Every finding on record at Interim Healthcare Hospice of Ohio, Inc.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the initial comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. Clinical Record 1: The date of election for hospice care was 11/22/2023. The initial nursing assessment was completed on 11/22/2023, and the spiritual care assessment was completed on 11/23/2023. The initial social work assessment was completed on 11/28/2023, with six (6) days outstanding. A clinical record review revealed no documentation explaining the delay in the social work assessment. In an interview on 02/21/2024, the Senior Director of Clinical Services and the Administrator reviewed the record. They stated, "Our social worker usually documents a note when an initial assessment is not done within the first five days, but there is no note for this record."

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 14 (7%) clinical records reviewed, the agency did not ensure that the patient's clinical record included all physician orders. Clinical Record 8: The patient elected hospice care on 04/06/2022. The nursing visit notes dated 05/30/2023 and 06/01/2023 documented "oxygen continuously at 4 liters." A review of the clinical record revealed no physician's orders for oxygen. In an interview on 02/21/2024, the Senior Director of Clinical Services and the Administrator reviewed the record. They stated, "I will speak with the nurse and see if the order is at the facility since it is not in the record."

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 1 (100%) home visit observed of a patient residing in a skilled nursing facility (SNF), the agency did not ensure that the most current plan of care was available to the SNF. Home Visit 3/Clinical Record Clinical Record 5: During the home visit with the Registered Nurse (RN) [Personnel Record 7], a review of the patient's SNF hospice binder revealed the last plan of care provided to the SNF was dated 03/03/2023. In an interview on 02/21/2024, the Senior Director of Clinical Services and the Administrator stated "I will have a staff member take the current plan of care out to the facility today."