Every finding on record at All Saints Hospice Care

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. NEW REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the hospice did not ensure the individualized plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 07/30/2024. The initial nursing assessment dated 07/30/2024 included documentation that the patient had 8/10 pain that interfered with daily living. The plan of care dated 07/30/2024-08/06/2024 revealed pain as a problem, with the goal of "pain." The plan did not reflect the patient's goals associated with pain. Clinical Record 2: The patient elected the hospice benefit on 07/12/2024. The initial nursing assessment dated 07/12/2024 included documentation that the patient had 10/10 pain that interfered with daily living. The plan of care dated 07/12/2024-08/06/2024 revealed pain as a problem, with the goal of "pain." The plan did not reflect the patient's goals associated with pain. During a joint clinical record review and an interview on 08/06/2024, the Director of Nursing agreed there was no documented evidence that the written plan of care reflect patient and family goals for pain. Additionally, during an interview on 08/06/2024, the Director of Nursing stated, "That isn't a real goal, we need to update that to include the patient's goal, not sure why it wasn't done correctly."

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 3 (100%) In 3 of 3 (100%) clinical records reviewed with a discharge due to death, the hospice did not ensure that bereavement services were provided to the bereaved. Document 2: Agency Policy, "Bereavement Policy No. PC.26," dated 12/01/2019, stated in part, "After the death of the patient: the Bereavement Coordinator will complete a follow-up assessment and develop a plan of care for Bereavement Services based on the re-assessment and the family/caregiver's willingness to receive services. This plan of care will be discussed at the next IDG meeting. The Bereavement Coordinator will ensure bereavement services reflect the needs of the bereaved. The Bereavement Plan of Care will include delineation of services and frequency to be provided, which may include, but not be limited to, the following: individual bereavement counseling, support groups, telephone calls, memorial services, cards, letters, mailings, and referrals to community services as appropriate....A bereavement file will be maintained on each family/caregiver and will contain all bereavement assessments, all bereavement plans of care, all bereavement clinical notes and documentation of letters and or resources sent to the bereaved, and all contacts, declinations of bereavement assistance, inability to contact and referrals will be documented in the patient's medical record." Clinical Record 3: The patient’s date of election was 04/29/2024. The patient died on 06/24/2024. There was no documented evidence of a post-death bereavement assessment, contact after death, discussion at an IDG meeting after death, bereavement plan of care (POC), declination of bereavement support, or that bereavement services were provided. Clinical Record 4: The patient’s date of election was 04/11/2024. The patient died on 07/04/2024. There was no documented evidence of a post-death bereavement assessment, contact after death, discussion at an IDG meeting after death, bereavement plan of care (POC), declination of bereavement support, or that bereavement services were provided. Clinical Record 5: The patient’s date of election was 02/24/2023. The patient died on 07/17/2024. A telephone call was documented on 07/18/2024 that revealed a voice mail was left by the bereavement coordinator on 07/15/2024 and 07/18/2024. There was no documented evidence of a post-death bereavement assessment, discussion at an IDG meeting after death, bereavement plan of care (POC), declination of bereavement support, or that bereavement services were provided. During an interview on 08/06/2024, the Administrator agreed that the action plan had not been followed and did not have additional information to provide. During a joint clinical record review and an interview on 08/06/2024, the Director of Nursing agreed there was no documented evidence that bereavement services were provided. Additionally, during an interview on 08/06/2024, the Director of Nursing stated, "The bereavement coordinator still isn't providing bereavement services, she needs more education, or we need someone else." During a joint clinical record review and an interview on 08/06/2024, the Bereavement Coordinator stated, "I still do not know what I need to do for bereavement, can you give me a list to explain what all needs to be done." The Bereavement Coordinator agreed there was no documented evidence bereavement services were provided for the records identified.

It is required that the hospice must conduct and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, document review and interviews which revealed the hospice: Failed to ensure a medication reconciliation was completed and medications updated to the medication profile {HCPC.15. I/L530}; and Failed to ensure the comprehensive assessment included an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death {HCPC.13. I/L531}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.54: Initial and comprehensive assessment of the patient. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 3 (67%) clinical records reviewed revealed the organization did not ensure a medication reconciliation was completed and medications updated to the medication profile. Home Visit 2: The date of election was 10/16/2023. The date of the last nursing comprehensive nursing assessment was 06/17/2024. The medication profile dated 06/12/2024-08/10/2024 revealed Fluoxetine HCl oral capsules 10mg, take one capsule daily and Megestrol Acetate Oral Suspension 40mg/ml, take 20ml daily. During the Home Visit with the Registered Nurse (Personnel Record 2) on 06/26/2024, the medication bottles revealed Fluoxetine HCl 10mg capsules, three capsules by mouth daily, Atropine Sulfate solution 1%, take two drops under the tongue every 4-6 hours as needed for excessive secretions dated 12/29/2023; GNP Gas Relief chew 80mg, take one chew by mouth four times a day dated 06/18/2024; Melatonin 5mg tablet, take one tablet by mouth at bedtime dated 06/24/2024; Promethazine 25mg tablet, take one tablet by mouth every 6 hours as needed for nausea and vomiting dated 02/26/2024; Trazadone 50mg tablet, take one tablet by mouth at bedtime dated 06/18/2024; and Chest Congestion 400mg tablet, take one tablet by mouth twice a day dated 06/10/2024. The Registered Nurse stated that the Megestrol Acetate Oral Suspension has not been present since February or March of 2024, when she took over the care from the previous nurse. The Registered Nurse stated that the medications in the home had been the correct medications, dosages, and instructions since February or March of 2024, when she took over the care from the previous nurse. Home Visit 3: The date of the election was 02/24/2023. The date of the last comprehensive nursing assessment was 06/21/2024. The medication profile dated 05/08/2024-07/06/2024 revealed Eliquis oral tablet 5mg, take one tablet twice daily; Simvastatin oral tablet 40mg, take one tablet at bedtime; Metoprolol Tartrate oral tablet 50mg, take 0.5 tablets (25mg) twice daily; Hydroxyzine Pamoate oral capsule 100mg, take one tablet four times a day; and Sulfasalazine oral tablet delayed release 500mg, take one tablet twice a day. During the Home Visit with the Chaplain (Personnel Record 7) on 06/26/2024, the medication bottles revealed Eliquis oral tablet 2.5mg, take one tablet by mouth twice a day; Simvastatin oral tablet 20mg, take one tablet at bedtime; Hydroxyzine Pamoate oral capsule 50mg, take one capsule by mouth four times a day dated 06/03/2024; and Magnesium tablet 500mg, take two tablets by mouth daily. The Director of Nursing was present during the visit and stated that the Magnesium was started on 03/14/2024. The Director of Nursing reported that the Metoprolol Tartrate was stopped approximately one month ago, and the Sulfasalazine was stopped before taking over the care of the patient and that the above medication bottles had the correct dosages and instructions since February or March 2024, when she took over the patient's care from the previous nurse. During a joint record review and interview on 06/26/2024, the Director of Nursing confirmed that there was no documented evidence the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure the comprehensive assessment included an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Clinical Record 4: The date of the election was 03/22/2024. The record lacked evidence of an initial bereavement assessment. Clinical Record 6: The date of the election was 04/11/2024. The record lacked evidence of an initial bereavement assessment. Clinical Record 7: The date of the election was 10/16/2023. The Bereavement Assessment dated 10/18/2023 stated, "Chaplain called Power of Attorney (POA) twice. Left messages. Calls not returned." The record lacked any other attempt to contact Power of Attorney or family for bereavement assessment. The record lacked evidence of an initial bereavement assessment. Clinical Record 8: The date of the election was 03/08/2024. The record lacked evidence of an initial bereavement assessment. Clinical Record 12: The date of the election was 02/27/2024. The record lacked evidence of an initial bereavement assessment. During a joint clinical record review and interview on 06/27/2024, the Director of Nursing confirmed that the record lacked an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by document review and interview. In 2 of 2 (100%) clinical records reviewed with a discharge due to death, the agency did not ensure that bereavement services were provided to the bereaved. Document 1: Agency Policy, "Bereavement Policy No. PC.26," dated 12/01/2019, stated in part, "After the death of the patient: the Bereavement Coordinator will complete a follow-up assessment and develop a plan of care for Bereavement Services based on the re-assessment and the family/caregiver's willingness to receive services. This plan of care will be discussed at the next IDG meeting. The Bereavement Coordinator will ensure bereavement services reflect the needs of the bereaved. The Bereavement Plan of Care will include delineation of services and frequency to be provided, which may include, but not be limited to, the following: individual bereavement counseling, support groups, telephone calls, memorial services, cards, letters, mailings, and referrals to community services as appropriate....A bereavement file will be maintained on each family/caregiver and will contain all bereavement assessments, all bereavement plans of care, all bereavement clinical notes and documentation of letters and or resources sent to the bereaved, and all contacts, declinations of bereavement assistance, inability to contact and referrals will be documented in the patient's medical record." Clinical Record 13: The patient’s date of election was 07/11/2023. The patient died on 01/24/2024. There was no documented evidence of a bereavement plan of care (POC), declination of bereavement, or that bereavement services were provided. Clinical Record 14: The patient’s date of election was 04/18/2023. The patient died on 10/16/2023. There was no documented evidence of a post-death bereavement risk assessment, a bereavement POC, a declination of bereavement, or that bereavement services were provided. During a joint clinical record review and an interview on 06/27/2024, the Director of Nursing agreed there was no documented evidence that bereavement services were provided.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. A review of the agency’s volunteer program, there was no documented evidence of efforts to retain volunteers. During an interview on 06/27/2024, the Human Resources/Volunteer Coordinator and the Administrator confirmed that the retention efforts were not documented from January 2024 through June 2024. Upon reviewing the volunteer program, the documentation lacked evidence of efforts to retain volunteers.