Every finding on record at Mesun Health Services, Inc

Based on staff interviews and the review of emergency preparedness (EP) policies, procedures, and agency EP documents, it was determined that the agency failed to comply with all applicable Federal, State and local EP requirements by not testing the EP program to include the required number of exercises/events annually followed by an analysis and documentation of the agency's response with revision to the EP program as needed. Findings include: --- Review of the agency Emergency Preparedness (EP) document and EP policies and procedures lacked documentation of an exercise (actual event or mocked event) performed within the last one year to meet the minimum number of exercises/events the EP regulations require. The agency failed to ensure the required number of EP exercises/events were met. An interview was conducted with the Administrator on 4/11/2023 at 1:30 p.m. at the hospice agency. During the interview, the Administrator acknowledged that no exercises were conducted within the last one year as required by the EP regulations. The hospice agency failed to produce a policy to reference that the agency must establish and test the EP program to include the required number of exercises/events annually followed by an analysis and documentation of the agency's response with revision to the EP program as needed.

Based on staff interview, record reviews, and review of policy titled ";Bereavement," the hospice agency failed to ensure that a bereavement plan of care was in place for the bereavement recipients that reflected the bereavement services and the frequency of services of two patients (P) (#7, #9) of two sampled patients. The findings include: --- Review of the policy titled ";Bereavement," Reviewed/Revised 05/2020 reveals: Policy Statement: MeSun clinical team will assess and provide or connect appropriate resource for bereavement. 1. A review of the clinical record for P#7 revealed the patients date of death was 1/14/2022. Review of the closed clinical record and bereavement documentation revealed that the record failed to include a post death bereavement assessment and bereavement plan of care and failed to include documentation of contacts with the bereaved that included mailings of cards, letter and periodic telephone calls. 2. A review of the clinical record P#9 revealed the patients date of death was 3/3/2022. Review of the closed clinical record and bereavement documentation revealed that the record failed to include a post death bereavement assessment and bereavement plan of care and failed to include documentation of contacts with the bereaved that included mailings of cards, letters and periodic telephone calls. An interview conducted at the agency on 4/11/2022 at 2:00 p.m., with the Administrator and the Director of Nursing (DON). The Administrator and the DON confirmed the clinical record failed to have documentation of a bereavement plan of care, and the bereavement policy with revision date of 5/2020 was not followed for P#7 and P#9.

Based on staff interview, record reviews, and the policy titled ";Discharge Policy" the hospice failed to ensure that a comprehensive discharge summary was completed and included in the documentation to assist in continuity of care post-discharge for four patients (P) (P#5, #6, #8, and #10,) of four patients who were discharged, transferred, or revoked the hospice benefit. The findings include: --- 1. A review of clinical record revealed P#5 admitted to hospice on 12/2/2021 with a diagnosis of cerebral vascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) and hypertension (blood pressure that is higher than normal). Review of the clinical note dated 1/2/2022 revealed the patient discharged from hospice on 1/2/2022, due to the patient was admitted to a non-contracted facility. The clinical record failed to have a comprehensive discharge summary to include a summary of P#5s stay including treatment, symptoms and pain management, the current plan of care, latest physician orders and any additional documentation to assist in post-discharge planning. 2. Review of the clinical record for P#10 revealed that patient admitted to hospice on 8/5/2021 with the diagnosis of Alzheimers disease (most common cause of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life). Review of financial payor discharge form dated 2/20/2022 revealed that P#10 discharged from hospice on 2/20/2022, due to extended prognosis. The clinical record failed to have a comprehensive discharge summary to include a summary of P#10's stay including treatment, symptoms and pain management, current plan of care, latest physician orders and any documentation to assist in post-discharge planning. 3. Review of the clinical record for P#6 revealed that patient admitted to hospice on 2/17/2021 with the diagnosis of Alzheimers disease (most common cause of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life). Review of clinical note dated 1/9/2022 revealed that P#6 discharged from hospice on 1/9/2022, due to patient seeking aggressive treatment. The clinical record failed to have a comprehensive discharge summary to include a summary of the P#10's stay including treatment, symptoms and pain management, the current plan of care, latest physician orders and any additional documentation to assist in post-discharge planning. 4. Review of the clinical record for P#8 revealed admitted to hospice on 1/15/2022 with the diagnosis of acute respiratory failure (occurs when the air sacs of the lungs cannot release enough oxygen into the blood). Review of the revocation form dated 1/20/2022 revealed P#8 discharged from the current hospice to another hospice agency. The clinical record failed to have a comprehensive discharge summary to include a summary of the P#8's stay including treatment, symptoms and pain management, the current plan of care, latest physician orders and any additional documentation to assist in post-discharge planning. An interview was conducted with the Administrator and the Director of Nursing (DON) at the agency on 4/11/23 at 2:00 p.m. The Administrator and the DON confirmed the clinical record failed to have a discharge summary that contains all information required for a comprehensive discharge assessment. The hospice agency failed to produce a discharge policy to reference that the agency must complete a comprehensive discharge summary to assist in continuity of care post-discharge for patients who discharged, transferred, or revoke the hospice benefit.