Volume 2024 | No. 2
SURVEYOR
HOSPICE
Tips for compliance:
n The IDG ensures the plan of care is being followed. Updates and revisions to the plan require clear, consistent communication. Review responsibilities with IDG members and retrain as necessary. n Documented visits must match the frequency ordered. Seek revision or updates when visit frequency needs review. n Audit patient records for compliance.
n IDG meeting note has no signatures of any disciplines to validate participation in review and no updates. There was no hard copy of attendance as back up. n The initial chaplain evaluation visit indicated the patient’s religious preference was Methodist. The revised plan of care/IDG documentation section for religious preference is blank. n Document review and revision of the plan of care no less than every 15 calendar days. Monitor timeframes and educate staff as necessary. n A thorough and complete review includes:
Tips for compliance:
HSP5-4F Overview of the requirement:
Updated comprehensive assessment. .Advance directives and code status. Implementation of IDG plan of care in all settings.
The IDG reviews and revises the individualized plan of care based on reassessment data. The review is evidenced by documentation and occurs as frequently as the patient’s condition requires, but no less than every 15 calendar days. Compliance is assessed through response to interviews and review of patient records. The revised plan of care must note the patient’s progress towards outcomes/goals, and this was the commonly cited deficiency.
ٝ Documentation of IDG findings and resulting decisions about revisions. Documentation of patient response to treatment and medications. Effectiveness of pain and symptom management. Ongoing spiritual and psychosocial needs. Determination if hospice services are still needed. n When new orders are received, goals and interventions must be updated as well.
Comment on deficiencies:
Frequency of citation:
22%
Examples of surveyor findings:
n There was no evidence the plan of care had been reviewed/updated since the initial plan was developed more than 15 days prior. n The record indicated that the patient was discharged for extended prognosis. There was no evidence that the IDG discussed and planned for the discharge. n The medical record includes nursing documentation that the patient was experiencing unmanaged anxiety and that after collaboration with the medical director there was a subsequent order to increase medication dosage. The plan of care includes no problems, goals, or interventions related to anxiety. n The record indicated the patient had a UTI and an antibiotic was ordered. There was no evidence of a care plan for this infection that included goals and interventions for this infection. n The RN documented under the imminent death section of the assessment the patient was having increased respiratory distress. There was no evidence the plan of care was updated to manage patient and the family needs during the final two days of life. n The patient receives monthly visits from the spiritual care counselor and the MSW. There are no problem statements with interventions and goals for the SCC and MSW services. n There is no evidence in the patient record that the written plan of care was developed by the IDG in consultation with a physician other than the hospice medical director.
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