Every finding on record at Novant Health Rowan Medical Center LLC

Observed in Individual Tracer. In 7 of 7 individual patient tracers, it was noted that the organization did not ensure that the Hospice Healthcare Consent and Authorization Form(s) included all required information. For example, during a review of the Hospice Healthcare Consent and Authorization Form the following information was noted: “Please bill my health insurance plan as a service to me. I am aware that this does not mean they will agree to pay for any services. I agree to pay whatever amount is not covered.” A review of the Hospice Healthcare Consent and Authorization Form(s) for Inpt#1, RRHV#1, RRHV#2, and RRHV#3, RRHV#4, RRHV#5 and RRHV#6, revealed that patients were not informed of their financial responsibility prior to beginning care, treatment, or services. The consent form did not include the amount of financial responsibility and was signed by the patient or the patient’s caregiver. This observation was reviewed with the Senior Director of Home Care and Hospice.

Observed in Individual Tracer. A review of 1 of 24 medical records revealed that the organization did not ensure that initial assessments by members of the interdisciplinary group included all required information. For example, a review of the medical record for RRHV#4, revealed no documented evidence that an initial bereavement risk assessment was completed. This observation was reviewed with the Quality Improvement Manager and the Senior Director of Home Care and Hospice.

Observed in Individual Tracer. Example #2: A review of the 6th and 10th update to the plan of care documentation for RRHV#6, revealed that after the patient experienced multiple falls, the plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury related to fall prevention interventions. This observation was reviewed with the Quality Improvement Manager and the Senior Director of Home Care and Hospice. Observed in Individual Tracer. In 2 of 24 patient record reviewed, it was noted that the organization did not ensure that the plan of care was revised when the patient's condition changed. For example, a review of the 5th update to the plan of care documentation for RRHV#2, revealed that the clinician documented the patient ...becomes intermittently anxious and combative with staff. The plan of care was not updated with interventions and a goal statement to address Alzheimer's Dementia related behaviors.