Every finding on record at Hope Healthcare & Hospice Bc, LLC

Based on record reviews and interviews, it was determined that the agency failed to ensure all members of the interdisciplinary group completed the comprehensive assessment no later than 5 days of the election of hospice care for 3 (Patient #5, #13, and #15) of 19 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) sampled patients reviewed for initial comprehensive assessments. Findings included: --- Patient #5 Review of Patient #5s Medicare Hospice Election Statement and Medicaid Hospice Recipient Notice of Election dated 05/22/2023 revealed Patient #5s spouse elected hospice services for Patient #5 on 05/22/2023. Review of Patient #5s Initial Psychosocial Comprehensive Assessment revealed the assessment was completed on 07/05/2023. There was no documented evidence, and the agency presented no documented evidence, an Initial Psychosocial Comprehensive Assessment and/or social worker visit was completed within 5 days of the election of hospice services. In an interview on 11/26/2024 at 2:51PM, S2Administrator/Director of Nursing (DON) indicated at the time of Patient #5s admit, the social worker was in training, and the agency failed to have another employee complete the Psychosocial Comprehensive Assessment no later than the 5 days of the election of hospice services. Patient #13 Review of Patient #13s Medicare Hospice Election Statement dated 08/16/2024 revealed Patient #13 elected hospice services on 08/16/2024. Review of Patient #13s Initial Psychosocial Comprehensive Assessment revealed the assessment was completed on 08/21/2024. There was no documented evidence, and the agency presented no documented evidence, Patient #13 had an Initial Psychosocial Comprehensive Assessment completed by 08/20/2024. In an interview on 11/26/2024 at 3:16PM, S10Quality Assurance Nurse indicated the social worker had miscalculated the 5 deadline; therefore did not complete the Initial Psychosocial Comprehensive Assessment within the required timeframe as required. Patient #15 Review of Patient #15s Medicare Hospice Election Statement dated 05/01/2024 revealed Patient #15 elected hospice services on 05/01/2024. Review of Patient #15s Initial Psychosocial Comprehensive Assessment revealed the assessment was completed on 05/06/2024. Review of Patient #15s Initial Spiritual Comprehensive Assessment revealed the assessment was completed on 05/07/2024. There was no documented evidence, and the agency presented no documented evidence, Patient #15 had the Initial Psychosocial and Spiritual Comprehensive Assessments completed by 05/05/2024 as required. In an interview on 11/26/2024 at 3:18PM, S2Administrator/DON indicated the social worker and chaplain did not complete the Initial Psychosocial and Spiritual Comprehensive Assessments within the required timeframes.

Based on record review and interview it was determined that the agency failed to ensure initial bereavement assessments were completed for (Patient #5, #16, and #19) of 19 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) sampled patients reviewed for initial bereavement assessments. Findings included: --- Patient #5 Review of Patient #5s record revealed Patient #5 was admitted to the agency on 05/22/2023. There was no documented evidence, and the agency presented no documented evidence, Patient #5 had an initial bereavement assessment completed. In an interview on 11/26/2024 at 2:51PM, S2Administrator/Director of Nursing (DON) indicated the agency did not ensure an initial bereavement assessment was completed for Patient #5. Patient #16 Review of Patient #16s record revealed Patient #16 was admitted to the agency on 06/23/2023. There was no documented evidence, and the agency presented no documented evidence, Patient #16 had an initial bereavement assessment completed. In an interview on 11/26/2024 at 3:19PM, S2Administrator/DON indicated Patient #16 did not have a bereavement assessment completed as required. Patient #19 Review of Patient #19s record revealed Patient #16 was admitted to the agency on 03/07/2024. There was no documented evidence, and the agency presented no documented evidence, Patient #19 had an initial bereavement assessment completed. In an interview on 11/26/2024 at 3:32PM, S2Administrator/DON indicated Patient #19 did not have a bereavement assessment completed as required.

Based on record reviews and interview, it was determined that the agency failed to ensure a patient received skilled nursing services per the ordered frequency for 1 (Patient #9) of 19 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) sampled patients reviewed for care and services per the plan of care and physician orders. Findings included: --- Review of Patient #9s Physician Order dated 10/28/2024 revealed Patient #9 was to receive skilled nursing services once a week for one week, then twice a week for twelve weeks. Review of Patient #9s record revealed the only skilled nurse visit completed for the week of 11/17/2024 through 11/23/2024 was completed on 11/20/2024. In an interview on 11/26/2024 at 3:45PM, S2Administrator/Director of Nursing (DON) indicated the nurse did not complete a second skilled nurse visit as required.

Based on record reviews and interviews, it was determined the agency failed to notify the patients physician of a change in condition for 2 (Patient #16 and #17) of 19 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) sampled patients reviewed for a change in condition. Findings included: --- Patient #16 Review of Patient #16s Skilled Nurse PRN (as needed) Visit note dated 07/21/2024 revealed, in part, the skilled nurse completed a visit due to the facility nurse reporting an abscess (pocket of infection under the skin) to Patient #16s groin. Further review revealed Patient #16 was assessed as having a small hardened abscess to the left labia (exterior portion of the vaginal area) with a pinhole size open are where discharge was leaking. Further review revealed no documented evidence, and the agency presented no documented evidence, Patient #16s physician was notified of Patient #16s groin/left labia abscess. In an interview on 11/26/2024 at 3:19PM, S2Administrator/Director of Nursing (DON) indicated the agency had no documented evidence Patient #16s physician was notified of the new abscess. S2Administrator/DON further confirmed Patient #16s physician should have been notified of the new abscess. Patient #17 Review of Patient #17s record revealed Patient #17 had a fall on 11/18/2024. Review of Patient #17s Skilled Nurse Visit dated 11/19/2024 revealed Patient #17 was assessed as having new left ankle pain with facial grimacing. Further review revealed, no documented evidence, and the agency presented no documented evidence Patient #17s physician was notified of Patient #17s new complaint of left ankle pain. In an interview on 11/26/2024 at 3:26PM, S2Administrator/DON indicated Patient #17s physician was notified of Patient #17s new complaint of left ankle pain on 11/19/2024.

Based on record review, wound care standards of practice, and interview, it was determined the agency failed to ensure wounds were measured and assessed weekly for 2 (Patient #13 and #17) of 5 (Patient #3, #4, #11, #13, and #17) sampled patients reviewed for wound assessment. Findings included: --- Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed assessment and documentation of wound status, which includes comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment included: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates; evidence of infection in surrounding tissues. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Patient #13 Review of Patient #13s Skilled Nurse Visit note dated 10/25/2024 revealed, in part, Patient #13 had a non-blanchable (skin which does not turn pale when compressed) redness to the coccyx (area around the tailbone). Further review of Patient #13s Skilled Nurse Visit note revealed no documented evidence Patient #13s coccyx wound was measured. Review of Patient #13s record revealed no documented evidence, and the agency presented no documented evidence, Patient #13s coccyx wound was measured weekly for the weeks of, 10/27/2024 through 11/02/2024, 11/03/2024 through 11/09/2024, and 11/10/2024 through 11/16/2024. In an interview on 11/26/2024 at 3:16PM, S2Administrator/Director of Nursing (DON) indicated wound care measurements were not obtained for Patient #13 as required. Patient #17 Review of Patient #17s Registered Nurse (RN) Initial/Comprehensive Assessment dated 10/10/2023 revealed Patient #17 was admitted with the following wounds, in part, stage 3 (wound that extends into the subcutaneous tissue) to the sacrum (area of the upper portion of the middle buttock); wound to the left anterior shin (front of lower leg) with no wound type documented; diabetic ulcer to the left great toe (big toe); diabetic ulcer to left medial (inside portion) heel; diabetic ulcer to the left Achilles area (back of ankle); diabetic ulcer to the left lateral malleolus (left foot); diabetic ulcer to the right heel; diabetic ulcer to the right lateral foot (outside portion of the foot). Further review revealed Patient #17 resided in a nursing facility. Review of Patient #17s record revealed no documented evidence, and the agency presented no documented evidence, Patient #17s above mentioned wounds were assessed and measured by the agency skilled nurse from 10/15/2023 through 11/26/2023. In an interview on 11/26/2024 at 3:26PM, S2Administrator/DON indicated the agency had no documented evidence Patient #17s wounds were measured weekly as required. S2Administrator/DON indicated the agencys skilled nurse should have coordinated with the nursing facilitys wound care nurse to assess and measure the wounds weekly as required.

Based on record review and interview it was determined the agency failed to assess patient and/or caregiver bereavement needs after the patient expired to develop individualized bereavement plans of care for 2 (Patient #18 and #19) of 3 (Patient #17, #18, and Patient #19) sampled patients reviewed for bereavement services. Findings included: --- Patient #18 Review of Patient #18s record revealed Patient #18 was admitted to the agency on 12/14/2023 and expired on 12/18/2023. There was no documented evidence, and the agency presented no documented evidence, a bereavement assessment was completed. In an interview on 11/26/2024 at 10:07AM, S6Chaplain indicated he did not complete and document a bereavement assessment to identify any individualized concerns Patient #18s caregiver may have. Patient #19 Review of Patient #19s record revealed Patient #18 was admitted to the agency on 03/07/2024 and expired on 03/19/2024. There was no documented evidence, and the agency presented no documented evidence, a bereavement assessment was completed after Patient #18 expired to assess Patient #18s caregivers individualized needs. In an interview on 11/26/2024 at 10:08AM, S6Chaplain indicated did not complete a bereavement assessment after Patient #19 expired to identify any individualized needs, and started the agencys standard bereavement care plan program.

Based on record review and interview, the hospice agency failed to ensure core services were provided as evidence by the hospice agency not having a medical Chaplain hired from 07/29/2021 to present 01/06/2022. Record review of the hospice agency's personnel files revealed no documented evidence of a chaplain being employed at the Hospice Agency. Record review of Patient #2, Patient #3, Patient #4, Patient #5 Patient #6, Patient #7, Patient #8, and Patient #9's records revealed no documented evidence of the patients having had chaplain visits. In an interview on 01/06/2022 at 9:45am, S1Chief Operating Officer/Quality Assurance Performance Improvement Coordinator stated the hospice agency has not had a chaplain employed at the hospice agency from 07/29/2021 to present 01/06/2022. In an interview on 01/06/2022 at 12:50pm, S1Chief Operating Officer/Quality Assurance Performance Improvement Coordinator confirmed the hospice agency did not have a chaplain to provide core services for the Hospice Agency.