Hope & Grace Hospice Inc.

“Based on record review and interviews, the agency failed to have a complete clinical record available for 3 out of 14 patient records reviewed (Patient 1, Patient 3, and Patient 4). This failure resulted in an incomplete record for the above patients and could have resulted in patients receiving inadequate care due to the nurses not having the most current information on the patients. Findings included: Review of Patient 1’s clinical record revealed a document called “Plan of Care Order” dated for the period of 4/9/26-6/7/26, which showed a terminal diagnosis of Alzheimer’s disease (a progressive, irreversible brain disorder—the most common form of dementia—that destroys memory, thinking, and eventually, the ability to function), and orders for Skilled Nursing twice a week and Hospice Aides 3 times a week. Review of Patient 1’s clinical record on 4/22/26 revealed a page titled, “Benefit Period Manager: View: Nursing” which showed all of the patient’s visits for the certification period of 4/9/26 - 6/7/26. The first 5 visits (4/9/26. 4/10/26 4/13/26, 4/15/26, 4/17/26) were all red and marked as “Not Started” in the system. Review of Patient 3’s clinical record revealed a document called “Plan of Care Order” dated for the period of 4/1/26-4/23/26, which showed a terminal diagnosis of Alzheimer’s disease (a progressive, irreversible brain disorder—the most common form of dementia—that destroys memory, thinking, and eventually, the ability to function), and orders for Skilled Nursing twice a week and Hospice Aides 3 times a week. Review of Patient 3’s clinical record on 4/22/26 revealed a page titled, “Benefit Period Manager: View: Nursing” which showed all of the patient’s visits for the cert period of 4/1/26-6/29/26. Skilled Nursing Visits on 4/2/26, 4/13/26, and 4/15/26 were all red and marked as “Not Started” in the system. Review of Patient 4’s clinical record revealed a document called “Plan of Care Order” dated for the period of 2/19/26-5/19/26, which showed a terminal diagnosis of Alzheimer’s disease, and orders for Skilled Nursing twice a week and Hospice Aides 1 time a week.Review of Patient 4’s clinical record on 4/22/26 revealed a page titled, “Benefit Period Manager: View: Nursing” which showed all of the patient’s visits for the cert period of 2/19/26-5/19/26. Skilled Nursing Visits # 18 - 22 (4/8/26, 4/10/26, 4/13/26, 4/15/26, 4/17/26) were all red and marked as “Not Started” in the system. On 04/21/2026 at 1:34 p.m. an interview was conducted with the ASN. The clinical record for Patient 3 was reviewed. The ASN acknowledged the skilled nurse visit notes were not documented in the patient record for multiple skilled nursing visits in April. Surveyor asked what was the timeframe that the plan of care and skilled nurse visit notes were expected to be documented in the clinical record. The ASN stated notes were supposed to be in the clinical record within 48 hours but that she had been very busy. On 4/23/26 at 1:00 PM, an interview with conducted with the Administrator. The Surveyor asked what the expectation for Nursing and Aide notes to be completed in the patient’s chart was. The Administrator stated that clinicians needed to document their notes within 48 and it needed to be completed within 14 days. The Administrator stated, “No one still handwrites notes anymore so that policy needs to be updated. They need to start the notes in the system within 48 hours and complete it within 14 days.” The Administrator clarified that notes are started and completed in the Electronic Health Record and that staff did not handwrite notes anymore, but rather they chart in the Electronic Health Record. The Administrator did not know why Patient 1, Patient 3, and Patient 4 nursing notes for most of April said “not started” in the Electronic Health Record. She stated it was the responsibility of the nurse to get the notes submitted in a timely manner. The Surveyor asked why it was important to patient care to ensure charting was started and completed in the EHR on time. The Administrator stated that if a different nurse went out to see the patient, and someone else went to see the patient on the next visit, they would need to be able to review the notes and see if the patient had any changes in order to know how the patient was doing and what their needs were. She stated that it helps track the health status of the patient.On 4/23/2026 at 3:57 PM, an interview was conducted with LVN A. LVN A stated that charting was supposed to be done 24-28 hours after a visit, but she did not see that in the policy. She confirmed that she had not done some of her April notes for Patient 3 and Patient 4 as of earlier this week but stated that yesterday she went in and completed everything. She stated she was not sure of the exact wording of the agency policy. Review of the hospice’s policies and procedures revealed a policy titled, “Timelines” last updated 8/01/2015, which read in part, “All clinical and progress notes will be written the day service is rendered.” The policy did not address when the notes needed to be incorporated in the clinical record.”