HospitalInspections.org

Based on review of facility documentation, medical records (MR) and staff (EMP) interview, it was determined the facility failed to provide a list of available Hospice care facilities to the patient or patient representative for one of one applicable medical record reviewed (MR1) and the facility failed to document the reason a patient did not qualify for in-patient hospice for one of one applicable medical record reviewed (MR1).

Findings include:

1) Review on May 15, 2019, of the facility's "Discharge Planning (Nursing and Care Coordination)" policy, no review date, revealed "Purpose It is the policy of Lehigh Valley Hospital - Pocono (LVH-P) that the need for discharge planning is assessed prior to or on admission and updated throughout the duration of hospitalization. Discharge planning is an interdisciplinary process that provides for continuing care based upon the individual patient's assessed needs. A plan to meet these needs shall be developed and interventions to meet specific discharge planning goals shall be designated. The plan will be monitored and revised as necessary throughout the hospital stay. ... Discharge planning will be documented in the Case Manager notes. ... Patient's rights to choice and right to participate in the discharge plan will be honored. Lists of appropriate Medicare certified post-acute providers will be given to meet individual patient needs and will be documented in the Case Manager Notes. ..."

A request was made of EMP1 and EMP2 on May 15, 2019, for the list of post-acute hospice providers. None was provided.

Review of MR1 on May 15, 2019, revealed Care Management documentation indicating this patient required hospice services. There was no documentation in MR1 indicating the facility provided this patient or this patient's representatives with a list of post-acute hospice providers to make an informed decision regarding hospice placement.

Interview with EMP1 and EMP2 on May 15, 2019, at approximately 2:00 PM confirmed Care Management documentation indicating this patient required hospice services and there was no documentation indicating the facility provided this patient or this patient's representatives with a list of post-acute hospice providers to make an informed decision regarding hospice placement. EMP1 and EMP2 revealed the facility does not have a list of post-acute hospice providers.

2) A request was made of EMP1 and EMP2 on May 15, 2019, for a facility policy, procedure or guideline facility staff utilize regarding hospice documentation in the medical record. None was provided.

Review of MR1 on May 15, 2019, revealed Care Management documentation indicating this patient required hospice services following discharge and this patient's family requested in-patient hospice located in the facility. Further review revealed documentation MR1 did not qualify for in-patient hospice. There was no documentation in MR1 indicating why this patient did not qualify for in-patient hospice or that MR1's family was provided an explanation regarding why this patient did not qualify for in-patient hospice.

Interview with EMP1 and EMP2 on May 15, 2019, at approximately 2:15 PM confirmed Care Management documentation indicating MR1 required hospice services following discharge; this patient's family requested in-patient hospice care located in the facility; Care Management documentation indicating MR1 did not qualify for in-patient hospice and that there was no documentation indicating why this patient did not qualify for in-patient hospice or that MR1's family was provided an explanation regarding why this patient did not qualify for in-patient hospice. EMP1 and EMP2 revealed it would be the responsibility of the hospice staff to document reasons why a patient did not qualify for in-patient hospice care. EMP2 revealed there was no place in the medical record for hospice staff to document their findings.