Every finding on record at Hackensack Meridian Ambulatory Care, Inc.

Based on medical record review, staff interviews, and a review of facility policies, it was determined that the facility failed to develop a plan of care that meets patient needs for counseling in three of four medical records reviewed (Patient (P) 1, 2, and 29). --- Findings include: Facility policy titled "Care Planning Process", last revised 03/2022, states, "Purpose: To provide clinical direction to clinicians providing direct patient care. Policy: ... The patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient... Procedure: 1. At the time of initial assessment, the clinician, along with the physician (or other authorized licensed practitioner) and other involved disciplines, will develop the patient plan of care based upon the patient's identified needs... 2. All clinicians will consider the conclusions of initial, comprehensive and ongoing assessments in their care planning process, including, but not limited to: ... E. Psychosocial and spiritual needs of patient and family/caregiver, as appropriate." On 9/12/24 at 1:30 PM, a review of P1s medical record was conducted with Staff (S) 1, Manager of Clinical Practice, and S2, Clinical Director and revealed the following: P1 was admitted to hospice services on 8/23/24. On 8/26/24, S24, a Chaplain, conducted an initial evaluation for counseling services. S24 documented in the visit note, ";Chaplain will continue pastoral visits as needed and through team communication and IDG." A review of P1's plan of care on 9/12/24 indicated a physician's order, ";1 visit every day for 1 day on 9/11/2024." There was no documented evidence of a routine visit order being created by the IDG for chaplain services after the initial evaluation to meet the needs of P1. This finding was confirmed by S1 and S2. On 9/12/24 at 1:40 PM, a review of P2s medical record was conducted with S1 and S2, and revealed the following: P2 was admitted to hospice services on 8/29/24. A review of S25's, a Licensed Clinical Social Worker (LCSW), initial hospice assessment dated 8/10/24 stated, ";[P2s daughter] shared [P2] is catholic, and [P2s daughter] is receptive to volunteer and chaplain for an extra layer of support." On 8/13/24, S24 conducted an initial evaluation for chaplain services. S24 documented in the comments, ";Patient welcome prayer at times and closed [his/her] eyes during prayer. Chaplain prayed for peace and comfort. Patient smiled and seemed pleased with visit. [P2] was agreeable to a FU (follow up) visit..." On 9/8/24, S24 conducted a visit for chaplain services. S24 documented in the comments, ";Chaplain introduced the idea of prayer and patient was receptive... Patient indicated that prayer was helpful to [him/her] and gave [him/her] comfort and peace." A review of the visit order for chaplain in P2's plan of care reviewed on 9/12/24 revealed a one-time order which stated, ";1 visit every day for 1 day on 9/8/2024." There was no documented evidence of a routine visit order being created by the IDG for chaplain services after the initial evaluation to meet the needs of P2. Findings were confirmed by S1 and S2. On 9/13/24 at 9:26 AM, a review of P29s medical record was conducted with S1 and S2, and revealed the following: P29 was admitted to hospice services on 6/26/24. On 6/27/24, S24 conducted an initial evaluation for chaplain services. S24 documented in the comments, ";Chaplain shared reason for being present to patient and offered prayer and a blessing. Patient nodded [his/her] head in approval. Patient seemed to accept and understand prayer that was offered, and return of the same a couple times monthly." There was no documented evidence that the IDG created a routine visit order for P29 until the 7/26/24 plan of care. There was no documented evidence that P29 received another counseling/chaplain services visit until 7/31/24 (36 days after the initial evaluation). The order for the chaplain on the 7/26/24 plan of care stated ";1 visit every 30 days for 30 days from 7/31/2024 to 8/29/24" rather than two visits a month as S24 indicated on the initial evaluation visit note. Findings were confirmed by S1 and S2 NJAC 8:42C - 6.2 (b) (1) (ii)

Based on review of two (2) of three (3) medical records (#18 and #19), staff interviews, and review of facility policies and procedures, it was determined the facility failed to ensure hospice aides perform assigned tasks identified in the patient's plan of care. Findings include: Reference #1: Facility policy titled "The Plan of Care" states, " ... The care provided to the patient must be in accordance with the plan of care. ... Procedure: ... 3. All hospice care and services furnished to patient and their families will follow an individualized written plan of care will be written for all hospice care and services furnished. ..." Reference #2: Facility policy titled "Hospice Aide Services" states, "Policy: Hospice aide services will include personal care ... These activities, in accordance with the interdisciplinary plan of care and .... will be assigned and supervised by a hospice registered nurse. ..." 1. On 3/8/22, a review of hospice aide services assigned for the aide to provide patient care was reviewed in the following medical records and revealed the following: a. Medical Record #18 - On 2/23/22, the "Plan of Care" had the following hospice aide's assignments to be completed at each visit: Assist Repositioning, Transfer, Change Bed Linens, Assist Elimination, Incontinence Care, Apply Lotion/Cream, Assist Bath, Dressing Assist, Facial Shave, Foot Care, and Perineal Care. b. On the 3/1/22 visit, Staff #20, a hospice aide, documented the following assignments as "Not Applicable," and did not have a 'check-mark' next to the assignment: Assist Repositioning, Transfer, Change Bed Linens, Assist Elimination, Incontinence Care, Apply Lotion/Cream, Assist Bath, Dressing Assist, Facial Shave, Foot Care, and Perineal Care. c. Medical Record #19 - On 12/19/21, the "Plan of Care" included the hospice aide assignment to 'Shampoo' at each visit. On the 2/27/22 visit, there was no 'check-mark' indicating the shampoo was completed, and Staff # 21, a hospice aide, documented: "Previously done." 2. At 12:30 PM Staff #3 and Staff #19 confirmed if there is no 'check-mark' documented then the aide did not provide that specific assigned care during the visit. The aide should have completed the care or there should have been a note to notify the RN of why it was not completed. 3. At 1:20 PM, Staff #1, Staff #3 and Staff #19 confirmed the above findings, and confirmed that there were no additional aide notes found in the medical records related to notify the RN of assignments not completed. N.J.A.C. 8:42-7.5(c)