Every finding on record at Mercy Hospice, LLC

Upon patient record review, 1 of 19 (Patient #3) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 3: On 06.25.2024, the SNF called the hospice to report the patient was experiencing shortness of breath. The on call telephone SN instructed the facility to utilize the PRN O2 for relief. The facility requested a SN come to see the patient for a PRN visit to further assess the patient, ensure the shortness of breath was relieved, and no further interventions were required. A PRN visit was made by the on call visiting nurse, but there was no evidence in the documentation that shortness of breath was assessed or addressed during the PRN visit. Further, there was no evidence during the next regularly scheduled SN visit that shortness of breath was assessed or addressed.

Upon patient record review, 1 of 19 (Patient #6) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 6: On 06.26.2024, monthly chaplain visits were discontinued, with an order for PRN visits only by the chaplain ongoing. (corrected onsite)

Upon patient client record review, 1 of 19 (Patient #9) 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 9: A visit note dated 06.21.2024 for a patient with a similar name was located in the patient record. An IT ticket was created immediately by the Regional Administrator to have the documentation moved to the correct patient record. (corrected onsite)