Every finding on record at Camino Hospice Corporation

Based on record review and interview the hospice interdisciplinary team failed to update the comprehensive assessment for 3 of 14 patients (Patient #4, #5 and #6) for which records were reviewed. The IDG failed to update the patient care plans and discontinue orders for SC visits after these patients declined spiritual care/counseling services. Failure to ensure patient records were updated caused valuable patient information to not be available to the IDT so that they could make informed decisions regarding care and services for each patient. --- Findings include: Record review for Patient #4 revealed a start of care date of 10/25/2024 with a terminal diagnosis of Heart Failure. Review of the plan of care for the time period 01/23/2025 – 04/22/2025 revealed orders: revealed spiritual counseling services- 1M4 (once per month for 4 months) + prn (as needed). Review of the initial SC assessment dated 11/11/2024 indicated SC visits were declined. The IDG failed to update the plan of care and discontinue SC services. Record review for Patient #5 revealed a start of care date of 06/04/2024 with a terminal diagnosis of heart disease. Review of the plan of care for the time period 01/30/2025 – 03/12/2025 revealed orders: spiritual counseling services- 1M3 (once per month for 3 months) + prn. Review of a communication note dated 06/05/2024 read, ";Patient declined SC since initial admission per our nurse admission report". The document was signed by the Chaplain. Record review for Patient #6 revealed a start of care date of 04/22/2024 with a terminal diagnosis of Senile Degeneration of the Brain. This disease causes a decline in memory, thinking and reasoning. Review of the plan of care for the time period 01/30/2025 – 03/12/2025 revealed orders: spiritual counseling services- 1M3 (once per month for 3 months) + prn. Review of a care coordination note dated 07/01/2024 read, ";After several attempts to reach out to (family member) and primary caregiver, she sent to me a text message stating that she does not want spiritual care for (patient) because she does not need it". The document was signed by the Chaplain. The Administrator was interviewed on 03/12/2025 at 10:33 AM. Clinical records for Patients #3, #4 and #5 were reviewed. Administrator confirmed spiritual care services were declined although there were active orders for visits once per month and prn. Surveyor asked if spiritual care services were reviewed during IDG meetings. Administrator stated, ";Yes. We were aware spiritual care was declined." Surveyor asked why the orders for SC visits were not discontinued by the IDG. Administrator stated, ";We were told by previous surveyors we should leave it on the plan of care and continue to encourage patients to accept spiritual care services." Administrator acknowledged spiritual care orders should have been discontinued, and the plan of care should have been updated. Surveyor conducted a telephone interview on 03/18/2025 at 12:40 PM with the agency Chaplain. Surveyor reviewed the clinical records for Patients #3, #4 and #5 with Chaplain. Chaplain confirmed spiritual care services were declined by each patient or a family member. Surveyor asked if these patients were discussed during IDG meetings. Chaplain stated yes. Surveyor asked if IDG was informed spiritual care services were declined. Chaplain stated ";Once the patient (patient) or family declined the IDG was notified usually by coordination note. We dont really discuss it after that." Surveyor asked if the chaplain was aware the patients had active orders for spiritual care visits monthly and prn. Chaplain stated he was not aware there were active orders. Surveyor asked who would be responsible for obtaining an order to discontinue spiritual care visits. Chaplain stated the doctor or nurse would do that. Review of the agencys policy and procedure manual revealed a policy titled, ";INTERDISCIPLINARY GROUP (IDG) ASSESSMENT AND PLAN OF CARE, REFERENCE #1903, (no revision date), which read ";The hospice IDG is responsible for developing and maintaining a system of communication, coordination and integration of services that the plan of care is reviewed and updated no less frequently than every 15 calendar days. The interdisciplinary group reviews the plan of care regularly."

Based on record review and interviews the agency failed to ensure clinical records included documentation of a plan of care for 2 of 14 records (Patient #9 and #14) for which records were reviewed. The clinical record for Patient #9 did not include a plan of care for the certification period 12/31/2024 – 02/28/2025. The clinical record for Patient #14 did not include a plan of care for the certification period 01/02/2025 – 02/18/2025. Failure to ensure patient records were completely and accurately documented, organized and readily accessible, caused valuable patient information to not be available to the IDT so that they could make informed decisions regarding care and services for these patients. --- Findings Included: Review of the clinical record for Patient #9 revealed a start of care date of 03/06/2024. Review of the certification period 12/31/2024 – 02/28/2025 revealed no documentation of a plan of care. Review of the clinical record for Patient #14 revealed a start of care of 09/04/2024. Review of the certification period 01/02/2025 – 02/18/2025 revealed no documentation of a plan of care. An interview was conducted with the AA/SN on 03/13/2025 at 1:00 PM. Surveyor reviewed the clinical records for Patients #9 and #14 and documentation of plan of care was requested for review. AA/SN stated there is a ";glitch" in the EMR software that will only allow care plans to be created during the last 5 days of a certification period. If the care plan is created after the 5 days, the date automatically inserts the dates of the next certification period. Surveyor asked if the agency can correct the dates. AA/SN stated no. AA/SN stated the agency has notified the software provider, but the issue has not been fixed yet. Review of the agencys policy and procedure manual revealed a policy titled, ";CONTENT OF THE CLINICAL RECORD, REFERENCE #10001, (no revision date) which read, ";The clinical record shall contain sufficient information to identify the patient, describe patient problems/needs, justify care, treatment and services, accurately document care, treatment and/or service provided and results in detail and facilitate continuity of care among hospice interdisciplinary group members and contract staff. The minimum content of the clinical record includes: Plan of care".