Failure to Coordinate and Document Hospice Care Planning
Penalty
Summary
A deficiency was identified in the facility's management of hospice services for a resident with severe cognitive impairment and a diagnosis of unspecified dementia with behavioral disturbance. The resident was admitted with advanced directives specifying do not resuscitate, do not intubate, do not hospitalize, and to provide comfort care. Despite being on hospice care, the only intervention documented in the care plan was to honor the resident's and family's wishes, with no further revisions or comprehensive end-of-life care planning. The facility failed to develop a care plan that coordinated services between the hospice provider and the facility, and did not initiate an end-of-life (hospice) care plan for over 95 days after hospice admission. Additionally, the facility did not ensure timely receipt of hospice renewal orders and plans of care, as there was no 90-day re-certification paperwork available after a certain date. The hospice provider was not routinely invited to participate in care plan meetings for hospice residents, and the required documentation for hospice certification periods was only obtained after surveyor inquiry, well after the resident had been on hospice services. These actions and omissions were not in accordance with the facility's own policy, which required comprehensive, coordinated care planning in collaboration with the hospice agency.