Every finding on record at Pocono VNA Hospice

Based on a review of agency policy, a review of clinical records, and an interview with the agency Administrator, the agency failed to complete the interdisciplinary group comprehensive assessment no later than 5 calendar days after the patient election of hospice care for two (2) of three (3) clinical records (CR) reviewed (CR#2, CR#3). --- Findings: Agency policy was reviewed March 21, 2023 at approximately 11:30 a.m. Agency policy 'Admission-Home Hospice-Home Health Services' section 'III. Procedure' states "Once a patient is admitted to service, the organization will be responsible for providing care and services within its financial and services capabilities, mission, and applicable laws and regulations." Section (6) states "When hospice eligibility criteria are met, ....... The admitting clinician: (a) Reviews all contents of the hospice admission packet. (b) Establishes the hospice plan of care, including but not limited to the individualized goals of the patient and caregivers. (c) Documents this information in the patient's medical record. .... Section (14) states "A comprehensive assessment will be completed by other disciplines involved in the patients care within 5 days of the election of the hospice benefit." .... (17) After admission into the hospice program, the comprehensive psychosocial/spiritual bereavement risk assessments will be completed within five (5) days." A review of CRs was conducted on March 21, 2023 at approximately 12:30 p.m. revealed the following: CR#2 Start of Care 01/17/23: Patients certification period 01/17/23-03/17/23 reviewed. 'Communcation Notes' dated 01/19/23 'Communication details' include "Phone call to patient/caregiver to schedule MSW evaluation visit. No answer therefore voicemail message left requesting call back including this MSW contact information." No documentation provided of further follow up correspondence. The Social Worker did not complete the initial assessment until 01/25/23, eight (8) days after the patient's election of hospice benefits. CR#3 Start of Care 02/02/23: Patients certification period 02/02/23-05/02/23 reviewed. Chaplain did not complete the initial assessment until 02/13/23, eleven (11) days after the patient's election of hospice benefits. An interview conducted on March 21, 2023 at approximately 2:45 p.m. with the agency Administrator confirmed the above findings.