Every finding on record at Lamar Area Hospice Association

Based on interviews and record reviews, the agency failed to develop an emergency preparedness plan that was reviewed and updated annually. --- Findings Include: On 5/14/25 at 11:48 a.m., an interview with the administrator revealed the agency failed to update the emergency preparedness plan annually. The administrator was directed to review Appendix Z emergency preparedness regulations, and then stated she was not aware of the requirements. She went on to say the agency would update it's emergency preparedness plan immediately.Review of the agency's emergency preparedness plan showed no evidence the plan had been updated on an annual basis.These findings were acknowledged by the administrator and chief financial officer during the exit conference.

Based on an interview and record review, the agency failed to complete an all hazards risk assessment for 2024 and 2023. --- Findings include:On 5/14/25 at 11:48 a.m., an interview with the administrator revealed that the agency had not completed an all hazards risk assessment for the emergency preparedness plan for 2024 and 2023. The administrator then presented a risk assessment from previous years to demonstrate compliance with the requirement. She further stated the agency would complete an all hazards risk assessment immediately.Review of the agency's emergency preparedness plan showed no evidence the agency had conducted an all hazards risk assessment for 2023 and 2024.These findings were acknowledged by the administrator and chief financial officer during the exit conference.

Based on interview and record review, the agency failed to ensure all disciplines provided a patient-specific comprehensive assessment in 2 of 11 patient records reviewed (Patients #4 and #5). Findings include: AGENCY POLICY According to the agency policy titled, "IDG Visits Frequency," dated 9/2017 (in pertinent parts): "The Social Worker will conduct a Psychosocial, Volunteer, Bereavement And Spiritual Admission Assessment within seven (7) working days of the date the patient is admitted to service." 1. The clinical record for Patient #4 was reviewed on 5/23/22. The patient was admitted to hospice care and services on 2/25/22, with a terminal diagnosis of chronic obstructive pulmonary disease and heart failure. The plan of care (POC) for the certification period dated 2/25/22 to 5/25/22 and 5/26/22 to 8/23/22 included orders for skilled nursing (SN) services once a week for assessments, certified nurse aide (CNA) services twice a week for assistance with personal cares, medical social worker (MSW) services for an undetermined frequency for assistance with community resources, and spiritual care (SC) services for an undetermined frequency for spiritual needs. a) The agency failed to ensure SC services provided a comprehensive assessment of Patient #4's spiritual needs. Review of the clinical record for Patient #4 dated 2/25/22 to 5/20/22 revealed no evidence a SC assessment was completed for Patient #4. Further review of the clinical record revealed no evidence any other discipline, including SN and MSW, had completed an assessment of spiritual needs. 2. The clinical record for Patient #5 was reviewed on 5/23/22. The patient was admitted to hospice care and services on 5/18/22, with a terminal diagnosis of senile degeneration of the brain. The POC for the certification period dated 5/18/22 to 8/15/22 included orders for SN services for an undetermined frequency for assessments, CNA services one to two times a week for personal cares, MSW services for an undetermined frequency for assistance with community resources, SC services for an undetermined frequency for spiritual care services, and volunteer services once a week for companionship. a) The agency failed to ensure MSW services provided a comprehensive assessment of Patient #5's psychosocial needs. Review of the clinical record for Patient #4 dated 5/18/22 to 5/23/22 revealed no evidence a MSW assessment was completed for Patient #5. Further review of the clinical record revealed no evidence any other discipline, including SN had completed an assessment of psychosocial needs. 3. During an interview on 5/25/22 at 1:48 p.m., Employee #5 stated the SN's did not complete the MSW assessments, but they could complete the SC assessment if needed. She further stated the SC assessment was the only discipline assessment that was optional. During an interview on 5/25/22 at 3:15 p.m., Employee #1 stated the MSW completed the assessments for spiritual and social work and if the patient wanted SC services, the MSW notified the chaplain. However, this was not seen in the patient records for Patients #4 and #5.

Based on interview and record review, the hospice failed to ensure visit frequencies were provided as established by the interdisciplinary group (IDG) in accordance with the plan of care for 2 of 11 patients receiving certified nurse assistant (CNA) services (Patients #4 and #6). Findings include: 1. The clinical record for Patient #4 was reviewed on 5/23/22. The patient was admitted to hospice care and services on 2/25/22, with a terminal diagnosis of chronic obstructive pulmonary disease and heart failure. The plan of care (POC) for the certification period dated 2/25/22 to 5/25/22 and 5/26/22 to 8/23/22 included orders for skilled nursing (SN) services once a week for assessments, CNA services twice a week for assistance with personal cares, medical social worker (MSW) services for an undetermined frequency for assistance with community resources, and spiritual care (SC) services for an undetermined frequency for spiritual needs. a) The hospice failed to ensure SN visits were provided in accordance with Patient #4's plan of care. Review of the plan of care dated 2/25/22 to 5/25/22, revealed physician orders for SN services once a week for assessments. Review of the SN visit schedule dated 3/6/22 to 5/20/22 revealed the SN was seeing Patient #4 twice a week. Review of the physician orders dated 2/25/22 to 5/20/22, revealed no evidence of physician's orders increasing the number of SN visits for Patient #4. 2. The clinical record for Patient #6 was reviewed on 5/24/22. The patient was admitted to hospice care and services on 4/15/21, with a terminal diagnosis of metabolic encephalopathy. The POC for the certification period dated 4/15/22 to 7/15/22 included orders for SN services for an undetermined frequency for assessments, CNA services twice a week for personal cares, and MSW services for an undetermined frequency for assistance with community resources. a) The hospice failed to ensure CNA visits were provided in accordance with Patient #6's plan of care. Review of the plan of care dated 4/15/22 to 7/15/22, revealed physician orders for CNA services three times a week for personal care. Review of the CNA visit schedule dated 3/1/22 to 5/23/22 revealed the CNA was making three visits a week from 3/1/22 to 4/9/22, however, from 4/10/22 to 5/23/22, the CNA visited Patient #6 twice a week. Clinical record review for the period 3/1/22 to 5/23/22, revealed no evidence of physicians orders to decrease CNA frequencies to twice a week. Review of the clinical record dated 3/1/22 to 5/23/22 revealed no evidence of missed visit documentation for the weeks of 4/10/22 to 5/23/22. Further review revealed no evidence of the CNA visits having been canceled by the physician or the IDG. 3. During an interview on 5/24/22 at 11:58 p.m., Employee #2 stated the discipline frequencies were known among the staff assigned to each patient. She acknowledged the POC did not contain all visit frequencies for all disciplines assigned to each patient. During an interview on 5/25/22 at 1:32 p.m., Employee #10 stated when the agency received orders to change visit frequencies, these changes were communicated among the team members. She further stated she did not obtain physician orders for the change in frequencies, she just increased the number of visits for a patient if they required it. During an interview on 5/25/22 at 3:14 p.m., Employee #1 stated every POC was discussed in IDG meetings every fourteen days and in staff meetings every Friday. She further stated every POC for every patient was discussed in the IDG meetings and the POC was revised during IDG if it was needed. During further interview, Employee #1 stated the agency had a policy that stated SN visits were to be done twice a week, however, she further stated the agency did not address SN frequencies in their standing orders on admission to hospice services, and they did not receive orders for visit frequencies from the physician.

Based on interview and record review, the agency failed to complete an individualized plan of care that included a detailed statement of each disciplines' scope and frequency of services necessary to meet the specific patient and family needs in 11 of 11 patient records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11). Findings include: 1. The clinical record for Patient #8 was reviewed on 5/24/22. The patient was admitted to hospice care and services on 4/19/22, with a terminal diagnosis of metastatic lung cancer. The plan of care (POC) for the certification period dated 4/19/22 to 7/19/22 included skilled nursing (SN), master of social work (MSW), spiritual care (SC) and certified nursing assistant (CNA) services for an undetermined frequency for pain management and comfort measures physically and psychosocially. a) The hospice failed to ensure the POC included a detailed statement of the duration and frequency of all IDG services provided to Consumer #8. Specifically, the POC failed to include the duration and frequency of MSW and SC services. Review of the most recently reviewed POC dated 5/13/22 failed to reveal a detailed duration and frequency of each discipline which provided services to Consumer #8. Review of the MSW clinical documentation between 4/19/22 to 5/23/22 revealed the MSW had completed a visit on the following three dates: 4/19/22, 4/25/22 and 4/28/22. The record failed to reveal MSW documentation of recommended ongoing visit frequencies or durations to be reviewed by the IDG and included in the POC. Review of the SC clinical documentation between 4/19/22 to 5/23/22 revealed the SC had completed a visit 5/4/22 and 5/11/22. The record failed to reveal SC documentation of recommended ongoing visit frequencies or durations to be reviewed by the IDG and included in the POC. 2. The clinical record for Patient #7 was reviewed on 5/24/22. The patient was admitted to hospice care and services on 4/1/21, with a terminal diagnosis of senile degeneration of the brain. The POC for the certification period 3/27/22 to 5/25/22 included SN, MSW and SC services for an undetermined frequency for pain management and comfort measures physically and psychosocially. The POC further included CNA services two times per week throughout the certification period to provide personal care services. a. The agency failed to ensure the POC included a detailed statement of the duration and frequency of services provided to Patient #7 to meet the specific patient and family needs. Review of the POC dated 5/24/22 revealed a duration and frequency for CNA services two times per week for assistance with personal care. Further review of the POC failed to reveal documentation of the duration and frequency of SN, MSW or SC services. Review of the SN clinical documentation between 3/1/22 to 5/23/22 revealed SN visits were conducted regularly two times per week. Review of the MSW clinical documentation between 3/1/22 to 5/23/22 revealed MSW visits were conducted on these six dates: 3/2/22, 3/9/22, 4/8/22, 4/11/22, 4/25/22 and 4/27/22. Review of the SC clinical documentation between 3/1/22 to 5/23/22 revealed an SC visit was conducted on 3/1/22. 3. The clinical record for Patient #5 was reviewed on 5/23/22. The patient was admitted to hospice care and services on 5/18/22, with a terminal diagnosis of senile degeneration of the brain. The POC for the certification period dated 5/18/22 to 8/15/22 included SN services, MSW services and SC services for an undetermined frequency for pain management and comfort measures physically and psychosocially. The POC further included orders for CNA services one to two times per week throughout the certification period to provide personal care services. a. The agency failed to ensure the POC included a detailed statement of the duration and frequency of services provided to Patient #5 to meet the specific patient and family needs. Review of the initial POC dated 5/23/22 revealed a duration and frequency for CNA services one to two times per week throughout the certification period, dependent on the Patient's tolerance of personal care. Further review of the initial POC failed to reveal documentation of the duration and frequency of SN, MSW or chaplain services. Review of SN documentation between 5/18/22 to 5/23/22 revealed an initial SN comprehensive assessment was completed on 5/18/22. Review of this comprehensive assessment revealed a frequency for CNA services; however, failed to reveal SN duration or frequency of services recommended to be provided. Review of MSW documentation between 5/18/22 to 5/23/22 revealed an initial MSW comprehensive assessment was completed on 5/18/22. Review of this comprehensive assessment failed to reveal MSW duration or frequency of services recommended to be provided. Review of Patient #5's record between 5/18/22 to 5/23/22 failed to reveal the SC had completed a comprehensive assessment or met with the patient to discuss SC services. Further review of the SN and MSW initial comprehensive assessments failed to reveal that SC services were discussed or offered. 4. Similar findings of the failure to include SN frequencies in the POC were found in the records of Consumers #1, #2, #3, #6, #10 and #11. 5. Similar findings of the failure to include MSW frequencies in the POC were found in the records of Consumers #4, #6, #9 and #10. 6. Similar findings of the failure to include SC frequencies in the POC were found in the records of Consumers #1, #2, #3, #4 and #6. 7. During an interview on 5/24/22 at 11:58 a.m., the director of nursing (DON) stated the POC listed the number of visits remaining between interdisciplinary group (IDG) meetings and this was the discipline frequency. During an interview on 5/25/22 at approximately 1:50 p.m., registered nurse (RN) #5 stated SN visit frequencies followed an internal agency policy which divided SN frequencies into three levels of care dependent on the patient's immanence to death. RN #5 stated these frequencies were not on a standard order; however, were communicated with physicians. RN #5 further stated SN frequencies were not included on the POC as the agency policy could be referenced. During an interview on 5/25/22 at approximately 3:15 p.m., the administrator and DON stated the agency policy for visit frequencies was determined by immanence to death and discussed internally with the IDG every other week; however, not documented clearly on the POC. The administrator stated MSW and SC duration and frequencies were generally not defined on the POC due to changing needs during patient decline in health.

Based on record review and interview, the agency failed to ensure infection control education was provided to all staff in 1 of 1 contracted personnel records reviewed (licensed social worker (LSW) #4). Findings include: 1. Record review on 5/25/22 revealed LSW #4 had a contracted hire date of 7/19/21. a. The agency failed to ensure LSW #4 completed education on infection control. Review of the record failed to reveal documentation of any agency training completed for LSW #4, including infection control. 2. During an interview on 5/25/22 at 11:15 a.m., the administrator stated contracted staff was newer to the hospice program and the administrator was unsure of the requirements for contracted staff. During an interview on 5/25/22 at 3:26 p.m., the administrator stated an orientation was completed for LSW #4 which included discussion on policies and procedures, which reviewed infection control; however, training specifically on infection control had not been completed.

Based on interview and record review, the agency failed to ensure all employees and volunteers were adequately trained for the type of services they provided in 1 of 4 clinical personnel whose records were reviewed (registered nurse (RN) #5). Findings include: 1. Record review on 5/25/22 revealed RN #5 had a hire date of 6/3/16. a. The agency failed to ensure RN #5 was adequately trained for the type of services provided. Review of RN #5's record failed to reveal a competency checklist had been completed at hire or annually since the date of hire. RN #5's record revealed an orientation checklist had been completed; however, this checklist failed to reveal the specific competencies reviewed, by whom, and whether the competency was observed or verbally completed. During an interview on 5/25/22 at 3:37 p.m., the director of nursing (DON) stated the agency believed the orientation checklist was sufficient to the regulation requirement. The DON further stated that the competency checklist would be revised for ongoing RN training.