Every finding on record at Dallam-Hartley Counties Hospital District

Based on interview and record review, the IDG (interdisciplinary group) failed to update the comprehensive assessment at least every 15 days for 2 of 2 (#5 and 11) patient records reviewed with December 8, 2023 to March 6, 2024 included in the review period. This failure of the hospice to perform updates to the comprehensive assessments at least every 15 calendar days could cause patients not to receive appropriate care and services and not having care updated with their most current identified needs. --- Findings include: Patient #5 – Review of the clinical record for the certification period from 12/08/23 to 03/06/24 included a review of the IDG (Interdisciplinary Group) updates of the plan of care that indicated that updates were conducted on 12/12/23 and 01/09/24 (28 days) between IDG meetings to review and update the comprehensive assessment. Patient #11 – Review of the clinical record for the certification period from 12/08/23 to 03/06/24 included a review of the IDG (Interdisciplinary Group) updates of the plan of care that indicated that updates were conducted on 12/12/23 and 01/09/24 (28 days) between IDG meetings to review and update the comprehensive assessment. During an interview conducted on 03/20/24 at 2:45 p.m., with Alternate Administrator/Supervising Nurse B, when presented with IDG dated 12/12/23 and asked if there were additional IDGs held in December 2023, Alternate Administrator/Supervising Nurse B said the IDG was due to be held on 12/26/23 but was not held due to staff being off for the holidays and she was seeing the patients and on call. During an interview conducted on 03/21/24 at 9:17 a.m., with Office manager/Chaplain/Bereavement Coordinator/Volunteer Coordinator I, when asked if an IDG meeting was held from 12/13/23 to 01/09/24, Office manager/Chaplain/Bereavement Coordinator/Volunteer Coordinator I said he did not know because he was on vacation from 12/15/23 to 01/03/24. Surveyor requested IDG sign in sheets. The IDG meeting staff sign in sheets were presented to the surveyor on 03/21/24 at 10:00 a.m., these indicated IDG meetings were conducted on 12/12/23 and 01/09/24 (28 days between meeting to review and update the comprehensive assessment). During an interview conducted on 03/21/24 at 11:21 a.m. with MSW C when asked if the hospice had an IDG meeting from 12/12/23 to 01/09/24, MSW C said she knows some staff were sick and others were off for the holidays, and she did not remember attending an IDG during that time. Review of the hospice policy titled, ";Reassessment/Update to the Comprehensive Assessment", with a revision date of 02/2021 included ... ";Procedure-1. The update of the comprehensive assessment must be accomplished by the Hospice IDG (in collaboration with the patients attending physician, if any) and must consider changes that have taken place since the initial assessment. It must include information on the patient's progress toward desired outcomes, as well as a reassessment of the patients response to care. The assessment updates must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. ... 4. Staff will analyze the data from assessments and reassessments. Such analysis of data will assist staff in identifying and prioritizing patient needs and problems to direct care and services and update the IDG care plan."

Based on interview and record review, the hospice failed to ensure the registered nurse conducted an on-site visit to the patients home no less frequently than every 14 days to supervise services provided by the home health aide for 1 of 2 (#5) patients reviewed in which home health aide services were provided for more than 2 weeks. This failure could result in the skilled nurse failing to identify and address areas of concern with the services provided by the home health aide. --- Findings include: Patient #5 - Review of the clinical record certification period from 12/08/23 to 03/06/24 included a physicians order for hospice aide services 2 times a week for 12 weeks. Review of the hospice aide visit notes indicated hospice aide service began on 12/21/23. Review of the skilled nursing visits indicated a hospice aide supervisory visit was performed on 01/05/24 by RN E. (15 days after hospice aide services began). During an interview conducted on 03/21/24 at 2:41 p.m., with RN E, when asked if there were additional hospice aide supervisory visits performed from 12/21/23 to 01/05/24, RN E stated she thought the hospice aide had to be present for her to perform a supervisory visit and the aide was not present so the supervisory visit was not performed, but later had learned that the supervisory visits could be performed without the aide present. Review of the agency policy titled, ";Hospice Aide Supervision", with a revision date of 03/2013 included, ";Policy – All Hospice Aide supervisory visits will be made at least every 14 days." ... ";Procedure- Hospice Aides are closely supervised to ensure their competence in providing care. At least every 14 days the registered nurse (RN) makes an onsite home supervisory visit to assess relationships and determine whether goals are being met. This is done with or without the aides presence." ...