Failure to Maintain Complete Hospice Documentation in Medical Record
Penalty
Fine: $13,247
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Medical record review showed that the resident was admitted to the facility in August 2023 and began receiving hospice services in June 2024. However, the resident's medical record did not contain any documentation from hospice, such as progress notes, assessments, or care plans. This lack of hospice documentation was confirmed during an interview with the Director of Nursing, who acknowledged that the records were missing at the time of review.