Every finding on record at Osf Healthcare System

Based on a review of clinical records, Hospice policy, and Staff interview, it was determined the Hospice failed to ensure bereavement services were provided as required. This was found in 1 of 3 (Pt. #21) closed clinical records reviewed, wherein the Pt. had expired. --- Findings include: 1. Pt. #21 was admitted for Hospice services on 06/28/23 with the diagnosis of Malignant Neoplasm of Upper Lobe Left Lung. The clinical record was reviewed on 08/21/24. The clinical record contained documentation that the Hospice provided services, until the Pt. expired on 08/14/23. As of 08/21/24, the Hospice lacked documentation that post bereavement services were provided to the identified primary family member. 2. The Hospice policy titled; "Hospice Bereavement for Patient Survivors" was reviewed on 08/21/24. The policy required, "...1. The patient, identified significant other, or identified primary family member have bereavement services offered to them prior to them... for a minimum of 13 months following the death of a patient... 3... Included in the records are the Bereavement Care Plan, any documented visits, and all dates and types of contact with the survivors. These are maintained in the EHR by the Bereavement Coordinator or designee. Bereavement narrative documentation is completed the same day of services or contacts...." 3. During an interview on 08/22/24 at 9:43 AM with Hospice Manager #1 and Hospice Manager #2, the Hospice Manager #2 confirmed the above findings.

Based on Staff interview, it was determined the Hospice failed to ensure the clinical records were readily available as requested for survey review. --- 3.On 08/21/24 at 3:15 PM of survey day 3, the Hospice clinical records were not available for review for 3 of the 5 surveyors. During the interview with the Hospice Clinical Manager, it was stated they were requesting help to gain access of the electronic records. 4.The findings were confirmed during the interview with the Hospice Manager, on 08/21/24 at 3:30 PM. 2. The hospices clinical records were not readily accessible or available upon request made to the Hospice Director Operations Hospice and Palliative Care and the Home Health Manager - Northern Region, for access to Pt. #4's EMR until 08/21/24, at 1:30 PM (day 3 of survey). Findings include: 1. On 08/19/24 at 10:05 AM, an entrance interview was conducted onsite with the Hospice Clinical Supervisor #1 and Home Health Manager-Northern Region. A request was made for the Hospice to provide access to Pt. clinical records and the ability to review staff personnel files. During the same interview, the Hospice Clinical Supervisor #1 stated the organization use an electronic medical record (EMR) system for patients and employee personnel files. Several hours after the entrance interview, Hospice staff presented a document with a login (username and password), and a Hospice issued laptop to access Pt. clinical records. After multiple attempts, the login provided was unsuccessful. As of 08/19/24 at 4:00 PM, unable to access the Hospice's EMR to review Pt. clinical records. This issue was reported to Hospice and Home Health supervisor/administrative staff. 08/20/24 at 2:55 PM, unable to access Hospice Pt. medical records after multiple attempts with the assistance of Hospice staff. Informed the Director Operations Hospice & Palliative Care, and Hospice Manager #1 the requirement and need to access Pt. clinical records. At 3:55 PM, Hospice staff provided a different Hospice issued laptop and new password, technical assistance from IT staff, still unable to access Pt. medical records. Reiterated with the Director Operations Hospice & Palliative Care the importance to review Pt. clinical records in a timely manner. 08/21/24 at 8:15 AM, Hospice staff presented a printed summary of some services provided by staff for Pt. #2 (a document similar received on 08/20/24). After multiple interactions with the Director Operations Hospice & Palliative Care, able to access the first clinical record on 08/21/24 at 1:30 PM. As of 08/21/24, the Hospice was unable to provide access to Pt. clinical records in a well-timed manner.

Based on the observation of the facility clinical record review and Staff interview, it was determined in 1 of 4 visits (Pt. #3), the Hospice failed to ensure the Hospice plans of care was provided to the Skilled Facility. --- Findings include: 1.Pt. #3 was admitted to Hospice services on 04/08/24 with diagnosis of Severe Protein Malnutrition. On 08/20/24 at 2:20 PM, during the visit with the Chaplain, the facility clinical record was reviewed. The facility clinical record lacked the Hospice plan of care. 2.The findings were confirmed during the interview with the Hospice Manager #1, on 08/21/24 at 3:00 PM.