Every finding on record at Henderson County Health Department Hospice

Based on document review and interview, it was determined in 2 of 6 (Pt #1,Pt #2) patient records reviewed, the Hospice filed to ensure the initial assessment was completed within the required timeframe. --- 1. Pt #1 Start of Care (SOC): 4/3/2023. Diagnosis: Dementia with Lewy Bodies. Pt #1's record was reviewed on 10/25/2023. The record indicated the initial assessment was started on 4/4/2023 and completed on 8/28/2023. 2. Pt #2 SOC: 3/15/2023 Date of Death 3/30/2023.Diagnosis: Progressive Supranuclear Ophthalmoplegia. Pt #2's record was reviewed on 10/24/2023. The record indicated the initial assessment was started on 3/17/2023 but was not completed until 9/11/2023. 3. The policy titled "Hospice Admit Procedure" was reviewed on 10/26/2023. The policy required "The admitting nurse will complete the Plan of Care, the Initial Assessment..." 4. During an interview on 10/26/2023 at approximately 2:30 PM, E#1 (Office Manager) reviewed Pt #1 and Pt #2's record and verbally agreed the initial assessment was not completed on admission, within the 48 hour regulation requirement, and should have been.

Based on document review and interview, it was determined in 2 of 6 (Pt #1,Pt #2) patient records reviewed, the Hospice failed to ensure the comprehensive assessment was completed within the required timeframe of 5 days. --- 1. Pt #1 Start of Care (SOC): 4/3/2023 Diagnosis: Dementia with Lewy Bodies. Pt #1's record was reviewed on 10/25/2023. The record indicated the comprehensive assessment was started on 4/4/2023 and completed on 8/28/2023. 2. Pt #2 SOC: 3/15/2023 Date of Death 3/30/2023.Diagnosis: Progressive Supranuclear Ophthalmoplegia. Pt #2's record was reviewed on 10/24/2023. The record indicated the comprehensive assessment was started on 3/17/2023 but was not completed until 9/11/2023. 3. The policy titled "Hospice Admit Procedure" was reviewed on 10/26/2023. The policy required "The admitting nurse will complete the Plan of Care, the Initial and Comprehensive Nursing Assessment..." 4. During an interview on 10/26/2023 at approximately 2:30 PM, E#1 (Office Manager) reviewed Pt #1 and Pt #2's record and verbally agreed the comprehensive assessment was not completed no later than 5 days after election as regulation requirement, and should have been.

Based on document review and interview, it was determined for 1 of 6 (Pt#2) patients records reviewed, the Hospice failed to ensure Plan of Cares (POCs) were developed. --- Findings include: 1.Patient #2 Start of Care SOC: 3/15/2023 Date of Death (DOD): 3/30/2023. Diagnosis: Progressive supranuclear ophthalmoplegia. The record was reviewed on 10/24/2023. The record lacked a completed Plan of Care (POC). The POC was initiated on 3/15/2023 and as of 10/24/2023 remains incomplete. 2. The Hospice policy titled ";Care Plans" (Date of Implementation: 5/01/2022) was reviewed on 10/26/2023. The policy required ";The Care Plan must be filed in the clients chart within seven (7) days of the initial visit." 3. During an interview on 10/24/2023 at 2:40 PM, E#3 (Director of Nursing) reviewed Pt #2s record and verbally agreed that the record lacked a completed POC.

Based on document review and interview, it was determined for 3 of 6 (Pt #1, Pt #2, Pt #5) patients, the Hospice failed to ensure records were accurate and completed in a timely manner per Hospice policy. --- 1. Pt #1 Start of Care (SOC): 4/23/2023 Diagnosis: Dementia with Lewy Bodies. The record was reviewed 10/25/2023. The Nursing Visit Notes by Registered Nurse (E #3) dated 9/14/2023 was completed on 9/29/2023, the 9/16/2023 visit note was completed on 10/2/2023, the 9/25/2023 visit note was not completed until 10/14/2023 and the visit note of 10/12/2023 was completed on 10/24/202 2. Pt #2 SOC: 3/15/2023 Diagnosis: Progressive Supranuclear Ophthalmoplegia. The record was reviewed on 10/24/2023. The Nursing Visit Notes by Registered Nurse (E #3) dated 3/17/2023, 3/21/2023, 3/23/2023, 3/27/2023, 3/28/2023 and 3/30/2023 lacked documentation of the complete nursing visit assessment. Visit 3/17/2023 and 3/24/2023 lacked E #3's signature. 3. Pt #5 SOC: 3/8 /2023 Diagnosis: Malignant Neoplasm of Right Lung. The record was reviewed on 10/25/2023. The Nursing Visit Note dated 3/10/2023 was completed by Registered Nurse (E #3) on 10/25/2023, 5 months late. Nursing visit notes for 3/13/2023 and 3/16/2023 lack documentation of the visit assessment and lack the E #3 signature. Nursing visit notes for 3/20/2023 and 4/13/2023 lack the Registered Nurse (E #3) visit assessment documentation. 4. On 10/26/2023 the policy titled "Clinical Documentation" (Date of Implementation 4/7/2020) was reviewed. The policy required, "A separate note shall be completed for each visit, signed, and dated by the appropriate professional. Documentation of services on the plan of care will be completed the day service is rendered and incorporated into clinical record within seven days after the care has been provided.". 5. During an interview on 10/26/2023 at approximately 3:00 PM, E #1 (Office Manager) reviewed Pt #2 and Pt #5's records and verbally agreed the documentation was incomplete.

Based on document review and interview, it was determined in 1 of 1 (Pt #5) patient, who revoke Hospice services, the Hospice failed to ensure drug disposal was conducted per policy. --- 1. Pt #5 Start of Care (SOC): 3/8/2023 Date of Revoke 4/16/2023. Date of Death 4/16/2023. Diagnosis: Malignant Neoplasm Right Lung. The record was reviewed on 10/26/2023. The "Medication Profile" dated 3/8/2023 indicated the following medications: Lorazepam 2mg/ml liquid concentrate, Hydrocodone-Acetaminophen 5-325 mg tabs oral, and Morphine Sulfate (Concentration) 20 mg/ml liquid concentrate. The record lacked documentation the medications were disposed of after the patient revoked hospice services and was admitted to Hospice House on 4/16/2023 and expired. 2. The policy titled "Controlled Drug Disposal" (Date of Implementation 5/1/2022) was reviewed on 10/26/2023. The policy required ";When a patient no longer requires the controlled drug, the nurse will inform the family of the need to destroy the remaining medication. The method of how the medication was destroyed along with the name of the medication, the dosage and the amount of the drug will be documented, and a witness will be present, and a signature will be obtained. 3. On 10/26/2023 at approximately 2:00 PM an interview was conducted with E #1 (Office Manager) and E #3 (Director of Nursing). Both E #1 and E #3 reviewed Pt #5's record. Both E #1 and E #3 verbally agreed the record lacked documentation of the medication disposal.