Failure to Maintain Hospice Communication Records
Penalty
Summary
Saint Mary's at Asbury Ridge was found to be non-compliant with the quality of care requirements as outlined in 42 CFR Part 483, Subpart B, and the 28 PA Code. The deficiency was identified during an Abbreviated Complaint Survey, which revealed that the facility failed to maintain current information related to Hospice services for a resident. The facility had a Hospice Care Services Agreement that required communication and coordination of patient care services between the hospice and the facility. However, the clinical records for a resident, who had been admitted with diagnoses including senile degeneration of the brain and was receiving palliative care, showed a lack of hospice communication documentation after a certain date. The resident's clinical record indicated that hospice services were revoked on a specific date, but there was no evidence of hospice communication documents between the last recorded visit and the revocation date. This gap in documentation was confirmed by the Director of Nursing during an interview. The absence of these records suggests a failure to adhere to the established agreement and maintain necessary documentation for the coordination of care, as required by the regulations.
Plan Of Correction
The facility is unable to produce hospice records/communication documents related to CR1's hospice services from 06/18/2024 through 08/19/2024 while at the facility. All in-house residents with orders for hospice services will be reviewed by the Director of Nursing and or designee to assure the clinical record has current hospice communication/information documented in the clinical record. 01/24/2025 An in-service will be conducted by the Director of Nursing and or designee to all licensed nursing staff in regard to maintaining current hospice communication/information documented in the clinical record of any resident that receives hospice services. 02/13/2025 The Administrator communicated documentation expectations with the Clinical Director and/or Administrator of our current contracted hospice agencies and followed up with a letter to assure notification of hospice documentation expectations. 01/16/2025 A Quality Assurance monitor will be completed by the Director of Nursing and or designee to assure that any resident with hospice services will have current hospice communication and or information documented in the resident's clinical record. This monitor will be completed weekly for 2 months, then monthly for 3 consecutive months and will be submitted to the monthly Quality Assurance Committee. If the Quality Assurance monitor reflects 100% compliance for 3 consecutive months, then the monitor will be completed on a quarterly basis. 02/25/2025