Every finding on record at Hospice of West Tennessee

Based on policy review, medical record review and interview, the facility failed to ensure an initial bereavement risk assessment was performed per facility policy for 1 of 10 (Patient #3) sampled active patients. The findings included: 1. Review of the facility's "BEREAVEMENT SERVICES" policy revealed, "...A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice..." 2. Medical record review for Patient #3 revealed a Start of Care (SOC) date of 11/20/2023. Review of Social Work visit notes beginning 11/20/2023 through 5/6/2024 revealed the initial bereavement risk assessment was not performed until 4/17/2024, 5 months after the patient's admission to hospice services. In an interview on 5/8/2024 at 10:38 AM, the facility's Director of Hospice verified the initial bereavement risk assessment was not performed until 4/17/2024.

Based on policy review, medical record review and interview, the facility failed to follow the plan of care (POC) for 4 of 10 (Patients #1,3, 5, and 10) active patients reviewed. The findings included: 1. Review of the facility's "THE PLAN OF CARE" policy revealed, "...The care provided to the patient must be in accordance with the plan of care...The written plan of care will contain, but will not be limited to, the following...Frequency of services..." 2. Medical record review for Patient #1 revealed a POC dated 3/15/2024 through 5/13/2024 with diagnoses that included Malignant Neoplasm of pelvic bones, sacrum and coccyx. Review of 3/15/2024 POC Chaplain orders revealed visit frequency of 1 visit monthly through 4/30/2024. Review of Chaplain visits beginning 3/15/2024 through 4/30/2024 revealed no Chaplain visit documented in the month of April. 3. Medical record review for Patient #3 revealed a POC dated 2/18/2024 through 5/17/2024 with diagnoses that included Alzheimer's Disease and Heart Failure. Review of 3/1/2024 Social Work orders revealed visit frequency of 1 visit monthly for 3 months. Review of Social Work visits beginning 3/1/2024 through 5/7/2024 revealed no Social Work visit documented in the month of March. 4. Medical record review for Patient #5 revealed a POC dated 2/2/2024 through 5/1/2024 with diagnoses that included Vascular Dementia. Review of 3/1/2024 Social Work orders revealed visit frequency of 1 visit monthly for 3 months. Review of Social Work visits beginning 3/1/2024 through 5/1/2024 revealed no Social Work visit documented in the month of March. 5. Medical record review for Patient #10 revealed a POC dated 3/8/2024 through 5/6/2024 with diagnoses that included Congestive Heart Failure. Review of Home Health Aide (HHA) orders beginning week of 3/10/2024 revealed visit frequency of two visits weekly. Review of HHA visits beginning week of 3/10/2024 through 5/6/2024 revealed no HHA visits documented week of 3/24/2024, and only 1 HHA visit documented week of 3/31/2024. In an interview on 5/8/2024 at 10:38 AM, the Director of Hospice verified the visits were not performed as ordered per the patients' POC.

Based on policy review, document review, observation, and interview, the facility failed to implement additional precautions intended to mitigate the transmission and spread of COVID-19 for 1 of 1 (Hospice Aide #1) unvaccinated staff member observed during home visit. The findings included: 1. Review of the facility's "COVID-19 Vaccination Requirements" policy dated 1/18/2022, revealed a component had not been developed and implemented for mitigating the transmission and spread of COVID-19 for all staff who are not fully vaccinated. 2. Review of the facility staff vaccination log revealed Hospice Aide #1 had filed for an exemption from the vaccine requirements and the outcome was pending. 3. Observations on 1/31/2022 at 2:05 PM, revealed Hospice Aide #1 entered Patient #2's home for a scheduled visit. Hospice Aide #1 wore a surgical mask and face shield while providing care to Patient #2. 4. In a telephone interview on 1/31/2022 at 2:40 PM, the Director of Infection Control verified the facility did not differentiate between vaccinated and unvaccinated staff. In an interview in the conference room on 2/1/2022 at 10:15 AM, the facility Director provided an updated "COVID-19 Vaccination Requirement" policy with a revision date of 2/1/2022. The Director verified the revised policy included the component on additional precautions for mitigating the transmission and spread of COVID-19 for all staff who are not fully vaccinated. The Director verified all staff who are not fully vaccinated were to wear KN95/N95's face mask and a face shield.