Every finding on record at Franciscan Care Services, Inc.

Based on record review, policy and procedure review, and staff interview, the hospice failed to provided social work services as ordered on the plan of care for 5 of 7 patients (Patient 3, 5, 7, 8, and 12) who received social work services. Total sample size was 14. The census was 4. --- Findings are: A. Review of the agency policy and procedure titled, Plan of Care, revised 12/22, revealed: 1. Each patient admitted to the hospice program will have an individualized plan of care. 2. The care provided to the patient must be in accordance with the individualized plan of care. B. Review of the agency policy and procedure titled, Hospice Services and Disciplines, revised 7/2020, revealed social work services are to be provided in accordance with the plan of care and recognized standards of practice. C. Review of Patient 3's clinical record: 1. The Interdisciplinary Group (IDG) (hospice team that meets at least every 15 days to discuss the patient's plan of care) meeting notes for the dates of 4/25/23, 5/9/23, and 5/23/23, all include orders for Medical Social Worker (SW), 1 to 3 times per month for 2 months from 4/25/23 through 5/31/23. 2. There was no documentation to indicate a SW visit was conducted in May and July 2023. D. Review of Patient 5's clinical record revealed: 1. A verbal order dated 4/25/23 included an order for SW 1-3 times per month for two months effective 4/25/23 through 5/31/23. 2. A verbal order dated 6/20/23 included an order for SW 1-2 times per month for two months effective 6/20/23 through 7/11/23. 3. There was no documentation to indicate a SW visit was conducted in May and June 2023. E. Review of Patient 7's clinical record revealed: 1. IDG meeting notes dated 1/31/23 and 2/28/23 included orders for SW 1-2 times per month for 3 months effective 1/17/23 through 3/29/23. 2. There was no documentation to indicate a SW visit was conducted in February 2023. F. Review of Patient 8's clinical record revealed: 1. IDG meeting notes dated 8/2/22 and a verbal order dated 7/27/22 both included orders for SW 1-3 times per month for 3 months effective 7/27/22 through 9/30/22. 2. There was no documentation to indicate a SW visit was conducted in August 2023. G. Review of Patient 12's clinical record revealed: 1. IDG meeting notes dated 7/5/22, 8/2/22, and 8/16/22 included orders for SW 1-4 times per month for 2 months effective 7/3/22 through 8/25/22. 2. There was no documentation to indicate a SW visit was conducted in July and August 2023. H. During an interview on 8/3/23 at 09:30 AM, the Hospice Manager confirmed Patient 3, 5, 7, 8, and 12's plan of care included orders for SW services that were not completed as ordered by the Hospice SW.

Based on record review, policy and procedure review, and staff interview, the hospice failed to include a plan of care for volunteer services including the scope and frequency of services to be provided for 2 of 2 patients (Patient 5 and 7) who received volunteer services. Total sample size was 14. The census was 4. --- Findings are: A. Review of the agency policy and procedure titled, Plan of Care, revised 12/22, revealed: 1. Each patient admitted to the hospice program will have an individualized plan of care. 2. The care provided to the patient must be in accordance with the individualized plan of care. 3. The plan of care must state in detail the scope and frequency of the services needed to meet the patient and family's needs. B. Review of Patient 5's clinical record revealed: 1. The Hospice Plan of Care (POC) dated 1/13/23 through 4/12/23 and 4/13/23 through 7/11/23 included orders for Volunteers for respite as needed (PRN). 2. Volunteer Progress Notes for April, May, and June 2023 reveal documentation of 4 to 6 volunteer visits weekly until the patient's death on 6/22/23. 3. The initial and updated POCs did not include specific scope and frequency for volunteer services. C. Review of Patient 7's clinical record revealed: 1. The POC for 12/30/22 through 3/29/23 did not include specific scope and frequency for volunteer services. 2. Volunteer Progress Notes dated 1/4/23 through 1/24/23 showed 3 volunteer visits conducted per week in January 2023. D. During an interview on 8/3/23 at 1:15 PM, the Hospice Manager confirmed the orders for Patient 5 and Patient 7 were not specific and were missing the scope and frequency for volunteer services provided by the hospice.

Based on record review, policy and procedure review, and staff interview, the hospice failed to follow their policy and procedures to develop a individualized bereavement plan of care (POC) based on the bereavement assessment to be completed following the death of the hospice patient for 8 of 8 records reviewed (Patient 5, 6, 7, 8, 9, 10, 13, and 14). Total sample size was 14. The census was 4. --- Findings are: A. Review of the hospice policy and procedure titled, Bereavement Program, last reviewed 2/22, revealed the Bereavement Program was developed to provide for regular survivor contact following the death of the hospice patient. B. Review of the hospice policy and procedure titled, Hospice Services and Disciplines, last revised 7/2020, revealed the Bereavement POC outlines the organized program followed by the hospice staff to offer services to the family members of the hospice patient once the patient has passed. The Bereavement POC reflects the family needs, as well as identifies the types of services to be provided, and their frequencies, up to 13 months following the death of the patient. C. Review of the agency policy and procedure titled, Plan of Care, revised 12/22, revealed a Bereavement POC will be developed if bereavement services are desired by the family and other individuals. D. Review of the clinical records for patient 5, 6, 7, 8, 9, 10, 13, and 14 revealed there was no documentation in the clinical records of a Bereavement POC developed by the hospice for the survivors following the death of the hospice patient, if the family or other individuals chose to participate in the Bereavement Program. E. During an interview on 8/8/23 at 10:00 AM, the Bereavement Coordinator (BC) confirmed the hospice does not develop a written Bereavement POC based on the post-death assessment of the patient's survivors. The BC confirmed this holds true for all bereavement services provided by the hospice for the survivors after the death of all hospice patients.