Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two residents who received hospice services. The agreement between the facility and the hospice provider outlined the hospice's responsibility to provide necessary documentation, including the Hospice Benefit of Election form, plan of care, and other critical information. However, this information was not documented in the clinical records of the two residents reviewed. Resident 27, who had diagnoses including heart failure and adult failure to thrive, was admitted to the facility and received hospice care. Despite the hospice provider's care plan indicating scheduled visits, there was no documented evidence of the Hospice Benefit of Election form or communication from the hospice provider after a certain date. This lack of documentation indicates a failure in maintaining accurate and complete records as required by the agreement. Similarly, Resident 36, who had a history of cerebral vascular accident with hemiplegia and aphasia, was also receiving hospice care. The resident's clinical record lacked the Hospice Benefit of Election form, which was confirmed during an interview with the Nursing Home Administrator. The absence of this documentation in both residents' records highlights a deficiency in the facility's coordination and communication with the hospice provider.
Plan Of Correction
1. Facility ensured that Benefit of election from and required documents were filed into resident 27 and resident 36 clinical chart on 4/18/2025. Facility has no additional Hospice residents at this time. 2. Facility social worker has been identified as coordinator to ensure communication the plan is implemented and that appropriate documents are available in the physical chart for the interdisciplinary team with all future hospice admissions as of 4/25/25. 3. Facility and Hospice provider will implement a communication plan that ensures physical documents are available in the physical chart for interdisciplinary team review by 5/23/2025. 4. Facility will complete on the spot education regarding communication plan to their interdisciplinary team as well as Hospice Director of Business Development by 5/30/2025. 5. Administrator or designee will complete monthly audits of new hospice charts to ensure communication plan is in place and that required documentation is available to the interdisciplinary team in the chart. Audits will be conducted for 3 consecutive months and results will be reported at Quality Assurance and Performance Improvement Meeting.