Every finding on record at North Hawaii Hospice, Inc

Based on record reviews and interview, the facility failed to report to the Executive Director (ED) complaints from two patients (P), P6 and P7, that involved alleged mistreatment of P6 and P7 by Hospice Aide (HA)1. This deficient practice violates the patients right to be free from possible emotional and physical injury and has the potential to affect all patients receiving care from the facility. Findings include: --- Cross reference L517 Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse 1) On 01/18/23 at 12:45 PM, reviewed the facilitys grievances and incident reports. Read "ACCIDENT OR INCIDENT REPORT" with a date of incident 10/28/22 for P6. P6 was standing in the shower when the HA assisted him to sit in the shower chair and he landed roughly on the chair sustaining three red marks to his spine. Summary on the ";Complaint" form revealed, ";...State he felt unsafe standing and had to say ";Im falling" several times and when she did help him sit, it was a rough landing resulting in him hitting (sic) back hard, red marks to spine resulted." Further documentation on the ";Complaint" form dated 11/03/22 stated that HA1 was in a rush that day. 2) On 01/18/23 at 12:50 PM, reviewed the facilitys grievances and incident reports. Read ";Complaint" form for P7 received by Registered Nurse (RN)2 on 10/31/22. Summary stated, ";...Pt [patient] reports feeling unsafe w/ [with HA1] due to feeling rushed during care. Pt. afraid she may fall...Requesting to d/c [discontinue] HA1s visits – willing to work with a different HA [hospice aide]." On 01/27/23 at 12:30 PM, in a phone interview with the Executive Director (ED), the ED stated that she was unaware of P6's and P7's complaints so no investigation was done by her. Reviewed the facilitys policy, ";Policy Number: PC.A15 ABUSE, NEGLECT, MISTREATMENT AND EXPLOITATION," with no date. It stated under ";Procedures: ... 3. Alleged violations of abuse, neglect, mistreatment and/or exploitation involving a hospice employee or contractor are brought to the attention of the Administrator immediately."

Based on record reviews and interview, the facility failed to immediately investigate an alleged mistreatment of P6 by Hospice Aide (HA)1, which could have possibly prevented an alleged mistreatment of P7. This deficient practice violates the patients right to be free from possible emotional and physical injury and has the potential to affect all patients receiving care from the facility. Findings include: --- Cross reference to L508 Ensure that alleged violations are reported immediately to the hospice administrator and L517 Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse 1) On 01/18/23 at 12:45 PM, reviewed the facilitys grievances and incident reports. Read "ACCIDENT OR INCIDENT REPORT" with a date of incident 10/28/22 for P6. P6 was standing in the shower when the HA assisted him to sit in the shower chair and he landed roughly on the chair sustaining three red marks to his spine. No documentation was found under ";Investigation" and ";Recommendations." The ";Supervisor Signature" was dated 11/03/22. Summary on the ";Complaint" form revealed, ";...State he felt unsafe standing and had to say ";Im falling" several times and when she did help him sit, it was a rough landing resulting in him hitting (sic) back hard, red marks to spine resulted." Further documentation on the ";Complaint" form for follow up dated 11/03/22 stated that HA1 was in a rush that day. 2) On 01/18/23 at 12:50 PM, reviewed the facilitys grievances and incident reports. Read ";Complaint" form for P7 received by Registered Nurse (RN)2 on 10/31/22. Summary stated, ";...Pt [patient] reports feeling unsafe w/ [with HA1] due to feeling rushed during care. Pt. afraid she may fall...Requesting to d/c [discontinue] HA1s visits – willing to work with a different HA [hospice aide]." Reviewed the facilitys policy, ";Policy Number: PC.A15 ABUSE, NEGLECT, MISTREATMENT AND EXPLOITATION," with no date. It stated under ";Procedures: ... 5. The Administrator immediately (as soon as possible and not more than 24 hours after discovery of the incident) investigates alleged violations involving persons providing services on behalf of the hospice and immediately takes action to prevent potential further violations(s) during the investigation." On 01/27/23 at 12:30 PM, in a phone interview with the Executive Director (ED), the ED stated that she was unaware of P6's and P7's complaints involving alleged mistreatment by HA1, so no investigation was done by her.

Based on record reviews and interviews, the facility failed to prevent the alleged mistreatment of two patients (P), P6 and P7, by Hospice Aide (HA)1. This deficient practice violated their right to be free from possible emotional and physical injury and has the potential to affect all patients receiving care from the facility. Findings include: --- On 01/18/23 at 12:45 PM, reviewed the facilitys grievances and incident reports. Read "ACCIDENT OR INCIDENT REPORT" with a date of incident 10/28/22 for P6 documented by the Interim Clinical Director (ICD)2. P6 was standing in the shower when the HA assisted him to sit in the shower chair and he landed roughly on the chair sustaining three red marks to his spine. Summary on the ";Complaint" form revealed, ";...State he felt unsafe standing and had to say ";Im falling" several times and when she did help him sit, it was a rough landing resulting in him hitting (sic) back hard, red marks to spine resulted." Further documentation on the ";Complaint" form dated 11/03/22 stated that HA1 was in a rush that day. On 01/18/23 at 12:50 PM, reviewed the facilitys grievances and incident reports. Read ";Complaint" form for P7 received by Registered Nurse (RN)2. Summary stated, ";...Pt [patient] reports feeling unsafe w/ [HA1] due to feeling rushed during care. Pt. afraid she may fall...Requesting to d/c [discontinue] HA1s visits – willing to work with a different HA [hospice aide]." On 01/19/23 at 1:27 PM, the Interim Clinical Director (ICD)1 was interviewed. ICD1 stated that remediation was done with HA1 in the form of education and joint visits with the registered nurse. P7 was adamant of not having HA1 deliver her care and that a call-in HA replaced HA1. On 01/20/23 at 10:20 AM, a concurrent observation of HA1s personnel file and interview were done with the Human Resources Director (HRD). HRD confirmed that HA1s disciplinary action items for P6s and P7s complaints were not in her personnel file and they should have been placed in there. On 01/27/23 at 12:30 PM, in a phone interview with the Executive Director (ED), the ED stated that she was unaware of P6's and P7's complaints so no investigation was done by her.

Based on record reviews and interview, the facility failed to ensure that all members of the interdisciplinary group (IDG) participated in the patient's (P) comprehensive assessment for six, P1, P4, P6, P11, P8, and P9, out of 11 patients sampled. The IDG is comprised of the Hospice physician or the patient-designated attending physician, registered nurse, social worker, and pastoral/spiritual counselor. There was no signature by the doctor on the patients' comprehensive assessment to confirm their participation. This deficient practice fails to ensure that all members of the interdisciplinary group (IDG) were informed of all components of the patients' comprehensive assessment and of their identified needs and has the potential to affect all patients admitted to the facility. Findings include: --- 1) Reviewed policy, ";COMPREHENSIVE ASSESSMENT OF THE PATIENT," policy number, ";PC.C31," with no date. It stated, ";...2. The comprehensive assessment of the patient is completed by designated members of the IDG [interdisciplinary group], in consultation with the patients attending physician..." 2) Reviewed P8s electronic health record (EHR). P8 was admitted to the facility on 01/05/23 under his attending physician. Read ";Combined Disciplinary Comprehensive Assessment" dated 01/05/23. Under the heading, ";IDG Approval," ";N/A" was documented after the entry: ";Collaborated with Attending Physician:" No other documentation was found in P8's EHR to indicate that the IDG collaborated with P8's attending physician in completing P8's initial comprehensive assessment. 3) Reviewed P9s EHR. P9 was admitted to the facility on 12/12/22 under his attending physician. Read ";Combined Disciplinary Comprehensive Assessment" dated 12/17/22. There was no documentation on the form or anywhere else in the EHR that indicated that P9s initial comprehensive assessment was done in collaboration with P9s attending physician. Based on record review and interview with staff members, the facility failed to ensure all members of the interdisciplinary group (IDG). An interdisciplinary group is comprised of a doctor or medicine or osteopathy who is an employee or under contact with the hospice, registered nurse, social worker, and pastoral or other counselor) participated in 7 (Patients 1, 4, 6, 11...) of 11 patients comprehensive assessment. There was no signature by the hospice physician to confirm participation in the comprehensive assessment. Findings include: The facilitys Patient Care Policies and Procedure titled ";Comprehensive Assessment of the Patient" and ";Comprehensive Assessment - Content" were reviewed. The policy notes ";The hospice IDG conducts and documents a patient-specific comprehensive assessment that identified the patients need for hospice care, including medical, nursing, psychosocial, emotional and spiritual care". Due to the COVID-19 pandemic, Interdisciplinary Group (IDG) meetings were conducted virtually. Observation on 01/18 /23 at 01:00 PM, the meeting was held with attendants virtually and in person. ) Patient (P)1s election of hospice care (EOHC) date was 06/24/22. A review of the first comprehensive assessment dated 06/27/22 documents the Nurse electronically signed for the hospice physician. On 01/18/23 at 11:25 AM, concurrent record review and interview was conducted with the Interim Clinical Director (ICD)1. ICD1 confirmed the comprehensive assessment was electronically signed by the nurse and there was no documentation the nurse signed the assessment based on a verbal order by the physician. ) P6s EOHC date was 10/17/22. A review of the first comprehensive assessment done on 10/26/22 documents the Nurse electronically signed for the Hospice Physician. Record review and concurrent record review was done with the ICD1 on 01/19/23 at 01:45 PM. ICD1 confirmed the nurse electronically signed the assessment for the hospice physician. ICD1 reported the ";box" to indicate there was a verbal order for signature was not checked. ) P4s EOHC date was 11/22/22. A review of the first comprehensive assessment completed on 11/22/22 documents the nurse electronically signed the assessment for the hospice physician. On 01/19/23 at 02:06 PM, concurrent record review and interview was conducted with ICD1. ICD1 confirmed the comprehensive assessment was not signed by the hospice physician. The nurse electronically signed for the hospice physician. ICD1 confirmed there was no verbal order by the hospice physician to sign the assessment. ) P11s EOHC date was 11/16/22. A review of the first comprehensive assessment was done on 11/17/22. The assessment was not signed by the hospice physician.

Based on record review and interview with staff members, the facility did not assure the written individualized plan of care was established by the hospice interdisciplinary group (IDG) for 6 out of the 11 patients sampled. 1) There was no attestation of the Hospice Physicians participation in the development of the comprehensive plan of care for 3 patients (P), P1, P4, and P11 as evidenced by the lack of the hospice physician's signature to confirm participation and approval of the plan of care. 2) The written individualized plan of care was not done in collaboration with the attending physician for 3 other patients (P), P2, P7, and P9. This deficient practice has the potential to affect all patients receiving care from the facility. Findings include: --- 4) Reviewed P2's electronic health record (EHR). P2's initial EOHC was on 11/16/22 under her attending physician. The "Combined Disciplinary Plan of Care" documents for 11/23/22, 12/07/22, and 12/21/22 were reviewed. Under "IDG approval," "N/A [not applicable]" was documented for the entry "Collaborated with Attending Physician." On 11/19/22 at 12:53 PM, interviewed Interim Clinical Director (ICD)1. ICD1 stated that the "Combined Disciplinary Plan of Care" documents are faxed to the attending physician for review and approval. ICD1 was unable to produce the fax reports to verify her statement. 5) Reviewed P7's EHR. P7's second EOHC was on 11/17/22 under her attending physician. The "Combined Disciplinary Plan of Care" documents for 11/23/22 and 12/07/22 were reviewed. Under "IDG approval," "N/A [not applicable]" was documented for the entry "Collaborated with Attending Physician." 6) Reviewed P9's EHR. P9's initial EOHC was on 12/12/22 under his attending physician. The "Combined Disciplinary Plan of Care" documents for 12/21/22 and 01/04/23 were reviewed. Under "IDG approval," "N/A [not applicable]" was documented for the entry "Collaborated with Attending Physician." The facilitys Patient Care Policies and Procedures titled ";Plan of Care" and ";Plan of Care – Content" were reviewed. The policy notes ";care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the patients attending physician, and if appropriate, the patient and/or his/her representative. The plan of care includes but is not limited to interventions to manage pain and symptoms; a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs; drugs and treatments necessary to meet the needs of the patient; medical supplies, equipment, and appliances necessary to meet the needs of the patient. Cross Reference to L679. All entries must be appropriately authenticated and dated in accordance with accepted standards of practice. The comprehensive care plan was not signed by the hospice physician to authenticate participation and/or approval of the plan of care. ) Patient (P)1s election of hospice care (EOHC) date was 06/24/22. The first comprehensive plan of care was completed on 06/25/22. The plan of care was electronically signed by the registered nurse for the hospice physician. There was no electronic signature by the hospice physician. On 01/18/23 at 11:25 AM, Interim Clinical Director (ICD)1 confirmed there was no signature by the hospice physician. ) P4s EOHC date was 11/22/22. The first comprehensive plan of care was completed on 11/22/22. There is no electronic signature by the hospice physician, the plan of care was electronically signed by the registered nurse. On 01/19/23 at 02:06 PM, the ICD1 confirmed there was no signature by the hospice physician. ) P11s EOHC date was 11/16/22. A review of the comprehensive plan of care completed on 11/17/22 found no electronic signature by the hospice physician. The plan of care was electronically signed by the registered nurse.

Based on record review and interview with staff members, the facility failed to specify the frequency of services with ranges that did not include ";0" (zero) for 8 of 11 patients (P) reviewed, P1, 3, 4, 6, 11, 8, 9, and 10. This deficient practice has the potential to affect all patients receiving care from the facility. Findings include: --- 6) Reviewed P8's electronic health record (EHR). P8's EOHC was on 01/15/23. Reviewed the initial "Combined Disciplinary Plan of Care" section for 01/05/23. The designated frequencies for the social worker and spiritual counselor were zero to one visit before the next scheduled IDG meeting. 7) Reviewed P9's EHR. P9's EOHC was on 12/12/22. Reviewed the initial "Combined Disciplinary Plan of Care" section for 12/12/22. The designated frequencies for the social worker and spiritual counselor were zero to one visit before the next scheduled IDG meeting. Reviewed the "Combined Disciplinary Plan of Care" document for 12/21/22. The designated frequencies for the social worker was zero to one visit and for the spiritual counselor was zero to two visits before the next scheduled IDG meeting. 8) Reviewed P10's EHR. P10's initial EOHC was on 12/02/22. Reviewed the initial "Combined Disciplinary Plan of Care" section for 12/02/22. The designated frequencies for the hospice aide was zero to one visit, social worker was zero to one visit, volunteer zero to two visits, and spiritual counselor zero to one visit before the next scheduled IDG meeting. ) Record review on 01/17/23 at 12:43 PM found Patient (P)1 was admitted for hospice care on 06/04/22. A review of P1s plan of care found services with frequency of a minimum of zero and maximum of one. The plan of care dated 12/07/22 with next scheduled review of 12/21/22 notes the interdisciplinary group (IDG) approved ";Minimum number of Social Worker visits before next IDG review" for zero and ";Maximum number of Social Worker visits before next IDG review" as one. The plan of care for time period of 11/09/22 to 11/23/22 notes IDG approval for social worker and spiritual counselor visits a minimum of zero with maximum of one before the next scheduled IDG meeting. ) Record review on 01/18/23 at 11:55 AM found P3 was admitted for hospice care on 12/20/22. A review of the 12/21/22 to next IDG meeting of 01/04/23 documents IDG approval for social worker and spiritual counselor visits for a minimum of zero with a maximum of one before the next scheduled IDG meeting. The plan of care for 01/04/23 to 01/18/23 notes IDG approval for social worker and spiritual counselor visits for a minimum of zero with a maximum of one before the next scheduled IDG meeting. Also noted, hospice aide visit frequency was a minimum of zero with a maximum of three visits before the next IDG meeting. ) Record review on 01/19/23 at 02:06 PM found P4 was admitted for hospice care on 11/22/22. A review of the plan of care for period of 11/22/22 to 12/07/22 and 12/07/22 to 12/21/22 documents IDG approval for social worker and spiritual counselor visits for a minimum of zero with a maximum of one before the next IDG meeting. Also noted, for the time period of 11/22/22 to 12/07/22, hospice aide visit frequency was zero to one. ) Record review on 01/19/23 at 01:45 PM found P6 was admitted to the facility on 10/17/22. Review of the plan of care for 10/17/22 to 10/26/22 notes IDG approval for social worker and spiritual counselor visits for a minimum of zero with a maximum of one before the next IDG meeting. Subsequent IDG plan of care meetings for: 10/26/22 to 11/09/22; 11/09/22 to 11/23/22; and 12/07/22 to 12/21/22 also documents IDG approval for visit frequencies of minimum of zero to maximum of one before the next IDG meeting. ) Record review on 01/19/23 at 08:30 PM found P11 was admitted on 11/16/22. Review of the plan of care for 01/04/23 noted IDG approval for social worker and spiritual counselor visits for a minimum of zero to maximum of one before the next IDG meeting. Also noted, hospice aide services were approved for zero to four visits before the next IDG meeting.

Based on record review and interview with staff members, the facility failed to provide care and services in accordance with the plan of care for 2 patients (P) P3 and P4, out of 11 patients in the active case sample. This deficient practice has the potential to affect all patients in the facility. --- 1) Patient (P)3s election of hospice care (EOHC) date was 12/20/22. Diagnoses include but not limited to osteomyelitis of vertebra, sacral and sacrococcygeal region, quadriplegia, and chronic rhinitis. P3 residents in a long-term care facility. Review of the care plan for 12/21/22 to 01/04/23 notes maximum social work visits before the next interdisciplinary group (IDG) review for one visit. Review of the social work progress notes and calendar found the social worker made visits on 12/21/22 and 01/03/23. There was also an ";on call" progress note entry for 12/30/22. On 01/18/23 at 11:55 AM concurrent record review and interview was conducted with the Interim Clinical Director (ICD)1. ICD1 reviewed the record and reported the visit on 12/21/22 was to complete the comprehensive assessment and 01/03/23 was a visit. ICD1 reported the ";on call" progress note for 12/30/22 was erroneous, this was not a visit. ICD1 confirmed the social worker did not follow the plan of care and made an extra visit. There was no verbal order for a prn (as needed) visit. 2) P4s EOHC date was 11/22/22. Diagnoses include but not limited to Alzheimers disease; rheumatic mitral valve disease; and vascular dementia. A review of the plan of care for 11/22/22 to 12/07/22 indicates hospice aide visits for a minimum of zero and maximum of one visit before next scheduled IDG review. A review of the hospice notes and calendar for this period found hospice aide made two visits during this period, 11/30/22 and 12/02/22. The next period of 12/07/22 to 12/21/22 notes registered nurse visit a minimum of one and maximum of four visits before the next scheduled IDG meeting with hospice aide visits at a minimum of two and maximum of four. Review of the progress notes found no documentation of registered nurse visit during this period and hospice aide made one visit on 12/15/22, not meeting the minimum number of visits. Subsequent period of 12/21/22 to 01/04/23 notes hospice aide services for a minimum of two and maximum of four before the next IDG meeting. Review of the progress notes found hospice aide did not meet the minimum requirement of two visits, there was documentation of one visit on 12/30/21. On 01/19/23 at 02:06 PM concurrent record review and interview was conducted with the ICD1. The ICD1 reported for the period of 12/7/22 to 12/21/22 the assigned hospice aide was sick, and the minimum visits were not done. ICD1 confirmed for the period of 12/21/22 to 01/04/23 the hospice aide did not meet the minimum visits of two, only one visit was made.

Based on record reviews and interview, the facility failed to ensure that the initial certification of terminal illness (CTI) for 2 patients (P), P2 and P3, out of a sample of 11, were signed by the attending physician as directed in §418.22. This deficient practice fails to ensure that the patients initial CTI is accurate and complete as certified by their attending physician prior to their admission into hospice and has the potential to affect all patients admitted into the facility under their attending physician. Findings include: --- ) Patient (P)3s election of hospice date was 12/20/22. A review of the initial certification of terminal illness notes the patients attending physician did not sign the ";Attending Certification of Terminal Illness". Interview with Interim Clinical Director (ICD)1 on 01/19/23 confirmed the certification was not signed by the residents attending physician. 1) Reviewed policy ";CERTIFICATION OF TERMINAL ILLNESS," policy number, ";PC.C05," with no date. It stated, ";POLICY: When a patient is first admitted to North Hawaii Hospice, Inc., the Medical Director or physician member of the IDG and the patients attending physician (if the patient has one) sign a written statement certifying that the patients prognosis is 6 months or less if the terminal illness follows its normal course." 2) Reviewed P2s electronic health record (EHR). No written initial CTI signed by P2s attending physician was found. On 01/19/23 at 12:53 PM, a concurrent observation of P2s EHR and interview were done with Interim Clinical Director (ICD)1. ICD1 confirmed that there was no written CTI signed by P2s attending physician uploaded into P2s EHR.

Based on record reviews and interviews, the facility failed to ensure that the advance health care directive (AHCD) and/or durable power of attorney (DPOA) were in the electronic health records (EHR) for 5 patients (P), P3, P4, P7, P8, and P10, out of a sample of 11 patients. This deficient practice fails to convey important patient care information to the facility of current medical decisions and/or fails to identify the person who is allowed to make medical decisions on the patient's behalf. Findings include: --- Review of the facilitys policy and procedures titled ";Advance Directives" notes the facility will be in compliance with all State and Federal laws regarding advance directives and informs and distributes written information to the patient on his/her right to formulate advance directives. The procedure includes, if available, a copy of any advance directive is placed in the patients clinical record and the patients wishes, including his/her DNR status, are communicated to members of the hospice IDG to be included in care planning for the patient. ) On 01/17/23 at 10:15 AM record review found Patient (P)3s election of hospice care (EOHC) date was 12/21/22. Review could not find a copy of the patients advance healthcare directive in the electronic health record. On 01/18/23 at 12:10 PM, the Interim Clinical Director (ICD)1 confirmed P3 only has a POLST (Physician Orders for Life Sustaining Treatment) in the electronic health record. ) On 01/18/23 at 12:25 PM record review found P4s EOHC date was 11/22/22. Review could not find a copy of the patients advance healthcare directive in the electronic record. On 01/19/23 at 02:06 PM, the ICD1 confirmed although the facility is aware the patient has an advance healthcare directive, a copy is not in the patients electronic health record or a hard copy on file. 1) Reviewed the facilitys policy, ";Advance Directives," policy number ";PC.A35" with no date. It stated, ";...3. If available, a copy of any advance directive is placed in the patients clinical record and the patients wishes...are communicated to members of the hospice IDG [interdisciplinary group] to be included in care planning for the patient..." 2) Reviewed P7s EHR. P7s ";Election of Care" form dated 08/19/22 indicated that P7 had an AHCD and DPOA. No AHCD and DPOA were found in P7s EHR. On 01/19/23 at 12:53 PM, conducted a concurrent observation of P7s EHR and interview with the Interim Clinical Director (ICD)1. Observed with ICD1 areas in the EHR where the AHCD and DPOA would be located, and ICD1 confirmed that P7s AHCD and DPOA were not in her EHR. ICD1 stated that the documents should have been uploaded into the EHR. 3) Reviewed P8s EHR. P8s ";Election of Care" form dated 01/05/23 indicated that P8 had an DPOA. No DPOA could be found in P8s EHR. 4) Reviewed P10s EHR. P10s ";Election of Care" form dated 12/02/22 indicated that P10 had an AHCD and DPOA. Both documents could not be found in P10s EHR.

Based on record reviews and interview, the facility failed to ensure that the initial visit frequency orders were signed by the physician for 6 patients (P), P1, P4, P6, P8, P9, and P10 out of 11 patients in the sample. This deficient practice fails to provide physician acknowledgement and verification of services to be provided to patients and has the potential to affect all patients admitted to the facility. Findings include: --- ) A review of Patient (P)1s first comprehensive assessment found the registered nurse electronically signed for the Hospice Physician. On 01/18/23 at 11:25 AM, interview with the Interim Clinical Director (ICD)1 confirmed the nurse electronically signed for the medical director. ICD1 reported the nurse can electronically sign for the hospice physician if there is a verbal order. Further review, ICD1 reported there was no verbal order for the registered nurse to sign for the physician. ) A review of P4s ";Combined Disciplinary Comprehensive Assessment" and ";Combined Disciplinary Plan of Care" noted the registered nurse signed the documents for the hospice physician. The assessment was electronically signed on 11/22/22 by the registered nurse and the plan of care was electronically signed by the nurse for the hospice physician. On 01/19/23 at 02:06 PM interview and concurrent record review with ICD1 confirmed the registered nurse electronically signed for the hospice physician. ICD1 confirmed there was no verbal order by the hospice physician for the registered nurse to sign these documents. ) A review of P6s initial comprehensive assessment and initial plan of care noted the registered nurse electronically signed the documents for the hospice physician. On 01/19/23 at 01:45 PM, interview and concurrent record review was done with ICD1. ICD1 confirmed the registered nurse electronically signed the documents for the hospice physician. ICD1 reported there was no verbal order from the hospice physician to sign the comprehensive assessment. ICD1 reported there was a verbal order for the registered nurse to electronically sign the comprehensive plan of care. ) Reviewed P8's electronic health record (EHR). P8's election of hospice care (EOHC) initiated on 01/05/23. The "Combined Disciplinary Plan of Care" on 01/05/23 revealed that under "Hospice Physician Signature" a nurse electronically signed the document. The "Visit Frequencies" or "Physician Orders" did not reveal any ordered discipline visits and their frequencies. On 01/20/22 at 10:45 AM, interviewed Interim Clinical Director (ICD)2. ICD2 stated that frequency and type of hospice visits are established during the interdisciplinary (IDG) plan of care meetings and noted on the "Combined Disciplinary Plan of Care" document, so as an order the Hospice Physician should sign the document instead of the nurse. ) Reviewed P9's EHR. P9's EOHC initiated on 12/12/22. The "Combined Disciplinary Plan of Care on 12/12/22 with the established initial discipline visits and their frequencies was signed by the nurse electronically under "Hospice Physician Signature."

Based on record review, review of the facility's policy and procedures and interview with staff members, the facility did not assure all entries were appropriately authenticated and dated in accordance with accepted standards of practice. --- 1) Cross Reference L523. The initial comprehensive assessment for residents were not electronically signed by the hospice physician. The hospice nurses were electronically signing for the hospice physician. The signature of the hospice physician authenticates participation in the comprehensive assessment. 2) Cross Reference L543. The first plan of care for residents were not electronically signed by the hospice physician. The hospice nurses were electronically signing for the hospice physician. The signature of the hospice physician authenticates her participation in the plan of care and orders for treatment and services.