Volume 2024 | No. 2
SURVEYOR
HOSPICE
n Educate staff on proper visit documentation, including the use of “PRN” or “per patient choice.” Whether for personal or nonpersonal care tasks, the use of these terms is unacceptable, unless the RN has documented that the patient is cognitively and functionally able to make the decision n Observe and assess aide visits to ensure consistency between tasks and orders. n Audit patient records and work with the RN to update plans of care when needed.
n Election of benefit did not contain start of care date. n On admission the patient was documented as 80 years old. The patient was 83 years old on admission. n Implement regular audits to confirm the patient record reflects the most recent, accurate information. n Review election statements to ensure all items are present and completed correctly. Educate all members of the Interdisciplinary team on the required elements of the standard for information entered into the patient record: Include signatures, credentials and dates. Check and recheck entries for accuracy. Correct typos and use clear language. Avoid abbreviations that are not generally understood and/or approved by the agency. The hospice interdisciplinary team must complete a written, patient-specific assessment within five calendar days of the election of hospice care. The comprehensive assessment considers physical health, mental health, functional limitations, pain management, and social, environmental, and economic components. A bereavement assessment is conducted, and the patient’s spiritual needs are evaluated. Evidence of compliance is based on review of patient records. While deficiencies were sometimes cited due to lack of psychosocial assessments, the vast majority of findings were related to spiritual and bereavement components.
Tips for compliance:
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT HSP5-1A Overview of the requirement:
A patient record is maintained for each individual who receives care. All entries are legible, clear, complete, appropriately authenticated, and dated. The patient record documents home visits, treatments, and all care/services provided. Evidence of compliance is evaluated through review of patient records and response to interviews. Many deficiencies related to errors in documentation, specifically incomplete authentication (missing signatures and credentials).
Comment on deficiencies:
HSP5-3C Overview of the requirement:
Frequency of citation:
51%
Examples of surveyor findings:
n The nursing notes do not contain evidence that they are appropriately authenticated and dated within the currently accepted standards of practice. n The Consent for Hospice Care listed the MD name but had no NPI or telephone number. n Visit notes do not include credentials as part of the electronic signature. n The advanced directive is not on record. n The documentation does not use agency-approved abbreviations. n Consent lists all disciplines with checkbox for disciplines patient accepts. All options are left blank. n The physician’s certification, SN initial comprehensive assessment, and visit notes indicate the patient’s primary terminal diagnosis is congestive heart failure. The initial plan of care indicates the patient’s primary terminal diagnosis is cancer of the stomach. n The documentation is not specific for the wound assessment/description and the actual dressing changes performed. n The nurse documented providing instruction for breathing treatments. Upon interview, the documentation is incomplete as the patient did not have a working machine at the time of the visit. The hospice ordered a replacement nebulizer which was not documented. n Visit date, MD name, and RN CM name listed on missed visit note. No evidence that any of the remaining questions were answered or documentation as to the reason for missing the visit.
Comment on deficiencies:
Frequency of citation:
46%
Examples of surveyor findings:
n Patient records did reflect that the comprehensive assessment was completed no later than five calendar days after the election of hospice care. n The comprehensive initial assessment did not identify the psychosocial needs of the patient/family. n Patient records do not contain all social components: communication strengths and barriers, response to previous loss, literacy and language skills. n Clinical record did not show evidence that bereavement assessment was completed within five days of admission. n Bereavement assessment documented first name and phone number with no evidence of address. Relationship was not completed.
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