Aseptic Hospice and Palliative Health Care LLC

“It is required that the hospice implements emergency (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address: Development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment. The documented discussion of the plan provided to the patient/family and maintained by the hospice. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure development of an individualized emergency plan for hospice patients/families. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/13/2025 with diagnoses of cerebrovascular disease, hypertension, hyperlipidemia, gastroesophageal reflux disease, recurrent major depressive, chronic hepatitis C, and brain aneurysm. The agency used a form titled “Individualized Emergency Plan” to document the specific emergency plan for the patient. Clinical record review revealed the Individualized Emergency Plan form in the patient’s chart was left blank, except for the patient’s name. The agency did not develop and document an emergency plan for the patient. CLINICAL RECORD 2: The patient elected the hospice benefit on 03/29/2025 with diagnoses of chronic obstructive pulmonary disease, hyperlipidemia, type 2 diabetes mellitus, spondylolisthesis, and insomnia. Clinical record review revealed there were two copies of the Individualized Emergency Plan form in the patient’s chart and both copies of the form were left blank, except for the patient’s name. The agency did not develop and document an emergency plan for the patient. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/03/2025 with diagnosis of acute chronic systolic congestive heart disease. Clinical record review revealed the Individualized Emergency Plan form in the patient’s chart was left blank, except for the patient’s name. The agency did not develop and document an emergency plan for the patient. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/02/2023 with diagnosis of acute and chronic diastolic congestive heart disease. Clinical record review revealed the Individualized Emergency Plan form in the patient’s chart was left blank, except for the patient’s name. The agency did not develop and document an emergency plan for the patient. CLINICAL RECORD 5: The patient elected the hospice benefit on 01/20/2025 with diagnoses of chronic obstructive pulmonary disease, hepatitis C, type 2 diabetes mellitus, hypertension, and lumbar pain. Clinical record review revealed the Individualized Emergency Plan form in the patient’s chart was left blank, except for the patient’s name. The agency did not develop and document an emergency plan for the patient. During joint review of the records and interviews on 06/10/2025 and 06/11/2025, the Administrator (Personnel Record 1) and Alternate Administrator (Personnel Record 2) confirmed the records did not include a patient specific emergency plan. On the morning of 06/12/2025, the Administrator and Alternate Administrator stated they were completed and added to the clinical record.”

“It is required that the hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to: a second full-scale exercise that is community-based or a facility-based functional exercise, or a mock disaster drill, or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. The agency did not ensure the Emergency Preparedness (EP) plan was tested annually. Review of the agency’s EP plan and program revealed no documented evidence of a full-scale exercise that is community based every 2 years and no documented evidence of a tabletop exercise or workshop to test the emergency plan for 2024. While reviewing the EP plan and program the Administrator (Personnel Record 1) stated, we didn’t have any patients in 2024 and there is no documentation that the agency performed patient care during 2024 or performed any Emergency Preparedness testing during the year. During the survey on the morning of 06/12/2025, the Alternate Administrator presented documentation of an implementation of their Emergency Plan in March 2025. There was no documented evidence of a full-scale exercise that is community based every 2 years and no documented evidence of a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan for 2024.”

“It is required that the written Patient Bill of Rights includes the right to: receive information about the services covered under the hospice benefit. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not provide the patient with information about the services covered under the hospice benefit. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/13/2025 with diagnoses of cerebrovascular disease, hypertension, hyperlipidemia, gastroesophageal reflux disease, recurrent major depressive, chronic hepatitis C, and brain aneurysm. Review of the patient’s informed consent dated 05/13/2025 revealed the section titled “Services/Rights/Hot Line Procedures” was left blank. The patient was receiving Skilled Nurse, Chaplain, and Medical Social Services. There was no documented evidence in the clinical record that the patient received information on the services covered under the hospice benefit. CLINICAL RECORD 2: The patient elected the hospice benefit on 03/29/2025 with diagnoses of chronic obstructive pulmonary disease, hyperlipidemia, type 2 diabetes mellitus, spondylolisthesis, and insomnia. Review of the patient’s informed consent dated 04/03/2025 revealed the section titled “Services/Rights/Hot Line Procedures” was left blank. The patient was receiving Skilled Nurse, Chaplain, and Medical Social Services. There was no documented evidence in the clinical record that the patient received information on the services covered under the hospice benefit. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/03/2025 with diagnosis of acute chronic systolic congestive heart disease. Review of the patient’s informed consent dated 04/03/2025 revealed the section titled “Services/Rights/Hot Line Procedures” was left blank. The patient was receiving Skilled Nurse, Chaplain, and Medical Social Services. There was no documented evidence in the clinical record that the patient received information on the services covered under the hospice benefit. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/02/2023 with diagnosis of acute and chronic diastolic congestive heart disease. Review of the patient’s informed consent dated 10/02/2023 revealed the section titled “Services/Rights/Hot Line Procedures” was left blank. The patient was receiving Skilled Nurse, Chaplain, and Medical Social Services. There was no documented evidence in the clinical record that the patient received information on the services covered under the hospice benefit. CLINICAL RECORD 5: The patient elected the hospice benefit on 01/20/2025 with diagnoses of chronic obstructive pulmonary disease, hepatitis C, type 2 diabetes mellitus, hypertension, and lumbar pain. Review of the patient’s informed consent dated 01/20/2025 revealed the section titled “Services/Rights/Hot Line Procedures” was left blank. The patient was receiving Skilled Nurse, Chaplain, and Medical Social Services. There was no documented evidence in the clinical record that the patient received information on the services covered under the hospice benefit. During an interview with the Administrator (Personnel Record 1) on 06/10/2025, the Administrator was shown the blank section of the consent forms, which included the section for the services to be provided which was left blank. During the exit conference on 06/12/2025, the Administrator (Personnel Record 1) and the Alternate Administrator (Personnel Record 2) stated, “No they are complete.” They were asked to get the patient records and upon review the consent forms had been completed. They were then asked if they remembered the site visitor showing them the blank forms and they stated, “Yes.” The forms were completed after it was brought to their attention on 06/10/2025.”

“It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes: The patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed, the agency did not ensure the patients pain assessment included the patient’s goal for pain management and their satisfaction with the current level of pain control. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/13/2025 with diagnoses of cerebrovascular disease, hypertension, hyperlipidemia, gastroesophageal reflux disease, recurrent major depressive, chronic hepatitis C, and brain aneurysm. The initial nursing comprehensive assessment dated 05/13/2025 included documentation that the patient rated their pain at 7 on a numeric scale of 1-10. The Skilled Nurse (SN) documented on the nursing visit note dated 05/20/25 that the patient rated pain at an 8. The SN documented on the nursing visit note dated 06/03/2025 that the patient rated pain at a 9. The comprehensive assessment and the nursing visit notes did not include documentation of the patient’s goals for pain management and the patient’s satisfaction with the current level of pain control. CLINICAL RECORD 2: The patient elected the hospice benefit on 03/29/2025 with diagnoses of chronic obstructive pulmonary disease, hyperlipidemia, type 2 diabetes mellitus, spondylolisthesis, and insomnia. The initial nursing comprehensive assessment dated 03/29/2025 included documentation that the patient rated their pain at 6 on a numeric scale of 1-10. The SN documented on the nursing visit note dated 04/05/2025 that the patient rated pain at a 6. The SN documented on nursing visit notes dated 04/12/2025, 04/19/2025, and 04/26/2025 that the patient rated pain at a 7. The nursing visit note dated 05/03/2025 included documentation that the patient rated pain at an 8 and the nursing visit note dated 05/10/2025 included documentation that the patient rated pain at a 9. The SN documented on nursing visit notes dated 05/17/2025, 05/24/2025, and 05/31/2025 that the patient rated pain at an 8. The nursing visit note dated 06/07/2025 included documentation that the patient rated pain at a 7. The comprehensive assessment and the nursing visit notes did not include documentation of the patient’s goals for pain management and the patient’s satisfaction with the current level of pain control. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/03/2025 with diagnosis of acute and chronic systolic congestive heart disease. The SN documented on the initial nursing comprehensive assessment dated 04/03/2025 that the patient rated their pain at 6 to the lower back. The comprehensive assessment did not include documentation of the patient’s goals for pain management and the patient’s satisfaction with the current level of pain control. During the interview on 06/10/2025, the Administrator (Personnel Record 1) stated, “the pain score is before they take their pain medication.” During the discussion and review of findings, the Administrator did agree that the records did not have documentation to support that the pain score was documented before the patient took pain medication and the records did not include a pain goal for the patient.”

“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 4 of 5 (80%) clinical records reviewed, the agency did not ensure the Registered Nurse documented coordination of care with other disciplines that were providing care to the patient. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/13/2025 with diagnoses of cerebrovascular disease, hypertension, hyperlipidemia, gastroesophageal reflux disease, recurrent major depressive, chronic hepatitis C, and brain aneurysm. The initial nursing comprehensive assessment dated 03/29/2025 included documentation that the patient rated their pain at 6 on a numeric scale of 1-10. The SN documented on the nursing visit note dated 04/05/2025 that the patient rated pain at a 6. The SN documented on nursing visit notes dated 04/12/2025, 04/19/2025, and 04/26/2025 that the patient rated pain at a 7. The nursing visit note dated 05/03/2025 included documentation that the patient rated pain at an 8 and the nursing visit note dated 05/10/2025 included documentation that the patient rated pain at a 9. The SN documented on nursing visit notes dated 05/17/2025, 05/24/2025, and 05/31/2025 that the patient rated pain at an 8. The nursing visit note dated 06/07/2025 included documentation that the patient rated pain at a 7. There was no documented evidence in the clinical record that the SN had coordinated with the physician related to the patient’s reports of increased pain. There was also no documented evidence in the clinical record that the Registered Nurse coordinated care with the other disciplines that were providing care to the patient, including the Chaplain and the Medical Social Worker. CLINICAL RECORD 2: The patient elected the hospice benefit on 03/29/2025 with diagnoses of chronic obstructive pulmonary disease, hyperlipidemia, type 2 diabetes mellitus, spondylolisthesis, and insomnia. The initial nursing comprehensive assessment dated 03/29/2025 included documentation that the patient rated their pain at 6 on a numeric scale of 1-10. The SN documented on the nursing visit note dated 04/05/2025 that the patient rated pain at a 6. The SN documented on nursing visit notes dated 04/12/2025, 04/19/2025, and 04/26/2025 that the patient rated pain at a 7. The nursing visit note dated 05/03/2025 included documentation that the patient rated pain at an 8 and the nursing visit note dated 05/10/2025 included documentation that the patient rated pain at a 9. The SN documented on nursing visit notes dated 05/17/2025, 05/24/2025, and 05/31/2025 that the patient rated pain at an 8. The nursing visit note dated 06/07/2025 included documentation that the patient rated pain at a 7. There was no documented evidence in the clinical record that the SN had coordinated with the physician related to the patient’s reports of increased pain. There was also no documented evidence in the clinical record that the Registered Nurse coordinated care with the other disciplines that were providing care to the patient, including the Chaplain and the Medical Social Worker. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/03/2025 with diagnosis of acute chronic systolic (congestion) heart disease. The SN documented on the initial nursing comprehensive assessment dated 04/03/2025 that the patient rated their pain at 6 to the lower back. There was no documented evidence in the clinical record that the SN had coordinated with the physician related to the patient’s report of pain to the lower back rated at a 6. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/02/2023 with diagnosis of acute and chronic diastolic congestive heart disease. The SN documented on the initial nursing comprehensive assessment dated 10/02/2023 that the patient rated their pain at 6 and the patient stated an acceptable level of pain was 2. The nursing visit note dated 10/16/2023 included documentation that the patient rated pain at a 7 and the nursing visit note dated 10/19/2023 included documentation that the patient rated pain at a 9. The SN documented on the nursing visit note dated 10/23/2023 that the patient rated pain at 8 and on the nursing visit note dated 10/30/2023 the SN documented the patient rated pain at 7. Review of the SN visit notes dated 10/16/2023, 10/19/2023, 10/23/2023, and 11/06/2023 revealed the section of the note titled “coordination of care/professional management /education” had been left blank. There was no documented evidence in the clinical record that the SN had coordinated with the physician related to the patient’s increased level of pain assessed during SN visits. During the interview on 06/10/2025, the Administrator (Personnel Record 1) stated, “the pain score is before they take their pain medication.” During the discussion and review of findings, the Administrator did agree that the records did not have documentation to support that the pain score was documented before the patient took pain medication and the records did not include documentation of coordination between disciplines.”

“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 3 of 5 (60%) clinical records reviewed, the agency did not ensure the individualized plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/13/2025 with diagnoses of cerebrovascular disease, hypertension, hyperlipidemia, gastroesophageal reflux disease, recurrent major depressive, chronic hepatitis C, and brain aneurysm. The plan of care dated 05/13/2025 included an intervention for the Skilled Nurse to “monitor pain level and treat as indicated.” The plan of care did not include a measurable outcome/goal for pain management. CLINICAL RECORD 2: The patient elected the hospice benefit on 03/29/2025 with diagnoses of chronic obstructive pulmonary disease, hyperlipidemia, type 2 diabetes mellitus, spondylolisthesis, and insomnia. The plan of care dated 04/03/2025 included an intervention for the Skilled Nurse to “monitor pain level and treat as indicated.” The plan of care did not include a measurable outcome/goal for pain management. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/03/2025 with diagnosis of acute chronic systolic congestive heart disease. The plan of care dated 04/03/2025 included an intervention for the Skilled Nurse to “monitor pain level and treat as indicated.” The plan of care did not include a measurable outcome/goal for pain management. During record review and interview on 06/12/2025, the Administrator (Personnel Record 1) and Alternate Administrator (Personnel Record 2) confirmed the plans of care needed to include measurable goals.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene. This standard was not met as evidenced by document review and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure the clinicians performed hand hygiene as required by agency policy. Agency policy IC.3 Hand Hygiene, reviewed 04/01/17, required in part, III. A. Decontaminate hands prior to entry into supply bag. D. Decontaminate hands after contact with patient’s/client’s intact skin, even when gloves are worn. HOME VISIT 2: During the home visit observation on 06/11/2025 with the Registered Nurse (RN) (Personnel Record 1), the nurse was observed to clean hands with hand sanitizer, then put on a pair of gloves. The RN was observed to touch the patient, use vital sign equipment, touch the patient’s front door, cleaned vital sign equipment and put equipment back in the visit bag without changing gloves during the home visit observation.”

“It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by personnel record review and interview. In 3 of 6 (50%) personnel records reviewed for licensed professionals, the agency did not ensure staff participated in agency in-service training for 2024. PERSONNEL RECORD 1: Administrator/Registered Nurse date of hire 04/28/2023. Personnel record review revealed no documented evidence that the Administrator participated in in-service training in 2024. PERSONNEL RECORD 2: Alternate Administrator/Registered Nurse date of hire 04/05/2023. Personnel record review revealed no documented evidence that the Alternate Administrator participated in in-service training in 2024. PERSONNEL RECORD 5: Medical Social Worker date of hire 04/26/2023. Personnel record review revealed no documented evidence that the Medical Social Worker participated in in-service training in 2024. On 06/12/2025 the Administrator (Personnel Record 1) provided a binder titled, “In-services”. In the binder was a form, Inservice Record for Year __________. In the binder was presentations for 31 different in-services. The Administrator was informed that the site visitor needed to see the in-service records for the individual staff members. She then presented documents with in-services for January 2025, February 2025, March 2025, April 2025, and May 2025. She stated, “we didn’t have any patients in 2024.””

“It is required that a hospice aide receives at least 12 hours of in-service training during each 12-month period. This standard was not met as evidenced by personnel record review and interview. In 1 of 1 (100%) personnel record reviewed for hospice aides, the agency did not ensure the hospice aide received at least 12 hours of in-service during each 12-month period. PERSONNEL RECORD 6: Hospice aide date of hire 04/26/2023. Personnel record review revealed no documented evidence that the aide received at least 12 hours of in-service training for the 12 months of 2024. During a review of the personnel record and interview on 06/11/2025, the Administrator (Personnel Record 1) stated, “we didn’t have any patients in 2024.””

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in the amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During the review of the agency’s volunteer program and interview with the Alternate Administrator (Personnel Record 2) on 06/12/2025, the Alternate Administrator was unable to provide documentation of the agency’s volunteer hours for the year 2024. During the interview the Alternate Administrator provided documentation to show that the agency had started collecting volunteer hours in May 2025. During the review of the agency’s volunteer program, there was no documented evidence of volunteer hours for the year 2024.”

“It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. This standard was not met as evidenced by document review, clinical record review, and interview. In 4 of 5 (80%) clinical records reviewed, the agency did not ensure entries in the clinical record were legible, complete, and appropriately authenticated. Agency policy IM.9 Medical Record Entries, required in part, “A.1. Clearly and permanently identify any amendments, corrections or delayed entries as such and, 2. Clearly indicate the date and author of any amendment, correction or delayed entry and 3. Clearly identify all original content, without deletion. B. Paper Medical Records: When correcting a paper medical record, these principles are generally accomplished as follows: 1. Using a single line strike through the original content so the original content is still readable. The author of the alteration must sign and date the revision.” CLINICAL RECORD 1: The patient elected the hospice benefit on 05/13/2025 with diagnoses of cerebrovascular disease, hypertension, hyperlipidemia, gastroesophageal reflux disease, recurrent major depressive, chronic hepatitis C, and brain aneurysm. Clinical record review revealed the initial comprehensive assessment included documentation of the date completed. The documentation showed the date of 05/23/2025 with a 1 written over the 2 (to look like 05/13/2025). CLINICAL RECORD 2: The patient elected the hospice benefit on 03/29/2025 with diagnoses of chronic obstructive pulmonary disease, hyperlipidemia, type 2 diabetes mellitus, spondylolisthesis, and insomnia. Review of the documents completed during the admission process revealed the Hospice Informed Consent, Notice of Non-covered Services, Individualized Bereavement Risk Assessment, and Hospice Election Statement were all dated 03/29/2025. The documents included the first initial and last name of the nurse who completed the forms; however, the documents/forms did not include the title/occupation of the nurse that completed the entries. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/03/2025 with diagnosis of acute chronic systolic congestive heart disease. The patient request for notification of hospice non-covered items, services and drugs dated 04/03/2025 had “white out” used on the signature line of beneficiary/patient representative. The skilled nurse visit note had “white out” on the visit date line with the date of 04/10/2025 written over the white out. CLINICAL RECORD 5: The patient elected the hospice benefit on 01/20/2025 with diagnoses of chronic obstructive pulmonary disease, hepatitis C, type 2 diabetes mellitus, hypertension, and lumbar pain. The initial comprehensive assessment dated 01/20/2025 included the first initial and last name of the nurse who completed the assessment; however, it did not include the title/occupation of the nurse that completed the entry. During an interview on 06/10/2025, the Administrator (Personnel Record 1) was shown the forms with the white out and the write overs. The Administrator agreed the documentation was not completed per policy.”

“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. This standard was not met as evidenced by clinical record review and document review. In 2 of 2 (100%) clinical records reviewed with patient discharge, the agency did not ensure the discharge summary included a summary of the patient’s stay including treatments, symptoms, and pain management. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/02/2023 and was discharged from the agency on 11/20/2023. The discharge summary in the clinical record included the statement, “faxed to physician,” however the summary did not include a summary of the patient’s stay including treatments, symptoms, and pain management. CLINICAL RECORD 5: The patient elected the hospice benefit on 01/20/2025 and was discharged from the agency on 01/30/2025. The discharge summary in the clinical record included the statement, “faxed to physician,” however the summary did not include a summary of the patient’s stay including treatments, symptoms, and pain management. During interview on 06/11/2025, the Administrator (Personnel Record 1) and the Alternate Administrator (Personnel Record 2) stated they did not know what had to be included in the discharge summary.”

“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 the patient’s current plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient discharge, the agency did not ensure the discharge summary included the patient’s current plan of care. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/02/2023 and was discharged from the agency on 11/20/2023. The discharge summary in the clinical record included the statement, “faxed to physician,” however the summary did not include the patient’s current plan of care. CLINICAL RECORD 5: The patient elected the hospice benefit on 01/20/2025 and was discharged from the agency on 01/30/2025. The discharge summary in the clinical record included the statement, “faxed to physician,” however the summary did not include the patient’s current plan of care. During an interview on 06/11/2025, the Administrator (Personnel Record 1) and Alternate Administrator (Personnel Record 2) stated they did not know what had to be included in the discharge summary.”