Every finding on record at Hospice Care by Pennswood Village

Based on a review of hospice policy, review of clinical records (CRs), and staff interviews, the hospice failed to document that services were provided in accordance with the plan of care for five (5) of eleven (11) CRs reviewed. (CR# 1, 2, 3, 5 & 6) Findings Included: A review of hospice policy No. A-6.0 titled "Admission, Assessment and Establishment of Plan of Care" conducted on March 30, 2022, at approximately 2:00 P.M. stated, "The Hospice IDT...reviews, revises and documents the individualized plan of care as frequently as the patient's condition requires...the plan is updated and revised as needed at each team meeting relative to frequency of services and any changed in location or level of care...missed visits are reflected in the team meeting notes or individually in the patient clinical record if the visits are out of the frequency of services noted in the plan of care..." A review of CRs was conducted on 3/29/22, from approximately 10:30 A.M. to 2:00 P.M. and 3/30/22, from approximately 10:00 A.M. to 11:30 A.M. revealed the following: CR#1, Start of Care: 2/17/22, Certification Period Reviewed: 2/17/22-5/17/22. The Plan of Care (POC) contained physician orders for skilled nursing (SN) visits 1-3 per week and PRN (as needed); HHA (home hospice aide) 3-5 days per week; MSW (medical social worker) 1 visit per week and PRN; Chaplain 1-4 visits per week and PRN ; Volunteers 1-7 visits per week and PRN. The CR contained no documentation of a Chaplain visit the week of 3/6/22-3/12/22 and 3/13/22-3/19/22. The CR contained no documentation of a MSW visit the week of 3/6/22-3/12/22, 3/13/22-3/19/22 and 3/20/22-3/26/22. In addition there was only 1 aide visit conducted the first week and no volunteer visit (2/17/22-2/19/22). CR#2. Start of Care: 12/22/21. Certification Period Reviewed: 12/22/21-3/21/22. The POC contained physician orders for SN 1-2 visits per week and PRN, HHA 3-5 visits per week, MSW 1-2 visits per month and PRN, Chaplain 1-4 visits per month, and Volunteer 1-5 visits per month. The CR contained no documentation of HHA the first week (12/22/21-12/25/21). CR#3. Start of Care: 11/17/21. Certification Period Reviewed: 2/15/22-4/15/22. The POC contained physician orders for SN 1-3 visits per week and PRN, HHA 3-5 visits per week, MSW 1-2 visits per month and PRN, Chaplain 1-4 visits per week and PRN, and Volunteers 1-4 visits per week and PRN. The CR contained no Chaplain visit for the week of 3/6/22-3/6/22, 3/13/22-3/19/22. CR #5. Start of Care: 11/12/21. Certification Period Reviewed: 2/10/22-5/10/22. The POC contained physician orders for SN 1-3 visits per week and PRN, HHA 3-5 visits per week, MSW 1-2 visits per week, Chaplain 1-4 visits per month and PRN, and Volunteers 1-4 visits per week and PRN. The CR contained no Volunteer visits on the following weeks: 2/13/22-2/19/22, 2/20/22-2/26/22, and 2/27/22-3/5/22. CR#6. Start of Care: 1/31/22. Certification Period Reviewed: 1/31/22-4/30/22. The POC contained physician orders for SN 1-3 visits per week and PRN, HHA starting 3/22/22 1 visit per week, MSW 1-2 visits per month and PRN, Chaplain 1-4 visits per month and PRN. The CR contained no HHA visits for the week of 3/20/22-3/26/22 (order was to start HHA on 3/22/22). An interview with the administrator and clinical director on 3/31/22, at approximately 12:00 P.M confirmed the above findings.