Every finding on record at Hospice of the Plains Inc

Based on interview and record review, the hospice failed to ensure comprehensive assessments were completed by the interdisciplinary group (IDG) no later than five (5) calendar days after the election of hospice care for 2 of 10 patients reviewed who received chaplain services (Patients #8 and #9). Findings include: HOSPICE POLICY According to the policy, "Comprehensive Interdisciplinary Team Plan of Care", undated (in part): "The comprehensive Plan of Care must be completed within five days of the initial assessment." 1. The clinical record for Patient #8 was reviewed on 10/20/21. The patient was admitted for hospice care and services on 9/13/21, with a terminal diagnosis of heart failure. The Plan of Care orders for the certification period dated 9/13/21 to 12/11/21 included orders for skilled nurse (SN) visits one to two times weekly for three months; medical social worker (MSW) visits one to three times monthly for three months; chaplain visits one to three times monthly for three months; and certified nursing assistant (CNA) services as needed (PRN). Patient #8 resided at home. a) The hospice IDG failed to complete Patient #8's comprehensive assessment within five (5) days following the patient's election of hospice services. Clinical record review revealed Patient #8 elected hospice benefits on 9/13/21. Additional review revealed the chaplain had not made an initial assessment visit to Patient #8 to assess his emotional and spiritual needs until 9/20/21, seven days after the patient elected hospice benefits. There was no evidence in the record the chaplain made contact with Patient #8 prior to 9/20/21. 2. The clinical record for Patient #9 was reviewed on 10/20/21. The Hospice Plan of Care dated 10/1/21 to 12/20/21 revealed a start of care date of 7/6/21; with terminal diagnoses of acute and chronic respiratory failure with hypoxia, diastolic heart disease, neurofibromatosis and other pulmonary embolism without acute cor pulmonale. Plan of care orders included; SN services one to two times a week for three months for assessment and pain management; CNA services two times a week for three months for personal cares and safety monitoring; chaplain services one to three times per month for three months for spiritual support and bereavement follow up; and MSW services one to three times per month for three months for psychosocial and bereavement support. a) The hospice IDG failed to complete Patient #9's comprehensive assessment within five (5) days following the patient's election of hospice services. Clinical record review revealed Patient #9 elected hospice benefits on 7/6/21. Additional review revealed the chaplain had not made an initial assessment visit to Patient #9 to assess his emotional and spiritual needs until 7/14/21, eight days after the patient elected hospice benefits. There was no evidence in the record the chaplain made contact with Patient #9 prior to 7/14/21. During an interview on 10/20/21 at 2:20 p.m. the administrator stated that they went over frequencies at IDG but not everyone was able to attend. During an interview on 10/21/21 at 9:53 a.m., the chaplain stated she tried to check her hospice issued electronic device daily for communication about new admissions, however she stated she was older, got busy and forgot. She stated she learned about admissions and deaths via electronic mail (emails) and attempted to call the patients/families within three to five days but was not always successful in reaching them. She stated she was not aware of the five day regulation for evaluation and did not always document her conversations with patients or family members requesting a delay in the chaplain assessment as she should. The chaplain further stated she did not check the orders or care plan prior to making visits and she just went to the patient's home to complete an assessment. During an interview on 10/21/21 at 10:15 a.m., the administrator stated when a patient was admitted to hospice services, the chaplain typically waited until the admission was completed and then scheduled a face to face or telephone initial assessment with the patient. She further stated the hospice expectation was for all disciplines, including chaplain, to complete their assessments within five days following the election of hospice benefits.

Based on interview and record review, the hospice failed to ensure the interdisciplinary group (IDG) included all required individuals, specifically the medical social worker (MSW) and chaplain, for all IDG meetings for 6 of 11 patient records reviewed (Patients #1, #2, #4, #5, #9, and #10). Findings Include: 1. During an interview on 10/18/21 at 2:13 p.m., the administrator stated the IDG was comprised of herself, medical director, chaplain, certified nurse aide, nurse, MSW, and any other staff who had direct contact with the patient. a) The hospice failed to ensure a MSW participated in all IDG meetings and contributed to the patient's comprehensive and ongoing assessments and care planning process. Review of the IDG meeting sign-in sheets for the meetings dated 7/14/21 through 10/6/21, for Patients #1, #2, #4, #5, #9, and #10, revealed no signature from a MSW as being in attendance on 8/11/21. b) The hospice failed to ensure a chaplain participated in all IDG meetings and contributed to the patient's comprehensive and ongoing assessments and care planning process. Review of the IDG meeting sign-in sheets for the meetings dated 7/14/21 through 10/6/21, for Patients #1, #2, #4, #5, #9, and #10, revealed no signature from a chaplain as being in attendance on 9/8/21. During an interview on 10/21/21 at 10:05 a.m., the administrator confirmed the MSW did not attend the IDG meeting on 8/11/21. She was unable to recall why the MSW did not attend. Additionally, the administrator confirmed the chaplain did not attend the IDG meeting on 9/8/21 and stated the chaplain "may have had something else to do."

Based on interview and record review, the hospice failed to ensure the interdisciplinary group (IDG), in collaboration with the attending physician, reviewed, revised, and documented the Plan of Care as frequently as the patient's condition required, but no less than every 15 days for 2 of 11 patient's records reviewed (Patients #4 and #10). Findings include: HOSPICE POLICY According to the policy, "Interdisciplinary Team Meeting", undated (in part): "The Interdisciplinary Team will meet no less than every 14 calendar days to discuss patient/family/caregiver updates in the Plan of Care (POC), deaths and changes in patient/family/caregiver circumstances, admission/certification and re-certification of patients on the hospice program. Each patient's Plan of Care will be reviewed on a bi-weekly basis." 1. The clinical record for Patient #4 was reviewed on 10/19/21. The patient was admitted for hospice care and services on 5/5/21, with a terminal diagnosis of heart failure. The Plan of Care orders for the certification period dated 5/5/21 to 8/2/21 included orders for skilled nurse (SN) visits one to two times weekly for three months; medical social worker (MSW) visits one to three times monthly for three months; chaplain evaluation and assessment; and certified nursing assistant (CNA) services as needed (PRN). Subsequent Plan of Care orders for the certification period dated 8/3/21 to 10/31/21 included orders for SN visits one to two times weekly for three months; and MSW visits one to three times monthly for three months. Patient #4 resided at home until 9/2/21 when the patient was transferred to a Skilled Nursing Facility (SNF). a) The agency failed to ensure the IDG reviewed, revised and documented the individualized plan no less frequently than every 15 calendar days. Review of IDG documentation revealed an IDG meeting was held on 8/25/21. However, further review of the documentation failed to reveal Patient #4 was discussed at the meeting. Additionally, there was no evidence in Patient #4's record the Plan of Care had been reviewed, revised, and/or updated since 7/28/21. 2. The clinical record for Patient #10 was reviewed on 10/20/21. The patient was admitted for hospice care and services on 6/17/21, with a terminal diagnosis of dementia with Lewy bodies. The Plan of Care orders for the certification period dated 6/17/21 to 9/14/21 included orders for SN visits twice weekly for four months; MSW visits twice monthly for four months; chaplain visits two to three times monthly for four months; and CNA services PRN. Subsequent Plan of Care orders for the certification period dated 9/15/21 to 12/13/21 included orders for SN visits one to two times weekly for three months; MSW visits one to two times monthly for three months; and chaplain visits one to two times monthly for three months. Patient #10 resided at home. a) The agency failed to ensure the IDG reviewed, revised and documented the individualized plan no less frequently than every 15 calendar days. Review of IDG documentation revealed an IDG meeting was held on 8/25/21. However, further review of the documentation failed to reveal Patient #10 was discussed at the meeting. Additionally, there was no evidence in Patient #10's record the Plan of Care had been reviewed, revised, and/or updated since 7/28/21. 3. During an interview on 10/21/21 at 10:03 a.m., the administrator stated she knew all patients were discussed at every IDG meeting but acknowledged she was not able to find any evidence Patient #4 and Patient #10 were discussed at the IDG meeting held on 8/25/21.

Based on interview and record review, the hospice failed to ensure a registered nurse (RN) made an on-site visit to the patient's residence no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide for 1 of 4 patients reviewed receiving certified nurse aide (CNA) services (Patient #6). This deficiency was cited previously during a federal recertification survey 11/15/18. Although the hospice corrected the deficiency, based on the findings below, the hospice has not maintained compliance with this regulation requirement. Findings include: HOSPICE POLICY According to the policy titled, "Hospice Nursing Care", not dated (in pertinent parts): "3. The hospice nurse will supervise the CNA no less than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice Interdisciplinary Team meets the patient's needs. The hospice aide does not have to be present during the visit. Documentation of this supervisory oversight will be completed within the patient's chart via the Nursing Visit Record. The Nursing Visit Record cannot be closed within the electronic medical record until this section is complete." According to the policy titled, "Responsibilities/Supervision of Clinical Services", dated 12/12/2018 (in pertinent parts): "6. The Clinical Director will assure that the following supervision is maintained within hospice. -Hospice Aides - A registered nurse (RN) must make an on-site visit to the patient's home: --No less frequency than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. The hospice aide does not have to be present during the visit. --If an area of concern is noted by the supervising nurse, the RN must make an on-site visit to the location where the patient is receiving care in order to observe and assess the aide while he or she is performing care." 1. The clinical record for Patient #6 was reviewed on 10/20/21. The patient was admitted for hospice care and services on 9/29/21, with terminal diagnosis of Chronic kidney disease stage 3 and dementia. The Plan of Care orders for the certification period dated 9/29/21 to 12/27/21 included orders for skilled nurse (SN) services one time a week for four months and 12 as needed (PRN) for symptom management and patient needs; certified nurse aide (CNA) services two times per week for four months for personal cares, ambulation assist and safety monitoring; chaplain services one to three times per month for four months for spiritual support and bereavement follow up; and medical social worker (MSW) services one to three times per month for four months for psychosocial and bereavement support a) Review of the clinical record revealed the hospice failed to ensure CNA supervisory visits were conducted by the RN at least every 14 days. Review of the clinical record from 9/29/21 to 10/19/21 showed CNA services were provided to Patient #6 two times per week. However, further review showed there was no evidence the RN had conducted supervisory visits to the patient between 9/29/21 and 10/19/21, a lapse of 20 days, in order to assess the quality of care and services provided by the CNA. Additionally, there was no documentation which explained why the supervisory visits were not conducted every 14 days according to regulation and agency policy. During an interview on 10/21/21 at 9:30 a.m., CNA #3 stated the RN was present during one visit with Patient #6, however no cares were provided during the time the RN was present, therefore a supervisory visit was not completed. CNA #3 could not recall any supervisory visits being completed for Patient #6. During an interview on 10/21/21 at 10:13 a.m., the administrator stated the hospice tried to do indirect supervisory visits once a week so the visits were not missed. She further stated that every 14 days and every 12 calendar months, the RN was expected to do an on-site supervisory visit. During an interview on 10/21/21 at 10:57 a.m., RN #6 stated she had not supervised CNA #3 with Patient #6 since CNA services started and was not aware that she needed to do a supervisory visit every 14 days.

Based on interview and record review the hospice failed to ensure the patients clinical record contained all appropriate physician orders for treatment/interventions and discipline frequencies, for 1 of 4 patients receiving certified nursing aide (CNA) services (Patient #9), and 3 of 11 patients receiving chaplain services (Patients #2, #4, and #9). Findings include: 1. The clinical record for Patient #9 was reviewed on 10/20/21. The patient was admitted for hospice care and services on 7/6/21, with terminal diagnoses of acute and chronic respiratory failure with hypoxia, diastolic heart disease, neurofibromatosis and other pulmonary embolism without acute cor pulmonale. The Plan of Care orders for the certification period dated 7/6/21 to 9/30/21 included orders for SN services two times a week for four months for assessment and pain management; and MSW services two times per month for four months for psychosocial and bereavement support. a) The hospice failed to ensure physician orders were obtained for CNA services. Review of the initial plan of care, dated 7/8/21 and signed by the physician on 7/16/21, failed to reveal an order for CNA visits. Further review of the clinical record revealed completed CNA visit notes two times per week from 7/6/21 to 9/30/21. However, record review failed to reveal an updated Plan of Care including orders for frequency and services of CNA visits to Patient #9. b) The hospice failed to ensure orders were obtained for chaplain services. Review of the initial plan of care, dated 7/8/21 and signed by the physician on 7/16/21, failed to reveal an order for chaplain services beyond evaluation and assessment. Further review of completed clinical notes showed the chaplain conducted an evaluation to Patient #9 on 7/14/21 and conducted subsequent visits to Patient #9 on 7/28/21, 8/11/21, 9/8/21, and 9/22/21. Record review failed to reveal an updated Plan of Care including orders for frequency and services of chaplain visits to Patient #9. During an interview on 10/20/21 at 2:20 p.m., the administrator stated she was not able to find any other orders to support the frequency of chaplain visits and stated she realized it would be a citation but she would turn it into a performance improvement project. 2. The clinical record for Patient #4 was reviewed on 10/19/21. The patient was admitted for hospice care and services on 5/5/21, with a terminal diagnosis of heart failure. The Plan of Care orders for the certification period dated 5/5/21 to 8/2/21 included orders for skilled nurse (SN) visits one to two times weekly for three months; medical social worker (MSW) visits one to three times monthly for three months; chaplain (CH) evaluation and assessment; and CNA services as needed (PRN). Subsequent Plan of Care orders for the certification period dated 8/3/21 to 10/31/21 included orders for SN visits one to two times weekly for three months; and MSW visits one to three times monthly for three months. Patient #4 resided at home until 9/2/21 when the patient was transferred to a Skilled Nursing Facility (SNF). a) The hospice failed to ensure physician orders were obtained for chaplain services. Review of the Plan of Care for the certification period dated 8/3/21 to 10/31/21 revealed Patient #2 was to have SN and MSW services. Review of completed clinical notes showed the chaplain conducted a visits to Patient #4 on 9/6/21 and 10/5/21. However, the record failed to reveal a chaplain evaluation or physician orders for chaplain services. 3. The clinical record for Patient #2 was reviewed on 10/19/21. The patient was admitted for hospice care and services on 8/18/21, with a terminal diagnosis of chronic respiratory failure with hypoxia. The Plan of Care orders for the certification period dated 8/18/21 to 11/21/21 included orders for SN visits one to two times weekly for three months; MSW visits one to three times weekly for three months; chaplain evaluation and assessment; and CNA services as needed (PRN). Patient #3 resided in an Assisted Living Facility (ALF). a) The hospice failed to ensure orders were obtained for chaplain services. Review of the Plan of Care for the certification period dated 8/18/21 to 11/21/21 revealed Patient #2 was to have an evaluation and assessment of chaplain services. However, review of completed clinical notes showed the chaplain conducted an evaluation to Patient #2 on 8/23/21 and conducted subsequent visits to Patient #2 on 8/31/21, 9/14/21, 9/29/21, 10/2/21, and 10/12/21. Record review failed to reveal an updated Plan of Care including orders for frequency and services of chaplain visits to Patient #2. During an interview on 10/20/21 at 11:56 a.m., the administrator confirmed the hospice had not received orders for chaplain services for Patient #2. During an interview on 10/21/21 at 9:53 a.m., the chaplain stated she did not check the Plan of Care prior to conducting visits to patients and she just went to the patient's home to complete an assessment and visits, without knowledge if the hospice had received orders for chaplain services.