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F0849
D

Failure to Accurately Document Hospice Services and Orders in Medical Record

Philadelphia, Pennsylvania Survey Completed on 12-22-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that a resident’s hospice services were accurately reflected in the clinical record. Clinical record review and staff interviews showed that one resident (R81) received hospice services between August 15, 2025, and December 2, 2025. However, the resident’s progress notes contained no documentation regarding the resident’s clinical condition or the resident’s choice related to the election of hospice services. In addition, review of physician orders revealed there were no physician orders for hospice care documented from September 5, 2025, until November 18, 2025, despite the resident receiving hospice services during this period. These findings were confirmed with the Director of Nursing on December 5, 2025, at 10:25 a.m. The deficiency was cited under 28 Pa Code 211.5(f)(i)(ii) related to medical records, based on the lack of appropriate hospice-related documentation in the resident’s clinical record and the absence of corresponding physician orders for hospice care over a defined timeframe.

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