Every finding on record at Crisp Regional Hospital, Inc.

Observed in Individual Tracer. In 1 of 5 patient records reviewed, the hospice plan of care did not reflect required goals based on the assessement. RR#2 NHV developed 3+ pitting edema of the right leg and the care plan did not reflect any goals and or interventions to address the identified problem. This observation was discussed with the director.

Observed in Record Review. In 2 of 5 patient records reviewed, the hospice plan of care did not comprehensively reflect all orders required to address the patients' needs. RR#3 NHV had a neck wound that required packing and had purulent drainage. A review of the care plan and interim orders did not reflect the actual frequency of the wound care. The RN was visiting this patient 3x per week. RR#1 had a volunteer and there were no orders for the volunteer visits. This observation was discussed with the director.

Observed in Record Review. In 14 of 14 patient records reviewed, it was noted that there was no documentation of the need for volunteer services to offer support or respite to the patient, family, or other caregivers. For example, in records HOSHV#1 through #4 and HOSNHV#1 through #10 there was no documentation of the need for volunteer services on initial assessment or at reassessment. In records HO RRNHV#2 and #9 there was no documentation of the patient’s psychosocial status, such as family relationships, social history, the source and adequacy of environmental and other resources, coping mechanisms, and the patient’s and family’s reactions to illness. This was discussed with the Director and Clinical Coordinator present.

Observed in Record Review. In 14 of 14 patient records reviewed, it was noted that the interdisciplinary group did not include a social worker, marriage and family therapist or mental health counselor. For example in records HOSHV#1 to #4 and HOSNHV#1 to #10 there was no documentation of a social worker, marriage and family therapist or mental health counselor attending IDG as a result the comprehensive assessment collaboration was not complete. .Upon discussion with the Director, Quality nurse and Clinical Coordinator the full time social worker had left suddenly and unexpectedly 2 months ago and the team had been working with a PRN MSW who did not attend IDG or provide regular patient care. The prn MSW was available only for emergency situations. Leadership stated that there is a new MSW who will be starting next week.

Observed in Record Review. In 14 of 14 patient records reviewed, it was noted that the interdisciplinary group did not include a social worker, marriage and family therapist or mental health counselor. For example in records HOSHV#1 to #4 and HOSNHV#1 to #10 there was no documentation of a social worker, marriage and family therapist or mental health counselor attending IDG. Upon discussion with the Director, Quality nurse and Clinical Coordinator the full time social worker had left suddenly and unexpectedly 2 months ago and the team had been working with a PRN MSW who did not attend IDG or provide regular patient care. The prn MSW was available only for emergency situations. Leadership stated that there is a new MSW who will be starting next week.

Observed in Record Review. In 13 of 14 patient records reviewed, it was noted that the written plan of care was not based on the patient's individualized goals and the time frames, settings and services required to meet the goals. For example, the goals Patient achieves feelings of spiritual comfort. and Survivor will be knowledge of bereavement services and when needed, will use available support to achieve a more positive grief outcome.. were not individualized it was stated verbatim in multiple records. In record HOSRRHV#1 and HOSRRNHV#5 the plan of cares included a goal for emergency evacuation however the interventions were for fall risk. In record HOSHV#3 the patient had a G-tube that he received bolus feedings and medications through, However there were no goals or interventions related to the G-tube since admission over 3 months prior and no goals or interventions were documented when the patient was placed in a SNF for respite care 4 days ago. In record HOSRRHV#4 there were 3 respiratory goals started on admission in 2022, for example Patient/cg demonstrate proper administration of oxygen. The goals had not been updated and based on nurse notes appeared to have been achieved. This was discussed with the Clinical Coordinator present.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted that the plan of care did not include all treatment necessary to meet the patient's needs. For example, in record HOSRRHV#4 the POC orders included foley catheter 2 flushes(20ml) but no indication of what to flush the catheter with. This was confirmed with the Clinical Coordinator present.

Observed in Record Review. In 14 of 14 patient records reviewed, it was noted that the interdisciplinary group did not include a social worker, marriage and family therapist or mental health counselor. For example in records HOSHV#1 to #4 and HOSNHV#1 to #10 there was no documentation of a social worker, marriage and family therapist or mental health counselor attending IDG. Upon discussion with the Director, Quality nurse and Clinical Coordinator the full time social worker had left suddenly and unexpectedly 2 months ago and the team had been working with a PRN MSW who did not attend IDG or provide review and revision of the plan of care as the patient's condition required, but no less frequently than every 15 days. The prn MSW was available only for emergency situations. Leadership stated that there is a new MSW who will be starting next week.

Observed in Record Review. During review of a bereavement care plan with the chaplain/bereavement coordinator, the hospice pharmacy surveyor noted that two sisters were having a disagreement over the key elements which were involved in grieving the loss of their mother. Although the chaplain was aware this was occurring, he did not identify any documented interventions in the documented bereavement plan of care to improve this problem. This was reviewed with the chaplain at thentime of the survey. Observed in Record Review. During review of a bereavement care plan with the chaplain/bereavement coordinator, the hospice pharmacy surveyor noted that this patient's bereavement care plan included the required telephone calls and mailings; however this record did not include that the calls were being made at the specified intervals. The chaplain indicated a call was probably last made to the bereaved in Dec 2024 with no documentation found in the record that this occurred or whether there was a connection made or what timeframe for a callback was planned. This issue was reviewed with the chaplain at the time of the survey.

Observed in Tracer Activities. During a review of the volunteer program with the new current volunteer coordinator, the interim volunteer coordinator and the hospice director, the hospice pharmacy surveyor noted that documentation of recruitment and retention activities was not available for review for all of 2023 and in 2024 only for the first quarter and resumed the first quarter of 2025.

Observed in Tracer Activities. During a review of the volunteer hours presented, the hospice pharmacist surveyor noted that the organization had not accurately documented the estimated cost savings for 2023 and 2024 as they had not met the required 5% of total patient care hours that were provided by volunteers. Estimated cost savings for 2023 was $1990 and for 2024 was $8040. This issue was validated with the volunteer coordinator and the director at the time of the survey.

Observed in Document Review. The volunteers must provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. The hospice must maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked. The Hospice pharmacy surveyor observed in tracer activities and during a discussion with the volunteer coordinator and review of available records prepared in 2024, documentation of direct patient care and administrative hours to equal 1.31% of the total patient care hours of all paid employees in 2023. The amount of savings achieved for 2024 was documented to be at 1.96 %,. The validation of this information was reviewed with the volunteer coordinator and director at the time of the survey

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level finding at 418.78 and 418.56 as significant issues with care planning, physician orders and there were instances of not following physician orders as per policy.

Observed in HR File Review. In 2 of 2 HR files reviewed, for the only two volunteers currently providing services to hospice patients, the hospice pharmacy surveyor noted that initial competencies was not a part of the orientation process. Both of these volunteers came on board in the summer of 2023, This omission was validated with the hospice director and clinical coordinator at the time of the survey.

Observed in Record Review. In 3 of 13 patient records reviewed, the organization did not assess the patient according to defined time frames. The hospice interdisciplinary group did not complete the comprehensive assessment within five days of the election of hospice care. In review of the record for HV#1 and HV#5, it was noted the initial MSW psychosocial assessment was completed 13 days after the patient's admission to hospice. In RR#2, the initial MSW psychosocial and Chaplin spiritual care assessments were completed six (6) days from the patient's election of hospice care. This was reveiwed and confirmed with the Director.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization did not assess/reassess its patient. Hospice did not conduct/document a patient-specific comprehensive assessment that included severity of symptoms. In RR#5, it was documented in the RN initial assessment and the Certificate of Terminal Illness the patient had a pressure ulcer/decubitus of the buttock. There was no detailed wound assessment performed/documented by the RN per organizational policy upon admission to hospice. This was reviewed and confirmed with the Clinical Coordinator.

Observed in Record Review. In 3 of 3 patient records reviewed, the hospice did not conduct and document survivor risk factors, including behaviors after the death, availability of coping mechanisms, and the potential for pathological grief reactions. In BR#1, BR#2, and BR#3, there was no post-death bereavement assessment completed/documented by the bereavement staff (MSW and Chaplin). The bereavement plan of care was developed based on the initial bereavement assessment completed by the RN at the start of care. This was reveiwed and confirmed with the Director.

Observed in Record Review. In 2 of 13 patient records reviewed, the organization did not plan the patient's care by including all services in the hospice plan of care needed for the palliation and management of the terminal illness and related conditions, including anticipated measurable outcomes/goals. In review of the record for HV#3, the patient had an indwelling foley catheter due to urinary retention. The catheter was recently discontinued with a new medication added to the plan of care for Mybetriq 25mg by mouth daily for 14 days. It was noted there were no goals/anticipated outcomes established for the patient's GU status in the hospice plan of care. In RR#1, the RN assessment/plan of care indicated the patient was non-ambulatory/non-weightbearing, chair/bed-fast, and at high risk for skin breakdown per the Braden scale. There were no goals/anticipated outcomes identified in the plan of care related to the patient's integumentary risk status. This was reveiwed with the Director and Clinical Coordinator.

Observed in Data Session. The organization did not analyze and compare internal data over time to identify levels of performance, patterns, trends and variations. During the hospice system tracer session for Data Management it was noted, that although the hospice collected data from care staff and performed follow-up on individual medication errors and/or adverse drug reactions, there was no data aggregated or analysis performed over time to determine trends and patterns. This was reviewed and confirmed with the Director.