Ims Home Health & Hospice Care, Inc.

“Based on record review, observation, and interview, the Hospice failed to ensure hospice care and services followed an individualized written plan of care established by the interdisciplinary group for 2 of 3 (Patient #5, and Patient #8) active hospice patients and 1 (Patient #3) of 11 inactive hospice patients whose records were reviewed, in that the skilled nurse (SN) did not follow the frequency of visits as ordered in the plan of care. This deficient practice placed the agencys active patients at risk of receiving inadequate care and services and could place the patients at risk of experiencing negative health outcomes. The findings included: Record review of Patient #5’s electronic medical record (EMR) included a “Plan of Care Order” signed and dated 11/07/24 that documented Patient #5 as an 82-year-old male with a diagnosis of Alzheimer’s disease, unspecified (a progressive brain disorder that destroys memory and thinking skills). Furthermore, the POC documented a current benefit period dated 11/05/24 through 02/02/25 and the following services ordered, “Skilled Nursing 2 to 5 times per week for 3 months and 2 prn visits for change in condition (2 times per week)”. Record review of Patient #5’s EMR indicated the Agency performed the following SN visits between 11/05/24 through 01/11/25 as follows: 11/07/24, 11/11/24, 11/12/24, 11/14/24, 11/18/24, 11/21/24, 11/27/24, 12/04/24, 12/11/24. 12/18/24, 12/23/24, 12/30/24, and 01/08/25. Record review of Patient #5 failed to show documentation of an updated POC order that indicated SN frequency change or evidence that 2 to 5 skilled nurse visits were conducted as per POC. During a home visit on 01/08/25 at approximately 10:55 a.m., Patient #5 and home was observed clean and well-kept, sitting in dining room chair, patient was free of pain, comfortable, and surrounded by family members. In an interview during this home visit, CG A stated the Patient #5 had been receiving services from the Agency for approximately 1-2 months after a referral from her physician. CG A stated she and the patient were happy with services received from the staff and the Agency. CG A stated the Agency had provided her with information regarding the patient rights, information on how to contract the Agency after hours, advanced directives, emergency plan/211, complaint policies and other Agency/Patient information in the patient’s admission home folder and had no questions regarding it. Record review of Patient #8’s EMR included a POC signed and dated 09/12/24 that documented Patient #8 as a 91-year-old male with a primary diagnosis of Alzheimer’s disease (progressive brain disorder that destroys memory and thinking skills). Furthermore, the POC documented a benefit period dated 09/10/24 through 12/08/24 and the following services ordered, “Skilled Nursing 3 to 7 times per week for 12 times per quarter and 2 prn visits for change in condition each month”. Review of Patient #8’s EMR included a POC signed and dated 12/09/24 that documented a current benefit period 12/09/24 through 03/09/25. Further record review of Patient #8’s POC documented the following services ordered “Skilled Nursing 3 to 7 times per week for 12 times per quarter and 2 prn visits for change in condition each month”.Record review of Patient #8’s EMR indicated the Agency performed the following SN visits between certification period 09/10/24 through 12/08/24 as follows: 09/10/24, 09/12/24, 09/16/24, 09/19/24, 09/19/24, 09/23/24, 09/28/24, 09/30/24, 10/03/24, 10/10/24, 10/17/24, 10/24/24, 10/31/24, 11/07/24, 11/11/24, 11/21/24, 11/29/24, and 12/05/24. Further review of Patient #8’s EMR indicated the Agency performed the following SN visits between certification period 12/09/24 through 03/08/25 as follows: 12/10/24, 12/17/24, and 12/23/24. Record review of Patient #8’s EMR failed to show documentation of an updated POC order that indicated SN frequency change or evidence that 3 to 7 skilled nurse visits were conducted as per POC. During a home visit on 01/08/25 at approximately 11:50 a.m., Patient #8 and home was observed clean and well-kept, sitting in living room chair, patient was free of pain, comfortable and surrounded by family member. In an interview during this home visit, CG B stated Patient #8 had been receiving services from the Agency after family member had requested to be admitted to Agency. CG B stated Patient #8 was happy with the services received by the Agency and the staff who visited him Monday through Friday including the nurse and chaplain. CG B stated Agency had provided her with information regarding the patient rights, information on how to contract the Agency after hours, advanced directives, emergency plan/211, complaint policies and other Agency/Patient information in the patient’s admission home folder and had no questions regarding it. Record review of Patient #3’s EMR included a POC signed and dated 07/05/24 that documented Patient #3 as a 91-year-old female with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (cancer of an unspecified part of the bronchus or lung). Furthermore, the POC documented a benefit period dated 07/01/24 through 09/28/24 and the following services ordered, “Skilled Nursing 3 to 7 times per week for 12 weeks and 2 prn (as needed) visits for change in condition”. Record review of Patient #3’s EMR indicated that the Agency performed the following SN visits between certification period 07/01/24 through 08/11/24 as follows: 07/01/24, 07/02/24, 07/05/24, 07/09/24, 07/11/24, 07/17/24, 07/18/24, 07/22/24, 07/26/24 (documented as missed visit), 08/01/24, 08/02/24, 08/06/24, 08/08/24, and 08/11/24. Record review of Patient #3’s EMR failed to show documentation of an updated POC order that indicated SN frequency change or evidence that 3-7 skilled nurse visits were conducted per POC. In an interview on 01/14/25 at approximately 11:35 a.m., the Adm/DON stated the SN frequency was not followed according to the plan of care or the Agency’s policies for Patient #3, Patient #5, and Patient #8. The Adm/DON stated there were no updates to the POC to reflect changes in the SN frequency. Adm/DON stated she did not see documentation or communication notes documenting reason why nursing visits were decreased. The Adm/DON stated it was the supervising nurse’s responsibility to ensure the plan of care was followed for each patient related to skilled nurse frequency. The Adm/DON stated this was not “100 percent done” because of failure to monitor. The Adm/DON stated not following the POC could have negative patient care outcomes because the Agency would not be “unable to meet patient care”. Record review of the Agency’s policy titled “Plan of Care” (POC), with a revised date 03/25/15, quoted in part, “The Hospice interdisciplinary group (IDG) must prepare an individualized and patient specific written plan of care for each patient. The written plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs, as identified in the comprehensive assessment and as related to the terminal illness and related conditions…. (B) The written plan of care will include the following… (3) (b) A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs….””

“{THIS IS A CONTINUING DEFICIENCY FROM 02/10/22 SURVEY, FORMERLY CITED UNDER TAG L0563}Based on record review and interview, the Hospice failed to maintain a Quality Assessment Performance Improvement (QAPI) program for 3 (2022, 2023, and 2024) of 3 years reviewed in that: 1. It did not staff its QAPI Committee membership with the required Agency staff, which included an individual who represented each scope of services by the Agency This failure could place the Hospice’s active patients at risk of receiving inadequate care and services due to the agency not being able to trend patterns in negative patient care outcomes, effectiveness & safety of services provided including promptness of service delivery. The findings included: Review of the Hospice QAPI binder included 11 Agency forms titled “Utility Care Hospice, Hospice Utilization Review Quarterly Report” signed and dated as follows: · 04/13/22 – 1st quarter 2022 · 07/12/22 – 2nd quarter 2022 · 10/13/22 – 3rd quarter 2022 · 01/12/23 – 4th quarter 2022 · 04/13/23 – 1st quarter 2023 · 07/11/23 – 2nd quarter 2023 · 10/10/23 – 3rd quarter 2023 · 01/09/24 – 4th quarter 2023 · 04/09/24 – 1st quarter 2024 · 07/16/24 – 2nd quarter 2024 · 10/08/24 – 3rd quarter 2024 The forms reviewed contained signatures of the QAPI utilization review committee members including the Adm/DON, Medical Director (MD), the chaplain, members from the nursing discipline including a registered nurse (RN) and a licensed vocational nurse (LVN), and a member from the therapy discipline indicating participation in the QAPI program. The forms reviewed contained documentation of the following required quality indicator data in the Hospice’s QAPI program including an analysis of a representative sample of services furnished to clients contained in both active and closed records, a review of complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed staff, infection control activities, medication administration and errors, the competency of agency’s clinical staff, the appropriateness of the agency’s response to client complaints and incidents, a determination that services have been performed as outlined in the plan of care (POC), an analysis of client complaint and satisfaction survey data and an annual evaluation of the total operation. Each form reviewed failed to include the following quality indicator data including negative patient care outcomes, effectiveness and safety of services provided and promptness of service delivery. Furthermore, each form reviewed failed to contain documentation that a member from the medical social service (MSW) discipline participated in the QAPI program. In an interview on 01/14/25 at 04:10 p.m., the Adm/DON stated the Agency meet quarterly every 2nd or 3rd week of the month for their QAPI program meetings. The Adm/DON stated the QAPI committee members consisted of the supervising nurse, social services, the chaplain, the medical director, a member of therapy and any other individual the Agency might invite. The Adm/DON stated the MSW had not been participating to any of the meetings because she had another job and was working for the Agency only part time. The Adm/DON stated the Agency did not have too many patients and it (scheduling) had not been working out because the MSW had a different job and was working from home as well. The Adm/DON stated the Agency had not included negative client care outcomes, effectiveness and safety of services provided and promptness of service delivery in their QAPI program. The Adm/DON stated she was not sure why they were not included and does not remember why they were removed. The Adm/DON stated these indicators were important components of the QAPI program because the Agency needed this information so that they could correct and monitor these issues. The Adm/DON stated she was responsible for ensuring these components were included in the QAPI program and that they Agency was currently not following the Agency policies or regulation in maintaining their QAPI program because not all indicators were on QAPI and MSW did not participate in the QAPI meetings. Review of the Agency policies titled “Quality Assessment and Performance Improvement (QAPI)”, with a revised date 03/26/15, quoted in part, “The Hospice must develop, implement, and maintain an effective, ongoing hospice-wide data-driven quality assessment and performance improvement program…Q. QAPI Committee membership. At a minimum, the QAPI committee will consist of…””

“Based on record review and interview, the Hospice failed to include in the patients record physician orders for 3 inactive (Patient #1, Patient #4, and Patient #6) of 14 patient records whose records were reviewed. This deficient practice could place the Hospices patients at risk of not receiving needed services and inadequate care. The findings included: Review of Patient #1’s electronic medical record (EMR) included a “Plan of Care Order” (POC) signed and dated 12/19/24 that documented a benefit period of 12/06/24 through 03/05/25 and a terminal diagnosis of “Parkinson’s disease without dyskinesia without mention of fluctuations” (a movement disorder of the nervous system without jerky or fluctuating manifestations). Review of Patient #1’s EMR included skilled nurse (SN) notes signed and dated: 1. 12/09/24 that documented “Wound 1 – Location coccyx (bone of pelvis) …treatment assessed area and applied prevent silicone cream to the redden area to the coccyx…Skin…comments: SN noted Stage I reddened area and skin still intact to the coccyx area. SN applied protective silicone cream to the area and instructed caregiver (CG) to reposition every 2 hours to prevent ulcers…Conferenced with Adm/DON regarding…Stage 1 to coccyx…” 2. 12/10/24 that documented “Wound 1 – Location coccyx…Treatment: SN cleansed with NS (normal saline) and gauze, patted dry with gauze and applied duoderm to area…Wound 2 – Location Sacrum…Treatment: SN cleansed wound with NS and gauze, patted dry with gauze and applied duoderm…Wound 3 – Location Sacrum…Treatment: SN cleansed wound with NS and gauze, patted dry with gauze and applied duoderm… Review of Patient #1’s EMR failed to include physician orders that addressed wounds identified and wound care provided on SN visits 12/09/24 and 12/10/24. Review of Patient #4 EMR included a POC signed and dated 10/10/24 that documented a benefit period of 10/02/24 through 12/30/24 and a terminal diagnosis of “other specified diseases of pancreas”. Review of Patient #4 EMR included SN notes signed and dated: 1. 10/09/24 by RN A that documented Skin comments…Mottling (skin that has patchy and irregular colors) to the lower back…Coordination with Adm/DON regarding pt status/fall…order changes... none…Assessment/Instruction/Performance…changes noted to the pts (patient) skin color and mottling visible to the lower back and BLE (bilateral lower extremities). Pt (Patient) was found on floor by caregiver (CG) and notified [Agency] to assist in lifting pt off of the ground…RN notified FNP….”2. 10/09/24 by LVN C that documented Skin comments…Mottling to the lower back…Assessment/Instruction/Performance…Changes noted to the pts skin color and mottling visible to the lower back and BLE. Pt was found on the floor by CG and notified [Agency] to assist in lifting pt off of the ground…SN assisted RN with HV…Pt suffered a lesion to back of head and SN performed wound care…SN notified FNP and Adm/DON…”3. 10/09/24 by LVN C that documented “Wound 1 – Location Back of head…Treatment SN using aseptic technique and sterile supplies cleansed wound with anaspet spray, pat dried with 4x4 gauze, applied TAO (triple antibiotic ointment) using CTA (cotton tipped applicator), applied 2x2 border gauze…” 4. 10/10/24 by LVN C that documented ““Wound 1 – Location Back of head…Treatment SN using aseptic technique and sterile supplies cleansed wound with anaspet spray, pat dried with 4x4 gauze, applied TAO using CTA, applied 2x2 border gauze…”5. 10/12/24 by LVN C that documented “Wound 1 – Location back of head…Treatment SN using aseptic technique and sterile supplies cleansed wound with anasept spray, pat dried with 4x4 gauze, applied TAO (triple antibiotic ointment) using CTA, applied 2x2 border gauze…”6. 10/14/24 by LVN C that documented “Wound 1 – Location back of head…Treatment SN using aseptic technique and sterile supplies cleansed wound with anasept spray, pat dried with 4x4 gauze, applied TAO (triple antibiotic ointment) using CTA, applied 2x2 border gauze…”Review of Patient #4’s EMR failed to include physician orders that addressed wounds identified and wound care provided on SN visits 10/09/24 through 10/14/24. Review of Patient #6’s EMR included a POC signed and dated 07/18/24 that documented a benefit period of 07/11/24 through 10/08/24 and a terminal diagnosis of “end stage renal disease” (advanced kidney failure).Review of Patient #6 EMR included SN notes signed and dated:1. 07/11/24 signed by RN B that documented “Integumentary Status…Wound 1 – Location sacrum Status, Open, present on admission…Treatment Zinc Oxide twice daily…Patient response to treatment: No complaint, healing appropriately…” 2. 08/21/24 signed by LVN E that documented “Wound 1 – Location: sacrum, Status, closed, Present on admission…Wound 2 – Location: Left buttock Status, open… Onset date 08/21/24, Type Stage 2…Treatment…SN using aseptic tech (technique), cleanse wound with wound cleanser, pat dry, apply Medi honey with cotton tipped applicator, cover with silicone dressing…” 3. 08/23/24 signed by LVN E that documented “Wound 2 – Location: Left buttock Status, open… Onset date 08/21/24, Type Stage 2…Treatment…SN using aseptic tech (technique), cleanse wound with wound cleanser, pat dry, apply Medi honey with cotton tipped applicator, cover with silicone dressing…”4. 08/26/24 signed by LVN E that documented “Wound 2 – Location: Left buttock Status, open… Onset date 08/21/24, Type Stage 2…Treatment…SN using aseptic tech (technique), cleanse wound with wound cleanser, pat dry, apply Medi honey with cotton tipped applicator, cover with silicone dressing…”5. 08/28/24 signed by LVN E that documented “Wound 2 – Location: Left buttock Status, open… Onset date 08/21/24, Type Stage 2…Treatment…SN using aseptic tech (technique), cleanse wound with wound cleanser, pat dry, apply Medi honey with cotton tipped applicator, cover with silicone dressing…”6. 08/30/24 signed by LVN E that documented “Wound 2 – Location: Left buttock Status, open… Onset date 08/21/24, Type Stage 2…Treatment…SN using aseptic tech (technique), cleanse wound with wound cleanser, pat dry, apply Medi honey with cotton tipped applicator, cover with silicone dressing…”Review of Patient #4’s EMR failed to include physician orders that addressed wounds identified and wound care provided on SN visits 08/21/24 through 08/30/24. In[E(1] an interview on 01/14/25 at 09:40 a.m., RN A stated onset of the wound to Patient #1 was on 12/10/24. RN A stated caregiver and staff had been placing a barrier/silicone cream to prevent skin breakdown. RN A stated patient’s wife had called requesting wound care on that day and that she had to perform a “prn visit” in the afternoon because she did not have enough supplies to provide wound care on her initial visit for the day. RN A stated Patient #1 had 3 wounds that were “real close together” RN A stated Patient #1 had skin breakdown and developed the wounds “pretty quickly”. RN A stated Agency was notified, and Adm/DON was notified of the wound breakdown and the need for wound care orders. RN A stated, “we were pending orders”. RN A stated she did not enter an additional note to document her communication with the Adm/DON or of any orders received and she did not follow up to see what orders had come in from the physician’s office. In an interview on 01/14/25 at 09:50 a.m., the Adm/DON stated there was no communication and no wound care orders obtained from physician for wound care provided on 12/09/24 and 12/10/24 for Patient #1. The Adm/DON stated there was no documentation of the physician being notified of the need for wound care for the patient. The Adm/DON stated not having wound care orders could affect patient care because the patient had a wound that needed to be taken care of and his wife needed to be taught to provide for the wound care. The Adm/DON stated that in review of the Patient #1’s EMR she was able to “see where the nurse made a call” but did not see a “documented response or any coordination note’. In a subsequent interview and record review on 01/14/25 at 11:05 a.m. of Patient #4 and Patient #6, the Adm/DON stated Patient #4 did not have any physician orders for wound care provided on 10/09/24 through 10/19/24. The Adm/DON stated the Agency did not call the physician back to obtain orders after notifying him of the wound. The Adm/DON stated the nurse continued to provide wound care but did not see an order documented with each visit performed. The Adm/DON stated the Agency should have obtained an order to do the wound care that was documented. The Adm/DON continued by stating there was no documentation of physician orders for wound care provided to Patient #6 on 08/21/24 through 08/30/24. The Adm/DON confirmed that wound care was provided and stated that she was not sure why the agency did not obtain orders for the wound care provided. During an interview on 01/14/25 at approximately 03:45 p.m., the Adm/DON stated the Agency was not ensuring physician orders were in place regarding wound care orders. The Adm/DON stated she was responsible for ensuring this was being followed and that it was not being done due to “lack of monitoring”. The Adm/DON stated not ensuring physician orders were in place affected patient care because the Agency was not “meeting the needs of the patient”. Review of the Agency’s policies titled “Physician’s Orders” with a revised date 01/31/15, quoted in part, “The hospice must follow protocols and procedures related to physician orders…””

“Based on record review and interview, the Hospice failed to ensure a completed discharge summary of the patients stay Including treatments, symptoms, pain management, the current plan of care, and the latest physician orders for 3 (Patient #3, Patient #9, Patient #13) of 11 inactive patients whose records were reviewed. This failure placed the Hospice patients at risk of not receiving the appropriate post discharge continuity of care and services including medications, supplies and equipment Findings included: Review of Patient #3’s electronic medical record (EMR) included a “Plan of Care Order” (POC) signed and dated 07/05/24 that documented a benefit period of 07/01/24 through 09/28/24 and a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer). Further review of Patient #3’s EMR included an interdisciplinary group (IDG) note signed and dated 08/01/24 that documented “Summary/Comments…Reported to MD (medical doctor) and team, patient arrangements to transfer patient to [different state] …” Review of SN (skilled nurse) visit signed and dated 08/08/24 documented “discharge as pt will be leaving to [different state] … RN reviewed contract/form change in hospice designation with Pt/CG/MPOA (medical power of attorney) and informed that the transfer date has been set for 08/11/24 to…” Review of SN visit signed and dated 08/11/24 documented “… [Patient #3] being discharged/transferred to hospice…upon patient request…5-day discharge notice/visit was on 08/08/24…Pt/CG (caregiver) verbalized understanding of the use of portable O2 (oxygen) machine and discharge instructions…” Review of Patient #3 EMR included a “Discharge- Live” note signed and dated 08/11/24 that documented “Discharge order date 08/08/24, Discharge date 08/11/24, Patient status: Discharged/transferred to hospice-home…Reason for Discharge: Discharged – Patient transferred to another hospice…” Review of Patient #3 EMR failed to include documentation a discharge summary with documentation patient or receiving facility received information of the following: latest physician orders, advanced directives, most current list of medications, most current POC (including hospice aide plan if applicable), last nursing note, durable medical equipment needed, symptoms, treatments, pain management, etc. Furthermore, review of Patient #3 EMR failed to include documentation of notification to the attending physician of the patient’s transfer or discharge. Review of Patient #9’s EMR included a “POC Order” signed and dated 04/25/24 that documented a benefit period of 04/19/24 through 05/06/24 and a terminal diagnosis of chronic obstructive pulmonary disease (lung disease that prevents airflow in the lungs). Further review of Patient #9’s EMR included a “Discharge – Live” note signed and dated 05/06/24 that documented “Discharge order date 05/06/24, Discharge date 05/06/24, Patient status: Discharged to Home or Self-Care…Reason for Discharge: Discharge for Cause, Comments: Patient discharged per MD order and family request…”Review of Patient #9 EMR failed to include documentation a discharge summary with documentation patient received or receiving facility received information of the following: latest physician orders, advanced directives, most current list of medications, most current POC (including hospice aide plan if applicable), last nursing note, durable medical equipment needed, symptoms, treatments, pain management, etc. Furthermore, review of Patient #9 EMR failed to include documentation of notification to the attending physician of the patient’s transfer or discharge. Review of Patient #13’s EMR included a “POC Order” signed and dated 04/11/24 that documented a benefit period of 04/06/24 through 07/04/24 and a terminal diagnosis of degenerative disease of nervous system (chronic condition that damages and destroys parts of the nervous system over time). Further review of Patient #13’s EMR included an IDG meeting note signed and dated 06/20/24 that documented “Summary/Comments…Patient [family member] has decided to revoke services due to requesting curative services…” Review of Patient #13’s EMR included a “Discharge – Live” note signed and dated 07/04/24 that documented “Discharge order date 07/04/24, Discharge date 07/04/24, Patient status: Discharge to home or self-care, Comments: Patient was discharged upon CG request…”Review of Patient #13 failed to include documentation a discharge summary with documentation patient received or receiving facility received information of the following: latest physician orders, advanced directives, most current list of medications, most current POC (including hospice aide plan if applicable), last nursing note, durable medical equipment needed, symptoms, treatments, pain management, etc. Furthermore, review of Patient #13 EMR failed to include documentation of notification to the attending physician of the patient’s transfer or discharge. During an interview and simultaneous record review on 01/14/25 at 01:40, the Adm/DON stated discharging a patient from the agency consisted of documenting a written discharge summary and 5-day notice in the patient’s EMR. The Adm/DON stated there was a final discharge note in the EMR that was part of the discharge process, but that it did not consist of the complete process. The Adm/DON stated a discharge consisted of providing the patient with a copy of the 5-day notice and had a reminder that would be scheduled for the nurse’s visit and would include the nursing final note and discharge notice. The Adm/DON stated the discharge for Patient #3 was discussed with the MD but did not write out an order or get it signed. The Adm/DON stated the Agency did not anticipate Patient #3 moving out of state. The Adm/DON stated Patient #3 did have a discharge notice and summary provided to her to take to the receiving facility but did the EMR did not reflect the documentation. The Adm/DON stated Patient #3 had durable medical equipment provided to her for transportation and that this reflected the Agency performing the complete discharge process. The Adm/DON stated the Agency would attempt to obtain a copy of the documentation from the receiving facility and present this to the surveyor. The Adm/DON stated Client #9 was taken to the hospital by a family member. The Adm/DON stated there was “no actual discharge visit” documented for him because his family member did not want him receiving hospice services. The Adm/DON stated the Agency did receive a call from the MD’s office and that there “should have been a fax” documenting the discharge order. The Adm/DON stated Patient #13’s family members were seeking curative treatments and decided to revoke hospice services. The Adm/DON stated MD was made aware of Patient #13’s decision to revoke during previous IDG meeting on 06/20/24. The Adm/DON stated there was no documentation of the signed revocation, discharge summary or the discharge notice in Patient #13’s EMR. In a subsequent interview on 01/14/25 at 03:45 p.m., the Adm/DON stated the Agency was not following their policies regarding discharge planning from hospice care, providing discharge notices and obtaining discharge orders. The Adm/DON stated she was responsible for ensuring these policies and procedures were implemented and that this was not being done because of “failure to monitor 100%”. The Adm/DON stated the agency had an incomplete record and that this is how it could negatively affect client care. The Adm/DON stated the Agency was unable to obtain a copy of the discharge information provided to Client #3 from the receiving facility. The Adm stated all other documentation should be included in the patient’s records within 14 days of their discharge and for Patient #9 and Patient #13, the documentation was not available. Review of the Agency’s policies titled “Discharge from Hospice Care”, with a revised date, 03/27/15, quoted in part, “The hospice may discharge a patient from hospice care if the patient moves out of the hospice’s service area or transfers to another hospice, the patient is no longer terminally ill, or the hospice determines that the behavior of the patient or other person in the patient’s home is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired…(B) If a patient is being discharged for cause the hospice will… (C) If a patient moves out of the service area with notice, the hospice will…(D) If a patient moves out of the service area without notice, the hospice will…(E) If a patient notifies the hospice of leaving the agency’s service area temporarily, the hospice will…(F) If the hospice Medical Director has determined the patient’s prognosis is greater than 6 months, the hospice will….(4). Provide a copy of the Discharge Summary and, if requested, a copy of the Clinical Record to the Attending Physician, if any, and other service providers who will provide care, treatment, or services to the patient…Review of the Agency’s policies titled “Discharge from Hospice Care”, with a revised date, 03/27/15, quoted in part, “…(J) A hospice discharge summary must include…(1) A summary of the patient’s stay, including treatments, symptoms, and pain management…(2) the patient’s current plan of care…(3) the patient’s latest physician orders…(4) any other documentation needed to assist in post-discharge continuity of care or that is requested by the attending practitioner or receiving facility or agency…” Review of the Agency’s policies titled “Discharge from Hospice Care”, with a revised date, 03/27/15, quoted in part, “…(L) If a patient is discharged from hospice, the hospice must forward to the patient’s attending physician, a copy of each of the following…(1) The hospice discharge summary, which includes…(a) a summary of the patient’s stay including treatments, symptoms and pain management…(b) the patient’s current plan of care…(c) The patient’s latest physician orders, and…(d) any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility…(2) the patient’s clinical record if requested…””