Every finding on record at Rockbridge Area Hospice Inc

Based on a review of clinical records and staff interview it was determined the hospice agency failed to ensure the documentation of measurable outcomes for each problem documented on the plans of care for (12) of (13) records in the survey sample (Clinical record #'s 2-13). --- The findings:Thirteen clinical records were reviewed in the agency on 12/06/2022 and 12/07/2022 with the assistance of staff member #1 as the navigator. Clinical records #14 and #15 were selected and reviewed for bereavement services only. The plan of care failed to contain measurable goals/outcomes for the patients listed below. 1.The clinical record for patient #2 was reviewed for the time period of 11/17/2022 through 01/05/2023. 2.The clinical record for patient #3 was reviewed for the time period of 10/27/2022 through 01/24/2023. 3.The clinical record for patient #4 was reviewed for the time period of 11/24/2022 through 02/21/2023. 4. The clinical record for patient #5 was reviewed for the time period of 11/17/2022 through 02/14/2023. Interview:During the electronic navigation clinical record review conducted on 12/06/2022 at 2:55 PM, The MFI (Medical Facilities inspector) asked the hospice Director of Nursing (staff member #1) if they noticed the goals were not measurable for patients 2, 3 and 4, and that the goals for these patients were all the same. The Director of Nursing acknowledged the failure of measurable goals listed on the patient's plan of care. 5. The clinical record for patient #6 was reviewed for the time period of 10/26/2022 through 11/17/2022. 6. The clinical record for patient #7 was reviewed for the time period of 05/02/2022 through 06/03/2022. 7. The clinical record for patient #8 was reviewed for the time period of 07/27/2022 through 10/07/2022. 8. The clinical record for patient #9 was reviewed for the time period of 10/06/2022 through 10/11/2022. 9. The clinical record for patient #10 was reviewed for the time period of 05/22/2022 through 07/28/2022. 10. The clinical record for patient #11 was reviewed for the time period of 12/01/2022 through 02/28/2023. 11. The clinical record for patient #12 was reviewed for the time period of 10/11/2022 through 12/09/2022. 12. The clinical record for patient #13 was reviewed for the time period of 11/30/2022 through 01/28/2023. Interview: On 12/07/2022, this MFI showed the hospice Executive Director the plan of care with no measurable goals and the Executive Director confirmed these findings.

Based on a review of clinical records and staff interview it was determined the agency failed to ensure care and services were provided in accordance with the patient's plan of care for three (3) of thirteen (13) clinical records in the survey sample. (Clinical record #s 2, 5 and 6). --- The findings:Thirteen clinical records were reviewed in the agency on 12/06/2022 and 12/07/2022 with the assistance of staff member #1 as the navigator. Clinical records #14 and #15 were selected and reviewed for bereavement services only. The clinical record for patient #2 was reviewed for the time frame of 11/17/2022 through 01/05/2023. The plan of care for the above noted time frame contained orders for Skilled Nurse (SN) to visit the patient two (2) times a week. The clinical record failed to contain documentation of a second SN visit or missed visit for the time frame of 11/20/2022 to 11/26/2022. 2. The clinical record for patient #5 was reviewed for the time period of 11/17/2022 through 02/14/2023. The plan of care for the above noted time frame contained orders for hospice aide to visit the patient two (2) times a week. The clinical record failed to contain documentation of an aide visit or missed visit for the time frame of 11/20/2022 to 11/26/2022. 3. The clinical record for patient #6 was reviewed for the time period of 10/26/2022 through 11/17/2022. The plan of care for the above noted time frame contained orders for SN to visit the patient one (1) time a week. The clinical record failed to contain documentation of an SN visit or missed visit for the time frame of 11/06/2022 to 11/12/2022. The lack of documentation of care being provided in accordance with the patient's plan of care was acknowledged by the hospice Director of Nursing during the clinical record reviews.

Based on a review of clinical records and staff interview it was determined the agency failed to ensure their interdisciplinary group (IDG) documented the patient's progress toward outcomes and goals specified in the plans of care for (12) of (13) patients in the survey sample (Clinical record #'s 2 - 13). --- The findings:Thirteen clinical records were reviewed in the agency on 12/06/2022 and 12/07/2022 with the assistance of staff member #1 as the navigator. Clinical records #14 and #15 were selected and reviewed for bereavement services only. Twelve (12) of (13) patients failed to contain evidence of IDG documentation of the patient's progress toward outcomes and goals specified in the plans of care below. 1. The clinical record for patient #2 was reviewed for the time period of 11/17/2022 through 01/05/2023. 2. The clinical record for patient #3 was reviewed for the time period of 10/27/2022 through 01/24/2023. Interview:During the electronic navigation clinical record review conducted on 12/06/2022 at 3:00 PM the hospice Director of Nursing (staff member #1) acknowledged the failure of IDG to document the patients progress towards outcomes and goals, and further stated "We are documenting in the primary care plan, however our software does not pull over the IDG meeting notes". 3. The clinical record for patient #4 was reviewed for the time period of 11/24/2022 through 02/21/2023. 4. The clinical record for patient #5 was reviewed for the time period of 11/17/2022 through 02/14/2023. 5. The clinical record for patient #6 was reviewed for the time period of 10/26/2022 through 11/17/2022. 6. The clinical record for patient #7 was reviewed for the time period of 05/02/2022 through 06/03/2022. 7. The clinical record for patient #8 was reviewed for the time period of 07/27/2022 through 10/07/2022. 8. The clinical record for patient #9 was reviewed for the time period of 10/06/2022 through 10/11/2022. 9. The clinical record for patient #10 was reviewed for the time period of 05/22/2022 through 07/28/2022. 10. The clinical record for patient #11 was reviewed for the time period of 12/01/2022 through 02/28/2023. 11. The clinical record for patient #12 was reviewed for the time period of 10/11/2022 through 12/09/2022. 12. The clinical record for patient #13 was reviewed for the time period of 11/30/2022 through 01/28/2023. The lack of documentation by the agency's IDG regarding the patient's progress toward outcomes and goals specified in the plans of care for the above noted patients was discussed with hospice Director of Nursing prior to and during the exit conference on 12/07/2022.

Based on a review of clinical records and staff interview, it was determined the agency failed to ensure one (1) of four (4) clinical records reviewed which were closed/discharged records failed to contain a discharge summary and for whom a discharge summary was applicable (Clinical record: #6). --- The findings:Five (5) closed/discharge clinical records were reviewed in the agency on 12/06/2022 and 12/07/2022 with the assistance of staff member #1 as the navigator. The clinical record for patient #6 was reviewed for the time period of 10/26/2022 through 11/17/2022. According to clinical record documentation the patient revoked hospice services on 11/17/2022. The clinical record failed to contain a documentation of a discharge summary. The lack of a discharge summary was acknowledged by Director of Nursing and the Executive Director during the exit conference conducted in the agency on 12/07/2022.