Failure to Maintain and Coordinate Hospice Documentation and Care Plan
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services had appropriate hospice documentation and a coordinated care plan in accordance with professional standards of practice. The resident, who had diagnoses including anxiety disorder, major depressive disorder, and acute on chronic heart failure, was admitted to the facility already enrolled in hospice. Despite this, the facility did not have documentation of the resident's hospice enrollment, admission assessment, care plan, orders, or visit notes in the electronic health record. Additionally, there was no facility-generated care plan addressing hospice for the resident prior to the surveyor's inquiry. Interviews with facility staff revealed inconsistent processes for obtaining and storing hospice documentation. The RN stated that hospice care plans and visit notes should be faxed and scanned into the EHR, but only one hospice note was found, and no care plan was available. The DON indicated that hospice documentation should be available in binders on the unit, but was only able to provide the required documents after the surveyor's request. The hospice nurse confirmed that routine visit notes were not regularly faxed to the facility and that the care plan and visit notes were only sent after a recent request. This lack of timely and accessible hospice documentation resulted in the facility not meeting its policy requirements for coordinated care for residents on hospice.