Empyrean Hospice of Georgia, LLC-(Blairsville)

“It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) records reviewed of active patients with chronic pain revealed that the agency did not ensure that the staff documentation was entered into the record in a timely manner and according to their policy. Clinical/Services Data Collection Policy No. 6-022 states in part, “Documentation in the clinical/service record will be timely, detailed, accurate and reflect the care or services provided.” “Time means actual time that an event occurred, which is not necessarily the time when the documentation was entered into the record. The date and time requirement applies to all entries in the record and the medical record should accurately reflect a clear account of the patient’s entire course of care. The clinical record should tell a linear story of the course of the patient’s care that is managed and delivered by the organization.” It also states in part, “Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday.” Clinical Record 4: The patient accepted the hospice benefit on 07/03/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease. The initial comprehensive assessment was completed on 07/03/2024 by the RN. On 07/08/2024 the RN made a visit and documented those new medications had been started on the patient. Per a doctor’s order on 07/11/2024 there was another new medication started but no documented evidence why the medication was ordered for the patient. During further review of the record there was no documentation of follow up for new medication effectiveness or patient concerns as of 07/18/2024. The RN was interviewed by the surveyor and Chief Compliance Officer. She stated she did make the visits and followed up on the patient’s pain and effectiveness of new medications but has not entered it into the electronic medical record. She presented proof to the surveyor that the follow up had been done as evidence by call logs and handwritten notes. Clinical Record 3: The patient accepted the hospice benefit on 06/27/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease. On the initial comprehensive assessment, the RN documented that the patient has chronic pain in his lower back and extremities. The patient rated his pain 6/10. New medications were ordered for this patient. Follow up for effectiveness of new medication were done on 06/28/2024 by the RN. A visit was made by the RN on 07/03/2024 the patient reported pain 6/10. The RN received ordered from the doctor to increase the pain medication. During further review of the record that was no documented evidence that the RN followed up with the patient to assess effectiveness of medication. During an interview with RN and Chief Compliance Officer the RN stated and presented proof she did follow up with the patient but did not document it in the electronic medical record. The RN added these late notes to record on 07/18/2024. Clinical/Services Data Collection Policy No. 6-022 states in part, “Documentation in the clinical/service record will be timely, detailed, accurate and reflect the care or services provided.” “Time means actual time that an event occurred, which is not necessarily the time when the documentation was entered into the record. The date and time requirement applies to all entries in the record and the medical record should accurately reflect a clear account of the patient’s entire course of care. The clinical record should tell a linear story of the course of the patient’s care that is managed and delivered by the organization.” It also states in part, “Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday.””