Every finding on record at Bjk Enterprises Inc

Based on record review and interview, the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), failed to complete the comprehensive assessment no later than 5 calendar days after the election of hospice care in 5 (#1, #3, #4, #7, & #10) of 5 records reviewed with cancer diagnosis. The failure placed the patients at risk of receiving improper or inadequate care from the agency when the patient's spiritual and social needs are not met. --- Record review of Patient #1s record revealed the initial plan of care with a start of care date of 6/30/2022. The initial nursing assessment was completed on 6/30/2022. The chaplain and bereavement assessment were not completed until 7/12/2022. Record review of Patient #3s record revealed the initial plan of care with a start of care date of 4/7/2022. The initial nursing assessment was completed 4/7/2022 and only stated the patient was a part of a religious or spiritual community. The "IDG (interdisciplinary group) Meeting" note dated 4/22/2022 reflected the chaplain visit frequency was 1 to 2 times a month. The record revealed several missed visits by the chaplain (4/11/2022, 4/12/2022, & 5/12/2022). No chaplain or bereavement assessment was found in the electronic medical record. The Bereavement Plan of Care stated, ";A bereavement assessment must be completed in order to create the Bereavement Plan of Care." During an interview on 4/3/2023 about 10:12 AM, the Director of Nurses stated, ";He did not get an assessment." Record review of Patient #4s record revealed the initial plan of care with a start of care date of 7/11/2022. The initial nursing assessment was done 7/11/2022 and does not address the spiritual or religious beliefs or needs of the patient. There are missed visit notes dated 7/15/2022 for the chaplain and bereavement assessments. No chaplain or bereavement assessments were located in the electronic medical record. During an interview on 3/29/2023 about 12:33 PM, the Director of Nurses stated, ";nurses do (spiritual assessment) on admission in case they (patient) did not want a chaplain. I dont see it." Record review of Patient #7s record revealed the initial plan of care with a start of care date of 3/17/ 2022. The initial nursing assessment was done 3/17/2022 and does not address the spiritual or religious needs of the patient. There was missed visit notes on 3/23/2022 for the bereavement and chaplain assessments. No chaplain assessment was found in the electronic medical record. Record review of Patient #10s record revealed the informed consent with an start of care election date of 2/22/2023. The initial nursing assessment was completed 2/22/2022. The ";MSW (social worker) Assessment" was not completed until 3/1/2023. The bereavement assessment was done 3/1/2023 and the chaplain assessment was completed 3/9/2023. The agency did not have a social worker for some time and the social worker at present in new and is currently in orientation. Record review of the agency policy (Policy PE.2) titled ";Patient Assessment Guidelines." The policy read in parts:" ...Purpose: To provide accurate and consistent patient assessments...Policy: Agency will utilize and adhere to defined assessment guidelines in order to accurately assess the patients needs as a basis for planning care. Each assessment will be completed by qualified Agency staff who have the necessary skills and training and comply with all federal and state laws and regulations.... Procedure: 1. Agency will assign staff to perform patient assessments according to each patients specific/ individualized needs and required level of care. 3. Each disciplines standards of practice will be referenced for decision-making when assessing for admission. 4. The assessment data/ information will be gathered and documented on the appropriate disciplines assessment form(s). 9. Comprehensive Health Assessments from an intra-agency referral (within agency) are as follows: Nursing 48 hours, Social Worker 5 days, Chaplain 5 days..." Record review of the agency policy (Policy PE.3) titled ";Initial Patient Assessment/ Patient Admission." The policy read in parts: ";...Purpose: To identify patient needs and assess the patients residence as a basis for planning individualized, outcome-oriented care... Policy: The IDT must develop an individualized written plan of care for each patient...The IDT, in consultation with the patients attending physician, will perform and make available to each patient admitted, a patient-specific Comprehensive Health Assessment, no later than 5 calendar days after election of hospice care. The Comprehensive Health Assessment will identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addresses in order to promote the hospice patients well-being, comfort, and dignity throughout the dying process... Procedure: 7. The Initial Comprehensive Health Assessment, with input from Appropriate IDT members and the attending physician, will be completed within 5 calendar days and will include assessment of the following...Spiritual orientation and needs... Cultural or spiritual practices that may affect care... Psychosocial, social, and emotional wellbeing... Bereavement: An initial bereavement assessment of the needs of the patients family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patients death... 7.1 The Initial Comprehensive Health Assessment includes the following forms:...Social Worker Assessment... Spiritual Assessment... Initial Bereavement Assessment... 8. The interdisciplinary POC will be determined by the interdisciplinary team following completion of the comprehensive health assessment."

Based on record review and interview, the agency failed to include updates of the comprehensive assessment by the interdisciplinary team to meet the patient's progress toward desired outcomes and reassessments of the patient's response to care for 4 of 5 patients (Patients #3, #4, #7, and #10) reviewed with a cancer diagnosis. The failure placed the clients at risk for not having specific needs met. --- Record review of Patient #3s record revealed the initial plan of care with a start of care date of 4/7/2022. The IDG (interdisciplinary group) Meeting note dated 4/22/2022 showed no physician, chaplain, or social worker input or detailed statements on the care plan. Review of the "Benefit Period Manager: IDG Meeting" note in the electronic medical record showed no social worker or chaplain input. Record review of Patient #4s record revealed the initial plan of care with a start of care date of 7/11/2022. The IDG (interdisciplinary group) Meeting notes dated 7/29/2022, 8/12/2022, 8/26/2022, and 9/9/2022 showed no physician, chaplain, or social worker input or detailed statements on the care plan. Review of the "Benefit Period Manager: IDG Meeting" note in the electronic medical record showed no social worker or chaplain input. Record review of Patient #7s record revealed the initial plan of care with a start of care date of 3/17/ 2022. The IDG (interdisciplinary group) Meeting note dated 3/25/2022 shows no physician, chaplain, or social worker input or detailed statements on the care plan. Review of the "Benefit Period Manager: IDG Meeting" note in the electronic medical record showed no social worker or chaplain input. Record review of Patient #10s record revealed the informed consent with a start of care election date of 2/22/2023. The IDG (interdisciplinary group) Meeting note dated 3/10/2023 shows no physician or chaplain input or detailed statements on the care plan. Review of the "Benefit Period Manager: IDG Meeting" note in the electronic medical record showed no chaplain input. Per interview 3/30/2023 about 2:00 PM, when asked how input from each team member was entered into the interdisciplinary note the Director of Nurses stated, "each team member is responsible for entering the information." During an interview 4/3/2023 about 1:30 PM, the surveyor questioned where the IDT (interdisciplinary team) documentation for the meeting between 8/26/2022 and 9/23/2022 was located and the Director of Nurses responded, "nurse didn't document it." The agency had a job description for the chaplain that read in parts: "...Essential Functions: Assess hospice patient to identify spiritual need as evidenced by POC, documentation, clinical records, and IDT conference minutes... ...Collaborate with interdisciplinary team to promote coordination of patient care..." The agency had a job description for the medical social worker that read in parts: "...Essential Functions: Assess hospice patient to identify psychosocial, financial, environmental and community needs as evidenced by POC documentation, clinical records, team meeting minutes and community resource referrals... ...Attend interdisciplinary team meeting, participate in the patient care planning process and collaborate with Interdisciplinary Team to promote coordination of patient care..." The agency had a policy (TX.8) titled, ";Interdisciplinary Team, Coordination of Care and Services." The policy read in parts: ";...Purpose: To describe the process by which the Interdisciplinary Team (IDT) ensures the monitoring and coordination of the patient/ familys specific needs and problems. ...Policy: The agency will designate an Interdisciplinary Team, who in consultation with the patients attending physician, work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. The IDT will prepare a written plan of care for each patient/ family, which specifies the care and services necessary to meet the patient/ family-specific needs identified in the comprehensive assessment, as those needs relate to the terminal illness and related conditions. ...Procedure: 1. Plan of Care ...1.2 Content of the POC (plan of care) will reflect patient/ family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation/ management of the terminal illness and related conditions. ...2. ...Communication regarding the patients plan of care is not restricted to the formal case conference but includes informal verbal and written communication among all staff members providing care. This will serve as documentation of effective interchange and reporting, as well as coordination of care. ...3. Coordination of Services: 3.1 Include, at least, the RN (registered nurse), Physician, Social Worker, and Counselor..." The agency had a policy (TX.9) titled, ";Review and Revision of Patient Care." The policy read in parts: ";...Purpose: To ensure patient care is reviewed and that appropriate changes are made as necessary. ...Policy: Agency will review and revise patient care in accordance with changes in the patients condition; spiritual status; psychosocial status; residential environment; patients response to care; and changes that have occurred regarding diagnosis, treatment, medications, precautions, and limitations. ...Procedure: ...2. Upon identifying that patient care needs have changed (according to Agency policy), adjustments to the care planning documents will be made as follows: ...IDT Plan of Care RN, PT, OT, MSW, Counselor (Chaplain)... 4. All written changes to the plan of care will be incorporated into the patients medical record as changes occur. The agency had a policy (LD.7) titled, ";Interdisciplinary Team (IDT)/ Core Services." The policy read in parts: ";...Purpose: To establish the Agency interdisciplinary team in accordance with applicable laws and regulations. ...Policy: Agency will designate an Interdisciplinary group or groups composed of individuals who provide or supervise the care and services offered. Agency will routinely provide substantially all core services directly by hospice employees... ...Procedure: 1. Agency will establish and maintain a group of professional individuals, the core group, who are employees of the hospice and include at least: One physician; One registered nurse; A social worker; A pastor or counselor... ...3. The IDT responsibilities will include but not be limited to: participation in the establishment of the plan of care..."

Based on record review and interview, the agency failed to establish a bereavement plan of care and to make bereavement services available to the family or other individuals up to 1 year following the death of the patient in 4 (#2, #3, #4, & #13) of 9 death records. This failure placed the family members and other individuals at risk of improper grieving and poor psychosocial coping. --- Record review of Patient #2's record revealed the initial doctors order with a start of care date of 9/13/2021. The Discharge- Death form shows a discharge date of 10/30/2021. There is a missed visit for the bereavement assessment dated 9/18/2021 and the post bereavement assessment dated 10/30/2021 states "phone call to bereaved. No answer." The electronic medical record that revealed no attempts to contact the bereaved after this date. Record review of Patient #3s record revealed the initial plan of care with a start of care date of 4/7/2022. The initial nursing assessment was completed 4/7/2022. The Discharge- Death documents a date of death of 5/2/2022. No bereavement assessment was found in the electronic medical record. The Bereavement Plan of Care stated, ";A bereavement assessment must be completed in order to create the Bereavement Plan of Care." The electronic medical record that revealed no attempts to contact the bereaved after the death. During an interview on 4/3/2023 about 10:12 AM, the Director of Nurses stated, ";He did not get an assessment." Record review of Patient #4s record revealed the initial plan of care with a start of care date of 7/11/2022. The Discharge- Death note reveals a discharge date of 9/14/2022. There is a missed visit note dated 9/20/2022 for the post bereavement assessment. No bereavement assessment was found in the electronic medical record. The Bereavement Plan of Care stated, ";A bereavement assessment must be completed in order to create the Bereavement Plan of Care." The electronic medical record that revealed no attempts to contact the bereaved after the death. During an interview on 3/29/2023 about 12:33 PM, the Director of Nurses stated, ";nurses do (spiritual assessment) on admission in case they (patient) did not want a chaplain. I dont see it." Record review of Patient #13's record revealed the initial plan of care with a start date of 1/25/2023. The Discharge- Death note shows a discharge date of 1/29/2023. There are missed visit notes for the Chaplain and Bereavement assessments dated 1/29/2023 stating "patient died prior to assessment." The Bereavement Plan of Care stated, ";A bereavement assessment must be completed in order to create the Bereavement Plan of Care." The electronic medical record that revealed no attempts to contact the bereaved after the death.

Based on record review and interview, the agency failed to include all necessary components of summary of patient stay including treatments, symptoms and pain management, current plan of care, latest physician orders, and any other documentation that would assist in post-discharge continuity of care in the discharge summaries for 4 (#1, #8, #9, & #14) of 5 live discharged patients. This failure could result in the improper continuity of care by the receiving physician or healthcare facility. --- Record review of Patient #1s record revealed the initial plan of care with a start of care date of 6/30/2022. The initial nursing assessment was completed on 6/30/2022. Per the Discharge-Live form the patient was discharged 8/26/2022. The surveyor was unable to locate a discharge summary in the electronic medical record. Record review of Patient #8s record revealed the initial plan of care with a start of care date of 10/5/2020. The Discharge- Live form shows the patient was discharged 12/30/2022. The discharge summary did not address treatments, symptoms or pain management, current plan of care, or latest physician orders. Record review of Patient #9s record revealed informed consents with an election start of care date of 7/15/2022. The Discharge- Live form shows the patient transferred to another hospice on 11/18/2022 medical record did not include a discharge summary only a statement regarding the patient desire to transfer to another agency. Record review of Patient #14s record revealed informed consents with an election start of care date of 7/19/2021. The Discharge- Live form revealed the patient was discharged for cause on 8/8/2022. The discharge does not contain any components of a discharge summary. During an interview on 4/3/2023 about 2:51 PM, the Director of Nurses stated, "the nurse writes the discharge order and I do the summary." The agency had a policy (PE.5) titled, ";Patient Transfer/ Agency Dissolution." The policy read in parts:"...Purpose: To ensure appropriate, timely, and coordinated patient transfers... Policy: I. Agency will initiate patient transfer or transfer and discharge when: A. The patient/ family requests transfer to another hospice... I. Inter-Agency... I. Prior to transfer, the Agency will provide the receiving agency with the following: 1. Discharge summary, to include services being rendered... J. The Discharge Summary will include: 1. Summary of the patients stay including treatments, symptoms, and pain management, 2. Patients current POC (plan of care), 3. Patients latest physician orders, and 4. Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility."