Every finding on record at Centra Health Inc, Hospice of the Hills

Based on clinical record review and staff interview it was determined the agency failed to ensure the Interdisciplinary Team (IDT) completed the patient's comprehensive assessment no later than five (5) days of election of hospice for three (3) of sixteen (16) clinical records in the survey sample (Clinical records #2, #4 and #5) Findings Sixteen clinical records (16) clinical records were reviewed in the agency on 09/13/2022 with the following findings: 1. The clinical record of patient #2 with an election of hospice benefit date of 08/20/2022 failed to contain documentation the agency's Interdisciplinary Team (IDT) completed the patient's comprehensive assessment within five (5) days of election of the hospice benefit. The first documentation of IDT involvement was on 08/30/2022. 2. The clinical record of patient #4 with an election of hospice benefit date of 08/05/2021 failed to contain documentation the agency's Interdisciplinary Team (IDT) completed the patient's comprehensive assessment within five (5) days of election of the hospice benefit. The first documentation of IDT involvement was on 08/11/2021. 3. The clinical record of patient #5 with an election of hospice benefit date of 07/12/2021 failed to contain documentation the agency's Interdisciplinary Team (IDT) completed the patient's comprehensive assessment within five (5) days of election of the hospice benefit. The first documentation of IDT involvement was on 07/22/2021. The lack of documentation of the agency's Interdisciplinary Team (IDT) completing the patient's comprehensive assessment within five (5) days of election of the hospice benefit was acknowledged by the Administrator during the clinical record reviews and again during the exit conference conducted in the agency on 09/14/2022.

Based on clinical record review and staff interview it was determined the agency's Interdisciplinary Team (IDT) failed to document the patient's progress toward goals and outcomes noted in the patients plans of care for six (6) of sixteen (16) clinical records in the survey sample (Clinical records #1, #4, #6, #7, #9 and #16) Findings Sixteen (16) clinical records were reviewed in the agency on 09/13/2022 with the following findings 1. The clinical record of patient #1 was reviewed for the timeframe of 08/16/2022 to 09/12/2022. Per clinical record documentation a (Interdisciplinary Team) IDT meeting was held on 08/31/2022. IDT documentation for the above noted IDT meeting failed to contain documentation of the patient's progress toward goals and outcomes as noted in the patient's plan of care. 2. The clinical record of patient #4 was reviewed for the timeframe of 07/31/2022 to 09/12/2022. Per clinical record documentation, (Interdisciplinary Team) IDT meetings were held on 08/11/2022, 08/25/2022 and 09/08/2022. IDT documentation for the above noted IDT meetings failed to contain documentation of the patient's progress toward goals and outcomes as noted in the patient's plan of care. 3. The clinical record of patient #6 was reviewed for the timeframe of 08/09/2022 to 09/12/2022. Per clinical record documentation (Interdisciplinary Team) IDT meetings were held on 08/17/2022 and 08/31/2022. IDT documentation for the above noted IDT meetings failed to contain documentation of the patient's progress toward goals and outcomes as noted in the patient's plan of care. 4. The clinical record of patient #7 was reviewed for the timeframe of 07/09/2022 to 09/06/2022. Per clinical record documentation (Interdisciplinary Team) IDT meetings were held 07/20/2022 08/03/2022, 08/17/2022 08/31/2022. IDT documentation for the above noted IDT meetings failed to contain documentation of the patient's progress toward goals and outcomes as noted in the patient's plan of care. 5. The clinical record of patient #9 was reviewed for the timeframe of 02/01/2022 to 02/21/2022. Per clinical record documentation IDT meetings were held on 02/03/2022 and 02/17/2022 IDT documentation for the above noted IDT meetings failed to contain documentation of the patient's progress toward goals and outcomes as noted in the patient's plan of care. 6. The clinical record of patient #16 was reviewed for the timeframe of 08/05/2022 to 09/12/2022. Per clinical record documentation IDT meetings were held on 08/11/2022, 08/25/2022 and 09/08/2022. IDT documentation for the above noted IDT meetings failed to contain documentation of the patient's progress toward goals and outcomes as noted in the patient's plan of care. The lack of documentation in reference to the patient's progress toward outcomes and goals was reviewed with the Administrator prior to and during the exit conference conducted in the agency on 09/14/2022.

Based on clinical record review and staff interview it was determined the agency failed to ensure care and services were provided in accordance with the patient's plan of care for three (3) of sixteen (16) clinical records in the survey sample. (Clinical records #7, #10 and #12) Findings Sixteen clinical records were reviewed in the agency on 09/13/2022 with the following findings: 1. The clinical record for patient #7 was reviewed for the time frame of 07/09/2022 to 09/06/2022. The clinical record contained documentation of Medical Social Work (MSW) visits on 07/26/2022 and 09/01/2022. The clinical record failed to contain a physician's order for the above noted MSW visits. In addition, the clinical record contained documentation of Chaplain visits on 08/03/2022 and 08/15/2022. The clinical record also failed to contain a physician order for the above noted Chaplain visits. 2. The clinical record for patient #10 was reviewed for the time frame of 05/29/2022 to 07/27/2022. The plan of care for the above noted time frame contained orders for Medical Social Worker (MSW) and a Chaplain visit one (1) to two (2) times a month for three (3) months effective 05/29/2022. The clinical record failed to contain documentation of a MSW or Chaplain visit or missed visits for the time frame of 05/29/2022 to 05/31/2022. In addition, the clinical record also failed to contain documentation of a MSW visit or missed visit for the month of June. 3. The clinical record for patient #12 was reviewed for the time frame of 05/22/2022 to 07/19/2022. The plan of care for the above noted time frame contained orders for Skilled Nurse (SN) visits two (2) times a week for nine (9) weeks. SN to flush port-a-cath at least monthly and weekly/PRN (as needed) when in use with ten (10) milliliters (ml) of normal saline followed by five (5) ml 100 unit/ml heparin. Per clinical record documentation, the port -a-cath was last flushed 04/19/2022. The clinical record failed to contain documentation of the port-a-cath being flushed in May or June 2022. The lack of documentation of care being provided in accordance with the patient's plan of care was acknowledged by the Administrator during the clinical record reviews and again during the exit conference conducted in the agency on 09/14/2022.