Every finding on record at Crossroads Hospice of Northeast

Based on medical record review and staff interview, the agency failed to implement the interdisciplinary plan of care for one of three medical records reviewed (Patient #1). The agency's census was 446. Findings include: --- Review of Patient #1's medical record revealed she elected hospice benefits from the agency on 06/18/23. She was admitted with a terminal diagnosis of Malignant Neoplasm of upper-outer quadrant of right female breast with metastasis to bone. A lock box for her pain medication and daily visits were implemented on 08/27/23 due to discrepancies with controlled substances. Review of the agency call log revealed on 09/02/23 at 12:40 PM the patient called and spoke with Staff K and asked to know what time the nurse would arrive today because she had plans. The call was sent to a Licensed Practical Nurse to call with an estimated time of arrival. There was no documentation indicating the patient was contacted and an arrival time was discussed. Review of the call log revealed on 09/02/23 at 9:06 PM Patient #1 called and stated she needed to let the nurse know that she was on her way home. Staff D returned call to Patient #1 at 9:32 PM with no answer. A message left stating Patient #1 remains on a daily watch and was to be seen tomorrow on 09/03/23. The message also asked that if Patient #1 had any needs or concerns she was to call. Review of the call log revealed on 09/03/23 at 9:16 AM Staff D spoke with Patient #1's daughter who demanded that someone go to Patient #1's home now and open the lockbox to get Patient #1's pain medications as no one showed up last night to do so. The daughter was advised that Patient #1 did call in last night to the call center and relayed that Patient #1 was on her way home. Staff D did call back and did not get an answer. A voice message was left stating to call back with needs. Staff B was interviewed on 10/18/23 at 2:50 PM. Staff B reported the agency did not dispatch nurses to patients' homes until the patients were home. Patient #1 called and stated she was on her way home. Staff D called Patient #1 and did not get an answer and Patient #1 did not call the agency back on 09/02/23. There was no evidence in the patient's record that the agency attempted to contact Patient #1's family/caregivers when the agency was unable to reach Patient #1 for a visit required to distribute Patient #1's pain medications. This deficiency represents non-compliance investigated under Substantial Allegation 101061.

Based on review of agency policy, review of incident/complaints, and staff interview, the agency failed to investigate and provide resolution to a family complaint. This affected one (Patient #1) of three former patients whose records were reviewed. Findings include: Review of an incident complaint dated 07/19/22 revealed Patient #1's daughter had called the agency upset as she did not feel the agency took care of her father as needed, stating nursing should be doing more than just vital signs and checking feet. She was upset Patient #1 died unattended. There was no follow up to this complaint documented by the agency. Review of the agency policy titled "Investigation and Resolution of Patient/Family Conflicts, Grievances, and/or Complaints," renewed 05/26/22, revealed it was agency policy for the Clinical Director and/or Executive Director (or their designee) to be responsible for immediately beginning to investigate concerns or grievances and should make every effort to resolve the concern/grievance to the patient and/or family's satisfaction. The policy further revealed the resolution/outcome information was to be communicated to the complainant either verbally or in writing. Interview on 08/24/22 at 1:34 PM the Director of Nursing (DON) verified the final complaint filed by Patient #1's daughter on 07/19/22 was not followed up on and Patient #1's daughter had never been called back regarding her complaint.

Based on medical record review, policy review and staff interview, the agency failed to ensure the interdisciplinary group (IDG) followed and revised the plan of care for one (Patient #4) of 20 patient reviewed. The agency's active census at the time of the survey was 487. Findings include: Review of Patient #4's record revealed the IDG reviewed Patient #4's frequency of nursing visits on 06/15/22 and 06/29/22. The ordered nursing visits stated one visit per day. The agency completed skilled nursing visits for Patient #4 on 06/14/22, 06/16/22, 06/30/22 and 07/08/22. The agency did not conduct skilled nursing visits once a day per the IDG frequency. Review of the agency policy titled "IDG Hospice Plan of Care - Content, Plan, Goals, Interventions and Outcomes Policy #223-A," revised 12/08/18, revealed under the heading Coordination of Services the hospice will develop and maintain a system of communication and integration in accordance with policies and procedures, to ensure that the care and services are provided in accordance with the plan of care. Under the heading Review of the Plan of Care the hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. Interview on 07/14/22 at 12:20 PM, Staff A confirmed the care plan was not revised for the actual frequency assessed. The ordered frequency should have been documented as one visit per week.