Every finding on record at Clay County Health Department

Based on document review and interview, it was determined for 5 of 5 (Pt #2, Pt #6, Pt #7, Pt #9, and Pt #10) patients reviewed for initial bereavement assessment, the Hospice failed to ensure the assessment was conducted and incorporated into the Plan of Care (POC). This has the potential to affect all patients serviced by the Hospice. Findings include: --- 1. The policy titled "Bereavement Services (reviewed by Hospice 6/2019)" was reviewed on 10/18/23 at approximately 9:00 AM. The policy stated, "... Procedure: The Bereavement Initial Assessment/Care Plan is completed by the MSW on the first visit." 2. Pt #2 SOC: 05/24/23 Dx: Malignant Neoplasm of upper-outer quadrant of left female breast The record was reviewed on 10/18/23 at approximately 11:45 AM. The record lacked an initial bereavement assessment. 3. Pt #6 SOC: 08/09/23 Dx: End Stage Liver Disease. The record was reviewed on 10/18/23 at approximately 2:00 PM. The record lacked an initial bereavement assessment. 4. Pt #7 SOC: 04/11/23 Dx: Heart Failure, unspecified. The record was reviewed on 10/18/23 at approximately 3:30 PM. The record lacked an initial bereavement assessment. 5. Pt #9 SOC: 07/05/23 Dx: Pneumonitis due to inhalation of food and vomit. The record was reviewed on 10/19/23 at approximately 9:15 AM. The record lacked an initial bereavement assessment. 6. Pt #10 SOC: 06/20/23 Dx: Malignant neoplasm of prostate. The record was reviewed on 10/19/23 at approximately 10:00 AM. The record lacked an initial bereavement assessment. 7. An interview was conducted with the Clinical Coordinator (E #2) on 10/19/23 at approximately 3:00 PM. E #2 reviewed the records and verbally agreed the records lacked initial bereavement assessments. E #2 stated, "We have a newer electronic system and the initial bereavement assessments are not getting documented into the system."

Based on clinical record review and staff interview, it was determined in 1 of 2 (Pt #2) patents with wounds, the Hospice failed to ensure wound measurements were completed weekly as required. This has the potential to affect all hospice patients who have wounds. Findings include: --- 1. Pt. #2. SOC 05/24/23. Hospice Diagnosis: Malignant neoplasm of upper-outer quadrant of left female breast. The clinical record was reviewed on 10/18/23 at 11:45 AM. The record included a "Hospice Supplementary Order" dated 07/26/2023. The physician's order stated, "Integumentary Skin integrity wound treatment: Perform wound care as follows: may cleanse left breast/nipple area with NS (normal saline) pat dry, apply dry dressing daily and prn (as needed). The record lacked wound measurements 6/9 weeks (week of 8/20, 8/27, 9/3, 9/10, 9/17 and 10/1) during the certification period 8/20/2023 thru 10/18/2023. . 2. The policy titled, " Wound Care/Assessment (effective date 05/20/2020)" was reviewed on 10/18/23 at 1:00 PM. The policy stated, "... Procedure:... C. RN is to measure wounds on a weekly basis if patient allows..." 3. An interview was conducted with the Clinical Coordinator (E #2) on 10/19/2023 at approximately 12:00 PM. E #2 reviewed Pt #2's record and verbally agreed the record lacked the required wound measurements and stated, "The wound measurements should be completed and documented weekly."

Based on document review and interview, it was determined the Hospice failed to ensure bereavement services were under the supervision of a medical social worker who is qualified in grief and loss counseling. This has the potential to affect all patients and families who are serviced by the hospice. Findings include: --- 1. The policy titled "Bereavement Services (reviewed by Hospice 6/2019)" was reviewed on 10/19/23 at approximately 9:00 AM. The policy stated, "... Policy:.... Bereavement program is under the direction of the Bereavement Coordinator and supervised by Medical Social Worker who is qualified in grief and loss counseling." 2. An interview was conducted with the Bereavement Coordinator (E #3) on 10/20/23 at approximately 1:00 PM. E #3 stated, "My background is in finance. The only experience I have with Hospice is when my mother was on hospice." When E #1 was asked if a Social Worker supervises the bereavement program, E #1 stated, "No. The social worker can and will make home visits if the nurse or myself sees the need. The social worker does not oversee the bereavement program." 3. An interview was conducted with the Home Care Director (E #1) on 10/20/23 at approximately 1:15 PM. E #1 stated, "We had a part-time social worker that probably oversaw the bereavement program. Our census has been down so the Social Worker is prn and does not supervise the bereavement program. That has slipped. We will correct that."