Every finding on record at Intrepid of Southern Indiana, Inc

Upon patient record review, 2 of 13 (Patient #4, 6) 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. Patient Record #4, #6: Missing evidence of an initial bereavement assessment being completed.

Upon client record review, 1 of 13 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient Record #1: IDG/POC, physician orders for SC frequency of 2/month and 2 prn change in condition. Visits made by SC in February were 2/1, 2/8, 2/14, 2/21, 2/28. There was no documented evidence that a change in condition occurred to warrant PRN visits. The number of visits made exceeded the ordered visits.

Upon patient record review, 3 of 13 (Patient #1, 7, 12) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #1: 1/27/22 MSW Comprehensive Assessment, the MSW documents that "family agreed to monthly SW visits." There is no evidence of orders for additional visits in IDG/POC. No documented evidence of follow up communication from MSW or documented evidence patient refused. Patient #7: 2/13/22 MSW documented "Family agreed to 2x monthly SW visit". 2/28/22 MD order for MSW 1/mo.. The IDG/POC was was blank for MSW visit frequency. MSW was not identified on initial IDG/POC frequency or on updates. Patient #12: 12/20/22 MSW Initial Assessment, the MSW documented "agreeable to SW returning to visit him in future 1/month." There is no evidence of orders for additional visits in IDG/POC. No documented evidence of follow up communication from MSW or documented evidence patient refused. Patient passed away 1/26/21.