Every finding on record at John Paul Home Hospice LLC

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes, for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles and EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by document review, interview and personnel record review. In 9 of 10 (90%) personnel records reviewed it was revealed that the agency did not ensure that the employees and individuals providing services under an arrangement received and documented emergency preparedness training on hire and annually per the agency's policy. Document 2: The agency’s policy titled, In-service Programs – Mandatory Education (Revised 7/2015) stated in part, “Mandatory Annual Training will include, at minimum: a. Emergency/disaster training." Personnel Record 1: The employee was hired as a Registered Nurse (RN) on 11/06/2022. The personnel record did not contain documented evidence that the employee completed the initial and annual training (2023), per the agency's policy, on the hospice's EP policies and procedures consistent with the expected role of the RN. Personnel Record 2: The employee was hired as a Home Health Aide (HHA) on 09/14/2023. The personnel record did not contain documented evidence that the employee completed the initial training, per the agency's policy, on the hospice's EP policies and procedures consistent with the expected role of the HHA. Personnel Record 3: The employee was hired as a Medical Social Worker (MSW) on 02/24/2021. The personnel record did not contain documented evidence that the employee completed the annual training (2022 and 2023), per the agency's policy, on the hospice's EP policies and procedures consistent with the expected role of the MSW. Personnel Record 4: The employee was hired as a Chaplain on 09/01/2020. The personnel record did not contain documented evidence that the employee completed the annual training (2021, 2022, and 2023), per the agency's policy, on the hospice's EP policies and procedures consistent with the expected role of the Chaplain. Personnel Record 5: The employee was hired as a Bereavement Coordinator on 09/12/2022. The personnel record did not contain documented evidence that the employee completed the initial training, per the agency's policy, on the hospice's EP policies and procedures consistent with the expected role of the Bereavement Coordinator. Personnel Record 6: The employee was hired as a Volunteer Coordinator and Licensed Practical Nurse (LPN) on 05/18/2022. The personnel record did not contain documented evidence that the employee completed the initial training, per the agency's policy, on the hospice's EP policies and procedures consistent with the expected roles of the Volunteer Coordinator and LPN. Personnel Record 7: The employee was hired as the Registered Nurse (RN) and Director of Patient Care Services on 08/29/2022. The personnel record did not contain documented evidence that the employee completed the initial training, per the agency's policy, on the hospice's EP policies and procedures consistent with the expected roles of the RN and Director of Patient Care Services. Personnel Record 8: The Medical Director signed a contract for the position of Hospice Medical Director on 03/06/2022. The personnel record did not contain documented evidence that the employee completed the initial and annual training, per the agency's policy, on the hospice's EP policies and procedures consistent with the expected role of the Medical Director. Personnel Record 9: The employee was hired as the Registered Nurse (RN) on 05/15/2023. The personnel record did not contain documented evidence that the employee completed the initial training, per the agency's policy, on the hospice's EP policies and procedures consistent with the expected role of the RN. On 03/28/2024, joint personnel record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed the records identified did not contain documented evidence to support that Emergency Preparedness education on hire and annually had been provided per the agency's policy.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed it was revealed that the agency did not ensure that the hospice Interdisciplinary Group (IDG) completed the initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 6: The election of hospice care and the initial nursing assessment were completed on 02/29/2024 followed by the initial comprehensive psychosocial and emotional assessment completed by the Medical Social Worker (MSW) on 03/04/2024; however, the assessments did not include a comprehensive spiritual assessment. The Chaplain documented a completed spiritual assessment on 03/08/2024, eight (8) calendar days after hospice care was elected. Clinical Record 7: The election of hospice care and the initial nursing assessment were completed on 11/06/2023. The nurse’s assessment narrative (11/06/2023) included documentation regarding the patient and family’s refusal of a Chaplain visit. The MSW documented attempts to contact the patient and family by telephone on 11/07/2023 and 01/08/2024 without success. The initial nursing assessment and documentation did not contain the required data needed for the psychosocial, emotional, and spiritual comprehensive assessments. Clinical Record 11: The election of hospice care and the initial nursing assessment were completed on 02/09/2023. The nurse’s assessment included documentation that the patient was not religious, had no religious affiliation, and that a chaplain visit was declined. The Medical Social Worker completed the psychosocial and emotional assessment on 02/13/2023. The initial nursing and MSW assessments and documentation did not contain the required data needed for the spiritual comprehensive assessments. Clinical Record 12: The election of hospice care and the initial nursing assessment were completed on 10/13/2022. The MSW documented a completed psychosocial, emotional, and spiritual assessment on 10/20/2022, seven (7) calendar days after hospice care was elected. On 03/28/2024 joint clinical record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed that the clinical records identified did not contain documented evidence to support a comprehensive assessment was completed by the IDG within five (5) calendar days of the election of hospice care.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 8 of 14 (57%) clinical records reviewed it was revealed that the agency did not ensure that the comprehensive assessment included an initial bereavement assessment focusing on the social, spiritual, and cultural factors that could impact the family's ability to cope with the patient's death. Clinical Record 1: The Registered Nurse and Medical Social Worker completed their respective initial assessments on 12/22/2023 followed by the Chaplain's completion of the spiritual assessment on 12/23/2023; however, the assessments did not include documentation focusing on the specific family needs that could impact their grieving process. The clinical record did not contain documented evidence to support that an initial bereavement risk assessment was completed. Clinical Record 3: The Registered Nurse completed the initial nursing assessment on 03/01/2024 followed by the completion of the psychosocial, emotional, and spiritual assessments by the MSW and Chaplain on 03/02/2024. The assessment did not include documentation focusing on the specific family needs that could impact their grieving process. The clinical record did not contain documented evidence to support that an initial bereavement risk assessment was completed. Clinical Record 5: The Registered Nurse completed the initial nursing assessment on 01/29/2024 followed by the completion of the psychosocial, emotional, and spiritual assessments by the MSW on 02/02/2024. The assessment did not include documentation focusing on the specific family needs that could impact their grieving process. The clinical record did not contain documented evidence to support that an initial bereavement risk assessment was completed. Clinical Record 7: The Registered Nurse completed the initial nursing assessment on 11/06/2023; however, the assessment did not include documentation focusing on the specific family needs that could impact their grieving process. The clinical record did not contain documented evidence to support that an initial bereavement risk assessment was completed. Clinical Record 8: The Registered Nurse completed the initial nursing assessment on 02/28/2024 followed by the completion of the psychosocial, emotional, and spiritual assessments by the Chaplain on 03/01/2024 and MSW on 03/02/2024. The assessments did not include documentation focusing on the specific family needs that could impact their grieving process. The clinical record did not contain documented evidence to support that an initial bereavement risk assessment was completed. Clinical Record 10: The Registered Nurse completed the initial nursing assessment on 04/28/2023 followed by the completion of the psychosocial, emotional, and spiritual assessments by the Chaplain on 04/29/2023 and MSW on 05/03/2023. The assessments did not include documentation focusing on the specific family needs that could impact their grieving process. The clinical record did not contain documented evidence to support that an initial bereavement risk assessment was completed. Clinical Record 11: The Register Nurse completed the initial nursing assessment on 02/09/2024 followed by the Medical Social Worker's completion of the psychosocial and emotional assessment on 02/13/2024; however, the assessments did not include documentation focusing on the specific family needs that could impact their grieving process. The clinical record did not contain documented evidence to support that an initial bereavement risk assessment was completed. Clinical Record 12: The Register Nurse completed the initial nursing assessment on 10/13/2022 followed by the Medical Social Worker's completion of the psychosocial, emotional, and spiritual assessment on 10/20/2022; however, the assessments did not include documentation focusing on the specific family needs that could impact their grieving process. The clinical record did not contain documented evidence to support that an initial bereavement risk assessment was completed. On 03/28/2024 joint clinical record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed that the clinical records identified did not contain documented evidence to support an initial bereavement assessment was performed as part of the initial comprehensive assessment. Leadership also confirmed that the assessments performed by the Registered Nurse, Medical Social Worker, and Chaplain for the identified clinical records did not contain documentation to support that bereavement needs were addressed within their discipline-specific assessments.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (42%) clinical records reviewed it was revealed that the agency did not ensure that each patient's individualized written plan of care reflected goals and interventions associated with problems identified in the initial comprehensive assessment. Clinical Record 2: The initial nursing assessment completed on 06/20/2023 documented a medication regimen that included two opioid medications, hydrocodone-acetaminophen, and morphine sulfate ER, for management of pain. The plan of care, effective 06/20/2023 through the current date, did not include goals and interventions associated with the patient's identified risk of opioid-induced constipation. Clinical Record 3: The initial nursing assessment completed on 03/01/2024 identified the patient as having a terminal diagnosis of malignant neoplasm of the lung with a respiratory assessment finding the patient with dyspnea caused by minimal exertion and diminished lung sounds. The plan of care orders, effective 03/01/2024 and updated 03/20/2024, did not contain goals and interventions associated with dyspnea as identified in the initial comprehensive assessment. Clinical Record 4: The initial nursing assessment completed on 10/20/2023 identified the patient as having a terminal diagnosis of malignant neoplasm of the vulva with a respiratory assessment finding the patient had dyspnea caused by minimal exertion as well as while resting at times. The plan of care orders, effective 10/20/2023, did not contain goals and interventions associated with dyspnea as identified in the initial comprehensive assessment. Clinical Record 6: The initial nursing assessment completed on 02/29/2024 identified the patient, a resident of a skilled nursing facility, as having a terminal diagnosis of senile degeneration of the brain. The nurse documented the following problems found during the assessment: dyspnea with minimal exertion, edema, dysphagia, and a deep tissue injury (DTI) wound on the coccyx. The plan of care order written on 03/06/2024 for the benefit period 02/29/2024 through 04/28/2024 did not contain goals and interventions associated with dyspnea, edema, dysphagia, and the coccyx DTI wound identified in the initial comprehensive assessment. Clinical Record 7: The initial nursing assessment completed on 11/06/2023 identified the patient as having a terminal diagnosis of unspecified cerebral infarction. The nurse documented that the following problems were found during the assessment: a fall risk score of seven (7) out of ten (10), bedbound existence, and incontinence of bowel and bladder. The plan of care order written on 11/14/2023 for the benefit period 11/06/2023 through 02/03/2024 did not contain goals and interventions associated with the fall risk or risk for impaired skin integrity related to decreased mobility and incontinence identified in the initial comprehensive assessment. Clinical Record 8: The initial nursing assessment completed on 02/28/2023 identified the patient as having a terminal diagnosis of unspecified severe protein-calorie malnutrition. The nurse documented that the patient had an arterial wound, in which the skilled nursing facility staff were providing care, to the left lower extremity. The plan of care, effective 02/28/2023, did not contain goals and interventions associated with skin integrity and the wound identified in the initial comprehensive assessment. On 03/28/2024, joint clinical record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed that the clinical records identified did not contain documented evidence to support the patients' individualized plans of care included goals and interventions associated with all problems identified in each initial assessment.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview and personnel record review. In 3 of 10 (30%) personnel records reviewed it was revealed that the agency did not ensure the employee records included documentation of the annual education provided in infection control. Document 2: The agency’s policy titled, “In-service Programs – Mandatory Education” (Revised 7/2015) stated in part, “Mandatory Annual Training will include, at minimum: …Infection control training including: i. Tuberculosis, ii. Bloodborne pathogens…” Personnel Record 3: The employee was hired as the Medical Social Worker (MSW) for hospice on 02/24/2021. The personnel record did not contain documented evidence that the MSW received education on the agency's infection control program at hire and annually (2022 and 2023) per the agency's policy. Personnel Record 4: The employee was hired as the Chaplain for hospice on 09/01/2020. The personnel record did not contain documented evidence that the Chaplain received education on the agency's infection control program at hire and annually (2021, 2022, and 2023) per the agency's policy. Personnel Record 8: The Medical Director signed a contract for the position of Hospice Medical Director on 03/06/2022. The personnel record did not contain documented evidence that the Medical Director received education on the agency's infection control program at hire and annually (2023) per the agency's policy. On 03/28/2024 joint personnel record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed the records did not contain documented evidence to support employees and contracted providers had received infection control education annually per the agency's policy.

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by document review, interview and personnel record review. In 2 of 8 (38%) personnel records reviewed it was revealed that the agency did not ensure all licensed professionals participated in hospice-sponsored in-service training. Document 2: The agency’s policy titled, In-service Programs – Mandatory Education (Revised: 7/2015) stated in part, “Non direct care staff must have a minimum of 8 hours of in-service/continuing education per year. Direct care staff, including Hospice Aides, must have a minimum of 12 hours of in-service/continuing education per year.” Personnel Record 3: The employee was hired as the Medical Social Worker (MSW) on 02/24/2021. The personnel record did not contain documented evidence that the MSW participated in at least 12 hours of annual in-service training, per the agency's policy, in 2022 and 2023. Personnel Record 4: The employee was hired as the Chaplain on 09/01/2020 and holds a doctorate in ministry. The personnel record did not contain documented evidence that the Chaplain participated in at least 12 hours of annual in-service training, per the agency's policy, in 2021, 2022, and 2023. On 03/28/2024 joint personnel record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed the records identified did not contain documented evidence to support that employees had participated in hospice-sponsored in-service training annually per the agency's policy.

It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, and per the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, it was revealed that the agency did not ensure medical social services were provided based on the psychosocial assessment, the patient's and family's needs, and the plan of care. Clinical Record 1: The plan of care (POC) orders, effective 12/27/2023 and updated 01/10/2024 and 01/24/2024, included a visit frequency for the Medical Social Worker (MSW) of one (1) visit per week. The MSW completed the initial psychosocial assessment visit on 12/22/2023, and a physician’s order to discontinue MSW services was written on 02/07/2024. There was no documentation of MSW weekly visits from the week of 12/24/2023 through the week of 01/28/2024 or documentation to support why the visits were missed. Clinical Record 2: The plan of care (POC) orders, effective 01/24/2024 and updated 02/07/2024, 02/16/2024, 02/21/2024, and 02/25/2024, included a visit frequency for the Medical Social Worker (MSW) of two (2) visits per month. The MSW documented a completed visit on 02/20/2024. There was no documentation of a second visit in February 2024 or documentation to support why the visit was missed. Clinical Record 7: The plan of care (POC) orders, effective for the benefit period 11/06/2023 through 02/03/2024, included a visit frequency for the Medical Social Worker (MSW) of one (1) visit per quarter. The MSW documented phone calls were made on 11/06/2023 and 02/03/2023 and no one answered the calls. The clinical record did not contain documented evidence to support that the MSW completed a visit during the identified benefit period, documentation of additional attempts to contact the patient or caregiver, or documentation to support why the visit was missed. On 03/28/2024 joint clinical record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed that the clinical records identified did not contain documented evidence to support that MSW visits were completed as ordered or why the visits were missed.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed, in which bereavement services were accepted, it was revealed that the agency did not ensure a bereavement plan of care was developed and included the type and frequency of service to be delivered. Clinical Record 14: The patient’s date of death was documented as 04/07/2023. The Bereavement Coordinator (BC) documented a bereavement risk assessment on 04/08/2023 identifying the bereaved spouse’s risk score as “low”, and documented phone calls were completed to the bereaved along with mailings on 04/24/2023, 05/26/2023, 06/26/2023, 09/25/2023, and 12/25/2023. There was no documented evidence that a bereavement plan of care was developed that included the types and frequency of bereavement services to be provided. On 03/28/2024 joint clinical record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed that the clinical record identified did not contain a bereavement plan of care detailing the types and frequency of services to be provided.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 12 (33%) clinical records reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure the Registered Nurse (RN) provided specific patient care instructions for the hospice aide to follow. Clinical Record 3: The hospice aide care plan, effective 03/01/2024, documented instructions for the aide to perform three types of baths: a complete bed bath, partial bath/shower, and complete shower as needed. In addition to the bath instructions, the care plan documented for the aide to perform the following tasks as needed: assist in dressing, comb hair, pericare, shampooing hair, skin care, backrub/massage, oral hygiene denture care, checking pressure areas, nail care, shave, change linen, assist in ambulation, assist in transfer, turn or position, range of motion, incontinent care, and assist with bedside commode. The care plan did not provide clear, specific instructions to the aide regarding the type of bath to be given or specific frequencies on when to perform the tasks assigned. Clinical Record 6: The hospice aide care plan, effective 02/29/2024, documented instructions for the aide to perform the tasks of back rub/massage, nail care, and assist in transfer "PRN (as needed)." The plan did not provide specific instructions on when the aide was to perform the back rub/massage, nail care, and assist in transfers. Clinical Record 9: The hospice aide care plan, effective 01/10/2024, documented instructions for the aide to perform the tasks of nail care, assist in ambulation, and assist in transfer “PRN (as needed) or “as tolerated.” The plan did not provide specific instructions on when the aide was to perform nail care, assistance with ambulation, and assistance with transfers. Clinical Record 11: The hospice aide care plan, effective 02/09/2024, documented instructions for the aide to perform the tasks of nail care, assist in ambulation, and incontinence care “as needed.” The plan did not provide specific instructions on when the aide was to perform nail care, assistance with ambulation, and incontinence care. On 03/28/2024 joint clinical record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed that the aide care plans identified did not contain specific instructions for all tasks assigned.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure the hospice aide provided services ordered by the Interdisciplinary Group (IDG) and included in the plan of care. Clinical Record 14: The hospice aide care plan, effective on 03/01/2023, instructed the aide to perform a complete shower every visit. The aide visit completed on 04/01/2023 documented that a bed bath was given in place of the shower. The clinical record did not contain documented evidence to support that the aide had received instructions from the Registered Nurse (RN) to perform a bed bath instead of the shower. On 03/28/2024 joint clinical record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed that the aide did not follow the instructions provided on the identified care plan for bathing, and the clinical record did not contain documented evidence to support that the aide received instructions from the RN to perform a bed bath instead of a shower.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) clinical records reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure the hospice aides reported changes in the patient's medical and nursing needs, related to the plan of care, to the Registered Nurse (RN) or documented the report of changes. Clinical Record 11: The hospice aide care plan, effective 02/09/2024, instructed the aide to perform multiple personal care tasks, including a bath. The aide visit completed on 02/13/2024 documented “no” to the performance of all assigned tasks and included a narrative note stating the bath was declined and the patient’s sister had requested to review the care plan with the aide to determine what tasks should be performed during the aide’s visits. The clinical record did not include documented evidence to support that the aide had reported to the Registered Nurse the declined care for the patient during the visit and the request from the patient’s sister to review and develop the aide care plan. Clinical Record 14: The hospice aide care plan, effective on 03/01/2023, instructed the aide to perform a complete shower every visit. The aide visit completed on 04/01/2023 documented that a bed bath was given in place of the shower. The clinical record did not contain documented evidence to support that the aide had reported changes in the patient’s condition to the Registered Nurse (RN) to elicit the required changes to the aide’s care plan. On 03/28/2024 joint clinical record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed that the clinical records identified did not contain documented evidence that the aide contacted the RN regarding the refusal of care ordered, changes in the patient's condition, or a need to update the plan of care.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) clinical records reviewed, in which hospice aide services were provided, it was revealed that the agency did not ensure the Registered Nurse (RN) performed on-site supervisory visits of the hospice aides no less frequently than every 14 days. Clinical Record 2: A hospice aide supervisory visit was documented as completed on 02/14/2024. The next hospice aide supervisory visit was not documented as completed until 03/16/2024, which was 31 days. Clinical Record 7: The hospice aide’s first completed visit was documented on 11/07/2023. The hospice aide supervisory visits were documented as completed on 11/20/2023 (23 days after the aide visits began), 12/18/2023, 01/03/2024 (16 days since last supervisory visit), 01/15/2024, and 01/30/2024 (15 days after last supervisory visit). On 03/28/2024 joint clinical record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed that the clinical records identified did not contain documented evidence to support on-site supervisory visits of the hospice aides were completed no less frequently than every 14 days.

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDTION LEVEL DEFICIENCY This CONDITION was not met as evidenced by clinical record review personnel record review, and interview which revealed significant issues with the organization and administration of services in the areas of Human Resource Management in which the agency failed to ensure staff met all requirements for initial and ongoing training and competency, [HSRM.17.I/L586, HSRM.15.I/L661, HSRM.14.I/L663, HSRM.25.I/L629, HSEP.5.DE37]; issues in the delivery of Hospice Aide services in which the agency failed to ensure the Hospice aides received and followed patient specific care instructions, [HCDT.15.I/L625, HCDT.16.I/L626, HCDT.18.I/L628]; and issues in the documentation of Care, Delivery and Treatment, [HCDT.38.I/L682, HCDT.39.I/L683, HCDT.40.I/L684] in which the agency failed to ensure the continuity of care was provided by documenting physician orders, providing information to the primary care physician, and to non--hospice providers. The cumulative effect of these deficiencies has resulted in the hospice agency's inability to ensure the provision of quality care under the Condition of Participation CRF 418.100, Organization and Administration of Services. The collective deficient practice illustrates systematic process failures that has the potential to affect all patients receiving hospice services from the agency.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by document review, interview, and personnel record review. In 8 of 10 (80%) personnel records reviewed it was revealed that the agency did not ensure personnel records included documentation of all training provided to employees on hire including training on the hospice philosophy. Document 1: The agency’s policy titled, “Employment Process” (Revised 4/2015) stated in part, “Hospice follows a recruitment, screening and orientation process… 5) Introductory Period/Orientation… b. The organization will have a checklist to verify that all required topics have been discussed with individual workers.” Personnel Record 1: The employee was hired and signed a job description describing the employee's specific job duties as a Registered Nurse on 11/06/2022. The personnel record did not contain documented evidence that the employee received orientation on the hospice philosophy. Personnel Record 2: The employee was hired and signed a job description describing the employee's specific job duties as a Home Health Aide on 09/14/2023. The personnel record did not contain documented evidence that the employee received orientation on the hospice philosophy. Personnel Record 4: The employee was hired and signed a job description describing the employee's specific job duties as a Chaplain on 09/01/2020. The personnel record did not contain documented evidence that the employee received orientation on the hospice philosophy or that a checklist was completed verifying all required topics were discussed per the agency's policy. Personnel Record 5: The employee was hired and signed a job description describing the employee's specific job duties as a Bereavement Coordinator on 09/12/2022. The personnel record did not contain documented evidence that the employee received orientation on the hospice philosophy or that a checklist was completed verifying all required topics were discussed per the agency's policy. Personnel Record 6: The employee was hired and signed a job description describing the employee's specific job duties as a Volunteer Coordinator and Licensed Practical Nurse (LPN) on 05/18/2022. The personnel record did not contain documented evidence that the employee received orientation on the hospice philosophy or that a checklist was completed verifying all required topics were discussed per the agency's policy. Personnel Record 7: The employee was hired and signed a job description describing the employee's specific job duties as a Registered Nurse (RN) and Director of Patient Care Services on 08/29/2022. The personnel record did not contain documented evidence that the employee received orientation on the hospice philosophy or that a checklist was completed verifying all required topics were discussed per the agency's policy. Personnel Record 8: The Medical Director signed a contract for the position of Hospice Medical Director on 03/06/2022. The personnel record, nor signed contract, contained documented evidence that the employee received orientation on the hospice philosophy or that a checklist was completed verifying all required topics were discussed per the agency's policy. Personnel Record 9: The employee was hired and signed a job description describing the employee's specific job duties as a Registered Nurse (RN) on 05/15/2022. The personnel record did not contain documented evidence that the employee received orientation on the hospice philosophy or that a checklist was completed verifying all required topics were discussed per the agency's policy. On 03/28/2024 joint personnel record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed the records identified did not contain documented evidence to support employees and contracted providers had completed orientation training required per the agency's policy.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency. This standard was not met as evidenced by document review, interview and personnel record review. In 6 of 10 (60%) personnel records reviewed it was revealed that the agency did not ensure there was documentation that skills and competency assessments were completed for all individuals providing care, on hire and annually per agency policy. Document 3: The agency’s policy titled, Agency Competency (Revised: 5/2012) stated in part, “All staff will be assessed for competency prior to assuming the duties for which they were hired… Validation of skills competency is conducted annually thereafter.” Personnel Record 1: The employee was hired as a Registered Nurse on 11/06/2022. The personnel record did not contain documented evidence that the skills and competency of the employee were assessed at hire per the agency's policy. Personnel Record 3: The employee was hired as a Registered Nurse on 02/24/2021. The personnel record did not contain documented evidence that the skills and competency of the employee were assessed annually for the years 2022 and 2023 per the agency's policy. Personnel Record 5: The employee was hired as a Bereavement Coordinator on 09/12/2022. The personnel record did not contain documented evidence that the skills and competency of the employee were assessed at hire and annually (2023) per the agency's policy. Personnel Record 4: The employee was hired as a Chaplain on 09/01/2020. The personnel record did not contain documented evidence that the skills and competency of the employee were assessed annually for the years 2021, 2022, and 2023 per the agency's policy. Personnel Record 6: The employee was hired as a Volunteer Coordinator and Licensed Practical Nurse (LPN) on 05/18/2022. The personnel record did not contain documented evidence that the skills and competency of the employee as an LPN were assessed at hire per the agency's policy. Personnel Record 7: The employee was hired as a Registered Nurse (RN) and Director of Patient Care Services on 08/29/2022. The personnel record did not contain documented evidence that the skills and competency of the employee were assessed at hire and annually (2023) per the agency's policy. On 03/28/2024 joint personnel record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed the records identified did not contain documented evidence to support assessment of the skills and competencies of the employees had been performed on hire and annually per the agency's policy.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by document review and interview. In 7 of 14 (50%) clinical records reviewed it was revealed that the agency did not ensure the patient's clinical record contained physician orders for all care and services provided. Clinical Record 2: The plan of care order, effective 03/20/2024, included interventions, to administer supplemental oxygen and assess oxygen saturation levels "as ordered." The clinical record did not contain physician orders specifying the amount (liter flow), route, or frequency of the oxygen to be given. Clinical Record 5: The plan of care, effective 01/29/2024 included interventions, to administer oxygen and assess oxygen saturation “as ordered.” The clinical record did not contain physician orders specifying the amount (liter flow), route, or frequency of the oxygen to be given or specific physician orders for assessing oxygen saturation. Clinical Record 6: The plan of care updated and effective on 03/20/2024 included a goal to keep an identified wound clean and free from pain and odor. The clinical record did not contain physician orders identifying the location of the wound and the specific wound care to be provided. Clinical Record 7: The plan of care updated 02/07/2024, effective for benefit period 02/04/2024 through 05/03/2024, identified pain as a problem for the patient and included interventions to administer pain medications and to titrate pain medications “as ordered” as well as to educate on and evaluate the effectiveness of the pain medication regimen. The clinical record did not contain physician orders for pain medications. Clinical Record 8: The nursing recertification assessment dated 02/17/2024 documented “blisters” to the patient’s bilateral lower extremities and included a note stating the nursing facility would be providing wound care. The clinical record did not contain a physician’s order for specific wound care. Clinical Record 11: The nursing assessment completed on 02/21/2024 documented that the patient was using acetaminophen for pain control. An assessment note titled, "Discharge-Live" completed on 03/13/2024 documented that the patient was discharged from hospice services due to seeking aggressive treatment at the hospital for an infection. The clinical record did not contain physician orders for acetaminophen and the discharge from hospice services. Clinical Record 12: The plan of care, effective 10/18/2022 and reviewed by the interdisciplinary group no less frequently than every 15 days through 01/10/2023, included a visit frequency order for the volunteer of two (2) visits per month. The last documented note completed by the volunteer was on 04/16/2022. The clinical record did not contain a physician’s order to discontinue volunteer services or documentation to support why the visits were missed. On 03/28/2024 joint clinical record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed that the clinical records identified did not contain evidence to support that physician orders were received and documented for all care and services provided.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed, in which the patient was transferred to a Medicare-certified facility, it was revealed that the agency did not ensure a copy of the hospice discharge summary was forwarded to the facility. Clinical Record 11: A nursing assessment note titled, "Discharge-Live" was completed on 03/13/2024 and documented that the patient was seeking aggressive treatment at the hospital for an infection. The clinical record did not contain documented evidence that a copy of the hospice discharge summary was forwarded to the facility. On 03/28/2024 joint clinical record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed that the clinical record identified did not contain documented evidence to support that a hospice discharge summary was forwarded to the Medicare-certified facility that the patient was transferred to.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, in which the patient was discharged from hospice care, it was revealed that the agency did not ensure that a copy of the discharge summary was forwarded to the attending physician. Clinical Record 11: A nursing assessment note titled, "Discharge-Live" was completed on 03/13/2024 and documented that the reason for discharge was that the patient was seeking aggressive treatment at the hospital for an infection. The clinical record did not contain documented evidence that a copy of the hospice discharge summary was forwarded to the patient’s attending physician. Clinical Record 12: A nursing assessment note titled, "Discharge-Live" was completed on 10/07/2023 and documented that the reason for discharge was that the patient was no longer terminally ill. The clinical record did not contain documented evidence that a copy of the hospice discharge summary was forwarded to the patient’s attending physician. On 03/28/2024 joint clinical record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed that the clinical records identified did not contain documented evidence to support that a hospice discharge summary was forwarded to the patient's attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, in which the patient was discharged from hospice care, it was revealed that the agency did not ensure a discharge summary, including the patient's hospice stay, treatments, symptoms, pain management, plan of care, physician orders, and other documentation to assist in continuity of care, was documented. Clinical Record 11: A nursing assessment note titled, "Discharge-Live" was completed on 03/13/2024 and documented that the reason for discharge was that the patient was seeking aggressive treatment at the hospital for an infection. The clinical record did not contain documented evidence of a discharge summary containing a summary of the patient’s hospice stay, including treatments, symptoms, pain management, the current plan of care, the latest physician orders, and any other documentation to promote continuity of care post-discharge. Clinical Record 12: A nursing assessment note titled, "Discharge-Live" was completed on 10/07/2023 and documented that the reason for discharge was that the patient was seeking aggressive treatment at the hospital for an infection. The clinical record did not contain documented evidence of a discharge summary containing a summary of the patient’s hospice stay, including treatments, symptoms, pain management, the current plan of care, the latest physician orders, and any other documentation to promote continuity of care post-discharge. On 03/28/2024 joint clinical record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed that the clinical records identified did not contain a discharge summary.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and document review. In 3 of 3 (100%) clinical records reviewed, of patients that resided in a skilled nursing facility (SNF), it was revealed that the agency did not ensure that the hospice plan of care identified the provider responsible for performing specific functions agreed upon and included in the plan of care. Clinical Record 2: The patient’s caregiver elected hospice services to be provided to the patient, who was a resident of a skilled nursing facility, on 06/20/2023. The plan of care order, updated 03/20/24, included interventions, to administer supplemental oxygen and assess oxygen saturation levels "as ordered." The POC did not identify which provider was responsible for performing these interventions. Clinical Record 6: The initial nursing assessment dated 02/29/2024 documented a DTI (deep tissue injury) wound to the coccyx, and the nursing narrative noted that the nursing home’s wound care team would be providing the care, and a physician order was written detailing the wound care to be provided. The plan of care was initiated on 02/29/2024 and updated every 14 days to the current date; however, the plan of care did not identify which provider was responsible for performing the ordered wound care. Clinical Record 8: The initial nursing assessment dated 02/28/2023 documented an arterial wound on the left lower extremity and included a note that the nursing facility would be providing wound care. The recertification nursing assessment on 02/17/2024 documented “blisters” to bilateral lower extremities and included a note that the nursing facility would be providing wound care. The initial plan of care (02/28/2023) and the plan of care for the current benefit period (02/23/2024 through 04/22/2024) did not identify which provider was responsible for performing the wound care initially or with updated plans of care. On 03/28/2024 joint clinical record reviews and interviews were conducted with the Administrator, Director of Operations/Finance, and Director of Patient Care Services who agreed that the plans of care for the clinical records identified did not specify which provider would be responsible for performing the interventions.

Based on document review and interview, the hospice failed to ensure the patient and patient's family were treated with dignity and respect in 1 (MR#1) of 6 clinical records reviewed, resulting in the hospice's inability to ensure the patient's right to exercise their rights and respect for person for all 10 current patients. Findings include: MR#1: This patient (subject of the complaint) was admitted to hospice on 9/22/2021 with diagnoses of end-stage renal disease (ESRD), dementia, and failure to thrive. Review of clinical record noted a skilled nursing visit by Staff D on 9/23/21 at 5:30 PM through 6:30 PM. Staff D documented the following concerning the patient's condition: "Patient recently signed on the hospice service shortly status is active passing away transitioning so notified (Staff D) RN Status is active Alert oriented to person, nonverbal open eyes after reposition Heart sound Noted AP (apical pulse) with Heart Sound S1 S2 SM Respirations 16 to 24 shallow pupil reactive to light stimuli placed non-rebreather mask at 100% infusion well daughter self-catheter early in day only received small amount of concentrated dark amber urine." (sic) The next and last entry in the clinical record was "Discharge - Death" on 9/24/22 by the Director of Clinical Services (Staff B). Staff B documented under "Comments/Summary" the following: "Patient pronounced by Police Department and EMS per family request, ME (medical examiner) provided TOD (time of death) to writer of 06:39 Medical Examiner# 21-11629." Review of a filed Gross Pointe Farms Public Saftey police report on 5/9/22 at 5 PM., noted the following narrative dated 9/24/21 at 07:43 AM. "Dispatched to listed location on report of a Hospice Death for (MR#1). Dispatch advised me there was no Hospice paperwork but there is a ME (medical examiner) number. Upon arrival I spoke with MR#1's daughter, (Family A). (Family A) advised Officers the hospice nurse has yet to arrive at the house to pronounce a time of death. However, John Paul Home Hospice and Hospice nurse, (Staff D), contacted the ME, announced Time of Death, and the ME provided a case number. (Family A) and family were advised by Officers that this was uncommon practice. Director of John Paul Home Hospice, (Staff B), was contacted on behalf of the error. (Staff B) stated they made an error by releasing the Time of Death and contacting the ME without proper medical personnel on scene to examine the body. Note: MR#1was on hospice for Kidney failure. (Family A) saw her father take his last breaths at approximately, 03:00 hours on 9/24/21. (Family A) contacted nurse (Staff D) who claimed to be en route to the home, but still hadn't showed by the time Officers arrived on 06:18. During that time slot, (Staff D) contacted the ME and was given a case number without physically examining the body first. The family of MR#1 was upset on how Hospice had handled the situation and requested John Paul Home Hospice to no longer be of service to them." The Director (Staff B) was queried during the complaint investigation interview 5/10/22 at 11:35 AM., what the agency expectation was for staff to arrive on-site when notified that a patient has passed? Staff B replied, "Within one hour." The complaint intake noted the family had called the Agency to inquire about staff coming and helping the family with the death of MR#1 four times between 3:20 AM and 5 AM. Each time the family was told, "The nurse was on the way and was 20 minutes out." Eventually after no response from the hospice, the family reached to outside resources for help-see police report above. Review of the clinical record found no evidence of call log documentation. When Staff B was asked about the absence of any call logs within the agency, Staff B replied, "I have a notebook at my bedside that I write them down on, as I'm on-call throughout the night." Staff B was further queried if she transferred the notebook call logs to the medical record? Staff B replied, "No." During an interview 5/10/22 at 11:40 AM., Staff B was queried what the agency expectation was for follow-up condolences/emotional support concerning family members of the deceased. Staff B replied, " We send out a sympathy card at 3, 6, 9, and 13 months, and of course whenever there's a need." When asked who's responsible for this follow-up, Staff B replied, "That would be the Chaplin, and if they are refused due to religious reasons, then the Social Worker would do it." Further review of the clinical record found no evidence of a bereavement risk assessment, or bereavement services following the patient's death. Subsequently, the Medical Social Worker (Staff E) was interviewed on 5/10/22 at 12:54 PM., concerning the events surrounding MR#1. Staff E was queried about bereavement services and why the clinical record was void of any documented efforts made to offer emotional support to the family. Staff E replied, "I was new at the time and didn't know better. I take responsibility for that. Now I know the process, and I contact them (family) if the Chaplin is refused." On 5/10/22 at 1:15 PM., interviews concerning the above findings were conducted with the Administrator (Staff A), Director of Clinical Services (Staff B) and the Office Manager (Staff C). The findings were reviewed and acknowledged by Staff A, B, and C. Staff A stated, "We're going to learn from this and get better. At least we did the right thing and terminated (Staff D) within a week of this happening." The Agency failed to ensure appropriate and timely measures were taken to help assist family members with the death of a hospice patient and failed to offer continuing emotional support and bereavement services to family members of the deceased.

Based on record review and interview, the agency failed to ensure the patient and family were free from mistreatment and neglect for 1 of 1 records reviewed (The subject of the complaint, MR#1), resulting in the hospice neglecting the needs of the patient and family. Findings include: **Agency policy: Death of Patient in the Home, page 154, dated 2014 stated, "At the time of death, family should be asked to call the Homecare/Hospice office or after-hours number and nurse [sic] will go to patient's home to pronounce the patient." On 9/24/21, the complainant stated in the complaint that, "The patient passed away at 3:00 a.m. A call was made to the hospice at 3:20 a.m. to report the death and request the nurse to come out. We were told they would contact the nurse and that he would be on the way shortly. When they had not arrived by 4:15 a.m., we called back. We were told that the nurse was on the way and would be at our house in 20 minutes. Around 4:45 a.m., staff from the funeral home came to the house to take the patient into their care. We were surprised because the hospice nurse still had not come to examine the patient. When the hospice nurse had not arrived by 5:00 a.m., we called back. Again, we were told the nurse was on the way and was 20 minutes out. The hospice nurse still had not arrived by 6:15 a.m. At that point, the funeral home called the police. The police arrived at the patient's home. After talking with the family, the funeral home, the medical examiner and the hospice staff, the police stated, "The hospice got a death certificate case number from the medical examiner without ever coming to the home after death, without examining the patient or pronouncing the patient's death. The police contacted Emergency Medical Services (EMS), who arrived at the house and declared the time of death. During record review on 5/10/22, it was discovered that no skilled nursing visit was documented for 9/24/22. An agency nurse never arrived at the home to pronounce the time of death. The nurse neglected the needs and wishes of the family by not visiting the patient's house to pronounce a time of death. This neglect caused undo stress and anxiety on the family as stated by the complainant, "The death of a loved one is hard enough to endure without the added stress of an incompetent, uncaring and neglectful hospice involvement. We would have been better off without having this hospice involved in our father's care. They caused increased anxiety, frustration, grief to our family." During an interview on 5/10/22 at 10:40 a.m., the Director of Clinical Services (Staff B) was asked about the agency's time frame expectation for the nurse to arrive at the home to pronounce the time of death. Staff B stated, "Our expectation is to arrive within one hour from notification of the patient's death."

Based on record review and interview, the agency failed to ensure the registered nurse (RN), and the medical social worker (MSW), actively participated in the coordination of all aspects of the patient's hospice care in 1 of 1 records reviewed (The subject of the complaint, MR#1), resulting in the hospice not meeting the counseling, education, and emotional support needs of the patient and family. Findings include: **Agency policy: Death of Patient in the Home, page 154, dated 2014 stated, "At the time of death, family should be asked to call the Homecare/Hospice office or after-hours number and nurse [sic] will go to patient's home to pronounce the patient." **Agency policy: MSW Coordination of Services, dated 5/2012, page 286: Responsibilities; section 2-n stated, "Assessing bereavement needs. Assessing need for counseling related to risk assessment for pathological grief." During review of the complaint on 5/10/22 it was documented that the complainant stated, "Hospice agreed to meet us at home on the day of discharge (9/21/22). They did not and told us it was too late." During record review on 5/10/22, it was discovered that no agency visits were documented for 9/21/22. On 9/22/22, the complainant stated in the complaint that, "An agency nurse would be out to the house at 10:00 a.m. They did not come until 11:00 a.m., after we called to request." During record review on 5/10/22, it was discovered that the initial agency visit (Skilled nursing), was documented on 9/22/22 at 10:30 a.m. On 9/23/22, the complainant stated in the complaint that, "We called the hospice at 9:00 a.m., to report that the patient had taken a turn for the worse (Unresponsive, trouble breathing, wet respirations) and that we wanted a nurse to come out and assess him as soon as possible (ASAP). We also told the agency that the patient had low to unreadable oxygen saturations. The patient had a nasal cannula with oxygen, but the patient was a mouth breather and needed a different set-up. The nurse did not come to the house until 5:30 p.m., and the new oxygen set-up did not arrive until 6:30 p.m." During record review on 5/10/22, it was discovered that a skilled nursing visit was documented on 9/23/22 at 5:30 p.m., 8.5 hours after requested. On 9/24/21, the complainant stated in the complaint that, "The patient passed away at 3:00 a.m. A call was made to the hospice at 3:20 a.m. to report the death and request the nurse to come out. We were told they would contact the nurse and that he would be on the way shortly. When they had not arrived by 4:15 a.m., we called back. We were told that the nurse was on the way and would be at our house in 20 minutes. Around 4:45 a.m., staff from the funeral home came to the house to take the patient into their care. We were surprised because the hospice nurse still had not come to examine the patient. When the hospice nurse had not arrived by 5:00 a.m., we called back. Again, we were told the nurse was on the way and was 20 minutes out. The hospice nurse still had not arrived by 6:15 a.m. During record review on 5/10/22, it was discovered that no skilled nursing visit was documented for 9/24/22. During an interview on 5/10/22 at 10:40 a.m., the Director of Clinical Services (Staff B) was asked about the agency's time frame expectation for the nurse to arrive at the home to pronounce the time of death. Staff B stated, "Our expectation is to arrive within one hour from notification of the patient's death." During record review on 5/10/22, it was discovered that a medical social worker (MSW) missed visit (Initial assessment visit) had been documented on 9/22/21. The missed visit reason was, "Patient transitioned prior to MSW being able to complete assessment. There was no documented evidence that any further visits were provided or attempted by the MSW.

Based on record review and interview, the agency failed to ensure the medical social worker (MSW) provided counseling/bereavement servicies for 1 of 1 records reviewed (The subject of the complaint, MR#1), resulting in the hospice not meeting the counseling, or emotional support needs of the patient and family. Findings include: **Agency policy: MSW Coordination of Services, dated 5/2012, page 286: Responsibilities; section 2-n stated, "Assessing bereavement needs. Assessing need for counseling related to risk assessment for pathological grief." During record review on 5/10/22, it was discovered that a medical social worker (MSW) missed visit (Initial assessment visit) had been documented on 9/22/21. The missed visit reason was, "Patient transitioned prior to MSW being able to complete assessment." During a phone interview with the MSW on 5/10/22 at 12:50 p.m., when asked about the bereavement process stated, "The spiritual counselor handles the bereavement process." When asked who handles bereavement when spiritual counseling is declined the MSW stated, "The MSW handles the bereavement process when spiritual counseling is declined. I was new to the hospice position at that time, and I did not know about the MSW bereavement responsibilities when chaplain/spiritual services were declined. I was not familiar with follow-up appointments for bereavement at that time either."