Every finding on record at Memorial Regional Health Home Health and Hospice

Based on interview and record review, the hospice failed to ensure the registered nurse completed an initial assessment within 48 hours after the election of benefits for hospice care for 1 of 11 patient records reviewed (Patient #4). Findings include: 1. The clinical record for Patient #4 was reviewed on 2/1/22. The patient was admitted to hospice care and services on 7/26/21, with a terminal diagnosis of Alzheimer's disease. The plan of care (POC) for the certification period dated 7/26/21 to 10/23/21 included orders for skilled nursing (SN) services for an undetermined frequency for pain management and comfort measures. a) The hospice failed to ensure the registered nurse (RN) completed and initial assessment within 48 hours of the election of hospice benefits. Review of the clinical record for Patient #4 revealed the patient had been admitted to hospice care and services on 7/26/21. However, further review revealed no evidence the RN had completed an initial comprehensive assessment within 48 hours of Patient #4 beginning services with the agency. During an interview on 2/1/22 at 8:38 a.m., the Director of Nursing (DON) stated the agency had had an issue with their electronic medical record (EMR) that had caused issues with initial assessments not being saved to the system, this may be why it was not found in the record. The DON further stated she had just recently found these issues while conducting audits of patient records.

Based on interview and record review, the hospice failed to ensure comprehensive assessments were completed by the medical social worker (MSW) and chaplain (CH) no later than five (5) calendar days after the election of hospice care for 4 of 11 patient records reviewed (Patients #2, #5, #8, and #11). Findings include: 1. The clinical record for Patient #2 was reviewed on 1/31/22. The patient was admitted to hospice care and services on 11/23/20, with a terminal diagnosis of coronary artery disease. The plan of care (POC) for the certification period dated 11/17/20 to 2/17/21 was missing from the patient record. a) The hospice failed to ensure the MSW completed their initial assessment within 5 days of admission to hospice services. Review of the clinical record for Patient #2 revealed a start of care date (SOC) of 11/23/20. Further review of the clinical record revealed the MSW completed their initial assessment on 12/8/20, 14 days after Patient #2's SOC. 2. The clinical record for Patient #5 was reviewed on 2/1/22. The patient was admitted to hospice care and services on 9/15/21, with a terminal diagnosis of prostate cancer. The plan of care (POC) for the certification period dated 9/15/21 to 12/13/21 included orders for skilled nursing (SN) services for an undetermined frequency for pain management and comfort measures. a) The hospice failed to ensure the MSW completed their initial assessment within 5 days of admission to hospice services. Review of the clinical record for Patient #5 revealed a SOC of 9/15/21. Further review of the clinical record showed no evidence the MSW performed an initial assessment with Patient #5. 3. The clinical record for Patient #10 was reviewed on 2/2/22. The patient was admitted to hospice care and services on 12/14/21, with a terminal diagnosis of lung cancer. The plan of care (POC) for the certification period dated 12/14/21 to 3/13/22 included orders for skilled nursing (SN) services for an undetermined frequency for pain management and comfort measures. a) The hospice failed to ensure the MSW completed their initial assessment within 5 days of admission to hospice services. Review of the clinical record for Patient #11 revealed a SOC of 3/20/21. Further review of the clinical record showed no evidence the MSW performed an initial assessment with Patient #11. 4. The clinical record for Patient #8 was reviewed on 2/1/22. The patient was admitted to hospice care and services on 5/3/21, with a terminal diagnosis of osteomyelitis of the spine. The plan of care (POC) for the certification period dated 5/3/21 to 7/31/21 included orders for skilled nursing (SN) services for an undetermined frequency for pain management and comfort measures. a) The hospice failed to ensure the CH completed their initial assessment within 5 days of admission to hospice services. Review of the clinical record for Patient #8 revealed a SOC date of 5/3/21. Further review of the clinical record showed no evidence the CH or the skilled nurse completed the spiritual care assessment with Patient #8. During an interview on 2/1/22 at 8:38 a.m., the Director of Nursing (DON) stated the agency had had an issue with their electronic medical record (EMR) that had caused issues with initial assessments not being saved to the system. The DON stated she had just recently found these issues while conducting audits of patient records. The DON further stated the MSW assigned to these patients was no longer an employee of the agency and she could not speak to why the assessments were not completed. During an interview on 2/2/22 at 8:47 a.m., the DON stated she was under the impression that if the patient or family declined CH services the CH did not have to perform an initial assessment.

Based on interview and record review, the hospice failed to ensure the interdisciplinary group (IDG) included all required individuals, specifically the chaplain, for all interdisciplinary group meetings for 11 of 11 patient records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11). Findings Include: 1. During an interview on 1/31/22 at 12:15 p.m., the administrator stated the interdisciplinary group (IDG) was comprised of herself, the hospice medical director (HMD), back up medical director, director of nursing (DON), medical social worker (MSW), operations supervisor, and the chaplain (CH). a) The hospice failed to ensure a CH participated in all IDG meetings and contributed to the patient's comprehensive and ongoing assessments and care planning process. Review of the IDG meeting sign-in sheets for the meetings dated 12/2/20 through 1/11/22, for Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 revealed no signatures from the CH as being in attendance or participating in the IDG meetings. During an interview on 2/2/22 at 8:47 a.m., the DON stated she could not get the CH engaged in coming to the IDG meetings or the spiritual care responsibilities of the agency. She stated the agency was under the impression that if patients declined CH services the CH did not have to attend the IDG meetings every 15 days. She further stated the CH had been terminated as of January 2022, and the agency had hired a new CH who was currently going through the agency orientation process and would be trained on the responsibilities of the CH in the IDG process.

Based on interviews and record reviews the agency failed to include the disciplines providing cares and a detailed scope and frequency of services necessary to meet the specific patient and family needs in the plan of care for 11 of 11 patient records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11). Findings include: 1. The clinical record for Patient #1 was reviewed on 1/31/22. The patient was admitted to hospice care and services on 5/17/21, with a terminal diagnosis of liver cancer. The plans of care (POC) for the certification periods dated 8/15/21 to 11/12/21, 11/13/21 to 1/11/22, and 1/12/22 to 3/12/22 included orders for skilled nursing (SN) services for an undetermined frequency for pain management and comfort measures. a) The agency failed to ensure visit disciplines and frequencies were included on the patient's plan of care (POC). Review of the clinical record for Patient #1 revealed the SN performed an initial comprehensive assessment and Patient #1 was admitted to hospice care and services on 5/17/21. Review of the POC's dated 8/15/21 to 11/12/21, 11/13/21 to 1/11/22, and 1/12/22 to 3/12/22 revealed no orders for which disciplines were expected to provide cares, and how often those cares would be provided. Review of the interdisciplinary group (IDG) notes dated 11/17/21 to 1/11/22 revealed documentation of visit frequencies as; "for the next 2 weeks: SN 4." It was unclear whether this frequency was four times a day or four times a week for the next two weeks. 2. The clinical record for Patient #3 was reviewed on 2/1/22. The patient was admitted to hospice care and services on 6/23/21, with a terminal diagnosis of chronic obstructive pulmonary disease. The plan of care (POC) for the certification period dated 6/23/21 to 8/21/21 included orders for skilled nursing (SN) services for an undetermined frequency for pain management and comfort measures. a) The agency failed to ensure visit disciplines and frequencies were included on the patient's plan of care (POC). Review of the clinical record for Patient #3 revealed the SN performed an initial comprehensive assessment and Patient #3 was admitted to hospice care and services on 6/23/21. Review of the POC's dated 6/23/21 to 8/21/21 revealed no orders for which disciplines were expected to provide cares, and how often those cares would be provided. 3. The clinical record for Patient #4 was reviewed on 2/1/22. The patient was admitted to hospice care and services on 7/26/21, with a terminal diagnosis of Alzheimer's disease. The plan of care (POC) for the certification period dated 7/26/21 to 10/23/21 included orders for skilled nursing (SN) services for an undetermined frequency for pain management and comfort measures. a) The agency failed to ensure visit disciplines and frequencies were included on the patient's plan of care (POC). Review of the clinical record for Patient #4 revealed the SN performed an initial comprehensive assessment and Patient #3 was admitted to hospice care and services on 7/26/21. Review of the POC's dated 7/26/21 to 10/23/21 revealed no orders for which disciplines were expected to provide cares, and how often those cares would be provided. Similar findings of failure to ensure visit disciplines and frequencies were included on the POC were found for Patients #2, #5, #6, #7, #8, #9, #10, and #11. During an interview on 1/31/22 at 12:15 p.m., the agency administrator stated the POC contained patient demographics, goals and treatments, medications, durable medical equipment, the disciplines providing care, and the frequencies of visits. During an interview on 2/1/22 at 8:38 a.m., the Director of Nursing (DON) stated the frequencies were listed on the IDG meeting documentation, but was not on the POC. She further stated she did not realize the frequencies were missing from the POCs, but they were in the IDG notes so the staff did know when to go out.

Based on interview and record review the hospice failed to provide all core services. Specifically, the hospice failed to provide spiritual care services consistent with acceptable standards of practice. 1. During an interview on 2/2/22 at 8:47 a.m., the agency administrator (Employee #1) stated the agency currently did not have a chaplain (CH) as the previous chaplain was terminated in January 2022. She further stated that while the CH was employed by the agency she could not get the him to engage with interdisciplinary group meetings, or perform the initial spiritual care assessments required on admission to hospice care and services. Employee #1 further stated the CH would take sabbatical leave and vacation time and would leave the agency with no spiritual care services during these times. a) The agency failed to provide spiritual care services consistent with acceptable standards of practice. Review of the IDG meeting sign-in sheets for the meetings dated 12/2/20 through 1/11/22, for Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 revealed no signatures from the CH as being in attendance in the IDG meetings. Review of the clinical records for Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 revealed the skilled nurse (SN) performing the initial comprehensive assessments. Further review of the clinical records revealed no evidence the CH had completed any initial spiritual care assessments with the patients and had not followed up with spiritual care concerns for the patients who were admitted to hospice care and services. 2. During an interview on 1/31/22 at 12:15 p.m., the administrator stated the IDG was comprised of herself, the hospice medical director (HMD), back up medical director, director of nursing (DON), medical social worker (MSW), operations supervisor, and the chaplain (CH). She stated the agency was under the impression that if patients declined CH services the CH did not have to attend the IDG meetings every 15 days. She further stated the agency had hired a new CH who was currently going through the agency orientation process and would be trained on the responsibilities of the CH in the IDG process.

Based on interview and record review, the hospice failed to ensure the patient record included the patient plan of care in 2 of 11 records reviewed (Patients #2 and #9). Findings include: 1. The clinical record for Patient #2 was reviewed on 1/31/22. The patient was admitted to hospice care and services on 11/23/20, with a terminal diagnosis of coronary artery disease. The plan of care (POC) for the certification period dated 11/17/20 to 2/17/21 was missing from the patient record. a) The hospice failed to ensure the patient record included a patient plan of care. Review of the clinical record for Patient #2 revealed the SN performed an initial comprehensive assessment and the patient was admitted to hospice services on 11/23/20. Further review of the clinical record revealed no evidence of a plan of care in Patient #2's record for the three months the patient was on hospice services. 2. The clinical record for Patient #9 was reviewed on 2/2/22. The patient was admitted to hospice care and services on 5/13/21, with a terminal diagnosis of prostate cancer. The plan of care (POC) for the certification period dated 5/13/21 to 8/12/21 was missing from the patient record. a) The hospice failed to ensure the patient record included a patient plan of care. Review of the clinical record for Patient #9 revealed the SN performed an initial comprehensive assessment and the patient was admitted to hospice services on 5/13/21. Further review of the clinical record revealed no evidence of a plan of care in Patient #9's record for the three months the patient was on hospice services. During an interview on 2/1/22 at 8:38 a.m., the agency Director of Nursing (DON) stated the agency had had issues in the past with the electronic medical record (EMR) software not generating POC orders when the initial comprehensive assessment was documented. She stated she recently had begun doing chart audits and that was when she found some of the clinical records were missing their POC's. She further stated there had been an issue with staff not knowing the EMR system well.