Every finding on record at Free Spirit Hospice Inc

It is required that a hospice aide provides services ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 6 (17%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the aide provided services included in the plan of care as ordered by the Interdisciplinary Group. Home Visit 1/Clinical Record 1: During the home visit, on 11/26/2024, with the Hospice Aide (Personnel Record 7) she was observed to ask the patient for her glucometer and then perform a fingerstick. This was not included on the Hospice Aide Plan of Care (POC) dated 07/01/2024. The POC also had noted for the hospice aide to use a "mechanical lift" every visit but the patient did not have a mechanical lift present in her house. Both the aide and the patient reported the aide did not use a lift to move/transfer the patient. During the clinical record review, it was revealed that the POC dated 07/01/2024 included the relevant tasks of showering the patient, applying lotion, and dressing patient every visit. The hospice aide visit dated 07/22/2024 documented, "Patient had a shower, shampoo, applied lotion, dressed." The aide note dated 09/09/2024 documented, "Patient had a shower, shampoo, dressed, applied lotion." The aide plan of care did not have the task "shampoo" ordered for the hospice aide. An interview on 11/26/2024 with the Director of Nursing revealed the hospice aide did not follow the care plan. The Director of Nursing was surprised to hear the hospice aide had done the blood sugar on the patient and "wasn't sure why she had chosen to do that." She said that previously the aide had said she had been trained to do finger sticks in {Name of State} but had not been requested to do them for this hospice.

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. This standard was not met as evidenced by document review and interview. An Interview with the Director of Nursing and a document review of the Volunteer Requirement Report revealed the third quarter percentage for the agency was 1.43%, less than the required 5% of total patient care hours. An Interview with the Director of Nursing and a document review of the Volunteer Requirement Report revealed the third quarter percentage for the agency was 1.43%, less than the required 5% of total patient care hours.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview and personnel record review. In 4 of 8 (50%) personnel records reviewed revealed the agency did not ensure the competencies were completed per agency policy. Agency Policy titled "Competency Based Orientation Policy No 3-002.1 Revised April 2021" stated in relevant part, "Hospice ensure that the competency of all personnel is assessed on hire, prior to providing care to hospice patients. 2. Observe specific tasks to assure satisfactory performance of essential duties and procedures." Agency policy titled "Scope of the Program/Process Methodology Policy No 3-001.1 Revised April 2021" stated in relevant part, "2. Competencies must be successfully demonstrated before hospice personnel complete orientation. 3. Hospice will clearly identify which skills are clearly essential to be observed for the determination of competence. 6. After completion of orientation of orientation, competencies will be completed at least annually." Personnel Record 5: The Social Worker’s date of hire was 11/18/2023. A review of the personnel record indicated that the initial skills competencies for this social worker were completed on the day of hire by "interview". The record lacked evidence that the skills and competencies had been demonstrated and observed, per policy. Personnel Record 6: The Spiritual Counselor/Bereavement Coordinator’s date of hire was 09/16/2023. A review of this personnel record indicated that the annual competency was due in September 2024 and was absent. There was also not an initial competency for bereavement coordinator. The record lacked evidence that the skills and competencies had been demonstrated and observed, per policy. Personnel Record 7: The Hospice Aide’s date of hire was 11/25/2023. A review of the personnel record indicated that the initial skills competencies for this hospice aide were completed on the day of hire by "interview". The record lacked evidence that the skills and competencies had been demonstrated and observed, per policy. Personnel Record 8: The Volunteer Coordinator’s date of hire was 04/22/2024. A review of the personnel record indicated that the initial skills competencies for this volunteer coordinator were not present. The record lacked evidence that the skills and competencies had been demonstrated and observed, per policy. An interview and personnel record review were conducted with the Director of Nursing on 11/26/2024 in which she responded that the "personnel files had to be recreated after the previous leadership left."

It is required the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management; The patient’s current plan of care; The patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed. in which the patient was live discharged, revealed the agency did not ensure the discharge summary included at least a summary of the patient's current plan of care. Clinical Record 5: The patient elected to revoke their hospice benefit on 09/17/2024. The hospice discharge summary in the clinical record dated 09/17/2024 stated "Patient wishes to continue taking Calquence, MD (medical director) and DON (Director of Nursing) notified." There was no evidence that the discharge summary included the patient's current plan of care. Clinical Record 6: The patient elected to revoke their hospice benefit on 07/21/2024. The hospice discharge summary in the clinical record dated 07/21/2024 stated "Daughter took patient to hospital for higher acuity of care." There was no evidence that the discharge summary included the patient's current plan of care. Clinical Record 7: The patient elected to revoke their hospice benefit on 05/03/2024. The hospice discharge summary in the clinical record dated 05/03/2024 stated "Patient elected to seek emergency treatment at {Hospital} for higher level of care and treatment." There was no evidence that the discharge summary included the patient's current plan of care. During an interview and joint clinical record review with the Director of Nursing on 11/26/2024, it was confirmed the discharge summaries did not contain the patient's current plan of care.