Every finding on record at Intrepid of Central Virginia, Inc

Upon patient record review 1 of 13 (Patient #1) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1: SOC was 8/3/21. The Spiritual Assessment was not completed until 8/10/21 by the SC.

Upon patient record review 1 of 13 (Patient #2) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #2: SOC was 9/11/21. There was no evidence in the record of a psychosocial assessment having been completed.

Upon patient record review, 1 of 13 (Patient #1) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1: SOC was 8/3/21. The Initial Bereavement Assessment was completed 8/10/21 by the SC.

Upon patient record review, 1 of 13 (Patient #4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #4: 8/17/21 Plan of Care includes orders for Hospice SN to insert 18 Fr. coude indwelling catheter. Family to manage, SN to manage with visits and change as needed. The order was not specific to the balloon size or the as needed qualifier.

Upon patient record review 4 of 10 applicable (Patient #1, 2, 4, 5) did not have evidence in the patient record that hospice aide assignments and duties are appropriately assigned with a specified frequency. Patient #1, 2, 4, 5: HA Assignment includes task of "partial bath/shower" option, which is assigned every visit, rather than specifically a partial bath or a shower

Upon patient record review 1 of 10 applicable (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care Patient #2: HA assignment included "shampoo first visit every week". Shampoo was marked complete for 10/13/21, 10/14/21, 10/20/21, 10/22/21 and 10/27/21 which were not the first visit of respective weeks.

Upon patient record review, 1 of 13 (Patient #5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course.

Upon patient record review, 2 of 13 (Patient #5, 13) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #5: Patient benefit period was inaccurately entered in EMR as 90 day benefit period, when it should have been 60 day. The periods could not be corrected electronically, but the agency identified error and performed Face to Face and created CTI to correspond with 60 day benefit period requirements. However, the CTI intended for 10/4/21-12/2/21 was inadvertently dated for 12/3/21-1/31/21. During IDG 11/2/21, an attestation statement was created to amend the CTI. Patient #13 SC Visit was scheduled in the EMR for 6/21/21 and was electronically signed and dated 6/21/21. The date entered on the visit note reflected 5/21/21 in error.