Baraga County Home Care & Hospice

“Observed in Record Review. Example #4: A review of the medical record for HosRRNHV#4, revealed that the Certification of Terminal Illness statement for benefit period #1, did not document clinical information to support the medical prognosis and support for certification of hospice services [The primary terminal condition, related diagnosis, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of the patient’s conditions unrelated to the terminal condition]. This area of the document was left blank. This observation was reviewed with the Director of Home Care and Hospice. Observed in Record Review. In 4 of 10 patient records reviewed, the organization did not ensure its policy titled Certification of Terminal Illness was implemented. For example, a review of the medical record for HosRRHV#2, revealed that there was no documented evidence that a Certification of Terminal Illness statement for benefit period #1 was completed. In addition, the Physician’s physical exam statement did not document clinical information to support the medical prognosis and support for certification of hospice services [The primary terminal condition, related diagnosis, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of the patient’s conditions unrelated to the terminal condition].Example #2: A review of the medical record for HosRRNHV#1, it was noted that there was no documented evidence that a Certification of Terminal Illness statement for benefit period #1 was completed. In addition, the Physician’s physical exam statement did not document clinical information to support the medical prognosis and support for certification of hospice services [The primary terminal condition, related diagnosis, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of the patient’s conditions unrelated to the terminal condition].Example #3: A review of the medical record for HosRRNHV#2, revealed that there was no documented evidence that a Certification of Terminal Illness statement for benefit period #1 was completed. The Certifying Physician Summary did not document clinical information to support the medical prognosis and support for certification of hospice services [The primary terminal condition, related diagnosis, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of the patient’s conditions unrelated to the terminal condition]. This area of the document was left blank. This observation was reviewed with the Administrator of Home Care and Hospice.”

“Observed in Record Review. In 2 of 10 patient records reviewed, the organization did not ensure its policy titled Certification of Terminal Illness was implemented. For example, a review of the medical record for HosRRHV#2, it was noted that there was no documented evidence that Certification of Terminal Illness statement(s) for benefit period #2, and benefit period #3 were completed. In addition, the Physician’s physical exam statement did not document clinical information to support the medical prognosis and support for recertification of hospice services [The primary terminal condition, related diagnosis, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of the patient’s conditions unrelated to the terminal condition]. Example #2: A review of the medical record for HosRRNHV#1, it was noted that there was no documented evidence that a Certification of Terminal Illness statement for benefit period #2 was completed. In addition, the Physician’s physical exam statement did not document clinical information to support the medical prognosis and support for recertification of hospice services [The primary terminal condition, related diagnosis, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of the patient’s conditions unrelated to the terminal condition]. This observation was reviewed with the Administrator of Home Care and Hospice.”

“Observed in Individual Tracer. Example #2: Individual tracer activities for HosRRHV#1, revealed that plan of care did not include an accurate description of the medication’s the patient was currently taking. The following medication was not listed: Carafate 10ml by mouth up to 3 times per day as needed. During interview the patient’s daughter stated this medication was started 1 month ago. This observation was reviewed with the Administrator of Home Care and Hospice. Observed in Individual Tracer. In 2 of 2 individual tracers, it was noted that the organization did not ensure the medication list included accurate information. For example, individual tracer activities for HOSRRHV#2, revealed that the plan of care did not include an accurate description of the medication’s the patient was currently taking. The following medications were not listed: Brimonidine Tartrate 0.2% 1 drop in each eye daily and Benadryl 25 mg/1-2 tablets by mouth every 6 hours as needed for itching. The plan of care listed: Protonix 40 mg delayed release by mouth 1 tablet twice a day. An interview with the patient’s caregiver revealed the patient is currently taking Protonix 40 mg by mouth once a day. This observation was reviewed with the Director of Home Care and Hospice services.”