Failure to Establish Timely Hospice Care Plan and Authorized Hospice Agreement
Penalty
Summary
The deficiency involves the facility’s failure to timely develop a hospice baseline care plan, obtain a hospice physician order, and secure an authorized hospice agreement prior to initiation of hospice services for one resident. The facility’s hospice program policy, last reviewed July 25, 2025, required that an agreement with the hospice provider be signed by a facility representative and a hospice agency representative before hospice services were furnished. The resident in question had clinical diagnoses including cerebral infarction, atrial fibrillation, and hospice status, and the admission MDS dated December 3, 2025, showed a BIMS score of 11, indicating moderately impaired cognition. Section O of the MDS documented that the resident was on hospice status upon admission on November 26, 2025. Record review showed that the resident’s baseline care plan was not created until December 4, 2025, which was eight days after admission and not within 48 hours as required. Review of the physician orders for November 2025, December 2025, and January 2026 did not reveal any physician order for hospice services. When surveyors requested the hospice agreement on January 13, 2026, the facility could not provide it until January 14, 2026, and the agreement produced was not signed by the hospice agency. In an interview on January 14, 2026, the Nursing Home Administrator confirmed that the baseline care plan was not developed within 48 hours of admission, there was no hospice physician order in the medical record, and the hospice agreement had not been authorized by both the facility and the hospice agency before hospice services were initiated.
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