Every finding on record at Intrepid of the Appalachians, Inc

Upon patient record review 1 of 11 (Patient #11) 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. #11: Patient admitted 1/3/22. Initial spiritual assessment was performed 1/21/22 by SC, exceeding 5 days.

Upon patient record review 2 of 11 (Patient #6, 9) did not have evidence in the patient record that the comprehensive assessment identifies the 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. #6 and #9 have no documentation of initial spiritual assessment.

Upon patient record review, 1 of 11 (Patient #9) 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. #9: There is no documentation of initial bereavement assessment. There is no related documentation at all regarding omission.

Upon patient record review, 1 of 11 (Patient #10) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #10: Patient admitted with BL nephrostomy tubes. There is no documented evidence of patient education to family related to nephrostomy tubes. Upon interview, the administrator recalls that family had managed nephrostomy prior to admission, but this was not included in the documentation and no evidence of verified competence.

Upon patient record review, 3 of 11 (Patient #1, 7, 10) 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. #1: Patient admitted with left heel wound. 3/15/22 Admission POC Order to "Clean with DWC, apply Medi-honey, gauze and Hypafix tape daily, to be performed by LTC staff. Hospice RNCM to help. Order is unclear regarding hospice RNCM intervention. #7: Patient admitted with radiation related chest wound. 11-4-21 Admission (Initial POC) order to cleanse wound with DWC. Apply Aquacell, skin prep, gauze, tape 3x/wk and prn without a reason for the prn. 2/2/22 order to clean right chest wall wound with DWC W/D QOD and prn. Hospice RN to perform. Order does not indicate reason for prn. #10: Patient admitted with BL nephrostomy tubes. Admission Initial POC Order for Wound Care as follows: change nephrostomy bandages every week as needed." The order is incomplete in that it does indicate a reason for "as needed" for bandage changes.

Upon client record review, 2 of 11 (Patients #6, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. #6: Initial RN Assessment 2/21/22 references suprapubic catheter, last changed 2/21/22. 2/28/22 visit “catheter was placed, 20fr, 5 ml.” 3/13/22 “Suprapubic Foley changed with 20fr, 5 cc balloon. 3/26/22 “Suprapubic cath changed with 20fr 5cc balloon." 4/8/22 suprapubic cath changed with silicone catheter. There are no physician orders for suprapubic catheter, size, type, irrigation, changes. #10: Patient admitted with BL nephrostomy tubes. Admission Initial POC Order for Wound Care as follows: change nephrostomy bandages every week as needed." There is no documentation that nephrostomy bandage changed at all.

Upon patient client record review, 3 of 11 (Patient #1, 5, 10) 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. #1: Patient admitted with left heel wound. 3/15/22 Admission POC Order to "Clean with DWC, apply Medi-honey, gauze and Hypafix tape daily, to be performed by LTC staff. Hospice RNCM to help. 3/4/22 SN Note: Wound care per order. 3/15/22 Wound dressed per order. 4/1/22 No documented wound assessment. Documentation is not specific regarding wound assessment and wound care performed. #5: RN Visit 3/7/22 "Patient agrees to have labs drawn as ordered by physician.” No documentation related to whether venipuncture performed and/or labs obtained. Upon interview, DPOS reported that venipuncture was performed by RN that date, (but not documented) and lab results were presented to surveyor and uploaded/attached to visit. #10: The initial comprehensive assessment checked urostomy under GU body system assessment. In fact, patient admitted with BL nephrostomy tubes. There was no documentation regarding assessment of bandage, tubes or drainage in initial comprehensive assessment. Follow up visit note 1/27/22 SN correctly references nephrostomy tubes, as opposed to urostomy.

Upon client record review, 1 of 1 applicable records (Patient #1) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. #1-3/15/22 Admission POC Order to "Clean with DWC, apply Medi-honey, gauze and Hypafix tape daily, to be performed by LTC staff. 4/8/22 and 4/13/22 SN visit documentation included treatment as CA Alginate, gauze, Hypa-fix tape. There was no documented physician order or update to POC for change in wound care.