Failure to Secure Hospice Contract and Maintain Hospice Records
Penalty
Summary
Facility staff failed to secure a written agreement with a hospice provider prior to the initiation of hospice services for a resident with multiple complex medical conditions, including dementia, severe protein calorie malnutrition, major depressive disorder, and total dependence for activities of daily living. The resident was started on hospice services, but the required contract with the hospice provider was not in place until the first day of the survey. Additionally, hospice care documentation, including care plans, visit notes, and medication and treatment orders, was not maintained in the resident's electronic health record during the period hospice services were provided. The deficiency was identified through interviews, clinical record review, and facility documentation. The administrator and staff were unable to locate the original hospice contract and had to request a new one from the hospice provider. Communication between facility staff and hospice was described as occurring verbally and by telephone, but there was no established process for ensuring hospice records were integrated into the facility's electronic health record.