Every finding on record at Hospice of the Rock River Valley

A. Based on clinical records review, Hospice policy review and staff interview it was determined that the Agency failed to ensure that the entire interdisciplinary group members supervise care and services to meet spiritual and bereavement needs of the hospice patients and families. This was found in 8 of 13 clinical records reviewed (Pts. #1, 2, 13, 8, 12, 9, 6 and 7). Findings include: 1. Pt. #1 SOC 05/02/2022 Diagnosis: Intrahepatic Bile duct Carcinoma. The clinical record of Pt. #1 was reviewed on 06/14/2022 at 12:30 PM. The IDG notes dated 05/08/2022 lacked doucumentation of the participation of the Chaplain/Spiritual Counselor. 2. Pt. #2 SOC 05/12/2022 Diagnosis: Malignant Neoplasm of Overlapping Sites of Brain. The clinical record was reviewed on 06/14/2022 at 12:30 PM. The IDG notes dated 05/13/2022 lacked documentation of the participation of the Chaplain /Spiritual Counselor with the IDG team. 3. Pt. #13 SOC 11/04/2021 Diagnosis: Alcoholic Cirrhosis of Liver with Ascites. The clinical record was reviewed on 06/15/2022 at 11:00 AM. The IDG notes dated 11/09/2021 lacked the documentation of the participation of the Chaplain /Spiritual Counselor with the IDG team. 4. Pt. #8 SOC 05/11/2022 Diagnosis: Malignant neoplasm of prostate. The clinical record was reviewed on 06/15/2022 at 11:30 AM. The IDG notes dated 05/13/2022 lacked the documentation of the participation of the Chaplain /Spiritual Counselor with the IDG team. 5. Pt. # 12 SOC 05/06/2022 Diagnosis: Intestinal Pulmonary Disease, Unspecified. The clinical record was reviewed on 06/14/2022 at 1:30 PM. The IDG notes dated 05/13/2022 lacked the documentation of the participation of the Chaplain /Spiritual Counselor with the IDG team. 6. Pt. #9 SOC 05/25/2022 Diagnosis: Acute Respiratory Failure with Hypercapnia. The clinical record was reviewed on 06/15/2022 at 10:30 AM. The IDG notes dated 06/03/2022 lacked the documentation of the participation of the Chaplain /Spiritual Counselor with the IDG team. 7. Pt. #6 SOC 11/09/2021 Diagnosis: Malignant Neoplasm of Ampulla of Vater. The clinical record was reviewed on 06/15/2022 at 2:15 PM. The IDG notes dated 11/10/2021 lacked documentation of the participation of the Chaplain/Spiritual Counselor with the IDG team. 8. Pt. #7 SOC 05/12/2022 Diagnosis: Acute on Chronic (Congestive) Heart Failure. The clinical record was reviewed on 06/16/2022 at 10:00 AM. The IDG notes dated 05/13/2022 lacked documentation of the participation of the Chaplain/Spiritual Counselor with the IDG team. 9. The Hospice policy titled "Assessment- Comprehensive Assessment of the Patient" was reviewed on 06/16/2022 at 1:30 PM. The policy required "...POLICY: The Hospice interdisciplinary team conducts and documents....spiritual care.... PROCEDURE... 4. Each member or designee of the interdisciplinary team provides input into the comprehensive assessment within the scope of his/her practice..." 10. The above findings were confirmed during the interviews with the Executive Director Administrator and the Intake/ Administrative Assistant on 06/16/2022 between 9:30 AM and 12:30 PM. and on 06/17/2022 at 11:30 AM.

A. Based on staff interviews and clinical records review, it was determined the Hospice failed to ensure bereavement services were provided as required. This was found in 2 of 2 bereavement records reviewed (Pts. #10 and 11). Findings include: 1. During an interview with the Bereavement Coordinator on 06/15/2022 at 10:15 AM, she stated the hospice provides bereavement services for thirteen months following a patient's death. She stated an initial visit or phone call is made within the first few weeks depending on need of the bereaved, and then routine services are provided at three, six, nine and twelve months. 2. Pt. #10 SOC 05/13/2021 Diagnosis: Malignant Neoplasm of Bladder. The clinical record was reviewed on 06/15/2022 at 1:00 PM. The patient expired on 05/17/2021. The record included a section titled, "Bereavement" with a subsection titled, "Main Contact Log." This section included documentation of bereavement services provided initially on 05/17/2021, at three months on 08/24/2021 and 08/25/2021, and at six months on 11/18/2021. The section also included documentation dated 06/16/2022, "9 month mailing went out with 12 month mailing." The record lacked documentation of bereavement services provided in February 2022, the ninth month, and in May 2022, the twelfth month, after Pt. #10 expired. 3. Pt. #11 SOC 04/28/2021 Diagnosis: Malignant Neoplasm of Pancreas. The clinical record was reviewed on 06/15/2022 at 1:30 PM. The patient expired on 05/15/2021. The record included a section titled, "Bereavement" with a subsection titled, "Main Contact Log." This section included documentation of bereavement services provided initially on 05/17/2021 and 05/18/2021, at two months on 07/13/2022, at three months on 08/19/2022 and at six months on 11/10/2022. The record lacked documentation of bereavement services provided during month nine and twelve. 4. During an interview with the Executive Director and Intake/Administrative Assistant on 06/16/2022 at 12:15 PM the above findings were confirmed.