Every finding on record at St. Joseph's Care Hospice Services

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1 had medications on the POC that had been discontinued on the medication profile. (Oxybutynin and Trazadone).

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #9 was a live discharge due to extended prognosis. The IDT meeting notes did not show evidence of a group discussion prior to discharge. The individual Nurse notes and SW notes contained documentation of discussion with the MD and with the patient and family for 2 weeks prior to discharge. These notes also included the planning discussions and SW assistance with setting patient up to resume care with PCP. There is no evidence the plan of care was updated to reflect the interventions and goals for the patient/family for discharge.

Upon client record review, 2 of 14 (Patient #5,6) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #5,6 were transfers to another Hospice. There was evidence of a transfer form. However; no evidence of a transfer summary. The Discharge Summary was completed however; no evidence of what information was sent to receiving Hospice

Upon client record review, 1 of 14 (Patient #1) did not have evidence that all drugs and biologicals are labeled in accordance with currently accepted professional practice and include appropriate usage and cautionary instructions, as well as an expiration date, if applicable. Patient #1 had Anti-Diarrheal 2mg oral tablets with instructions of "take 2 tablets initially, then 1 tablet at each stool as needed for diarrhea". The label did not contain the cautionary instructions of "not to exceed 4 tablets in 24 hours".

Observed in Record Review. In 1 of 1 patient records reviewed that were discharges for revocation, the organization did not respect the patient rights to revoke hospice. On review of RRDC #2, the organization did not obtain a complete revocation form on revocation. The chart did not have a signed revocation form and the organization produced a blank revocation form with only a electronic signature but the fields for the patient name and revocation dates were all blank. Reviewed requirements to have a completed form and have it in the medical record with the organization. Finding reviewed with agency leadership.

Observed in Record Review. On 1 of 2 active patient records reviewed the organization failed to complete initial assessment within the 5 day window of Hospice Election. On RRHV #1, all disciplines went into the home within the required timeframes, however the RN visit notes are blank and it has been 27 days since admission. This finding was reviewed with agency leaders regarding the need to have completed documentation.

Observed in Patient Home. In 1 of 1 home visits conducted, the hospice nurse surveyor noted that the organization had not completed a review of all current medications. During RRHV #1, it was noted on review of medications with the daughter and patient that the medication list was not updated with all medications that the patient is taking. The patient and daughter reported that the patient takes Tylenol 500mg as needed for pain and uses it about once per week. She also stated that she gets constipated and will use Milk of Magnesia or Exlax and states that she has to use that about one time per month. This was discussed with athe administrator who was present for the visit.

Observed in Record Review. In 1 of 2 active patient records reviewed, the organization failed to provide interdisciplinary, collaborative treatment, or services. During record review for RRHV #1, it was noted in the IDG notes that the chaplain was not involved in the IDG meeting as evidence by no signature of attendance or notes from the chaplain demonstrating that the chaplain was present in the care planning process. This was reviewed with agency leadership.

Observed in Record Review. In 2 of 2 active patient records reviewed goals were not time specific, measurable and specific to the care needs of the patient. On review of RRHV #1, patient had diabetes and reported she always is in pain there were no goals related to pain or diabetes on the plan of care. Goals patient did have were not measurable as well and include: establishing normal bowel function, discussing techniques on prevention of potential infections associated with bladder disturbance. On review of RRNHV #1, goals were not measurable or specific to the patient examples of goals include: safe environment without injury, reorienting to person, time, place and event, being free of injury or falls. This was discussed with agency leadership.

Observed in Record Review. In 2 of 2 patient records reviewed the plan care was not updated every 15 days with the interventions for care and treatment of the patient. On review of RRHV #1, the patient started care 27 days ago and the orders for care was a template form that did not have the blanks filled in including the visit frequency for each discipline seeing the patient. In addition, the patient has a urinary catheter and while there were goals related to the urinary catheter there was no orders for the care of the catheter. On review of RRNHV #1, the IDG notes state the refusal of the chaplain and MSW but the MSW had been making monthly visits and there were no orders for those visits. This finding was reviewed with agency leaders.

Observed in Record Review. In 1 of 2 active patient records reviewed the Interdisciplinary team did not review the plan of care at least every 15 days. On RRNHV #1, the Interdisciplinary Group had not reviewed the POC every 15 days. Last one was 6/28 was due on 7/12 and today is 7/18. This finding was reviewed with agency leaders.

Observed in Record Review. In 3 of 5 patient records reviewed, the clinician did not follow physician orders. On review of RRHV #1, the orders did not have frequency of care orders for all disciplines. In addition, the patient has a urinary catheter and there was no ordered care for the catheter. ON RRHV #2, it was noted that the MSW was making visits to the patient and there was no orders for those visits. On RRBR #1, the organization was not able to produce the documentation of the bereavement provided for the patient after the death of the patient to show that they followed the plan of care. This was reviewed with agency leaders.

Observed in Record Review. In 1 of 1 bereavement records reviewed the bereavement care plans did not include specific, individualized interventions and care to be provided. On review of RRBR #1, the surveyor was unable to review the bereavement records beyond the initial and post death assessment because the MSW has the documentation in a binder that is not at the office. Reviewed with leadership that records of care need to be available and retrievable during the survey process to assess compliance.

Observed in Record Review. In 1 of 2 patient active records reviewed that had aide services ordered, the organization did not conduct a hospice aide supervision every 14 days. During record review of RRNHV #1, there had not been an aide supervision done in the month. This finding was discussed with agency leaders.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by deficiencies in §418.56 and §418.104. The concern with the continued noncompliance with standards was reviewed with the organization.

Observed in HR File Review. On 1 of 3 HR files reviewed, ongoing competency was not assessed by the organization. On review of HR # 3, it was noted that the MSW did not have a competency assessment done in the last three years. Agency policy is that staff have a competency completed at least every 3 years. The administrator stated it wasn't done because they don't have a MSW to do the competency assessment. This finding reviewed with the agency leadership.

Observed in Record Review. In 4 of 5 patient records reviewed, documentation was not accurate and timely in the patient record. Agency policy is that documentation of visits are completed within 3 days and all documentation in place within 30 days of discharge. On RRHV #1, multiple SN and HHA visit notes since admission 27 days ago are blank including the admission RN visit. SOC orders are a template that had not been completed including blank fields for visit frequency of care. Patient has pain issues and stated during visit that she uses Tylenol for pain but there is not medications on the care plan to reflect pain. On RRNHV #2, the documentation states the patient declined MSW but the MSW is making visits to the home. On RRDC #2, the patient revoked care 3 months ago and the revocation was not in the medical record and when asked for where the revocation was the org had form with the fields blank but the revocation signed. On RRBC #1, the organization could not produce the bereavement records of the patient because the MSW had the binder and was not able to access the records during survey. This finding was reviewed agency leaders.

Observed in Record Review. In 1 of 2 the active patient records, the record did not reflect all medications needed for care of the patient.. On review of RRHV #1, during the home visit the patient's daughter and patient stated that the patient uses Tylenol PRN for headaches and that she has been using it about once a week for awhile. In addition they reported that she uses Exlax and Milk of Magnesia for constipation issues. This finding was reviewed with the administrator who was present for the home visit and returned to the office after the visit and got an order.

Observed in Record Review. In 2 of 2 active patient record reviews, documentation in the patient record was not authenticated as required. Agency policy states that records will be completed in 3 business days. In RRHV #1 and RRHV #2, both records have visit notes and orders that have not been authenticated by the caregiver in over three days per policy. On discussion with the leaders they stated they are aware of the issue and continue to struggle with their EMR system and are looking into changing to a different EMR. This finding was reviewed with agency leaders.

Observed in Record Review. In 2 of 3 patient records reviewed, the hospice did not assess and re-assess its patients as required. In record RRHV#1 the RN used the template for a routine visit note for the initial comprehensive assessment. This did not include all components of a comprehensive assessment. And in RRNHV#1 both the RN and MSW initial comprehensive assessment templates were blank. This RFI was reviewed with the Administrator and DPCS.

Observed in Record Review. In 1 of 3 patient records reviewed, the hospice did not plan review and revise plans of care every 15 days or less. In the record of RRDC#1 only one comprehensive reassessment was documented in 12 weeks. This RFI was reviewed with the Administrator and DPCS.

Observed in Record Review. In 2 of 3 patient records reviewed, the hospice did not consistently provide documentation of an interdisciplinary process. In record RRNHV#1 and RRDC#1 the MSW and Spiritual Coordinator did not sign five of seven notes, thus it was not possible to know if all required core services were present at the meeting. This RFI was reviewed with the Administrator and DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the hospice did not develop and individualized plan of care with patient and family goals based on identified problems. No goals were documented in the records reviewed. This RFI was reviewed with the Administrator and DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the hospice did not insure that plans of care included measurable outcomes anticipated from implementing and coordinating the plan of care. In every record there no goals documented, thus no outcomes were identified. This RFI was reviewed with the Administrator and DPCS.

Observed in Record Review. In 2 of 3 patient records reviewed, where aide services were ordered the hospice did not ensure that care was documented as having been provided. In record RRNHV#1 three of three aide visit templates were blank. And in record RRDC#1 15 of 21 aide visit templates were blank. This RFI was reviewed with the Administrator and DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the hospice did not assess care and services provided by hospice aides. In record RRHV#1 two of two templates were blank. In record RRNHV#1 no assessment was documented in the first 17 days the patient was receiving care. And in record RRDC#1 no assessment was documented for the first five weeks the patient was receiving care. This RFI was reviewed with the Administrator and DPCS.

Observed in Tracer Activities. Leaders did not manage implementation of patient care policies and procedures governing the provision of care as evidenced by condition level findings at §418.54, §418.56, §418.76, and §418.104. This RFI was reviewed with the Administrator and DPCS.

Observed in Patient Home. In 1 of 1 home visits conducted, the hospice did not ensure that the patient record reflected the patient's treatment. During the visit of RRHV#1 the Surveyor found that the medication list in the patient's home was inaccurate. The patient was taking the following medications that were not on the list: Linzess 290 mcg daily; Depakote 500 mg twice daily; Acetaminophen 1000 mg thrice daily; Quetiapine 75 mg every evening; Gabapentin 300 mg thrice daily. All were ordered one or more months prior to this survey date. This RFI was reviewed with the Administrator and DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the hospice did not ensure that entries in the clinical record were authenticated. In record RRHV#1 the comprehensive assessments were not signed by the MSW and Spiritual Coordinator. In record RRDC#1 a visit note by the MSW was not signed. And in all three records the RN did not sign the verbal certification section on the CTIs. This RFI was reviewed with the Administrator and DPCS.

Observed in Record Review. In 1 of 1 patient records reviewed, where the patient was discharged, a summary was not documented, and the attending physician was not notified of the availability of that summary. This RFI was reviewed with the Administrator and DPCS.

Observed in Record Review. In 2 of 3 patient records reviewed, the hospice did not maintain complete and accurate records. In record RRNHV#1 two RN visit notes were blank. And in RRCD#1 one MSW visit note was blank. This RFI was reviewed with the Administrator and DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the Surveyor had been unable to validated the patient plans of care had been updated nor that there had been an IDG to review and discuss the patients as all the IDG meeting notes had been blank. RRNHV #1 had no plan of care established. RRNHV #2 and RRNHV #3 there had been no updates to the poc since the evaluation visit 2 months ago. This was validated with the DPCS and the Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, the Surveyor noted that all IDG meeting notes had been blank, so the Surveyor had been unable to validate that all members had attended and participated. This was validated with the DPCS and the Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, the Surveyor had not been able to review any goals for the patients as they had not been established nor had the plans of care updated. RRNHV #1 had no goals in the record. RRNHV #2 and #3 both had some problems present, but the rest had been blank. Discussion with the DPCS, and she reports that they have not implemented any of the changes required to clear the CLD's. The DPCS is going to reach out the EMR vendor for assistance.

Observed in Record Review. In 3 of 3 patient records reviewed, the Surveyor had been unable to validated the patient plans of care had been updated nor that there had been an IDG to review and discuss the patients as all the IDG meeting notes had been blank. The Surveyor had also not been able to validate that an RN had made a comprehensive visit to the patient every 15 days. This was present in all records reviewed. This was validated with the DPCS and the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, where the patient had Hospice Aide services (HA) ordered, the Surveyor had been unable to validated that the visits had occurred as ordered nor that care had been provided according to the POC as both records had been missing documentation to support that the visits occurred. . This was validated with the DPCS and the Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, the Surveyor had been unable to validate any Hospice Aide Supervisory visits. There have not been any supervisory visits documented. They appear to have been scheduled; however they are all blank. Discussion with the DPCS and she reports that they have not implemented any of the changes required to clear the CLD's. This finding was reviewed with the DPCS and Administrator.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition Level deficiencies in §418.102, §418.104, §418.112, §418.56, §418.76.

Observed in Record Review. In 1 of 1 patient records reviewed, where the patient had been recertified for ongoing hospice care, the Medical Director failed to review the clinical information and sign the CTI prior to recertification. The CTI for the current episode of care is blank and unsigned. The surveyor had been unable to validate that the patient had been discussed with the physician as there had been no IDG to review. This was validated with the DPCS and the Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, all the documentation in the clinical record had been blank, there had been no method of validating the required elements for care treatment and services had been met. In 1 of 10 the active patient records, the record did not reflect all the required elements for care treatment and services. On review of RRHV #3, during the home visit the patient's son stated he needed medications filled for his mom that she uses. It was noted that patient was taking Naproxen and ferrous sulfate that were not listed in the medication record. This finding was reviewed with the administrator who was present for both visits.

Observed in Record Review. In 3 of 3 patient records reviewed, The Surveyor had been unable to validate that the patient care documentation had not been authenticated in accordance with state law, as all the patient clinical notes had been blank, including all IDG's. . This was validated with the DPCS and the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, In 2 of 2 discharged patient records reviewed where patient discharged from service, a discharge summary for care and treatment was not sent to the provider or a notification given that it was available on request. In RRDC #1, the discharge summary was completed but not signed by the completing clinician and it was not sent to the MD and there was no documentation to indication its availability to the receiving MD. On review of RRDC #2, the discharge summary was completed but it was not marked as sent to the receiving MD nor was there any documentation to let the receiving MD know of its availability. This was reviewed and validated with the Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, the Surveyor had unable to validate that the care ordered was provided as all patient visit notes had been blank. This was validated with the DPCS and the Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, the Surveyor had been unable to validated that the patient had an active plan of care and that visits had been made per the plan of care as no visits had been documented. Visits dates had been present; however, all had been blank. No interventions implemented to bring CLD's into compliance. This was validated with the DPCS and the Administrator.

Observed in HR File Review. In 1 of 6 HR files reviewed, there was no documentation to validate staff were provided emergency management training at least every 2 years. On review of the HR #2 the volunteer had not received emergency management training at least every two years over the past 3 years. This was validated in discussion with the administrator.

Observed in Record Review. In 1 of 2 patient records reviewed that were live discharges, the organization did not respect the patient rights to revoke hospice. On review of RRDC #2, the organization did not obtain a revocation, their is documentation in the chart from the Social worker stating patient/family were considering revocation but there was no signed revocation that could be found in the chart. This finding was reviewed with the administrator. Observed in Record Review. In 1 of 2 discharge records reviewed, the patient discharged from service without the completion of a Notice of Medicare Non Coverage (NOMNC) prior to discharging patient from service. On review of RRDC #1, the agency did not have record that the NOMNC was completed prior to discharging the patient due to no longer qualifying for Hospice. This finding was reviewed with the Administrator.

Observed in Record Review. On 1 of 14 patient records reviewed the organization failed to complete initial assessment within the 5 day window of Hospice Election. On RRHV #1, the chaplain and social worker failed to complete an initial assessments within five days after the election of hospice and there was no documentation that refusal of the service took place. This finding was reviewed with the administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice nurse surveyor noted that the organization had not completed a review of all current medications. During RRHV #1, it was noted by the administrator and LVN that the patient was not taking any medication. On arrival to the home the patient had a bucket of medications sitting by her, when I asked if she was taking them she stated every morning she takes the medications in the bucket and has been for a long time. On review of the meds in the bucket the fill dates on the label were all before the admission to hospice. This was discussed with and confirmed with the administrator who was present for the visit.

Observed in Record Review. In 11 of 14 patient records reviewed, the organization failed to provide interdisciplinary, collaborative treatment, or services. During record review for RRHV #1, it was noted in the IDG notes that the chaplain and social worked were not involved in the IDG meeting as evidence by no signature of attendance. In addition, none of the notes have anything from the chaplain recorded during the IDG. On review of RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6, RRNHV #7, RRHV #2, RRHV #3 and RRDC #2, it was noted in the record that the social worker and chaplain were not involved in IDG meetings as evidenced by no signature on IDG and notes were not entered for the MSW and chaplain demonstrating that they were present in the care planning process. This was discussed and reviewed with the administrator.

Observed in Record Review. In 6 of 10 active patient records reviewed goals were not time specific, measurable and specific to the care needs of the patient. On review of RRHV #1, the patient was requesting assistance with assisted death and patient reported during the home visit that was her reason for choosing hospice and that the hospice social worker was helping with working through the process and the plan of care did not include any related goals. On review of RRHV #2, patient is noted to have several wounds with dressings in place but no goals on the plan of care to address this problem. On review of RRHV #3, the goals were not time specific and had teaching elements that had been on the care plan for multiple IDGs without adjustment. For example, goal for teaching fall prevention but there was no timeframe for completion. In addition, it was noted on assessment the presence of a wound with no goals for the wound care. On review of RRNHV #1, the goals had not been updated during the last 10 months patient has been on service and goals were not time specific or measurable. On review of RRNHV #2, the patient is in their first benefit period and has had two IDG meetings with no goals created for the patient. On review of RRNHV #3, the patient is in their first cert period and had multiple IDGs and no goals have been created to address the patients care needs. On review of RRNHV #6, no goals have been created for the patient's identified problems. This was reviewed with the administrator.

Observed in Record Review. In 3 of 14 patient records reviewed the plan care was not updated every 15 days with the interventions for care and treatment of the patient. On review of RRNHV #1, the last two certification periods no recert orders where created and no IDG notes were found in the chart that specified orders for any care providers. There was no ordered interventions or frequencies for any disciplines yet SN and HHA visits had been performed. On review of RRNHV #5, the plan of care did not have any orders for any disciplines for the last certification period but the nurse had been making visits to the home. On review of RRNHV #7, the patient started the 2nd certification period in the middle of September and there are no orders for visit for any disciplines but the HHA has been making visits. This finding was reviewed with the administrator. This finding was reviewed with the administrator.

Observed in Record Review. In 4 of 14 patient records reviewed the Interdisciplinary team did not review the plan of care at least every 15 days. On review of RRDC #1, for 35 days prior to discharge the patient had not had a IDG meeting. .On review of RRBR #1, patient had not had a IDG review done in the last certification period that patient was on service which was a gap in 35 days. On review of RRNHV #1, their had not been any IDG notes documented from May through October. On review of RRNHV #7, the patient has not had any IDG meetings documented since the middle of September. This finding was reviewed with the Administrator.

Observed in Record Review. In 6 of 14 patient records reviewed, the clinician did not follow physician orders. On review of RRBR #2, the patient was to have a sympathy card mailed within two weeks after the death of the patient but there is no documentation that indicated that was sent. On review of RRDC #2, the orders for care were for weekly SN visits. One time in April and two times in May the SN did not complete their weekly ordered visit and no documentation as to why the visits were not made per orders. On review of RRHV #1, the admission orders were for HHA to see the patient 2 times per week but this order was not followed because there are no notes that the HHA has made a visit. On review of RRHV #3, the orders were for a HHA 2 times per week and there was only one visit during a week in September with no documentation as to why the visit was missed. On review of RRNHV #4, the plan of care was for aide visits and the aide has not made any of the ordered visits with no documentation as to why visits not made. On review of RRNHV #6, the plan of care was ordered for RN visits 2 times per week and on one week in both August and September there was only one visit made that week with no update noted to the md or in IDG why the visit was not made.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization’s infection prevention and control activities were not implemented. Agency policy (5.4.1) states that thermometer will be cleaned with alcohol and other equipment with agency approved disinfectant. During RRHV #1, the clinician was observed cleaning all her vital signs equipment with Clorox wipes. The equipment was placed back in the bag without following the 4-minute wet time as indicated per manufacturer’s instructions for Clorox wipes. In addition, the thermometer was not cleaned per policy with alcohol. This was discussed and validated with the administrator who was present during the visit.

Observed in Record Review. In 2 of 2 bereavement records reviewed the bereavement care plans did not include specific, individualized interventions and care to be provided. Agency bereavement policy states the organization will discuss the case on the next IDG after patient's death to determine bereavement needs of the patient. On review of RRBR #1 and RRBR #2, their was no IDG documented in the patient record after the patient passed away to develop a plan of care of the bereaved. This finding was reviewed with the Administrator.

Observed in Record Review. In 2 of 8 records reviewed with Home Health Aide services, the home health aide did not provide care according to the patient's plan of care. Upon review of the record for RRHV#2, the aide did not provide care that was ordered on the Plan of care. Examples included: Range of motion, dressing, mouthcare. On review of RRNHV #1, the aide on multiple visits did not follow the plan of care for the ordered assist with dressing that was ordered to be done every visit. This was reviewed and validated with the administrator.

Observed in Record Review. In 4 of 8 patient record reviews that had aide services ordered, the organization did not conduct a hospice aide supervision every 14 days. During record review of RRHV #2, there had not been an aide supervision done in the months of August and September, the agency performed LVN supervision during that time but did not do the aide supervision. On review of RRNHV #1, there has not been any aide supervisory visits for at least 19 days, since the start of the cert period 19 days ago. On review of RRNHV #6, the patient has been receiving aide services since July and there has been no aide supervisory visits completed. On review of RRNHV #7, there has not been an aide supervisory visit completed since the middle of September. This finding was reviewed with the administrator.

Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by condition level deficiencies in §418.56 and §418.104. This finding was discussed with the administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, documentation was not accurate in the patient record. On review of RRHV #1, the patient was noted during the home visit to have a wound to her coccyx that was being treated with ointment that the nurse assessed during the visit but the documentation in the record for that visit states no wound issues. In addition, the notes read there were no medication changes, however, there was noted medication updates that occurred during the visit. This finding was reviewed with the administrator who was present during the visit.

Observed in Record Review. In 1 of 10 the active patient records, the record did not reflect all the required elements for care treatment and services. On review of RRHV #3, during the home visit the patient's son stated he needed medications filled for his mom that she uses. It was noted that patient was taking Naproxen and ferrous sulfate that were not listed in the medication record. This finding was reviewed with the administrator who was present for both visits.

Observed in Record Review. In 2 of 14 patient record reviews, documentation in the patient record was not authenticated as required. Agency policy states that records will be authenticated in accordance with state law. In RRDC #1 the record contained multiple records in the chart that had not been authenticated by the documenting clinician and the patient has been off service for 4 months. On review of RRDC #2, the clinician who completed the discharge summary had not authenticated the record and the patient has been off service for six months. This finding was reviewed with the administrator.

Observed in Record Review. In 2 of 2 discharged patient records reviewed where patient discharged from service, a discharge summary for care and treatment was not sent to the provider or a notification given that it was available on request. In RRDC #1, the discharge summary was completed but not signed by the completing clinician and it was not sent to the MD and there was no documentation to indication its availability to the receiving MD. On review of RRDC #2, the discharge summary was completed but it was not marked as sent to the receiving MD nor was there any documentation to let the receiving MD know of its availability. This was reviewed and validated with the Administrator.

Observed in Patient Home. On 1 of 3 home visits conducted, the surveyor noted that there was no documentation provided to the patient regarding their policy on controlled substance disposal. Agency Medication Disposal Policy (8.10.1) states when starting a controlled substance the agency will provide written copy of the policy on controlled substance. On RRHV #2, patient is on a controlled substance and there was no policy in the home. This finding was reviewed and confirmed with the administrator who was present for the home visit.

Observed in Tracer Activities. On review of the agency contracts, it was noted there was no provision in the DME contract and pharmacy contract that the contracted entities obtain a criminal background check for employees that are making deliveries or have access to patient records. This was reviewed and confirmed with the Administrator.