Every finding on record at Astrum Hospice, Inc.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that there was no evidence of a Registered Nurse comprehensive assessment for the interdisciplinary team completed every 15 days. For example, a review of the medical record for RRHV#3 revealed the 4th comprehensive assessment [update] was completed 18 days after the 3rd update. The 6th update was completed 16 days after the 5th update. Example #2: A review of the medical record for RRNHV#5 revealed the 3rd comprehensive assessment [update] was completed 24 days after the 2nd update, during the 1st benefit period. During the 2nd benefit period the 3rd update was completed 17 days after the 2nd update. This observation was reviewed with the Director of Patient Care Services.

Observed in Data Session. The organization did not take action when it did not achieve planned improvements. For example, the performance improvement goal for the organization's fall prevention program was to decrease the number of falls for the year(s) 2022, 2023. A review of the annual incident report data revealed that the patient’s experienced falls and the fall rate did not decrease. The organization’s goal was not achieved and steps to achieve success or change outcomes were not described in the reporting document. This observation was reviewed with the Director of Patient Care services.

Observed in Data Tracer. Since the organization did not document steps to achieve success or change outcomes in the reporting document related to fall prevention for the year(s) 2022, and 2023. The hospice did not track its performance related to improvements with the fall prevention program. This observation was reviewed with the Director of Patient Care services.

Observed in Record Review. In 3 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 Certification of Terminal Illness statement(s) for benefit period #5, and benefit period #6 for RRNHV#1, revealed that the Certifying Physician Summary did not document clinical information to support the medical prognosis and support for recertification of hospice services. This area of the document was left blank. Tools to document determining terminal prognosis such as the fiscal intermediary’s Local Coverage Determinations was also left blank. Example #2: A review of the Certification of Terminal Illness statement(s) for benefit period #5 for RRNHV#2, revealed that the Certifying Physician Summary did not document clinical information to support the medical prognosis and support for recertification of hospice services. This area of the document was left blank. Tools to document determining terminal prognosis such as the fiscal intermediary’s Local Coverage Determinations was also left blank. Example #3: A review of the Certification of Terminal Illness statement(s) for benefit period #1, and benefit period #2 for RRNHV#6, revealed that the Certifying Physician Summary did not document clinical information to support the medical prognosis and support for recertification of hospice services. This area of the document was left blank. Tools to document determining terminal prognosis such as the fiscal intermediary’s Local Coverage Determinations was also left blank. This observation was reviewed with the Director of Patient Care Services.

Observed in Record Review. In 5 of 10 patient records reviewed, it was noted that the organization did not implement its policy related to entries in the medical record. For example, during the review of the medical record for RRHV#3, the Medical Director's signature line on the Certification of Terminal Illness statement(s) for benefit period #1, and benefit period #2, did not include a date. Example #2: During a review of the medical record for RRNHV#1, the Medical Director’s signature line on the Certification of Terminal Illness statement(s) for benefit period #5 and benefit period #6, did not include a date. Example #3: During a review of the medical record for RRNHV#2, the Medical Director’s signature line on the Certification of Terminal Illness statement(s) for benefit period #5 did not include a date. Example #4: During a review of the medical record for RRNHV#3, and RRNHV#6, the Medical Director’s signature line on the Certification of Terminal Illness statement(s) for benefit period #1 and benefit period #2, did not include a date. This observation was reviewed with the Director of Patient Care Services.