High Country Hospice LLC

“It is required that each patient’s individualized written plan of care reflects patient, and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review, and interview. In 4 of 11 (36%) clinical records reviewed revealed the agency did not ensure each patient’s written plan of care reflected patient and family goals and/or identified patient specific interventions based upon updated assessment findings. CLINICAL RECORD 1: The patient, who resided in a nursing facility, elected the hospice benefit on 09/27/2024 with the diagnosis of senile degeneration of the brain. The plans of care for 09/27/2024 to 12/25/2024 and 12/26/2024 to 03/25/2025 were reviewed. During the Nurse Practitioner’s (NP) Face to Face visit documented for 12/20/2024, included in part that the “... Pt is on a mechanical soft diet due to dysphagia and risk for aspiration ... Today, the patient endorses congestion, dry cough, and shortness of breath. Upon auscultation, it is noted that pt has expiratory wheezes in all upper and lower lobes and diminished lung sounds to bilateral bases... Today, 12/20/2024, Augmentin was initiated for possible aspiration pneumonia...” A physician’s order documented 12/20/2024 included Augmentin 125mg/31.25mg - one tablet by mouth every eight hours for infection. During the Interdisciplinary Group Meeting on 12/26/2024, “... Over the past two weeks, pt has been treated for possible aspiration PNA. Pt currently taking Augmentin, receiving neb treatments BID...Pt continues to have ... difficulty sleeping...” The plans of care for the benefit periods 09/27/2024 to 12/25/2024 and 12/26/2024 to 03/25/2025 did not include the identification of a problem of dysphagia for the patient with the inclusion of aspiration precautions. The treatment of aspiration pneumonia was identified in the nurse’s interdisciplinary note during the meeting on 12/26/2024 with the intervention of antibiotic treatment, but there were no goals for the care and treatment. CLINICAL RECORD 2: The patient, who resided at home, elected the hospice benefit on 11/29/2024 with the diagnosis of senile degeneration of the brain. The plan of care for the benefit period 11/29/2024 to 02/26/2025 was reviewed. During the visit on 11/29/2024 by the Registered Nurse (RN), it was noted that the patient’s oxygen saturation reading was 76% on room air. The nurse also included in part that the “... CG reports chronic constipation, frequently needing Miralax or milk of mag. Pt typically goes every 5-7 days... “ During the Interdisciplinary Group Meeting on 12/11/2024, the nurse noted “ ... RA saturation 68%...” On 12/27/2024, the nurse documented an oxygen reading of 82% on room air and documented that “... “2L O2 NC placed with the improvement of O2 from 82% to 97%” diminished lung sounds ... CG reports intermittent episodes of productive green sputum. She reports she will administer a nebulizer treatment before bedtime... “ On 01/03/2025, the RN documented “... oxygen saturation of 79% on room air ... 2L O2 applied via NC. CG reports that the patient’s productive cough has resolved. Lung sounds diminished to the right lower lobe...” Orders dated 11/29/2024 included Budesonide 0.25mg/2ml—two ml inhalation every twelve hours for shortness of breath, DuoNeb 0.5-2.5mg/3m—three ml inhalation every six hours as needed for shortness of breath, and oxygen two liters per minute via nasal cannula for shortness of breath. The plan of care identifies the problem of airway and breathing problems without any specific goal of care for the patient’s treatment with nebulizer medications and oxygen and chronically low oxygen saturations on room air. An order dated 11/29/2024 was included in the plan of care for Senna Plus 8.6mg/50mg - one tablet per gastric tube twice a day as needed for constipation. On 12/10/2024, an order was documented for Dulcolax 10mg suppository - one suppository daily as needed for constipation. On 01/02/2025, an order was documented for Milk of Magnesia 400mg/5ml - thirty ml twice a day as needed for constipation. The plan of care identified a problem with bowel elimination without any patient-specific goals that reflect this patient’s chronic constipation and expected goals of care for treatment since the patient’s bowel pattern per caregiver differs from the usual expected number of bowel movements per day/week. CLINICAL RECORD 5: The patient, who resided in a nursing facility, elected the hospice benefit on 11/07/2024 with the diagnosis of Parkinson’s disease. He died on hospice services on 01/13/2025. The plan of care for the benefit period 11/07/2024 to 02/04/2025 was reviewed. The Registered Nurse (RN) documented in the initial visit on 11/08/2024 in part that “ ...Staff concerned pt will become dehydrated due to recent diarrhea. Loperamide order PRN ... Stool culture pending...” During the Interdisciplinary Group Meeting (IDG) on 11/14/2024, the nurse’s update included that the “... Pt is becoming more agitated during wound care, stating he just wants to be left alone... Pt currently receiving treatment for Cdiff with Vanco... Lorazepam ordered PRN for pts occasional agitation. Pt becomes anxious at times, trying to get out of bed ... Then, during the IDG Meeting on 11/27/2024, the nurse documented, “...Pt completed his Vanco for Cdiff, pt occasionally has loose stool. Pt recovered well from COVID. Pt tested positive 11/16, declined Paxlovid ... “ On 12/11/2024, the IDG Meeting noted “...Pt completing another round of Vanco for Cdiff, pt having loose, green/mucous like stools...” During a nursing visit on 12/16/2024, the RN documented that the “...Pt continues to have stools daily, more formed, and not suspicious of Cdiff... staff reports that pt will become easily agitated with them...” The RN noted during her visit on 12/26/2024, “... Staff reports pt has been agitated during the day, trying to get out of bed. Pt typically able to be redirected. Lorazepam was given ... On 12/31/2024, the nurse documented during her visit that the patient was again having loose stool and received an order for a stool culture to rule out a reoccurrence of clostridium difficile. Physician orders dated 11/09/2024 and 12/06/2024 included Vancocin 125mg by mouth four times daily for infection. On 11/11/2024, an order was documented for Lorazepam 2mg/ml—0.25 ml by mouth every six hours as needed for anxiety or agitation. The plan of care identified a problem with bowel elimination. Still, no infection control precautions or interventions were included for the clostridium difficile except for the medication and the stool sample via physician order. There were also no patient-specific goals that reflected this patient’s goals of care for the treatment of the ongoing infection. No infection control precautions were included for the patient’s COVID-19 infection. The patient’s anxiety/agitation was only identified through a physician’s order for Lorazepam with the indication to treat anxiety/agitation. No other interventions or goals of care were documented. CLINICAL RECORD 8: The patient, who resided in a nursing facility, elected the hospice benefit on 09/11/2024 with the diagnosis of unspecified sequelae of cerebral infarction. The patient died on hospice services on 12/20/2024. The plans of care for the benefit periods 09/11/2024 to 12/09/2024 and 12/10/2024 to 03/09/2025 were reviewed. The patient’s medication list included an order dated 10/03/2024 for Lorazepam 0.5mg - two tablets by mouth every six hours for anxiety and/or agitation and 10/09/2024 for Haloperidol Lactate 2mg/ml - 0.5 ml by mouth every four hours for agitation. During the Registered Nurse (RN) visit documented on 11/25/2024, it was noted that the “...Pt continues to have paranoia/agitation, current regimen of haloperidol has been effective... Pt often states people are trying to hurt her .... Pt has received two rounds of antibiotics for infection to L hip ... Pt is drinking 16 oz of Ensure daily. Pt is not eating her pureed food ... at risk for aspiration...” The nurse documented on 11/27/2024 that the patient continued to have paranoia and agitation, often stating that people were trying to help her. The dose of haloperidol was reported as effective. The patient had received two rounds of antibiotics to treat an infection in the patient’s left hip. Antibiotic orders dated 10/24/2024 and 11/05/2024 included Cephalexin 500mg by mouth every six hours for infection. An order was documented on 12/03/2024 for Haloperidol lactate 2mg/ml—one ml by mouth every four hours for agitation. On 12/12/2024, the nurse documented during her visit that the patient had been agitated with the hospice aide during personal care and that the hospice doctor had been contacted. An order was received to schedule the Lorazepam dose when it was previously only as needed. The patient’s plans of care for 09/11/2024 to 12/09/2024 and 12/10/2024 to 03/09/2025 did not identify a problem of ongoing anxiety or agitation, and it only was recognized as the indication for the ordered medications, which were also the only interventions. There was no goal of care for treatment. The patient’s left hip infection was identified in the nurse’s note in the Interdisciplinary Group Meeting, but no goal for the treatment with Cephalexin was included. It was confirmed during a joint clinical record review and interview with the Director of Nursing (Personnel Record 2) on 01/15/2024 that the plans of care were not updated to reflect newly identified problems with associated patient-specific interventions or goals.”

“It is required that each patient’s individualized written plan of care Includes all services necessary for the palliation and management of the terminal illness, including the following measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 11 of 11 (100%) clinical records reviewed revealed the agency did not ensure that the patient’s plan of care included individualized and measurable goals of care. CLINICAL RECORD 1: The patient, who resided in a nursing facility, elected the hospice benefit on 09/27/2024 with the diagnosis of senile degeneration of the brain. The plans of care for 09/27/2024 to 12/25/2024 and 12/26/2024 to 03/25/2025 were reviewed. The documented goals for the patient were not patient/family-specific, the expected timeframes to accomplish the goals were not identified, and the goals were not measurable enough to determine if the care and services provided were effective. The patient’s goals consisted of the following: that the patient would obtain optimal breathing patterns, airway patency and comfort, fall occurrences would be prevented/reduced whenever possible throughout a patient’s length of stay -, that the patient would maintain optimal urinary elimination pattern and comfort, that the patient would achieve and maintain optimal skin integrity as the disease progressed, to achieve and maintain regular bowel elimination, and to minimize anxiety episodes and allow the patient to be able to openly express feelings as able within the confines of their disease process. There was no documented evidence that the patient’s plan of care included individualized and measurable goals of care. CLINICAL RECORD 2: The patient, who resided at home, elected the hospice benefit on 11/29/2024 with the diagnosis of senile degeneration of the brain. The plan of care for the benefit period 11/29/2024 to 02/26/2025 was reviewed. The documented goals for the patient were not patient/family-specific, the expected timeframes to accomplish the goals were not identified, and the goals were not measurable enough to determine if the care and services provided were effective. The patient’s goals consisted of the following: that the patient would maintain optimal nutrition and hydration, would achieve and maintain optimal skin integrity as disease progressed, fall occurrences would be prevented/reduced whenever possible during the patient’s length of stay, that the patient would achieve optimal breathing patterns, airway patency, and comfort, to maintain optimal urinary elimination patterns and comfort, to promote optimal patient orientation and communication abilities, that the patient’s infection process will be contained, comfort promoted and further infection prevented, and to promote a dignified death for the patient and optimal family coping skills during the process. There was no documented evidence that the patient’s plan of care included individualized and measurable goals of care. CLINICAL RECORD 3: The patient, who resided in a nursing facility, elected the hospice benefit on 09/24/2024 with the diagnosis of hypertensive heart disease with heart failure. The plans of care for the benefit periods 09/24/2024 to 11/22/2024 and 11/23/2024 to 01/21/2025 were reviewed. The documented goals for the patient were not patient/family-specific, did not identify the expected timeframes to accomplish the goals, and were not measurable to be able to determine if the care and services provided were effective. The patient’s goals consisted of the following: the patient would achieve optimal breathing patterns, airway patency, and comfort; the patient would maintain adequate cardiac/circulatory function and fluid volume as long as possible; fall occurrences would be prevented/reduced whenever possible during the patient’s length of stay, the patient would maintain optimal urinary elimination patterns and comfort, that the patient would achieve and maintain regular bowel elimination and skin integrity, and to minimize anxiety episodes and allow the patient to be able to openly express feelings as able within the confines of their disease process. There was no documented evidence that the patient’s plan of care included individualized and measurable goals of care. CLINICAL RECORD 4: The patient, who resided at home, elected the hospice benefit on 09/06/2024 with the diagnosis of chronic obstructive pulmonary disease. The plans of care for the benefit periods 09/06/2024 to 12/04/2024 and 12/05/2024 to 03/04/2025 were reviewed. The documented goals for the patient were not patient/family-specific, did not identify the expected timeframes to accomplish the goals, and were not measurable to determine if the care and services provided were effective. The patient’s goals consisted of the following: to maintain a breathing pattern that is comfortable for the patient utilizing comfort medications, to promote optimal patient comfort and prevent injuries. that the patient will achieve and maintain regular bowel elimination and skin integrity, and to minimize anxiety episodes and allow the patient to be able to openly express feelings as able within the confines of the disease process. There was no documented evidence that the patient’s plan of care included individualized and measurable goals of care. CLINICAL RECORD 5: The patient, who resided in a nursing facility, elected the hospice benefit on 11/07/2024 with the diagnosis of Parkinson’s disease. He died on hospice services on 01/13/2025. The plan of care for the benefit period 11/07/2024 to 02/04/2025 was reviewed. The documented goals for the patient were not patient/family-specific, the expected timeframes to accomplish the goals were not identified, and the goals were not measurable enough to determine if the care and services provided were effective. The patient’s goals consisted of the following: to promote optimal patient safety and prevent injuries, that the patient would achieve optimal breathing patterns, airway patency, and comfort; to achieve and maintain regular bowel elimination and skin integrity, that the patient would maintain optimal nutrition and hydration, and to promote a dignified death for the patient with optimal family coping skills during the dying process. There was no documented evidence that the patient’s plan of care included individualized and measurable goals of care. CLINICAL RECORD 6: The patient, who resided at home, elected the hospice benefit on 12/27/2024 with the diagnosis of chronic obstructive pulmonary disease. The patient died on hospice services on 01/07/2025. The plan of care for the benefit period 12/27/2024 to 03/26/2025 was reviewed. The documented goals for the patient were not patient/family-specific, the expected timeframes to accomplish the goals were not identified, and the goals were not measurable enough to determine if the care and services provided were effective. The patient’s goals consisted of the following: that the patient would maintain optimal urinary elimination pattern and comfort, that the patient would achieve and maintain optimal physical comfort, that fall occurrences would be prevented/reduced when possible, to maintain optimal nutrition and hydration, for continued spiritual comfort, acceptance of death, and utilization of spiritual resources, to achieve optimal breathing patterns, airway patency, and comfort, to achieve and maintain regular bowel elimination and skin integrity, and to promote a dignified death for patient and optimal family coping skills during the dying process. There was no documented evidence that the patient’s plan of care included individualized and measurable goals of care. CLINICAL RECORD 7: The patient, who resided in a nursing facility, elected the hospice benefit on 11/01/2024 with the diagnosis of unspecified protein-calorie malnutrition. They died on hospice services on 11/08/2024. The plan of care for the benefit period 11/01/2024 to 01/29/2025 was reviewed. The documented goals for the patient were not patient/family-specific, the expected timeframes to accomplish the goals were not identified, and the goals were not measurable enough to determine if the care and services provided were effective. The patient’s goals consisted of the following: the patient would achieve optimal breathing patterns, airway patency, and comfort, to promote optimal safety and prevention of injuries, to achieve and maintain regular bowel elimination and skin integrity, to be oriented to the extent possible, to maintain optimal nutrition and hydration, and to promote a dignified death for patient and optimal family coping skills during the dying process. There was no documented evidence that the patient’s plan of care included individualized and measurable goals of care. CLINICAL RECORD 8: The patient, who resided in a nursing facility, elected the hospice benefit on 09/11/2024 with the diagnosis of unspecified sequelae of cerebral infarction. The patient died on hospice services on 12/20/2024. The plans of care for the benefit periods 09/11/2024 to 12/09/2024 and 12/10/2024 to 03/09/2025 were reviewed. The documented goals for the patient were not patient/family-specific, the expected timeframes to accomplish the goals were not identified, and the goals were not measurable enough to determine if the care and services provided were effective. The patient’s goals consisted of the following: the patient would achieve and maintain optimal skin integrity as the disease progressed, maintain optimal urinary elimination patterns and comfort, promote optimal patient safety, and prevent injuries, achieve, maintain regular bowel elimination, skin integrity, and remain free from skin breakdown, to achieve a tolerable level of pain, and to achieve and maintain optimal physical comfort. There was no documented evidence that the patient’s plan of care included individualized and measurable goals of care. CLINICAL RECORD 9: The patient, who resided in a nursing facility, elected the hospice benefit on 09/19/2024 with the diagnosis of muscular dystrophy. The patient was discharged from hospice services on 11/18/2024 due to being in a non-contracted facility when the patient was transferred to an out-of-state hospital for care. The plan of care for the benefit period 09/19/2024 to 12/17/2024 was reviewed. The documented goals for the patient were not patient/family-specific, did not identify the expected timeframes to accomplish the goals, and were not measurable to be able to determine if the care and services provided were effective. The patient’s goals consisted of the following: the patient would understand the care needs to maintain safety, the patient would maintain optimal urinary elimination patterns and comfort, to achieve and maintain regular bowel elimination and skin integrity, fall prevention, and maintain an airway and decrease oral secretions. CLINICAL RECORD 10: The patient, who resided in a nursing facility, elected the hospice benefit with the diagnosis of chronic obstructive pulmonary disease. The patient revoked hospice services on 12/10/2024 to move out of the state. The plans of care for the benefit periods 09/08/2024 to 12/06/2024 and 12/07/2024 to 02/04/2025 were reviewed. The documented goals for the patient were not patient/family-specific, the expected timeframes to accomplish the goals were not identified, and the goals were not measurable enough to determine if the care and services provided were effective. The patient’s goals consisted of the following: to promote optimal patient safety and prevention of injury, that the patient would maintain optimal urinary elimination patterns and comfort, that the patient would achieve and maintain regular bowel elimination and skin integrity, to maintain the patient’s oxygen saturations and minimize shortness of breath. There was no documented evidence that the patient’s plan of care included individualized and measurable goals of care. CLINICAL RECORD 11: The patient, who resided in a nursing facility, elected the hospice benefit on 09/18/2024 with the diagnosis of senile degeneration of the brain. The patient revoked hospice services on 11/06/2024 to pursue aggressive treatment. The plan of care for the benefit period 09/18/2024 to 12/16/2024 was reviewed. The documented goals for the patient were not patient/family-specific, did not identify the expected timeframes to accomplish the goals, and were not measurable to determine if the care and services provided were effective. The patient’s goals consisted of the following: to promote optimal patient safety and prevention of injury, that the patient would maintain optimal urinary elimination patterns and comfort, that the patient would achieve and maintain regular bowel elimination and skin integrity, to promote optimal communication abilities, and to achieve and maintain optimal skin integrity as the disease progressed. There was no documented evidence that the patient’s plan of care included individualized and measurable goals of care. During a joint clinical record review and interview with the Director of Nursing (Personnel Record 2) on 01/15/2024, the DON confirmed that the goals included in the patients’ plans of care were not individualized, specific, and measurable”

“It is required that the hospice aide services must be provided by an individual who as successfully completed the competency evaluation by observation of an aide’s performance with a patient or pseudo-patient during a simulation. The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 5 (20%) of applicable personnel records reviewed, which required a documented competency skills form completed, it revealed the agency did not ensure there was documentation in the personnel record that all hospice aide skills were assessed as competently performed prior to the first aide visit with a patient and the competency present in the file did not have the required observation of all skills required. AGENCY POLICY: The hospice’s policy “Hospice Aide Competency Evaluation (1.13)” dated 10/07/2024 read in part that “... aides may be evaluated through a combination of written or oral examination and observed performance. The evaluation is performed by a qualified ... registered nurse. Items that are evaluated by observation of the aide’s performance with a patient include the following: communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff ... appropriate and safe techniques in performing personal hygiene and grooming tasks, including bed bath, tub bath, and shower; hair shampoo in sink, tub, or bed; nail and skin care; oral hygiene; and toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning... The hospice aide may not furnish hospice service until after successful completion of the competency program.” PERSONNEL RECORD 5: A review of the personnel record for the hospice aide with a hire date of 02/09/2024 included a form, “Hospice Aide Competency Evaluation: Basic Skills Test dated 11/20/2024.” The agency admitted their first patient on 09/06/2024, and the first aide visit was performed on 09/11/2024 - over two months before the aide competency that was documented in the file. Additionally, the Hospice Aide Competency Evaluation: Basic Skills Test dated 11/20/2024 included the tasks for the aide to perform tub/shower, hair shampoo via tub/shower, filing nails, safe transfer technique, ambulation, active/passive range of motion and proper positioning of the patient in a bed and chair all documented as by verbal review with the Registered Nurse and not observed. During an interview with the Director of Nursing (DON) (Personnel Record 2) on 01/15/2025, she confirmed this was the only documentation available. The DON stated there was an initial competency completed prior to the first aide visit, but when the 11/20/24 competency was completed, she discarded the initial competency and no longer had the documentation. She thought she only needed to keep the most current competency assessment. She also stated she didn’t realize the competency tasks could have different dates (for different patient tasks) to ensure all hands-on tasks were demonstrated. She was not aware that personal care tasks could not be verbally reviewed with the aide.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 9 (22%) applicable clinical records in which hospice aide services were accepted revealed the agency did not ensure that the Registered Nurse provided full and complete instructions to the aide in the aide care plan. CLINICAL RECORD 3: The patient, who resided in a nursing facility, elected the hospice benefit on 09/24/2024 with the diagnosis of hypertensive heart disease with heart failure. The plans of care for the benefit periods of 09/24/2024 to 11/22/2024 and 11/23/2024 to 01/21/2025 were reviewed and included physician orders for the hospice aide to visit the patient twice weekly, effective 09/25/2024. The hospice aide plan of care for 10/31/2024 to current included personal care interventions to shampoo and shower the patient. During the Registered Nurse (RN) visit on 11/21/2024, the nurse documented that the patient’s oxygen saturation was 89% on room air and required three liters per minute of continuous oxygen. The patient was short of breath with conversation. There was an abdominal wound measuring 2.8cm by 1.5cm to the abdomen noted. During the nurse visit on 12/12/2024, the patient again had an 89% oxygen level, and the shortness of breath was managed with oxygen use and albuterol nebulizer treatments as needed. On 01/02/2025, the nurse noted in part that the “... Pt has SOB, which is managed well with oxygen use and PRN albuterol. Pt has a chronic wound to ABD...” The instructions from the RN to the hospice aide did not include any precautions or direction regarding the patient’s oxygen or wound to the aide when they provided personal care to the patient. CLINICAL RECORD 5: The patient, who resided in a nursing facility, elected the hospice benefit on 11/07/2024 with the diagnosis of Parkinson’s disease. He died on hospice services on 01/13/2025. The care plan for the benefit period 11/07/2024 to 02/04/2025 was reviewed and included physician orders for the hospice aide to visit the patient twice weekly. During the Registered Nurse’s (RN) visit on 11/08/2024, it was noted in part that “Staff concerned pt will become dehydrated due to recent diarrhea. Loperamide order PRN ... Stool culture pending...” During the Interdisciplinary Group Meeting (IDG) documented on 11/14/2024, the nurse noted that the “ ... Pt is currently receiving treatment for Cdiff with Vanco. Staff reports ... Then, during the IDG Meeting on 11/27/2024, “...Pt completed his Vanco for Cdiff, pt occasionally has loose stool. Pt recovered well from COVID. Pt tested positive 11/16, and declined Paxlovid ... Then it was noted that the patient completed another round of Vancomycin for Clostridium Difficile after having loose, green, mucous stools. Then, the nurse documented on 12/31/2024 that the patient again had loose stools, and a stool culture had been obtained and sent for culture to rule out a reoccurrence of Clostridium Difficile. On 01/06/2025, the RN documented that “... staff reports they sent a stool culture, pending results...” The instructions from the RN to the hospice aide did not include any contact precautions in the aide care plan for the identification and treatment of clostridium difficile or any airborne/COVID precautions. It was confirmed during joint clinical record review and interview with the Director of Nursing (Personnel Record 2) on 01/15/2025 that the aide care plans did not provide the aide the needed instructions regarding each patient’s wounds and what to do should the dressing become wet, soiled, or loose and did not provide the aide the proper infection control precautions and PPE for the patient’s clostridium difficile infection or his COVID infection.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) applicable clinical records in which a patient was either discharged or revoked, the hospice benefit revealed that the agency did not ensure that the patient’s documented discharge summary was sent to the patient’s attending physician. CLINICAL RECORD 10: The patient, who resided in a nursing facility, elected the hospice benefit with the diagnosis of chronic obstructive pulmonary disease. The patient revoked hospice services on 12/10/2024 to move out of the state. There was no documented evidence that the discharge summary dated 12/10/2024 was sent to the patient’s attending physician. It was confirmed during joint clinical record review and interview with the Director of Nursing (Personnel Record 2) on 01/14/2025 that the discharge summaries were not provided to the patient’s physician, and there was no further documentation that a summary of the patient’s hospice stay, their plan of care, and latest physician orders were provided separately.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) applicable clinical records in which a patient was either discharged or revoked the hospice benefit revealed the agency did not ensure that the patient’s documented discharge summary included a summary of the patient’s hospice care, the patient’s plan of care, or any physician orders. CLINICAL RECORD 9: The patient, who resided in a nursing facility, elected the hospice benefit on 09/19/2024 with the diagnosis of muscular dystrophy. The patient was discharged from hospice services on 11/18/2024 due to being in a non-contracted facility when the patient was transferred to an out-of-state hospital for care. A discharge summary was documented on 11/18/2024 and included only demographic information, medication allergies, hospice disciplines involved in care and their visit frequency, the patient’s hospice diagnosis, code status, and reason for the discharge. There was no documented evidence that the summary of care was documented, and the discharge summary did not include the patient’s care plan or medications. CLINICAL RECORD 10: The patient, who resided in a nursing facility, elected the hospice benefit with the diagnosis of chronic obstructive pulmonary disease. The patient revoked hospice services on 12/10/2024 to move out of the state. A discharge summary was documented on 12/10/2024 and included only demographic information, medication allergies, hospice disciplines involved in care and their visit frequency, the patient’s hospice diagnosis, code status, and reason for the discharge. There was no documented evidence that the summary of care was documented, and the discharge summary did not include the patient’s care plan or medications. CLINICAL RECORD 11: The patient, who resided in a nursing facility, elected the hospice benefit on 09/18/2024 with the diagnosis of senile degeneration of the brain. The patient revoked hospice services on 11/06/2024 to pursue aggressive treatment. A discharge summary was documented on 11/06/2024 and included only demographic information, medication allergies, hospice disciplines involved in care and their visit frequency, the patient’s hospice diagnosis, code status, and reason for the discharge. There was no documented evidence that the summary of care was documented, and the discharge summary did not include the patient’s care plan or medications. During a joint clinical record review and interview on 01/14/2025 with the Director of Nursing (DON) (Personnel Record 2) it was confirmed that the stated required elements were not documented on the discharge summaries. Further, she confirmed there was no documentation in a note or scanned documents that provided evidence that the required information was provided to the patients’ physicians.”