Every finding on record at Hospice - Circle of Love Association

Based on record review and interview, the hospice failed to: 1. ensure completion of the initial spiritual assessment no later than 5 calendar days after the election of hospice care for five (Patients #2, 8, 16, 17 and 18) of 19 patients; and 2. ensure completion of the initial psychosocial assessment no later than 5 calendar days after the election of hospice care for three (Patients #11, 16 and 17) of 19 patients. --- 1. Patient #2 A review of the clinical record showed an election of the hospice benefit on 11/28/23 with no completion of the initial spiritual assessment from 11/28/23 to 02/07/24 (71 days after the election of the hospice benefit) with no documentation of patient or caregiver refusal of visits. Patient #8 A review of the clinical record showed an election of the hospice benefit on 11/08/23 with no completion of the initial spiritual assessment from 11/08/23 to 02/05/24 (90 days after the election of the hospice benefit) with no documentation of patient or caregiver refusal of visits. Patient #16 A review of the clinical record showed an election of the hospice benefit on 12/06/23 with no completion of the initial spiritual assessment from 12/06/23 to 12/27/23 (21 days after the election of the hospice benefit) with no documentation of patient or caregiver refusal of visits. Patient #17 A review of the clinical record showed an election of the hospice benefit on 12/08/23 with no completion of the initial spiritual assessment from 12/08/23 to 12/19/23 (12 days after the election of the hospice benefit) with no documentation of patient or caregiver refusal of visits. Patient #18 A review of the clinical record showed an election of the hospice benefit on 11/09/23 with no completion of the initial spiritual assessment from 11/09/23 to 11/21/24 (12 days after the election of the hospice benefit) with no documentation of patient or caregiver refusal of visits. 2. Patient #11 A review of the clinical record showed an election of the hospice benefit on 12/08/23 with no completion of the initial psychosocial assessment from 12/08/23 to 02/07/24 (60 days after the election of the hospice benefit) with no documentation of patient or caregiver refusal of visits. Patient #16 A review of the clinical record showed an election of the hospice benefit on 12/06/23 with no completion of the initial psychosocial assessment from 12/06/23 to 12/27/23 (21 days after the election of the hospice benefit) with no documentation of patient or caregiver refusal of visits. Patient #17 A review of the clinical record showed an election of the hospice benefit on 12/08/23 with no completion of the initial psychosocial assessment from 12/08/23 to 12/19/23 (12 days after the election of the hospice benefit) with no documentation of patient or caregiver refusal of visits. On 02/07/24 at 12:15 pm, Staff B stated: 1.the initial spiritual assessments for Patients #2, 8, 16, 17 and 18 were not completed within the first 5 calendar days after the election hospice care, and 2. the initial psychosocial assessments for Patients # 11, 16 and 17 were not completed within the first 5 calendar days after the election of hospice care.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for eighteen (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18 and 19) of 19 patients reviewed. --- Patient #1 A plan of care dated 10/17/23 to 12/15/23 documented a primary diagnosis of Parkinson's disease and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #2 A review of the plan of care dated 11/28/23 to 02/25/23 documented a primary diagnosis of cancer of the breast and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #3 A plan of care dated 09/20/23 to 12/08/23 documented a primary diagnosis of age-related cognitive decline and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #4 A plan of care dated 01/31/24 to 04/29/24 documented a primary diagnosis of multiple myeloma showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #5 A plan of care dated 12/01/23 to 02/28/24 documented a primary diagnosis of age-related cognitive decline and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #6 A plan of care dated 01/31/24 to 04/29/24 documented a primary diagnosis of pancreatic cancer and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #7 A plan of care dated 10/19/23 to 12/17/23 documented a primary diagnosis of Alzheimer's disease and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #8 A plan of care dated 11/08/23 to 02/05/24 documented a primary diagnosis of Alzheimer's disease and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #9 A plan of care dated 12/13/23 to 03/11/24 documented a primary diagnosis of cancer of the prostate and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #10 A plan of care dated 12/21/23 to 03/19/24 documented a primary diagnosis of age-related cognitive decline and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #11 A plan of care dated 12/08/23 to 03/06/24 documented a primary diagnosis of cancer of the bladder and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #12 A plan of care dated 12/01/23 to 02/28/24 documented a primary diagnosis of age-related cognitive decline and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #13 A plan of care dated 10/26/23 to 01/23/24 documented a primary diagnosis of progressive supranuclear ophthalmoplegia and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #14 A plan of care dated 11/19/23 to 02/16/24 documented a primary diagnosis of Alzheimer's disease and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #16 A plan of care dated 12/06/23 to 03/04/24 documented a primary diagnosis of pulmonary fibrosis and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #17 A plan of care dated 12/08/23 to 03/06/24 documented a primary diagnosis of congestive heart failure and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #18 A plan of care dated 11/09/23 to 02/06/24 documented a primary diagnosis of senile degeneration and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #19 A plan of care dated 12/11/23 to 02/08/24 documented a primary diagnosis of atherosclerotic heart disease and showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 02/07/24 at 1:35 pm, Staff B stated the plans of care for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18 and 19 failed to include services necessary for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to ensure quality indicator data was used in the design of the QAPI program for all 24 current patients and any new patients admitted to the hospice. --- A review of QAPI records showed no use of quality indicator data in the QAPI program documentation for 2022 and 2023. On 02/07/24 at 1:30 pm, Staff B stated the QAPI program did not include the use of quality indicator data.

Based on record review and interview, the hospice failed to the ensure plans of care was coordinated with the long-term care facility for four (Patients #1, 2, 3 and 5) of 19 patients reviewed. --- Patient #1 A plan of care dated 10/17/23 to 12/15/23 documented no specific responsibilities to be provided by the nursing home or the hospice. Patient #2 A plan of care dated 11/28/23 to 02/25/24 documented no specific responsibilities to be provided by the nursing home or the hospice. Patient #3 A plan of care dated 09/20/23 to 12/18/23 documented no specific responsibilities to be provided by the nursing home or the hospice. Patient #5 A plan of care dated 12/01/23 to 02/28/24 documented no specific responsibilities to be provided by the nursing home or the hospice. On 02/07/24 at 1:50 pm, Staff stated the plan of care for Patients #1, 2, 3 and 5 did not outline the specific responsibilities to be provided by the nursing home or the hospice.