Every finding on record at Mi Casa Hospice, LLC

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed revealed that the hospice did not ensure the implementation of the interdisciplinary plan of care or services followed the individualized plan of care established by the hospice IDG. Clinical Record 4: The hospice election of benefit was on 12/06/2023. The plan of care (POC) dated 12/06/2023 included an order for Chaplain (CH) services 1-2 times monthly. A review of the clinical record revealed the CH had not made any visits for December 2023 for January as of January 24, 2024. Interview with the Director of Nursing on 01/26/2024 agreed that the chaplain had not made visits as ordered by the interdisciplinary group. Clinical Record 6: The hospice election of benefit was on 01/19/2023. The POC dated 01/19/2023, and the POC updated orders dated 04/19/2023, and 06/18/2023 included an order for CH services 1-2 times monthly. A review of the clinical record revealed there was no documented evidence of chaplain visits made for April, June, and July 2023. During an interview with the DON, she agreed the visits were not made and that this was an error on the plan of care order. The DON further stated that the chaplain services should have been discontinued per the patient's request. Clinical Record 9: The hospice election of benefit was on 09/17/2023. The POC dated 09/17/2023 included an order for CH services 1-4 times a month. The chaplain documented a missed visit dated 09/18/2023 due to no answer to the phone or door. There was no additional documentation of attempts to visit the patient/family. The patient revoked their hospice election benefit on 09/29/2023. During the interview with DON on 01/26/24, she agreed chaplain should have made further attempts to visit. Clinical Record 11: The hospice election of benefit was on 02/24/2023. The POC dated 02/24/2023 and the updated POC dated 03/30/2023, 04/20/2023, and 05/09/2023included an order for CH services 1-4 x month. There was no documented evidence of CH visits until 05/09/23. During the interview with the DON on 1/26/24, she agreed notes were not documented in the EMR but stated the chaplain had made visits to the patient each month.