Every finding on record at Lakeview Christian Hospice

Based on record review and interview the facility failed to ensure the plan of care specified which provider (hospice or nursing facility) would ensure that the patients needs were met for 1 (P[patient] 5) of 5 (P3, P5, P11, P13, and P14) patients reviewed for receiving care while residing at a nursing facility. This deficient practice could lead to the patients needs not being met. The findings are: --- A. Record review of P5s face sheet revealed P5 resided in a nursing home. Review of P5s plan of care dated 10/8/2024 did not reveal any evidence of which provider (nursing home staff or hospice staff) would be involved in the plan of care and what care and services each provider would be responsible for. B. During an interview on 02/04/2025 at 3:45 PM with S (staff)1, clinical, confirmed that P5s plan of care did not specify which discipline was responsible for completing tasks listed in the plan of care.

Based on clinical record review, staff interview, and review of agency policy, it was determined the hospice failed to ensure that the care and services provided were based on all initial assessments of the patient and family needs in 5 of 11 patient (Patient (P) 1, 3, 4, 5, 7) records reviewed. This lack of coordination provides the potential for a patient needing hospice services that they do not receive. This failure could potentially affect the 19 patients who were currently receiving hospice services and all future hospice patients. Findings include: P1: This patient was admitted on 01/19/22 with a diagnosis of end stage atherosclerotic heart disease. The "Combined Disciplinary Plan of Care," dated 2/16/22, specified "Social Worker Visit Frequency - start date Jan 19, 2022 - 1 visit per 1 week." At the time of the 03/04/22 clinical record review, there was no documentation of Medical Social Work (MSW) assessments or home visits in the clinical record. There was no evidence that the MSW was seeing the patient once weekly as ordered by the physician in the plan of care (POC). There was no evidence the patient was receiving MSW services as deemed necessary by the initial assessment of needs completed by the interdisciplinary group at the start of care. P3: This patient was admitted on 01/05/22 with a diagnosis of end stage congestive heart failure. On the admitting nurse's assessment titled, "Nurse Progress Note Initial Assessment," dated 01/05/22, the nurse documented under "Patient/Family Discussion," that the "following services were accepted: Social work, Spiritual care, Volunteer, Hospice Aide." At the time of the 03/04/22 clinical record review, there was no documentation of MSW assessments or home visits in the clinical record. There was no evidence that the MSW had been included in the "Combined Disciplinary Plan of Care" dated 01/05/22 as requested by the patient/family at the start of care. There was no evidence the patient was receiving MSW services as deemed necessary by the initial assessment of needs completed by the admitting nurse at the start of care. P4: This patient was admitted on 01/19/22 with the diagnosis hypertensive heart disease with heart failure. On the admitting nurse's assessment titled "Nurse Progress Note Initial Assessment," dated 01/19/22, the nurse documented under "Patient/Family Discussion," that the "following services were accepted: Social work, Spiritual care, Bereavement." At the time of the 03/04/22 clinical record review, there was no documentation of MSW assessments or home visits in the clinical record. There was no evidence that the MSW had been included in the "Combined Disciplinary Plan of Care" dated 01/20/22 as requested by the patient/family at the start of care. There was no evidence the patient was receiving MSW services as deemed necessary by the initial assessment of needs completed by the admitting nurse at the start of care. P5: This patient was admitted on 02/10/22 with the diagnosis of Alzheimer's disease with late onset. On the admitting nurse's assessment titled "Nurse Progress Note Initial Assessment," dated 02/10/22, the nurse documented under "Patient/Family Discussion," that the "following services were accepted: Social work, Spiritual care, Bereavement, Hospice Aide." At the time of the 03/04/22 clinical record review, there was no documentation of MSW assessments or home visits in the clinical record. There was no evidence that the MSW had been included in the "Combined Disciplinary Plan of Care" dated 02/16/22 as requested by the patient/family at the start of care. There was no evidence the patient was receiving MSW services as deemed necessary by the initial assessment of needs completed by the admitting nurse at the start of care. P7: This patient was admitted on 01/06/22 with the diagnosis of end stage atherosclerotic heart disease. On the admitting nurse's assessment titled "Nurse Progress Note Initial Assessment," dated 01/06/22, the nurse documented under "Patient/Family Discussion," that the "following services were accepted: Social work, Spiritual care, Volunteer." At the time of the 03/04/22 clinical record review, there was no documentation of MSW assessments or home visits in the clinical record. There was no evidence that the MSW had been included in the "Combined Disciplinary Plan of Care" dated 01/12/22 as requested by the patient/family at the start of care. There was no evidence the patient was receiving MSW services as deemed necessary by the initial assessment of needs completed by the admitting nurse at the start of care. The agency policy titled, "Medical Social Services" dated 9/21, stated "Psychosocial services are provided in accordance with the IDT (interdisciplinary team) and POC to assist the patient/family in dealing with the psychosocial aspects of terminal illness." During an interview completed on 03/04/22 at 4:30 PM, the Hospice Director (HD) and Patient Care Coordinator (PCC) verified these findings and acknowledged the hospice's responsibility in ensuring all members of the IDT are available as requested by the patient at the start of care. The PCC stated "We aren't identifying the correct frequency of visits based on the nurse's initial assessment. We need to find a way to document that correctly."

Based on personnel file review, staff interview, and review of agency policy, it was determined the hospice failed to implement accepted standards of practice to prevent the transmission of infections and communicable diseases regarding hepatitis B prevention in 2 of 4 professional staff files (Home Hospice Aide (HHA)1, Medical Social Worker (MSW), and 5 of 5 hospice volunteer files (Volunteer (Vol) 1, 2, 3, 4, 5) reviewed. Findings include: RN1: The Registered Nurse's date of hire was 08/05/21. At the time of the personnel file review conducted on 03/03/22, there was no evidence that the hepatitis vaccine had been offered, accepted, or declined by this employee since the date of hire. MSW: The Medical Social Worker's date of hire was 05/06/19. At the time of the personnel file review conducted on 03/03/22, there was no evidence that the hepatitis vaccine had been offered, accepted, or declined by this employee since the date of hire. Vol 1: The Volunteer's date of hire was 07/19/21. At the time of the personnel file review conducted on 3/03/22, there was no evidence that the hepatitis vaccine had been offered, accepted, or declined by this employee since the date of hire. Vol 2: The Volunteer's date of hire was 04/23/17. At the time of the personnel file review conducted on 3/03/22, there was no evidence that the hepatitis vaccine had been offered, accepted, or declined by this employee since the date of hire. Vol 3: The Volunteer's date of hire was 07/27/21. At the time of the personnel file review conducted on 3/03/22, there was no evidence that the hepatitis vaccine had been offered, accepted, or declined by this employee since the date of hire. Vol 4: The Volunteer's date of hire was 02/20/17. At the time of the personnel file review conducted on 3/03/22, there was no evidence that the hepatitis vaccine had been offered, accepted, or declined by this employee since the date of hire. Vol 5: The Volunteer's date of hire was 12/01/18. At the time of the personnel file review conducted on 3/03/22, there was no evidence that the hepatitis vaccine had been offered, accepted, or declined by this employee since the date of hire. The agency policy titled "Preventative Spread of HIV, Hepatitis B," undated, stated "In compliance with OSHA (Occupational Safety and Health Administration) standards, ... the hospice will provide vaccination against the Hepatitis B Virus. Employees who decline the Hepatitis B Vaccine will be required to sign a waiver stating that they are aware of the risk of infection and decline the vaccine." During an interview with the Volunteer Coordinator (VC) on 03/03/22 at 3:25 PM, the VC was queried about whether each volunteer is offered the Hepatitis B vaccine upon hire. The VC stated "No, we don't do that." During an interview after the personnel file review was completed on 03/03/22 at 4:30 PM, the Hospice Director verified these findings and acknowledged that health screening had not been completed as required by agency policy. The Hospice Director stated, "I didn't realize they weren't being done."

Based on observation during home visit, record review and interview, it was determined the hospice failed to ensure the Home Hospice Aide (HHA) performed care only as directed on the HHA plan of care during one of one home visit observation, and in one of one record reviewed (Patient (P)3) in which HHA services were provided. This could allow HHA's to complete tasks that were not ordered by the interdisciplinary group or appropriate for a specific patient. This deficient practice had the potential to affect the 19 patients who were currently receiving hospice services and all future hospice patients. Findings include: Record review revealed P3 was admitted to the hospice on 01/05/22 with the terminal diagnosis of chronic systolic congestive heart failure. On 03/04/22 at approximately 2:30 p.m., a joint survey home visit was conducted with Home Hospice Aide (HHA)1. Upon arriving to the home, HHA1 began the home visit by taking and recording the patient's blood pressure, heartrate, respiratory rate, and temperature. When queried, HHA1 stated "I always start my visits by taking the patient's vital signs" (blood pressure, heartrate, respiratory rate and temperature). Upon review of the "Hospice Aide Visit Assignment" document developed for P3, dated 01/05/22, it was noted there was no evidence that the HHA had been directed by the supervising Case Manager Registered Nurse (CMRN) in the HHA plan of care to obtain the patient's blood pressure, heartrate, respiratory rate, and temperature during the home visits. It was also noted that there were no parameters identified to direct the HHA when to notify the CMRN of abnormal or concerning vital sign results. During review of 16 home visit notes documented by HHA1 between the dates of 01/07/22 to 02/14/22, it was noted that on each home visit HHA1 documented taking the patient's blood pressure, heartrate, respiratory rate, and temperature during the home visits. Review of the review of the personnel file for HHA1 on 03/03/22 revealed there was no documented competency to indicate that HHA1 had been instructed in, and demonstrated the correct procedure for monitoring blood pressure, heartrate, respiratory rate, and temperature. During an interview on 03/03/22 at approximately 4:00 PM, the Hospice Patient Care Coordinator (PCC) verified these findings and stated "I wasn't aware that vital signs were being monitored during these home visits.

Based on personnel file review, staff interview, and review of agency policy, it was determined the hospice failed to ensure that an initial hospice orientation had been documented for each Volunteer providing patient care services in five of five Volunteer files (Volunteer (Vol) 1, 2, 3, 4, 5) reviewed. This could potentially allow Volunteers who had not been oriented to their specific job responsibilities to fail to be responsive to the hospice needs of the patient/family. This had the potential to affect the 19 patients who were currently receiving hospice services and all future hospice patients. Findings include: Vol1's date of hire was 07/19/21. At the time of the personnel file review conducted on 03/03/22, there was no evidence of a completed orientation or training that addressed the Volunteer's role, responsibilities, or specific job duties in the personnel file provided. Vol2's date of hire was 04/23/17. At the time of the personnel file review conducted on 03/03/22, there was no evidence of a completed orientation or training that addressed the Volunteer's role, responsibilities, or specific job duties in the personnel file provided. Vol3's date of hire was 07/27/21. At the time of the personnel file review conducted on 03/03/22, there was no evidence of a completed orientation or training that addressed the Volunteer's role, responsibilities, or specific job duties in the personnel file provided. Vol4's date of hire was 02/20/17. At the time of the personnel file review conducted on 03/03/22, there was no evidence of a completed orientation or training that addressed the Volunteer's role, responsibilities, or specific job duties in the personnel file provided. Vol5's date of hire was 12/01/18. At the time of the personnel file review conducted on 03/03/22, there was no evidence of a completed orientation or training that addressed the Volunteer's role, responsibilities, or specific job duties in the personnel file provided. The agency policy titled "Assessment Qualifications," dated 09/21, stated "Competency will be evaluated during the orientation process." During an interview with the Volunteer Coordinator (VC) on 03/03/22 at 3:15 PM, the VC verified that home visits by hospice volunteers had been resumed and were being conducted at the present time after being paused during the pandemic. The VC was queried about how each volunteer is oriented to their hospice role upon hire. The VC stated "We don't have a training program per se ... I just talk to them about what hospice is." There was no evidence of a training program developed for the hospice volunteer which included necessary topics such as handwashing, infection prevention, safety, hospice goals and services, or family dynamics, coping mechanisms and psychological issues surrounding terminal illness, death, and bereavement. During an interview after the volunteer file review was completed on 03/03/22 at 4:30 PM, the Hospice Director verified these findings and stated, "I thought there was a more structured program for the volunteers." The Hospice Director acknowledged that per agency policy, each employee was required to complete orientation appropriate to their job functions ... and that documentation of successful completion of the orientation program should be retained in the employee's personnel file.

Based on personnel file review, staff interview, and review of agency policy, it was determined the hospice failed to ensure that an initial hospice orientation addressing the employee's specific duties had been documented for each professional staff member providing patient care services in three of three professional files (Registered Nurse (RN) 2, Licensed Practical Nurse (LPN)1), and Medical Social Worker (MSW) reviewed. This could potentially allow employees who had not been oriented to their specific job responsibilities to fail to be responsive to the hospice needs of the patient/family. This had the potential to affect the 19 patients who were currently receiving hospice services and all future hospice patients. Findings include: RN2's date of hire was 08/05/21. At the time of the personnel file review conducted on 03/03/22, there was no evidence of a completed orientation that addressed the employee's specific job duties in the personnel file provided. MSW's date of hire was 05/06/19. At the time of the personnel file review conducted on 3/03/22, there was no evidence of a completed orientation that addressed the employee's specific job duties in the personnel file provided. LPN1's date of hire was 12/19/19. At the time of the personnel file review conducted on 03/03/22, there was no evidence of a completed orientation that addressed the employee's specific job duties in the personnel file provided. The agency policy titled, "Assessment Qualifications," dated 9/21, stated "At the time that each clinician is hired, his/her clinical experience and qualifications will be checked to assure necessary skills and training to complete assigned assessments. Competency will be evaluated during the orientation process, including the understanding and ability to perform physical and psychosocial assessments, as well as ability to use equipment." During an interview on 3/03/22 at 4:30 PM, the Hospice Director verified these findings and stated, "We transition our employees into their hospice roles but do not have documentation of a completed hospice orientation." The Hospice Director acknowledged that per agency policy, each employee was required to complete orientation appropriate to their job functions ... and that documentation of successful completion of the orientation program should be retained in the employee's personnel file.