Every finding on record at Home-Based Care Partners of VA, Inc.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 12 (8%) records reviewed the agency did not ensure that the drug profile contained the patient's current prescription and over the counter (OTC) drugs. Document 6: The agency policy titled; Medication Profile read in part "Procedure: 2. The medication profile must include: a. All current patient medications. 3. The patient's medication profile is reviewed by the IDG whenever there is a significant change and, at a minimum, every 15 days. 5. The patient's medication profile review includes but is not limited to: a. Determining the accuracy and completeness of the profile." Clinical Record 7: The physician's order dated 09/02/2023 read "Oxygen 2 liters per minute (lpm) via nasal cannula for comfort/shortness of breath daily as needed". The interdisciplinary team meeting notes dated 09/13/2023, and 09/27/2023 included documentation of a "completed medication profile review." At the time of the review on 12/05/2023, the medication profile did not include oxygen. During an interview on 12/06/2023, the DPCS stated that the medication had not been added to the medication profile and had since been corrected.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 12 (17%) records reviewed the agency did not ensure an initial bereavement assessment was completed as a part of the comprehensive assessment. Document 2: Agency policy 2.18 titled: Admission and Initial Assessment, read in part, "Initial Assessment - An Initial comprehensive assessment is completed by: 12. The hospice interdisciplinary group in consultation with the individual's attending physician (if any) must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care and includes: vii. Bereavement component that includes a bereavement assessment that considers the needs of the patient's family and other individuals, and focuses on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death." Clinical Record 3: The hospice election of benefit form was dated 11/10/2023. The initial bereavement risk assessment had not been completed at the time of the review on 12/05/2023, which exceeded the 5-day window. The Registered Nurse (RN) start of care assessment was completed on 11/10/2023 and the Medical Social Worker (MSW) initial assessment was completed on 11/11/2023 however, neither discipline completed an initial bereavement risk assessment. Clinical Record 7: The hospice election of benefit form was dated 06/27/2023. The initial bereavement risk assessment had not been completed at the time of the review on 12/06/2023 which exceeds the 5-day window. The Registered Nurse (RN) start of care assessment, the Medical Social Worker (MSW) and the Chaplain's initial assessments were completed on 06/27/2023, however there was no evidence of completion of the initial bereavement risk assessment. During interview on12/06/2023, the DPCS stated the initial bereavements assessments had inadvertently been omitted and had since been corrected.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) records reviewed the agency did not ensure the written plan of care included a detailed scope and frequency of ordered services. Document 3: Agency policy titled Plan of Care, read in part, "2. The hospice must develop an individualized plan of care for each patient. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: f. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs." Clinical Record 1: The hospice election of benefit form was dated 07/27/2023. The hospice plan of care dated 10/25/2023 read "Nursing 3 prn" and contained no visit frequency for the Chaplain. The 11/08/2023 and the 11/21/2023 updated hospice plans of care reviewed by the interdisciplinary team also read "Nursing 3 prn" and contained no visit frequency for the Chaplain. Nursing visit note documentation reflected nursing visits were made on 10/26/2023, 10/27/2023, 10/31/2023, 11/03/2023, 11/07/2023, 11/10/2023, 11/14/2023, 11/17/2023, 11/21/2023, 11/27/203, 12/01/2023, 12/02/2023 and 12/03/2023. Chaplain visit note documentation reflected Chaplain visits were made on 10/26/2023, 11/10/2023 and 11/17/2023. All visit notes were documented as reviewed by the Interdisciplinary team meeting on the team notes dated 11/08/2023 and 11/21/2023. Clinical Record 10: The hospice election of benefit form was dated 05/10/2023. The hospice plan of care dated 08/08/2023 read "Medical Social Worker (MSW) 4 prn, Spiritual Care (SC) 4 prn". The 08/16/203 and the 08/30/2023 updated hospice plans of care reviewed by the interdisciplinary team also read "MSW 4 prn, SC 4 prn." There was no documentation of chaplain nor social work visit note documentation found at the time of the review on 12/05/2023 and all visit documentation was documented as reviewed by the Interdisciplinary team meeting on team notes dated 08/16/2023, 08/30/2023 and 09/13/2023. During interview on 12/06/2023, the DPCS stated that the stand alone as needed (prn) frequencies were entered in error and had since been corrected.

It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that care and services provided are in accordance with the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) records reviewed the agency did not ensure care and services were provided in accordance with the plan of care. Document 1: Agency policy 2.28 titled, Coordination of Services read in part "1. The hospice will maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to: b. Ensure that the care and services are provided in accordance with the plan of care." Clinical Record 2: The hospice election of benefit was dated 10/19/2023. The 10/19/2023 hospice plan of care read "N 2week13." There was documentation of only one visit made the week of 10/19/2023 dated 10/19/2023. The physician's order dated 10/25/2023 read "SC 1week12." There was no documentation of a chaplain visit for the week of 11/02/2023. At the time of the review on 12/05/2023 there was no documented explanation of why nursing and chaplain services were not provided at frequency ordered. Clinical Record 7: The hospice election of benefit form was dated 06/27/2023. The hospice plan of care dated 06/27/2023 read "MSW 1week14; SC 1week14." There was documentation of only one visit made the week of 06/272023 dated 06/27/2023 for both the social worker and the chaplain. At the time of the review on 12/05/2023 there was no documented explanation of why social work and chaplain services were not provided at frequency ordered. Clinical Record 8: The hospice election of benefit form was dated 09/01/2023. The hospice plan of care dated 09/01/2023 read "SC 1week1." There was no documentation of a chaplain visit made the week of 09/01/2023. At the time of the review on 12/05/2023 there was no documented explanation of why chaplain services were not provided at frequency ordered. During an interview on 12/06/2023, the DPCS stated that the frequencies not met had been discussed at team meetings however missed visit entries had not been entered and had since been corrected.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered, and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 6 (33%) records reviewed which included the provision of bereavement services, the agency did not complete a post death bereavement risk assessment. Document 4: The agency policy, Bereavement Program Procedures read in part "Procedure 2. A bereavement assessment will be completed by the palliative care team after patient's death. Based on the presence of risk factors, patients will be assessed as needing direct or indirect contact. 3. Based on the assessed bereavement risks, a plan of care will be developed for the bereaved." Clinical Record 8: The hospice election of benefit form was dated 09/01/2023. The patient's date of death was documented as 09/21/2023. A post death bereavement assessment had not been completed at the time of the review on 12/05/2023. Clinical Record 11: The hospice election of benefit form was dated 06/27/2023. The patient's date of death was documented as 06/29/2023. A post death bereavement assessment had not been completed at the time of the review on 12/05/2023. however, at the time of the review on 12/05/2023. During interview on 12/06/2023, the DPCS stated the assessments had not been completed per agency policy and had since been corrected.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review and interview. In 10 of 12 (83%) records reviewed the agency did not ensure that all entries were approximately authenticated in accordance with hospice policy. Document 5: Agency policy 2.24, titled, Clinical Records, read in part "2. n. All entries must be legible, clear, complete, and appropriately authenticated in accordance with hospice policy and currently accepted standards of practice. p. Each entry is dated and signed, including title and credential, by the person providing the care/services.' Clinical Record 1: The physician's signature on the physician order entries dated 10/25/2023 through 11/21/2023 contained no associated credentials with the signature and date. Clinical Record 2: The physician's signature on the physician order entries dated 10/24/2023 through 11/28/2023 contained no associated credentials with the signature and date. Clinical Record 4: The physician's signature on the physician order entries dated 06/23/2023 through 08/21/2023 contained no associated credentials with the signature and date. Clinical Record 5: The physician's signature on the physician order entries dated 05/31/2023 through 06/27/2023 contained no associated credentials with the signature and date. Clinical Record 6: The physician's signature on the physician order entry dated 09/14/2023 contained no associated credentials with the signature and date. Clinical Record 7: The physician's signature on the physician order entries dated 06/27/2023 through 09/10/2023 contained no associated credentials with the signature and date. Clinical Record 8: The physician's signature on the physician order entries dated 09/01/2023 through 09/21/2023 contained no associated credentials with the signature and date. Clinical Record 10: The physician's signature on the physician order entries dated 08/08/2023 through 08/24/2023 contained no associated credentials with the signature and date. Clinical Record 11: The physician's signature on the physician order entry dated 06/27/2023 contained no associated credentials with the signature and date. Clinical Record 12: The physician's signature on the physician order entries dated 08/23/2023 through 08/30/2023 contained no associated credentials with the signature and date. During an interview on 12/06/2023, the DPCS stated that she had spoken with the EMR vendor and upon investigation, the credentials had been removed inadvertently and had since been corrected.