Excellent Hospice and Palliative Care

“It is required that the hospice designates an Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records agency policy and interview revealed that the hospice failed to ensure that the designated registered nurse (RN) member of the IDG provided care coordination, continuous assessment of each patient’s and family’s needs, and the implementation of the interdisciplinary plan of care. [HCPC.19.I/418.56(a)/L540]; and that the IDT failed to review the individualized plan of care as frequently as the patient’s condition required, but no less than every 15 calendar days every fifteen days [HCPC.22.I/L552/418.56(d)]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.56: Interdisciplinary Group, Care Planning, and Coordination of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) clinical record review revealed the agency did not ensure that the designated registered nurse (RN) member of the IDG provided care coordination, continuous assessment of each patient’s and family’s needs, and the implementation of the interdisciplinary plan of care. CLINICAL RECORD 2: The patient elected the hospice benefit on 07/22/2022, benefit period 07/22/2022-10/19/2022, DX unspecified severe protein-calorie malnutrition. The following services were ordered: SN 1X week, Spiritual Counselor 1X month; and Social Worker 1X month. The RN completed the comprehensive assessment on 07/22/2022. The initial accreditation site visit ended on 07/28/2022. The clinical record review lacked evidence of an Interdisciplinary Group being conducted after July 20, 2022. There was no documented evidence of any visit activity, IDG review, care plan updates, or discharge plan documented from 07/23/2024 through the time of this review, on 06/30/2025. The clinical record review revealed no evidence that the designated RN coordinated care to ensure all disciplines provided the services ordered by the IDG (Interdisciplinary Group), ensured a continuous assessment of the patients’ and families’ needs, and ensured the implementation of the interdisciplinary plan of care and discharge plan. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/13/2022, DX Hypertensive Heart Disease with Heart Failure. A discharge order included that this patient was discharged to a non-contracted facility on 08/02/022. The clinical record review lacked evidence of an Interdisciplinary Group being conducted after July 20, 2022, an updated plan of care, and a discharge plan. The clinical record review revealed no evidence that the designated RN provided care coordination for services ordered by the IDG ensured a continuous assessment of the patient’s needs, and implementation of the interdisciplinary plan of care and discharge plan. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/13/2022, DX Hypertensive Heart Disease with Heart Failure. A discharge order included that the patient was discharged on 07/29/2022 following an emergency room visit. The clinical record review lacked evidence of an Interdisciplinary Group care plan updates or a discharge plan, and a discharge plan. The clinical record review revealed no evidence that the designated RN provided care coordination for discharge planning by the IDG, and implementation of the interdisciplinary plan of care. During an interview on 06/30/2025, the Director of Nurses (Personnel Record 6) stated that she does not know what happened to the clinical record of these patients, as she was not in management at the time. No additional documentation was presented before the conclusion of the site visit on 06/30/2025.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) clinical record review of patients who elected the hospice benefit revealed the agency did not ensure that the Interdisciplinary Group reviewed, revised, and documented the individualized care plan as frequently as the patient’s condition required, but no less frequently than every 15 days. CLINICAL RECORD 2: The patient elected the hospice benefit on 07/22/2022, benefit period 07/22/2022-10/19/2022, DX Unspecified severe protein-calorie malnutrition. There was no documented evidence of any visit activity after the RN comprehensive assessment on 07/22/2022. There was no documented evidence that the Interdisciplinary Group meeting was held conducted after July 20, 2022. The clinical record review revealed that this patient is no longer active; however, there was no documentation of any visit activity after the initial comprehensive assessment on 07/22/2022; or a discharge plan from 07/23/2022 to the time of this site visit on 06/30/2025. There was no documented evidence that the IDG reviewed, or updated the care plan at least every 15 days. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/13/2022, DX Hypertensive Heart Disease with Heart Failure. A discharge order included that this patient was discharged to a non-contracted facility on 08/02/022. There was no documented evidence of any visit activity after the initial comprehensive survey ended on 06/18/2022. There was no documented evidence that the Interdisciplinary Group meeting was held conducted after July 20, 2022. The clinical record review did not contain evidence that the Interdisciplinary Group updated or revised the plan of care to support the discharge prior to the discharge. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/13/2022, DX Hypertensive Heart Disease with Heart Failure. A discharge order included that the patient was discharged on 07/29/2022 following an emergency room visit. There was no documented evidence of any visit activity or a discharge plan after the initial comprehensive survey ended on 06/18/2022. The clinical record review did not contain evidence that the Interdisciplinary Group updated or revised the plan of care to support the discharge prior to the discharge. During an interview on 06/30/2025, The Director of Nurses (Personnel Record 6) stated that she does not know what happened to the clinical record of these patients, as she was not in management at the time. No additional documentation was presented before the conclusion of the site visit on 06/30/2025.”

“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 and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) applicable records reviewed for patient’s who were discharged live from Hospice care revealed that the hospice did not ensure that the discharge summary was forwarded the attending physician. CLINICAL RECORD 2: The patient elected the hospice benefit on 07/22/2022. There was not evidence of a discharge summary and discharge date. There was no documentation that mentioned a discharge plan, of an actual discharge date. it was unknown when the patient was discharged. The clinical record did not contain evidence that a discharge summary was sent to the attending physician. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/13/2022. The patient was discharged to a non-contracted facility on 08/02/2022. The clinical record did not contain evidence that a discharge summary was sent to the attending physician. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/13/2022. The patient was discharged on 7/29/2022 following an emergency room visit. The clinical record did not contain evidence that a discharge summary was sent to the physician. During an interview on 06/30/2025, the Director of Nurses (Personnel Record 6) stated that she does not know what happened to the clinical records of these patients, as she was not in management at the time. No additional documentation was presented before the conclusion of the site visit on 06/30/2025.”

“It is required that the hospice discharge summary provided 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, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) applicable records reviewed for patients requiring a discharge summary revealed that the hospice did not ensure that a discharge summary was completed. CLINICAL RECORD 2: The patient elected the hospice benefit on 07/22/2022. The discharge date was unknown and was not documented in the clinical record. There was no documented evidence that the discharge summary was completed. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/13/2022. The patient was discharged on 08/02/2022 to a non-contracted facility. There was no documented evidence that the discharge summary was completed. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/13/2022, and it is unknown when the patient was discharged. The patient was discharged on 07/29/2022 following a visit to the emergency room. There was no documented evidence that the discharge summary was completed. During an interview on 06/30/2025, the Director of Nurses (Personnel Record 6) stated that she does not know what happened to the clinical record of these patients, as she was not in management at the time. No additional documentation was presented before the conclusion of the site visit on 06/30/2025.”