PRESTONSBURG, KY- PRESTONBURG HEALTH CARE CENTER

Review of the facility’s, Hospice Services Agreement dated 12/31/2019, with the Hospice provider, revealed the facility and Hospice provider will jointly develop and agree upon a coordinated, interdisciplinary Plan of Care. Further review revealed the facility and Hospice provider were to periodically conduct joint reviews of each Plan of Care and modify the Plan of Care, if necessary for the involved Hospice residents. 

Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #38 to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating severe cognitive impairment. Continued review of the MDS revealed the facility assessed Resident #38 to require extensive assistance with all Activities of Daily Living (ADLs). Further review of the MDS revealed not documented evidence the facility identified Resident #38 had received Hospice care prior to his/her admission or while a resident residing in the facility.

Review of the facility’s Care Plan, dated 08/16/2022 for Resident #38, revealed no documented evidence Hospice care plan had been developed for the resident.

Review of the Physician Note dated 07/28/2022, revealed Resident #38 had been on Hospice at home prior to admission to the facility for long-term care.

Review of the Form CMS-802 Matrix for Providers, received on 08/23/2022, present in the Resident #38’s record revealed it identified the resident as being on Hospice care.

Interview on 08/25/2022 at 2:22 PM, with the MDS Coordinator revealed she was not aware of Resident #38 receiving Hospice services and could not identify why the resident required Hospice services. The MDS Coordinator stated Hospice was a new service that the facility was providing. She revealed Hospice was not provided by the facility; the service was provided by the contracted Hospice company, so there would be no Physician’s Order or care plan completed by the facility. Further interview revealed the MDS Coordinator stated the Hospice service was not placed on the MDS assessment either.

Interview on 08/25/2022 at 3:03 PM, with the Medical Records Clerk revealed there was no written documentation exchanged between the Hospice provider and the facility.

Interview on 08/25/2022 at 3:21 PM, with the Hospice Executive Director (ED) revealed the facility and the Hospice company, had a contract for an extended length of time; however, they only recently began providing Hospice services to the facility’s residents. The Hospice ED further stated the Hospice company should have been providing the Hospice Order and Hospice care plan for the resident and be involved in the care planning process.

Interview on 08/25/2022 at 2:51 PM, with the Administrator revealed the facility just started taking Hospice residents within the last two (2) months and the process was new to everyone. The Administrator stated verbal communication was to occur to inform staff of the resident being on Hospice. She revealed she was unaware of any documents or care plans provided between the facility and the Hospice company. The Administrator further stated there should be a Physician’s Order for Hospice and the MDS assessment should identify the Hospice services for the resident.

An additional interview on 08/26/2022 at 11:49 AM, with the Administrator revealed her expectation was for Hospice services to be coordinated with the Hospice provider and facility staff. Further interview revealed the expectations were for an Physician’s Order to be obtained, Hospice should be identified on the resident’s MDS Assessment, and a Hospice care plan should be in place as required.