Every finding on record at Caring Hands Hospice

Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 418.56, INTERDISCIPLINARY GROUP, CARE PLANNING AND COORDINATION OF SERVICES was out of compliance. A recertification survey initiated on 3/7/22, revealed a pattern of failures in regard to the hospice ensuring the interdisciplinary group (IDG) maintained responsibility for directing and coordinating all aspects of care and services provided by the hospice. Additionally, the hospice failed to provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services were provided directly or under arrangement. Further review revealed the hospice failed to develop an individualized written plan of care for each patient, reflective of patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments, including all services necessary for the palliation and management of the terminal illness and related conditions. The hospice failed to ensure the IDG revised the plan of care based on the patient's updated comprehensive assessments and failed to note the patient's progress towards outcomes and goals specified in the plan of care. The hospice failed to ensure each patient's plan of care included a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs and the hospice failed to ensure care and services were provided in accordance with the plan of care for all patients who received hospice services. These failures had the potential to affect all patients served by the hospice. L538- Based on interview and record review, the IDG failed to ensure each patient's plan of care included the specific hospice care and services necessary to address the patient's needs for 4 of the 10 discharge records reviewed (Patient #3, #6, #8 and #9). L541- Based on interview and record review, the hospice systemically failed to ensure the interdisciplinary group (IDG) included all required individuals, specifically the medical social worker (MSW) and chaplain, for all IDG meetings for 9 of 9 patient records reviewed who had IDG meetings (Patients #1, #2, #3, #4, #5, #6, #7, #9, and #10). L543- Based on interview and record review, the hospice failed to ensure services were provided in accordance with the individualized written plan of care established by the hospice IDG in collaboration with the attending physician for 4 of 10 discharged patient records reviewed (Patient #1, #3, #5, and #9). L545- Based on interview and record review, the hospice failed to develop an individualized written plan of care for each patient, reflective of patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments, including all services necessary for the palliation and management of the terminal illness and related conditions. This failure affected 5 of 10 discharged patients whose records were reviewed (Patients #2, #3, #5, #9 and #10). L552- Based on interview and record review, the hospice failed to ensure the IDG, in collaboration with the attending physician, reviewed, revised, and documented the plan of care as frequently as the patient's condition required, but no less than every 15 days for 3 of 11 patient records reviewed (Patients #5, #6, and #11).

Based on interview and record review, the interdisciplinary group (IDG) failed to ensure each patient's plan of care included the specific hospice care and services necessary to address the patient's needs for 4 of the 10 discharge records reviewed (Patient #3, #6, #8 and #9). Findings include: AGENCY POLICY According to the undated agency policy titled, Physician Orders and Plan of Care, (read in pertinent parts): "Diagnostic and therapeutic orders will be obtained from the attending physician, [or designated], according to Hospice policy and applicable law and regulation." "The contents of the orders (Plan of Care) will include: -The patient's diagnosis; -A description of the treatment and/or procedure to be done, including, when appropriate, the type, frequency and duration; -Who is to perform the treatment or procedure; - A description of equipment, if any, necessary in the provision of care; - A description of current medication, including name, dose, frequency and route of each medication; A description of any medical, physical, psychosocial or environmental precautions or limitations that affect the implementation of the Plan of Care. All diagnostic and therapeutic orders, including verbal orders, will be signed by the physician and incorporated into the clinical record in a timely manner. The Plan of Care will be reviewed orally and in writing with the physician as often as necessary, but at least each certification period or as the patient's condition warrants." 1. The clinical record for Patient #3 was reviewed on 3/7/22. The patient was admitted for hospice care and services on 12/14/20 with a terminal diagnosis of senile degeneration of the brain. The plan of care for the certification period dated 12/14/20 to 3/13/21 included orders for skilled nurse (SN) visits three times a week for thirteen weeks; medical social worker (MSW) visits zero times for the first week and one time a week for one week; volunteer coordinator visits as needed (PRN); and home health aide (HHA) visits two times a week for a week and three times a week for 12 weeks. a) The IDG failed to include specific orders regarding the care and treatment of Patient # 3's stage two right ankle wound, stage two right hip wound and stage one right upper back wound discovered during Patient #3's initial comprehensive assessment SN visit, completed by registered nurse (RN) #4, and listed as diagnoses on the plan of care for the certification period dated 12/14/20 to 3/13/21. Further review of the plan of care for the certification period dated 12/14/20 to 3/13/21 included standing SN orders which included the following wound care order: "Apply moisture barrier cream of choice, such as baza or Calazime to reddened areas as needed to prevent further skin breakdown. For stage II or greater pressure ulcers or any open areas, contact hospice nurse for instruction." The plan of care failed to have any further specific wound care orders for Patient #3's stage II wounds. Review of verbal orders for Patient #3 dated 12/14/21 to 1/25/21 failed to show any additional wound care orders for Patient #3. Review of communication notes during this period, failed to show any RN's communicated with a physician to receive wound care orders. Review of the SN comprehensive assessment visit dated 12/14/20, completed by RN #4 revealed RN #4 performed the following wound care for Patient #3's stage II right ankle wound: cleaned with normal saline (NS), filled with hydrophilic paste (a paste used for light to moderate levels of wound drainage), covered with maxorb extra AG (a type of wound dressing used for moderately to heavily draining wounds which contains alginate) and secured with optifoam dressing (a foam dressing that has a silicone adhesive border). For Patient #3's stage II right hip wound, RN #4 cleaned the wound with NS, filled it with medihoney (a wound and burn gel which contains antibacterial and bacterial resistant properties), covered it with maxorb extra AG and secured the maxorb with an optifoam dressing. For Patient #3's stage I right back of shoulder wound, RN #4 documented she covered the wound with optifoam for pressure offloading. RN #4 failed to follow the standing orders for stage I wound care for Patient #3's stage I right back of shoulder wound and failed to obtain orders from an medical doctor (MD) for the wound care she provided to Patient #3's stage II right ankle and right hip wounds. Review of the SN note dated 12/15/20, completed by RN #5, revealed RN #5 performed wound care on three wounds for Patient #3. RN #5 identified a sacral wound on Patient #3 that RN #5 described as a friction/shearing wound which RN #5 cleaned the wound (she did not state what she cleaned the wound with), applied Triad cream (brand name for hydrophilic paste) and covered the wound with a foam dressing. On Patient #3's hip wound, which RN #5 staged as a II to III pressure ulcer and did not indicate if it was on Patient#3's left or right hip, RN #5 cleaned the wound with water, patted the wound dry, applied Triad cream and covered the wound with an adhesive foam dressing. On Patient #3's ankle ulcer, which RN #5 did not stage and identified as being on Patient #3's left ankle, RN #5 documented she continued the dressing from Patient #3's start of care and cleaned the wound, patted it dry, applied medihoney and covered the wound with a foam dressing. RN #5 failed to obtain orders from an MD for the wound care she provided to Patient #3's, sacral, hip and ankle wounds. Review of the SN note dated 12/16/20, completed by RN #6, revealed RN #6 performed the following wound care for Patient #3: RN #6 identified Patient #3's left ankle wound as a Venous Stasis ulcer and documented she cleaned the wound with NS, applied Triad and covered the wound with Optifoam secured with Mefix tape; and to Patient #3's right ankle wound, which RN #6 identified as a Venous Stasis ulcer, she documented she cleaned the wound with NS, applied Triad and covered the wound with Optifoam and Mefix tape. RN #6 failed to obtain orders from an MD for the wound care she provided to Patient #3 right and left ankle wounds. Review of the SN note dated 12/17/20, completed by RN #5, revealed RN #5 identified Patient #3 to have stage III pressure ulcers to her right ankle, hip and sacrum. RN #5 documented she did not perform wound care to Patient #3's hip or sacral wound as the dressing were intact. RN #5 documented she cleansed Patient #3's right ankle ulcer with wound wash, patted the wound dry, applied alginate, covered the wound with Duoderm (a type of dressing used to control drainage) and covered the dressing stockinet (a seamless knit cotton tubular bandage). RN #5 failed to obtain orders from an MD for the wound care she provided to Patient #3's right ankle wound. Review of the SN note dated 12/19/20, completed by RN #5 for a visit that occurred from 9:59 a.m. to 10:59 a.m., showed RN #5 documented she changed the dressing for the stage III pressure ulcers on Patient #3's right ankle, sacrum, and right hip. RN#5 did not document the specific wound care she provided at this visit. RN #5 failed to obtain orders from an MD for the wound care she provided to Patient #3's three wounds. Review of the SN note dated 12/19/20, completed by RN #5 for a visit that occurred from 8:12 p.m. to 8:49 p.m., showed RN #5 documented she changed the dressing on Patient #3's sacral wound. RN #5 did not document the specific wound care she provided at this visit. RN #5 failed to obtain an order from and MD for the wound care she provided to Patient #3's sacral wound. During an interview on 3/9/22 at 1:30 p.m., the interim administrator stated Patient #3 was a patient of the wound care clinic in town. The interim administrator stated the hospice physicians did not manage the hospice patient wounds and all patients with wounds were referred to the wound care clinic for care and the hospice nurses received orders from the wound care clinic for their hospice patients. The interim administrator stated Patient #3's chart should have contained orders for her wound care. The interim administrator, after reviewing Patient #3's chart, acknowledged Patient #3's chart did not contain any wound care orders until her first IDG review and plan of care update that occurred on 12/21/20. b) The agency failed to ensure the RN received a physician order prior to inserting a Foley catheter into Patient #3. Review Patient #3's, plan of care, verbal orders and communication notes revealed Patient #3 had an order as part of the agency's standing physician orders if a patient had a Foley catheter to irrigate it with 30-60 cc sterile water as needed to maintain patency and prevent obstruction. There were no further orders or discussion in communication notes/ IDG reviews regarding RN #5 seeking orders to insert a Foley catheter for Patient #3. Review of SN note dated 12/15/20, completed by RN #5, showed RN #5 inserted a #16 French indwelling Foley catheter placed with 5 ml balloon into Patient #3 and attached the Foley to 1000 ml collection bag to a leg strap. Review of SN note dated 12/17/20, completed by RN #5, showed RN #5 adjusted Patient #3's leg strap to secure the Foley catheter so it was not pulling or causing Patient #3 discomfort. Review of SN note dated 12/19/20 for a visit that occurred from 9:59 a.m to 10:59 a.m., completed by RN #5, showed Patient #3 had pulled out her indwelling catheter. RN #5 replaced Patient #3's indwelling Foley catheter using a #16 indwelling catheter with 5 ml balloon connected to a large collection bag. RN #5 stated she brought Patient #3 long soft pajamas and large knit soft tights to wear, with instructions for ALR staff to feed tubing of catheter through the pants to attempt to reduce Patient #3 from pulling on the tubing. Review of SN note dated 12/19/20 for a visit that occurred from 8:12 p.m. to 8:49 p.m., completed by RN #5, showed RN #5 was asked to come assess Patient #3 as she had been holding her lower abdomen in pain. When RN #5 arrived to Patient #3's ALR, Patient #3 was calm in bed with her clothing and chux wet with urine. Patient #3 had pulled out her indwelling Foley catheter for a second time that day. RN #5 instructed due to Patient #3 not tolerating the Foley catheter she would not reinsert it. Review Patient #3's orders and communication notes revealed Patient #3 had an order as part of the agency's standing physician orders that if a patient had a Foley catheter to irrigate it with 30-60 cc sterile water as needed to maintain patency and prevent obstruction. There were no further orders or discussion in communication notes/ IDG reviews regarding RN #5 seeking orders to insert a Foley catheter for Patient #3. During an interview on 3/9/22 at 1:10 p.m., the interim administrator acknowledged Patient #3 did not have a physician order for inserting a Foley catheter. 2. The clinical record for Patient #9 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 9/10/20 with a terminal diagnosis of malignant neoplasm of the bronchus or lung. The plan of care for the the certification period dated 12/9/20 to 3/8/21 included orders for SN visits one time a week for 13 weeks, one time a week for one week and 13 PRN visits; and MSW visits one time a month for three months and four PRN visits. a) The hospice IDG failed to ensure the RN was given orders for the application of UNNA Boots (a compressive dressing used in the treatment of venous stasis ulcers- similar to a cast, applied wet and dries similar to a cast but allows for unrestricted motion of the ankle joint) on Patient #9's lower legs. Review of SN note dated 1/5/21, completed by RN #5 from 11:03 a.m. to 6:15 p.m., showed RN #5 assessed Patient #9 to have had a decline in neurological function. RN #5 wrapped both of Patient #9's legs with UNNA Boots with two layer compression wraps due to Patient #9 having 3+ edema (when you put push on someone's skin and it indents 5-6 mm and takes up to 30 seconds to rebound) and weeping tissue on Patient #9's right foot to prevent infection. Review of communication notes and orders for Patient #9 failed to show RN #5 communicated with a physician or received orders to apply UNNA Boots to Patient #9. During an interview on 3/9/22 at 2:52 p.m., the interim administrator stated RN #5 no longer worked for the hospice. The interim administrator reviewed the orders for Patient #9 and stated there were no orders in Patient #9's EMR directing RN #5 to apply UNNA Boots to both of Patient #9's lower legs. 3. The clinical record for Patient #6 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 4/8/21 with a terminal diagnosis of chronic obstructive pulmonary disease with acute exacerbation. The plan of care for the certification period dated 4/8/21 to 7/6/21 included orders for SN visits one time a week for one week, then two times a week for 12 weeks and 13 PRN visits; physical therapy (PT) visit one time a week for one week; occupational therapy (OT) visit one time a week for one week, MSW visits one time a month for three months and three PRN visits, and HHA visits zero visits for one week, four times a week for one week, five times a week for 11 weeks and two times a week for one week. a) The agency failed to ensure the RN received a physician order prior to inserting a foley catheter for Patient #6. Review of SN note dated 5/13/21, for a visit completed from 9:15 a.m. to 9:35 a.m. by RN #4, showed RN #4 assessed Patient #6 to be in the transitional phase of dying and incontinent of urine. RN #4 discussed the possibility of inserting a Foley catheter for Patient #6 for her comfort, with Patient #6 and her family. Review of SN note dated 5/13/21, for a visit completed from 3:00 p.m. to 4:40 p.m. by RN #4, showed RN #4 inserted a 16 French Foley catheter with 5 cc of water in the balloon into Patient #6 and Patient #6 had 500 cc of output upon insertion. Review Patient #6's orders and communication notes revealed Patient #6 had an order as part of the agency's standing physician orders if a patient had a Foley catheter to irrigate it with 30-60 cc sterile water as needed to maintain patency and prevent obstruction. There were no further orders or discussion in communication notes regarding RN #4 seeking orders to insert a Foley catheter for Patient #6. During an interview on 3/9/22 at 2:34 p.m., the interim administrator stated she had received a verbal order for the insertion of the Foley catheter for Patient #6, but she forgot to document the verbal order. 4. The clinical record for Patient #8 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 3/4/21 with a terminal diagnosis of Parkinson's disease. The plan of care for the certification period dated 3/4/21 to 6/1/21 included orders for SN visits once weekly for 14 weeks, with 16 PRN visits; MSW visits zero visits for one week, one visit for a week and four PRN visits. a) The agency failed to ensure the RN received a physician order prior to inserting a foley catheter for Patient #8. Review of SN visit noted dated 3/8/21, completed by RN #4, showed RN #4 documented there was concern Patient #8 was holding her urine. RN #4 inserted a Foley catheter (no information provided on size of Foley or amount of water in balloon) to reduce discomfort associated with turning and changing the patient. Review of communication notes and orders in Patient #8's EMR and paper record failed to show RN #4 communicated with and/or received an order to insert a Foley catheter for Patient #8. During an interview on 3/9/22 at 2:41 p.m. the interim administrator stated she thought the hospice standing orders had an order for Foley catheter insertion. The interim administrator reviewed the standing hospice order and acknowledged the standing hospice orders failed to have an order for Foley insertion at RN discretion as she thought they did. The interim administrator stated the attending physicians and hospice medical director had instructed the hospice RN's to use their clinical judgment to decide if a patient needed a Foley catheter inserted and would not be pleased if the RN called them every time they wanted to insert a Foley catheter into a patient.

Based on interview and record review, the hospice systemically failed to ensure the interdisciplinary group (IDG) included all required individuals, specifically the medical social worker (MSW) and chaplain, for all IDG meetings for 9 of 9 patient records reviewed who had IDG meetings (Patients #1, #2,, #3, #4, #5, #6, #7, #9, and #10). Findings Include: AGENCY POLICY According to the undated agency policy titled, Interdisciplinary Team Meeting, (read in pertinent parts): "The Team meets bi-monthly. The Team discusses updates to the Plan of Care, changes in the patient, family or caregiver circumstances, death of patients and bereavement actions." "The Hospice Medical Director and other Team members are present, including volunteers, and attending physicians. Hospice informs clinical personnel of the meetings and the schedule. Attendance is open to patients, families or caregivers regarding their care only. All other patient discussions are confidential." "Those present at the Team meeting sign the Attendance Form." According to the undated agency policy titled, Interdisciplinary Team (IDT) Assessment and Plan of Care, (read in pertinent parts): "The interdisciplinary team (IDT) is composed of, but not limited to, Hospice physician (employee of or under contract with the Hospice), Hospice RN, social worker (and designee) and pastoral or other counselor." "It is not permissible for either the attending physician or the Hospice Medical Director to provide the sole guidance for the plan of care. The law and regulations require that it be the combined work of the IDT." 1. During an interview on 3/7/22 at 12:09 p.m., the chief clinical officer stated the members of the IDG were the hospice administrator, nurses, home health aides (HHA), hospice medical director, social worker, and chaplain. During an interview on 3/7/22 at 1:22 p.m., the chief clinical officer for the hospital associated with the hospice, stated the hospice had two chaplains. They used a Catholic deacon and a non-Catholic chaplain. During an interview on 3/7/22 at 2:47 p.m., the interim administrator stated the IDG meetings were held every other Wednesday. The interim administrator stated that the personnel who typically were a part of the IDG meetings were the hospice medical director, the administrator, the social worker, the RN caring for the patient if he/she could make it and the HHA caring for the patient if they had one. The interim administrator stated the participants of the IDG for each patient would sign an attendance sheet and this form would be found in each patient's electronic medical record (EMR). The IDG participants would update the patient's plan of care at each meeting and the updated plan of care was signed by the hospice medical director and then was scanned into the patient's EMR. During continued interview, the interim administrator stated she took over as the interim administrator in January 2021 and since she had been the interim administrator the IDG meeting had been attended by the interim administrator, who also was the RN providing care to the patients, and the hospice medical director. The interim administrator stated the licensed clinical social worker (LCSW), who was an external LCSW who provided social work services for hospice patients, had not attended any of the IDG meetings as she was on maternity leave. During an interview on 3/7/22 at 3:35 p.m., the external LCSW stated she usually attended IDG meetings for hospice patients and when she attended, she signed the attendance form. She stated she was out on maternity leave for three months and returned from maternity leave approximately a month ago. During an interview on 3/8/22 at 1:34 p.m., the interim administrator stated when the external LCSW was on maternity leave, the hospice did not have another social worker to provide social services to their patients. The interim administrator also stated the hospice did not have any chaplains contracted to provide services to patients and the chaplains did not attend IDG meetings. She stated patients received spiritual care from their own pastors/priests and the hospice in the past could reach out to the Catholic deacon and non-Catholic chaplain, but neither of these people were official members of the hospice IDG team. During an interview on 3/9/22 at 1:24 p.m., the external LCSW stated that before her maternity leave, she did her best to attend IDG meetings and if she attended, she would have signed the IDG meeting attendance sheet. She stated in 2021 there were many IDG meetings she could not attend due to other work obligations. She stated if she was unable to attend but a hospice patient or their family had a social work need, another member of the IDG would communicate this need to her so she could address the patient/family need(s). 2. The clinical record for Patient #9 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 9/10/20 with a terminal diagnosis of malignant neoplasm of the bronchus or lung. The plan of care for the certification period 9/10/20 to 12/8/20 included orders for skilled nurse (SN) visits one time a week for a week, no visit for two weeks, one time a week for a week, no visit for a week, then one time a week for five weeks (however there were conflicting orders of SN for one time a week for a week, no visits for two weeks, one time a week for a week, no visits for two weeks and then weekly visits following the previous orders); and MSW visits six as needed (PRN) visits. Subsequent plan of care orders for the certification period dated 12/9/20 to 3/8/21 included orders for SN visits one time a week for 13 weeks, one time a week for a week and 13 PRN visits; and MSW visits one time a month for three months and four PRN visits. a) The hospice failed to ensure a social worker and chaplain participated in all IDG meetings for Patient #9 and contributed to Patient #9's comprehensive and ongoing assessments and care planning process. Review of the IDG meeting sign-in sheets and IDG updated plans of care for Patient #9 for the meetings dated 9/22/20, 10/7/20, 10/19/20, 11/3/20, 11/13/20, 11/23/20, 12/8/20, 12/21/20, 1/4/21 and 1/16/21 revealed no signature from a social worker or chaplain as being in attendance for any of these ten IDG meetings. 3. The clinical record for Patient #5 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 4/20/20, with a terminal diagnosis of malignant neoplasm of unspecified part of the right bronchus or lung. The plan of care orders for the certification period dated 10/17/20 to 12/15/20 included SN visits for no visits the first week, then one visit a week for nine weeks with six PRN visits and home health aide (HHA) visits for no visits the first week the two visits a week for eight weeks, then one visit a week with six PRN visits. Subsequent plan of care orders for the certification period dated 12/16/20 to 2/23/21 included orders for SN visits for no visit the first week, then one visit a week for eight weeks with eight PRN visits, HHA visits one time a week for a week then two times a week for eight weeks with three PRN visits and MSW visits one time a month for two months. a) The hospice failed to ensure a social worker and chaplain participated in all IDG meetings for Patient #5 and contributed to Patient #5's comprehensive and ongoing assessments and care planning process. Review of IDG meeting sign-in sheets for the meetings and IDG updated plans of care dated 11/3/20, 11/13/20, 11/23/20, 12/8/20, 12/23/20, 1/6/21, 1/18/21 and 2/3/21 revealed no signature from a social worker or chaplain as being in attendance for any of these eight IDG meetings. 4. The clinical record for Patient #1 was reviewed on 3/7/22. The patient was admitted for hospice care and services on 11/24/20 with a terminal diagnosis of senile degeneration of the brain. The plan of care for the certification period dated 5/23/21 to 7/2121 included orders for SN visits one time a week every other week for nine weeks and five 5 PRN visits, and MSW visits one time a month for two months. Subsequent Plan of Care orders for the certification period dated 7/22/21 to 9/19/21 included orders for SN visits one time a week for nine weeks and nine PRN visits; and MSW visits three PRN visits. a) The hospice failed to ensure a social worker and chaplain participated in all IDG meetings for Patient #1 and contributed to Patient #1's comprehensive and ongoing assessments and care planning process. Review of the IDG meeting sign-in sheets and IDG updated plans of care for Patient #1 for the meetings dated 5/26/21, 6/8/21, 6/23/21, 7/7/21, and 7/20/21 revealed no signature from a social worker or chaplain as being in attendance for any of these five IDG meetings. 5. The clinical record for Patient #2 was reviewed on 3/7/22. The patient was admitted for hospice care and services on 5/19/21, with a terminal diagnosis of Alzheimer's disease. The plan of care orders for the certification period dated 5/19/21 to 8/16/21 included orders for SN visits twice the first week then three times a week for 12 weeks and 12 PRN; and HHA services once the first week, then three times a week for 12 weeks and 12 PRN. a) The hospice failed to ensure a social worker and chaplain participated in all IDG meetings for Patient #2 and contributed to Patient #2's comprehensive and ongoing assessments and care planning process. Review of the IDG meeting sign-in sheets and IDG updated plans of care for Patient #2 for the meetings dated 5/25/21, 6/18/21, 6/23/21, and 7/7/21 revealed no signature from a social worker or chaplain as being in attendance for any of these four IDG meetings. 6. The clinical record for Patient #3 was reviewed on 3/7/22. The patient was admitted for hospice care and services on 12/14/20 with a terminal diagnosis of senile degeneration of the brain. The plan of care for the certification period dated 12/14/20 to 3/13/21 included orders for SN visits three times a week for thirteen weeks; MSW visits zero times for the first week and one time a week for a week; volunteer coordinator visits PRN; and HHA visits two times a week for a week and three times a week for 12 weeks. a) The hospice failed to ensure a social worker and chaplain participated in all IDG meetings for Patient #3 and contributed to Patient #3's comprehensive and ongoing assessments and care planning process. Review of the IDG meeting sign-in sheets and IDG updated plans of acre for Patient #3 for the meetings dated 12/21/20, 1/4/21, 1/6/21, and 1/18/21 revealed no signature from a social worker or chaplain as being in attendance for any of these four IDG meetings. 7. The clinical record for Patient #6 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 4/8/21 with a terminal diagnosis of chronic obstructive pulmonary disease with acute exacerbation. The plan of care for the certification period dated 4/8/21 to 7/6/21 included orders for SN visits one time a week for a week, then two times a week for 12 weeks and 13 PRN visits; physical therapy (PT) visit one time a week for a week; occupational therapy (OT) visit one time a week for one week, MSW visits one time a month for three months and three PRN visits, and HHA visits zero visits for one week, four times a week for one week, five times a week for 11 weeks and two times a week for one week. a) The hospice failed to ensure a social worker and chaplain participated in all IDG meetings for Patient #6 and contributed to Patient #6's comprehensive and ongoing assessments and care planning process. Review of the IDG meeting sign-in sheets and IDG updated plans of care for Patient #6 for the meetings dated 4/27/21 and 5/11/21 revealed no signature from a social worker or chaplain as being in attendance for either of these two IDG meetings. 8. The clinical record for Patient #4 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 8/16/21, with a terminal diagnosis of malignant neoplasm of the peritoneum. The plan of care for the certification period dated 8/16/21 to 10/15/21 included orders for SN visits five times for one week and MSW once every two months. Patient #4 expired on 8/18/21. a) The hospice failed to ensure a social worker and chaplain participated in the IDG meeting for Patient #4 and contributed to Patient #4's comprehensive and ongoing assessments and care planning process. Review of the IDG meeting sign-in sheets and IDG updated plan of Care for Patient #4 for the meeting dated 8/20/21 revealed no signature from a social worker or chaplain as being in attendance for the IDG meeting. 9. The clinical record for Patient #7 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 3/3/21, with a terminal diagnosis of malignant neoplasm of the right kidney. The plan of care for the certification period dated 3/3/21 to 5/31/21 included orders for SN visits two times the first week, then once a week for eight weeks; MSW visits one time the first week then six PRN; and HHA services once the first week, then twice a week for seven weeks and eight PRN. a) The hospice failed to ensure a social worker and chaplain participated in the IDG meeting for Patient #7 and contributed to Patient #7's comprehensive and ongoing assessments and care planning process. Review of the IDG meeting sign-in sheets and IDG updated plan care for Patient #7 for the meeting dated 3/16/21 revealed no signature from a social worker or chaplain as being in attendance for the IDT meeting. 10. The clinical record for Patient #10 was reviewed on 3/9/22. The patient was admitted for hospice care services on 1/15/21 with a terminal diagnosis of malignant neoplasm of the brain. The plan of care for the certification period 1/15/21 to 4/14/21 included orders for SN visits one time a week for four weeks and eight PRN visits; MSW visits zero visits for the first week, then one time a week for a week; and HHA visits zero visits for the first week and two times a week for three weeks with eight PRN visits. Patient #10 expired on 1/21/21. a) The hospice failed to ensure a social worker and chaplain participated in the IDG meeting for Patient #10 and contributed to Patient #10's comprehensive and ongoing assessments and care planning process. Review of the IDG meeting sign-in sheets and IDG updated plan of care for Patient #10 for the meeting dated 1/18/21 revealed no signature from a social worker or chaplain as being in attendance for the IDG meeting.

Based on interview and record review, the hospice failed to ensure services were provided in accordance with the individualized written plan of care established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician for 4 of 10 discharged patient records reviewed (Patient #1, #3, #5, and #9). Findings include: AGENCY POLICY According to an undated agency policy titled, Physician Orders and Plan of Care, (read in pertinent parts): "Diagnostic and therapeutic orders will be obtained from the attending physician, [or designated], according to Hospice policy and applicable law and regulation." "The contents of the orders (Plan of Care) will include: - A description of the treatment and/or procedure to be done, including, when appropriate, the type, frequency and duration; -Who is to perform the treatment or procedure; A description of equipment, if any, necessary in the provision of care; - All diagnostic and therapeutic orders, including verbal orders, will be signed by the physician and incorporated into the clinical record in a timely manner." 1. The clinical record for Patient #3 was reviewed on 3/7/22. The patient was admitted for hospice care and services on 12/14/20 with a terminal diagnosis of senile degeneration of the brain. The plan of care for the certification period dated 12/14/20 to 3/13/21 included orders for skilled nurse (SN) visits three times a week for thirteen weeks; medical social worker (MSW) visits zero times for the first week and one time a week for a week; volunteer coordinator visits as needed (PRN); and home health aide (HHA) visits two times a week for one week and three times a week for 12 weeks. a) The hospice failed to ensure the SN's were following the wound care orders provided for Patient #3 in accordance with Patient #3's individualized written plan of care established by the hospice IDG. Review of the IDG team review updated plans of care dated 12/21/20, 1/4/21 and 1/6/21 , for Patient #3 revealed the following orders for wound care: Medihoney (a wound and burn gel which contains antibacterial and bacterial resistant properties) to right ankle and right hip, cover with maxorb AG (a type of wound dressing used to manage moderately to heavily draining wound which contains alginate) and optifoam (a foam dressing that has a silicone adhesive border) and right scapula cover with optifoam. Review of the SN note dated 12/21/20, completed by RN #6, showed RN #6 cleaned Patient #3's right ankle wound and two right buttocks wounds with normal saline (NS), applied Triad Cream (a cream used to manage light to moderate levels of wound drainage) and covered the wounds with Optifoam dressings. The wound care provided by RN #6 was not in accordance with the physician ordered wound care on the plan of care. Review of the SN note dated 12/24/20, completed by RN #6, showed RN #6 cleaned Patient #3's right ankle wound and right hip area lower buttocks wound with NS, applied Triad cream and covered the wounds with Optifoam and Mefix tape. The wound care provided by RN #6 was not in accordance with the physician ordered wound care on the plan of care. Review of the SN note dated 12/28/20, completed by RN #6, showed RN #6 cleaned Patient #3's right ankle wound with NS and applied Triad cream and covered the wound with an Optifoam dressing and cleaned Patient #3's two right buttocks wounds with NS, then applied Triad cream and covered the wounds with Optifoam dressing and Mefix tape. The wound care provided by RN #6 was not in accordance with the physician ordered wound care on the plan of care. Review of the SN note dated 12/29/21, completed by RN #6, showed RN #6 changed the dressing on Patient #3's buttocks as the dressing had fallen off, no other documentation on wound care was provided for this visit. The wound care provided by RN #6 was not in accordance with the physician ordered wound care on the plan of care. Review of the SN note dated 12/31/20, completed by RN #6, showed RN #6 cleaned Patient #3's right ankle wound with NS and applied Triad cream and covered the wound with an Optilock (a nonadhesive dressing that absorbs fluid) and Mefix tape and cleaned Patient #3's two mid right buttocks wounds with NS and covered them with Maxorb AG, Optilock cast padding and Coban (a self-adherent elastic wrap that functions like a tape, but sticks only to itself). The wound care provided by RN #6 was not in accordance with the physician ordered wound care on the plan of care. Review of the SN note dated 1/1/21, completed by RN #5, showed RN #5 provided wound care for Patient #3's sacral wound. RN #5 cleaned the wound with wound wash, patted it dry, applied [Tricare] paste, covered the wound with white blue back foam dressing and secured the dressing with Medipore tape. The wound care provided by RN #5 was not in accordance with the physician ordered wound care on the plan of care. Review of the SN note dated 1/4/21, completed by RN #6, showed RN #6 cleaned Patient #3's right ankle wound with NS, applied Triad cream and covered the wound with Opitfoam wrapped with rolled gauze and Coban. RN #6 cleaned Patient #3's two right buttocks wounds with NS, applied Triad cream, and covered the wounds with an Optilock dressing adhered with Mefix tape. The wound care provided by RN #6 was not in accordance with the physician ordered wound care on the plan of care. Review of the SN notes dated 1/6/21 and 1/11/21, completed by RN #6, showed RN #6 cleaned Patient #3's right ankle wound with NS, applied Triad cream and covered the wound with Optilock cast padding adhered with Coban. RN #6 cleaned Patient #3's two buttocks wounds with NS, applied Triad cream, and covered the wounds with Optilock dressings adhered with Mefix tape. The wound care provided by RN #6 was not in accordance with the physician ordered wound care on the plan of care. Review of the SN note dated 1/8/21, completed by RN #6, showed RN #6 cleaned Patient #3's right ankle and two right buttocks wounds with NS, applied Triad cream, and covered each of the wounds with an Optilock dressing adhered with Mefix tape. The wound care provided by RN #6 was not in accordance with the physician ordered wound care on the plan of care. Review of verbal orders (VO) and communication notes revealed no evidence RN's #5 and #6 had communicated with or received orders from the physician to change Patient #3's wound care orders. Review of the SN note dated 1/13/21, completed by RN #4, showed RN #4 cleaned Patient's right buttock and right hip wounds with wound wash, applied Medihoney to the wound bed, covered with Maxorb AG and secured with Telfa (non-adherent dressing) and Mefix tape. RN #4 documented that Patient #3's right buttock and right hip wounds persist and Patient # 3's right ankle wound is worse compared to the last time RN #4 observed the wound, 12/14/20. RN #4 placed a call to Patient #3's attending physician and received orders to increase Patient #3's pain medication dosage prior to wound care. RN #4 documented ankle wound care would be discussed in the next IDG meeting with a consult placed to a wound care specialist. There was no evidence in Patient #3's medical record that RN #4 received orders to change Patient #3's wound care to her right buttock and right hip wounds. Review of the SN note dated 1/14/21, completed by RN #4, showed RN #4 cleaned Patient #3's right ankle wound with NS, put iodoform in the wound bed, Maxorb AG, covered with Optifoam and wrapped with cast padding and secured with Coflex (similar to Coban). RN #4 documented she received new orders to increase Patient #3's pre-medicated dose of pain medication prior to wound care. There was no evidence in Patient #3's medical record that RN #4 received orders to change Patient #3's right ankle wound care. Review of SN note dated 1/15/21, completed by licensed practical nurse (LPN) #7, showed LPN #7 cleaned Patient #3's right upper and lower buttocks wounds with NS, applied alginate to wound bed and covered with Optifoam. Review of VOs and communication notes revealed no evidence LPN #7 communicated with or received orders from the physician to change Patient #3's wound care orders. Review of the IDG review updated plan of care dated 1/18/21 for Patient #3 revealed the following orders for wound care: clean right ankle wound with NS, apply Iodosorb (an iodine based dressing which has a variety of mediums and no further specification on which type was listed) to wound bed of right ankle, cover with Maxorb, then foam or island dressing; clean right buttock and hip wounds with NS apply small amount of Therahoney (brand name for a type of medihoney a wound and burn gel which contains antibacterial and bacterial resistant properties), cover with bordered dressing. Review of SN note dated 1/18/21, completed by LPN #7, showed LPN #7 cleaned Patient #3's right ankle wound with NS, applied Iodosorb, covered the wound with Optifoam and secured the dressing with cast padding and Coflex. LPN #7 cleaned Patient #3's upper and lower right buttocks wound with NS, applied alginate to the wound beds and covered them with Optifoam, The wound care provided by LPN #7 was not in accordance with the physician ordered wound care on the plan of care. Review of SN notes dated 1/20/21 and 1/27/21, completed by LPN #7, showed LPN #7 cleaned Patient #3's right ankle with NS, applied Iodosorb and Optifoam and cleaned Patient #3's two buttocks wounds with NS and applied alginate and covered with optifoam. The wound care provided by LPN #7 was not in accordance with the physician ordered wound care on the plan of care. Review of SN note dated 1/22/21, completed by RN #4, showed RN #4 cleaned Patient #3's right ankle wound with NS and Dakins (an antiseptic), filled with Iodosorb, covered with Maxorb and then Optifoam, gently wrapped with Unna (specialized gauze) and 2 layers. The wound care provided by RN #4 was not in accordance with the physician ordered wound care on the plan of care. Review of SN note dated 1/25/21, completed by LPN #7, showed LPN #7 cleaned Patient #3's right ankle wound with NS, applied Iodosorb covered the wound with alginate and Optifoam and secured the dressing loosely with cast padding and Coflex. LPN #7 cleaned Patient #3's upper and lower right buttocks wound with NS applied alginate and Optifoam. The wound care provided by LPN #7 was not in accordance with the physician ordered wound care on the plan of care. Review of the SN note dated 1/29/21, completed by LPN #7, showed LPN #7 cleaned Patient #3's right ankle wound with NS, applied Iodosorb to the wound bed, covered with alginate and Optifoam. LPN #7 cleaned Patient #3's right upper and lower buttocks wounds with NS, applied alginate and Optifoam. The wound care provided by LPN #7 was not in accordance with the physician ordered wound care on the plan of care. Review of VOs and communication notes revealed no evidence RN #4 and LPN #7 had communicated with or received orders from the physician to change Patient #3's wound care orders. During an interview on 3/9/22 at 1:10 p.m., the interim administrator stated Patient #3 was a patient of the wound care clinic in town and the hospice nurses took orders from the wound care manager of this clinic, who was a physical therapist overseen by a medical doctor (MD). The interim administrator stated the hospice physicians did not manage the hospice patient wounds and all patients with wounds would be referred to the wound care clinic for care. The hospice nurses would receive orders from the wound care clinic for their hospice patients. During continued interview, the interim administrator stated Patient #3's chart should have contained orders for her wound care from the wound care clinic but acknowledged Patient #3's chart failed to show these orders. Furthermore, the interim administrator reviewed Patient #3's verbal orders and communication notes and acknowledged there were no additional orders found in Patient #3's medical record. The interim administrator stated RN #4, #5, and #6 and LPN #7 no longer were employed by the hospice. The interim administrator acknowledged the documentation of wound care provided by RN #4, #5, and #6 and LPN #7 failed to follow the wound care as ordered. b) The hospice IDG failed to ensure the HHA followed the order for frequency of visits as outlined on the plan of care. Review of HHA notes for Patient #3 from 12/14/20 through 1/13/21 completed by HHA #3 and HHA #12 showed Patient #3 received two visits the week of 12/19/20 to 12/25/20 on 12/21/20 and 12/24/20 and two visits the week of 12/26/20 to 1/1/21 on 12/28/20 and 12/31/20. Patient #3 did not receive three times a week visits these weeks as ordered by the physician on the plan of care. Review of patient #3's medical record failed to show missed visit documentation stating why Patient #3 did not receive HHA visits three times a week as ordered those two weeks. Additionally, the record failed to show if the hospice physician was notified of the missed visits and how Patient #3's HHA needs were met with the missed visits. During an interview on 3/9/22 at 1:10 p.m., the interim administrator stated HHA #12 no longer worked for the hospice and HHA #3 was in the process of returning to work for the hospice. The interim administrator reviewed Patient #3's medical record and acknowledged Patient #3 did not meet her HHA frequency for visits those two weeks and acknowledged Patient #3's chart lacked missed visit communication notes/orders for missed HHA visits. 2. The clinical record for Patient #9 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 9/10/20 with a terminal diagnosis of malignant of the bronchus or lung. The plan of care for the certification period 9/10/20 to 12/8/20 included orders for SN visits one time a week for a week, no visit for two weeks, one time a week for a week, no visit for a week, then one time a week for five weeks (however there were conflicting orders of SN for one time a week for a week, no visits for two weeks, one time a week for a week, no visits for two weeks and then weekly visits following the previous orders); and MSW visits six as needed (PRN) visits. a) The hospice IDG failed to ensure the SN provided visits as ordered on the plan of care. Review of the orders section of Patient #9's electronic medical record (EMR) showed Patient #9's SN orders were as followed: SN zero times a week for a week effective 9/13/20 SN zero times a week for a week effective 9/20/20 SN zero times a week for a week effective 10/4/20 SN zero times a week for a week effective 10/18/20 SN one time a week for a week effective 9/10/20 SN one time a week for a week effective 9/27/20 SN one time a week for one week effective 10/11/20 SN one time a week for one week effective 10/25/20 SN one time a week for one week effective 11/1/20 SN one time a week for three weeks effective 11/8/20 SN one time a week for one week, no visits for two weeks, one time a week for one week, no visits for two weeks and then weekly visits without an effective date listed. Further review of orders revealed Patient #9 had an addendum order effective 9/18/20 and signed by Patient #9's attending physician on 9/22/20 adding six PRN SN visits. Review of SN notes dated 9/10/20 to 12/8/20 revealed patient received the following SN visits: Start of Care on 9/10/20 Week of 9/13/20 to 9/19/20 no visits, Week of 9/20/20 to 9/26/20 one visit on 9/24/20, Week of 9/27/20 to 10/3/20 no visit, Week of 10/4/20 to 10/10/20 one visit on 10/8/20, Week of 10/11/20 to 10/17/20 no visit, Week of 10/18/20 to 10/24/20 one visit on 10/22/20, Week of 10/25/20 to 10/31/20 no visit, Week 11/1/20 to 11/7/20 one visit on 11/5/20, Week of 11/8/20 to 11/14/20 one visit on 11/12/20, Week of 11/15/20 to 11/21/20 one visit 11/19/20, Week of 11/22/20 to 11/28/20 no visit, Week of 11/29/20 to 12/5/20 two visits on 12/1/20 and 12/2/20, Week of 12/6/20 to 12/8/20 one visit on 12/7/20. Review of Patient #9's EMR and paper file failed to show missed visit communication on why Patient #9 did not have a visit the week of 10/25/20 to 10/31/20 or 11/22/20 to 11/28/20 as ordered or how his SN needs were met those two weeks. During an interview on 3/9/22 at 2:52 p.m., the interim administrator stated the RNs (RN #4 and #5) who treated Patient #9 from 9/10/20 to 12/8/20 were no longer employed with the hospice. The interim administrator stated the SN visits provided to Patient #9 were out of compliance with orders for Patient #9 and she did not have an explanation for why this happened. 3. The clinical record for Patient #1 was reviewed on 3/7/22. The patient was admitted for hospice care and services on 11/24/20 with a terminal diagnosis of senile degeneration of the brain. The plan of care for certification period dated 5/23/21 to 7/2121 included orders for SN visits one time a week every other week for nine weeks and five PRN visits; and MSW visits one time a month for two months. a) The hospice IDG failed to ensure the MSW provided visits as ordered on Patient #1's plan of care. Review of Patient #1's MSW visit notes from 5/23/21 to 7/21/21 revealed Patient #1 did not receive any MSW visits during this time. Review of communication notes from 5/23/21 to 7/21/21 revealed no communication note or missed visit note for the MSW not providing a visit once a month as ordered on the plan of care to Patient #1 during this timeframe. Review of the scheduled visit calendar failed to show documentation of any missed MSW visits. During an interview on 3/9/22 at 1:24 p.m., the external licensed clinical social worker (LCSW), stated she would call Patient #1 and her family to set up a visit but the patient/her family would decline the visit. The external LCSW stated she thought she documented this on the scheduling calendar for Patient #1 but stated the EMR was difficult to use and she may not have done it correctly. 4. The clinical record for Patient #5 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 4/20/20, with a terminal diagnosis of malignant neoplasm of unspecified part of the right bronchus or lung. The plan of care for the certification period dated 12/16/20 to 2/23/21 included orders for SN visits for no visit the first week, then one visit a week for eight weeks with eight PRN visits, HHA visits one time a week for a week then two times a week for eight weeks with three PRN visits and MSW visits one time a month for two months. a) The hospice IDG failed to ensure the MSW provided visits as ordered on Patient #5's plan of care. Review of MSW notes for Patient #5 from 12/16/20 to 2/20/21 revealed no MSW visits were documented during this time. During an interview on 3/9/22 at 1:24 p.m., the external LCSW stated she never met Patient #5 as he/family declined to meet with her and she did not remember whether she documented the patient/family had declined to meet with her.

Based on interview and record review, the hospice failed to develop an individualized written plan of care for each patient, reflective of patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments, including all services necessary for the palliation and management of the terminal illness and related conditions. This failure affected 5 of 10 discharged patients whose records were reviewed (Patients #2, #3, #5, #9 and #10). Findings include: 1. The clinical record for Patient #9 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 9/10/20 with a terminal diagnosis of malignant neoplasm of the bronchus or lung. The plan of care for the certification period 9/10/20 to 12/8/20 included orders for skilled nursing (SN) visits one time a week for a week, no visit for two weeks, one time a week for a week, no visit for a week, then one time a week for five weeks orders (however there were conflicting orders of SN for one time a week for a week, no visits for two weeks, one time a week for a week, no visits for two weeks and then weekly visits following the previous orders); and medical social worker (MSW) visits six as needed (PRN) visits. Subsequent plan of care orders for the certification period dated 12/9/20 to 3/8/21 included orders for SN visits one time a week for 13 weeks, one time a week for one week and 13 PRN visits; and MSW visits one time a month for three months and four PRN visits. a) The hospice failed to ensure Patient #9's plan of care contained goals or interventions for care needs identified during comprehensive assessments. Review of the initial comprehensive assessment RN visit note completed by RN #5 on 9/10/20, showed RN #5 assessed Patient #9 to have care needs regarding pain management, anxiety, shortness of breath, nausea, constipation, dehydration, gastroesophageal reflux disease (GERD), oversight of medication, lab work, abnormal gait, fall risk, assistance with mobility/activities of daily living (ADLs) and spouses coping difficulties. Review of the plan of care dated 9/10/20 for Patient #9, completed by RN #5 and signed by the attending physician on 9/15/20, showed Patient #9's care needs were identified to be alterations in coping of the patient/family/caregiver and impaired physical mobility. Both of these care needs failed to have goals or interventions documented on the plan of care. The plan of care failed to show any other care needs for Patient #9 and no further goals or interventions were listed for pain management, anxiety, shortness of breath, nausea, constipation dehydration, GERD, abnormal gait, oversight of medication, lab work, abnormal gait, fall risk prevention, assistance with mobility/ADLs, and spouses coping difficulties as identified in the comprehensive assessment. Review of the 9/22/20 and 10/7/20 interdisciplinary group (IDG) review updated plans of care for Patient #9 showed Patient #9's care needs were identified to be alterations in coping of the patient/family/caregiver and impaired physical mobility. Both of these care needs failed to have goals or interventions documented on the plan of care.The plan of care failed to show any other care needs for Patient #9 and no further goals or interventions were listed for pain management, bowel elimination, dehydration, oversight of medication, fall risk prevention and assistance with mobility/ADLs as identified in the comprehensive assessment. Further review of the 9/22/20 IDG review updated plans of care for Patient #9 showed Patient #9 potassium levels returned to a normal range so he no longer had a need for lab work. Review of a SN assessment completed on 10/22/20 by RN #5 for Patient #9, showed RN #5 assessed Patient #9 to have problems with pain, shortness of breath, nausea, dehydration, GERD,difficulty with ambulation, and decreased activity tolerance. Review of the 11/3/20 IDG review updated plan of care completed by RN #5, showed RN #5 identified Patient #9 to have care needs of alterations in coping of patient/family/caregiver and had a goal that the patient/family would maintain adequate/appropriate social emotional adjustment." Interventions for this goal was to assist with funeral arrangements and identify emotional and spiritual needs of the patient and family to be completed by the RN. The care need of impaired physical mobility was also identified with the two goals of 1. Improve coping for patient/caregiver regarding impaired mobility; and 2. Complications related to immobility will be prevented. Interventions for these goals were listed as: preventive skin care, educate patient and caregiver to maintain a safe environment, teach a bowel program, and teach preventative skin care regimen. The plan of care failed to show any other care needs for Patient #9 and no further goals or interventions were listed for pain management, nausea, dehydration, GERD or shortness of breath as identified in the SN assessment completed on 10/22/20 by RN #5. Review of a SN assessment completed on 11/12/20 by RN #5 for Patient #9, showed RN #5 assessed Patient #9 to have problems with pain, shortness of breath, nausea, GERD and decreased activity tolerance. Review of the 11/13/20 IDG review updated plan of care completed by RN #5, showed RN #5 identified Patient #9 to have care needs of alterations in coping of patient/family/caregiver and had a goal that the patient/family would maintain adequate/appropriate social emotional adjustment. Interventions for this goal was to assist with funeral arrangements and identify emotional and spiritual needs of the patient and family to be completed by the RN. The care need of impaired physical mobility was also identified with the two goals of 1. Improve coping for patient/caregiver regarding impaired mobility; and 2. Complications related to immobility will be prevented. Interventions for these goals were listed as: preventive skin care, educate patient and caregiver to maintain a safe environment, teach a bowel program, and teach preventative skin care regimen. The plan of care failed to show any other care needs for Patient #9 and no further goals or interventions were listed for pain management, GERD, shortness of breath or decreased activity tolerance as identified in the SN assessment completed on 11/12/20 by RN #5. Review of a SN assessment completed on 11/19/20 by RN #5 for Patient #9, showed RN #5 assessed Patient #9 to have problems with pain, anxiety, shortness of breath, nausea, GERD, gait impairments and decreased activity tolerance. Review of the 11/23/20 IDG review updated plan of care completed by RN #4, showed RN #4 identified Patient #9 to have care needs of alterations in coping of patient/family/caregiver and had a goal that the patient/family would maintain adequate/appropriate social emotional adjustment. Interventions for this goal was to assist with funeral arrangements and identify emotional and spiritual needs of the patient and family to be completed by the RN. The care need of impaired physical mobility was also identified with the two goals of 1. Improve coping for patient/caregiver regarding impaired mobility; 2. Complications related to immobility will be prevented. Interventions for these goals were listed as: preventive skin care, educate patient and caregiver to maintain a safe environment, teach a bowel program, and teach preventative skin care regimen. The plan of care failed to show any other care needs for Patient #9 and no further goals or interventions were listed for pain management, GERD, shortness of breath or decreased activity tolerance as identified in the SN assessment completed on 11/19/20 by RN #5. Review of a SN assessment completed on 12/31/20 by RN #5 for Patient #9, showed RN #5 assessed Patient #9 to have problems with pain, anxiety, edema, shortness of breath, decreased bowel sounds, poor hydration, decreased mobility/ADLs, and decreased activity tolerance. Review of the 1/4/21 and 1/6/21 IDG reviews updated plans of care completed by RN #4 showed RN #4 identified Patient #9 to have care needs of alterations in coping of patient/family/caregiver and had a goal that the patient/family would maintain adequate/appropriate social emotional adjustment. Interventions for this goal was to assist with funeral arrangements and identify emotional and spiritual needs of the patient and family to be completed by the RN. The care need of impaired physical mobility was also identified with the two goals of 1. Improve coping for patient/caregiver regarding impaired mobility; and 2. Complications related to immobility will be prevented. Interventions for these goals were listed as: preventive skin care, educate patient and caregiver to maintain a safe environment, teach a bowel program, and teach preventative skin care regimen. The plan of care failed to show any other care needs for Patient #9 and no further goals or interventions were listed for pain management, shortness of breath or decreased activity tolerance as identified in the SN assessment completed on 12/31/20 by RN #5. During an interview on 3/9/22 at 2:52 p.m., the interim administrator reviewed the plans of care for Patient #9 and IDG reviews. She acknowledged many of these plans of care/IDG reviews were missing identified care needs, goals and interventions. The interim administrator stated RN #4 and #5 no longer worked for the hospice. The interim administrator stated she was familiar with Patient #9 and stated he had a significant amount of pain and she agreed his plans of care should have contained goals and interventions for all care needs identified and especially for pain management. 2. The clinical record for Patient #10 was reviewed on 3/9/22. The patient was admitted for hospice care services on 1/15/21 with a terminal diagnosis of malignant neoplasm of the brain. The plan of care for the certification period 1/15/21 to 4/14/21 included orders for SN visits one time a week for four weeks and eight PRN visits; MSW visits zero visits for the first week, then one time a week for a week; and home health aide (HHA) visits zero visits for the first week and two times a week for three weeks with eight PRN visits. a) The hospice failed to ensure Patient #10's plan of care contained goals or interventions for care needs identified during comprehensive assessments. Review of the comprehensive assessment completed by RN #5 on 1/15/21 showed RN #5 assessed Patient #10 to have problems with shortness of breath, endocrine issues, potential for bowel issues due to medication use, urinary retention with indwelling Foley, mobility/ADL needs, fall risk, visual changes and new onset of seizures. Review of the 1/15/21 and 1/19/21 plans of care revealed, Patient #10's was identified as having care needs in following areas: bowel elimination, impaired mobility, knowledge deficit/terminal care, and HHA care plan. The 1/15/21 Plan of Care and 1/18/21 IDG updated plan of care both contained interventions for the HHA, but no goal. The 1/15/21 plan of care and the 1/18/21 IDG updated plan of care failed to have goals or interventions listed for the care needs of bowel elimination, impaired mobility, and knowledge deficit/terminal care. Further review of the documents failed to show goals or interventions for Patient #10's identified needs in the 1/15/22 comprehensive assessment of shortness of breath, endocrine issues, urinary retention with use of indwelling catheter, fall risk prevention, visual changes and seizures. During an interview on 3/9/22 at 3:06 p.m., the interim administrator reviewed the 1/15/21 plan of care and the 1/18/21 updated plan of care for Patient #10 and acknowledged both were lacking goals and interventions for the care needs identified in these documents. She further acknowledged that Patient #10 had suffered a Grand Mal seizure at the hospital prior to his admission to hospice and stated both the 1/15/21plan of care and the 1/18/21 IDG updated plan of care should have contained goals and interventions for all care needs identified in his initial comprehensive assessment including his new onset of seizures. 3. The clinical record for Patient #3 was reviewed on 3/7/22. The patient was admitted for hospice care and services on 12/14/20 with a terminal diagnosis of senile degeneration of the brain. The plan of care for the certification period dated 12/14/20 to 3/13/21 included orders for SN visits three times a week for thirteen weeks; MSW visits zero times for the first week and one time a week for a week; volunteer coordinator PRN; and HHA visits two times a week for a week and three times a week for 12 weeks. a) The hospice failed to ensure Patient #3's plan of care contained goals or interventions for care needs identified during the comprehensive assessments. Review of the SN comprehensive assessment completed on 12/14/20 by RN #4, showed RN #4 assessed Patient #3 to have the following issues: decreased mobility/ADLs, decreased nutritional intake, pain, anxiety/confusion, incontinence of stool, incontinence of urine with use of a Foley catheter, fall risk, decreased skin integrity. Patient #3 suffering from three wounds (one on her right hip, her right ankle and back of her right shoulder), decreased social support, lack of funeral planning, need for HHA assistance, and need for care coordination with the ALR staff and hospice staff on Patient #3's care needs. Review of the plan of care dated 12/14/20 completed by RN #4 and signed by Patient #3's attending nurse practitioner (NP) on 12/24/20 showed no care needs were identified for Patient #3 and no goals or interventions were listed for Patient #3's decreased mobility/ADLs, decreased nutritional intake, pain, anxiety/confusion, incontinence of stool, incontinence of urine with use of Foley catheter, fall risk, decreased skin integrity with Patient #3 suffering from 3 wounds, decreased social support, lack of funeral planning, HHA needs and need to coordinate care with ALR staff as identified in the 12/14/20 comprehensive assessment of Patient #3. Review of an assessment completed on 12/20/20 by RN #5, showed RN #5 assessed Patient #3 as having the following issues: pain; altered mental status; constipation; decreased nutrition/hydration; incontinence of urine (but no longer with a Foley catheter as patient no longer tolerating it); decreased mobility/ADLs, psychosocial/spiritual concerns, and wounds on her right ankle, right sacrum and right hip. Review of an assessment completed on 12/21/20 by RN #6 showed RN #6 assessed Patient #3 to have the following issues: pain; altered mental status; incontinence of urine; wounds on her right ankle and two areas on her right buttocks. Review of the 12/21/20 IDG review updated plan of care completed by RN #4 showed Patient #3 had the following care needs identified with goals and interventions in place: anxiety, skin integrity (wound care), alternate facility for care, pain, knowledge deficit terminal care, bowel elimination/constipation/impaction and HHA care plan. The IDG review updated plan of care failed to have any goals or interventions for the identified right sacral wound, altered mental status, incontinence of urine, decreased nutritional intake and decreased psychosocial/spiritual needs as identified in the assessments completed on 12/20/20 by RN #5 and 12/21/20 by RN #6. Review of the assessment completed on 1/4/21 by RN #6, showed RN #6 assessed Patient #3 to be suffering from the following issues: pain, decreased mental status and suffering from three wounds (her right ankle and two on her right buttocks). Review of the assessment completed on 1/6/21 by RN #6, showed RN #6 assessed Patient #3 to be suffering from the following issues: pain, constipation, decreased mental status and three wounds (her right ankle and two on her right buttocks). Review of the 1/4/21 and 1/6/21 IDG reviews updated plans of care completed by RN #4 showed Patient #3 had following care needs identified with goals and interventions in place: anxiety, impaired skin integrity, alternate facility for care, pain, terminal care knowledge deficit, bowel elimination (constipation/impaction) and HHA care plan. The IDG review updated plan of care failed to have any goals or interventions identified for the two right buttocks wounds identified by RN #6 on the 1/4/21 and 1/6/21 assessment. Review of an assessment completed on 1/13/21 by RN #4, showed RN #4 assessed Patient #3 to be suffering from the following issues: pain, decreased mental status/alertness, incontinence, injuries from previous fall (fall occurred on 1/8/21) and three wounds (right ankle, right buttocks, and right hip). Review of an assessment completed on 1/14/21 by RN #4, showed RN #4 assessed Patient #3 to be suffering from the following issues: pain, decreased mental status/alertness, incontinence and three wounds (her right ankle and did not state location of other two wound care sites). Review of the 1/18/21 IDG review updated plan of care completed by RN #4 showed Patient #3 had the following care needs identified with goals and interventions in place: anxiety, impaired skin integrity, alternate facility for care, pain, terminal care knowledge deficit, bowel elimination (constipation/impaction), and a HHA care plan. The IDG review updated plan of care failed to have any goals or interventions for the incontinence and right buttocks wound identified in the 1/13/21 and 1/14/21 assessments completed by RN #4. During an interview on 3/9/22 at 1:10 p.m., the interim administrator reviewed Patient #3's plan of care and IDG review updated plans of care and acknowledged they were missing goals and interventions for issues identified in Patient #3's comprehensive assessments. 4. Similar findings of the hospice failing to ensure patient's plans of care contained goals and interventions for problems identified in the comprehensive assessments were found for Patients #2 and #5. Specifically Patient #2's plan of care was missing goals and interventions for his psychosocial care needs and Patient #5's plan of care dated 10/17/20 was missing goals for the following care needs identified: activity tolerance, ineffective airway clearance, alterations in coping of patient/family/caregiver, bereavement concerns and plan of care, dysphagia, pain, and altered thought process.

Based on interview and record review, the hospice failed to ensure the interdisciplinary group (IDG), in collaboration with the attending physician, reviewed, revised, and documented the Plan of Care as frequently as the patient's condition required, but no less than every 15 days for 3 of 11 patient's records reviewed (Patients #5, #6, and #11). Findings include: AGENCY POLICY According to undated policy titled, Interdisciplinary Team Meeting, (read in pertinent parts): "The Team meets bi-monthly. The Team discusses updates to the Plan of Care, changes in the patient, family or caregiver circumstances, death of patients and bereavement actions." 1. During an interview on 3/7/22 at 2:47 p.m., the interim administrator stated the agency tried to hold IDG every other week on Wednesdays. The interim administrator stated sometimes the agency had to move the meetings around depending on the availability of the hospice medical director. 2. The clinical record for Patient #5 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 4/20/20, with a terminal diagnosis of malignant neoplasm of unspecified part of the right bronchus or lung. The plan of care orders for the certification period dated 4/20/20 to 7/18/20 included orders for skilled nursing (SN) visits one time a week for nine weeks, with six as needed (PRN) visits, and home health aide (HHA) visits twice a week for eight weeks. a) The agency failed to ensure the IDG reviewed, revised and documented the individualized plan of care no less frequently than every 15 calendar days. Review of IDG documentation revealed Patient #5's first IDG meeting was held on 5/12/20, 22 days after his start of services and seven days after his first IDG meeting was due. There was no evidence his plan of care had been updated or revised since his start of care on 4/20/20. 3. The clinical record for Patient #6 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 4/8/21 with a terminal diagnosis of chronic obstructive pulmonary disease with acute exacerbation. The plan of care for the certification period dated 4/8/21 to 7/6/21 included orders for SN visits one time a week for a week, then two times a week for 12 weeks and 13 PRN visits; physical therapy (PT) visit one time a week for a week; occupational therapy (OT) visit one time a week for one week, medical social worker (MSW) visits one time a month for three months and three PRN visits, and HHA visits zero visits for one week, four times a week for one week, five times a week for 11 weeks and two times a week for one week. a) The agency failed to ensure the IDG reviewed, revised and documented the individualized plan of care no less frequently than every 15 calendar days. Review of IDT documentation revealed Patient #6's first IDG meeting was held on 4/27/21, 19 days after her start of services and four days after her first IDG meeting was due. There was no evidence her plan of care had been updated or revised since her start of care on 4/8/21. 4. The clinical record for Patient #11 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 2/22/22, with a terminal diagnosis of acute myeloblastic leukemia. The plan of care orders for the certification period dated 2/22/22 to 5/25/22 included orders for SN visits one time the first week, then once a week for four weeks, then two times a week for five weeks and 12 PRN. a) The agency failed to ensure the IDG reviewed, revised and documented the individualized plan of care no less frequently than every 15 calendar days. Review of IDG documentation revealed Patient #11 had not had an IDG meeting as of the date of the exit of this survey, 3/10/22, and was due to be completed on 3/9/22. 5. During an interview on 3/9/22 at 2:34 p.m., the interim administrator stated if the documentation was not in the patient's chart to show the IDG meeting was on time, then it was late as the documentation showed. The interim administrator stated for Patient #6 she remembered the agency being very busy and the administrator at the time (RN #4) being pulled to work on the floor with hospital patients so she probably could not have scheduled the initial IDG in a timely manner. The interim administrator acknowledged the IDG as late for Patient #11.

Based on interview, administrative record review and nature of standard level deficiencies referenced to the Condition, it was determined the CONDITION OF PARTICIPATION 418.58, Quality Assessment and Performance Improvement (QAPI) was out of compliance. The hospice failed to provide evidence it had developed, implemented and maintained an effective, ongoing, hospice-wide data driven QAPI program, failing to include the components. The agency failed to: collect, analyze, measure and track quality data; identify, analyze, track and measure effectiveness of performance improvement projects; document and demonstrate the operation of the QAPI program; and the governing body failed to ensure a program for quality improvement and patient safety was defined, implemented, maintained, and was evaluated annually. These failures had the potential to affect all patients admitted to the agency. L560- Based on interview and record review, the hospice failed to demonstrate and maintain documentary evidence of its quality assessment and performance improvement (QAPI) program. Furthermore, the governing body failed to ensure the program reflected the complexity of its organization and services, involved all hospice services, focused on indicators related to improved palliative outcomes and took action to demonstrate improvement in hospice performance.

Based on interview and record review, the hospice failed to demonstrate and maintain documentary evidence of its quality assessment and performance improvement (QAPI) program. Furthermore, the governing body failed to ensure the program reflected the complexity of its organization and services, involved all hospice services, focused on indicators related to improved palliative outcomes and took action to demonstrate improvement in hospice performance. Findings include: AGENCY POLICY The agency's policy, titled Quality Assessment and Performance Improvement (QAPI), not dated, read in pertinent parts; "Areas of needed focus will be determined/identified by multiple methods of self- assessment to include a review of current documents (e.g., review of clinical records, incident reports, complaints, patient satisfaction surveys, etc.), patient care, direct observation of clinical performance, and operating systems. Findings will be presented and prioritized in IDT meetings as necessary. Administrative assistants will record minutes of these meetings. QAPI staff will develop and implement performance improvement processes to improve the quality of services. At least one performance improvement process will be developed and implemented annually. QAPI staff will evaluate the effectiveness of the performance improvement process implemented. Agency director or designee will be responsible for implementing QAPI program. Staff will be educated on the implementation process and documentation needed to support that the actions deemed necessary are being done. The governing board and the advisory committee will be kept informed of the agency's QAPI policies, goals and outcomes at least annually." 1. Interview and administrative record review failed to show evidence the agency ensured an effective, ongoing, hospice-wide data-driven QAPI program was implemented, documented, maintained and approved by the governing body. a) During an interview on 3/8/22 at 12:56 p.m., the interim administrator confirmed that she was responsible for the agency's QAPI program. The interim administrator stated QAPI meetings were held quarterly and that the committee consisted of herself and several other hospital personnel as well as community persons. However, there were no hospice-specific QAPI meetings. She further stated the projects being worked on were for the hospital and were not specific to the hospice. During an interview on 3/7/22 at 12:06 p.m., the chief clinical officer stated that the quality director might be able to help confirm QAPI for the hospice. During an interview on 3/7/22 at 12:43 p.m., the quality director stated she did not know anything about the QAPI program for the hospice. She further confirmed she had no documentation for the QAPI program. b) Review of the QAPI documentation showed no collection, analyzing, measuring and tracking quality data; or identifying, analyzing, tracking and measuring effectiveness of performance improvement projects; the agency did not document and demonstrate the operation of the QAPI program; and the governing body failed to ensure a program for quality improvement and patient safety was defined, implemented, maintained, and evaluated annually. During an interview on 3/9/22 at 1:00 p.m., the interim administrator stated that the previous administrator used to audit and quality check the records, run the QAPI meetings and keep all the QAPI documentation. During an interview on 3/10/22 at 8:39 a.m., the interim administrator confirmed she had no current QAPI documentation.

Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 418.64, CORE SERVICES was out of compliance. A total of 14 clinical records were reviewed for compliance with the Condition and Standards for Core Services. Record review revealed a pattern of failures in regard to the hospice ensuring care and services provided by a medical social worker and Chaplain or counselor occurred. Review revealed no spiritual services were offered, and no bereavement care planning or follow up occurred. These failures had the potential to affect all patients served by the hospice. L 588 - Based on interview and record review the hospice failed to provide all core services. Specifically, the hospice failed to provide medical social worker (MSW) and spiritual care services consistent with acceptable standards of practice. L 596 - Based on interview and record review, the agency failed to have an organized program for the provision of bereavement services, ensure that bereavement services reflected the needs of the bereaved and ensure bereavement services were available to the family for up to one year following the death of the patient. L 598 - Based on interview and record review, the agency failed to ensure a spiritual assessment had been completed to meet the patient's needs and failed to ensure spiritual services were provided to meet each patient's religious needs.

Based on interview and record review the hospice failed to provide all core services. Specifically, the hospice failed to provide medical social worker (MSW) and spiritual care services consistent with acceptable standards of practice. (Cross reference L598) Findings include: AGENCY POLICY The agency policy, titled Interdisciplinary Team Meeting, not dated, read in pertinent parts; "The hospice medical director and other team members are present, Those present at the team meeting sign the attendance form, Hospice personnel use the meeting form to document patient discussion. To document changes about the patient, family those changes include, psychosocial and other consultations with patient, family or caregiver, ongoing spiritual support." The agency policy, titled Interdisciplinary Team Coordination of Care, not dated, read in pertinent parts; "The interdisciplinary team consists of physicians, nurses, social workers, certified home health aides, clergy, counselors, volunteers and therapists. The Team conducts assessments and develops and updates the plan of care. The team reviews the effectiveness of the Plan of Care during IDT meetings." 1. During an interview on 3/7/22 at 2:47 p.m., the interim administrator stated they did not have a MSW or Chaplain (CH) on staff but if a patient wanted someone they had a licensed clinicl social worker (LCSW) that worked at the behavioral clinic and both a Catholic Priest and non-Catholic chaplain they could use. She further stated that no MSW or CH attended the interdisciplinary team meetings (IDG), or performed the initial spiritual care assessments required on admission to hospice care and services. a) The agency failed to provide MSW and spiritual care services consistent with acceptable standards of practice. Review of the IDG meeting sign-in sheets for the meetings dated 11/3/20 through 3/10/22, for Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 revealed no signatures from the MSW or CH as being in attendance at the IDG meetings. Review of the clinical records for Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 revealed the skilled nurse (SN) performing the initial comprehensive assessments. Review of the clinical record for Patients #1, #2, #3, #6 snd #7 revealed an initial assessment completed by the MSW, however the record failed to reveal interventions or goals on the care plans. Furthermore, Patients #4, #5, #8 and #10 had no evidence of initial assessments being completed. Further review of the clinical records revealed no evidence the CH had completed any initial spiritual care assessments with the patients and had not followed up with spiritual care concerns for the patients who were admitted to hospice care and services. 2. During an interview on 3/7/22 at 12:09 p.m., the chief clinical officer stated the IDG was composed of the hospice director (which is a registered nurse), the hospice medical director, the MSW, and the CH. During an interview on 3/7/22 at 3:34 p.m., the LCSW stated she usually attended IDG, however she had been on maternity leave from the beginning of November 2021 until about one month ago and she was not aware of anyone covering for her at the IDG meetings. She further stated she thought she signed a form indicating she was in attendance During an interview 3/7/22 at 2:47 p.m., the interim director stated those in attendance at IDG had been herself (as the RN) and the medical director.

Based on interview and record review, the agency failed to have an organized program for the provision of bereavement services, ensure that bereavement services reflected the needs of the bereaved and ensure bereavement services were available to the family for up to one year following the death of the patient in 3 of 3 bereavement records reviewed (Bereavement Patients #1, #2, and #3). Findings include: AGENCY POLICY The agency policy, titled Bereavement Services and Assessment, not dated, read in pertinent parts; "Assessment provides groundwork for bereavement care services and should address family and significant others ' grief and bereavement responses and needs on physical, emotional, social, and spiritual levels and related levels. Assessment of these responses and needs begin at the time of the hospice patient ' s admission and continue through patient care, death, and bereavement care period provided by the hospice." "After the bereavement assessment is completed, Hospice personnel develop and implement a plan to address bereavement/grief issues. The bereavement plan of care should reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery." "The patient, family or caregiver may require bereavement counseling depending on the needs identified in the bereavement service before and after the patient ' s death. Often the patient, family or caregiver needs bereavement counseling before the patient ' s death." "If a person is experiencing normal grief, bereavement services include contact with the bereaved person for ongoing assessments and support at three, six and nine month intervals and at the anniversary of the patient ' s death." 1) The hospice routinely failed to complete an initial bereavement assessment and develop a bereavement plan of care that notes the kind of bereavement services to be offered at the start of care and again at the time of death. Bereavement services were not made available to the family and other individuals in the bereavement plan of care up to one year following the death of the patient, nor did they reflect the needs of the patient or their family. Review of clinical records revealed no evidence the licensed clinical social worker (LCSW) or chaplain (CH) had completed any initial bereavement assessments with the patients or families and had not followed up with bereavement concerns for the families at the time of death. a) During an interview on 3/7/22 at 3:37 p.m., the LCSW stated the process for providing bereavement services started with an initial bereavement assessment at the time of admission and again prior to death. She stated she talked with the family to see if they wanted any services. She further stated the first mailings went out to the bereaved several days after the patient's death (a sympathy card), a letter at three weeks, then other mailings at three, six, nine and 12 month marks. During the same interview, the LCSW stated she was responsible for all bereavement assessments and care plans. She further stated that she was never really shown how to enter them in the record, the old administrator would often enter them, so she was not sure if they were in the clinical record. b) The clinical record for Bereavement Patient #2 was reviewed on 3/8/22. The patient's date of death was 5/5/21. Review of Bereavement Patient #2's Bereavement record, failed to reveal an initial bereavement assessment upon admission or contact at time of death. Further review revealed that initial contact with the bereaved was made the day of death by mailing a sympathy card. Subsequent contacts occurred with mailings at one month on 6/8/21 and at three months on 8/25/21, with no evidence of further contact. c) The clinical record for Bereavement Patient #1 was reviewed on 3/8/22. The patient's date of death was 9/21/21. Review of Bereavement Patient #1's Bereavement record, failed to show any initial contact made at the time of death, or subsequent contact up to 13 months preceding death. d) The clinical record for Bereavement Patient #3 was reviewed on 3/8/22. The patient's date of death was 2/20/22. Review of Bereavement Patient #3's Bereavement record, failed to show any initial contact made at the time of death, or subsequent contact up to 13 months preceding death. e) During an interview on 3/9/22 at 1:19 p.m., the LCSW stated she had not heard about Bereavement Patients #2 or #3, and had only seen Bereavement Patient #1 one time. She confirmed that she was responsible for bereavement follow-up, however, did not save copies of any correspondence, nor did she document anything in the clinical record, for Patients #1, #2, or #3.

Based on interview and record review, the agency failed to ensure a spiritual assessment had been completed to meet the patient's needs and failed to ensure spiritual services were provided to meet each patient's religious needs. This failure occurred for 6 of 11 patients selected for review who accepted spiritual services (Patients #2, #3, #5, #7, #8, and #10). Findings include: AGENCY POLICY The agency policy, titled Spiritual Care, not dated, read in pertinent parts; "Hospice provides spiritual support in keeping with the patient's belief system and practice and as developed by the interdisciplinary team's Plan of Care." "The Hospice social worker or chaplain completes a Spiritual Support Needs Assessment." "With permission the hospice staff contacts the identified local church, the synagogue, the mosque, etc. to coordinate care. The identified spiritual support person is encouraged to participate as an interdisciplinary team member in developing the Plan of Care and to document interventions." "Interdisciplinary team members conduct ongoing assessments to identify any developing spiritual needs of the patient, family or caregiver and will establish a Plan of Care to meet those needs." 1. The clinical record for Patient #2 was reviewed on 3/7/22. The patient was admitted for hospice care and services on 5/19/21, with a terminal diagnosis of Alzheimer's disease. The plan of care for the certification period dated 5/19/21 to 8/16/21 included orders for skilled nurse (SN) visits twice the first week then three times a week for 12 weeks and 12 as needed visits (PRN); and home health aide (HHA) services once the first week, then three times a week for 12 weeks and 12 PRN. a) Clinical record review revealed a chaplain failed to conduct a complete and comprehensive spiritual assessment to evaluate the patient's and family's spiritual needs and to provide spiritual care to the patient and family. Review of the hospice RN admission note, completed by RN #4, dated 5/19/21, revealed the family had no spiritual support and was in need of funeral planning services. Review of a hospice medical social worker (MSW) admission visit note, completed by Employee #2, dated 5/27/21, failed to reveal a spiritual needs assessment had been completed. Clinical record review revealed no evidence a spiritual assessment had been completed from Patient #2 ' s admission date of 5/19/21 through the date of death on 7/7/21. 2. The clinical record for Patient #3 was reviewed on 3/7/22. The patient was admitted for hospice care and services on 12/14/20 with a terminal diagnosis of senile degeneration of the brain. The plan of care for the certification period dated 12/14/20 to 3/13/21 included orders for SN visits three times a week for thirteen weeks; medical social worker (MSW) visits zero times for the first week and one time a week for one week; volunteer coordinator visits as needed (PRN); and home health aide (HHA) visits two times a week for a week and three times a week for 12 weeks. a) Clinical record review revealed a chaplain failed to conduct a complete and comprehensive spiritual assessment to evaluate the patient's and family's spiritual needs and to provide spiritual care to the patient and family. Review of the hospice RN admission note, completed by RN #4, dated 12/14/20, revealed the patient had no spiritual support. It further revealed that the patient had no support from family or friends, along with no funeral planning. Review of the hospice MSW admission visit note dated 12/22/20, completed by Employee #3 failed to reveal any spiritual assessment had been completed. Clinical record review revealed no evidence a spiritual assessment had been completed from Patient #3 admission date of 12/14/20 through the date of death on 1/31/21. 3. The clinical record for Patient #5 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 4/20/20, with a terminal diagnosis of malignant neoplasm of unspecified part of the right bronchus or lung. The plan of care for the certification period dated 10/17/20 to 12/15/20 included orders for SN visits one time a week for nine weeks, with six PRN visits, MSW PRN, and HHA visits twice a week for eight weeks. Subsequent plan of care orders for the certification period dated 12/16/20 to 2/3/21 included orders for SN visits one time a week for nine weeks with six PRN visits, MSW once a month every other month, and HHA visits twice a week for eight weeks, with six PRN visits. a) Clinical record review revealed a chaplain failed to conduct a complete and comprehensive spiritual assessment to evaluate the patient's and family's spiritual needs and to provide spiritual care to the patient and family. Review of the interdisciplinary team review sheet for the start of care 4/20/20, not signed or dated, revealed a care plan stating psychosocial needs to work through stages of grief and dying were needed for the patient and family. However, the record failed to reveal any support was provided. Review of a hospice SN routine visit note, completed by RN #5, dated 11/3/20, failed to reveal any spiritual assessment had been completed. Further review of the record failed to reveal any chaplain or MSW assessment had been completed. Clinical record review revealed no evidence a spiritual assessment had been completed from Patient #5 ' s admission date of 4/20/20 through the date of death on 2/2//21. 4. The clinical record for Patient #7 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 3/3/21, with a terminal diagnosis of malignant neoplasm of the right kidney. The plan of care for the certification period dated 3/3/21 to 5/31/21 included orders for SN visits two times the first week, then once a week for eight weeks; MSW visits one time the first week then six PRN; and HHA services once the first week, then twice a week for seven weeks and eight PRN. a) Clinical record review revealed a chaplain failed to conduct a complete and comprehensive spiritual assessment to evaluate the patient's and family's spiritual needs and to provide spiritual care to the patient and family. Review of the hospice RN admission note dated 3/3/21, completed by RN #5 revealed the patient and family had no spiritual needs that date, but they were working on funeral arrangements. Review of the hospice MSW admission visit note, completed by Employee #2, failed to reveal any spiritual assessment. Clinical record review revealed no evidence a spiritual assessment had been completed from Patient #7's admission date of 3/3/21 through death on 3/25/21. 5. The clinical record for Patient #8 was reviewed on 3/8/22. The patient was admitted for hospice care and services on 3/4/21 with a terminal diagnosis of Parkinson's disease. The plan of care for the certification period dated 3/4/21 to 6/1/21 included orders for SN visits once weekly for 14 weeks, with 16 PRN visits; MSW visits zero visits for one week, one visit for a week and four PRN visits. a) Clinical record review revealed a chaplain failed to conduct a complete and comprehensive spiritual assessment to evaluate the patient's and family's spiritual needs and to provide spiritual care to the patient and family. Review of hospice RN admission note, completed by RN #4, dated 3/4/21, revealed the patient's spiritual needs were being met by the Baptist church. Further review revealed dignity was an issue for the patient, however no spiritual assessment was completed. Review of the hospice MSW admission visit note, completed by Employee #2, dated 3/10/21, revealed the family was struggling with funeral arrangements, and was not prepared for death. However, the record failed to reveal a spiritual assessment had been completed. Clinical record review revealed no evidence a spiritual assessment had been completed from Patient #8 ' s admission date of 3/4/21 through the date of death on 3/11/21. 6. The clinical record for Patient #10 was reviewed on 3/9/22. The patient was admitted for hospice care services on 1/15/21 with a terminal diagnosis of malignant neoplasm of the brain. The plan of care for the certification period 1/15/21 to 4/14/21 included orders for SN visits one time a week for four weeks and eight PRN visits; MSW visits zero visits for the first week, then one time a week for one week; and HHA visits zero visits for the first week and two times a week for three weeks with eight PRN visits. a) Clinical record review revealed a chaplain failed to conduct a complete and comprehensive spiritual assessment to evaluate the patient's and family's spiritual needs and to provide spiritual care to the patient and family. Review of Hospice RN admission note dated 1/15/21, completed by RN #4 revealed the patient was part of a faith-based spiritual community and wanted end of life support. However, the admission note failed to reveal a spiritual assessment had been completed. Review of the hospice MSW admission visit note dated 1/18/21, completed by Employee #2 revealed the patient and family had faith-based coping mechanisms in place. However, the record failed to reveal what these mechanisms were. Further review of the record failed to reveal a spiritual assessment had been completed. Review of Patient #10's clinical record from admission on 1/15/21 through 1/21/21 failed to show a chaplain's visit had been completed. 7. During an interview 3/7/21 at 12:09 p.m. the CCO, stated that the chaplain was a member of the IDG. During an interview 3/7/21 at 1:22 p.m. the interim administrator stated that they did not have a chaplain on staff. They did, however, have two community people they worked with for spiritual needs, a Catholic Priest and a non-Catholic minister. During an interview 3/8/21 at 1:35 p.m. the interim administrator stated they had no chaplain on staff. She further stated they used a Deacon from the Catholic church; however, she had not spoken to him since January of this year. During an interview 3/8/22 at 3:34 p.m., the LCSW stated she did not know who was responsible for the spiritual assessments.