Every finding on record at Buena Vista Hospice

Based on record review and interview, the hospice agency failed to ensure care and services were provided in accordance with the hospice plan of care (HPOC) for four of 19 sampled patients (Patients 3, 8, 9 and 10) when:a. A skilled nursing (SN) visit was missed for Patients 3 and 8.b. A hospice aide (HA) visit was missed for Patients 9 and 10.These failures had the potential to result in inconsistencies with care and symptom management of these patients affecting quality of life. --- During a review of Patient 10's health records on 5/1/25 at 12:06 pm, Patient 10 had an order for Home Hospice Aide (HHA) visit two times a week for 9 weeks for the certification period of 1/21/24 to 3/21/25. On week of 3/16/25 to 3/21/25 no HHA visit were made. No missed visit documentation found in the health records. During an interview with the DPCS on 5/1/25 at 3:45 pm, the DPCS acknowledged the missed visits for the week of 3/16/25 to 3/21/25. During the review of the facility policy and procedure (P&P) titled, "Missed Visits" dated, 11/ 2013, the P&P indicated, "Missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. A missed visit will be rescheduled the same week if possible... Missed visits will be documented in the clinical records."   During a review of Patient 8’s “HRP,” dated 1/27/25, the “HRP” indicated, 91 year old female with a start of care date (SOC) of 6/5/24 admitted for other sequelae (long term effects) following unspecified cerebral vascular disease (condition that impacts the brain’s blood vessels and blood flow).During a review of Patient 8’s “HRP,” dated 1/27/25, the “HRP” indicated, Nursing visit frequency is 1 time weekly.During a review of Patient 8’s “Client Calendar Report (CCR),” dated 5/1/25, the “CCR” indicated, missed nursing visit for the week of 2/23/25.During a review of Patient 9’s “HRP,” dated 1/9/25, the “HRP” indicated, 79 year old female with an SOC of 11/12/24 admitted for Alzheimer’s disease (progressive disease that destroys memory and other mental functions).During a review of Patient 9’s “HRP,” dated 1/9/25, the “HRP” indicated, Home health aide visit frequency is 2 times weekly.During a review of Patient 9’s “CCR,” dated 5/1/25. The “CCR” indicated, missed home health aide visit for the week of 1/12/25.During an interview on 5/1/25 at 3 p.m. with Director of Patient Care Services (DPCS), DPCS confirmed, nursing visit for Patient 8 was missed for the week of 2/23/25 and home health aide visit was missed for Patient 9 for the week of 1/12/25, and confirmed no missed visit notes noted.     Findings:During a review of Patient 3's "HPOC" for the recertification period 12/28/24 - 3/27/25, the HPOC indicated the home visit order "SN 1WK1, 2WK13 (one skilled nursing visit per week for one week, then two visits per week for 13 weeks)."During a review of Patient 3's "Client Calendar Report (a report of skilled home visits made to the patient by discipline and by date)," for the recertification period 12/28/24 - 3/27/25, the report indicated that on the week of 2/9/24, one SN visit was missed for Patient 3.  There was no documentation found in Patient 3's record to justify the missed SN visit.During a concurrent interview and record review on 5/1/25 at 3:05 p.m., with the agency's Director of Patient Care Services (DPCS), Patient 3's "Client Calendar Report," for the recertification period of 12/28/24 - 3/27/25 was reviewed.  DPCS confirmed that Patient 3 missed one SN visit on the week of 2/9/24 and found no documentation in the record to justify the missed visit.  DPCS acknowledged that staff should have documented the missed SN visit.

Based on record review, observation, and interview, the facility failed to ensure Patient 17s needs were met for symptom management and comfort by not administering oxygen as ordered by the Physician. This failure caused Patient 17 to experience agitation and discomfort from perceived breathing difficulty. --- Findings: During a review of Patient 17's ";Patient Information Report," (undated), the "Patient Information Report" indicated, end of life comfort care (hospice care) was admitted on 10/25/23 for generalized atherosclerosis (blocked blood flow). Review of Patient 17's ";Hospice Recertification Plan of Care Update (POC)" dated 8/15/24, the POC indicated, Patient 17 to receive ";...comfort care and alleviation of symptoms..." During a review of Patient 17's "Physician Orders (Orders), dated 10/25/23, the "Order" indicated, "Oxygen via n/c (nasal cannula - two small tubes inserted into nose) at a rate of 2 LPM as needed for respiratory comfort. SN (Skilled Nurse) may titrate 2-5 LPM for symptom management/pt (patient) comfort." During a concurrent home visit, interview, and record review on 9/26/24 at 7:50 a.m. with employee 3 at a skilled nursing facility (SNF), Patient 17 was observed to be restless and agitated. Patient 17 repeated three times, ";It feels like the oxygen tank is empty and Im not getting enough air. Im not comfortable." Employee 3 called the SNF licensed nurse 1 (SNF LN 1). SNF LN 1 entered the room and confirmed Patient 17s oxygen concentrator (machine--makes oxygen gas) was set to deliver 1.5 LPM oxygen. Patient 17's "Order" was reviewed and indicated, Oxygen via n/c 2 LPM. SNF LN 1 stated, ";Thats set wrong. The oxygen should be set to at least at 2 LPM not 1.5 LPM." During a concurrent interview and record review on 10/1/24 at 3:15 p.m. with the Hospice Director of Patient Clinical Services (DPCS), Patient 17's "Order" was reviewed and indicated, Oxygen via n/c 2 LPM. Review of the SNF "Medication Administration Record (MAR)," dated 9/1-9/30/2024,the MAR indicated, no documentation entries of Patient 17 receiving oxygen. Review of the Hospice Policy and Procedure (P&P) titled, ";Plan of Care," dated 11/2013, the P&P indicated, ";The plan of care will identify the patients needs and services to meet those needs..." When asked if Patient 17s needs for symptom control and comfort were met the DPCS stated, ";No comment."

Based on interview and record review, the hospice agency failed to ensure nursing care and services were provided to seven of 20 sampled patients (Patients 4, 5, 6, 7, 10, 13 and 15) when: 1. Patient 4 did not receive one home health aide (HHA) visit during certification period 4/17/24. 2. Patient 5 did not receive the ordered frequency of certified home health aide (CHHA) visits during the certification period 5/15/24 to 8/12/24. 3. Patient 6 did not receive one Skilled Nursing (SN) visit and two CHHA visits for the certification period 4/9/24 to 7/1/24. 4. Patient 7 did not receive two CHHA visits for the certification period from 4/9/24 to 7/7/24. 5. Patient 10 did not receive one of two ordered SN visits during the certification period 6/25/24 to 9/22/24. 6. Patient 13 did not receive one SN visit for the certification period 12/30/23 to 02/27/24. 7. Patient 15 missed two (2) hospice aide visits for the certification period of 11/11/23 – 2/8/24. These failures in the coordination and implementation of nursing care and services had the potential to cause the hospice to fail to meet and achieve the needs and goals of these patients. --- 7. During a review of Patient 15s, ";Hospice Certification and Plan of Care (POC – maps out the needs and services given to a patient facing a terminal illness, as well as the patients family/caregiver)," for the certification period of 11/11/23 – 2/8/24, the POC indicated in part the visit order, ";Frequency/Duration of Visits... HHA effective 11/12/23 2WK13 (home health/hospice aide to conduct home visit two times a week for 13 weeks, effective 11/12/23). During a review of Patient 15s, ";Hospice Physician Order," dated 11/28/23, the order indicated, ";Order Description... CHHA 3x weekly (certified home health/hospice aide three times weekly) ... Service Changes, Calendar Frequency... HHA Effective 11/26/23 3WK10, 2WK1 (home health/hospice aide to conduct home visit three times a week for 10 weeks, then two times a week for one week thereafter, effective 11/26/23)." During a review of Patient 15s, ";Client Calendar Report (CCR – documentation of completed home visits categorized by visit date, begin/end time of visit, service/discipline, and worker/employee name and telephone number)," for the certification period of 11/12/23 – 2/8/24, the CCR indicated Patient 15 missed one (1) HHA visit each for the weeks of 11/19/23 and 11/26/23 respectively, totaling two (2) missed HHA visits. During a concurrent interview and record review, on 10/1/24 at 2:25 p.m., with the agencys Director of Patient Care Services (DPCS), Patient 15s, ";Electronic Medical Record (EMR)," was reviewed. DPCS verbalized that physician orders for new home visits or modification of current home visit orders will be reflected on the patients POC after the order is entered in the EMR. For completed home visits, DPCS verbalized that staff documented them under the ";Visit Notes" section of the EMR and a summary of the completed visits can be generated under the CCR. For missed visits, DPCS verbalized that staff documented them under the ";Coordination Notes" section of the EMR. A comparative review of Patient 15s HHA visit notes and coordination notes, for the certification period of 11/11/23 – 2/8/24, identified two (2) HHA visits, either completed or missed, not documented in the EMR, one (1) visit each week for the weeks of 11/19/23 and 11/26/23 respectively. DPCS verbalized that HHA staff should have documented in Patient 15s EMR regardless of whether a home visit was completed or missed. During a review of the agencys policy & procedures (P&P), titled, ";Missed Visits," revised 11/2018, the P&P indicated in part, ";POLICY... Missed visits will be documented in the medical record. A missed visit will be rescheduled the same week as possible. Missed visits will be documented in the clinical record." The P&P indicated further, ";PROCEDURES... 2) If a visit is missed and not rescheduled, the clinician will: a) Notify the interdisciplinary group (IDG – a group of healthcare professionals with various areas of expertise who work together toward the goals of their clients) and the clinical supervisor of the missed visit and reason for missed visit; b) Document in the patients clinical record the following information: 1) Patients name, 2) Date and type of visit that was missed, 3) Reason for the missed visit...." During a review of the agency's P&P, titled "Entries into the Clinical Record," revised 11/2018, the P&P indicated in part, "POLICY. . . Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided." The P&P indicated further, "PROCEDURE ... 1) A clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies found in this manual, and will include at a minimum: ... J) Reasons for interruptions in the provision of care and services ...." 3. During a concurrent record review and interview with the hospice agencys (HAs) director of patient care services (DPCS) on 10/1/24, at 4:35 PM, patient 7s plan of care (POC) and clinical record (CR) for the certification period from 04/09/24 to 07/07/24 were reviewed. The POC included the frequency of the certified home health aide (CHHA) visits: twice per week for thirteen weeks (2WK13). A review of patient 7's visit calendar indicated that CHHA visits did not occur for 5/30/24 and 7/6/24. There was no indication in patient 7s CR ";coordination notes" that the provider was notified of the missing visits or that the visits were rescheduled. The missed CHHA visits in 5/30/24 and 7/6/24 were not discussed during the interdisciplinary group (IDG) meeting. The DPCS validated the finding. During a review of the hospice's policy and procedure (P&P) titled "Missed Visits" revised 11/2013, the P&P indicated, "5. If a patient is routinely refusing visits, the clinician and the IDG should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and Medical Director." 4. During a concurrent record review and interview with the hospice agencys (HAs) director of patient care services (DPCS) on 10/1/24, at 4:39 PM, patient 13s plan of care (POC) and clinical record (CR) for the certification period from 12/30/23 to 02/27/24 were reviewed. The POC included the frequency of the skilled nurse (SN) visits: once per week for nine weeks (1WK9). On 2/1/24, the number of SN visits was increased from once per week to twice per week. A review of patient 13's visit calendar revealed that one of the two proposed SN visits did not occur during week 9 (from 2/25/24 to 2/27/24). The coordination notes made no mention of the missed SN visit. This was validated with the DPCS. During a review of the hospice's policy and procedure (P&P) titled "Missed Visits" revised 11/2013, the P&P indicated, "...If a visit is missed and not rescheduled the clinician will document in the patients clinical record the reason for the missed visit..." 5. During a concurrent record review and interview with the hospice agencys (HAs) director of patient care services (DPCS) on 10/1/24, at 4:43 PM, patient 10s plan of care (POC) and clinical record (CR) for the certification period from 6/25/24 to 9/22/24 were reviewed. The POC included the frequency of skilled nurse (SN) visits: twice per week for thirteen weeks (2WK13). A review of patient 10's visit calendar for week 7 from 8/4/24 to 8/10/24 indicated that one of two SN visits did not occur. There was no explanation in patient 10s CR ";coordination notes" as to why one of two SN visits was missed, when the provider was notified of the missing visit, or whether the visit frequency was changed, and re-scheduled. The reason for the one missed skilled nurse visit in week 7 was not discussed at the interdisciplinary group (IDG) meeting on 8/14/24. This finding was validated by the DPCS. During a review of the hospice agency's policy and procedure (P&P) titled "Missed Visits" revised 11/2013, the P&P indicated, "...Missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record..." 6. During a concurrent record review and interview with the hospice agencys (HAs) director of patient care services (DPCS) on 10/1/24, at 4:46 PM, patient 5s plan of care (POC) from 5/15/24 to 8/12/24, as well as her clinical record (CR), were reviewed. The POC indicated, in part, the frequency of certified home health aide (CHHA) visits: twice per week for one week (2WK1), three times per week for twelve weeks (3WK12), and once per week for one week (1WK1). A review of patient 5's visit calendar revealed that the CHHA only made two of three proposed visits for week 5 (from 6/9-6/15/24), and three of three scheduled visits did not occur in week 9 (from 7/7-7/13/24). The CHHAs failure to complete the visits was not mentioned in the coordination notes for weeks 5 and 9, nor in the interdisciplinary group (IDG) meetings on 6/19/24 and 7/17/24. The preceding findings were discussed and confirmed with the DPCS. On 10/2/24, the DPCS was unable to provide additional proof as to why three of three CHHA visits did not occur in week 9 and one of the three visits did not occur in week 5. During a review of the hospice agency's policy and procedure (P&P) titled "Missed Visits" revised 11/2013, the P&P indicated, "...Missed visits will be documented in the clinical record..." 1) During a review of Patient 4s (PT4) health record on 9/30/24 at 10:25 am, PT4 had a visit order for home hospice aide (HHA) 1 time a week (1WK1) for the first week then 2 times a week for 12 weeks (2WK12) for the certification period 4/17/24 too. On the week of 5/26/24 to 6/1/24 the HHA missed one visit, no documentation of the missed visit is recorded in the health records. During an interview with the director of patient care services (DPCS) on 9/30/24 at 11 am, the DPCS acknowledged there was no documentation of the missed visit. 2) During a review of Patient 6s (PT6) health record on 9/30/24 at 11:33 am, PT6 had a home visit order for the skilled nursing (SN) 2 times a week for 13 weeks (2WK13) and a home hospice aide (HHA) 2 time a week for 12 weeks ordered on 4/14/24 for the certification period 4/9/24 to 7/1/24. On the week of 6/30/24 to 7/6/24 skilling nursing only had one visit. On the week of 4/24/24 to 4/20/24 the HHA had 2 missed visits. No documentation of the missed SN visit and HHA visit were recorded in the health records. During an interview with the director of patient care services (DPCS) on 9/30/24 at 12:12 pm. The DPCS acknowledged missed visits for the SN and HHA were not documented. The facility policy and procedure titled ";Missed Visits" dated Nov 2013 indicates, ";Missed visits will be communicated to the interdisciplinary group at the IDG Meeting. A missed visit will be rescheduled the same week as possible. Missed visits will be documented int eh clinical record. 1. During a review of Patient 4s "Hospice Recertification Plan of Care (POC)," dated 4/17/24, the POC indicated, a frequency of 1W1, 2W12 (one time a week for one week, two times a week for 12 weeks) for home health aid (HHA). Review of Patient 4's visit calendar indicated, during the week of 5/26/24, Patient 4 only received one HHA visit, instead of the ordered two. There was no documentation of the missed visit. During an interview with the director of patient care services (DPCS) on 9/30/24 at 11 am, the DPCS acknowledged there was no documentation of the missed visit. 2. During a concurrent interview and record review on 10/1/24 at 4:46 p.m., with the director of patient care services (DPCS), Patient 5s "Plan of Care (POC)," dated 5/15/24 to 8/12/24, was reviewed. The POC indicated, a frequency of 2W1, 3W12, 1W1 for certified home health aide (CHHA) visits. Review of Patient 5's visit calendar indicated, during the week of 6/9/24, Patient 5 only received two CHHA visits, instead of the ordered three. During the week of 7/7/24, Patient 5 did not receive CHHA visits, instead of the ordered three. There was no documentation of the missed visits. The preceding findings were discussed and confirmed with the DPCS. On 10/2/24, the DPCS was unable to provide additional proof as to why three of three CHHA visits did not occur in week 9 and one of the three visits did not occur in week 5. 3. During a review of Patient 6s "Hospice Certification Plan of Care (POC)," dated 4/9/24, the POC indicated, a frequency of 2W13 for Skilled Nursing visits (SN) and 2W12 for HHA. Review of Patient 6's visit calendar indicated, during the week of 6/30/24, Patient 6 only received one SN visit, instead of the ordered two. During the week of 4/21/24, Patient 6 did not receive any HHA visits. There was no documentation of the missed visits. During an interview with the director of patient care services (DPCS) on 9/30/24 at 12:12 pm. The DPCS acknowledged missed visits for the SN and HHA were not documented. 4. During a concurrent interview and record review on 10/1/24 at 4:46 p.m., with the director of patient care services (DPCS), Patient 5s "Plan of Care (POC)," dated 5/15/24 to 8/12/24, was reviewed. The POC indicated, a frequency of 2W1, 3W12, 1W1 for certified home health aide (CHHA) visits. Review of Patient 5's visit calendar indicated, during the week of 6/9/24, Patient 5 only received two CHHA visits, instead of the ordered three. During the week of 7/7/24, Patient 5 did not receive CHHA visits, instead of the ordered three. There was no documentation of the missed visits. The preceding findings were discussed and confirmed with the DPCS. During a concurrent record review and interview with the hospice agencys (HAs) director of patient care services (DPCS) on 10/1/24, at 4:35 PM, patient 7s plan of care (POC) and clinical record (CR) for the certification period from 04/09/24 to 07/07/24 were reviewed. The POC included the frequency of the certified home health aide (CHHA) visits: twice per week for thirteen weeks (2WK13). A review of patient 7's visit calendar indicated that CHHA visits did not occur for 5/30/24 and 7/6/24. There was no indication in patient 7s CR ";coordination notes" that the provider was notified of the missing visits or that the visits were rescheduled. The missed CHHA visits in 5/30/24 and 7/6/24 were not discussed during the interdisciplinary group (IDG) meeting. The DPCS validated the finding. During a review of the hospice's policy and procedure (P&P) titled "Missed Visits" revised 11/2013, the P&P indicated, "5. If a patient is routinely refusing visits, the clinician and the IDG should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and Medical Director." 4. During a concurrent record review and interview with the hospice agencys (HAs) director of patient care services (DPCS) on 10/1/24, at 4:39 PM, patient 13s plan of care (POC) and clinical record (CR) for the certification period from 12/30/23 to 02/27/24 were reviewed. The POC included the frequency of the skilled nurse (SN) visits: once per week for nine weeks (1WK9). On 2/1/24, the number of SN visits was increased from once per week to twice per week. A review of patient 13's visit calendar revealed that one of the two proposed SN visits did not occur during week 9 (from 2/25/24 to 2/27/24). The coordination notes made no mention of the missed SN visit. This was validated with the DPCS. During a review of the hospice's policy and procedure (P&P) titled "Missed Visits" revised 11/2013, the P&P indicated, "...If a visit is missed and not rescheduled the clinician will document in the patients clinical record the reason for the missed visit..." 5. During a concurrent record review and interview with the hospice agencys (HAs) director of patient care services (DPCS) on 10/1/24, at 4:43 PM, patient 10s plan of care (POC) and clinical record (CR) for the certification period from 6/25/24 to 9/22/24 were reviewed. The POC included the frequency of skilled nurse (SN) visits: twice per week for thirteen weeks (2WK13). A review of patient 10's visit calendar for week 7 from 8/4/24 to 8/10/24 indicated that one of two SN visits did not occur. There was no explanation in patient 10s CR ";coordination notes" as to why one of two SN visits was missed, when the provider was notified of the missing visit, or whether the visit frequency was changed, and re-scheduled. The reason for the one missed skilled nurse visit in week 7 was not discussed at the interdisciplinary group (IDG) meeting on 8/14/24. This finding was validated by the DPCS. During a review of the hospice agency's policy and procedure (P&P) titled "Missed Visits" revised 11/2013, the P&P indicated, "...Missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record..." 6. During a review of the hospice agency's policy and procedure (P&P) titled "Missed Visits" revised 11/2013, the P&P indicated, "...Missed visits will be documented in the clinical record..." 7. During a review of Patient 15s, ";Hospice Certification and Plan of Care (POC – maps out the needs and services given to a patient facing a terminal illness, as well as the patients family/caregiver)," for the certification period of 11/11/23 – 2/8/24, the POC indicated in part the visit order, ";Frequency/Duration of Visits... HHA effective 11/12/23 2WK13 (home health/hospice aide to conduct home visit two times a week for 13 weeks, effective 11/12/23). During a review of Patient 15s, ";Hospice Physician Order," dated 11/28/23, the order indicated, ";Order Description... CHHA 3x weekly (certified home health/hospice aide three times weekly) ... Service Changes, Calendar Frequency... HHA Effective 11/26/23 3WK10, 2WK1 (home health/hospice aide to conduct home visit three times a week for 10 weeks, then two times a week for one week thereafter, effective 11/26/23)." During a review of Patient 15s, ";Client Calendar Report (CCR – documentation of completed home visits categorized by visit date, begin/end time of visit, service/discipline, and worker/employee name and telephone number)," for the certification period of 11/12/23 – 2/8/24, the CCR indicated Patient 15 missed one (1) HHA visit each for the weeks of 11/19/23 and 11/26/23 respectively, totaling two (2) missed HHA visits. During a concurrent interview and record review, on 10/1/24 at 2:25 p.m., with the agencys Director of Patient Care Services (DPCS), Patient 15s, ";Electronic Medical Record (EMR)," was reviewed. DPCS verbalized that physician orders for new home visits or modification of current home visit orders will be reflected on the patients POC after the order is entered in the EMR. For completed home visits, DPCS verbalized that staff documented them under the ";Visit Notes" section of the EMR and a summary of the completed visits can be generated under the CCR. For missed visits, DPCS verbalized that staff documented them under the ";Coordination Notes" section of the EMR. A comparative review of Patient 15s HHA visit notes and coordination notes, for the certification period of 11/11/23 – 2/8/24, identified two (2) HHA visits, either completed or missed, not documented in the EMR, one (1) visit each week for the weeks of 11/19/23 and 11/26/23 respectively. DPCS verbalized that HHA staff should have documented in Patient 15s EMR regardless of whether a home visit was completed or missed. During a review of the agencys policy & procedures (P&P), titled, ";Missed Visits," revised 11/2018, the P&P indicated in part, ";POLICY... Missed visits will be documented in the medical record. A missed visit will be rescheduled the same week as possible. Missed visits will be documented in the clinical record." The P&P indicated further, ";PROCEDURES... 2) If a visit is missed and not rescheduled, the clinician will: a) Notify the interdisciplinary group (IDG – a group of healthcare professionals with various areas of expertise who work together toward the goals of their clients) and the clinical supervisor of the missed visit and reason for missed visit; b) Document in the patients clinical record the following information: 1) Patients name, 2) Date and type of visit that was missed, 3) Reason for the missed visit...." During a review of the agency's P&P, titled "Entries into the Clinical Record," revised 11/2018, the P&P indicated in part, "POLICY. . . Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided." The P&P indicated further, "PROCEDURE ... 1) A clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies found in this manual, and will include at a minimum: ... J) Reasons for interruptions in the provision of care and services ...."

Based on interview and record review, the hospice agency (HA) failed to ensure that missed chaplain services were rescheduled for two of 20 patients (Patients 13 and 5). This failure had the potential to deprive patients (facing end of life) and their families of a critical component of high-quality patient-centered hospice care. --- 1. During a concurrent interview and record review on 10/1/24 at 4:42 p.m. with the director of patient care services (DPCS), Patient 13s plan of care (POC) and clinical record (CR) for the certification period 12/30/23 to 02/27/24 was reviewed. The POC indicated, chaplain visits: once per month for two months (1M2) effective 01/01/24. A review of Patient 13's visit calendar indicated, the chaplain visit did not occur the month of January. A review of Patient 13s CR ";Coordination Notes," dated 1/31/24 indicated, the chaplain missed the visit due to ";run out of time". The DPCS confirmed the chaplain visit was not made due to the chaplain having run out of time. 2. During a concurrent interview and record review on 10/1/24 at 4:47 p.m. with the DPCS, Patient 5s plan of care (POC) and clinical record (CR) for the certification period 5/15/24 to 8/12/24 was reviewed. The POC indicated, chaplain visits: once per month for three months (1M3) effective 6/1/24. A review of Patient 5's visit calendar indicated, the chaplain visit did not occur the month of August. A review of Patient 5s CR ";Coordination Notes" dated 8/8/24 indicated, the chaplain missed the scheduled visit because ";the daughter requested the SC (spiritual counselor) to come another time." There was no evidence another visit was scheduled to accommodate the daughters request. The DPCS confirmed the chaplain visit was not rescheduled. During a review of the agency's policy and procedure (P&P) titled, "Missed Visits," revised 11/2013, the P&P indicated, "...A missed visit will be rescheduled the same week if possible..."

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that the organization did not ensure that the plan of care was revised when the patient’s condition changed. For example, during a review of the medical record for RR#4, it was noted that the patient experienced 2 falls during week 3 of services and 1 fall during week 4 of services. One of the falls during week 3 was a fall with skin tear injury to left shin. The fall during week 4 was a fall with skin tear injury to right arm. The plan of care was not updated with interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. This observation was reviewed with the Director of Patient Care Services.