Every finding on record at Crossroads Hospice of Philadelphia, LLC

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: Noted in the plan of care; and Documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) records reviewed of patients that receive Volunteer services revealed the agency did not ensure that the volunteers were following the frequency order in the plan of care CLINICAL RECORD 3: The patient election of benefit was 02/17/2024. A review of the clinical record revealed an order dated 06/26/2024 for volunteer services with a frequency of one (1) time a month. There was no documented evidence for volunteer visits for October and December of 2024 and no documentation for the reason for the missed visits.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes: The identification of each position that is occupied by a volunteer. The work time spent by volunteers occupying those positions; Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview which revealed during the review of the agency volunteer cost savings report with the Executive Director and the Volunteer Coordinator, it was found that the agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum equals 5% of the total patient care hours of all paid hospice employees and contract staff. The agency totaled 4.5% for the calendar year 2024. The Executive Director and the Volunteer Coordinator both agreed the agency did not meet the required 5% for 2024. During review of the volunteer cost savings report with the Executive Director and the Volunteer Coordinator, it was found that the agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum equals 5% of the total patient care hours of all paid hospice employees and contract staff. The agency totaled 4.5% for the calendar year 2024.

It is required that each patient’s individualized written plan of care: Reflects patient and family goals; Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; Includes all services necessary for the palliation and management of the terminal illness, including the following: Intervention to manage pain and symptoms. This standard was not met as evidenced by review of clinical records and discussion with the Clinical Director. In 1 of 13 (8%) records reviewed, the plan of care did not reflect all patient goals or interventions based on problems identified in the initial comprehensive assessment. Record #82349 - The patient was admitted on 3/2/2022 with a diagnosis of Malignant Neoplasm of the uterus. It is documented in the nursing assessment that the patient does experience intermittent pain and pain medication is ordered in the plan of care. There is no documentation in the plan of care that the nurse identified a goal or intervention for the patient to be free of pain. There are goals and interventions for relief of pain that could have been identified in the EMR but these care plans were not opened and included in the plan of care. The above evidence was reviewed, discussed and confirmed with the Clinical Director at the time of the clinical record review.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by review of clinical records and discussion with the Clinical Director. In 3 of 13 (23%) records reviewed, skilled nursing services were inconsistent with what was ordered on the plan of care. Record #83798 - The patient was admitted on 3/20/2022 with a skilled nurse visit frequency order of 2x/week. There was only one visit documented the week of 4/3/2022 and the week of 4/10/2022. No documentation was found to support a reason for the missed visits. Record: #16110 - The patient was admitted on 3/12/2022 with a skilled nurse visit frequency order of 1x/week and 2prn. The patient started to declined the week of 3/20/2022. The skilled nurse made 6 visits the week of 3/20/2022. There was no documentation found that the skilled nurse obtained an order for the additional visits. Record # 42751- The patient was admitted on 3/20/2022 with a skilled nurse frequency order of 2x/week. The was only one visit documented the week of 3/27/2022. No documentation was found to support a reason for the missed visit. The above evidence was reviewed, discussed and confirmed during the clinical record review with the Clinical Director.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care. This standard was not met as evidenced by review of clinical records and discussion with the Clinical Director. In 3 of 11 (27%) records reviewed , the aide services were inconsistent with the plan of care in relation to visit frequencies. Record #45115 - The aide was ordered to visit 2x/week starting at admission on 3/14/2022. The aide only visited one time the week of 3/20/2022. No documentation was found to support a reason for the missed visit. Record#17135 -The aide was ordered to visit 3x/week starting at admission on 2/12/2022. There was only one aide visit documented as performed the week of 2/27/2022. No documentation was found to support a reason for the two missed visits. Record #17021- The aide was ordered to visit 3x/week starting at admission on 3/7/2022. There was only two visits made the week of 4/3/2022 and no visits were made the week of 4/10/2022. The aide was discontinued after the missed visits. No documentation was found to support a reason for the missed visits. The above evidence was reviewed, discussed and confirmed with the Clinical Director at the time of the record review.