Every finding on record at Traditional Home Health Care, LLC

Based on review of hospice policies/procedures and clinical records and based on interview with the hospice director (Employee #13) and the hospice liaison (Employee #14), the hospice failed to ensure the "Interdisciplinary Group Meeting" care plan update form included documentation that the interdisciplinary team (IDT) reviewed the circumstances which resulted in the need for additional skilled nursing (SN) visits for three (3) of three (3) active patients for whom an as needed (PRN)/additional SN visit was performed. (Patients #3, #15 and #16) --- Findings include: On October 20, 2023 at approximately 4:58 PM, review of the agency policy titled "58. Hospice Interdisciplinary Team Coordination of Care" revealed the following: The type and scope of services provided by the team are based upon initial and ongoing assessments...The team will initiate changes as the patient, family and caregiver needs evolve during the terminal illness...The team conducts assessments and develops updates to the plan of care. The team reviews the effectiveness of the plan of care every two (2) weeks...Hospice personnel submit documentation of services provided (including clinical notes, the schedule of visits and patient evaluations) at least twice a week and participate in the interdisciplinary team meetings... Patient #3: On October 19, 2023 at approximately 1:37 PM, review of the SN visit frequency order revealed four (4) SN visits were to be provided during the treatment week of 09/03/2023 through 09/09/2023 as documented on the "Hospice Certification and Plan of Care" for the recertification period of 08/29/2023 through 10/27/2023. Review of "Skilled Nursing Visit Note" documentation revealed a total of five (5) SN visits were performed during the treatment week of 09/03/2023 through 09/09/2023. The 09/06/2023 SN visit was documented as being a PRN SN visit conducted for the purpose of enema administration. There was no documentation on the "Interdisciplinary Group Meeting" minutes forms dated 09/07/2023 and 09/21/2023 which provided evidence that the circumstances resulting in the need for a PRN SN visit on 09/06/2023 was reviewed by the IDT. Patient #15: On October 20, 2023 at approximately 3:19 PM, review of the SN visit frequency order revealed two (2) SN visits were to be provided during the treatment week of 10/08/2023 through 10/14/2023 as documented on the "Hospice Certification and Plan of Care" for the initial certification period of 10/02/2023 through 12/30/2023. Review of "Skilled Nursing Visit Note" documentation revealed a total of three (3) SN visits were performed during the treatment week of 10/08/2023 through 10/14/2023. The 10/12/2023 SN visit was documented as being conducted at the request of the patient's significant other during which the SN assisted with medication administration and provided instruction regarding to the patient's significant other. There was no documentation on the "Interdisciplinary Group Meeting" minutes dated 10/19/2023 which provided evidence hat the circumstances resulting in the need for the additional SN visit on 10/12/2023 were reviewed by the IDT. Patient #16: On October 20, 2023 at approximately 3:45 PM, review of the skilled nursing visit frequency order revealed two (2) SN visits were to be provided during the treatment week of 10/08/2023 through 10/14/2023 as documented on the "Hospice Certification and Plan of Care" for the initial certification period of 10/06/2023 through 01/03/2024.. Review of "Skilled Nursing Visit Note" documentation revealed a total of three (3) SN visits were performed during the treatment week of 10/08/2023 through 10/14/2023. The 10/14/2023 SN visit was documented as being conducted at the request of the patient's spouse during which the SN provided interventions to address a change in the patient's behavior. There was no documentation on the "Interdisciplinary Group Meeting" minutes dated 10/19/2023 which provided evidence that the circumstances resulting in the need for the additional SN visit on 10/14/2023 were reviewed by the IDT. During interview conducted on October 20,2023 at approximately 5:00 PM, the hospice director and hospice liaison confirmed documentation was not present in the clinical record which provided evidence that the circumstances resulting in the need for the additional SN visits were reviewed by the IDT for the above identified patients.