F0849

D

Failure to Coordinate and Document Hospice Services for Residents on End-of-Life Care

Pittsburgh, Pennsylvania Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to coordinate hospice services with facility services and to maintain required hospice documentation and care planning for residents receiving end-of-life care. Facility policy dated 9/29/25 states that when a resident elects hospice, the facility will coordinate care with hospice staff, maintain written agreements, communicate necessary information, and develop a coordinated plan of care that identifies which services each entity will provide. The policy also requires the facility to communicate with hospice, identify, follow, and document all interventions put into place by hospice and the facility. For one resident with heart failure and depression who was admitted to hospice on 10/29/25, the clinical record showed that hospice staff were last documented as providing care on 11/20/25, with no subsequent hospice documentation in the record. On 1/19/26, an LPN confirmed that this resident continued to receive hospice services and that hospice staff were present that day, but also confirmed there was no hospice clinical documentation past 11/20/25.

For a second resident with traumatic brain injury and a seizure disorder who was admitted to hospice on 12/16/25, review of the clinical record and care plans showed there was no hospice care plan implemented. A RN confirmed during interview that this resident remained on hospice and was receiving care from the hospice service, and also confirmed that the facility had failed to implement a care plan addressing the resident’s hospice needs. These findings demonstrate that, for both residents on hospice, the facility did not ensure coordination and documentation of hospice services in accordance with its own policy and did not incorporate hospice needs into the resident’s care planning process.