Every finding on record at Gems Hospice and Palliative Care Inc

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 as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed, it was revealed that the agency did not ensure that the Interdisciplinary Group, in collaboration with the individual's attending physician, reviewed, revised, and documented the individualized care plan no less frequently than every 15 calendar days. Clinical Record 2: The patient’s date of election was 3/19/2023. There was no documented evidence that the IDG reviewed, revised, and documented the individualized care plan between 10/6/2023-12/13/2023. The last IDG review meeting was documented on 10/5/2023. Additionally, the IDG comprehensive assessment update meetings on 9/21/2023, 9/7/2023, and 8/24/2023 did not include a Registered Nurse update or signature. During a joint record review and interview on 12/13/2023, the Director of Patient Care Services agreed there was no documented evidence that the Registered Nurse attended and documented the IDG review. During a joint record review and interview on 12/13/2023, the alternate Director of Patient Care Services stated, "I am not sure how we missed those, we had the meetings, but I needed to update the notes."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed, it was revealed that the agency did not ensure the patient’s clinical record included complete physician orders for medications. Clinical Record 2: The patient’s date of election was 3/19/2023. A physician’s order on 3/19/2023 ordered Morphine Sulfate 20mg/ml, dosage 0.25ml PRN for pain and shortness of breath. There was no documented evidence that the physician’s order included indications of when to give the Morphine Sulfate as needed. During a joint record review and interview on 12/14/2023, the Director of Patient Care Services agreed the physician’s order for Morphine Sulfate was incomplete.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients with a live discharge, it was revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 3: The patient’s date of election was 10/10/2021. The patient was discharged from hospice services on 6/7/2022 for extended prognosis. There was no documented evidence that the discharge summary was forwarded to the patient’s attending physician. Clinical Record 4: The patient’s date of election was 12/1/2021. The patient was discharged from hospice services on 5/29/2022 for improved status. There was no documented evidence that the discharge summary was forwarded to the patient’s attending physician. During a joint record review and interview on 12/15/2023, the Director of Patient Care Services agreed there was no documented evidence that the discharge summary was forwarded to the patient's attending physician.