Every finding on record at Lhcg Cvii, LLC

Based on record review and interview, the agency failed to ensure an initial bereavement assessment was completed no later than 5 days after the date of hospice election as part of the patients comprehensive assessment for 2 (#3, #8) out of 14 sampled patients --- Patient # 3. Review of the patients electronic clinical record revealed a start of care date of 03/15/2024. The patients admitting diagnosis was Senile Degeneration of the Brain and Dementia. The benefit period reviewed was 03/09/2024 to 05/07/2024. Review of the patients POC for benefit period 03/09/2024 to 05/07/2024 revealed an order for Chaplain ";effective 03/09/2024 2M2 (visits effective 03/09/2024, two visit a month for 2 months). Review of the patients electronic record revealed no documented evidence that an initial bereavement assessment was conducted. On 04/24/2024 at 9:10 a.m., S1ED (Executive Director) confirmed that Patient #3s initial bereavement assessment had not been conducted. Patient #8. Review of the agencys policy and procedure titled, Initial & Comprehensive Admission Assessment & Plan of Care with a revised date of 04/01/2022 revealed, ";Purpose: To describe the process of the initial and comprehensive hospice patient assessment... Procedure: 6. The Chaplain will complete the spiritual evaluation identifying goals and interventions needed no later than 5 days after the date of hospice election..." Review of the patients electronic clinical record revealed the start of care date and election date for hospice services was 01/10/2024. The patients admitting diagnosis was Hypertension. The benefit period reviewed was 04/09/2024 to 07/07/2024. Review of the patients POC for benefit period 04/09/2024 to 07/07/2024 revealed an order for Chaplain ";effective 04/09/2024 1M3 (visits effective 04/09/2024 one time a month for 3 months). Review of the patients Bereavement Risk Assessment Report revealed that it was dated 03/20/2024, which was 2 months after the date of hospice election and start of care. On 04/23/2024 at 9:02 a.m., an interview was conducted with S2CH (Chaplain). He confirmed that the initial Bereavement Risk Assessment was dated 03/20/2024 and that it was the only bereavement assessment that he completed. He confirmed that the assessment was 2 months later than the patients start of care and hospice election date.

Condition of participation: Interdisciplinary group, care planning, and coordination of services Condition of Participation for Interdisciplinary Group, Care Planning and Coordination of Services was not met as evidenced by: --- Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the agency failing to ensure SN (skilled nurse) visits were made as ordered per the POC (plan of care) for 5 (#2, #4, #7, #8, #14) out of 14 sampled patients (L-543). Based on record review and interview, the agency failed to maintain a system of communication to ensure that coordination of care was provided as evidenced by the SN (skilled nurse) failing to inform the physician of changes in a patients condition for 1 (#5) out 14 sampled patients (L-554).

Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the agency failing to ensure SN (skilled nurse) visits were made as ordered per the POC (plan of care) for 5 (#2, #4, #7, #8, #14) out of 14 sampled patients and failing to ensure HA (hospice aide) visits were made as ordered per the POC for 1 (#5) out 14 sampled patients. --- Patient #2. Review of the patients electronic clinical record revealed a start of care date of 03/08/2023. The patients admitting diagnosis was Hypertensive Heart Disease, Chronic Kidney Disease, Dependence on supplemental oxygen, and History of falls. The benefit period reviewed was 03/02/2024 to 04/30/2024. Review of the patient's POC (Plan of Care) for benefit period 03/02/2024 to 04/30/2024 revealed an order that read: SN (skilled nurse) effective 03/02/2024 for 2every2week2, 2wk7, 1wk1 for symptom management, 3PRN for urgent symptom management needs/change in condition. (skilled nurse visits two visits a week every second week for two weeks, two visits a week for 7 week, one visit a week for one week for symptom management and 3 visits as needed for urgent symptom management needs/change in condition). Review of the patients electronic clinical record for the weeks of 03/03/2024, 04/05/2024, and 04/16/2024 revealed that 2 SN visits were not made for those weeks as ordered per the benefit period POC. On 04/24/2024 at 9:00 a.m., an interview was conducted with S1ED. She reviewed the patients electronic record and confirmed that there was no evidence the skilled nurse made 2 visits as ordered per the POC for the week of 03/03/2024, 04/05/2024, and 04/16/2024. 2. Patient #4. Review of the patients electronic clinical record revealed a start of care date 02/07/2023. The patients admitting diagnosis included Hypertensive Chronic Kidney Disease. The benefit period reviewed was 04/02/2024 to 05/31/2024. Review of the patients POC for benefit period 04/02/2024 to 05/31/2024 revealed an order for SN effective 04/02/2024 1wk1, 2wk8 for symptom management, 3 prn for urgent symptom management needs/change in condition (skilled nurse visits one time a week for one week, two visits a week for eight weeks for symptom management, three visits as needed for urgent symptom management needs/change in condition). Review of the patients electronic clinical record for the week of 04/14/2024 revealed that 2 skilled nurse visits were not made for that week as ordered per the benefit period POC. On 04/22/2024 at 1:55 p.m., an interview was conducted with S1ED (Executive Director). S1ED reviewed the patients electronic clinical record and confirmed that there was no evidence the skilled nurse made 2 visits as ordered per the POC for the week of 04/14/2024. 3. Patient #5. Review of the patients electronic clinical record revealed a start of care date 06/16/2023. The patients admitting diagnosis included Hypertensive Heart Disease with Heart Failure. The benefit period reviewed was 04/11/2024 to 06/09/2024. Review of the patients POC for benefit period 04/11/2024 to 06/09/2024 revealed an order for HA visits effective 04/11/2024 1wk1, 3wk8 for bathing and ADLs (hospice aide visits one time a week for one week, three visits a week for eight weeks for bathing and activities of daily living). Review of the patients electronic clinical record for the week of 04/14/2024 revealed that 3 HA visits were not made for that week as ordered per the benefit period POC. On 04/22/2024 at 12:55 p.m., an interview was conducted with S1ED (Executive Director). S1ED reviewed the patients electronic clinical record and confirmed that there was no evidence the HA made 3 visits as ordered per the POC for the week of 04/14/2024. 4. Patient #7. Review of the patients electronic clinical record revealed a start of care date 09/26/2023. The patients admitting diagnosis included Neurofibromatosis. The benefit period reviewed was 03/24/2024 to 05/22/2024. Review of the patients POC for benefit period 03/24/2024 to 05/22/2024 revealed an order for SN effective 03/24/2024 1wk9 for symptom management, 3 prn for urgent symptom management needs/change in condition (skilled nurse visits one time a week for nine weeks for symptom management, three visits as needed for urgent symptom management needs/change in condition). Review of the patients electronic clinical record for the week of 04/07/2024 revealed that there was no evidence a skilled nurse visit was made for that week as ordered per the benefit period POC. On 04/23/2024 at 9:07 a.m., an interview was conducted with S1ED (Executive Director). S1ED reviewed the patients electronic clinical record and confirmed that there was no evidence the skilled nurse made a visit as ordered per the POC for the week of 04/07/2024. 5. Patient #8. Review of the patients electronic clinical record revealed the start of care date 01/10/2024. The patients admitting diagnosis was Hypertension. The benefit period reviewed was 04/09/2024 to 07/07/2024. Review of the patients POC for benefit period 04/09/2024 to 07/07/2024 revealed an order for SN effective 04/09/2024 1wk1, 2wk12 for symptom management, 3 prn for urgent symptom management needs/change in condition (skilled nurse visits one time a week for one week, two visits a week for twelve weeks for symptom management, three visits as needed for urgent symptom management needs/change in condition). Review of the patients electronic clinical record for the week of 04/09/2024 revealed that a skilled nurse visit was not made for that week as ordered per the benefit period POC. On 04/23/2024 at 9:07 a.m., an interview was conducted with S1ED (Executive Director). S1ED reviewed the patients electronic clinical record and confirmed that there was no evidence the skilled nurse made 2 visits as ordered per the POC for the week of 04/14/2024. 6. Patient #14. Review of the patients electronic clinical record revealed a start of care date 06/15/2023. The patients admitting diagnosis included Malignant Neoplasm of Bronchus or Lung. The benefit period reviewed was 04/10/2024 to 06/08/2024. Review of the patients POC for benefit period 04/10/2024 to 06/08/2024 revealed an order for SN effective 04/10/2024 1wk1, 2wk8 for symptom management, 3 prn for urgent symptom management needs/change in condition (skilled nurse visits one time a week for one week, two visits a week for eight weeks for symptom management, three visits as needed for urgent symptom management needs/change in condition). Review of the patients electronic clinical record for the week of 04/14/2024 revealed that there was no evidence 2 skilled nurse visits were made for that week as ordered per the benefit period POC. On 04/22/2024 at 2:40 p.m., an interview was conducted with S1ED (Executive Director). S1ED reviewed the patients electronic clinical record and confirmed that there was no evidence the skilled nurse made two visits as ordered per the POC for the week of 04/14/2024.

Based on record review and interview, the agency failed to maintain a system of communication to ensure that coordination of care was provided as evidenced by the SN (skilled nurse) failing to inform the physician of changes in a patients condition for 1 (#5) out 14 sampled patients. --- Patient #5. Review of the patients electronic clinical record revealed a start of care date 06/16/2023. The patients admitting diagnosis included Hypertensive Heart Disease with Heart Failure. The benefit period reviewed was 04/11/2024 to 06/09/2024. Review of the patients POC for benefit period 04/11/2024 to 06/09/2024 revealed an order for SN effective 04/11/2024 1wk1, 2wk8 for symptom management, 3 prn for urgent symptom management needs/change in condition (skilled nurse visits one time a week for one week, two visits a week for eight weeks for symptom management, three visits as needed for urgent symptom management needs/change in condition). Review of the patients SN visit note dated 04/15/2024 revealed, ";Received call from ans (answering) service... Pt (patient) having difficulty breathing and chest pain and unable to reach meds. Arrived at pts home. Pt laying in bed... Diminished breath sounds, bilateral rhonchi, coughing... States having electrical shocks, sharp, stabbing under left axilla. 10 1-10 scale. Has nitro on bedside table... Had pt put 02 (oxygen) on and take ntg (nitroglycerin tablet for chest pain)... Pt states she could not reach meds and it is worst feeling..." There was no evidence the skilled nurse informed the physician concerning the patients complaint of chest pain that rated a 10 on a pain scale of 1-10. On 04/22/2024 at 12:55 p.m., an interview was conducted with S1ED (Executive Director). S1ED reviewed the patients electronic clinical record and confirmed that there was no evidence the SN informed the physician concerning the patients chest pain rating a 10 and requiring nitroglycerin tablet. S1ED stated that the SN should have informed the physician concerning the patients chest pain.