Every finding on record at Harbor Hospice of South San Antonio, LP

Based on record review and interview the agency failed to provide social work to Pt #1 and nursing services to Pt #3 as ordered in the plan of care for 2 of 7 records reviewed. Failure to provide SW services to Pt #1 resulted in no assessments for her psychosocial status, safety concerns, monitoring for abuse/neglect and to provide referrals as appropriate. Failure to ensure the plan of care for Pt #3 was reviewed and skilled nurse frequencies were ordered correctly caused confusion among agency staff. --- Findings Included: Review of the clinical record for Pt #1 revealed a start of care date of 06/17/2023 with a terminal diagnosis of Alzheimers Disease. Review of the POC (plan of care) for the certification period 06/11/2024 – 08/09/2024 included order: Orders/Treatments: Medical Social Worker; 1 m 3 m 3 (one time per month for 3 months times 3 months) + 3 PRN. Review of the visit notes revealed no SW visits were conducted from 06/11/2024 – 08/09/2024. Surveyor conducted an interview on 09/24/2024 at 11:20 a.m. with the Administrator. The clinical record for Pt #1 was reviewed. Surveyor requested documentation of SW visits or missed visits for review. An interview was conducted on 09/25/2024 at 9:35 a.m. with the Administrator. Administrator stated after some research it was determined the SW visits were not conducted. Administrator stated the agencys SW had just resigned and they were trying to find a new SW. Review of the clinical record for Pt #3 revealed a start of care date of 11/05/2023 with a diagnosis of cancer. Review of the POC for the certification period 11/05/2023 – 01/06/2024 revealed orders; Orders/Treatments: Skilled Nursing; 1 d 4 wk (once per day for 4 weeks) + 6 prn. Beginning on 11/05/2023 – Ending on 12/2/2023. Review of skilled nurse visit notes revealed visits were conducted on 11/05/2023, 11/06/2023, 11/11/2023, 11/12/2023, 11/13/2023, 11/20/2023, and 11/30/2023. Surveyor conducted an interview on 09/24/2024 at 3:13 p.m. with the Administrator. The clinical record for Pt #3 was reviewed. Administrator confirmed the orders were 1 d 4 wk + 6 PRN. Administrator stated, I dont know why it is written that way", and felt the frequency was written incorrectly. Surveyor requested documentation of additional skilled nurse visits or missed visit documentation for review. Surveyor conducted an interview on 09/25/2024 at 9:35 a.m. with the Administrator. Administrator stated he and the ASN reviewed the clinical record for Pt #3 and determined the skilled nurse order was written incorrectly and should have been once per week + 6 PRN. Surveyor asked if the order was written incorrectly, why the order was not corrected. Administrator stated he did not know. Review of the agencys online policy and procedure manual revealed a policy titled, ";THE PLAN OF CARE, Policy No. 2-44.1, Revised May 2024", which read ";The care provided to the patient must be in accordance with the plan of care."