Pdsf Hospice & Palliative Care Inc.

“Based on record review and interview the agency failed to maintain a system of communication and integration in accordance with its policies to ensure that patient care coordination was documented in the patient records for 4 (#2, #3, #5, #6) of 5 active patient records reviewed; the patient records did not contain documentation that coordination occurred with the physician, social worker, chaplain, and hospice aide at the interdisciplinary group meetings. The failure placed the patients at risk that miscommunication could result in a negative outcome or poor symptom management. Review of the agency’s policy titled “Coordination of Care,” labeled PC.110, and last reviewed on 9/1/2024 read in part; “Purpose To ensure coordination of all care provided for patients receiving hospice services and/or services from other providers. Policy I. The Hospice will develop and maintain s system of communication and integration in accordance with the Hospice’s own policies and procedures to...D Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement...Procedure VI. All communications and coordination of care is documented in the clinical record.” Review of the agency’s policy titled “Interdisciplinary Group Roles and Responsibilities,” labeled PC.40, and last reviewed on 9/1/2024 read in part; “Purpose To identify the roles and responsibility of the Interdisciplinary Group/Team (IDG/IDT). Policy I. The Hospice will designate an IDG/IDT, who, in consultation with the patient’s attending physician, will work together to provide for the physical, medical, psychosocial, emotional, and spiritual needs of the terminally ill patient and/or family members as delineated in a patient specific Plan of Care (POC). II. The IDG/IDT must include...A. A Doctor of Medicine or Osteopathy (who is an employee or under contract with the hospice); B. A Registered Nurse; C. A Social Worker/Marriage Family Therapist or Mental Health Counselor; D. A pastoral or other counselor...Procedure...VII. The IDG/IDT meetings will be held during the course of patient care to monitor and evaluate the patient’s interdisciplinary POC progress, at least every 15 days...XI. Formal communication regarding the patient’s POC is documented at the IDG/IDT meeting ensuring care and services are provided in accordance with the POC. A. Informal and written communication demonstrating coordination of care among all staff members and other providing care is also documented in the medical record...” The surveyor was given documents titled “IDT sign-in sheet” for the Interdisciplinary Group Meetings that occurred between 9/4/2024 through 11/27/2024. The sign in sheets indicated that a physician, registered nurse, social worker, chaplain, and home health aide were present at each of the interdisciplinary group meetings. Patient #2: Record review of Patient #2’s clinical record revealed an Initial Plan of Care dated 6/14/2024. The Plan of Care indicated that Patient #2 was admitted to the agency’s service on 6/14/2024. The Plan of Care listed Hypertensive Heart Disease without Heart Failure (medical condition of the heart being affected by high blood pressure over a long period of time) as the terminal diagnosis. Record review of Patient #2’s record indicated that an interdisciplinary group meeting occurred on 9/4/2024, 9/11/2024, 9/25/2024, 10/9/2024, 10/23/20204, 11/6/2024, 11/13/2024, and 11/27/2024. The hospice failed to document in the patient record that coordination occurred with the physician, social worker, chaplain, and hospice aide at the interdisciplinary group meetings. Patient #3: Record review of Patient #3’s patient record contained an Interdisciplinary Group Meeting Comprehensive Assessment that was dated 11/27/2024. The Comprehensive Assessment indicated that Patient #3 was admitted to service on 11/5/2024. The Comprehensive Assessment indicated Chronic Diastolic Heart Failure (condition in which the heart’s main pumping chamber, left ventricle, becomes stiff and unable to fill properly) as the terminal diagnosis. Record review of Patient #3’s record indicated that an interdisciplinary group meeting occurred on 11/6/2024, 11/13/2024, and 11/27/2024. The hospice failed to document in the patient record that coordination occurred with the physician, social worker, chaplain, and hospice aide at the interdisciplinary group meetings. Patient #5: Record review of Patient #5’s patient record revealed an Initial Plan of Care dated 6/22/2024. The Plan of Care indicated that Patient #5 was admitted to the agency’s service on 6/22/2024. The Plan of Care listed Protein-Calorie Malnutrition (condition when the body doesn’t get enough protein, calories, and other nutrients, ranging from starvation to semistarvation) as the terminal diagnosis. Record review of Patient #5’s patient record indicated that an interdisciplinary group meeting occurred on 9/11/2024, 9/25/2024, 10/9/2024, 10/23/2024, 11/6/2024, 11/13/2024, and 11/27/2024. The hospice failed to document in the patient record that coordination occurred with the physician, social worker, chaplain, and hospice aide at the interdisciplinary group meetings. Patient #6: Record review of Patient #6’s patient record revealed an Initial Plan of Care dated 11/18/2024. The Plan of Care indicated that Patient #6 was admitted to the agency’s services on 11/18/2024. The Plan of Care listed Heart Failure Heart failure (condition developed when the heart doesn’t pump enough blood for the body’s needs) as the terminal diagnosis. Record review of Patient #6’s record indicated that an interdisciplinary group meeting occurred on 11/20/204 and 11/27/2024. The hospice failed to document in the Patient record that coordination occurred with the physician, social worker, chaplain, and hospice aide at the interdisciplinary group meetings. During an interview on 12/5/2024 at 12:12 p.m. with the Alternate Administrator/Supervising Nurse/Registered Nurse C, the surveyor discussed that the patient records did not contain documentation of coordination with the physician, social worker, chaplain, and hospice aide at the interdisciplinary group meetings. The Alternate Administrator/Supervising Nurse/Registered Nurse C stated, “I am responsible. I thought the paper one (sign in sheet) was good enough.” The surveyor asked were the sign in sheets included in the Patient records. The Alternate Administrator/Supervising Nurse stated, “No, they were not uploaded into the patient records.””