Every finding on record at Cp Ak Hospice LLC

Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed no later than 5 days after the election of hospice care for 2 of 6 records (#1 and #6) reviewed for completion of initial comprehensive assessments. This failed practice placed these patients at risk for not having a plan of care developed that identified the patient /family's spiritual needs and desires. --- Clinical record #1 Review of the clinical record on 9/22/23 for Patient #1 revealed the patient had an election of benefits signed on 8/8/23. The patient was admitted with diagnoses that included Alzheimer's Disease. Review of the patient's plan of care for the benefit period of 8/9/23 - 10/7/23 revealed no documentation of an initial evaluation / assessment performed by a spiritual counselor / chaplain within 5 days after the election of hospice date of 8/8/23. A review of Clinical Record #1 occurred on 9/22/23. The Date of election for hospice services was 8/8/23. The patient's primary diagnosis was Alzheimer's Disease. A further review of this record revealed there had been no spiritual assessment had occurred. Review of a telephone encounter hospice note signed by the Chaplain on 8/11/23 at 4:41 PM revealed, "[Representative of Patient #1] asked me to continue to visit [Patient #1]." Review of a 9/20/23 Chaplain repeat visit hospice signed by the Chaplain on 9/21/23 at 4:25 PM revealed a chaplain visit had occurred on 9/20/23 at 4:06 PM and ended at 4:22 PM. This note revealed, "Pray with pt {patient] as pt. is near death. Chaplain also arranged for a Presbyterian pastor to visit pt at 7 PM today to pray with pt. This was requested by pt. today ... " Clinical record #6 Review of the clinical record on 9/21/22 - 9/22/23 for Patient #6 revealed the patient had an election of benefits signed on 8/30/23. The patient was admitted with diagnoses that included Parkinson's Disease. Review of the patient's plan of care for the benefit period of 8/30/23 - 11/27/23 revealed no documentation of an initial evaluation / assessment performed by a spiritual counselor / chaplain within 5 days after the election of hospice date of 8/30/23. Review of a telephone encounter hospice note dated 9/1/23 at 5:33 PM and signed by Chaplain #1 stated, "[Power of attorney for Patient #6] said it would be okay for the chaplain to visit [Patient #6]." Review of an Encounter Note dated 9/7/23 at 8:45 PM, signed by Licensed Nurse #1 stated, "9:40 PM Call from [Assisted Living Facility caregiver] requesting chaplain to visit. RN advised no chaplain on call." Review of a SN Repeat Visit Hospice document dated 9/8/23 at 5:16 AM signed by Licensed Nurse #2 revealed the Patient #6 had passed away. During an interview on 9/21/23 at 3:30 PM, the Chaplain revealed, when asked if a spiritual assessment or chaplain visit had been completed, that no chaplain visit or spiritual assessment had occurred. The chaplain further revealed, "I was scheduled to go on September 7th, but it was a bad situation there." The chaplain agreed that there had been no attempt to visit in the first five days of the patient being on service so this visit was late even with the attempt of the chaplain to visit on September 7th, 2023 He also stated that there were no on - call after hours availability and that he worked Monday - Friday 8:30 AM - 4:30 PM. During an interview on 9/22/23 at 11:45 AM, the Assisted Living Facility caregiver for Patient #6 revealed asking for a chaplain to visit by calling Licensed Nurse #1 and requesting the visit. The patient and power of attorney revealed asking the power of attorney and patient if they wanted a chaplain visit, "[Patient #6 and his / her power of attorney] said, yes that would be nice]." During an interview on 9/22/23 at 2:10 PM, the Administrator agreed that the chaplain had not completed chaplain assessments or visits. During an interview on 9/22/23 at 2:00 PM, the Hospice Clinical Manager and Administrator revealed that there was a lack of initial evaluation / spiritual assessment being completed for Clinical Record #1 and #6. The agency policy titled "Spiritual Care Services" dated 4/2022 revealed, "Spiritual care Services will be available on a 24 hour basis when reasonable and necessary to meet the needs of the patient and family ... A spiritual care assessment will be performed on each new hospice admission no later than 5 calendar days after the election of hospice care, unless requested to be later than 5 days by the patient / family / caregiver."

Based on record review and interview, the agency failed to ensure the spiritual assessments and chaplain visits were completed after the election of hospice care for 2 of 6 records reviewed (#1 and #6). This failed practice placed the patients and their families at risk for not receiving spiritual counseling according to their desires and needs. --- Patient #1 A review of Clinical Record #1 occurred on 9/22/23. The Date of election for hospice services was 8/8/23. The patient's primary diagnosis was Alzheimer's Disease. A further review of this record revealed no spiritual assessment had occurred. A review of a Hospice Plan of Care updated 9/14/23 and effective from 9/14/23 - 9/27/23, revealed the chaplain was to visit every week for 9 weeks. This document stated, "Chaplain: Problem: Spiritual / Community Resources Chaplain starting 8/11/23 Identify patient / family spiritual or religious resources, Goal Hospice Spiritual / Community Resources starting 8/11/23 Patient / family identify their beliefs / practices that impact their hospice experience. Patient / family identify their beliefs / practices that support hospice experience. Patient / family coping identified. Spiritual distress identified and decreased with visit as evidenced by family's verbalization of satisfaction of spiritual care provided by 9/30/23. Intervention: Provide spiritual support, Chaplain Starting 8/11/23 Frequency: as needed, Provide ministry of presence and affirmation, asking exploratory questions that invite life stories, acknowledging the challenges being faced, offering empathetic listening and, as appropriate, individualized spiritual interventions such as prayer." Review of a telephone encounter hospice note signed by the Chaplain on 8/11/23 at 4:41 PM revealed, "[Representative of Patient #1] asked me to continue to visit [Patient #1]." Review of a 9/20/23 Chaplain repeat visit hospice signed by the Chaplain on 9/21/23 at 4:25 PM revealed a chaplain visit had occurred on 9/20/23 at 4:06 PM and ended at 4:22 PM. This note revealed, "Pray with pt. as pt. is near death. Chaplain also arranged for a Presbyterian pastor to visit pt at 7 PM today to pray with pt. This was requested by pt. today." Patient #6 A review of Clinical Record #6 occurred on 9/21/23 and 9/22/23. The Date of election for hospice services was 8/30/23. The patient's primary diagnosis was Parkinson's Disease. A further review of this record revealed there had been no spiritual assessment or chaplain visits made despite requests for the chaplain to visit. A review of the Hospice Plan of Care dated 8/30/23 revealed, "Chaplain visits 1 visit every 13 weeks for 13 weeks ... Problems as of 9/7/23 Chaplain Problem: Spiritual / Community Resources Chaplain starting 9/1/23 Identify patient / family spiritual or religious resources, Goal Hospice Spiritual / Community Resources starting 9/1/23 Patient / family identify their beliefs / practices that impact their hospice experience. Patient / family identify their beliefs / practices that support hospice experience. Patient / family coping identified. Spiritual distress identified and decreased with visit as evidenced by family's verbalization of satisfaction of spiritual care provided by 10/30/23. Intervention: Provide spiritual support, Chaplain Starting 9/1/23 Frequency: as needed, Provide ministry of presence and affirmation, asking exploratory questions that invite life stories, acknowledging the challenges being faced, offering empathetic listening and, as appropriate, individualized spiritual interventions such as prayer." Review of a telephone encounter hospice note dated 9/1/23 at 5:33 PM and signed by Chaplain #1 stated, "[Power of attorney for Patient #6] said it would be okay for the chaplain to visit [Patient #6]." Review of an Encounter Note dated 9/7/23 at 8:45 PM, signed by Licensed Nurse #1 stated, "9:40 PM Call from [Assisted Living Facility caregiver] requesting chaplain to visit. RN advised no chaplain on call." Review of a SN Repeat Visit Hospice document dated 9/8/23 at 5:16 AM signed by Licensed Nurse #2 revealed Patient #6 had passed away. During an interview on 9/21/23 at 3:30 PM, the Chaplain revealed, when asked if a spiritual assessment or chaplain visit had been completed, that no chaplain visit or spiritual assessment had occurred. The chaplain further revealed, "I was scheduled to go on September 7th, but it was a bad situation there." The chaplain agreed that there had been no attempt to visit in the first five days of the patient being on service, so this visit was late even with the attempt of the chaplain to visit on September 7th, 2023 He also stated that there were no on - call after hours availability and that he worked Monday - Friday 8:30 AM - 4:30 PM. During an interview on 9/22/23 at 11:45 AM, the Assisted Living Facility caregiver for Patient #6 revealed asking for a chaplain to visit by calling Licensed Nurse #1 and requesting the visit. The patient and power of attorney revealed asking the power of attorney and patient if they wanted a chaplain visit, "[Patient #6 and his / her power of attorney] said, yes that would be nice]." During an interview on 9/22/23 at 2:10 PM, the Administrator agreed that the chaplain had not completed chaplain assessments or visits. During an interview on 9/22/23 at 2:00 PM, the Hospice Clinical Manager and Administrator revealed that there was a lack of spiritual assessment being completed for Clinical Record #1 and #6. The agency policy titled "Spiritual Care Services" dated 4/2022 revealed, "Spiritual care Services will be available on a 24 hour basis when reasonable and necessary to meet the needs of the patient and family ... A spiritual care assessment will be performed on each new hospice admission no later than 5 calendar days after the election of hospice care, unless requested to be later than 5 days by the patient / family / caregiver."

Based on observation, policy review, and interview, the hospice agency failed to ensure staff changed gloves and completed hand hygiene when going from a dirty task to a clean task for one of one patient (Patient #8) during an observation of wound care. The failure to change gloves and complete hand hygiene when performing wound care had the potential to contaminate the wound which could lead to infection. This had the potential to affect all patients with wounds. Findings: During an observation on 11/18/21 at 1:00 PM, Licensed Nurse (LN) #1 removed a dressing from Patient #8's right breast area. While wearing the same gloves, LN#1 proceeded to clean the wound, sprinkled a small amount of powered metronidazole (used to reduce odor and exudate) to the wound bed, opened a new clean dry dressing, and applied it to the wound. During an interview on 11/18/21 at 1:45 PM, LN #1 confirmed that gloves should have been removed, hand hygiene completed, and clean gloves applied when going from a dirty task to a clean task. Review of the facility's undated policy titled, "Standard Precautions, Providence Hospice," indicated staff are to "Change gloves between tasks and procedures on the same patient...Remove gloves promptly after use before touching non-contaminated items..." During an interview on 11/19/21 at 12:30 PM, the Director of Hospice and Palliative Care confirmed LN #1 should have removed gloves, completed hand hygiene, and put on clean gloves when going from a dirty task (removing the old dressing) and before opening and applying the clean dressing. .