Every finding on record at Angel Pathway Hospice, Inc.

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. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial comprehensive assessments. Clinical Record 1: The initial social work assessment was completed on 02/22/2024 and ordered a frequency of "1 time per month with 1 as needed (PRN) for psychosocial crisis". The interdisciplinary group (IDG) POC dated 02/23/2024 lacked evidence of goal(s) and intervention(s) for social work. The initial Chaplain assessment was completed on 02/21/2024 and ordered a frequency of "1 time per month with 1 PRN for spiritual crisis". The IDG POC dated 02/23/2024 lacked evidence of goal(s) and intervention(s) for spiritual support. Clinical Record 5: On the initial nursing assessment dated 03/12/2024, the narrative reported "She experiences both bladder and bowel incontinence...". The IDG POC dated 03/12/2024 lacked evidence of goal(s) and intervention(s) for both the bladder and bowel incontinence. The Administrator/Director of Patient Care Services stated in an interview on 10/29/2024 that the agency did not ensure the IDG POC reflected patient and family goals and interventions based on problems identified in the initial comprehensive assessments.

It is required that medical social services are provided by a qualified social worker per the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the medical social services were being provided by the social worker per the interdisciplinary group (IDG) plan of care (POC). Clinical Record 1: The plan of care, dated 02/23/2024 to 05/23/2024, included an order for social workers to visit "1 time per month with 1 PRN (as needed) for psychosocial crisis." The record had evidence of social worker visits completed on: 02/22/2024 and 04/20/2024. There was no documentation that a social worker visit was completed for March 2024 and there was no evidence the visit was declined or that the visit frequency orders were changed. The Administrator/Director of Patient Care Services stated in an interview on 10/29/2024 that the agency did not ensure medical social services being provided by the social worker per the ordered frequency on the IDG POC.

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. 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 clinical record review and interview. In 2 of 4 (50%) clinical records reviewed for patients that expired revealed the agency did not ensure a post-death bereavement assessment and a post-death bereavement plan of care (POC) was completed. Clinical Record 4: The patient expired on 06/25/2024. The record lacked evidence of a completed post-death bereavement assessment and post-death bereavement POC. On 07/03/2024, there was evidence of phone contact to the family having offered bereavement services. Clinical Record 13: The patient expired on 07/27/2024. The record lacked evidence of a completed post-death bereavement assessment and post-death bereavement POC. There was evidence of a bereavement support letter that was sent on 08/27/2024 to the durable power of attorney (DPOA). The Owner/Administrator/Director of Patient Care Services/Registered Nurse/Volunteer coordinator stated in an interview on 10/29/2024 that the agency did not ensure a post-death bereavement assessment and a post-death bereavement POC was completed.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed in which the patient elected hospice aide services revealed the agency did not ensure the hospice aide reported changes in the patient's medical needs to the registered nurse (RN) as the changes related to the aide care plan. Clinical Record 8: The patient elected the hospice benefit on 07/05/2024 with a diagnosis of malignant neoplasm of the lung. The aide care plan dated 09/30/2024 ordered the tasks: "Bed Bath", "Shampoo", and "Blow Dry". The aide frequency was two (2) times per week. The aide visit note dated 10/17/2024 left the boxes blank for the 3 tasks: "Bed Bath", "Shampoo", and "Blow Dry" and reported for the bed bath, "Pt did not feel up to a bed bath this day" and "Pt refused" for shampoo and blow dry. The record lacked evidence that the aide reported changes in the patient's medical needs to the RN as the changes related to the aide care plan. The Administrator/Director of Patient Care Services stated in an interview on 10/29/2024 that the agency did not ensure the hospice aide reported changes in the patient's medical needs to the RN as the changes related to the aide care plan.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The review of the "Volunteer Savings Report" revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The review of the 2024 "Volunteer Saving Report" revealed the volunteer percentage of hours worked for 01/01/2024 - 10/30/2024 was 0%. The Owner/Volunteer Coordinator stated in an interview on 10/30/2024 that the agency had a current patients’ family that requested a volunteer for "Companionship" to start the week of 11/03/2024. Setting up the volunteer date and time to visit next week was completed prior to this site visitor exit conference. The Administrator/Volunteer Coordinator stated in an interview on 10/30/2024 that they were aware volunteers could be utilized in administrative roles and direct patient care but “was hoping to get the hours” from direct patient care. The review of the "Volunteer Savings Report" revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.