Every finding on record at USA Valley Hospice Inc

Upon patient record review, 5 of 14 (Patient #1, 2, 3, 4, 5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Upon patient record review, orders for PRN visits are not quantified. Patient #1: 4/22/24 order for SC to visit every month and as needed for spiritual care guidance. 4/19/24 MSW to visit once a month and as needed for psychosocial support. Patient #2: 4/26/24 MSW order to visit once a month and as needed for psychosocial support; 4/28/24 order for SC to visit every month and as needed for spiritual care guidance. Patient #3: 6/1/24 order for SC every month and as needed for spiritual guidance and MSW every Recert and as needed for psychosocial support. Patient #4: 6/3/24 SC to visit every month and as needed for spiritual guidance. 6/1/24 MSW to continue to be of assistance to patient and family for psychosocial support monthly, every recert and as needed. Patient #5: 6/8/24 chaplain follow up assessment will be conducted once a month and as needed. 6/5/24 SW to continue to be of assistance to patient and family for psychosocial support monthly and as needed.

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: 6/1/24 plan of care stated MSW every recert and as needed for psychosocial support. MSW performed phone visit 7/1/24 phone visit and includes plan to follow up with the pt/cg monthly to assist with community resources, there was no order present for this.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #11: Patient chose primary/referring physician as attending per election statement. The attending physician, who is not employed by the hospice, was the only physician who documented the certification of terminal illness for Benefit Periods 2, 3, and 4.

Upon patient client record review, 1 of 14 (Patient #8) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #8: Patient admitted 1/5/24 and chose his referring/primary physician as attending. However, there was no documented attending physician certification of terminal illness for the initial benefit period.

Upon patient client record review, 1 of 14 (Patient #12) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #12: Patient moved out of service area and revoked hospice, declining transfer. DC Summary narrative states that "DC summary and other info was shared with the hospital as allowed by pt/family to assist in post discharge continuity of care. IDG updated and informed." But patient was not discharged/transferred to hospital according to record and staff interview