Every finding on record at Community Hospice, LLC

Based on medical record review, staff interview and policy and procedure review, the facility failed to ensure the chaplain and social worker provided home visits and services in accordance with the plan of care (POC) for home visit frequency in three (3) of 13 medical records reviewed, Patient #4, #6, and #12. Findings Include: Review of medical record for Patient #4 revealed: " ...POC...Episode 10/08/2021 to 12/06/2021 Orders: ...Chaplain to provide spiritual support and reassessment for patient and family ...Chaplain visit frequency two (2) times a month ...Social Worker to assess needs, build a supportive relationship to allow for expressions of grief, provide emotional support, encouragement and assist as needed ...Social Worker visit frequency two (2) times a month ...". Further record review revealed Chaplain telehealth visit documented on 10/13/2021 with no further evidence documented of chaplain home visits for period reviewed. Further record review revealed Social Worker visit documented on 10/12/2021 with no further documented evidence of second home visit for the month of 10/2021. Review of medical record for Patient #6 revealed: " ...POC ...Episode 10/04/2021 to 01/01/2021 ...Orders: ...Chaplain to provide spiritual support and reassessment for patient and family ...Chaplain visit frequency two (2) visits a month ...". Further record review revealed Chaplain visit documented on 10/06/2021 and a second visit for the month documented on 10/15/2021 with no further documented evidence of Chaplain home visits or services for the period reviewed. Review of medical record for Patient #12 revealed: " ...POC ...Episode 11/12/2021 to 02/09/2021 ...Orders: ...Chaplain to provide spiritual support and reassessment for patient and family ...Chaplain visit frequency two (2) visits a month ...Social Worker to assess needs, build a supportive relationship to allow for expressions of grief, provide emotional support, encouragement and assist as needed ...Social Worker visit frequency two (2) times a month ...". Further record review revealed Chaplain visit documented on 11/16/2021 and no further documented evidence of visits or services for the period reviewed. Further record review revealed Social Worker documented a visit on 11/15/2021 with no further documented evidence of visits or services for the period reviewed. During an interview on 12/03/2021 at 11:00 a.m., the Executive Director confirmed she was aware of the chaplain and social worker missed visit frequencies and visit/service documentation for Patients #4, # 6, and # 12 for periods reviewed. Review of the facility's policy, number "2.003", revealed: " ...ongoing assessment of patients during hospice care ... the Chaplain will reassess the patient/representative regarding spiritual issues or goals and document any findings in the medical record ... based upon assessments, plan of care will be reviewed and revised accordingly by hospice in collaboration with all hospice interdisciplinary group members...". Review of the facility's policy, number "2.009", revealed: " ...4. The social worker will continue to visit the patient/family at intervals designated by the plan of care.". Review of the facility's policy, number "3.002", revealed: " ...agencies will need to update the plan of care ... 2. (d) ensuring that the care and services are provided in accordance with the plan of care ...". Review of the facility's policy, number "2.005", revealed: " ...3. The chaplain ... will continue to visit the patient/representative at intervals designated by the patient's plan of care." During Exit Conference on 12/03/2021 at 01:00 p.m., survey findings were discussed and no further documentation was submitted for review.