Every finding on record at Highland Hospice Care LLC

It is required that all entries in the patient record are legible complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) records reviewed it was revealed that the agency did not ensure that all entries in the patient's record were legible. Clinical Record 1: A patient with a hospice benefit election date of 5/4/2023 had IDG documentation dated 6/21/2023, 6/7/2023, and 5/24/2023 with a sub-section thirteen (13) thirteen in which the section titled "Emotional/Social Well-being" contained illegible handwritten additional comments. The initial spiritual assessment completed on 5/8/2023, included a sub-section three (3) which stated in part, "What type of spiritual/religious support does family desire?" The handwritten narrative stated, "Chaplain...illegible writing...use of religious...supportive...illegible...support." A joint record review and interview were conducted with the Administrator on 6/27/2023. It was confirmed the handwritten information under sub-section thirteen (13) titled "anticipatory grief" was illegible. The Administrator stated, "I looked the information over and didn't know what he was trying to say because I couldn't read it, but I didn't think to have him rewrite it so the surveyor could read it." The Administrator further confirmed they could not read the handwritten record because it was illegible. Clinical Record 2: The hospice benefit election date was 5/15/2023. The initial spiritual assessment was completed on 5/18/2023. Multiple sections of the spiritual assessment contained illegible handwriting. Sub-section two (2) stated in part, "faith bases...illegible ....and....illegible". In sub-section three (3), all handwriting was illegible. Sub-section seven (7) stated in part, "illegible...faith, attempts, in the ....illegible....and trust". A joint record review and interview was conducted with the Director of Nursing on 6/27/2023, confirming that the initial Spiritual assessment completed on 5/18/2023 was illegible. The Director of Nursing was unable to read sub-sections two (2), three (3), and seven (7).