Every finding on record at Grove Park Pharmacy Hospice Care, LLC

Based on record reviews and interview, the hospice did not ensure all staff participated in the hospice's Emergency Preparedness (EP) training. --- During review of the hospice's Emergency Preparedness Program (EPP) on 8/16/23 at 10:00 AM, there was no documentation that the physician participated in any EPP training and/or drills. In an interview on 8/16/23 at 2:00 PM, the Patient Care Coordinator (PCC) confirmed the physician had not participated in the hospice's EPP training or drills.

Based on record reviews and interview, the hospice did not ensure the patient's initial comprehensive assessment was completed no later than five calendar days after the date of the patient's notice of election for hospice for three of 14 patient records reviewed. (Patient 3, 4 and 7) --- On 08/15/23, at 1:22 PM Patient 4's record was reviewed. Patient 4 elected hospice care on 04/29/23 with a diagnosis of malignant neoplasm of the colon (colon cancer). The Chaplain initial assessment was completed on 05/11/23 (12 days after the election of hospice services). On 08/15/23, at 3:15 PM, during an interview with the Patient Care Coordinator (PCC), he/she reviewed Patient 4's record and confirmed the findings. On 08/14/23, at 1:38 PM Patient 7's record was reviewed. Patient 7 elected hospice care on 01/31/23 with a diagnosis of Alzheimers. The Medical Social Worker (MSW) and Chaplain both completed their initial assessments on 02/06/23 (6 days after the election of hospice services). On 08/15/23, at 2:56 PM, during an interview with the PCC, she/he reviewed Patient 7's record and confirmed the findings. Record review on 8/15/23 at 12:01 PM for Patient #3 with a Start of Care (SOC) 7/10/23 revealed that the Chaplain made an initial visit on 7/18/23, 8 days after the SOC.

Based on record reviews and interview, the hospice did not ensure the patient's initial bereavement risk assessment was completed as part of the patient's initial comprehensive assessment for one of 14 patient charts reviewed. (Patient 7) --- On 08/15/23 at 2:56 PM, the Patient Care Coordinator (PCC) during a concurrent review of Patient 7's record confirmed Patient 7 elected hospice services on 01/31/23. The PCC stated the patient's initial bereavement risk assessment was not completed until 02/06/23 which was 7 days after the patient's NOE for the hospice benefit.

Based on observations, record reviews, and interview, the hospice did not ensure the patient's plan of care included all services provided for 2 of 14 patient charts reviewed. Patient 4's plan of care did not include volunteer interventions or instructions and tPatient 12's plan of care did not include wound care. --- On 08/15/23 at 1:22 PM, review of Patient 4's record revealed a document, titled, "Volunteer Care Plan Details, which showed, "...Effective date...05/12/2023...Problems...Socialization...Emotional Support..." The area on the form for instructions was blank and there was no visit frequency. On 08/15/23 at 3:13 PM, the Patient Care Coordinator (PCC) confirmed there were no interventions/instructions for volunteer services in Patient 4's plan of care. On 08/15/23 at 10:25 AM, a visit was made to Patient 12's home with the Licensed Practical Nurse (LPN) who was observed providing wound care to Patient 12's right leg. On 08/15/23 at 12:22 PM, Patient 12's record revealed the patient was admitted on 06/2/23 with a diagnosis of malignant Melanoma (skin cancer) of the right lower limb. Patient 12's plan of care for the certification period from 06/02/23 to 08/30/23 revealed there was no wound care orders the patient's right leg included in the patient's plan of care. On 08/16/23 at 9:48 AM, the PCC, confirmed the findings. On 08/16/23 hospice policy, titled, "PLAN OF CARE" revealed, "...The plan of care must include...identification of the services...All Hospice interdisciplinary team members involved in the patient's care will contribute to the written plan of care...the interdisciplinary team members develop a list of patient problems and needs with corresponding goals, interventions...Hospice updates the plan of care as often as the condition of the patient indicates..."

Based on record reviews and interview, the hospice did not ensure visits were conducted as ordered in the plan of care for 3 of 14 patient charts reviewed. (Patient 3, 4 and 12) --- On 08/15/23, at 1:22 PM Patient 4's record was reviewed. Patient 4 was admitted to hospice care on 04/29/23 with a diagnosis of malignant neoplasm of the colon (colon cancer). The plan of care for the certification period 04/29/23 to 07/27/23 indicated the hospice aide (HA) was supposed to visit Patient 4 twice a week. The week of 05/28/23, the documentation indicated Patient 4 received one HA visit. On 06/13/23, there was an order to increase the HA visits to three times a week. The documentation indicated Patient 4 received two HA visits the week of 06/11/23 and the week of 07/16/23. On 08/15/23, at 3:13 PM, during an interview with the Patient Care Coordinator (PCC), he/she confirmed the findings. On 08/15/23, at 12:22 PM Patient 12's record was reviewed. Patient 12 was admitted to hospice care on 06/02/23 with a diagnosis of malignant melanoma (cancer) of the right lower limb. The plan of care for the certification period 06/02/23 to 08/30/23 indicated the HA was to visit Patient 12 two times a week. The documentation indicated there was on HA visit the week of 07/02/23. On 08/15/23, at 9:10 AM, during an interview with the PCC, she/he confirmed the findings. Record review on 8/15/23 9:00 AM of Patient #3 with a Start of Care 7/10/23 revealed physician orders for the Nurse to visit twice per week. There was one Nurse visit in Week 4 of care, with no Missed Visit Note for the second visit. This information was confirmed in an interview with the PCC on 8/15/23 at 3:00 PM.