Every finding on record at Hillside Hospice

Based on record review and interview, the agency failed to provide spiritual counseling services at end-of-life for 1 of 2 patients (Patient #13) that passed away in a total of 14 patient records reviewed. --- Findings include: Review of agency policy titled "Hospice Services and Admission Policy" dated 10/09/2023 revealed "Purpose: To describe Hospice services provided by the agency. 3.1 Core Services: a Services are available 24 hours a day. g. Counseling." Record review for Patient #13 revealed patient was admitted 07/23/2024 with terminal diagnosis of Acute and Chronic Respiratory Failure with Hypoxia. Initial MSW (Medical Social Worker) admission assessment dated 07/23/2024 revealed patient was not spiritual, was offered and declined Chaplain services. On 08/11/2024, Patient #13 passed away. Record review of SW "Collaboration Note" dated 08/08/2024 at 12:54 PM revealed "Chaplain Referral: Request for Spiritual Support. Referral being requested for: Patient and family. Spiritual beliefs: Upon admission this MSW was informed that they were not really religious and/or affiliated with any specific church but was informed by the nursing home SW that the wife was requesting spiritual support now that patient is declining. Specific Needs: Spiritual support as requested as patient is declining in condition. Wife has been sitting bedside and will be able to express any specific support needs." Record review for Patient #3 revealed no spiritual support/counseling/chaplain services were provided from referral on 08/08/2024 to patient passing 08/11/2024. During an interview with Administrative Secretary D on 10/10/2024 at 1:40PM, the above findings were reviewed. Administrative Secretary D stated, "We cannot find documentation. The patient refused Chaplain initially and was not spiritual. We have a volunteer who is also a Chaplain and may have made a visit, but we have no documentation of that or why a visit wasn't made."

Based on record review and interview, the agency staff failed to develop individual patient Plans of Care and provide coordination of services in 12 out of 12 patient records reviewed. (Patients #1-12) Findings include: Agency staff failed failed to ensure individualized Plans of Care were developed for each patient. See L545 Agency staff failed to develop measureable outcomes in patient Plans of Care. See L548 Agency staff failed to coordinate services on the Plans of Care of patients residing in a facility. See L774.

Based on record review, the agency staff failed to develop individualized Plans of Care that met the needs of each patient in 12 out of 12 patient records reviewed. (Patients #1-12.) Findings include: Review of "Plan of Care and Treatment Policy" last revised 10/7/2021 revealed" 2.2. Definitions -Plan of Care: patient specific, individualized tool to guide the care and services to be provided." Review of Patients #1-12 medical record revealed: Patient #1 was admitted to hospice on 1/4/2022 with a primary diagnosis of Multiple Sclerosis. Patient #2 was admitted to hospice on 9/29/2021 with a primary diagnosis of Alzheimer's Disease. Patient #3 was admitted to hospice on 12/10/2021 with a primary diagnosis of prostate cancer. Patient #4 was admitted to hospice on 12/4/2021 with a primary diagnosis of lung cancer. Patient #5 was admitted to hospice on 12/28/2021 with a primary diagnosis of ovarian cancer. Patient #6 was admitted to hospice on 1/22/2022 with a primary diagnosis of chronic obstructive pulmonary disease. Patient #7 was admitted to hospice on 9/11/2021 with a primary diagnosis of abnormal weight loss. Patient #8 was admitted to hospice on 7/17/2021 with a primary diagnosis of end stage heart disease. Patient #9 was admitted to hospice on 11/12/2021 with a primary diagnosis of sepsis. Patient #10 was admitted to hospice on 12/16/2021 with a primary diagnosis of Alzheimer's Disease. Patient #11 was admitted to hospice on 7/5/2021 with a primary diagnosis of gastrointestinal cancer, Patient #12 was admitted to hospice on 1/27/2022 with a primary diagnosis of Alzheimer's Disease. During medical record review the following intervention was listed on Patients #1-12 Plan of Care, "Instruct medication schedule, action, indication, possible side effects." It was not individualized to meet each patient's specific needs. During medical record review the following intervention was listed on Patients #1-11 Plan of Care, "Evaluate need for and instruct in use of DME (Durable Medical Equipment)/medical supplies." It was not individualized to meet each patient's specific needs. During medical record review the following intervention was listed on Patients #1-11 Plan of Care, "Instruct in environmental risk factors and recommend modification to prevent injury or falls." It was not indivdualized to meet each patient's specific needs. During medical record review the following intervention was listed on Patients #2, #3, #9, and #11 Plan of Care, "Instruct disease process, when to contact hospice." It was not individualized to meet each patient's specific needs. During medical record review the following intervention was listed on Patients #1-11 Plan of Care, "Instruct on dietary and hydration needs of dying person." It was not individualized to meet each patient's specific needs. During medical record review the following intervention was listed on Patients #1, #2, #3, #4, #9, #10, and #11 Plan of care,"Instruct measures to improve respiratory comfort." It was not individualized to meet each patient's specific needs. During medical record review the following intervention was listed on Patients #1, #2, #4, #5, #6, #7, #8, #9, #10, #11 and #12 Plan of Care, "Instruct on skin care and prevention of skin breakdown." It was not individualized to meet each patient's specific needs. During medical record review the following goal was listed on Patients #1-12 Plan of Care, "Patient/Caregiver will work with IDT(interdisciplinary team) to implement hospice services in order to meet their needs." It was not individualized to meet each patient's specific needs. During medical record review the following goal was listed on Patients #1, #7, #9, #10, #11, and #12 Plan of Care, l "Patient/Caregiver will state signs and symptoms approaching death, will have needs identified and met by hospice during dying process." It was not individualized to meet each patient's specific needs. During medical record review the following goal was listed on Patients #1, #4, #5, #6, and #8 Plan of Care Goal "Patient/Caregiver will state understanding of hospice services, how to contact agency 27/7. Will develop POC (Plan of Care) with hospice team." It was not individualized to meet each patient's specific needs. These findings were reviewed and confirmed with Administrator A on 2/8/2022 at 2:00 p.m. at which time he/she nodded his/her head in agreement.

Based on record review, agency staff failed to ensure that measurable outcomes were developed for each patient in 12 of 12 patient records reviewed (Patient's #1-12). Findings include: Review of "Plan of Care & Treatment Policy" last updated 10/7/2021 revealed in part, "3.2 Hospice. f. Contents: measureable outcomes anticipated." Review of Patients #1-12 medical record revealed: Patient #1 was admitted to hospice on 1/4/2022 with a primary diagnosis of Multiple Sclerosis. Patient #2 was admitted to hospice on 9/29/2021 with a primary diagnosis of Alzheimer's Disease. Patient #3 was admitted to hospice on 12/10/2021 with a primary diagnosis of prostate cancer. Patient #4 was admitted to hospice on 12/4/2021 with a primary diagnosis of lung cancer. Patient #5 was admitted to hospice on 12/28/2021 with a primary diagnosis of ovarian cancer. Patient #6 was admitted to hospice on 1/22/2022 with a primary diagnosis of chronic obstructive pulmonary disease. Patient #7 was admitted to hospice on 9/11/2021 with a primary diagnosis of abnormal weight loss. Patient #8 was admitted to hospice on 7/17/2021 with a primary diagnosis of end stage heart disease. Patient #9 was admitted to hospice on 11/12/2021 with a primary diagnosis of sepsis. Patient #10 was admitted to hospice on 12/16/2021 with a primary diagnosis of Alzheimer's Disease. Patient #11 was admitted to hospice on 7/5/2021 with a primary diagnosis of gastrointestinal cancer, Patient #12 was admitted to hospice on 1/27/2022 with a primary diagnosis of Alzheimer's Disease. Review of Patients #1-12's goals revealed the following unmeasurable goals: "Patient/Caregiver will work with IDT (interdisciplinary team) to implement hospice services in order to meet their needs. (Patients #1-12) There is no objective criteria to evaluate progress toward the goal. "Control respiratory distress with as needed oxygen."(Patient #9) There is no objective criteria to evaluate progress toward the goal. "Drain will be maintained." (Patient #3) There is no objective criteria to evaluate progress toward the goal. "Patient/Caregiver will have needs identified and met by hospice during dying process." (Patients #1, #7, #9, #10, #11, #12) There is no objective criteria to evaluate progress toward the goal. "Remain comfortable with minimal dyspnea (shortness of breath) and pain." (Patient #1) There is no objective criteria to evaluate progress toward the goal. "Client to remain comfortable through end of life." (Patient #6) There is no objective criteria to evaluate progress toward the goal. These findings were reviewed and confirmed with Administrator A on 2/8/2022 at 2:00 p.m. at which time he/she nodded his/her head in agreement.

Based on record review and interview, hospice staff failed to identify which provider was responsible for which functions on the Plans of Care for 6 of 6 patients that resided in a facility out of a total of 12 patient records reviewed (Patients #1, #2, #6, #7, #8 and #12.) Findings include: Review of "Plan of Care & Treatment Policy" last revised 10/7/2021 revealed no documentation of guidelines for developing a Plan of Care for patients residing in a facility. Review of Patient #1's Plan of Care dated 1/4/2022 - 4/3/2022 revealed Patient #1 was admitted to hospice with a primary diagnosis of Multiple Sclerosis. Patient #1 resided in an assisted living facility. Review of #1's Plan of Care revealed no documentation of which provider was responsible for which interventions on the Plan of Care. Review of Patient #2's Plan of Care dated 12/28/2021 - 3/27/2022 revealed Patient #1 was admitted to hospice on 9/29/2021 with a primary diagnosis Alzheimer's Disease. Patient #2 resided in an assisted living facility. Review of #2's Plan of Care revealed no documentation of which provider was responsible for which interventions on the Plan of Care. Review of Patient #6's Plan of Care dated 1/22/2022 - 4/21/2022 revealed Patient #6 was admitted to hospice with a primary diagnosis of Chronic Obstructive Pulmonary Disease. Patient #6 resided in an assisted living facility. Review of #6's Plan of care revealed no documentation of which provider was responsible for which interventions on the Plan of Care. Review of Patient #7's Plan of Care dated 12/10/2021 - 3/9/2022 revealed Patient #7 was admitted to hospice services on 9/11/2021 with a primary diagnosis of abnormal weight loss. Patient #7 resided in an assisted living facility. Review of #7's Plan of Care revealed no documentation of which provider was responsible for which interventions on the Plan of Care. Review of Patient #8's Plan of Care dated 1/13/2022 - 3/13/2022 revealed Patient #8 was admitted to hospice services 7/17/2021 with a primary diagnsis of end stage heart failure. Patient #8 resided in a skilled nursing facility. Review of #8's Plan of Care revealed no documentation of which provider was responsible for which interventions on the Plan of Care. Review of Patient #12's Plan of Care dated 1/27/2022 - 3/27/2022 revealed Patient #12 was admitted to hospice services on 10/10/2021 with a primary diagnosis of Alzheimer's Disease. Review of #12's Plan of Care revealed no documentation of which provider was responsible for which interventions on the Plan of Care. These findings were reviewed and confirmed during an interview with RN Supervisor B on 2/9/2022 at 11:50 a.m. When the regulatory requirement was explained, Supervisor B stated, "We've never understood what it meant so that's why we didn't do it. Thanks for the explanation."