Failure to Maintain Current Hospice Care Plans and Documentation
Penalty
Summary
The facility failed to meet hospice care requirements for a resident receiving hospice services by not maintaining readily accessible, current hospice documentation and by not clearly delineating care responsibilities between the facility and the hospice provider. The hospice agreement required both parties to keep complete, detailed, and readily accessible clinical records, organized to facilitate retrieval. For a resident over age 65 with hypertensive heart disease with heart failure, palliative care, and protein-calorie malnutrition, the electronic medical record contained a hospice plan of care that was only current through a certification period ending in mid-November 2025, with no updated hospice plan of care for the subsequent certification period beginning in January 2026. The resident’s hospice care plan in the facility record, initiated in March 2024 and revised in July 2024, included an intervention to work cooperatively with the hospice team, but there was no current hospice care plan from the hospice team in the record. Surveyors’ review of the resident’s electronic and physical charts did not show clinical documentation from routine hospice visits, including no visit notes from hospice staff on specific days when facility nurses reported hospice staff had been present. An RN stated that neither the physical chart nor the EMR contained the most recent hospice care plan and acknowledged that hospice notes were not updated or in chronological order. The RN also reported there was no system for hospice staff to sign in or for the facility to ensure required weekly hospice visits were completed, and that hospice CNAs typically came on certain days to assist with bathing without a formal system for charting or reporting the care provided. An LPN confirmed seeing hospice staff on particular days and relied on their informal check-ins rather than reviewing the chart, which lacked corresponding visit notes. The DON acknowledged that communication from the hospice company was poor and affirmed that the facility was ultimately responsible for ensuring hospice services were provided appropriately, yet the records did not demonstrate that hospice services and care planning requirements were being met for this resident.
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