Every finding on record at Delta Hospice Inc

Observed in Record Review. In 2 of 5 patient records reviewed, The organization failed to maintain complete and accurate medical records. For example: on review of RRHV#1 there was noted inaccurate documentation as there was documentation that noted the volunteer coordinator, and chaplain contacted the patient 8 days prior to referral and 9 days prior to admission where volunteer and spiritual care services were declined at that time. The documentation was signed on the day of communication by the DPCS Designee. The documentation also noted that the Medical Director and Attending were contacted 14 days prior to referral and 15 days prior to admission to inform of patient admission to hospice. Also noted that hospice team agreed on admission and proposed plan of care and was signed by the DPCS Designee on the date of the communication note. In RRHV#2 similar findings were noted in the communication documentation where the volunteer coordinator and chaplain were noted to contact family 12 days prior to referral, 13 days prior to admission. Further, communication noted MD and Attending were contacted 16 days prior to referral to inform patient was admitted to hospice, and a note to inform of drug interactions 15 days prior to referral. These observations were reviewed with the DPCS Designee where she noted that the communication note dates were incorrect.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to ensure that the patient and primary caregiver receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care. On review of RRHV#2 the medication profile listed the medication Clonidine HCL 0.1 mg 1 table by mouth twice daily as needed if SBP > 165 mmhg. On review of the record there was no documentation that the patient and/or caregiver were provided education on monitoring the patient's blood pressure and when to give Clonidine based on the orders instructions. This observation was reviewed with the DPCS Designee.

Observed in HR File Review. In 2 of 2 contracts reviewed, for hospice physicians the organization failed to ensure that physician services were made routinely available on a 24-hour basis 7 days a week. On review of the contracts for the Hospice Medical Director and the alternated Medical Director the contract specified that the Medical Director will be available from 8:00 - 4:30 Monday - Friday, for on-call consultation, assistance and decisions regarding patient care. The contracts did not specify availability outside of the stated times. This observation was reviewed with the CEO.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to ensure the medical director review the clinical information for each hospice patient and provide written certification that the patient's life expectancy is six months or less if the illness runs its normal course. For example on review of RRHV#2 the Certification of Terminal Illness (CTI) lacked all required elements as it stated patient xx yr old X admitted to hospice for routine level of care with admitting terminal diagnosis of malignant neoplasm of cervix. Has gen weakness and KPS = 40% as end of life stage. On review of RRHV#3 similar lack of all required elements was noted in the physician's CTI written narrative. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to ensure that the patient record contain information that reflects the patient's care, treatment, or services. For example: on review of the record for RRHV#1 there was no medical history and physical (H&P) noted on the record to detail the patient's clinical information leading to the hospice admission. RRHV#2 had a terminal diagnosis of cancer of the cervix and a comorbid of breast cancer yet no history and physical to provide details of the diagnosis that led to hospice referral. Throughout all records reviewed there was no documentation of H&P noted on the records. These observations were reviewed with the DPCS Designee.