Arden of North Mississippi (Oxford)

“Based on staff interviews, medical record reviews and policy/procedure review the facility failed to ensure the comprehensive assessment was updated by the hospice interdisciplinary group (IDG) and failed to document changes, or progress toward desired outcomes, or reassessment of the patients response to care for five (5) of twelve (12) medical records reviewed; Patient #4, #7, #9, #10 and #12. Findings Include: During an interview with the facility Executive Director (ED) on 02/14/2023 at 2:30 p.m., it was confirmed the Hospice Medical Director (MD) failed to document an updated summary on Patient #4s Plan of Care (POC) for the IDG meetings dated 11/17/2023 and 12/01/2023; and further confirmed the Social Worker (SW) failed to document an updated summary on the POC for the IDG meeting dated 12/29/2023. During an interview with facility ED on 02/14/2023 at 3:00 p.m., it was confirmed the MD failed to document an updated summary on Patient #7s POC for the IDG meetings dated 11/17/2023 and 12/01/2023. During an interview with the facility ED on 02/14/2023 at 3:30 p.m., for Patient #9, it was confirmed the MD failed to document an updated summary on Patient #9s POC for the IDG meeting dated 12/01/2023; further confirmed the Registered Nurse (RN) failed to document an updated summary on the POC for the IDG meeting dated 02/07/2023. During an interview with the facility ED on 02/14/2023 at 4:00 p.m. it was confirmed the MD failed to document an updated summary on Patient #10s POC for the IDG meetings dated 11/03/2023, 11/17/2023 and 12/01/2023 and further confirmed on 11/03/2023 the SW has no documented evidence of changes or progress toward desired outcomes of the patients response to care on the POC. During an interview with facility ED on 02/14/2023 at 3:00 p.m., it was confirmed the MD failed to document an updated summary on Patient #12s POC for the IDG meetings dated 07/28/2023 and 08/11/2023. Review of Patient #4s medical record confirmed the POC for the IDG meetings dated 11/17/2023 and 12/01/2023 have no documented evidence of progress toward desired outcomes or the patients response to care by the MD and on 12/29/2023 there is no documented evidence by the SW regarding changes or progress toward desired outcomes of the patients response to care on the POC. Review of Patient #7s medical record confirmed IDT meetings dated 11/17/2023 and 12/01/2023 have no documented evidence by the MD regarding changes or progress toward desired outcomes of the patients response to care on the POC. Review of Patient #9s medical record confirmed IDT meeting dated 12/01/2023 have no documented evidence by the MD on the POC of changes or progress toward desired outcomes of the patients response to care and on 02/07/2024 the POC has no documented evidence by an RN regarding changes or progress toward desired outcomes of the patients response to care. Review of Patient #10s medical record confirmed the IDT meetings dated 11/03/2023, 11/17/2023 and 12/01/2023 have no documented evidence by the MD of changes or progress toward desired outcomes of the patients response to care and the POC on 11/03/2023 has no documented evidence by the SW regarding changes or progress toward desired outcomes of the patients response to care. Review of Patient #12s medical record confirmed IDT meetings dated 07/28/2023 and 08/11/2023 have no documented evidence by the MD regarding changes or progress toward desired outcomes of the patients response to care on the POC. Review of the facility policy and procedures titled, “;IDG Care Planning Process,” policy # 9.12.1, Revised Date May 1, 2023, reveals “;...Procedure...The IDG (in collaboration with the patients attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patients condition requires, but no less frequently than every 15 calendar days. The revised plan of care includes information from the patients updated comprehensive assessment and notes the patients progress toward outcomes and goals specified in the plan of care, advance directives, effectiveness of pain and symptom management, and spiritual and psychosocial needs...” During the exit conference on 02/15/2024 at 2:00 p.m. with facility Executive Director, Vice President of Clinical, Quality and Operations, Executive Director/Care Team Lead, Executive Vice President and Chief Operating Officer, survey findings were discussed, and no further documentation was submitted for review.”

“Based on staff interview, medical record review and policy/procedure review the facility failed to ensure a Registered Nurse (RN) made an on-site visit to the patients home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patients needs for one (1) of 12 medical records reviewed: Patient #7. Findings Include: During an Interview with facility Executive Director (ED) at on 02/14/2024 at 3:00 p.m., it was confirmed a RN failed to make supervisory hospice aide visit within 14 days to the patients residence and failed to document a hospice aide supervisory visit for 12/29/2023 and 01/03/2024. Review of the medical record for Patient #7 revealed Hospice Aide (HHA) visits were made on 12/29/2023 and 01/03/2024 and the medical record contained no documented evidence a RN made a supervisory visit within 14 days. Review of the facility policy, “;Hospice Aide Supervision” Policy # 4.21.1 New January 2023, Revised May 1, 2023, “;...Policy...All Hospice Aide supervisory visits will be made at least every 14 days. Hospice will conduct the 14-day supervisory visit during an on-site visit, in person visit... Procedure...At least every 14 days the registered nurse (RN) makes an onsite home supervisory visit to assess relationships and determine whether goals are being met. This is done with or without the aides presence....”. During the exit conference on 02/15/2024 at 2:00 p.m. with facility Executive Director, Vice President of Clinical, Quality and Operations, Executive Director/Care Team Lead, Executive Vice President and Chief Operating Officer, survey findings were discussed, and no further documentation was submitted for review.”

“Based on staff interviews, medical record reviews and policy/procedure review the facility failed to ensure all entries were complete and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice on three (3) of (12) medical records reviewed; Patients #4, #7 and #9. Findings Include: During an interview with facility Executive Director (ED) on 02/14/2024 at 2:30 p.m. for Patient #4, it was confirmed Hospice Medical Director (MD) failed to sign Initial Plan of Care (POC) order for benefit period 11/17/2023 – 02/14/2024. During an interview with facility ED on 02/14/2024 at 03:00 p.m. for Patient #7, it was confirmed the MD failed to sign Initial POC order for benefit period 11/03/2023 – 01/31/2024. During an interview with facility ED on 02/14/2024 at 03:30 p.m. for Patient #9, it was confirmed the MD failed to sign Recertification POC order for benefit period 12/02/2023 – 01/30/2024. Review of the medical record for Patient #4, confirmed the initial POC order for benefit period 11/17/2023 – 02/14/2024 was not signed by the MD. Review of the medical record for Patient #7, confirmed the initial POC for benefit period 11/03/2023 – 01/31/2024 was not signed by the MD. Review of the medical record for Patient #9, confirmed the initial POC for benefit period 12/02/2023 – 01/30/2024 was not signed by the MD. Review of the facility policy, “;Physician Orders and Tracking System,” policy # 11.12.1, Revised May 1, 2023, revealed “;Policy...Physician orders are signed and returned to Hospice for the placement in the patients medical record within 30-60 days of the day they are written....” During the exit conference on 02/15/2024 at 2:00 p.m. with facility Executive Director, Vice President of Clinical, Quality and Operations, Executive Director/Care Team Lead, Executive Vice President and Chief Operating Officer, survey findings were discussed, and no further documentation was submitted for review.”