Every finding on record at Good Shepherd Hospice Care Inc

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 7 (57%) clinical records reviewed, the agency did not ensure that the comprehensive assessment contained an initial bereavement risk assessment. Clinical Record 1: The patient elected the hospice benefit on 05/02/2023, with a terminal diagnosis of Alzheimer’s disease. The clinical record contained no documented evidence that an initial bereavement risk assessment was completed. Clinical Record 4: The patient elected the hospice benefit on 08/26/2023, with a terminal diagnosis of red cell aplasia. The clinical record contained no documented evidence that an initial bereavement risk assessment was completed. Clinical Record 6: The patient elected the hospice benefit on 06/22/2023, with a terminal diagnosis of hemiplegia following cerebral infarct. The clinical record contained no documented evidence that an initial bereavement risk assessment was completed. Clinical Record 7: The patient elected the hospice benefit on 05/25/2023, with a terminal diagnosis of malignant neoplasm of lymphoid. The clinical record contained no documented evidence that an initial bereavement risk assessment was completed. During an interview on 100/6/23, the Director of Nursing (DON) stated the bereavement risk assessment is part of the spiritual counselor's assessment, and when the spiritual counselor is not able to visit the patient then it did not get done. Review of the comprehensive assessment with the DON revealed the initial comprehensive nursing assessment contained the question "current bereavement concerns for patient and primary care giver" which was answered as "none" for Clinical Records 1, 4, 6, and 7. The DON agreed the question within the nursing assessment was not enough to determine a bereavement risk level.

It is required that hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This standard was not met as evidenced by personnel record review and interview. Personnel Record 4: Review of the personnel record for the medical social worker revealed the social worker was a contracted employee. The file contained a W-9 [IRS form used to obtain taxpayer information for a independent contractor] and an employment agreement contract signed by the social worker on 09/26/2022. During an interview, on 10/04/23, the Director of Nursing confirmed that the social worker was contracted and that this individual is the only person providing psychosocial services to the agency's patients. The agency did not have any additional employed social workers. During an interview on 10/06/2023, the Administrator was asked if the agency had applied for any waivers or if it was felt they were under any "extraordinary circumstances." The Administrator stated "no." The cumulative effect of this deficient practice has resulted in the hospice agency's inability to ensure the provision of quality care for the Condition of Participation CFR 418.64, Core Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice services from the agency. Condition of Participation 418.64 (L-587) Hospice "core" services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed where aide services were provided, the agency did not ensure that the RN prepared patient specific written instructions for the hospice aide. Clinical Record 2: The patient elected the hospice benefit on 09/12/2023, with a terminal diagnosis of malignant neoplasm of the breast. The aide care plan assignment dated 09/12/2023 included the aide visit frequency of five times per week and assigned the aide the task of a patient shower every visit. The aide assignment included information that the patient used oxygen at 2 liters per minute continuously but did not include instructions to the aide related to if the oxygen could be removed during cares or if the oxygen needed to stay on the patient while the aide provided care. During the interview on 10/05/2023, the Director of Nursing stated the aides "should not remove the oxygen" but did agree that this directive should be written in the aide care plan assignment.

It is required that physician certification and recertification of terminal illness as required in 418.22 and 418.25 and described in 418.102(b) and 418.102(c) respectively, if appropriate. § 418.22 - Certification of terminal illness. (4) Face-to-face encounter. (i) As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient whose total stay across all hospices is anticipated to reach the 3rd benefit period. The face-to-face encounter must occur prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care. Per the interpretive guidelines in the state operations manual, "as a hospice employee, NPs (nurse practitioner's) may do face-to-face examination required for the 3rd or later hospice benefit period." This standard is not met as evidenced by clinical record review, personnel record review, and document review. In 1 of 7 (14%) clinical records reviewed, the agency did not ensure the nurse practitioner assigned to complete the face-to-face visit was a hospice employee. Clinical Record 1: The patient elected the hospice benefit on 05/02/2023, with a terminal diagnosis of Alzheimer’s disease. Clinical record review revealed the patient had a face-to face visit documented on 08/17/2023 for continued hospice care into the current benefit period dated 08/30/2023 through 10/28/2023. The face-to-face was documented by a Nurse Practitioner who was not listed on the agency’s list of employees. The agency did not ensure the NP who completed the face-to-face was a hospice employee. Personnel Record 2: Review of the personnel record for the Nurse Practitioner revealed the NP was a contracted employee, with a signed contract dated 05/01/2023. During an interview on 10/06/23, the Director of Nursing confirmed the Nurse Practitioner had been contracted to complete the visit. § 418.22 - Certification of terminal illness. (4) Face-to-face encounter. (i) As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient whose total stay across all hospices is anticipated to reach the 3rd benefit period. The face-to-face encounter must occur prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care. Per the interpretive guidelines in the state operations manual, "as a hospice employee, NPs (nurse practitioner's) may do face-to-face examination required for the 3rd or later hospice benefit period."