Every finding on record at Magnolia Regional Health Center Home Health and Hospice Agency

Based on staff interviews, medical record reviews and policy/procedure review the facility failed to ensure the comprehensive assessment was updated by the hospice interdisciplinary group (IDG) and failed to document changes, or progress toward desired outcomes, or reassessment of the patients response to care for (10) of (10) medical records reviewed; Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10. --- Findings include: During an interview with the facility Clinic Manager (CM) on 03/19/2024 at 2:30 p.m., it was confirmed the Hospice Medical Director (MD) failed to document an updated summary on Patient #1s Plan of Care (POC) for the Interdisciplinary Group (IDG) Meetings dated 01/22/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024; Patient #2s POC 01/08/2024, 01/22/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024. During an interview with the facility Clinic Manager (CM) on 03/20/2024 at 4:00 p.m., it was confirmed the Hospice Medical Director (MD) failed to document an updated summary on Patient #3s Plan of Care (POC) for the Interdisciplinary Group (IDG) Meetings dated 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024; No summary documented for Social Worker on 02/05/2024, and 03/04/2024, or for Chaplain on 02/05/2024, 02/19/2024, and 03/04/2024. During an interview with the facility Clinic Manager (CM) on 03/20/2024 at 4:00 p.m., it was confirmed the Hospice Medical Director (MD) failed to document an updated summary on Patient #4s Plan of Care (POC) for the Interdisciplinary Group (IDG) Meetings dated 01/22/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024; No summary documented for Social Worker on 01/22/2024, 02/05/2024, 02/19/2024, and 03/18/2024, or Chaplain on 01/22/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024. During an interview with the facility Clinic Manager (CM) on 03/20/2024 at 4:00 p.m., it was confirmed the Hospice Medical Director (MD), failed to document an updated summary on patient #5s Plan of Care (POC) for the Interdisciplinary Group (IDG) Meeting dated 03/18/2024. During an interview with the facility Clinic Manager (CM) on 03/20/2024 at 4:00 p.m., it was confirmed the Hospice Medical Director (MD) failed to document an updated summary on patient #6s Plan of Care (POC) for the Interdisciplinary Group (IDG) Meeting dated 01/08/2024, 01/22/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024; No summary documented for the Social Worker on 01/22/2024, 02/05/2024, 02/19/2024, and 03/18/2024, or Chaplain on 01/08/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024. During an interview with the facility Clinic Manager (CM) on 03/20/2024 at 4:00 p.m., it was confirmed the Hospice Medical Director (MD) failed to document an updated summary on Patient #7s Plan of Care (POC) for the Interdisciplinary Group (IDG) Meeting dated 01/22/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024; No summary documented for Social Worker on 01/22/2024, and 02/05/2024; or Chaplain on 02/05/2024, 02/19/2024 and 03/04/2024. During an interview with the facility Clinic Manager (CM) on 03/20/2024 at 4:00 p.m., it was confirmed the Hospice Medical Director (MD) failed to document an updated summary on Patient #8s Plan of Care (POC) for the Interdisciplinary Group (IDG) Meeting dated 03/04/2024, and 03/18/2024; No summary documented for Social Worker on 03/18/2024, or Chaplain on 03/04/2024, and 03/18/2024. During an interview with the facility Clinic Manager (CM) on 03/20/2024 at 4:00 p.m., it was confirmed the Hospice Medical Director (MD) failed to document an updated summary on patient #9s Plan of Care (POC) for the Interdisciplinary Group (IDG) Meeting dated 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024; no summary documented for the Social Worker on 02/05/2024, and 03/04/2024, or Chaplain on 02/05/2024, 02/19/2024 and 03/04/2024. During an interview with the facility Clinic Manager (CM) on 03/20/2024 at 4:00 p.m., it was confirmed the Hospice Medical Director (MD) failed to document an updated summary on Patient #10s Plan of Care (POC) for the Interdisciplinary Group (IDG) Meeting dated 01/22/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024; no summary documented for the Social Worker on 01/22/2024, 02/05/2024, 03/04/2024, and 03/18/2024, or Chaplain on 02/05/2024, 02/19/2024 and 03/04/2024. Review of the medical record titled, ";Interdisciplinary Group Meeting Plan of Care" for Patient #1, revealed no documented evidence of progress toward desired outcomes or the patients response to care by the Medical Director (MD) on the following IDG meeting dates: 01/22/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024 and Patient #2 on 01/08/2024, 01/22/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024 and Patient #5 on 03/18/2024. Review of the medical record titled, ";Interdisciplinary Group Meeting Plan of Care" for Patient #3, revealed no documented evidence of progress toward desired outcomes or the patients response to care by the Medical Director (MD) 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024; no summary documented for the Social Worker on 02/05/2024, and 03/04/2024, or the Chaplain on 02/05/2024, 02/19/2024, and 03/04/2024. Review of the medical record titled, ";Interdisciplinary Group Meeting Plan of Care" for Patient #4, revealed no documented evidence of progress toward desired outcomes or the patients response to care by the Medical Director (MD) 01/22/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024; no summary documented for the Social Worker 01/22/2024, 02/05/2024, 02/19/2024, and 03/18/2024, or the Chaplain on 01/22/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024. Review of the medical record titled, ";Interdisciplinary Group Meeting Plan of Care" for Patient #6, revealed no documented evidence of progress toward desired outcomes or the patients response to care by the Medical Director (MD) 01/08/2024, 01/22/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024; no summary documented for the Social Worker on 01/22/2024, 02/05/2024, 02/19/2024, and 03/18/2024, or the Chaplain on 01/08/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024. Review of the medical record titled, ";Interdisciplinary Group Meeting Plan of Care" for Patient #7, revealed no documented evidence of progress toward desired outcomes or the patients response to care by the Medical Director (MD) 01/22/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024; no summary documented for the Social Worker 01/22/2024, and 02/05/2024; or the Chaplain on 02/05/2024, 02/19/2024 and 03/04/2024. Review of the medical record titled, ";Interdisciplinary Group Meeting Plan of Care" for Patient #8, revealed no documented evidence of progress toward desired outcomes or the patients response to care by the Medical Director (MD) 03/04/2024, and 03/18/2024; no summary documented for the Social Worker on 03/18/2024, or the Chaplain on 03/04/2024, and 03/18/2024. Review of the medical record titled, ";Interdisciplinary Group Meeting Plan of Care" for Patient #9, revealed no documented evidence of progress toward desired outcomes or the patients response to care by the Medical Director (MD) 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024; no summary documented for the Social Worker on 02/05/2024, and 03/04/2024, or the Chaplain on 02/05/2024, 02/19/2024 and 03/04/2024. Review of the medical record titled, ";Interdisciplinary Group Meeting Plan of Care" for patient #10, revealed no documented evidence of progress toward desired outcomes or the patients response to care by the Medical Director (MD) 01/22/2024, 02/05/2024, 02/19/2024, 03/04/2024, and 03/18/2024; no summary documented for the Social Worker on 01/22/2024, 02/05/2024, 03/04/2024, and 03/18/2024, or the Chaplain on 02/05/2024, 02/19/2024 and 03/04/2024. Review of the facility policy and procedures titled, ";Hospice Care Planning Process", policy # HH_1123, Revised Date 08/21, confirmed ";...The attending physicians participation and approval will be documented in the medical record...2. Goals should be developed and mutually agreed upon by the hospice team, the patient/caregiver and physician...". Review of the facility document titled, ";Magnolia Regional Health Center Job Description Hospice Medical Director", effective date 4/22/15, signed 12/31/2022, confirmed ";...1.3 Reviews, revises, and documents the plan of care at least every 14 days. 1.4 Attends bi-monthly Interdisciplinary team meeting..." During the exit conference on 03/21/2024 at 1:00 p.m. with facility Clinical Manager and Operational Director, survey findings were discussed, and no further documentation was submitted for review.

Based on staff interview the facility failed to provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff on four (4) of four (4) survey days. --- Findings Include: Interview with the Volunteer Coordinator on 03/18/2024 at 11:30 a.m. confirmed cost savings for volunteer services- First quarter 2023 – three percent (3%), Second quarter 2023 – one percent (1%), Third quarter 2023 – one percent (1%), Fourth quarter 2023 – one percent (1%). Interview with Register Nurse (RN) #1 and RN #2 confirmed the facility did not have a Performance Improvement Plan (PIP) for volunteer services cost savings. RN #1 and #2 stated, ";I am not aware of a plan regarding volunteer services. Nothing is in our QAPI binder." Review of the facility Quality Assurance Performance Improvement documents revealed no documented information of Performance Improvement Projects for volunteer cost savings. Review of the facility policy and procedure titled, ";DOCUMENTATION OF TIME SPENT AND COST SAVINGS BY VOLUNTEERS", last review date 08/2021, reveals, ";...Magnolia Hospice will strive to maintain a level of volunteer activity equal to or exceeding 5% of the total patient care hours of all paid hospice employees...". Review of the document titled, ";VOLUNTEER CUMULATIVE HOURS/COST SAVINGS", reveals, ";...Quarter ending 12/31/22...Percentage of volunteer hours... Quarter ending 03/31/2023...Percentage of volunteer hours- 3%, Quarter ending 06/30/2023...Percentage of volunteer hours- 1%, Quarter ending 09/30/2023...Percentage of volunteer hours- 1%, Quarter ending 12/31/2023...Percentage of volunteer hours- 0%...." During the exit conference on 03/21/2024 at 12:30 p.m. with the Clinical Manager for Hospice and Operational Director Hospice, survey findings were discussed, and no further documentation was submitted for review.