Every finding on record at Cima Hospice of Corpus Christi LLC

Based on interview and record review, the hospice failed to follow an individualized written plan of care (POC) established by the hospice interdisciplinary team (IDT) in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patient's need in that: The hospice failed to ensure Chaplain services were provided according to the POC for 2 of 11 (#3 and 9) patients reviewed receiving Chaplain services. The hospice failed to ensure social worker services were provided according to the POC for 2 of 11 (#3 and 8) patients reviewed receiving social worker services. The hospice failed to ensure hospice aide services were provided according to the POC for 1 of 6 (#11) patients reviewed receiving hospice aide services. Failure to follow the patient's POC places patients at risk of not receiving the needed services as ordered by their physician to meet spiritual needs, psychosocial needs, promote optimal outcome, and improve their quality of life. --- Findings include: Patient #3 Review of the clinical record for the certification period of 10/24/22 to 12/22/22 included a physicians order for chaplain services once a month and social worker services once a month. The clinical record contained an additional physicians order dated 11/30/22 for social worker visits once a week for 2 weeks beginning the week of 12/04/22 Review of the chaplain visit notes did not indicate chaplain services were provided once a month for the month of November 2022. During an interview conducted on 01/12/23 at 11:40 a.m., when asked if chaplain services were provided for patient #3 during the month of November 2022, Chaplain F said he did not see the patient in November that he moved the visit to December and did not complete a MVR. Review of the social worker visit notes did not indicate social worker services were provided for the weeks of 12/04/22 to 12/10/22 and 12/11/22 to 12/17/22. During an interview conducted on 01/12/23 at 10:24 a.m., when asked if social worker services were provided to the patient from 12/04/22 to 12/17/22, MSW/volunteer coordinator E said the census was low and the order was written so he could spend additional time with the patient but then the patient did not need the extra visits, and MVR were not done. Patient #8 Review of the clinical record for the certification period of 10/13/22 to 12/11/22 included a physicians order dated 11/30/22 for social worker services once a week for 2 weeks beginning the week of 11/27/22. Review of the social worker visit notes did not indicate social worker services were provided the weeks of 11/27/22 to 12/03/22 and 12/04/22 to 12/10/22. During an interview conducted on 01/12/23 at 10:25 a.m., when asked if social worker services were provided during the weeks of 11/27/22 to 12/03/22 and 12/04/22 to 12/10/22, MSW E said the patients caregiver did not let him visit due to COVID and he did not complete MVRs. Patient #9 Review of the clinical record for the certification period of 11/13/22 to 01/11/23 included a physicians order for chaplain services once a month. Review of the chaplain visit notes did not indicate chaplain services were provided services during the month of December 2022. During an interview conducted on 01/12/23 at 11:36 a.m., when asked if chaplain services were provided for the month of December 2022, Chaplain F said he did not see the patient in December that the visit was moved to January 2023, and he did not complete a MVR for December. Patient #11 Review of the discharged clinical record for the certification period of 09/15/22 to 09/30/22 included a physicians order for hospice aide services 2 times a week. The clinical record did not include documentation of hospice aide visits for the week of 09/18/22 to 09/24/22. The record included one missed visit report dated 09/20/22. During an interview conducted on 01/12/23 at 2:02 p.m., when asked if hospice aide services were provided during the weeks of 09/18/22 to 09/24/22, the administrator/supervising nurse said the visits were scheduled in the electronic record and she had a missed visit for 09/20/22 but there were no additional missed visit reports, and she did not know why the visit was not completed. Review of the hospice policy titled, ";Plan of Care", dated 04/20/20 included, ";1. Policy Overview: The care and services provided to clients and their families are in accordance with an individualized written plan of care established by the hospice IDG in collaboration with the clients attending physician or allowed practitioner (if any), and, if appropriate, the client and/or his/her representative" ... Based on interview and record review, the hospice failed to follow an individualized written plan of care (POC) established by the hospice interdisciplinary team (IDT) in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patient's need in that: The hospice failed to ensure Chaplain services were provided according to the POC for 2 of 11 (#3 and 9) patients reviewed receiving Chaplain services. The hospice failed to ensure social worker services were provided according to the POC for 2 of 11 (#3 and 8) patients reviewed receiving social worker services. The hospice failed to ensure hospice aide services were provided according to the POC for 1 of 6 (#11) patients reviewed receiving hospice aide services. Failure to follow the patient's POC places patients at risk of not receiving the needed services as ordered by their physician to meet spiritual needs, psychosocial needs, promote optimal outcome, and improve their quality of life. Findings included: Patient #3 Review of the POC from 10/24/22 to 12/22/22 consist of a physicians order for Chaplain services once a month and for social worker services once a month. The clinical record had an additional physicians order dated 11/30/22 for social worker visits once a week for 2 weeks beginning the week of 12/04/22 Review of the Chaplain visit notes failed to provide documentation to support Chaplain services were provided once a month for the month of November 2022. During an interview conducted on 01/12/23 at 11:40 a.m., when asked if Chaplain services were provided for patient #3 during the month of November 2022, Chaplain F said he did not see the patient in November. He moved the visit with the patient to December and did not complete a MVR. Review of the social worker visit notes failed to provide documentation to support social worker services were provided for the weeks of 12/04/22 to 12/10/22 and 12/11/22 to 12/17/22. During an interview conducted on 01/12/23 at 10:24 a.m., when asked if social worker services were provided to the patient from 12/04/22 to 12/17/22, MSW/volunteer coordinator E said the census was low. The order was written so he could spend additional time with the patient, but then the patient did not need the extra visits. The MVRs were not done. Patient #8 Review of the POC from 10/13/22 to 12/11/22 consists of a physicians order dated 11/30/22 for social worker services once a week for 2 weeks beginning the week of 11/27/22. Review of the social worker visit notes failed to provide documentation to support social worker services were provided the weeks of 11/27/22 to 12/03/22 and 12/04/22 to 12/10/22. During an interview conducted on 01/12/23 at 10:25 a.m., when asked if social worker services were provided during the weeks of 11/27/22 to 12/03/22 and 12/04/22 to 12/10/22, MSW E said the patients caregiver did not let him visit due to COVID. He did not complete the MVRs. Patient #9 Review of the POC for 11/13/22 to 01/11/23 consists of a physicians order for Chaplain services once a month. Review of the Chaplain visit notes failed to provide documentation to support Chaplain services were provided during the month of December 2022. During an interview conducted on 01/12/23 at 11:36 a.m., when asked if Chaplain services were provided for the month of December 2022, Chaplain F said he did not see the patient in December. He moved the visits to January 2023, but did not complete a MVR for December. Patient #11 Review of the POC of 09/15/22 to 09/30/22 consist of a physicians order for hospice aide services 2 times a week. The clinical record failed to provide documentation to support hospice aide visits for the week of 09/18/22 to 09/24/22. There was one missed visit report dated 09/20/22 in the record. During an interview conducted on 01/12/23 at 2:02 p.m., when asked if hospice aide services were provided during the weeks of 09/18/22 to 09/24/22, the administrator/supervising nurse said the visits were scheduled in the electronic record. There was a missed visit for 09/20/22, but there were no additional missed visit reports. She did not know why the second visit was not completed. Review of the hospice policy titled, ";Plan of Care", dated 04/20/20 included, ";1. Policy Overview: The care and services provided to clients and their families are in accordance with an individualized written plan of care established by the hospice IDG in collaboration with the clients attending physician or allowed practitioner (if any), and, if appropriate, the client and/or his/her representative" ...

Based on clinical record review and interview the agency failed to ensure the patient's clinical record contained correct clinical information for 1 of 1 discharged patient record (#1) that was reviewed in that: The Hospice Skilled Nurse (HSN) incorrectly documented the location of an open wound. This failure has the potential to place Client #1 and the agency's Hospice's patients at risk of harm due to inaccurate or missing clinical information. The Findings Included: Review of discharged Patient #1's clinical record included an agency form entitled "Physician's Certification Of Terminal Illness, Hospice, Medicare/Medicaid Benefit" that revealed the certification date as 11/02/21 thru 01/30/22. His admitting terminal diagnosis were Unspecified severe protein-calorie malnutrition, Acquired Absence of Left Leg Below the Knee (BKA- Below the Knee Amputation) and encounter for change or removal of nonsurgical wound dressing / Pressure ulcer of other site stage 2. Review of discharged Patient #1's clinical record revealed Patient #1's Initial Assessment. It was dated 11/02/21 and was signed by RN B. Patient #1's clinical record included another agency form titled "Interdisciplinary Group/Update to The Comprehensive Assessment and Plan Of Care dated 12/01/21 that revealed a SN and visit frequency as three times a week. The form also contained a Physician order that Patient # 1 was to receive wound care to his Lower Right Medial Foot Wound as follows: Right Medial Foot and Right Heal. Cleanse with wound cleanser and gauze, pat dry with gauze, apply small amount of medihoney to wound base, cover with ABD pads and secure with Kerlix and tape." Patient #1's clinical record included three more agency form titled "Interdisciplinary Group/Update To The Comprehensive Assessment and Plan Of Care that were dated 12/16/21, 12/30/21 and 01/12/22 The forms all contained a Physician order for SN frequency to continue at three times per week and a Physicians order for Patient # 1 to receive wound care to his Lower Right Medial Foot Wound as follows: Right Medial Foot and Right Heal. Cleanse with wound cleanser and gauze, pat dry with gauze, apply small amount of medihoney to wound base, cover with ABD pads and secure with Kerlix and tape." Review of discharged Patient #1's clinical record revealed, Client #1's discharge summary. It was dated 01/15/22 and was signed by RN D. It revealed that the reason for discharge was that Patient #1's family member was seeking aggressive treatment for wound care/infection of his Right Medial Foot Wound. Review of discharged Patient #1's clinical record revealed a Patient #1's Initial Assessment. It was dated 11/02/21 and was signed by RN B. It also revealed that the reason for discharge was that Patient #1's family member was seeking aggressive treatment for wound care/infection of his Lower Right Medial Foot Wound. Review of the SN visits revealed that the frequency was being followed. 35 SN visits were documented. Review of 34 of the 35 SN visits revealed that wound care was done on Patient #1's Lower Right Medial Foot. Review of the SN visit note dated 01/13/22 and signed by RN C read in part: "Wound care to Right Medial Foot Wound completed, odor noted, cleared with cleansing wound. Wound is forming black eschar to 75% of wound, 25% muscle is visible, with s/s of infection. Coordination of care done with Medical Director and Clinical Manager (DON)." Review of the SN visit note dated 01/14/22 and signed by RN D read in part: "Wound care to Right Medial Foot completed at this time. Patient #1 tolerated wound care well. Eschar covering majority of Right Medial wound, serosanguinous drainage noted to foot. Edema noted to Right Lower Leg. Antibiotic to be started..." Review of the SN visit note dated 01/15/22 and signed by RN A read in part: "Foul smelling [sic] to Left Lower Extremity wound (Medial Foot Wound) and soiled wound dressing noted. Wound care preformed..." Note: Patient #1 has a Terminal diagnosis of Acquired Absence of Left Leg Below the Knee (BKA- Below the Knee Amputation). Further review of the SN visit note dated 01/15/22 and signed by RN A read in part: "Performed wound care as follows: Right Medial Foot. Cleanse with wound cleanser and gauze, pat dry with gauze, apply small amount of medihoney to wound base, cover with ABD pads and secure with Kerlix and tape..." During interview on 01/27/22 at 10:29 a.m. the Surveyor reviewed with the Adm Patient #1's entire clinical record, with special deference to the SN visit note dated 01/15/22. After reviewing the DON agreed with the following: - Patient #1's clinical record did not contain correct clinical information on the SN visit note date 01/15/22. Review of the Agency's Policy and Procedure Manual revealed s policy titled "Clinical Records", it was numbered PC.C15 but was not dated. It read it part: "A clinical record is established and maintained for every patient receiving care and services...The record is complete, promptly and accurately documented..."