Every finding on record at Guardian Angel Home Health Inc

Based on record review and interview the facility failed to have the Chaplain complete a comprehensive assessment no later than 5 days after the election of hospice for visits for 8 (P[patient] P1, P3, P4, P6, P7, P11, P12, and P13) of 14 (P1-P14) patients reviewed for care provided by hospice staff. This deficient practice could lead to a delay in treatment and poor outcomes. --- The findings are: A. Review of the facility's policy titled, "INITIAL COMPREHENSIVE ASSESSMENT OF PATIENTS" undated revealed ";The agency interdisciplinary group, in consultation with the individual's attending physician (if any), will complete the comprehensive assessment no later than 5 calendar days after the election of hospice care has been completed." B. Review of the facility's policy titled, "INTERDISCIPLINARY GROUP" undated revealed "The interdisciplinary group must include, but is not limited to, individuals who are qualified and competent to practice in the following professional roles: a Doctor of Medicine or osteopathy (who is an employee or under contract with the hospice), a registered nurse, A social worker, and a pastoral or other counselor." B. Record review of P1s, P3s, P4s, P6s, P7s, P11s, P12s, and P13 s medical record indicated a comprehensive assessment was not conducted within 5 days of the Notice of Election by S(Staff)5 Chaplin who is a member of the interdisciplinary group. C. During an interview with S1, Non-Clinical on 09/18/24 at 9:13 AM, S1 confirmed S5 had not completed the comprehensive assessment within 5 days of election.

Based on record review and interview the facility's IDG team failed to review, revise and document the individualized plan every 15 calendar days or less for 10(P[patient] P4, P6, P13and P15-21) of 21 (P1-P21) patients reviewed for care provided by hospice staff. This deficient practice could lead to poor treatment outcomes. --- The findings are: A. Review of the facility's policy titled, " INTERDICIPLINARY GROUP" undated under ";IDG performs the following:" revealed, ";Reviews, revise and documents the individualized plan of care for each patient and family as frequently as the patient's condition requires, but no less than every 15 days and obtains needed physician orders for care." B. Record review of P4s, P6s, and P13s medical record revealed that the IDG group did not review, revise and document the individualized plan every 15 calendar days or less. C. During an observation on 09/18/24 at 8:00 AM of an IDG meet, the IDG group did not review, revise and document the individualized care plan for P15-P21 patients discussed. D. During an interview with S (staff) 3, Clinical on 09/18/24 at 9:15 AM, S3 confirmed that patients individualized goals and care plans are not discussed during the IDG meeting, but what is discussed is the SBAR (Situation, Background, Assessment and Recommendation).