Every finding on record at John C Fremont Healthcare District Hospice

Based on interview and record review, the agency failed to incorporate patient family members grief/loss risk into the bereavement plan of care, prior to the patients death, through an initial bereavement (a period of mourning after a death of a loved one) risk assessment for three of 11 sampled patients (Patient 2, 4 and 6) when the initial bereavement was not completed. This failure placed the family member at risk for not receiving individualized bereavement service to cope with the patients death. --- Findings: During an entrance conference interview on 9/19/22, at 1 p.m., the Administrator (Adm) and the Director Patient Care Service/ Clinical Supervisor (DPCS/CS) stated, the agency did not currently have a chaplain and the agency was making efforts to hire a chaplain to provide counselling service to the family members. The Adm stated, the MSW was the one who identify any spiritual needs and refer the patients or family member accordingly to community upon her home visit (HV) to meet the counselling requirement. The Adm stated, the Master of Social Work (MSW) was handling the counselling and bereavement service by herself. The DPCS/CS stated, since the agencys census had been low the MSW was able to manage the chaplain service. The Adm and the DPCS/SC stated, the agency did not have bereavement coordinator or volunteer coordinator to assist the MSW. During an interview on 9/21/22, at 2:45 p.m., in Patient 2s home during a home visit (HV), Patient 2s family member (FM) 1, FM 1 stated, the MSW made a HV on 9/14/22 and during her visit she was asked if she needed any spiritual assistance. FM 1 stated, the MSW was supportive by reviewing advance directive and mortuary arrangement. FM 1 stated, she did not recall any other conversation pertaining to her bereavement. FM 1 expressed her feeling of being helpless when she encountered problem finding the right type of pressure relieving device for her mother to use in wheelchair. During a concurrent interview and record review on 9/22/22, at 4 p.m., with DPCS/CS, Patient 2s Plan of Care (POC) benefit period from 9/13/22 to 12/11/22 was reviewed. Patient 2s POC did not contain bereavement. The DPCS/CS stated the MSW made HV to Patient 2 on 9/14/22, but she did not complete her visit note yet. The DPCS/CS stated she did not know about FM 1s helpless feeling since she could not locate the initial bereavement assessment in Patient 1s clinical record. During a concurrent interview and record review on 9/27/22, at 11 a.m., with DPCS/CS, Patient 4s POC benefit period from 8/5/22 to 11/02/22 was reviewed. Patient 4s POC did not contain bereavement. The DPCS/CS stated, the MSW made HV to Patient 4 on 8/10/22, but she could not locate the initial bereavement assessment in Patient 4s clinical record. During a concurrent interview and record review on 9/27/22, at 2:20 p.m., with DPCS/CS, Patient 6s POC benefit period from 8/15/22 to 11/12/22 was reviewed. Patient 6s POC did not contain bereavement. The DPCS/CS stated, the MSW made HV to Patient 6 on 8/18//22, but she could not locate the initial bereavement assessment in Patient 6s clinical record. During an interview on 9/27/22 at 10:40 a.m., with the MSW, the MSW stated, she was the only staff who was qualified to oversee the counselling services for the agency. The MSW stated, she also covered the acute hospital patients and the home health agency patients. The MSW stated, she had to prioritize her workload strategically to accommodate the need of the community. The MSW stated, she did not have time to provide initial bereavement assessment unless there was an obvious risk. The MSW stated, currently she provide the bereavement service case by case after the death occurred. During an interview on 9/27/22, at 10:50 a.m., with the DPCS/CS, the DPCS/CS stated, the agencys bereavement service mission was to support patient and the family member with grief upon admission. The DPCS/CS stated, it was important for MSW to conduct an initial bereavement assessment so concerns could be discussed during the IDG (interdisciplinary group) meeting. During a review of the agencys policy and procedure (P&P) titled, ";Patient & Survivor Bereavement Service," dated 3/27/19, indicated, ";...The primary social worker makes an initial bereavement assessment and plan of care at admission to serve as a baseline for bereavement care throughout patient admission and beyond..."

Based on interview and record review, the agency failed to provide hospice aide services in accordance with the plan of care (POC) when the hospice aide missed scheduled home visits on 1/9/22, 1/14/22, 1/17/22, 1/21/22 for one of 11 sampled patients (Patient 8). This failure had the potential to result in the needs of Patient 8 going unmet when the hospice aide did not complete the scheduled home visits on 1/9/22, 1/14/22, 1/17/22 and 1/21/22. --- Findings: During a concurrent interview and Patient 8s clinical record review on 9/27/22 at 2:45 p.m., with the Director Patient Care Service/Clinical Supervisor (DPCS/CS), Patient 8s POC benefit period from 1/7/22 to 4/6/22 was reviewed, the POC indicated, the start of care was on 1/7/22 and aide service was ordered 1-2 times a week for the benefit period. The DPCS/CS stated, the aide service was scheduled on 1/14/22 but Hospice Aide (HA) 2 was sick, and the visit was missed. The DPCS/CS stated, during IDG (Intradisciplinary group) meeting on 1/11/22, the team discussed sending HA 1 to provide Patient 8s visit HA 2 missed. Patient 8s Aide Care Plan dated, 1/7/22 indicated, Patient 8 needed standby assist with ambulation with walker/Belt/Fall Risk and provide personal care per request and check the gauze pad and dressing supplies. The DPCS/CS stated, no aide visits were made to Patient 8 from 1/9/22 to 1/21/22. During a phone interview on 9/28/22 at 10:50 a.m., with Registered Nurse/Case Manager (RN/CM) 1, the RN/CM 1 stated, Patient 8 had a 24-hour paid care giver and declined aide service from the agency. RN/CM 1 stated she did not open the case so she could not answer when exactly Patient 8 declined aide service. RN/CM stated, if Patient 8 had full time caregiver at the start of care the team should have known the aide service was not needed. RN/CM 1 stated, the reason for missed visits for week of 1/16/22 -1/22/22 was not clearly communicated. RN/CM 1 stated, she contacted the physician to discontinue (DC) aide service when she found out on 1/25/22. During a review of Patient 8s ";Physician Order," dated 1/19/22, the "Physician Order" indicated, ";...Missed HHA (Home Health Aide) visits week of 1/09/22, due to employee illness..." The "Physician order," dated 1/28/22, indicated ";D/C (discontinue) HHA per C/G (caregiver) Request, C/G is able to perform showers. Missed HHA visits 01/14/2022, 01/17/2022, 01/21/2022. Digitally Signed by [RN 1] Date 01/25/22." During a review of the agencys policy and procedure (P&P) titled, ";Interdisciplinary Plan of Care & Updates" dated 3/27/19, indicated ";...The patient and their family will be included in the development of the Plan of Care...Identification of new problems/goals, including those identified by patient and family, are discussed, and documented..."

Based on interview and record review, the agency failed to develop a performance improvement project to ensure bereavement (a period of mourning after a death of a loved one) services were sustained after the Quality Assurance Performance Improvement Program (QAPI) designated the Master of Social Work (MSW) to perform the Chaplains role for 11 of 11 sampled patients. This failure placed the hospice patients and the family members at risk for bereavements needs to go unidentified and bereavement counselling to go unmet. --- Findings: During an entrance conference interview on 9/19/22, at 1 p.m., the Administrator (Adm) and the Director Patient Care Service/ Clinical Supervisor (DPCS/CS) stated, the agency did not currently have a chaplain and the agency was making efforts to hire a chaplain to provide counselling service. The Adm stated, the MSW was the one who identifies any spiritual needs and refers the patients or family member accordingly upon her home visit (HV) to meet the counselling requirement. The Adm stated, the MSW was handling the counselling and bereavement service by herself. The Adm and the DPCS/SC stated, the agency did not have bereavement coordinator or volunteer coordinator to assist the MSWs workload. During a concurrent interview and record review, on 9/22/22, at 4:10 p.m., with the Adm, the agencys ";Board of Directors Regular Board Meeting Minutes" dated 1/21/22, was reviewed. The board meeting minutes indicated, ";...towards the end of 2021, a medical [SIC] social worker (MSW) was hired, which has enabled the agency to once again follow regulations on social work services and bereavement assessments for its hospice patients. Efforts to hire a new chaplain have been ongoing, until one is onboard, the Hospice agency will remain out of compliance with regulatory guidelines..." During an interview on 9/22/22 at 4:20 p.m., the Adm stated, she could not provide any data to evaluate the MSWs workload and patient outcomes. The Adm was unable to provide data related to new admissions and numbers of referrals to the community on a quarterly basis. The Adm stated, she did not track the MSWs workload to ensure she had enough time to provide the bereavement service since she was the only qualified personnel. The Adm stated, she did not collect the data to evaluate the negative outcome caused by the lack of qualified personnel. The Adm stated, she knew the problem, but she did not do anything about it. The Adm stated, she was responsible for the Hospice QAPI and she should have all the elements to the performance improvement in counselling service which was the problem area. During an interview on 9/27/22 at 10:40 a.m., with the MSW, the MSW stated, she was the only staff who was qualified to oversee the counselling services for the agency. The MSW stated, she also covered the acute hospital patients and the home health agency patients. The MSW stated, she had to prioritize her workload strategically to accommodate the need of the community. The MSW stated, she did not have time to provide initial bereavement assessment unless there was an obvious risk. The MSW stated, currently she provide the bereavement service case by case after the death occurred. During an interview on 9/27/22, at 10:50 a.m., with the DPCS/CS, the DPCS/CS stated, the agencys bereavement service mission was to support patient and the family member with grief upon admission. The DPCS/CS stated, it was important for MSW to conduct an initial bereavement assessment so any concerns could be discussed during the IDG (interdisciplinary group) meeting. During a review of the agencys policy and procedure (P&P) titled ";Designation of Manager of Hospice" dated 2/7/19 indicated, ";...to ensure that a qualified person leads the Hospice department in a manner that meets State, Federal, and other mandated governing agency requirement... Department participation with on-going Quality Assurance Performance Improvement (QAPI) projects on a scheduled basis which addresses the 5 elements. This will include CQI (Continuing Quality Improvement) reports...Element 1: Design and Scope Element 2: Governance and Leadership Element 3: Feedback, Data Systems and Monitoring Element 4: Performance Improvement Projects (PIPs)- [Quality Improvement Projects] Element 5: Systemic Analysis and Systemic Action..."

Based on interview and record review, the agency failed to implement the agencys Infection Control policy and procedure (P&P) titled, ";Physical Examinations/Tuberculosis Screenings, Pre and Post Employment" and ";Volunteers" for one of 11 employees (Volunteer 1) when Volunteer 1 was allowed to visit Patient 3 and Patient 8s home without TB (tuberculosis -a disease caused by germs that are spread from person to person through the air usually affects lungs) screening. This failure placed Patient 3 and Patient 8 at risk for acquiring TB. --- Findings: During a concurrent interview and record review, on 9/19/22, at 11:45 a.m., with the Employee Health Nurse (EHN), Volunteer 1s health record was reviewed. Volunteer 1s health record indicated, Volunteer 1s hire date was 9/1/18. The EHN could not provide TB test result for 2020 and 2022. The EHN stated since March 2020 no volunteers were allowed to conduct home visits (HV). The EHN stated she did not know Volunteer 1 resumed HV. The EHN stated it was the agencys policy to have all employees who had patient contact to have a TB test every two years. During an interview on 9/19/22, at 1:15 p.m., the DPCS/CS stated, Volunteer 1 made a HV to Patient 3 and Patient 8 starting 2/15/22. The DPCS/CS stated, the EHN was not aware Volunteer 1 had resumed HV. During a review of the agencys P&P titled ";Infection Control", the P&P was dated 9/1/06. The current P&P draft dated 9/1/22 was presented by the DPCS /CS but the draft was not signed by the Governing Body. The DPCS/CS stated, the agency was in the process of establishing Hospice Specific Infection Control Binder. During a review of the agencys P&P titled ";Physical Examinations/Tuberculosis Screenings, Pre and Post Employment" dated 11/1/2019, the P&P indicated, ";All employees are subject to complete an annual tuberculosis screening questionnaire. TB/PPD (a skin test to detect the immunity developed against tuberculosis causing bacteria) testing will be required every 24 months. A blood test Quantiferon Gold (a simple blood test that aids in the detection of bacteria cause tuberculosis) blood will be used when there is a shortage of PPD solution." During a review of the agencys P&P titled ";Volunteers" dated 12/21/12, the P&P indicated, ";Volunteers must are subject to the same health status requirements as District employees (see P&P Physical examination/Pre-employment and Annual)."

Based on interview and record review, the agency failed to follow the policy and procedure titled, ";Patient & Survivor Bereavement Service" when the Master of Social Work (MSW) did not implement calls to the bereaved (someone who is suffering the death of a loved one) monthly for four of four sampled patients (Patient 6, 9, 10 and 11). This failure placed the family members of Patient 6, 9,10 and 11 at risk for not receiving individualized bereavement service to cope with the loss of their loved ones. --- Findings: During an entrance conference interview on 9/19/22, at 1 p.m., the Administrator (Adm) and Director Patient Care Service/ Clinical Supervisor (DPCS/CS) stated, the agency did not currently have a chaplain and the agency was making efforts to hire a chaplain to provide counselling service to the family members. The Adm stated, the MSW was the one who was qualified to identify any spiritual needs and refer the patients or family member to community to receive support they needed. The Adm stated, the MSW have been managing the counselling service by herself since the agencys census have been low. The Adm and the DPCS/SC, stated the agency did not have bereavement coordinator or volunteer coordinator to assist the MSWs workload. During a concurrent interview and record review on 9/27/22, at 2:20 p.m., with DPCS/CS, Patient 6s ";Bereavement Assessment" dated 8/29/22 was reviewed. The ";Bereavement Assessment" indicated, Patient 6 expired (died) on 8/28/22 and the MSW made calls on 8/29/22 and 8/30/22 after Patient 6s death for post bereavement assessment but the MSW was unable to reach the bereaved. The DPCS/CS could not provide any documented evidence whether the MSW followed up the bereaved after Patient 6s death. During a review of Patient 9s ";Bereavement Assessment" dated 1/3/22, the ";Bereavement Assessment" indicated, Patient 1 expired on 1/2/22 and the MSW called the bereaved on 1/3/22. There was no other documented evidence for any follow up by the agency for past 8 months after Patient 9s death. During a review of Patient 10s ";Bereavement Assessment" dated 5/20/22, the ";Bereavement Assessment" indicated, Patient 10 expired on 5/1/22 and the MSW called the bereaved on 5/20/22 (19 days after patients death). There was no other documented evidence of any additional follow up by the agency for past 4 months after Patient 10s death. During a review of Patient 11s ";Bereavement Assessment" dated 9/28/21, the bereavement assessment indicated, Patient 11 expired on 9/28/21 and the MSW visited the bereaved on 9/28/21. There was no other documented evidence for any follow up by the agency for past 12 months after Patient 11s death. During an interview on 9/27/22, at 10:40 a.m., with the MSW, the MSW stated, she was the only one who was qualified to oversee the counselling services for the agency. The MSW stated, she also covered the acute hospital patients and the home health agency patients. The MSW stated, she had to prioritize her workload strategically to accommodate the need of the community. The MSW stated, she did not have time to provide organized bereavement assessment unless there was an obvious need. The MSW stated, currently she provide the bereavement service case by case after the death occurred. The MSW stated, she did not have time to call the bereaved to identify the needs of support. The MSW stated, the agency currently utilized Hospice Aide (HA) 2 to send a monthly letter to the bereaved after patients death for a year. During an interview on 9/27/22, at 10:50 a.m., with the DPCS/CS, the DPCS/CS stated, the agency had no bereavement coordinator to assist the MSW. The DPCS/CS stated, the agency did not have a chaplain nor a qualified volunteer to help the MSW. The DPCS/CS stated, the agency designated Health Aide (HA) 2 to send monthly bereavement letter to the bereaved for 12 months after patients death. During a concurrent interview and record review on 9/28/22, at 11 a.m. with HA 2, the agencys spread sheet for the bereaved from 9/10/21 to 9/23/22 was reviewed. HA 2 stated it was her duty to update the list and send out monthly letter to the bereaved party on the list for a year. HA 2 stated, she did not make any calls to the bereaved. During a review of the agencys policy and procedure (P&P) titled, ";Patient & Survivor Bereavement Service" dated 3/27/19, indicated, ";...5. The Hospice Chaplain is available to visit survivors to assess and refer to community spiritual resources in the community....9. Monthly phone calls are placed by a member of the Hospice team to the survivors of the patient who has passed for up to one year after the death of the patient..."