Missing Current Hospice Plan of Care and Terminal Certification
Penalty
Summary
Facility staff failed to ensure that required hospice documentation was complete and available in the medical record for a resident receiving hospice services. The resident had multiple diagnoses, including diabetes, severe protein-calorie malnutrition, and a need for assistance with personal care, and the hospice care plan revised on a specified date documented that the resident was on hospice and had a DNR code status. Record review showed there was no current hospice plan of care and no current terminal diagnosis certification in the resident’s chart, both of which are required to initiate and maintain hospice services. When the surveyor requested these documents, the DON later provided a terminal certification with a benefit period that had expired 23 days earlier and only a facility-generated care plan, and the Administrator acknowledged that there was no current terminal certification or hospice plan of care in the resident’s record. The absence of required hospice documents created the potential for delayed or incomplete care due to lack of access to the hospice plan of care and current terminal certification.
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