Every finding on record at Good Samaritan Society Hcbs-Tx LLC

Based on record review and interview, the agency failed to protect the rights of the patient by failing to manage the pain and symptoms related to the terminal illness and related conditions, in 1 (Patient #3) of 5 patient records reviewed, where the agency received afterhours calls. The failure placed the agency's patients at risk for uncontrolled pain and symptoms. --- Findings: Record review of Patient #3's clinical record revealed a Plan of Care dated from 1/23/2023 to 3/23/2023. The Plan of Care indicated that Patient #3 started on the hospice's services on 3/29/2022. The Plan of Care listed Parkinson's Disease as the terminal diagnosis. The Plan of Care listed Long-term (current) Use of Opiate Analgesic as a diagnosis. The Plan of Care listed Morphine Sulfate (for pain) Concentrate 20 milligrams/milliliter, 0.25 milliliter to 1 milliliter every hour as needed by mouth comfort pak (sic), Acetaminophen-Codeine #3 twice a day by mouth, and Acetaminophen-Codeine #3 (for pain) every 6 hours by mouth as needed for pain as medications. The Plan of Care contained an order for the skilled nurse to assess location, intensity, duration, frequency, precipitating factors and character of pain every visit. The Plan of Care contained an order for the skilled nurse to instruct patient/family "to report poorly controlled pain to the Hospice RN." Registered Nurse D conducted a skilled nurse visit on 1/24/2023. Registered Nurse D documented that Patient #3 had pain scaled at 2/10 on a pain scale of 0-10 (did not specify site of pain). Registered Nurse D documented that Patient #3 had two falls in the last week and had been using 1 dose of Morphine and Ativan (pain and anxiety break through medications) 4-5 times a week (dosages not specified) along with the scheduled Acetaminophen-Codeine #3 and Lorazepam (for anxiety). Registered Nurse C conducted a visit on 2/8/2023. Registered Nurse C documented that Patient #3 was found on the floor. Patient #3 had told Registered Nurse C that Patient #3 was on the floor to fix wheelchair. Patient #3 was assisted from the floor and was unable to stand alone due to knees giving out. Registered Nurse C's documentation did not indicate that Patient #3 was experiencing pain. Patient #3 was eating 2 meals a day. Documentation of the agency's after hours answering service indicated that the agency was called on 2/11/2023 at 4:55 a.m. that Patient #3's Morphine was not working. The answering service forwarded the call to Registered Nurse E on 2/11/2023 at 4:58 a.m. Patient #3's clinical record did not contain evidence that Registered Nurse E followed up with a phone call, visit, or arranged for other hospice service. Registered Nurse F conducted a visit on 2/13/2023. Registered Nurse F documented that Patient #3 was nonverbal, mouth dry and tongue coated. Patient #3 had severe dyspnea (shortness of breath) without exertion, bilateral breath sounds diminished to lung bases, heart rate irregular, holding her abdomen and moaning. Patient #3's abdomen was soft with hypoactive bowel sounds and had last bowel movement on 2/9/2023. Registered Nurse F documented that the caregiver reported a decline since the last skilled nurse visit. Patient #3 could only move upper extremities. Registered Nurse F documented that Patient #3 had no by mouth intake (was eating 2 meals a day 2/8/2023). Registered Nurse F conducted a skilled nurse visit on 2/14/2023. Patient #3 was alert and disoriented x 3. Registered Nurse F documented that Patient #3 had a decline since 2/11/2023, (date the agency received an afterhours call and had not received contact from the on-call nurse). Patient #3 could transfer to the wheelchair with the assistance of one person but now Patient #3 was bedbound and taking in no food or fluids. A detailed February 2023 Pharmacy invoice between 2/8/2023 through 2/15/2023 did not indicate that changes to pain medications were made. During an interview on 3/3/2023 at approximately 9:30 a.m. with the Administrator, the surveyor discussed the on-call phone call received by the agency on 2/11/2023 regarding Patient #3's report that the pain medication was not working. The agency's policy was discussed and that the Patient record had not contain evidence that the on-call nurse, Registered Nurse E, follow-up regarding the pain medication. The Administrator stated, "Unable to locate" documentation the nurse returned the phone call or made a visit to Patient #3 to evaluate effectiveness of pain medication regimen. The agency had a policy titled "On-Call/Weekend Services" and was labeled Policy No. 4-036.1 - .2. The Policy read in part: " Purpose To establish the process by which patients have access to hospice services 24 hours per day. Policy Patient care needs are the highest priority; therefore, weekend and evening staffing will be scheduled accordingly. Clinical personnel are expected to perform visits on an as-needed basis, including weekends. There will be on-call staff available after office hours, Monday through Friday, and 24 hours a day on weekends. Staff on-call will be: 1. Administrative call by a senior management staff member 2. Clinical call by a registered nurse 3. Other interdisciplinary team members as needed (e.g., social worker, Hospice Chaplain). Procedure...2. The 0n-call schedule will be developed on a monthly basis by the Clinical Director or designee. The schedule will be forwarded to the answering service and on-call staff. Supplies and records will be available to the on-call staff, through direct access to the office 3. The on-call nurse will be issued a pager and/or a cellular phone to allow for mobility. 4. The on-call staff can be reached by calling the hospice number. After hours this number will be forwarded to the answering service. The answering service will pass every patient related call to the the on-call nurse. 5. The on-call nurse will provide follow-up appropriate to the call: A. Call the patient/family/caregiver B. Visit the patient, if necessary C. Obtain physician (or other authorized independent practitioner) orders, as needed D. Arrange for other hospice services, as needed...Guidelines The following list is meant to guide the on-call nurse. It is not an exhaustive list, but includes many problems that may require a visit from the hospice nurse...Unusual, Severe or uncontrolled pain..." The agency had a policy titled "Patient Bill of Right" that was labeled Policy No. 2-002.1 - .3. The policy read in part: "Purpose To encourage awareness of patient rights, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning...Procedure 1. The Patient Bill of Rights statement defines the right of the patient to...B. Received effective pain and symptom management for conditions related to the terminal illness(es)..."

Based on record review and interview, the interdisciplinary group did not include an individual that was qualified and competent to practice in the professional role of a pastoral or other counselor for 6 (#1, #2, #4, #6, #7, #8) of 10 active patient records reviwed. The failure placed at risk that the patients/families/caregivers spiritual needs would not be met. --- The agency had documentation of the interdisciplinary team meetings on worksheets titled "DFW Interdisciplinary Team Meeting" and "DFW IDG Schedule." The worksheets had notations regarding multiple clients. The worksheets were in a binder and were not part of the clinical records. The interdisciplinary team meetings were conducted on 9/29/2022, 10/13/2022, 11/9/2022, 11/22/2022, and 12/7/2022, 12/22/2022, 1/5/2023, 1/19/2023, 2/2/2023, 2/16/2023, 3/1/2023. The Interdisciplinary Team Meeting worksheet documentation did not indicate that a qualified pastoral or other counselor was included as part of the Interdisciplinary group. Patient #1:Record review of Patient #1's record revealed a Plan of Care dated 9/27/2022 to 11/25/2022. The Plan of Care indicated that Patient #1 started on the agency's services on 3/31/2022. The Plan of Care listed Alzheimer's Disease as the primary diagnosis. The Plan of Care contained orders for spiritual counseling. The patient record contained documentation by Registered Nurse C or Registered Nurse D of Interdisciplinary Team meetings that were conducted on 10/13/22, 10/27/2022, 11/9/2022, 11/22/2022, and 12/7/2022. The patient record did not contain evidence that a qualified pastoral or other counselor was included as part of the interdisciplinary group. Patient #2:Record review of Patient #2's record revealed a Plan of Care that was dated 10/31/2022 through 2/28/2023. The Plan of Care indicated that Patient #2 started on the agency's services on 8/2/2022. The Plan of Care listed Senile Degeneration of the Brain, Not elsewhere Classified as the primary diagnosis. The Plan of Care contained orders for spiritual counseling. The patient record contained documentation by Registered Nurse C or Registered Nurse D that Interdisciplinary Team meetings were conducted on 11/9/2022, 11/22/2022, 12/22/2022, 1/5/2023, 1/19/2023 and 2/2/2023. The patient record did not contain evidence that a qualified pastoral or other spiritual counselor was included as part of the interdisciplinary group. Patient #4:Record review of Patient #4's clinical record contained a Plan of Care dated 12/8/2022 to 3/7/2023. The Plan of Care indicated that Patient #4 started on the agency's services on 9/9/2022. The Plan of Care Listed Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung as the primary diagnosis. The Plan of Care contained orders for spiritual counseling. The Patient record contained documentation by Registered Nurse C or Registered Nurse D that Interdisciplinary Team meetings were conducted on 12/7/2022, 12/22/2022, 1/5/2023, and 1/19/2023. The patient record did not contain evidence that a qualified pastoral or other counselor was included as part of the interdisciplinary group. Patient #6:Record review of Patient #6's client record revealed a Plan of Care dated 11/30/2022 to 12/21/2022. The Plan of Care indicated that Patient #6 started on the agency's services on 11/30/2022. The Plan of Care listed Chronic Obstructive Pulmonary Disease Unspecified as the primary diagnosis. The Plan of Care contained orders for spiritual counseling. The patient record did not contain documentation of Interdisciplinary meetings. The agency worksheet documentation of the interdisciplinary team meetings listed Patient #6 on the agenda for interdisciplinary team meetings conducted on 12/7/2022, 12/22/2022, 1/5/2023, and 1/19/2023. Patient #7:Record review of Patient #7's record revealed a Plan of Care dated 11/16/2022 to 2/13/2023. The Plan of Care indicated that Patient #7 started on the agency's services on 11/16/2022. The Plan of Care listed Senile Degeneration of Brain not Elsewhere Classified as the primary diagnosis. The Plan of Care contained orders for spiritual counseling. The patient record did not contain documentation of Interdisciplinary meetings after 12/22/2022. The agency worksheet documentation of the interdisciplinary team meetings listed Patient #7 on the agenda for interdisciplinary team meetings conducted on 1/5/2023, 1/19/2023, and 2/2/2023. Patient #8:Record review of Client #8's record revealed a Plan of Care dated 11/8/2022 to 2/5/2023. The Plan of Care indicated that Patient #8 started on the agency's services on 11/8/2022. The Plan of Care listed Multiple Myeloma Not Having Achieved Remission as the primary diagnosis. The Plan of Care contained orders for spiritual counseling. The patient record contained documentation by Registered Nurse C that Interdisciplinary Team meetings were conducted on 11/9/2022, 11/22/2022, 12/7/2022, 1/5/2023, and 1/19/2023. The patient record did not contain evidence that a qualified pastoral or other counselor was included as part of the interdisciplinary group. During the entrance conference on 2/21/2023 at approximately 10:17 a.m., the agency's Administrator attended the conference via telephone. The Administrator informed the surveyor that Social Worker G was also the spiritual counselor. During a home visit conducted on 3/1/2023 at 8:50 a.m. with Patient #4, Patient #4 informed the surveyor that regarding chaplain services, "It would be nice but its not a requirement." Patient #4's family member informed the surveyor via telephone interview on 3/1/2023 at approximately 12:11 p.m., "Would like a Chaplain, the Social Worker arranged a visit, but they only came one time." During an interview on 3/2/2023 at approximately 12:06 a.m. with Social Worker G, the surveyor discussed Social Worker G's role as spiritual counselor. Social Worker G informed the surveyor that Social Worker G thought of the position as coordinating spiritual care. Social Worker G informed the surveyor that Social Worker G did not have Chaplain education or experience. "I am not providing Spiritual Counseling." Social Worker G stated "I would ask what denominations they aligned with and reached out to main number at church, see what ministries they have. I felt I was more of the spiritual counselor coordinator." The agency had a policy titled "Spiritual Care Counseling Services" that was labeled Policy No. 4-005.1 - .2. The policy read in part: "Purpose To provide guidelines for the appropriate assessment and provision of service to meet the spiritual needs of patients and families/caregivers. Policy Hospice will provide spiritual care counseling in keeping with the patient's/family's/caregiver's belief system and practice, and in accordance with the plan of care. The Hospice Chaplain (or designated spiritual care counselor) will provide direct support and coordinate services utilizing local clergy and other individuals, as appropriate. A Chaplain will be assigned to each patient based on the patient's needs and acceptance of these services. The Chaplain will be a member of the interdisciplinary group and will participate in the development, implementation, and revision of the plan of care...Procedure...2. The Hospice Chaplain will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient and family...4. The Hospice Chaplain will develop an individualized spiritual/pastor plan of care, which will demonstrate an effort to work closely with local clergy as desired by the patient, and provision of spiritual support as defined and requested by the patient and family/caregiver...7. If the patient and family/caregiver identifies involvement with a local church, synagogue, mosque, etc., and permission is given to contact them, the Hospice Chaplain will call to coordinate care. The identified spiritual support person will be encouraged to participate as an interdisciplinary group member in developing the plan of care and to document his/her interventions. 8. Spiritual are assessments and counseling will be documented in the patient's clinical record as part of the comprehensive assessment and in interdisciplinary visit notes as well as the plan of care...12. The Hospice Chaplain will attend interdisciplinary group meetings, and will work in a team approach with members of the group and other qualified professionals to evaluate patient and family/caregiver response to care and resolutions of ethical issues. 13. The Hospice Chaplain will provide staff, including IDG, support by: A. Meeting with individual staff members, upon request, regarding personal spiritual/pastoral issues that may affect their ability to function effectively B. Being available to staff for bereavement support C. Participating in development of approaches to meet staff counseling needs."

Based on record review and interview, the agency failed to provide supervision of the hospice aide every 14 days to assess the quality of care and services provided by unlicensed employees and to ensure that services ordered by the hospice interdisciplinary group met the patient's needs in 3 (#4, #5, and #9) of 10 active records The failure placed the patients at risk of receiving improper or inadequate care from an unlicensed person. --- Record Review of Patient #4's record revealed a Plan of Care dated 12/8/22 to 3/7/23 and had an admission date of 9/9/22. The primary diagnosis was Malignant neoplasm of unspecified part of unspecified bronchus or lung. The Plan of Care contained orders that the skilled nurse visit frequency was 1 time a week for 14 weeks and the aide visit frequency was 2 times a week for 1 week. The Plan of Care contained orders that the aide visit frequency was 5 times a week for 12 weeks effective 12/22/22. Per an interview on 3/3/23 about 0930 regarding supervisory visits between 1/19/23 and 2/16/23, the Administrator stated "none found." Record Review of Patient #5's record revealed a Plan of Care dated 11/24/22 to 1/22/23 and had an admission date of 3/29/22. The primary diagnosis was Hypertensive heart and chronic kidney disease with heart failure and stage 1 through 4 chronic kidney disease. The Plan of Care contained orders that the skilled nurse visit frequency was 1 time a week for 9 weeks and the aide visit frequency was 2 times a week for 1 week. The Plan of Care was updated to increase the aide visit frequency to 5 times a week for 8 weeks effective 11/27/22. The record revealed that LVN H conducted a visit on 11/22/22. RN E made a nursing visit on 12/1/22 but no aide supervision was conducted. LVN H visited the patient on 12/7/22. No aide supervisory visit was conducted between 11/20/22 and 12/13/22. Record Review of Patient #9's revealed a Plan of Care dated 12/23/22 to 2/20/23 and had an admission date of 7/1/21. The primary diagnosis was Hypertensive heart and chronic kidney disease with heart failure and stage 1 through 4 chronic kidney disease. The Plan of Care contained orders that the skilled nurse visit frequency was 1 time a week for 9 weeks and the aide visit frequency was 1 time a week for 1 week. Supplemental orders dated 12/25/22 to 2/20/23 increased the aide visit frequency to 5 times a week for 8 weeks effective 12/25/22. RN E visited the patient 1/21/23 but supervision was not completed. A phone call from RN C to the patient was made on 2/3/23. On 2/27/23 about 3:30 p.m., an interview was conducted regarding aide supervisory visits between 1/18/23 and 2/20/23 the Administrator informed the surveyor that there were "none found." The agency had a policy (Policy No. 4-002.1-3) titled, "Hospice Nursing Care," that was dated October 2012.The policy read in parts: "...Purpose: To specify the role of the nurse in hospice care... Policy: Nursing services will be provided in accordance with accepted standards of practice by or under the supervision of a registered nurse... A hospice registered nurse will be assigned as the Case Manager for each patient and family/ caregiver, and his/ her duties will be enumerated in a job description. Duties will include the responsibility for coordination of care and fostering communication between the patient and the interdisciplinary group. The Case Manager will assure that components of the plan of care are established and implemented by the interdisciplinary group. The Case Manager will determine the scope and frequency of services needed based on acuity and patient and family/ caregiver needs... Procedure: 4. The hospice registered nurse will supervise licensed practical/ vocational nurses, hospice aides, homemakers, and volunteers in the home and follow the family/ caregiver into the bereavement period, per organizational policy."