Every finding on record at Palliative Plus, LLC

Based on interview and record review, the agency failed to ensure clinical records contained all clinical notes in each patient record for three of three hospice patients (Patients #1, #2, and #3) in that: 1. There was one of one HHA visit notes not completed for Week 4 (05/01/2022 through 05/07/2022) for Patient #1. 2. There were no HHA visit notes completed for Week 7 ( 05/08/2022 through 05/14/2022), one of two HHA visit note not completed Week 8 ( 05/22/2022 through 05/28/2022), there were no HHA visit notes on Week 9 (05/29/2022 through 06/04/2022) and there were no SN visit notes for Week 7 for Patient #2. 3. There were no HHA visit notes for Week 4, Week 5 (May 8, 2022 through May 14, 2022), Week 6 (May 15, 2022 through May 21, 2022), Week 7, and week 8 and no SN visits notes documented on Week 5 and Week 8 for Patient #3. This deficient practice places the hospice patients at risk for poor communication and coordination of care among the team members from the lack of what services have or have not been provided. The findings included: 1. Review of the "Employee Handbook" (undated) revealed no documented evidence that indicated when visit notes were to be completed. Review of a document titled "Orientation Manual" dated 10/1/21 revealed a section titled "Documentation" revealed in part "Entries must be made in a timely manner. i.e.: notes turned in per hospice policy..." 1. Review of Patient #1's clinical record revealed a SOC of 10/18/21 for a POC certification period from 4/16/22 through 6/14/22 with a diagnosis of Heart Failure (when the heart no longer is able to pump blood through the body) and Dementia (a group of thinking and social symptoms that interferes with daily functioning). Further review of the POC revealed SN visits were one time per week (1 Xwk) and HHA visits were two times per week (2xwk) for the duration of the POC. Further review of the Patient #1's clinical record revealed there was one HHA visit completed on May 5, 2022 (week 4) but there was no evidence of a second visit conducted the same week. Review of Patient #2's clinical record revealed a SOC of 8/27/21 for a POC certification period from 4/6/22 through 6/4/22 with a diagnosis of Senile Dementia. Further review revealed SN frequency visits: 1 xwk and HHA frequency: three times a week (3 xwk) for the duration of the POC. Further review of Patient #2's clinical record revealed there were no HHA visit notes completed for Week 6 (May 8, 2022 through May 14, 2022), one of three HHA visit notes were not completed for Week 8 (May 22 through May 28, 2022), there were no HHA visit notes on Week 9 (May 29, 2022 through June 4, 2022) and there were no SN visit notes for Week 7 (5/15/22 to 5/21/22 for Patient #2. Review Patient #3's clinical record revealed a SOC on 8/17/21 for a POC certification period from 4/14/22 through 6/12/22 with a diagnosis of CVA (when the brain does not get enough oxygen often due to a blood clot). Further review of the clinical record revealed SN visit frequency: 1xwk and HHA visit frequency: 2xwk for the duration of the POC. Further review of the clinical record revealed there were no HHA visit notes for Week 4 (05/01/22 to 05/07/22), Week 5 (May 8, 2022 through May 14, 2022), Week 6 (May 15, 2022 through May 21, 2022), Week 7 (05/22/22 to 05/28/22), and Week 8 (05/29/22 to 06/04/22)and no SN visits notes documented on Week 5, and Week 8 for Patient #3. 2. During a concurrent interview and record review on 6/7/22 at 11:40 a.m., with the Admin/DON and the DON from the Round Rock office, the Alternate Admin stated that she did not see documentation for Patients #1, #2, and #3. The Alternate Admin further stated that it might be a computer issue and that the SN did not "sync" (download visit notes) on their computers with the EMR system and that the tablets for the HHAs were behind because they had to get new tablets and they had to "catch up on notes." During an interview on 6/7/22 at 12:10 p.m., with the Alternate Admin and the Director of Compliance, the Director of Compliance stated that the HHA tablets were missing, and that the agency had to order new tablets around 5/15/22 and the agency received them around Memorial Day weekend (May 31, 2022). She stated that "bottom line" the HHAs were behind, and the agency did not require the HHAs to document on paper, but to keep track of their visits in a notebook. Furthermore, she stated that the visits were done but not documented and late documentation can affect communication. An attempt to speak with HHA F was unsuccessful on 6/7/22 at 12:20 p.m. who provided care to Patient #3 During an interview on 6/7/22 at 12:44 p.m., with HHA E she stated that she saw Patient #2 last week and thought she finished all her notes. She further stated that "there was a lot going on." She added that she did not inform her supervisor that she was behind in notes. During an interview on 6/7/22 at 1:35 p.m., with the Alternate Administrator/DON and the Director of Compliance they stated that the goal for staff was to have their completed visit notes in the chart within 24 hours. The Director of Compliance stated the handbook stated documentation should be done within 24-48 hours. She further stated that the expectation and how she trained the staff was that documentation of visits should be completed within 24-48 hours. 3. Review of the agency's policy titled "Timelines" dated 8/1/15 revealed in part "The agency will ensure timely provision of care to meet patient's needs in compliance with federal and state laws and regulations...F. All clinical and progress notes will be written the day service is rendered..."