Greater Help Hospice LLC

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 6 (17%) clinical records reviewed it was revealed that the agency did not ensure that all members of the Interdisciplinary Group documented their attendance at the Interdisciplinary Group Meeting. Document 1: The agency policy Coordination of Care and Services and the Interdisciplinary Team (HC Policy 524) dated 4/8/2014 - reviewed and adopted 9/29/2022 included in part that “The agency will designate an Interdisciplinary Team who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice clients and families. The IDT will include, at a minimum, individuals who are qualified and competent to practice in the following professional roles: a Doctor of Medicine or osteopathy, a Registered Nurse, a Social Worker, and a Pastoral or other Counselor. Interdisciplinary Team Conferences will be held during the course of client care to monitor and evaluate the client’s progress. This will serve as documentation of effective interchange and reporting, as well as coordination of care. Coordination of services includes at least the RN, Physician, Social Worker, and Counselor. “ Clinical Record 6: The patient elected the hospice benefit on 5/24/2023. The Interdisciplinary (DG) Meeting/Plan of Care Updates for 6/7/2023 and 6/21/2023 had only two RNs and the Medical Director signed in as attending the meeting. The Interdisciplinary (DG) Meeting/Plan of Care Updates for 7/5/2023 included only signatures for the Medical Director, two RNs, the Social Worker, and the Hospice Aide in attendance. There was no documentation that the Chaplain/Counselor was present. The Interdisciplinary (DG) Meeting/Plan of Care Updates for 7/12/2023, 7/19/2023, and 7/26/2023 included only the Medical Director, two nurses, and the Hospice Aide’s signatures. The names of the Social Worker and Chaplain/Counselor were typed only. It was confirmed during an interview with the Director of Nursing (Staff 2) on 12/6/2023, that this was their first patient admitted and that they did not ensure that each member of the Interdisciplinary Team signed the team attendance forms documenting that they were in attendance.”

“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. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 6 (50%) clinical records reviewed it was revealed that the agency did not ensure that each entry into the patient’s clinical record was authenticated with the signature and date of the clinician providing care and that corrections were made per agency policy. Document 1: The agency policy Authorization and Authentication of Medical Record Entries (MOI Policy 724) dated 9/13/2013, reviewed and adopted 9/29/2022, included in part that, “All medical record entries will be made by appropriate staff and authenticated by the author of the entry. Medical record entries will be written in black ink or typed/computer generated. Each medical record entry will be dated and signed with the complete name and title of the person making the entry. Initials are acceptable only when requested. In the case of an alteration needing to be made in the medical record, one line should be made through the entry, and then the health care provider should date and initial the change.” Clinical Record 3: The patient elected the hospice benefit on 10/5/2023. On page 4 of 4 of the Medical Social Work Assessment, the staff member signed the assessment form, but the day of the month was illegible. The date had been written over versus one line through the incorrect date with the initials and date of the person making the correction. On the date of what appeared to be 11/7/23, the day of the month was written over versus corrected with one line and the initials and date of the person making the correction on Hospice Aide Care Plan/Progress Note. Clinical Record 4: The patient elected the hospice benefit on 3/18/2023. The Initial and Comprehensive Assessment documented on 3/18/2023 by the RN was typed. The last page (page 16 of 16) included a signature line that was blank. Narrative notes for a phone call dated 4/17/2023 at 2130, nurse visits documented on 4/18/2023 at 0745, and 4/18/2023 at 1140, did not include the name of the nurse or the signature of the nurse with the signature dated. Clinical Record 6: The patient elected the hospice benefit on 5/24/2023. On the 7/29/2023 Interdisciplinary Group (IDG) Meeting/Plan of Care Update, white-out was utilized to obscure the typed name of the Social Worker below the Social Worker’s signature. On the (IDG) Meeting/Plan of Care Update for 8/2/2023, white out was used to cover the typed name of the Social Worker. There was no signature of a Social Worker in attendance. It was confirmed during an interview with the Director of Nursing (Staff 2) on 12/6/2023 that these notes/documents were not properly authenticated and/or corrected per the hospice’s policy.”