Every finding on record at Lincoln Community Health

Based on interview and record review, the hospice failed to ensure the interdisciplinary group (IDG) included all required individuals, specifically the medical social worker (MSW) and chaplain, for all IDG meetings for 5 of 5 active patients (Patients #1, #2, #3, #4, and #5) and 6 of 6 discharged patients (Patients #6, #7, #8, #9, #10, and #11) records reviewed who had IDG meetings. --- Findings Include: AGENCY POLICY According to the agency policy dated 2/2/17 and last reviewed 3/4/20, titled Interdisciplinary Team Meeting, (read in pertinent parts): "The Interdisciplinary Team will meet on a bi-weekly basis to discuss patient/family/caregiver updates in the Plan of Care, deaths and changes in circumstances, admission/certification and recertification of patients on the hospice program. Each patient's Plan of Care will be reviewed on a weekly basis. The meeting will be facilitated by the Hospice Clinical Supervisor and/or designee. The Hospice Medical Director (as available) and all hospice Interdisciplinary Team members will be present, including volunteers and attending physicians as available." "Those at the Interdisciplinary Team meeting will sign an attendance form that will be kept by the Hospice Clinical Supervisor." 1. During an interview on 9/26/22 at 10:47 a.m., the hospice administrator stated the members of the IDG were the hospice administrator, nurses, home health aide (HHA)/bereavement coordinator/volunteer coordinator (Employee #5), hospice medical director, social worker, and chaplain. The hospice administrator stated the agency changed the electronic medical record (EMR) system they used in June of 2022. Prior to their use of their current EMR, the IDG would document their meetings on paper and had a paper sign in sheet for attendance. The hospice administrator stated with the use of the agency's current EMR, all IDG meetings were documented in the EMR including the attendance of participants. During an interview on 9/26/22 at 3:51 p.m., the hospice administrator stated the hospice chaplain lived over an hour away from the hospice, thus he did not attend the IDG meetings in person. She stated the Chaplain called into the meetings to participate and his presence at the IDG meetings was recorded on the attendance sign in sheet. The hospice administrator stated the Chaplain had not been present for the IDG meetings in June through September. During an interview on 9/27/22 at 10:18 a.m., RN #6 stated the members of the IDG present at the hospice's biweekly meeting were: the medical director, RN #2 and #6, the social worker, the bereavement/volunteer coordinator/HHA (Employee #5), the hospice administrator and the chaplain. RN #6 stated the social worker attended 75% of the IDG meetings. RN #6 stated the social worker could not attend all meetings due to other commitments. RN #6 also stated the Chaplain had called into the IDG meetings in the past, but had not called in for the IDG meetings since June of 2022. During an interview on 9/27/22 at 1:22 p.m., the licensed clinical social worker (LCSW) stated the participants of the IDG meeting were: the medical director, the hospice nurses, the hospice administrator for most meetings, the bereavement/volunteer coordinator/HHA (Employee #5) for most meetings, the chaplain and herself. The LCSW stated the Chaplain used to call in for the IDG meetings, but he had not participated since June of 2022. The LCSW stated she had not attended all IDG meetings as she was the only social worker for the hospice and if she was on vacation or had other work commitments there was no other person available to attend the meeting to represent the social work needs of patients. During an interview on 9/28/22 at 10:44 p.m., the hospice administrator stated when the chaplain started with the hospice in June of 2021 it was agreed that he would attend the IDG meetings. The hospice administrator stated he had attended the meetings, but since June of 2022 he had not attended. The hospice administrator stated the chaplain communicated his involvement in hospice patient's care to Employee #5 verbally and Employee #5 would report to the IDG during the IDG meetings for the chaplain. The hospice administrator stated, prior to June of 2022, Employee #5 would document the communication between herself and the chaplain in the agency's EMR, but since June of 2022 and the transition to the agency's new EMR, Employee #5 did not document the communication between the chaplain and herself. The hospice administrator stated if the LCSW could not attend IDG meetings, the LCSW would provide Employee #5 with a verbal report on her involvement/concerns for patients to be discussed at the IDG meeting she would miss, but there was no documentation of this communication. 2. The clinical record for Patient #1 was reviewed on 9/26/22. The patient was admitted for hospice care and services on 5/23/19 with a terminal diagnosis of chronic obstructive pulmonary disease. The plan of care for the certification period 6/12/22 to 8/10/22 included orders for skilled nurse (SN) visits one time a week for nine weeks with six as needed (PRN) visits and MSW two visits for one month, three visits for one month and one visit for a month. A verbal physician order written on 6/12/22 for Patient #1 showed 10 PRN visits had been ordered for chaplain visits and 15 PRN visits had been ordered for volunteer visits. Subsequent plan of care orders for the certification period dated 8/11/22 to 10/9/22 included orders for SN visits one time a week for eight weeks and three PRN visits; MSW visits two times a month for one month, three times a month for one month, and one time a month for one month. A supplemental physician order dated 8/11/22 for Patient #1 showed 15 PRN visits had been ordered for chaplain visits and 20 PRN visits had been ordered for volunteer visits. a) The hospice failed to ensure a social worker and chaplain participated in all IDG meetings for Patient #1 and contributed to Patient #1's comprehensive and ongoing assessments and care planning process. Review of the IDG meeting sign-in sheets and IDG updated plans of care for Patient #1 for the meetings dated 6/15/22, 6/29/22, 7/13/22, 7/27/22, 8/24/22, 9/7/22, and 9/21/22 revealed no signature from a chaplain as being in attendance for any of these seven IDG meetings and for meetings dated 6/29/22, 7/27/22 and 8/24/22 revealed no signature from a social worker as being in attendance for these three IDG meetings. 3. The clinical record for Patient #2 was reviewed on 9/27/22. The patient was admitted for hospice care and services on 6/7/22 with a terminal diagnosis of neoplasm of unspecified behavior of the digestive system. The plan of care orders for the certification period dated 6/7/22 to 9/4/22 included SN to assess and evaluate between 6/7/22 and 6/11/22 and then visits one time a week for 13 weeks with 10 PRN visits and MSW one time a week for 13 weeks with two PRN visits. A supplemental physician order for Patient #2 effective 8/17/22 showed 15 PRN chaplain visits and 20 PRN volunteer visits were ordered for Patient #2. Subsequent plan of care orders for the certification period dated 9/5/22 to 12/3/22 included orders for SN visits for one visit a week for 12 weeks. A verbal physician order written on 9/6/22 for Patient #2 showed MSW visits had been ordered one time a week for four weeks. A supplemental physician order for Patient #2 for the certification period 9/5/22 to 12/3/22 revealed 15 PRN chaplain visits and 20 PRN volunteer visits were ordered for Patient #2. a) The hospice failed to ensure a social worker and chaplain participated in all IDG meetings for Patient #2 and contributed to Patient #2's comprehensive and ongoing assessments and care planning process. Review of the IDG meeting sign-in sheets and IDG updated plans of care for Patient #2 for the meetings dated 6/15/22, 6/29/22, 7/13/22, 7/27/22, 8/24/22, 9/7/22, and 9/21/22 revealed no signature from a chaplain as being in attendance for any of these seven IDG meetings and for meetings dated 6/29/22, 7/27/22 and 8/24/22 revealed no signature from a social worker as being in attendance for these three IDG meetings. 4. The clinical record for Patient #5 was reviewed on 9/26/22. The patient was admitted for hospice care and services on 6/21/22 with a terminal diagnosis of Merkel cell carcinoma of the left upper limb including the shoulder. The plan of care for the certification period dated 6/21/22 to 9/18/22 included orders for SN visits one time a week for 13 weeks with three PRN visits and MSW to assess and evaluate 6/21/22 to 6/25/22, and then effective 6/27/22 one visit a week for three weeks. a) The hospice failed to ensure a social worker and chaplain participated in all IDG meetings for Patient #5 and contributed to Patient #5's comprehensive and ongoing assessments and care planning process. Review of the IDG meeting sign-in sheets and IDG updated plans of care for Patient #5 for the meetings dated 7/13/22, 7/27/22, 8/24/22, 9/7/22 and 9/21/22 revealed no signature from the chaplain as being in attendance for any of these five IDG meetings and for meetings on 7/27/22 and 8/24/22 revealed no signature from a social worker as being in attendance for these two IDG meetings. 5. Similar findings of the hospice failing to have a chaplain and/or social worker present at all IDG meetings was also found for Patients #3, #4, #6, #7, #8, #9, #10 and #11.

Based on interview and record review, the hospice failed to develop an individualized written plan of care for each patient, reflective of patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments, including all services necessary for the palliation and management of the terminal illness and related conditions. This failure affected 2 of 5 active patients whose records were reviewed (Patients #1 and #2). --- Findings include: AGENCY POLICY According to an agency policy dated 2/2/17 and last reviewed 3/5/20, titled Hospice - Initial Plan of Care, (read in pertinent parts): "The Initial Plan of Care will be developed by an RN at the initial visit that is consistent with the patient/family's immediate care needs. The RN, attending physician, confer to develop this plan prior to the delivery of care." "The Plan of Care and all updates thereafter will be developed always with the input of the patient/family, the physician and the Interdisciplinary Team. The following areas will be [review] and approved by the patient/family: -Scope and frequency of service -Medication administration and the side effects -Problems identified -Activity level and safety measures -Dietary suggestions Each patient will be assessed for his or her response to care or services provided against established goals and patient outcomes to determine if goals have been achieved. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing assessments, analysis of patient response to care against goals and outcomes." 1. During an interview on 9/26/22 at 10:47 a.m., the hospice administrator stated the patient's plans of care (POC) were developed by the registered nurse (RN). The hospice administrator stated patient POC's were to contain all information necessary to care for a patient including but not limited to: demographics, medications, visit frequency, services to be provided, durable medical equipment needs, goals and interventions for problems identified for the patient, patient's psychosocial and spiritual needs, and funeral arrangements. The hospice administrator stated patients' POCs were updated by the RN as needed and potentially at each visit as patient care needs changed. The hospice administrator also stated at the hospice interdisciplinary group (IDG) meetings the IDG team discussed each patient who was receiving care by the hospice at length regarding where each patient was spiritually, in their disease progression, how well they were coping and their care needs and would update the POC as needed. 2. The clinical record for Patient #2 was reviewed on 9/27/22. The patient was admitted for hospice care and services on 6/7/22 with a terminal diagnosis of neoplasm of unspecified behavior of the digestive system. The plan of care orders for the certification period dated 6/7/22 to 9/4/22 included skilled nurse (SN) to assess and evaluate between 6/7/22 to 6/11/22 and then visits one time a week for 13 weeks with 10 PRN visits and MSW one time a week for 13 weeks with two PRN visits. A supplemental physician order for Patient #2 effective 8/17/22 showed 15 PRN chaplain visits and 20 PRN volunteer visits were ordered for Patient #2. Subsequent plan of care orders for the certification period dated 9/5/22 to 12/3/22 included orders for SN visits for one visit a week for 12 weeks. A verbal physician order written on 9/6/22 for Patient #2 showed MSW visits had been ordered one time a week for four weeks. A supplemental physician order for Patient #2 for the certification period 9/5/22 to 12/3/22 revealed 15 PRN chaplain visits and 20 PRN volunteer visits were ordered for Patient #2. a) The hospice failed to ensure Patient #2's plan of care was updated to reflect all of Patient #2's care needs and contained goals or interventions for all care needs when Patient #2 developed new care needs. Review of the RN comprehensive assessment completed on 6/7/22 by RN #2 showed RN #2 identified Patient #2 to have the following care needs: constipation, weakness, and risk for falls/injury. The RN was to assess the patient's pain severity, frequency, location, quality, precipitating factors, and side effects so the patient could be pain free or verbalize an acceptable pain level with current pain management regimen. Review of the plan of care dated 6/7/22 for Patient #2, completed by RN #2 and signed by the medical director on 6/15/22 showed Patient #2's goals were as follows: patient will maintain optimal coping through hospice care; patient/caregiver can explain how to promote problem solving/adaptation, patient will be pain free or verbalize an acceptable pain level with current pain management regimen; and patient/caregiver will demonstrate necessary behaviors to maintain good safety awareness and minimize the risk of falls and/or injury. The interventions listed to address the goals set for Patient #2 were as follows: offer/provide counseling to patient with stages of acceptance through the dying process; encourage family to express concerns, participate in care; assess history of falls and/or injury, assess pain severity, frequency, location, quality, precipitating factors and side effects of pain, and assess patient's risk for falls. Review of the IDG meeting notes for the meetings held on 6/7/22, 6/29/22, 7/13/22, 7/27/22 for Patient #2 showed her POC was not changed or updated from her original POC established on 6/7/22. Review of a SN visit completed on 8/22/22 by RN #2 for Patient #2 showed RN #2 found Patient #2 to have a new open area to her left jaw where Patient #2's tumor was located. RN #2 measured the area to be 0.2 cm in length and 0.1 cm in width with a small amount of serous drainage (fluid that drains from a wound that is mostly composed of plasma cells). RN #2 documented she cleansed the wound with wound cleanser and applied a Mepilex dressing - a foam wound care bandage. Review of the IDG meeting on 8/24/22 showed RN #2 documented a preparation note regarding Patient #2 on 8/22/22 that stated on 8/20/22 RN #2 noted Patient #2 mass to her left jaw had a very small opening that was draining serous fluid and RN #2 covered the wound with Mepilex per instructions from Patient #2's family nurse practitioner (FNP #8). RN #2 documented that Patient #2 was concerned about why her left jaw mass developed a wound. Patient #2's POC for the 8/24/22 IDG meeting stated there were no changes made to the plan of care. Patient #2 was identified to have problems in coping, had altered family processes, pain management, and risk for falls/injury with goals and interventions for each of these identified care needs. However, the IDG failed to list Patient #2's new left jaw wound on the updated POC and failed to have goals and interventions listed for this wound. Review of the RN comprehensive assessment completed on 8/29/22 for Patient #2 by RN #2 showed RN #2 identified Patient #2 to have a left upper medial head jaw wound that measured 0.3 in length and 0.1 in width with small amount of serous drainage that RN #2 cleaned with normal saline and Chlorhexidine (a topical antiseptic) and covered with a Mepilex dressing. RN #2 also identified Patient #2 with the following care needs: coping, pain management, and risk for falls/injury. Review of the POC dated 9/5/22 for Patient #2 completed by RN #2 and signed by FNP #8 on 9/6/22 showed Patient #2's goals were as follows: patient will maintain optimal coping through hospice care; patient/family will have final arrangements in place; patient/caregiver will verbalize understanding of falls/injury prevention and home safety measures; and patient will be pain free or verbalize an acceptable pain level with current pain management regimen. Patient #2's interventions for these goals were as follows: discuss plans and needs; encourage venting of concerns or fears; assess for history of falls and/or injury; and assess pain severity, frequency, location, quality, precipitating factors, and side effects of pain. The IDG failed to identify that Patient #2 had developed a wound on her left jaw or to list goals or interventions for the care of Patient #2's left jaw wound. Review of the IDG meeting on 9/7/22 showed Patient #2's updated POC for this meeting showed Patient #2's care needs to be coping, lack of preparedness - funeral/final arrangements, risk for falls/injury, and pain management. The goal for Patient #2's coping issues was Patient #2 would maintain optimal coping through hospice care with the intervention of encouraging venting of concerns and fears. The goal for Patient #2's lack of preparedness was patient/family would have final arrangements in place with intervention to discuss plans and needs. The goal of Patient #2's risk of falls/injury was Patient #2/caregiver would verbalize understanding of falls/injury prevention and home safety measures with intervention of assess for history of falls and/or injury. The goal for Patient #2's pain management was Patient #2 would be pain free and verbalize an acceptable pain level with current pain management regimen with the intervention of assessing pain severity, frequency, location, quality, precipitating factors, and side effects of pain. The IDG failed to update Patient #2's POC to reflect her left jaw wound and failed to establish goals and interventions to address Patient #2's left jaw wound. Review of a SN note completed by RN #2 for Patient #2 on 9/12/22 showed Patient #2 continued to have a left upper medial head jaw wound that measured 0.3 cm in length and 0.1 cm in width with serous drainage that RN cleaned with wound cleanser and covered with Mepilex. Review of SN note completed by RN #2 for Patient #2 on 9/19/22 showed Patient #2 continued to have a left upper medial head jaw wound that measured 0.1 cm in length and 0.1 cm in width with no drainage that RN #2 cleaned with wound cleanser and covered with Mepilex. RN #2 also documented Patient #2 was complaining of visual disturbances, soreness, tearing, and blurring of the left eye. RN #2 informed FNP #8 who ordered Prednisone ophthalmic eye drops (prescription eye drops used to treat mild to moderate non-infectious eye allergies and inflammation) for Patient #2. RN #2 assessed Patient #2 to have new redness to the left underside of her breast that was dry and did not appear to be yeast. RN #2 informed FNP #8 who ordered a powder, Caldesene (a medicated powder that can be used for the prevention and treatment of prickly heat and chafing) for the treatment of the skin irritation. Review of the IDG meeting note for the meeting held on 9/21/22 showed RN #2 had completed a preparation note regarding Patient #2 on 9/20/22. RN #2 documented Patient #2's tumor to her left jaw continued to grow in size and RN #2 was providing dressing changes weekly and as needed with very little drainage noted from the wound. During RN #2's visits on 9/12/22 and 9/19/22,RN #2 documented Patient #2's visual disturbance and skin redness under her left breast noted at her 9/19/22 visit with Patient #2. The updated POC for this IDG meeting stated there were no changes since the 9/7/22 IDG meeting and POC and the problems, goals and interventions were all listed as documented on the 9/7/22 IDG meeting. The IDG failed to update Patient #2's POC to reflect her left jaw wound, her visual disturbance and skin redness under her left breast and failed to establish goals and interventions to address these new care needs. During an interview with RN #2 on 9/28/22 at 12:58 p.m. RN #2 stated she did not update Patient #2's POC with goals and interventions for her new care needs, specifically her left jaw wound as RN #2 was covering the wound with a Mepilex more for cosmetic purposes to make Patient #2 feel less subconscious as opposed to covering it for wound care. 3. The clinical record for Patient #1 was reviewed on 9/26/22. The patient was admitted for hospice care and services on 5/23/19 with a terminal diagnosis of chronic obstructive pulmonary disease. The plan of care for the certification period 6/12/22 to 8/10/22 included orders for SN visits one time a week for nine weeks with six PRN visits and MSW two visits for one month, three visits for one month and one visit for a month. A verbal physician order written on 6/12/22 for Patient #1 showed 10 PRN visits had been ordered for chaplain visits and 15 PRN visits had been ordered for volunteer visits. Subsequent plan of care orders for the certification period dated 8/11/22 to 10/9/22 included orders for SN visits one time a week for eight weeks and three PRN visits; MSW visits two times a month for one month, three times a month for one month, and one time a month for one month. A supplemental physician order dated 8/11/22 for Patient #1 showed 15 PRN visits had been ordered for chaplain visits and 20 PRN visits had been ordered for volunteer visits. a) The hospice failed to ensure Patient #1's plan of care identified all of Patient #1's care needs and contained goals or interventions for all care needs identified in the comprehensive assessment and/or interdisciplinary group (IDG) meetings for Patient #1. Review of the RN comprehensive assessment for Patient #1 completed on 8/8/22 by RN #2 showed RN #2 identified Patient #1's care needs as follows: altered nutrition/hydration status, anxiety/stress, chronic obstructive pulmonary disease (COPD), constipation, pain management, risk for falls/injury, and urinary incontinence. Review of the plan of care dated 8/11/22 for Patient #1, completed by RN #2 and signed by the attending physician on 8/15/22, showed Patient #1's goals were as follows: anxiety reduced and within manageable level during dyspneic (difficult or labored breathing) episodes, patient will maintain a reported anxiety score of 5/10 or less, on a scale of 0-10, patient will maintain a pain score of 5/10 or less, per patient/family preference, on a scale of 0-10. The interventions listed to address the goals for Patient #1 were as follows: assess pain severity, frequency, location, quality, precipitating factors and side effects of pain to be completed by the SN; assess patient's ability to cope with change in health status to be completed by the SN and MSW; assess patient's use of oxygen and oxygen effectiveness to be completed by the SN, and teach patient/caregiver on anxiety reduction and coping skills to be completed by the SN. The plan of care failed to show any goals and interventions for Patient #1's altered nutrition/hydration status, constipation, risk for falls/injury or urinary incontinence as identified in the comprehensive assessment. Review of the 8/24/20 IDG updated POC for Patient #1 showed RN #2 documented a preparation note for the meeting on 8/22/22 that showed Patient #1 continued to lose weight, have increased lethargy, with a poor appetite and concerns regarding his meal preparation. RN #2 also documented that Patient #1 was content with his sleep, pain, and bowel regimen with Patient #1 experiencing mild right lower quadrant pain, but Patient #1 felt the pain was acceptable. Patient #1's care needs were identified to be COPD, anxiety/stress and pain management. Patient #1's goal for his COPD was anxiety reduced and within manageable level during dyspneic episodes and the interventions to achieve this goal were: assess patient's ability to cope with change in health status and assess patient's use of oxygen and oxygen effectiveness to be completed by the IDG team. Patient #1's goal for his anxiety/stress was patient will maintain a reported anxiety score of 5/10 or less on a scale of 0-10 and the intervention to achieve this goal was to teach patient/caregiver on anxiety reduction and coping skills to be completed by the IDG team. Patient #1's goal for his pain management was he would maintain a pain score of 5/10 or less, per patient/family preference on a scale of 0-10 with the intervention of assessing pain severity, frequency, location, quality, precipitation factors and side effects of pain to be completed by the IDG team. The updated IDG POC failed to identified Patient #1's continued altered nutrition/hydration status nor have any goals/interventions pertaining to this care need. Review of the 9/7/22 IDG updated POC for Patient #1 showed RN #2 documented a preparation note for the meeting on 9/1/22 that showed Patient #1 reported his pain level was acceptable, he was having regular bowel movements, and he continued to lose weight and reported he had a difficult time choosing what to eat. Patient #1's care needs were identified to be COPD, anxiety/stress and pain management. Patient #1's goal for his COPD was anxiety reduced and within manageable level during dyspneic episodes and the interventions to achieve this goal were: assess patient's ability to cope with change in health status and assess patient's use of oxygen and oxygen effectiveness to be completed by the IDG team. Patient #1's goal for his anxiety/stress was patient will maintain a reported anxiety score of 5/10 or less on a scale of 0-10 and the intervention to achieve this goal was to teach patient/caregiver on anxiety reduction and coping skills to be completed by the IDG team. Patient #1's goal for his pain management was he would maintain a pain score of 5/10 or less, per patient/family preference on a scale of 0-10 with the intervention of assessing pain severity, frequency, location, quality, precipitation factors and side effects of pain to be completed by the IDG team. The updated IDG POC failed to identified Patient #1's continued altered nutrition/hydration status nor have any goals/interventions pertaining to this care need. Review of the 9/21/22 IDG updated POC for Patient #1 showed RN #2 documented a preparation note for the meeting on 9/20/22 that showed Patient #1 continued to be displeased with options for meals. Patient #1's care needs were identified to be COPD, anxiety/stress and pain management. Patient #1's goal for his COPD was anxiety reduced and within manageable level during dyspneic episodes and the interventions to achieve this goal were: assess patient's ability to cope with change in health status and assess patient's use of oxygen and oxygen effectiveness to be completed by the IDG team. Patient #1's goal for his anxiety/stress was patient will maintain a reported anxiety score of 5/10 or less on a scale of 0-10 and the intervention to achieve this goal was to teach patient/caregiver on anxiety reduction and coping skills to be completed by the IDG team. Patient #1's goal for his pain management was he would maintain a pain score of 5/10 or less, per patient/family preference on a scale of 0-10 with the intervention of assessing pain severity, frequency, location, quality, precipitation factors and side effects of pain to be completed by the IDG team. The updated IDG POC failed to identified Patient #1's continued altered nutrition/hydration status nor have any goals/interventions pertaining to this care need. During an interview on 9/28/22 at 12:58 p.m., RN #2 acknowledged the POC and updated IDG POC for Patient #1 did not have all of his care needs with related goals and interventions listed. RN #2 stated the agency changed the electronic medical record (EMR) it used in June of 2022 and she was still learning how to use the EMR. Specifically in regards to Patient #1 nutritional needs and continued weight loss, RN #2 acknowledged Patient #1 was continuing to suffer from this issue, but she did not include this care need on the 8/11/22 POC or subsequent IDG POC for 8/24/22, 9/7/22 or 9/21/22 as she did not feel the prefabricated goals in the agency's EMR fit Patient #1's needs and she was unfamiliar with how to generate a custom goal in the agency's EMR.

Based on interview and record review, the hospice failed to ensure the patient record included complete clinical notes, specifically regarding services provided by the chaplain, for 1 of 2 active patients reviewed who received chaplain services (Patient #1), and failed to ensure the patient record included complete clinical notes, specifically regarding services provided by the chaplain for 1 of 1 discharged patients reviewed who received chaplain services (Patient #10). --- Findings include: AGENCY POLICY According to the agency policy dated 2/2/17 and last reviewed on 3/5/20, titled Contents of Clinical notes, (read in pertinent parts): "The clinical record will contain notes for each hospice service provided, including contract personnel. A clinical note will be written for each visit made to a patient's home." "The clinical note will include: -What care was provided, -The date the service was provided, -The name and title of the hospice personnel providing the service, -Treatment and/or invasive procedures performed, -Patient response to treatment and/or procedures. 1. The clinical record for Patient #1 was reviewed on 9/26/22. The patient was admitted for hospice care and services on 5/23/19 with a terminal diagnosis of chronic obstructive pulmonary disease. The plan of care for the certification period 6/12/22 to 8/10/22 included orders for skilled nurse (SN) visits one time a week for nine weeks with six as needed (PRN) visits and MSW visits two for one month, three visits for one month and one visit for a month. A verbal physician order written on 6/12/22 for Patient #1 showed 10 PRN visits had been ordered for chaplain visits and 15 PRN visits had been ordered for volunteer visits. a) The hospice failed to ensure the chaplain documented a complete clinical note for services he provided Patient #1. Review of a Hospice Volunteer Contact Sheet completed by Chaplain #4 on 8/8/22 for Patient #1 indicated Chaplain #4 provided a one hour chaplain visit in person with Patient #1 which occurred at the assisted living (ALR) Patient #1 resided at. The note failed to indicate what specific services Chaplain #4 provided to Patient #1. 2. The clinical record for Patient #10 was reviewed on 9/27/22. The patient was admitted to hospice care and services on 5/20/21 with a terminal diagnosis of malignant neoplasm of meanings, unspecified. The plan of care for the certification period 3/6/22 to 5/14/22 included orders for SN visits twice a week for nine weeks; MSW no visits for one month and then one visit a month for two months; and three PRN visits for the chaplain. No volunteer visits were ordered. a) The hospice failed to ensure the chaplain documented complete clinical notes for services they provided to Patient #10. Review of Hospice Volunteer Contact Sheet for Patient #10 completed by Chaplain #4 showed Chaplain #4 documented he visited Patient #10 at the ALR she resided in for one hour on 3/26/22 and 4/9/22. The notes failed to indicate the specific services Chaplain #4 provided to Patient #10. 3. During an interview on 9/26/22 at 1:03 p.m., the volunteer coordinator stated the chaplain documented on a hospice form titled, Hospice Volunteer Contact Sheet. However, the notes failed to show what tasks/help/discussions had taken place during his visits. During an interview on 9/26/22 at 4:41 p.m. , the volunteer coordinator stated Chaplain #4 completed the Hospice Volunteer Contact Sheet to indicate what patient he visited, how long the visit lasted and on what day the visit occurred, however his documentation did not indicate what specific services he provided a patient at a visit. The volunteer coordinator stated Chaplain #4 would call or text her to inform her of the specifics of his and the volunteers visits (the volunteers all belong to Chaplain #4's congregation). The volunteer coordinator stated she did not document these telephone conversations or text in the patients' clinical records. During an interview on 9/28/22 at 10:44 a.m., the hospice administrator acknowledged the forms Chaplain #4 used to document, did not contain all the required information for a clinical note. The hospice administrator stated she planned to create two new forms, one specific to the chaplain and one specific to the volunteer and would educate Chaplain #4 and the volunteers on what information was required to be documented in a clinical note.