Failure to Maintain and Coordinate Hospice Documentation
Penalty
Summary
The facility failed to coordinate and maintain documentation of hospice care activities and the hospice care plan for four residents receiving hospice services. Hospice staff documented care and progress notes in their own electronic system and did not provide copies of this documentation to the facility. Facility staff received verbal updates from hospice staff, but written documentation, such as after-visit notes, was not consistently included in the residents' hospice binders or the facility's medical records. The only documentation provided by hospice to the facility included admission packets, DNR forms, POA forms, admission assessments, history and physicals, and occasionally physician orders. Interviews with facility RNs and the DON confirmed that hospice staff were expected to document in the hospice binder and provide verbal updates, but facility nurses only documented hospice notes when they initiated contact with hospice. Review of the hospice binders for the four residents revealed that essential hospice visit notes and after-visit documentation were missing. The binders typically contained only initial admission documents, consents, and sporadic physician orders, with little to no ongoing documentation of hospice visits or care provided. The facility care plans for each resident receiving hospice services were limited, listing only general goals and interventions related to comfort and pain management, with instructions to contact hospice as needed. The facility's agreement with the hospice provider stated that hospice would coordinate with the facility to ensure documentation of services was completed and that hospice care plans and documentation would be included in the facility medical record. However, this coordination and documentation did not occur as required, resulting in incomplete records of hospice care activities for the affected residents.