Direct Hospice Care Inc.

“Based on record review and interview the hospice failed to include the updated Plan of Care in the patient record for 1 (#1) of 2 patient records reviewed. The failure placed the patient at risk of receiving inappropriate care. Record review of Patient #1’s clinical record contained an updated Plan of Care for benefit period 12/14/2024 to 3/13/2024. The updated Plan of Care did not indicate the start of care date. The updated Plan of Care listed Atherosclerotic Heart Disease of Native Coronary Artery (plaque buildup in the arteries of the heart, narrowing the arteries) without Angina Pectoris (chest pain) as the terminal diagnosis. Patient #1’s clinical record contained a signed consent that hospice services were to begin on 9/19/2022. Patient #1’s clinical record contained a document titled “Discharge-Live” dated 4/10/2025. The document indicated that Patient #1 was transferred to Hospice X. Patient #1’s clinical record did not contain an updated Plan of Care for the timeframe between 3/14/2024 to 4/10/2024. During an interview on 10/17/2025 at 10:17 a.m. with the Administrator and Alternate Administrator/Supervising Nurse the surveyor discussed Patient #1’s record did not contain an updated Plan of Care that covered the timeframe for 3/14/2024 to 4/10/2024. The surveyor asked who would be responsible for developing the Plan of Care. The Alternate Administrator/Supervising Nurse stated, “the nurses were responsible and that the Interdisciplinary Group/Team would review them. The Alternate Administrator/Supervising Nurse informed the surveyor that it didn’t go through the normal quality assurance process and that it was an oversight. It would be updated for the interdisciplinary group/team meeting.” The surveyor asked who would be responsible to ensure that the updated Plan of Care would be included in the clinical record. The Alternate Administrator/Supervising Nurse stated, [Registered Nurse C] or I would be responsible.” During an interview on 10/17/2025 at 11:52 a.m. with Registered Nurse C, the surveyor discussed Patient #1’s record did not include the updated Plan of Care for 3/14/2024 to 4/10/2024. The surveyor asked what Registered Nurse C’s responsibilities were at the interdisciplinary group/team meetings. Registered Nurse C started, “I made sure interdisciplinary group/team notes and the plan of care were in the records, I closed (documentation was locked) the interdisciplinary group/team, that was new for me at that time. The surveyor asked why the updated Plan of Care was not in the patient record. Registered Nurse C stated, “Could have just forgotten to go in there (the record) to look. I was learning different things. We are more organized now, everyone knows what they are supposed to be doing.” Review of the agency’s policy titled “Clinical Records” that was undated read in part; “Policy The agency shall maintain a clinical record for each patient. Procedure...2. The clinical record shall contain data which includes, but is not limited to...v. Plans of Care...””

“Based on record review and interview, the agency failed to include in the patient discharge summary; a summary of the patient’s stay that included treatments, symptoms and pain management, the current plan of care, and the latest physician orders in 1 (#1) of 1 discharged record reviewed where the patient was discharged in accordance with the Code of Federal Regulations 418.26, transferred to another hospice. The failure placed the patient at risk for a negative outcome when post agency discharge continuity of care did not include up-to-date patient care information. The Code of Federal Regulations 418.26 read in part; “Reasons for Discharge. A hospice may discharge a patient if (1) The patient moves out of the hospice’s service area or transfers to another hospice; (2) The hospice determines that the patient is no longer terminally ill...” Patient #1:Record review of Patient #1’s clinical record contained a Plan of Care for benefit period 12/14/2024 to 3/13/2024. The Plan of Care did not indicate the start of care date. The Plan of Care listed Atherosclerotic Heart Disease of Native Coronary Artery (plaque buildup in the arteries of the heart, narrowing the arteries) without Angina Pectoris (chest pain) as the terminal diagnosis. Patient #1’s clinical record contained a consent that hospice services were to begin on 9/19/2022. Patient #1’s clinical record contained a document titled “Discharge-Live” dated 4/10/2025. The document indicated that Patient #1 was transferred to Hospice X. Patient #1’s clinical record did not contain a discharge summary. During an interview on 10/17/2025 with the Administrator and Alternate Administrator/Supervising Nurse, the surveyor discussed that Patient #1 did not have a discharge summary. The surveyor asked who would have been responsible for the discharge summary and why there was no discharge summary. The Administrator informed the surveyor that the process wasn’t where it should have been regarding the discharge summary. The Administrator stated, “[Patient #1] was the agency’s last patient. Shortly after [Patient #1] was discharged, we locked the [electronic medical record software], nothing else could be put in the chart.” The Administrator and Alternate Administrator/Supervising Nurse stated, “It was an oversight.” During an interview on 10/17/2025 at 3:45 p.m. with the Administrator and Alternate Administrator/Supervising Nurse, the surveyor asked what effect it could have on the patients, the Alternate Administrator/Supervising Nurse stated, “They [agency staff] wouldn’t know what was going on, what to do.””