Every finding on record at Origins Hospice Inc

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 5 (20%) clinical records reviewed revealed the agency did not ensure that all entries in the patient record were appropriately authenticated and dated by the clinician performing the care in accordance with hospice policy and current acceptable standards of practice. Document 1: Clinical Record Policy No. 6-042 stated in part, "Each entry will be dated and signed, including title and credentials, by the person providing the care/service." Clinical Record 1: The registered nurse (RN) visit note dated 04/17/2023 was not signed and dated by the RN that provided the care and services and did not include documentation of the RN's title and credentials as of the date of the record review on 05/02/2023. During an interview on 05/04/2023, the Alternate Director of Patient Care Services (DPCS) reviewed the record and stated the clinician inadvertently failed to sign the visit note, but the note had since been corrected. The DPCS also stated the agency expectation is for clinical notes to be completed and signed within 14 days, however, was unable to produce a policy to confirm agency standard/expectation and acknowledged that in this instance the 14-day window had expired.