 (Patients 10 and 12) of 14 sample patients. Failure to ensure an initial bereavement assessment is performed places patients and their families at risk for ineffective coping and grief management. Findings Include: Review of the HA policies provided, showed no written policy regarding the bereavement plan of care (POC.) Review of the undated HA document titled “;What is hospice?,” with unknown creation or review date, given to patients and families during admission, showed, “;Grief and bereavement services as well as support groups are also available for survivors coping with loss for 13 months following the death.” Review of the undated HA document titled “;Checklist for Hospice Patients,” with unknown creation or review date, used by HA staff during admission, showed, “;Bereavement ... Initiate Bereavement care ... Bereavement follow-up assessment (contact made within two-three weeks of death) ... Bereavement POC prepared for IDG and update as caregiver situations changes.” Review of the HA bereavement program showed a comprehensive 13-month program that included scheduled phone calls, letters, and grief support group resources to be provided to all patient families after patient death. Patient 10 Review of Patient 10s record showed a 68-year-old admitted to the HA on 03/06/24 with a primary diagnosis of chronic kidney disease stage 4 (gradual loss of kidney function) and additional diagnoses of acute and chronic respiratory failure (gradual loss of lung function) with hypoxia (poor oxygen level), anemia (low iron in blood), atherosclerotic heart disease of native coronary artery (plaque buildup in the arteries of the heart reducing blood flow) without angina pectoris (chest pain), chronic systolic congestive heart failure, nonrheumatic aortic valve stenosis (narrowing of the large blood vessel branching off of the heart), restrictive cardiomyopathy (stiff heart walls), and type 2 diabetes mellitus (a condition of poor insulin production causing high blood sugar) with hyperglycemia (high blood sugar.) Review of Patient 10s record showed patient death and discharge from the HA on 03/07/24. Review of Patient 10s record showed no initial bereavement assessment completion or bereavement related intervention on the POC. Review of Patient 10s record showed no bereavement POC created after Patient 10s death. Patient 12 Review of Patient 12s record showed a 64-year-old female admitted to the HA on 11/22/24 with a primary diagnosis of malignant neoplasm of the pancreas (pancreatic cancer) and the additional diagnosis of paroxysmal atrial fibrillation (a fast, irregular heartbeat.) Review of Patient 12s record showed patient death and discharge from the HA on 12/12/24. Review of Patient 12s record showed no initial bereavement assessment completion or bereavement related intervention on the POC. Review of patient 12s record showed no bereavement POC created after Patient 12s death. During an interview on 12/18/24 at 11:20 am, Staff D, Licensed Medical Social Worker (LMSW), Volunteer Coordinator (VC), and Bereavement Coordinator (BC), stated that social work is responsible for performing the initial bereavement assessment within the first 5 days after a patient is admitted to the HA. Staff D, LMSW, stated that a bereavement intervention is then added to the initial POC. Staff D, LMSW, VC, BC, stated that after a patient dies a bereavement POC is opened for each patient and an initial bereavement phone call is made to the patients family within the first 2 weeks. Staff D, LMSW, VC, BC, stated that each person accepting of bereavement is followed for 13 months following a patient death and then discharged from bereavement services. During an interview of 12/19/24 at 1:00 PM, Staff A, Director, Registered Nurse (RN), stated that Staff D, LMSW, VC, BC, performs all initial bereavement assessments and initiates the bereavement POC after the death of each patient. Staff A, Director, RN, stated that the RN doing the admission does not perform the initial bereavement assessment or initiate the bereavement POC. The HA failed to ensure performance of initial bereavement assessments on all patients receiving hospice services.”

“Based on policy review, record review, observation, and interview, the Hospice Agency (HA) failed to develop an individualized written plan of care (POC) that reflected problems, goals, and interventions identified in the comprehensive assessments for 2 (Patients 1 and 2) of 14 patients reviewed. Failure to ensure that each written POC include problems, goals, and interventions identified in the comprehensive assessment, places patients at risk for unmet needs and progress towards desired goals. Findings Include: Review of the HA policy titled, “;Physician Plan of Care,” last revised 01/01/18, showed, “;An individualized Plan of Care (POC) will be developed for each patient admitted to homecare and periodically reviewed/revised as needed to meet the patients needs. ... The Plan of Care includes: ... Patient-specific treatments, nursing care, therapy intervention ... Nutritional requirements ... Patient-specific interventions and education; measurable outcomes and goals ... The Plan of Care for each discipline will be updated and/or revised, to include such areas as problems, interventions, goals, psychosocial status, home environment, response to care, changes in diagnoses, treatments, equipment, precautions and limitations which might indicate the need to alter the Plan of Care.” Patient 1 Review of Patient 1s record showed a 90-year-old patient admitted on 03/18/24 with a primary diagnosis of nutritional deficiency, and additional diagnoses of vascular dementia without behavioral disturbance (a group of symptoms affecting memory, thinking, and social abilities caused by reduced blood flow to the brain), gastro-esophageal reflux disease (GERD, the backflow of stomach acid or bile into the throat) without esophagitis (inflammation of the tube that carries food from the mouth to the stomach), unspecified sequalae (previously caused by) of other cerebrovascular (blood vessels of the brain) disease, essential primary hypertension (high blood pressure), chronic pain, and urge incontinence (loss of bowel and bladder control.) Review of Patient 1s record showed an initial assessment performed on 03/18/24 that showed a pureed diet with honey thick liquids, difficulty swallowing foods and fluids, and high risk for poor nutrition with anticipated weight loss. Review of Patient 1s record showed the initial POC dated 03/18/24, had no dietary, nutrition, or swallowing problems or interventions. Review of Patient 1s record showed the POC dated 09/16/24, had no dietary, nutrition, or swallowing problems or interventions. Review of Patient 1s record showed the initial POC dated 11/11/24, had no dietary, nutrition, or swallowing problems or interventions. Patient 2 Review of Patient 2s record showed a 90-year-old patient admitted on 11/20/24 with a primary diagnosis of cerebral infarction due to thrombosis of unspecified precerebral artery (blockage of a blood vessel in the brain,) and additional diagnoses of dysphagia (difficulty swallowing,) Pneumonitis (inflammation of lung tissue) due to inhalation of food and vomit, and Alzheimers disease (a brain disorder that causes problems with memory, thinking, and behavior.) Review of Patient 2s record showed an initial assessment performed on 11/20/24 stating a pureed diet with thickened liquids, difficulty swallowing foods and fluids, and moderate risk for poor nutrition. Review of Patient 2s record showed the initial POC dated 11/20/24, had no dietary, nutrition, or swallowing problems or interventions listed. Review of Patient 2s record showed the POC dated 12/17/24, had no dietary or nutrition problems or interventions listed. During an interview of 12/19/24 at 1:00 PM, Staff A, Director, Registered Nurse (RN), stated that each patient admitted to the HA has an individual POC created at the time of admission based on the initial assessment, and it should reflect the all the needs of the patient. Staff A, Director, RN, stated that each POC is reviewed by the HA team during the interdisciplinary group (IDG) meeting directly following patient admission and each discipline that is accepted by the patient adds additional POC problems and interventions. Staff A, Director, RN, stated that if new problems or interventions occur for the patient, those interventions were added to the POC at that time.”

“Based on observation, policy review, record review, and interview, the Hospice Agency (HA) failed to ensure that the plan of care (POC) included all drugs and treatment necessary to meet the needs of 1 (Patient 1) of 14 sample patients. Failure to ensure all medications were on the POC places the patient at risk for potential adverse effects, ineffective medication therapy, medication to medication interaction, medication duplication, and ineffective goal and symptom management. Findings Include: Review of the HA policy titled, “;Physician Plan of Care,” last revised 01/01/18 showed, “;An individualized Plan of Care (POC) will be developed for each patient admitted to homecare and periodically reviewed/revised as needed to meet the patients needs. ... The Plan of Care includes: ... Medications, including route, dosage, frequency and if new or changed.” Review of the HA policy titled, “Medication Regimen Review,” last revised 10/08/21, showed, “;The Registered Nurse will be responsible for monitoring the patients medication regimen through a collaborative effort with the multi-disciplinary team, pharmacist and physician involved in the patients care. ... An accurate and current list of all prescription and over-the-counter (OTC) medications taken by the patient will be maintained on the medication profile. ... Changes in the medication regimen will be documented in the clinical record as well as communicated to the patient and/or caregiver.” Patient 1 Review of Patient 1s record showed a 90-year-old patient admitted on 03/18/24 with a primary diagnosis of nutritional deficiency, and additional diagnoses of vascular dementia without behavioral disturbance (a group of symptoms affecting memory, thinking, and social abilities caused by reduced blood flow to the brain), gastro-esophageal reflux disease (GERD, the backflow of stomach acid or bile into the throat) without esophagitis (inflammation of the tube that carries food from the mouth to the stomach), unspecified sequalae (previously caused by) of other cerebrovascular (blood vessels of the brain) disease, essential primary hypertension (high blood pressure), chronic pain, and urge incontinence (loss of bowel and bladder control). Review of Patient 1s record showed the POC dated 11/13/24 through 01/11/25, did not list the medications Atropine Sulfate, Hyoscyamine Sulfate, Ondansetron, or Scopolamine. Review of Patient 1s HA medication profile dated 11/13/24 through 01/11/25, showed “;Ativan Oral Tablet 0.5 MG ... Dose 1 Tab(s) ... Frequency: Every 4 hours ... Indication: anxiety, agitation, restlessness ... Instructions: Take 1-2 tablets by mouth every 4 hours as needed, if no relief after 30 minutes, may give additional 0.5 mg.” Review of Patient 1s skilled nursing center order summary dated 12/17/24, showed “;Atropine Sulfate Ophthalmic Solution 1% (Atropine Sulfate (Opthalmic)) Give 1 drop sublingually every 1 hours as needed for secretions.” Review of Patient 1s skilled nursing center order summary dated 12/17/24, showed “;Atropine Sulfate Ophthalmic Solution 1% (Atropine Sulfate (Opthalmic)) Give 2 drop sublingually every 1 hours as needed for secretions.” Review of Patient 1s skilled nursing center order summary dated 12/17/24, showed “;Hyoscyamine Sulfate Oral Solution 0.125 MG/ML (Hyoscyamine Sulfate) Give 1 ml by mouth every 4 hours as needed for increased secretions.” Review of Patient 1s skilled nursing center order summary dated 12/17/24, showed “;Hyoscyamine Sulfate Oral Solution 0.125 MG/ML (Hyoscyamine Sulfate) Give 2 ml by mouth every 4 hours as needed for increased secretions.” Review of Patient 1s skilled nursing center order summary dated 12/17/24, showed “;Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety, agitation, restlessness, for 180 Days may give additional 0.5mg if no relief after 30 minutes.” Review of Patient 1s skilled nursing center order summary dated 12/17/24, showed “;Ondansetron HCl Oral Tablet 4 MG (Ondansetron HCl) Give 1 tablet by mouth every 4 hours as needed for nausea.” Review of Patient 1s skilled nursing center order summary dated 12/17/24, showed “;Ondansetron HCl Oral Tablet 4 MG (Ondansetron HCl) Give 2 tablet by mouth every 4 hours as needed for nausea.” Review of Patient 1s skilled nursing center order summary dated 12/17/24, showed “;Scopolamine Transdermal Patch 72 Hour (Scopolamine) Apply 1.5 mg transdermal every 72 hours as needed for secretions.” During a home visit for Patient 1 on 12/17/24 at 2:25 PM, the observation was made that the HA medication list did not match the skilled nursing centers medication list. During an interview on 12/18/24 at 10:00 AM, Staff A, Director, Registered Nurse (RN), stated that every patient medication list is reviewed and discussed with the medical director and pharmacy at the time of admission and reviewed and updated with any changes in medications. Staff A, Director, RN, stated that after review of the skilled nursing centers order summary and the HA medication profile, the reason the two were not matching was the facility had entered the HA standing orders given at admission. Staff A, Director, RN, stated that standing orders are given at the time of admission but are not to be used unless initiated by the HA staff and medical director. The HA failed to ensure all medications on the POC matched the list of the medications given by patient caregiver.”

“Based on policy review, record review, and interview, the Hospice Agency (HA) failed to ensure that the plan of care (POC) was reviewed, revised, and documented by the interdisciplinary group (IDG) on 5 (Patients 1, 3, 7, 8, and 10) of 14 sample patients. Failure to ensure routine review, revision, and documentation of updated POCs by the IDG, places all patients at risk for unmet care needs and progress towards desired goals. Findings Include: Review of the HA policy titled, “;Physician Plan of Care” last revised 01/01/18 showed “;An individualized Plan of Care (POC) will be developed for each patient admitted to homecare and periodically reviewed/revised as needed to meet the patients needs. ... The Plan of Care is reviewed and revised by the multi-disciplinary team, in collaboration with the physician who is responsible for the POC and the patient/family as frequently as the patients condition or needs require, but no less frequently than once every 60 days.” Review of the HA policy titled, “;Case Conferences” last revised 08/20/20 showed “;Scheduled Team Conference – conferences will be held weekly, tentatively on Thursdays. Conferences may be moved to accommodate staff or census fluctuations. ... All disciplines providing services to a patient will be involved in patient care conferences. Coordination of care conversations with contracting therapies are documented in the medical record. Therapies may participate via phone, fax, or in person to facilitate this. All comments and patient progress will be shared through the team meeting. ... Evidence of discharge planning will be in the patient record and case conference notes. Physician agreement will be obtained prior to the discharge date and evident in the chart.” Patient 1 Review of Patient 1s record showed a 90-year-old patient admitted on 03/18/24 with a primary diagnosis of nutritional deficiency, and additional diagnoses of vascular dementia without behavioral disturbance (a group of symptoms affecting memory, thinking, and social abilities caused by reduced blood flow to the brain), gastro-esophageal reflux disease (GERD, the backflow of stomach acid or bile into the throat) without esophagitis (inflammation of the tube that carries food from the mouth to the stomach), unspecified sequalae (previously caused by) of other cerebrovascular (blood vessels of the brain) disease, essential primary hypertension (high blood pressure), chronic pain, and urge incontinence (loss of bowel and bladder control.) Review of Patient 1s record showed 03/18/24 no IDG meeting notes that reviewed Patient 1s POC from 06/18/24 through 07/16/24 for a span of 28 days. Patient 3 Review of Patient 3s record showed a 77-year-old patient admitted on 04/04/24 with a primary diagnosis of unspecified intellectual disabilities, and additional diagnoses of urinary tract infection (UTI), type 2 diabetes mellitus (a condition of poor insulin production causing high blood sugar.) Review of Patient 3s record showed no IDG meeting notes that reviewed Patient 3s POC from 06/18/24 through 07/16/24. Patient 7 Review of Patient 7s record showed a 93-year-old patient admitted on 05/08/24 with a primary diagnosis of bronchiectasis (permanent enlargement of the airways due to persistent infection), and additional diagnoses of pneumonia (an infection of the lungs or airways), dorsalgia (back pain), essential primary hypertension (high blood pressure), other diseases of the digestive system, non-pressure chronic ulcer (wound) of back with unspecified severity, non-ST elevation myocardial infarction (NSTEMI, heart attack), and anxiety disorder (a mental and behavioral disorder characterized by excessive, uncontrollable, and irrational worry). Review of Patient 7s record showed patient death and discharge from the HA on 05/13/24. Review of Patient 7s record showed no IDG meeting notes that reviewed the initial POC or bereavement POC after Patient 7s death. Patient 8 Review of Patient 8s record showed a 88-year-old patient admitted on 08/23/24 with a primary diagnosis of end stage renal disease (ESRD, loss of function of the kidney), other symptoms and signs concerning food and fluid intake, anuria (no urine production) and oliguria (lower than normal urine production), Methicillin susceptible Staphylococcus Aureus infection (bacterial infection), pressure ulcer (wound) of unspecified site, anemia (low iron in blood), and type 2 diabetes mellitus (a condition of poor insulin production causing high blood sugar.) Review of Patient 8s record showed patient death and discharge from the HA on 08/29/24. Review of Patient 8s record showed no IDG meeting notes that reviewed the initial POC or bereavement POC after Patient 8s death. Patient 10 Review of Patient 10s record showed a 68-year-old patient admitted to the HA on 03/06/24 with a primary diagnosis of chronic kidney disease stage 4 (gradual loss of kidney function) and additional diagnoses of acute and chronic respiratory failure (gradual loss of lung function) with hypoxia (poor oxygen level), anemia (low iron in blood), atherosclerotic heart disease of native coronary artery (plaque buildup in the arteries of the heart reducing blood flow) without angina pectoris (chest pain), chronic systolic congestive heart failure, nonrheumatic aortic valve stenosis (narrowing of the large blood vessel branching off of the heart), restrictive cardiomyopathy (stiff heart walls), and type 2 diabetes mellitus (a condition of poor insulin production causing high blood sugar) with hyperglycemia (high blood sugar.) Review of Patient 10s record showed patient death and discharge from the HA on 03/07/24. Review of Patient 10s record showed no IDG meeting notes that reviewed Patient 10s initial POC or bereavement POC after death. During an interview on 12/19/24 at 1:00 PM, Staff A, Director, Registered Nurse (RN) stated that every 2 weeks an IDG meeting occurs with all HA staff that includes a nurse, social worker, chaplain, and the medical director to review each patient that received services from the HA. Staff A, Director, RN, stated that a calendar of the IDG meetings is followed and the meetings are to take place at least every 15 days calendar days. Staff A, Director, RN, stated that an IDG meeting occurred on 07/02/24 however there was no documentation reflected in the electronic charting system or on paper showing the IDG meeting notes and review of each patient POC or that meeting. Staff A, Director, RN, stated that all patients that are newly admitted, currently on service, or recently discharged from service are reviewed during IDG meetings. Staff A, Director, RN, stated that bereavement and the bereavement POC for recently deceased patients are also discussed during IDG meetings. The HA failed to ensure that all patients on service have a POC review every 15 days.”

“Based on policy review, record review, and interview, and observation, the Hospice Agency (HA) failed to maintain a system of communication to provide for ongoing sharing of information with other non-hospice healthcare providers furnishing services for 1 (Patient 1) of 14 sample patients. Failure to ensure ongoing communication with patient healthcare providers places the patient at risk for unmanaged symptoms and unmet care needs. Findings Include: Review of the HA policy titled, “;Physician Plan of Care,” last revised 01/01/18, showed, “;An individualized Plan of Care (POC) will be developed for each patient admitted to homecare and periodically reviewed/revised as needed to meet the patients needs. ... The Plan of Care includes: ... Medications, including route, dosage, frequency and if new or changed ... Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient ... Patient and caregiver education and training ... Any revision to the POC due to a change in patient health status must be communicated to the patient, representative, if any, caregiver, and the physician who is responsible for the POC.” Review of the HA policy titled, “;Medication Regimen Review,” last revised 10/08/21, showed, “;The Registered Nurse will be responsible for monitoring the patients medication regimen through a collaborative effort with the multi-disciplinary team, pharmacist and physician involved in the patients care. ... An accurate and current list of all prescription and over-the-counter (OTC) medications taken by the patient will be maintained on the medication profile. ... Changes in the medication regimen will be documented in the clinical record as well as communicated to the patient and/or caregiver.” Patient 1 Review of Patient 1s record showed a 90-year-old patient admitted on 03/18/24 with a primary diagnosis of nutritional deficiency, and additional diagnoses of vascular dementia without behavioral disturbance (a group of symptoms affecting memory, thinking, and social abilities caused by reduced blood flow to the brain), gastro-esophageal reflux disease (GERD, the backflow of stomach acid or bile into the throat) without esophagitis (inflammation of the tube that carries food from the mouth to the stomach), unspecified sequalae (previously caused by) of other cerebrovascular (blood vessels of the brain) disease, essential primary hypertension (high blood pressure), chronic pain, and urge incontinence (loss of bowel and bladder control.) During a home visit for Patient 1 on 12/17/24 at 2:25 pm, the observation was made that the HA medication list did not match the skilled nursing centers medication list. During an interview on 12/18/24 at 10:00 AM, Staff A, Director, Registered Nurse (RN), stated that every patient medication list is reviewed and discussed with the medical director and pharmacy at the time of admission and reviewed and updated with any changes in medications. Staff A, Director, RN, stated that after review of the skilled nursing centers order summary and the HA medication profile, the reason the two are not matching is the facility had entered the HA standing orders given at admission. Staff A, Director, RN, stated that standing orders are given at the time of admission but are not to be used unless initiated by the HA staff and medical director. The HA failed to ensure adequate communication and updates to non-hospice staff who provided care for patients.”

“Based on policy review, document review, program review, record review, and interview, the Hospice Agency (HA) failed to ensure bereavement services were available to the family and other individuals in the bereavement plan of care (POC) up to 1 year following the death of the patient for 2 (Patients 10 and 12) of 14 sample patients. Failure to ensure bereavement services are available to families and other individuals after a patients death places them at risk for ineffective coping and grief management. Findings Include: Review of the HA policies provided, showed no policy regarding the bereavement plan of care (POC). Review of the HA document titled, “;What is hospice?,” with unknown creation or review date, given to patients and families during admission, showed, “;Grief and bereavement services as well as support groups are also available for survivors coping with loss for 13 months following the death.” Review of the HA document titled, “;Checklist for Hospice Patients,” with unknown creation or review date, used by HA staff during admission, showed, “;Bereavement ... Initiate Bereavement care ... Bereavement follow-up assessment (contact made within two-three weeks of death) ... Bereavement POC prepared for IDG and update as caregiver situations changes.” Review of the HA bereavement program showed a comprehensive 13-month program that included scheduled phone calls, letters, and grief support group resources to be provided to all patient families after patient death. Patient 10 Review of Patient 10s record showed a 68-year-old patient admitted to the HA on 03/06/24 with a primary diagnosis of chronic kidney disease stage 4 (gradual loss of kidney function) and additional diagnoses of acute and chronic respiratory failure (gradual loss of lung function) with hypoxia (poor oxygen level), anemia (low iron in blood), atherosclerotic heart disease of native coronary artery (plaque buildup in the arteries of the heart reducing blood flow) without angina pectoris (chest pain), chronic systolic congestive heart failure, nonrheumatic aortic valve stenosis (narrowing of the large blood vessel branching off of the heart), restrictive cardiomyopathy (stiff heart walls), and type 2 diabetes mellitus (a condition of poor insulin production causing high blood sugar) with hyperglycemia (high blood sugar.) Review of Patient 10s record showed patient death and discharge from the HA on 03/07/24. Review of Patient 10s record showed no initial bereavement assessment completion or bereavement related intervention on the POC. Review of Patient 10s record showed no bereavement POC created after Patient 10s death. Patient 12 Review of Patient 12s record showed a 64-year-old patient admitted to the HA on 11/22/24 with a primary diagnosis of malignant neoplasm of the pancreas (pancreatic cancer) and the additional diagnosis of paroxysmal atrial fibrillation (a fast irregular heartbeat.) Review of Patient 12s record showed patient death and discharge from the HA on 12/12/24. Review of Patient 12s record showed no initial bereavement assessment completion or bereavement related intervention on the POC. Review of Patient 12s record showed no bereavement POC created after Patient 12s death. During an interview on 12/18/24 at 11:20 AM, Staff D, Licensed Medical Social Worker (LMSW), Volunteer Coordinator (VC), Bereavement Coordinator (BC) stated that social work is responsible for performing the initial bereavement assessment within the first 5 days after a patient is admitted to the HA. Staff D, LMSW, VC, BC, stated that a bereavement intervention is then added to the initial POC and after a patient dies a bereavement POC is opened for each patient with an initial bereavement phone call to the patients family within the first 2 weeks. Staff D, LMSW, VC, BC stated that each person accepting of bereavement is followed for 13 months following a patient death and then discharged from bereavement services. During an interview ofn12/19/24 at 1:00 PM, Staff A, Director, Registered Nurse (RN), stated that Staff D, LMSW, VC, BC, performs all initial bereavement assessments and initiates the bereavement POC after the death of each patient. Staff A, Director, RN, stated that the RN doing the admission does not perform the initial bereavement assessment or initiate the bereavement POC. The HA failed to ensure establishment of a bereavement POC on all patients that received hospice services after death.”

“Based on policy review, document review, record review, and interview, the Hospice Agency (HA) failed to ensure that the attending physician was provided a copy of the patient’s discharge summary upon discharge or revocation of service for 1 (Patient 14) of 14 sample patients. Failure to provide the attending physician a copy of the patient discharge summary places patients at risk for unmanaged care needs after discharge from hospice services. Findings Include: Review of the HA policy titled, “;Discharge and Transfer Notification,” last reviewed 01/01/18, showed, “;When discharge is complete, the patients written discharge summary and current medication list is sent to the primary care physician or other health care professional who will be responsible for providing care and services to the patient after discharge from the agency. The discharge summary and medication list will be faxed to the physician within 5 business days of the patients discharge.” Review of the HA document titled, “Checklist for Hospice Patients,” with unknown creation or review date, showed, “;Discharge/Death ... Complete discharge summary to Dr if live discharge.” Patient 14 Review of Patient 14s record showed a 51-year-old patient admitted to the HA on 11/04/24 with a primary diagnosis of cerebral palsy (a group of conditions that affect movement, muscle tone, balance, and posture), and additional diagnoses of fluid overload, disturbances of salivary secretion, artificial openings of gastrointestinal tract, and hypoxemia (poor oxygenation). Review of Patient 14s record showed a revocation of HA services on 12/16/24. Review of Patient 14s record showed no evidence of a discharge summary sent to Patient 14s primary care physician after discharge. During an interview on 12/19/24 at 1:00 PM, Staff A, Director, Registered Nurse (RN), stated that any patient that discharges from service has a discharge summary and the physician is contacted. Staff A, Director, RN, stated that at the time of Patient 14s revocation from service, the physician was contacted by phone and aware of the discharge, but no discharge summary was sent to the primary care physician. The HA failed to send a discharge summary to a patients primary care provider after discharge from services.”