Every finding on record at Journey's Home Health LLC

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 certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 6 (17%) records reviewed, it was revealed that the agency did not ensure the clinical record included an initial certification of terminal illness signed by the attending physician within eight days after care was initiated, per agency policy. Agency policy No. MM-01, Certification of Terminal Illness (reviewed 1/11/23), stated in part, "If the written certification is not obtained within two calendar days following the initiation of hospice care, a verbal certification may be made within two days following the initiation of hospice care, with a written certification not later than eight days after care is initiated." Clinical Record 3: Patient elected the hospice benefit on 10/5/23 with a diagnosis of nutritional marasmus. Per the informed consent and election of benefit forms, the patient selected a medical doctor to follow as the attending physician. This physician was not the hospice medical director nor a nurse practitioner. The clinical record contained verbal certification of terminal illness (CTI) by both the attending physician and the hospice medical director. The hospice medical director developed the physician narrative and signed the certification of terminal illness document on 10/13/23. During an interview on 12/21/23, the Branch Director confirmed the finding and stated, that the CTI signed by the attending physician could not be located and, that "somehow with double checks in place we still missed this one."