Every finding on record at Ihc Health Services Inc

Based on medical record review, agency policy review, and staff interview, it was determined that 1 of 6 Patients (Patient #8) whose medical records were reviewed and who revoked hospice was not given a Notice of Medicare Noncoverage 2 days prior to discharge as per agency policy. This had the potential to leave patient and family unprepared to manage patient care without hospice benefits. Findings included: Patient #8 was a 92 year old female admitted to hospice on 6/16/22 with a terminal diagnosis of Alzheimer's Disease, unspecified. An RN visit completed on 7/27/23 included a "Hospice Benefit Revocation" form which had been signed by the patient's legal representative. The reason documented on the form stated: "No evidence of decline, weight is increased and stable; cognition, ADL ability and self care have greatly improved, pt [patient] is feeding self." There was no Notice of Medicare Noncoverage form in the file. An agency hospice policy titled "Hospice Discharge - No Longer Terminally Ill", dated 6/02/2023, was reviewed. The Policy stated: "Prior to Discharge if No Longer Terminally Ill...Verify NOMNC has been signed at least 2 days prior to discharge, for Medicare patients..." This was not done for patient #8. Patient #8 was not given the opportunity to dispute the decision to discharge from hospice services. The Nurse Administrator was interviewed on 7/12/23 beginning at 2:15 PM. The medical record of Patient #8 was reviewed in her presence. The Nurse Administrator agreed that Patient #8 should not have signed the revocation form as this was not a revocation. Patient #8 was discharged from hospice due to no longer qualifying as being terminally ill at that time. The Nurse Administrator confirmed that there was no NOMNC form found in record of Patient #8. Patient #8 was not discharged appropriately from hospice services.

Based on review of patient medical records, agency policies and staff interview, it was determined the agency failed to ensure the attending physician was notified of 2 unwitnessed falls and an ED transfer for 1 of 10 patients (Patient #10) whose records were reviewed. The attending physician was unaware of changes to Patient #10's medical condition. Findings included: Patient #10 was an 88 year old female admitted to hospice services on 6/05/23 with a terminal diagnosis of metastatic breast cancer. Patient #10's medical record was reviewed. An RN visit was completed on 6/26/23 and RN documented: "pt resting in chair upon arrival. Reports she had fallen over the weekend, hitting her head on the carbon monoxide monitor causing a small cut. Husband reported he did not take her to the ER because she was A&O pupils were reacting appropriately and she never showed s/s of conccusion [sic]." There was no documentation in Patient #10's medical record to indicate the attending MD was notified of the patient fall on 6/26/23. An RN visit completed on 7/3/23 documented: "...Pt had reported fall...patient requested to be sent to ED for xray and tx(treatment). ...revocation form filled out by spouse/caregiver." There was no documentation in Patient #10's medical record to indicate the attending MD was notified of the patient fall on 7/3/23 nor was there documentation that RN notified attending MD of revocation and ED transfer. An updated Process titled: "Unwitnessed Falls Documentation ", dated June 1,2023 was reviewed. The Updated Process stated: "Notify physician of all falls and document communication in a Case Communication, Falls Note." This process was not followed. The Nurse Administrator was interviewed on 7/12/23, beginning at 2:15 PM. The medical record of Patient #10 was reviewed in her presence. The Nurse Administrator confirmed there was no documentation indicating RN notified the attending MD of Patient #10's falls on 6/26/23 or on 7/3/23. The Nurse Administrator confirmed there was no documentation indicating RN notified the attending MD of Patient #10's revocation and ED transfer. The RN failed to follow agency Policy and Procedure for physician notification of all changes to patient condition.