Every finding on record at Envision Hospice

Based on record review and interview, the agency failed to ensure that care was provided according to the Interdisciplinary Group (IDG) written plan of care in 6 of 10 patients (Patients #1, 3, 4, 5, 7, 8) did not receive Chaplain services as written in the plan of care. This failure could have placed the agency's former hospice patients at risk of a decline in health from not receiving the necessary care and treatment. The agency has not had an active patient since November 2023. --- The findings included: Closed record reviews:1. Closed record review of Patient #4's plan of care for certification period 04/18/2022 through 06/13/2022 revealed a start of care date 04/18/2022 with a terminal diagnosis of Alzheimers disease (Alzheimers disease is a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks.) and orders for the Chaplain to visit one time a month. Further review of the clinical record revealed the Chaplain conducted 2 visits (05/02/22 and 05/16/22) for the month of 05/22 and 2 visits (06/06/22 and 06/13/22) for the month of 06/22. The clinical record did not contain documentation as to why 2 extra visits were provided. Review of IDG meetings revealed the following:IDG meeting dated 04/21/22 read in part, ";...Chaplain report...getting all plans together, will have a better report next week ...Changes to goals/POC: no changes at this time..."IDG meeting dated 05/05/22 read in part, ";...Chaplain report: ...High risk bereavement...Changes to goals/POC: no changes at this time..."IDG meeting dated 05/19/22 read in part, ";...Chaplain report: no changes needs being met...Changes to goals/POC: no changes at this time..."IDG meeting dated 06/02/22 read in part, ";...Chaplain report: no visits performed...Changes to goals/POC: no changes at this time..." 2. Closed record review of Patient #5's plan of care for certification period 10/17/2022 through 12/15/2022 revealed a start of care date 04/20/2022 with a terminal diagnosis of Unspecified systolic (congestive) heart failure (When the heart functions poorly as a pump and does not circulate blood adequately via the circulatory system to meet the demands of the body the term cardiovascular insufficiency is sometimes used. This generally leads to the syndrome of heart failure.) orders for the Chaplain to visit one time a month. Further review of the clinical record revealed the Chaplain conducted 3 visits (11/02/22, 11/16/22 and 11/30/22) for the month of 11/22 and 2 visits (06/06/22 and 06/13/22) for the month of 06/22. The clinical record did not contain documentation as to why 2 extra visits were provided.Review of IDG meetings revealed the following:IDG meeting dated 10/19/22 read in part, ";...Chaplain report: no visits performed...Changes to goals/POC: none..."IDG meeting dated 1/05/22 read in part, ";...Chaplain report: ...patient accepting of chaplain visits...Changes to goals/POC: none..."IDG meeting dated 11/16/22 read in part, ";...Chaplain report: no issues identified...Changes to goals/POC: none..."IDG meeting dated 11/30/22 read in part, ";...Chaplain report: no issues identified ...Changes to goals/POC: none..."IDG meeting dated 12/14/22 read in part, ";...Chaplain report: no issues identified ...Changes to goals/POC: DC instead of recertification as patient is not terminally ill..." 3. Closed record review of Patient #7's plan of care for certification period 11/16/2022 through 02/13/2023 revealed a start of care date 08/18/2022 with a terminal diagnosis of Unspecified systolic (congestive) heart failure (When the heart functions poorly as a pump and does not circulate blood adequately via the circulatory system to meet the demands of the body the term cardiovascular insufficiency is sometimes used. This generally leads to the syndrome of heart failure.) and orders for the Chaplain to visit one time a week and 3 visits as needed. Further review of the clinical record revealed the Chaplain conducted no visits for the week of 11/20-11/26, no visits for the week of 12/04-12/10, no visits for the week of 12/18-12/24, no visits for 4 weeks 12/25-01/21, no visits for 2 weeks 01/29-02/13. The clinical record did not contain documentation as to why ordered visits were not provided.Review of IDG meetings revealed the following:IDG meeting dated 12/14/22 read in part, ";...Chaplain report: no issues identified... Changes to goals/POC: no changes needed ..."IDG meeting dated 12/28/22 read in part, ";...Chaplain report: no visits performed...Changes to goals/POC: no changes needed..."IDG meeting dated 01/25/23 read in part, ";...Chaplain report: no visits performed...Changes to goals/POC: no changes needed..."IDG meeting dated 02/08/23 read in part, ";...Chaplain report: patient has concerns of death and dying. Accepting of my services...Changes to goals/POC: no changes needed..." 4. Closed record review of Patient #8's plan of care for certification period 02/07/2023 through 04/07/2023 revealed a start of care date 02/07/2023 with a terminal diagnosis of Alzheimer's disease, unspecified (Alzheimers disease is a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks.) and orders for the Chaplain to visit one time a week for a duration of one week. Further review of the clinical record revealed the Chaplain conducted a visit on 02/08. The Chaplain also made a visit on 02/24. The clinical record did not contain documentation as to why 1 extra visit was provided.Review of IDG meetings revealed the following:IDG meeting dated 02/09/23 read in part, ";...Chaplain report: ...until discussing with chaplain her concerns and then she started to feel better...Changes to goals/POC: no changes needed ..."IDG meeting dated 03/09/23 read in part, ";...Chaplain report: no issues identified...Changes to goals/POC: no changes needed ..." During an interview with the Director of Nursing (DON) on 10/29/2024 at 4:29 PM, the surveyor reviewed the above findings. This surveyor requested the DON review records in the event this surveyor might have missed documentation. During an interview the DON stated she did not have any additional information for the services not being provided according to the plan of care. The DON stated, ";Me and the IDG. We were all new to hospice and was trying to figure it out. I dont know what happened, I dont have an answer for why the frequencies were not followed. I believe some of the frequencies were entered in the plan of care in error typos. The POC was confusing to me about how to do the frequencies." The surveyor asked if the DON requested additional training. The DON stated ";No." During an interview with the Chaplain on 10/30/2024 at 12:30 PM, the surveyor reviewed the above findings. This surveyor asked the Chaplain did he get a weekly schedule. The Chaplain stated, ";No. The DON would tell me how often to visit the patients or sometimes someone from the office would tell me how often to visit. I informed the office when I had missed visits." Review of agency policy, dated 042120, quoted in part, "TX.12 Interdisciplinary Group, Coordination of Care and Services.... A. Plan of Care 1. All hospice care and services furnished to patients/families will follow an individualized written POC..."Review of agency policy, dated 042120, quoted in part, "TX.9 Plan of Care and Process...A. A registered nurse coordinates the implementation of the plan of care for each Patient and is responsible for insuring the following...5. Care coordination and case management, both internal and with other health care providers involved. 6. Ongoing evaluation and assessment, with recommendations to the IDG on modification to the POC.

Based on record review and interview the agency failed to develop a bereavement plan of care for up to one year after the patient's death for 2 of 2 patients who died. Citing Patients #11 and #12. This failure could place the bereaved at risk for not having their bereavement needs met after the death of a loved one. --- Findings: Patient chart reviews on reflected the following: Review of the medical record for patient #11 revealed a date of death as 05/12/2022. Further review of the medical record revealed that there was no bereavement plan of care developed. Review of the medical record for patient #12 revealed a date of death as 01/06/2023. Further review of the medical record revealed that there was no bereavement plan of care developed. In an interview with Chaplain A on 10/30/2024 at 12:41 PM, the surveyor reviewed the above findings with Chaplain A. The surveyor asked Chaplain A where the bereavement plan of cares could be found. Chaplain A stated, "I didnt know a bereavement plan of care was supposed to be done. We were all new to hospice and was trying to learn what all was supposed to be done. I did make visits after death and the office sent cards to the families. The surveyor asked if the visits were documented. Chaplain A stated, ";No." In an interview with the Administrator on 10/30/2024 at 12:55 PM, the surveyor reviewed the above findings with the Administrator. regarding why there was no bereavement plan of care for the above clients. The Administrator stated, ";No the Chaplain did not know to make a bereavement plan of care. He did make visits and calls to families afterwards." Review of agency policy, dated 101215, quoted in part, "TX.32 Pre and Post Bereavement...Policy: C. Following the death, the Agency will develop and implement the bereavement plan of care...Procedure...F. The bereavement plan of care will be developed and implemented following the death according to individual risk assessment score..."