Every finding on record at Loving Care Hospice Inc

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 3 of 14 (21%) clinical records reviewed in which a comprehensive assessment was performed, revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care. Clinical Record 10: Patient’s hospice benefit election was dated 10/4/21. The need for a MSW evaluation was documented on the comprehensive assessment. There was no documented evidence in the clinical record that the medical social worker (MSW) performed a MSW assessment within 5 calendar days after the election of hospice care. Clinical Record 11: Patient’s hospice benefit election was dated 12/21/22. The need for a MSW evaluation was documented on the comprehensive assessment. There was no documented evidence in the clinical record that the medical social worker (MSW) performed a MSW assessment within 5 calendar days after the election of hospice care. Clinical Record 13: Patient’s hospice benefit election was dated 5/5/23. The need for a MSW evaluation was documented on the comprehensive assessment. There was no documented evidence in the clinical record that the medical social worker (MSW) performed a MSW assessment within 5 calendar days after the election of hospice care. The quality compliance officer who reviewed records with this site visitor on 5/9/23 and 5/10/23 stated that he did not know why the comprehensive assessment was not completed within the 5 days.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. 6 of 14 (43%) clinical records reviewed revealed the hospice did not ensure that the interdisciplinary group completed the initial bereavement risk assessment. Clinical Record 1: Patient’s hospice benefit election was dated 4/21/2021. There was no evidence that an initial bereavement assessment was completed by the interdisciplinary group. Clinical Record 4: Patient’s hospice benefit election was dated 3/24/2022. There was no evidence that an initial bereavement assessment was completed by the interdisciplinary group. Clinical Record 5: Patient’s hospice benefit election was dated 8/30/2022. There was no evidence that an initial bereavement assessment was completed by the interdisciplinary group. Clinical Record 12: Patient’s hospice benefit election was dated 8/22/2022. There was no evidence that an initial bereavement assessment was completed by the interdisciplinary group. Clinical Record 14: Patient’s hospice benefit election was dated 7/27/2022. There was no evidence that an initial bereavement assessment was completed by the interdisciplinary group. Clinical Record 11: Patient’s hospice benefit election was dated 12/22/2022. There was no evidence that an initial bereavement assessment was completed by the interdisciplinary group. The quality compliance officer who reviewed records with this site visitor on 5/9/23 and 5/10/23 stated that he did not know why the initial bereavement assessments were not completed.

It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, and per the plan of care. The psychosocial assessment addresses the patient’s and the family’s adjustment to the terminal illness, the social and emotional factors related to the terminal illness, the presence or absence of adequate coping mechanisms, family dynamics and communication patterns, financial resources and any constraints, the caregiver’s ability to function effectively, obstacles and risk factors that may affect compliance with the plan of care, and family support systems to facilitate coping with end-of-life issues. This standard was not met as evidenced by clinical record review and interview. 3 of 14 (21%) clinical records reviewed revealed there was no documented evidence that a psychosocial assessment was completed by the MSW. Clinical Record 10: Patient’s hospice benefit election was dated 10/4/21. There was no documented evidence in the clinical record that the medical social worker (MSW) performed a psychosocial assessment. Clinical Record 11: Patient’s hospice benefit election was dated 12/21/22. There was no documented evidence in the clinical record that the medical social worker (MSW) performed a psychosocial assessment. Clinical Record 13: Patient’s hospice benefit election was dated 5/5/23. There was no documented evidence in the clinical record that the medical social worker (MSW) performed a psychosocial assessment. The quality compliance officer who reviewed records with this site visitor on 5/9/23 and 5/10/23 stated that he did not know why the MSW did not complete the psychosocial assessment.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of services, including the report of changes in the patient's needs. This standard was not met as evidenced by document review and interview. 2 of 14 (14%) clinical records reviewed revealed the hospice aide did not notify the RN when they were unable to or did not provide assigned tasks that were indicated on the hospice aide plan of care. Clinical Record 3: Patient elected the hospice benefit on 10/25/22 and revoked the benefit on 3/22/23. The hospice aide care plan in benefit period 2/22/23 - 3/22/23 directed the hospice aide to provide a shower and shampoo. On the patient visit dated 3/21/23, the hospice aide documented that no shower or shampoo was provided. There was no documented evidence in the clinical record as to why the shower and shampoo were not provided or that the registered nurse (RN) was notified. Clinical Record 4: Patient elected the hospice benefit on 3/24/22. The hospice aide care plan in the benefit period 1/28/23 - 3/13/23 directed the hospice aide to provide a shower and shampoo. On the patient visit dated 3/13/23, the hospice aide documented that no shower or shampoo was provided. There was no documented evidence as to why the shower and shampoo were not provided or that the RN was notified. The quality compliance officer who reviewed records with this site visitor on 5/9/23 and 5/10/23 confirmed that the aide did not notify the RN when they did not provide a shower or shampoo.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care and documented in the patient record. This standard was not met as evidenced by clinical record review and interview. 9 of 14 (64%) clinical records reviewed revealed there was no evidence that a volunteer was offered and/or the patient declined volunteer services. Clinical Record 1: Patient’s hospice benefit election was dated 4/21/2021. There was no documented evidence in the clinical record that a volunteer was offered. Clinical Record 2: Patient’s hospice benefit election was dated 2/15/2023. There was no documented evidence in the clinical record that a volunteer was offered. Clinical Record 3: Patient’s hospice benefit election was dated 10/25/2022. There was no documented evidence in the clinical record that a volunteer was offered. Clinical Record 4: Patient’s hospice benefit election was dated 3/24/2022. There was no documented evidence in the clinical record that a volunteer was offered. Clinical Record 5: Patient’s hospice benefit election was dated 8/30/2022. There was no documented evidence in the clinical record that a volunteer was offered. Clinical Record 6: Patient’s hospice benefit election was dated 11/32022. There was no documented evidence in the clinical record that a volunteer was offered. Clinical Record 8: Patient’s hospice benefit election was dated 7/27/2022. There was no documented evidence in the clinical record that a volunteer was offered. Clinical Record 9: Patient’s hospice benefit election was dated 6/20/2020. There was no documented evidence in the clinical record that a volunteer was offered. Clinical Record 10: Patient’s hospice benefit election was dated 10/4/2021. There was no documented evidence in the clinical record that a volunteer was offered. An interview with the quality compliance officer on 5/9/23 confirmed that there was no documentation regarding the offering of a volunteer. He stated that he did not know why it was not consistently documented that the volunteer was offered and/or refused.