Every finding on record at Lifeline Hospice, Inc.

Based on record review and interview, the hospice failed to ensure a bereavement care plan was initiated or was included as a part of the overall POC after the initial and ongoing spiritual/bereavement assessments for (Patients #1, 2, 3, 4, 5, 6, 7 and #11) of 11 patients. --- Findings: Patient #1 A review of the clinical record showed an election of the hospice benefit on 01/07/22 with a completion of the initial spiritual/bereavement assessment on 01/10/22 and an additional spiritual/bereavement assessment on 03/14/24. A review of a POC dated 02/26/24 to 04/25/24 and IDG updates to the POC on 03/07/24, 03/21/24, 04/04/24 and on 04/18/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #2 A review of the clinical record showed an election of the hospice benefit on 03/18/22 with a completion of the initial spiritual/bereavement assessment on 03/21/22. A review of a POC dated 03/07/24 to 05/05/24 and IDG updates to the POC on 03/07/24, 03/21/24, 04/04/24 and on 04/18/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #3 A review of the clinical record showed an election of the hospice benefit on 03/01/18 and showed no completion of the initial spiritual/bereavement assessment and showed no documentation of patient refusal of an initial spiritual/bereavement assessment. A review of a POC dated 04/02/24 to 05/31/24 and IDG updates to the POC on 04/04/24 and on 04/18/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #4 A review of the clinical record showed an election of the hospice benefit on 03/19/20 with a completion of the initial spiritual/bereavement assessment on 03/19/20. A review of a POC dated 02/27/24 to 04/26/24 and IDG updates to the POC on 03/07/24, 03/21/24, 04/04/24 and on 04/18/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #5 A review of the clinical record showed an election of the hospice benefit on 07/02/20 with a completion of the initial spiritual/bereavement assessment on 07/07/20. A review of a POC dated 04/12/24 to 06/10/24 and IDG updates to the POC on 04/18/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #6 A review of the clinical record showed an election of the hospice benefit on 03/15/24 with a completion of the initial spiritual/bereavement assessment on 03/18/24. A review of a POC dated 03/15/24 to 06/12/24 and IDG updates to the POC on 03/21/24, 04/04/24 and on 04/18/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #7 A review of the clinical record showed an election of the hospice benefit on 06/23/23 with a completion of the initial spiritual/bereavement assessment on 06/27/23. A review of a POC dated 02/18/24 to 04/17/24 and IDG updates to the POC on 02/22/24, 03/07/24, 03/21/24 and on 04/04/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. Patient #11 A review of the clinical record showed an election of the hospice benefit on 11/03/21 with a completion of the initial spiritual/bereavement assessment on 11/08/21. A review of a POC dated 12/23/23 to 02/20/24 and IDG updates to the POC on 12/28/23, 01/11/24, 01/25/24, 02/08/24 and on 02/22/24 showed no bereavement care plan and/or no bereavement interventions and goals included as a part of the overall POC. Documentation showed no changes in orders. On 04/25/24 at 1:50 p.m. to 2:50 p.m., Staff A stated: 1. The patients are given a bereavement risk score at the time of the initial spiritual/bereavement assessment and are advised of spiritual and bereavement services provided by the Hospice. If at any time the patient or family requests spiritual or bereavement services, the social worker or chaplain is added to the POC. The bereavement program consists of intermittently timed mail outs and follow up telephone calls which begin after the patients death; 2. Documentation for patient #3 shows no reason why the patient did not have an initial or follow up spiritual/bereavement assessment and; 3. The Hospice does not maintain a written POC for bereavement; bereavement is not included on the overall POC unless the patients family or caregiver is assessed as a high risk for bereavement.

Based on record review and interview, the hospice failed to ensure the plan of care was developed to include interventions and goals necessary for the identification, palliation and management of pain for one (Patient #6) of 11 patients. --- Findings: Patient #6 A plan of care dated 03/15/24 to 06/12/24 and IDG plan of care updates dated 03/21/24, 04/04/24 and 04/18/24 failed to include interventions necessary for the palliation and management of pain. A recertification assessment dated 03/15/24 identified the patient had facial grimacing and moaning; and pain was unable to be accurately assessed. Review of a medical History and Physical dated 12/05/22 documented the patient had hip and knee pain. Communication notes to the nurse practitioner dated 03/19/24 stated the patient was continuing to express signs and symptoms of pain and requested an order for Ativan per mouth every 12 hours as needed for pain. On 04/25/24 at 2:35 p.m., Staff A stated: 1. The POC did not include interventions for the palliation and management of pain and; The nurse practitioner thought the facial grimacing and moaning reported on 03/19/24 were related to behaviors and not pain.

Based on record review and interview, the hospice failed to ensure skilled nurse services were provided in accordance with the plan of care frequency for two (Patients #1 and #9) of 11 patients. --- Findings: Patient #1 A review of the plan of care dated 02/26/24 to 04/25/24 ordered SN visits at a frequency of one every week. Documentation showed during the weeks of 02/26/24 to 03/02/24 no SN visits were made (one visit ordered, no visit made). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the SN. Patient #9 A review of the plan of care dated 02/26/24 to 04/25/24 ordered SN visits at a frequency of two times every week. Documentation showed during the weeks of 12/03/23 to 12/09/23 one SN visit was conducted on 12/07/23 (two visit ordered, one visit made). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency for the SN. On 04/25/24 at 1:50 p.m. to 2:50 p.m., Staff A stated skilled nurse frequencies were not followed as ordered for patients #1 and #9.

Based on record review and interview, the hospice failed to ensure social work services were included on the POC for one (Patient #2) of 11 patients. --- Findings: Patient #2 A review of a POC dated 03/07/24 to 05/18/24 and IDG updates to the POC on 03/21/24, 04/04/24 and on 04/18/24 documented no social work services as a part of the POC. Documentation showed no patient refusal of social work services and no changes in orders. On 04/25/24 at 2:05 p.m., Staff A stated documentation showed no patient refusal of social work services and social work services should have been discussed during the IDG team meetings.

Based on record review and interview, the hospice failed to ensure on-site aide supervisory visits were completed every 14 days for two (Patients #6 and #7) of 11 patients. --- Findings: Patient #6 A review of the plan of care dated 03/15/24 to 06/12/24 showed a home health aide visit frequency of three times per week. Documentation showed supervisory visits were made on 03/29/24 and a scheduled supervisory visit on 04/12/24 was not started or completed (26 days between last conducted supervisory visit and the date of clinical record review on 04/24/24). Patient #7 A review of the plan of care dated 02/18/24 to 04/17/24 showed a home health aide visit frequency of two times per week. Documentation showed supervisory visits were made on 03/21/24 and a scheduled supervisory visit on 04/12/24 was not started or completed (33 days between last conducted supervisory visit and the date of clinical record review on 04/24/24). On 04/25/24 at 2:35 p.m. to 2:40 p.m., Staff A stated supervisory aide visits were not conducted/completed every 14 days for patients #6 and #7.

Based on record review and interview, the hospice failed to ensure documentation of physician certificate of terminal illness for subsequent certification periods for two (Patients #2 and #7) of 11 patients. --- Findings: Patient #2 A review of the clinical record showed a start of care date of 03/18/22 and subsequent recertification plans of care dated 03/13/23 to 05/11/23; 05/12/23 to 07/10/23; 07/11/23 to 09/08/23; 09/09/23 to 11/07/23; 11/08/23 to 01/06/24 and 01/07/24 to 03/06/24. Documentation showed no certificate of terminal illness for ongoing hospice services or related physician statement of imminence of death during the identified subsequent certification periods. Patient #7 A review of the clinical record showed a start of care date of 06/23/23 and subsequent recertification plans of care dated 08/22/23 to 10/20/23; 10/21/23 to 12/19/23 and 12/20/23 to 02/17/24. Documentation showed no certificate of terminal illness for ongoing hospice services or related physician statement of imminence of death during the identified subsequent certification periods. On 04/25/24 at 2:05 p.m. to 2:40 p.m., Staff A stated patients #2 and #7 had no certificate of terminal illness or related physician statement of imminence of death for identified subsequent certification periods.

Based on record review and interview, the hospice failed to ensure completion of a discharge summary of care for one (Patient #11) of 11 patients. --- Findings: Patient #11 A review of the clinical record showed the patient was discharged from the hospice on 02/21/24 to in-patient residential care services at the patients family request. Documentation showed no discharge summary of care was completed or provided to the attending physician. On 04/25/24 at 3:00 p.m., Staff A stated the hospice did not complete or provide a discharge summary of care to the attending physician for patient #11.

Based on observation, record review and interview, the hospice failed to ensure the IDG communicated and coordinated the patients care with the residential care facility (Nursing Home) for three (Patients #2, 3 and #4) of 11 patients. --- Findings: On 04/24/24 at 3:00 p.m., an onsite visit to the residential care facility for patients #2, 3 and #4 was conducted. Observations at the residential care facility nursing station showed no hospice chart (binder) for patients #3 and #4. A hospice chart (binder) for patient #2 showed documentation it was last updated with POC information on 10/23/23. NH Staff 1 (name and title withheld) stated there should have been a hospice chart at the nursing desk for all three of the hospice patients and did not know what services patients #1, 2 and #3 received other than hospice aide services three times a week. Patient #2 A review of the POC dated 03/07/24 to 04/05/24 showed orders for SN one time a week, hospice aide three times a week and chaplain services one time a month. Documentation showed no IDG communications or coordination of care with the residential care facility (Nursing Home). Patient #3 A review of the POC dated 04/02/24 to 05/31/24 showed orders for SN one time a week, hospice aide three times a week and volunteer services one time a month. Documentation showed no IDG communications or coordination of care with the residential care facility (Nursing Home). Patient #4 A review of the POC dated 02/27/24 to 04/26/24 showed orders for SN one time a week, hospice aide three times a week and chaplain services one time a month. Documentation showed no IDG communications or coordination of care with the residential care facility (Nursing Home). On 04/25/23 at 2:05 p.m. to 2:20 p.m., Staff A stated: 1. Patients #3 and #4 should have had a hospice chart (binder) at the Nursing Home kept at the nursing desk; 2. The hospice did not update the hospice chart (binder) with updated POCs since the COVID pandemic occurred when the Nursing Home limited care with the patients and they (Nursing Home) have not resumed patient conferences with the hospice and; 3. The hospice staff do not routinely document contact with the Nursing Home staff.