Failure to Maintain and Coordinate Required Hospice Documentation
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. Specifically, the facility did not obtain or maintain essential hospice documentation, including the Texas Medicaid Hospice Program Individual Election/Cancellation/Update (Form 3071), Physician Certification of Terminal Illness (Form 3074), Hospice Nurses' Notes, and Hospice Physician Orders. Interviews with the hospice case manager, ADON, DON, and administrator confirmed that these documents were not present in the resident's hospice binder, and there was a lack of verification to ensure the required documents were provided and maintained. The facility's own policy required these documents to be part of the clinical record, but the DON admitted she had not checked the hospice binders for completeness. The resident involved was an older male with chronic obstructive pulmonary disease and cancer, who was cognitively intact and required varying levels of assistance with activities of daily living. Although the resident had an order for hospice services and a care plan indicating hospice needs, the MDS assessment did not reflect hospice services, and the necessary hospice documentation was missing from the records. Staff interviews revealed uncertainty and lack of follow-through regarding responsibility for ensuring hospice documentation was complete and up to date, resulting in a failure to coordinate and communicate the resident's hospice care needs.