Every finding on record at Lighthouse Hospice Group, LLC

Based on record review, interview and review of the hospice's policies, the hospice failed to complete updated comprehensive assessments for 7 of 7 patient records reviewed (Patients #1, #2, #3, #4, #5, #6 and #7). --- Review of Patient #1's record on 01/07/25 at 11:08 AM revealed no documented evidence of any updates to the comprehensive assessment for the benefit period 11/20/24 to 01/18/25. In an interview with the Administrator (ADM) and the Assistant Director of Nurses (ADON) on 01/09/25 at 1:56 PM, they reviewed the record and confirmed the findings. Review of Patient #2's record on 01/07/25 at 3:10 PM revealed no documented evidence of any updates to the comprehensive assessment for the benefit period 11/22/24 to 02/19/25. In an interview with the ADM and the ADON on 01/09/25 at 2:20 PM, they reviewed the record and confirmed the findings. Review of Patient #3's record on 01/07/25 at 11:23 AM revealed no documented evidence of any updates to the comprehensive assessment for the benefit period 11/15/24 to 01/13/25. In an interview with the ADM and the ADON on 01/09/25 at 2:46 PM, they reviewed the record and confirmed the findings. Review of Patient #4's record on 01/08/25 at 10:25 AM revealed no documented evidence of any updates to the comprehensive assessment for the benefit period 07/29/24 to 10/26/24. In an interview with the ADM and the ADON on 01/09/25 at 3:09 PM, they reviewed the record and confirmed the findings. Review of Patient #5's record on 01/08/25 at 2:20 PM revealed no documented evidence of any updates to the comprehensive assessment for the benefit period 07/17/24 to 10/14/24. In an interview with the ADM and the ADON on 01/09/25 at 3:00 PM, they reviewed the record and confirmed the findings. Review of Patient #6's record on 01/08/25 at 3:20 PM revealed no documented evidence of any updates to the comprehensive assessment for the benefit period 02/16/24 to 05/15/24. In an interview with the ADM and the ADON on 01/09/25 at 3:11 PM, they reviewed the record and confirmed the findings. Review of Patient #7's record on 01/09/25 at 9:20 AM revealed no documented evidence of any updates to the comprehensive assessment for the benefit period 07/05/24 to 09/02/24. In an interview with the ADM and the ADON on 01/09/25 at 3:33 PM, they reviewed the record and confirmed the findings. Review of the hospice's policy titled, "Reassessment/Update to the Comprehensive Assessment," dated 2009, on 01/09/25 revealed, "The update of the comprehensive assessment must be accomplished by the Hospice IDG (in collaboration with the patient's attending physician, if any) and must consider changes that have taken place since the initial assessment. It must include information on the patient's progress toward desired outcomes, as well as a reassessment of the patient's response to care. The assessment updates must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days...The update to the comprehensive assessment will include assessments of changes in physical, psychosocial, emotional and spiritual needs..."

Based on observation, interview and record review, the hospice failed to ensure the plan of care was updated when changes occurred with the patients for two of seven patient records reviewed (Patients #4 and #5). --- Findings included: Review of Patient #4's record on 01/08/25 at 10:25 AM revealed Patient #4 was admitted to the hospice on 07/29/24 with a diagnosis of Parkinson's Disease. Review of the Hospice Nursing Initial Comprehensive Admission Assessment dated 07/29/24 revealed, "Requires max (maximum) assistance with increasing unsteadiness on feet even with assistive devices..." Review of the hospice initial plan of care for the benefit period 07/29/24 to 10/26/24 revealed, "...Fall Precautions Start Effective Date 07/29/2024...Musculoskeletal...Assess, perform, instruct safe transfers Start...07/29/2024...Provide assistive devices...WALKER, WHELCHAIR Start...07/29/2024...Patient will maintain optimal mobility...Start...07/29/2024...Patient will remain safe in environment...Start...07/29/24..." Review of the Hospice Nursing Clinical Note dated 08/16/24 revealed, "...Patient's [family member] reports complaints of patient having 'wobbly legs' since last visit...Patient's [family member] reports that patient has had 2 'near falls' where he got very wobbly on his legs attempting to ambulate..." Review of the next IDG Meeting Review dated 8/27/24 revealed no update/changes to the plan of care. Review of the IDG Meeting Review with a nursing visit date of 09/24/24 revealed, "[family member] reports increased episodes of difficulty with mobility." There was no update/changes to the plan of care. Further review of the record, including the nursing visit notes dated 10/01/24 and 10/02/24 revealed Patient #4 had a fall on 10/01/24 and was hospitalized. In an interview with the Administrator (ADM) and the Assistant Director of Nurses (ADON) on 01/09/24 at 3:09 PM, they reviewed the record and confirmed the findings. Review of Patient #5's record on 01/08/25 at 2:20 PM revealed Patient #5 was admitted to hospice 04/18/24 with a diagnosis of Nutritional Deficiency. Review of the initial plan of care for the benefit period 04/18/24 to 07/16/24 revealed, "Fall Precautions Start Effective Date 04/18/2024...Musculoskeletal...Assess, perform, instruct safe transfers...Patient will maintain optimal mobility...Patient will remain safe in environment..." There were no other care plan problems involving the patient's fall risk and safety. Review of the Patient Incident Report dated 06/04/24 revealed, "Pt (patient) had a fall while getting up from toilet. Pt fell back against the wall..." The IDG Meeting Review dated 06/18/24 revealed no update/changes to the plan of care after the fall. Review of a Patient Incident Report dated 10/17/24 revealed, "Patient's [family member] reported patient had a fall with injury to her nose..." Review of the undated IDG Meeting Review with a nursing visit date of 10/22/24 revealed there was no update/changes to the plan of care. In an interview with the ADM and the ADON on 01/09/25 at 3:00 PM, they reviewed the record and confirmed the findings. Review of the hospice's policy titled, "IDG Careplanning Process," dated 2009 on 01/09/24 revealed, "The IDG...reviews, revises and documents the individualized plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days...the revised plan of care includes information from the ptient's updated comprehensive assessment and notes the patient's progress toward outcomes and goals specified in the plan of care."

Based on observation, record review and interview the hospice failed to follow the plan of care when Hospice Aide (HA) visits were not completed according to the plan of care for 3 of 6 patients reviewed receiving HA services (Patients #1, #2, and #3). --- Findings include: Patient #1's record was reviewed on 01/07/25 at 11:08 PM. Review of the undated IDG (Interdisciplinary Group) Meeting Review for the benefit period 11/20/24 - 01/18/25 with a nursing visit date of 12/31/24 revealed, "FREQUENCIES...Active...HHA...5 x week for 9 weeks starting 11/20/2024." Review of the Hospice Aide Assignment dated 11/20/24 revealed, "Frequency...5 x Week (Monday - Friday)." Review of the HA visits to Patient #1 from 11/20/24 - 01/06/25 revealed the following: No HA visit on 11/28/24 (Thursday) and only four HA visits completed that week; No HA visit on 12/16/24 (Monday) and only four HA visits completed that week; No HA visit on 12/25/24 (Wednesday) only four HA visits completed that week; and No HA visit on 01/01/25 (Wednesday) and only four HA visits completed that week. In an interview with the Administrator (ADM) and the Assistant Director of Nurses (ADON) on 01/09/25 at 1:56 PM, they confirmed the findings. During a home visit observation to Patient #2 on 01/07/25 at 12:52 PM, a family member (FM) stated the HA visited five days a week, Monday through Friday. The FM stated if HA visits were available on Christmas Day, it would have been helpful for Patient #2's primary care giver (PCG) to have a visit that day. Patient #2's record was reviewed on 01/07/25 at 3:10 PM. Review of the undated IDG Meeting Review for the benefit period 11/22/24 - 02/19/25 revealed, "FREQUENCIES...Active...HHA...5 x week for 13 weeks starting 11/24/24..." Review of the HA Assignment dated 11/22/24 revealed, "Frequency...5 x Week (Monday - Friday)..." Review of the HA visits to Patient #2 from 11/22/24 to 1/7/25 revealed the following: No HA visit on 11/28/24 (Thursday) and only four HA visits completed that week; No HA visit on 12/25/24 (Wednesday) and only four HA visits completed that week; and No HA visit on 01/01/25 (Wednesday) and only four HA visits completed that week. In an interview with the ADM and the ADON on 01/09/25 at 2:15 PM, they confirmed the findings. Patient #3's record was reviewed on 01/07/25 at 3:34 PM. Review of the "IDG MEETING REVIEW" for the benefit period 11/15/24 to 01/13/25 with a nursing visit date of 12/31/24 revealed, "FREQUENCIES...Active...HHA...5 x week for 10 weeks..." Review of the "HOSPICE AIDE ASSIGNMENT" dated 11/15/24 revealed, "Frequency...5x/week Monday through Friday..." Review of the HA visits to Patient #3 from 11/15/24 to 01/07/25 revealed the following: No HA visit on 11/28/24 (Thursday) and only four HA visits completed that week; No HA visit on12/17/24 (Tuesday) and only three visits completed that week with one missed visit note; No HA visit on 12/25/24 (Wednesday) and only four HA visits completed that week; and No HA visit on 01/01/25 (Wednesday) and only four HA visits completed that week. In an interview with the ADM and the ADON on 01/09/25 at 2:28 PM, they confirmed the findings. Review of the hospice's undated policy titled, "IDG Care Planning Process" on 01/09/25 revealed, "All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any), the patient or representative and the primary caregiver in accordance with the patient's needs."

Based on observation, interview and document review, the hospice failed to ensure hospice staff followed infection prevention practices during 3 of 3 patient visits observed. --- Observation of a home nursing visit to Patient #1 by Registered Nurse (RN) #1 was conducted on 01/07/25 at 9:08 AM. RN #1 was observed to remove a small bottle of hand sanitizer from her/his pocket and use it during the assessment portion of the patient visit. RN #1 was observed to enter the nursing bag to get the blood pressure monitor after touching the patient and without disinfecting her/his hands first. RN #1 was also observed to return the blood pressure monitor and the pulse oximeter to the nursing bag without first disinfecting her/his hands. In an interview with RN #1 at 10:20 AM RN #1 confirmed her/his pocket had other items in it and was not a clean area for the bottle of hand sanitizer to be kept. RN #1 also confirmed she/he did not not sanitize her/his hands before re-entering the nursing bag. In an interview with the Administrator (ADM) and the Assistant Director of Nursing (ADON) on 01/09/25 at 1:55 PM, they confirmed RN #1 should not have kept the hand sanitizer in her/his pocket and should have sanitized her/his hands prior to entering and re-entering the nursing bag. Observation of a home visit to Patient #2 by the ADON was conducted on 01/07/25 at 12:52 PM. The ADON was observed to open a large side pocket on the nursing bag which lowered flat and she/he placed the vital signs equipment (i.e. blood pressure cuff, thermometer, pulse oximeter) and a bottle of hand sanitizer on it without a barrier. The ADON used the vital signs equipment to take Patient #2's vital signs and then placed the equipment back on the lowered side pocket. The ADON cleaned the blood pressure cuff with a sanitizing wipe and placed it back on the same open lowered part of the nursing bag on which the used blood pressure cuff had been placed after use on the patient. The ADON was also observed to keep the stethoscope around her/his neck before and after using it to assess the patient and did not disinfect it. The ADON was observed to remove her/his gloves and place them in a side area of the nursing bag during the patient assessment and nursing visit. In an interview with the ADON on 01/07/25 at 2:00 PM, she/he confirmed the findings. She/he stated she/he kept a small open plastic trash can on the side of the nursing bag which she/he put soiled gloves and trash in during the visit and then she/he emptied the plastic trash can into a trash in the car. The ADON said she/he did this with every nursing visit. In an interview with the ADM and the ADON on 01/09/25 at 2:14 PM, they confirmed a plastic trash can in the side pocket of the nursing bag should not be used for soiled trash, and they confirmed the open and lowered side pocket of the nursing bag should not be used to place vital signs equipment directly on (i.e. without use of a barrier) after use on a patient, after equipment is cleaned it should not be placed back on the same (dirty) area it had been, and the stethoscope should be disinfected before/after use. Observation of a home visit to Patient #3 by Hospice Aide (HA) #1 was conducted on 01/08/25 at 12:25 PM. HA #1 was observed to provide pericare (genito-rectal area) to Patient #3 and without removing her gloves, HA #1 used a hair brush to brush Patient #3's hair and with the same gloves on placed the gloved hand into a container of ointment and rubbed the ointment on Patient #3's face. During an interview with HA #1 immediately after the visit at 1:16 PM, HA #1 confirmed the findings. In an interview with the ADM and the ADON on 01/09/25 at 1:39 PM, they confirmed HA #1 should have removed the gloves after providing pericare and before touching anything else. Review of the Nursing Education Binder on 01/09/25 at 11:48 AM revealed an undated document titled, "Nursing Bag Technique," which indicated to wash hands prior to entering the equipment (nursing) bag and "...If re-entry into the equipment bag is necessary, wash your hands before removing supplies..." and after completing the visit to "Wash your hands and replace supplies in the equipment bag."

Based on record reviews and interview, the hospice failed to ensure an initial spiritual assessment was documented for 3 of 11 patient charts reviewed. (Patient #1, Patient #8, and Patient #11) The findings are: Patient #11 On 2/16/2022 at 11:40 AM, review of Patient #11's chart revealed no documentation of the initial spiritual assessment on admission. The finding was verified by the Administrator and Clinical Manager at 10:51 AM on 2/18/2022. Patient #1 On 2/16/2022 at 12:49 PM, review of Patient #1's chart revealed no documentation of the initial spiritual assessment on admission. The finding was verified by the Administrator and Clinical Manager at 11:31 AM on 2/18/2022. Patient #8 On 2/16/2022 at 3:08 PM, review of Patient #8's chart revealed no documentation of the initial spiritual assessment on admission. The finding was verified by the Administrator and Clinical Manager at 11:53 AM on 2/18/2022.

Based on record reviews and interview, the hospice failed to ensure documentation of the assessment of the patient's wound that included measurements of the wounds for three of three patients reviewed with wounds. (Patient #3, #4, and #8) The findings are: Patient #8 On 2/16/2022 at 3:08 PM, review of Patient #8's chart revealed Skilled Nurse (SN) documentation during a visit, dated 1/3/2022, that stated "Patient has several pressure ulcers to both feet and heels." During a visit dated 1/10/2022, the SN documented, "Patient has multiple pressure injuries, including 2 unstageable wounds to bilateral heels and Stage 2 to bilateral posterior hips." During a visit dated 1/18/2022, documentation in the patient's chart revealed, "Patient has multiple wounds to bilateral heels (Non-stageable) and bilateral hip (Stage 2) wounds." During the visit dated 1/24/2022, the SN documented "Skin is not intact, and unstageable wounds on bilateral heels and Stage 2 on bilateral hips." During the visit dated 1/31/2022, documentation in the patient's chart revealed, "bilateral heels wounds and Stage 2 bilateral hips." On 2/8/2022, the nursing note stated, "Patient has bilateral heel wounds and bilateral hip wounds." The SN documented "Wounds are being managed by the facility wound care nurse." There were no assessment and/or measurements of the wounds documented. There was no coordination of care with the facility since the hospice SNs are not monitoring the patient's wounds. The finding was verified by the Administrator and Clinical Manager at 11:53 AM on 2/18/2022. Patient #3 On 2/17/2022 at 9:09 AM, review of Patient #3's chart revealed during a SN visit dated 2/4/2022, the SN charted "Left ankle, medial side Stage 1 pressure ulcer and right ankle, lateral side, Stage 1 pressure ulcer." During the SN visit dated 2/11/2022, the SN documented "Left ankle, medial side Stage 1 pressure ulcer and right ankle, lateral side, Stage 1 pressure ulcer." No wound measurements were documented. The finding was verified by the Administrator and Clinical Manager at 11:11 AM on 2/18/2022. Patient #4 On 2/17/2022 at 11:15 AM, review of Patient #4's chart revealed the SN documented during a visit dated 11/5/2021 that "Stage I Sacrum." On 11/10/2021, the SN documented "Stage 1 on buttocks and small skin tear at base of sacrum." On 11/17/2021, there was no documentation of sacrum pressure area. On 11/24/2021, the SN documented "Stage 1 on buttocks." On 12/1/2021, the SN documentation revealed "Stage 1 on buttocks." On 12/7/2021, the SN documented "Stage 1 pressure ulcer to sacrum and stage 1 pressure ulcer to tip of right toe." On 12/23/2021, the SN documentation showed "Stage 2 decubitus ulcer to sacrum." On 12/28/2021, the SN documented "Stage 2 on sacrum." On 1/3/2022, there was no documentation of the pressure wound by the SN. On 1/10/2022, the SN documentation stated, "Sacral area of concern being managed by facility but appears to be healing." The SN charted on 1/18/2022, "Patient has skin tear to right lower extremity and has stage 1 pressure ulcer." On 1/24/2022, documentation showed "stage 2 on sacrum and slight skin tear on right shin." On 1/31/2022, the nurse documented "Sacral area of concern being managed by facility Stage 2." On 2/8/2022, the SN's notes stated, "Patient continues with a pressure ulcer to left buttocks (Stage 2)." The SN documented on 2/14/2022, "Right 3rd toe, pressure ulcer injury Stage 1." No wound measurements were documented with any of the above visits to the patient. The findings were verified by the Administrator and Clinical Manager at 11:47 AM on 2/18/2022.

Based on record reviews and interview, the Skilled Nurse (SN) failed to update the Aide Assignment for two of two patients who had more than one certification period. (Patient #2 and #3) The findings are: Patient # 3 On 2/17/2022 at 9:09 AM, review of the Aide Assignment Sheet revealed the Aide assignment was dated 7/16/2021. There was no updated/revised Aide Assignment Sheet in the patient's record. The certification period reviewed was 1/12/2022 to 3/12/2022. The finding was verified by the Administrator and the Clinical Manager at 11:11 AM on 2/18/2022. Patient # 2 On 2/17/2022 at 12:11 PM, review of the Aide Assignment Sheet revealed the Aide assignment was dated 3/15/2021. There was no updated/revised Aide Assignment Sheet in the patient's chart. The certification period reviewed was 1/9/2022 to 3/9/2022. The finding was verified by the Administrator and the Clinical Manager at 9:40 AM on 2/18/2022.

Based on record reviews and interview, the Interdisciplinary Group (IDG) failed to document the progress toward goals and/or outcomes for 11 of 11 patient charts and plan of care reviewed. (Patient #1- #11) The findings are: Patient #5 On 2/16/2022 at 9:26 AM, review of Patient #5's chart revealed the patient's Plan Of Care (POC) during the IDG meeting dated 11/23/2021 had no documentation for the patient's progress toward the outcomes and goals specified in the patient's POC." The finding was consistent with all the IDG meeting(s) documentation for Patient #5. The finding was verified by the Administrator and Clinical Manager at 10:30 AM on 2/18/2022. Patient #11 On 2/16/2022 at 11:40 AM, review of Patient #11's chart revealed the patient's POC reviewed during the IDG meeting dated 11/23/2021 had no documentation for the patient's progress toward the outcomes and goals specified in the patient's POC. The finding was consistent with all the IDG meeting(s) documentation for Patient #11. The finding was verified by the Administrator and Clinical Manager at 11:51 AM on 2/18/2022. Patient #9 On 2/16/2022 at 12:25 PM, review of Patient #9's chart revealed the patient's POC reviewed during the IDG meeting dated 2/1/2022 had no documentation for the patient's progress toward the outcomes and goals specified in the patient's POC. The finding was consistent with all IDG(s) meeting documentation for the patient. The finding was verified by the Administrator and Clinical Manager at 11:22 AM on 2/18/2022. Patient #1 On 2/16/2022 at 12:49 PM, review of Patient #1's chart revealed the patient's POC reviewed during the IDG meeting dated 2/1/2021 had no documentation for the patient's progress toward the outcomes and goals specified in the patient's POC. The finding was consistent with all IDG(s) meeting documentation for the patient. The finding was verified by the Administrator and Clinical Manager at 11:31 AM on 2/18/2022. Patient #8 On 2/16/2022 at 3:08 PM, review of Patient #8's chart revealed the patient's POC reviewed during the IDG meeting dated 1/4/2022 had no documentation for the patient's progress toward outcomes and goals specified in the patient's POC. The finding was consistent with all IDG(s) meeting documentation for the patient. The finding was verified by the Administrator and Clinical Manager at 11:53 AM on 2/18/2022. Patient #3 On 2/17/2022 at 9:09 AM, review of Patient #3's chart revealed the POC reviewed during the IDG meeting dated 7/20/2021 had no documentation for the patient's progress toward the outcomes and goals specified in the patient's POC. The finding was consistent with all IDG meeting(s) documentation for the patient. The finding was verified by the Administrator and Clinical Manager at 11:11 AM on 2/18/2022. Patient #6 On 2/16/2022 at 9:54 AM, review of Patient #6's chart revealed the patient's POC reviewed during the IDG meeting dated 12/7/2021 had no documentation for the patient's progress toward outcomes and goals as specified in the patient's POC. The finding was consistent with all IDG meeting(s) documentation for the patient. The finding was verified by the Administrator and Clinical Manager at 11:19 AM on 2/18/2022. Patient #7 On 2/17/2022 at 10:22 AM, review of Patient #7's chart revealed the patient's POC reviewed during the IDG meeting dated 2/1/2022 had no documentation for the patient's progress toward outcomes and goals specified in the patient's POC. The finding was consistent with all IDG meeting(s) documentation for the patient. The finding was verified by the Administrator and Clinical Manager at 10:10 AM on 2/18/2022. Patient #10 On 2/17/2022 at 10:48 AM, review of Patient #10's chart revealed the patient's POC reviewed during the IDG meeting dated 12/7/2022 had no documentation for the patient's progress toward outcomes and goals specified in the patient's POC. The finding was consistent with all IDG meeting(s) documentation for the patient. The finding was verified by the Administrator and Clinical Manager at 11:59 AM on 2/18/2022. Patient #4 On 2/17/2022 at 11:15 AM, review of Patient #4's chart revealed the patient's POC reviewed during the IDG meeting dated 10/26/2022 had no documentation for the patient's progress toward outcomes and goals specified in the patient's POC. The finding was consistent with all IDG meeting(s) documentation for the patient. The finding was verified by the Administrator and Clinical Manager at 11:47 AM on 2/18/2022. Patient # 2 On 2/17/2022 at 12:11 PM, review of Patient #2's chart revealed the patient's POC reviewed during the IDG meeting dated 1/4/2022 had no documentation for the patient's progress toward outcomes and goals specified in the patient's POC. The finding was consistent with all IDG meeting(s) documentation for the patient. The finding was verified by the Administrator and the Clinical Manager at 9:40 AM on 2/18/2022.

Based on patient record reviews and interview, the hospice failed to ensure the volunteer assessment for patient needs is documented in the patient's chart for 11 of 11 patient charts reviewed. (Patient #1-#11) The findings are: Patient #5 On 2/16/2022 at 9:26 AM, review of Patient #5's Plan Of Care (POC) revealed staff are to assess the patient for volunteer needs. The patient's chart had no follow through of a documented assessment for the patient's need/refusal of volunteer services. The finding was verified by the Administrator and Clinical Manager at 10:30 AM on 2/18/2022. Patient #11 On 2/16/2022 at 11:40 AM, review of Patient #11's POC revealed staff are to assess the patient for volunteer needs. The patient's chart had no follow through of a documented assessment for the patient's need/refusal of volunteer services. The finding was verified by the Administrator and Clinical Manager at 10:51 AM on 2/18/2022. Patient #9 On 2/16/2022 at 12:25 PM, review of Patient #9's POC revealed staff are to assess the patient for volunteer needs. The patient's chart had no follow through of a documented assessment for the patient's need/refusal of volunteer services. The finding was verified by the Administrator and Clinical Manager at 11:22 AM on 2/18/2022. Patient #1 On 2/16/2022 at 12:49 PM, review of Patient #1's chart revealed staff are to assess the patient for volunteer needs. The patient's chart had no follow through of a documented assessment for the patient's need/refusal of volunteer services. The finding was verified by the Administrator and Clinical Manager at 11:31 AM on 2/18/2022. Patient #8 On 2/16/2022 at 3:08 PM, review of Patient #8's POC revealed the hospice staff are to assess the patient for volunteer needs. The patient's chart had no follow through of a documented assessment for the patient's need/refusal of volunteer services. The finding was verified by the Administrator and Clinical Manager at 11:53 AM on 2/18/2022. Patient #3 On 2/17/2022 at 9:09 AM, review of Patient #3's POC revealed the hospice staff are to assess the patient for volunteer needs. The patient's chart had no follow through of a documented assessment for the patient's need/refusal of volunteer services. The finding was verified by the Administrator and Clinical Manager at 11:11 AM on 2/18/2022. Patient #6 On 2/17/2022 at 9:54 AM, review of Patient #6's POC revealed the hospice staff are to assess the patient for volunteer needs. The patient's chart had no follow through of a documented assessment for the patient's need/refusal of volunteer services. The finding was verified by the Administrator and Clinical Manager at 11:19 AM on 2/18/2022. Patient #7 On 2/17/2022 at 10:22 AM, review of Patient #7's POC revealed the hospice staff are to assess the patient for volunteer needs. The patient's chart had no follow through of a documented assessment for the patient's need/refusal of volunteer services. The finding was verified by the Administrator and Clinical Manager at 10:10 AM on 2/18/2022. Patient #10 On 2/17/2022 at 10:48 AM, review of Patient #10's POC revealed the hospice staff are to assess the patient for volunteer needs. The patient's chart had no follow through of a documented assessment for the patient's need/refusal of volunteer services. The finding was verified by the Administrator and Clinical Manager at 10:48 AM on 2/18/2022. Patient #4 On 2/17/2022 at 11:15 AM, review of Patient #4's POC revealed the hospice staff are to assess the patient for volunteer needs. The patient's chart had no follow through of a documented assessment for the patient's need/refusal of volunteer services. The finding was verified by the Administrator and Clinical Manager at 11:47 AM on 2/18/2022. Patient # 2 On 2/17/2022 at 12:11 PM, review of the patient's comprehensive spiritual assessment form revealed the patent's POC stated to assess for volunteer needs. The patient's chart had no follow through of a documented assessment for the patient's need/refusal of volunteer services. The finding was verified by the Administrator and the Clinical Manager at 9:40 AM on 2/18/2022.

Based on record reviews and interview, the hospice Chaplain did not conduct the spiritual assessment for nine of nine patient charts reviewed in which the Chaplain's services were not declined. The core service of the Chaplain was not utilized to complete the patient's initial spiritual assessment. (Patient #1-#4 and #7-#11) The findings are: Patient #11 On 2/16/2022 at 11:40 AM, review of Patient #11's chart revealed there were no visits by the Chaplain. Review of the initial Nursing Admission Assessment revealed Chaplain visits were not declined. The finding was verified by the Administrator and Clinical Manager at 10:51 AM on 2/18/2022. Patient #9 On 2/16/2022 at 12:25 PM, review of Patient #9's chart revealed the comprehensive spiritual assessment form was completed by the Master of Social Worker (MSW) and not by the Chaplain. The Administrator stated, "That is my fault. I made the decision for the spiritual assessment to be made by the MSW instead of the Chaplain." Chaplain services were not utilized by the hospice to conduct the patient's initial spiritual assessment. The finding was verified by the Administrator and Clinical Manager at 11:22 AM on 2/18/2022. Patient #1 On 2/16/2022 at 12:49 PM, review of Patient #1's chart revealed the Chaplain made no visits for this patient. Review of the patient's initial Nursing Admission Assessment revealed Chaplain visits was not declined by the patient. The finding was verified by the Administrator and Clinical Manager at 11:31 AM on 2/18/2022. Patient #8 On 2/16/2022 at 3:08 PM, review of Patient #8's chart revealed the Chaplain made no visits for the patient. Review of the patient's initial Nursing Admission Assessment revealed Chaplain visits were not declined by the patient. The finding was verified by the Administrator and Clinical Manager at 11:53 AM on 2/18/2022. Patient #3 On 2/17/2022 at 9:09 AM, review of Patient #11's chart revealed the patient's comprehensive spiritual assessment form was completed by the Master of Social Worker (MSW) and not by the Chaplain. The Administrator stated, "That is my fault. I made the decision for the spiritual assessment to be made by the MSW instead of the Chaplain." The finding was verified by the Administrator and Clinical Manager at 11:11 AM on 2/18/2022. Patient #7 On 2/17/2022 at 10:22 AM, review of Patient #7's chart revealed the patient's comprehensive spiritual assessment form was completed by the Master of Social Worker (MSW) and not by the Chaplain. The Administrator stated, "That is my fault. I made the decision for the spiritual assessment to be made by the MSW instead of the Chaplain." The finding was verified by the Administrator and Clinical Manager at 10:10 AM on 2/18/2022. Patient #4 On 2/17/2022 at 11:15 AM, , review of Patient #7's chart revealed the patient's comprehensive spiritual assessment form was completed by the Master of Social Worker (MSW) and not by the Chaplain. The Administrator stated, "That is my fault. I made the decision for the spiritual assessment to be made by the MSW instead of the Chaplain." The finding was verified by the Administrator and Clinical Manager at 11:47 AM on 2/18/2022. Patient #10 On 2/17/2022 at 10:48 AM, review of Patient #10's chart revealed comprehensive spiritual assessment form was completed by the Master of Social Worker (MSW) and not by the Chaplain. The Administrator stated, "That is my fault. I made the decision for the spiritual assessment to be made by the MSW instead of the Chaplain." The finding was verified by the Administrator and Clinical Manager at 11:59 AM on 2/18/2022. Patient # 2 On 2/17/2022 at 12:11 PM, review of the patient's comprehensive spiritual assessment form revealed the spiritual assessment form was completed by the Master of Social Worker (MSW) and not by the Chaplain. The Administrator stated, "That is my fault. I made the decision for the spiritual assessment to be made by the MSW instead of the Chaplain." The finding was verified by the Administrator and the Clinical Manager at 9:40 AM on 2/18/2022.