Every finding on record at St. Joseph Hospitium

It is required that each patient’s individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a clinical record review, document review and interview. 1 of 6 (17%) clinical records reviewed revealed the plan of care (POC) lacked patient goals and interventions based on problems identified in the updated comprehensive assessments. Clinical Record 1: The patient was admitted on 5/10/22. The skilled nurse visit note dated 7/9/22 stated the patient was on Oxygen 2 Liters/Minute via nasal cannula. The patient interdisciplinary group (IDG) plan of care (POC) dated 7/5/22 lacked evidence of a goal and interventions for Oxygen. DPCS/Alternate Administrator who was interviewed on Thursday 8/4/22 agreed with the finding. Agency Plan of Care Policy Policy #9-017, "Plan of Care (Dated: 11/2020)", stated in part, "The POC will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group... This plan will focus on identified problems, goals, and interventions."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review, document review and interview. 6 of 6 (100%) clinical records reviewed revealed the hospice agency did not ensure adherence to the agency's "Hospice Election Statement" policy. Clinical Record 3: The patient was admitted to hospice care on 7/21/22, the effective date on the signed Election of Hospice Benefit form. The record contained initials of the patient/representative which indicated that the election statement addendum had been requested. The record lacked evidence that the addendum was completed and provided to the patient/representative within 5 days from the date of election. Clinical Record 5: The patient was admitted to hospice care on 6/19/22, the effective date on the signed Election of Hospice Benefit form. The record contained initials of the patient/representative which indicated that the election statement addendum had been requested. The record lacked evidence that the addendum was completed and provided to the patient/representative within 5 days from the date of election. Clinical Record 4: The patient was admitted to hospice care on 7/21/22, the effective date on the signed Election of Hospice Benefit form. The record contained initials of the patient/representative which indicated that the election statement addendum had been requested. The record lacked evidence that the addendum was completed and provided to the patient/representative within 5 days from the date of election. Clinical Record 2: The patient was admitted to hospice care on 4/4/22, the effective date on the signed Election of Hospice Benefit form. The record contained initials of the patient/representative which indicated that the election statement addendum had been requested. The record lacked evidence that the addendum was completed and provided to the patient/representative within 5 days from the date of election. Clinical Record 0: The patient was admitted to hospice care on 5/17/22, the effective date on the signed Election of Hospice Benefit form. The record contained initials of the patient/representative which indicated that the election statement addendum had been requested. The record lacked evidence that the addendum was completed and provided to the patient/representative within 5 days from the date of election. Clinical Record 1: The patient was admitted to hospice care on 5/10/22, the effective date on the signed Election of Hospice Benefit form. The record contained initials of the patient/representative which indicated that the election statement addendum had been requested. The record lacked evidence that the addendum was completed and provided to the patient/representative within 5 days from the date of election. During an interview on Friday 8/5/22, the Director of Patient Care Services/Alternate Administrator reviewed and agreed that the addendum was requested and had not been provided within 5 days of each patient/representative requests. Agency Hospice Election Statement Policy Policy #1-031, "Hospice Election Statement (Dated: 11/2020)", stated in part, "7A. If the election statement addendum is requested at the time of the initial hospice election, the organization must provide the addendum, in writing, to the patient/representative within five (5) days from the date of election."