Every finding on record at My Own Hospice, LLC

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address the development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment, the documented discussion of the plan provided to the patient/family, and maintained by the hospice. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 19 (26%) clinical records reviewed revealed the agency did not ensure that each clinical record included documentation of a patient-specific emergency plan and communication of that plan as part of the initial comprehensive assessment. Document 1: The hospice's policy "Emergency Operation Plan," last revised 06/2024, included in part that "...Mitigation activities ... include ... The plans for patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive assessment ... Assisting patients and families to develop a home emergency plan. Educating patients and families about self-care, sources of alternative care in the community and (agency's) role during an emergency ..." Clinical Record 1: The patient elected the hospice benefit on 05/17/2024. The initial plan of care from 05/17/2024 to 07/22/2024 was reviewed. The comprehensive assessment completed on 05/17/2024 did not include documentation that an individual emergency plan was developed, documented, or discussed with the patient/family/caregivers as part of the comprehensive assessment. Clinical Record 3: The patient elected the hospice benefit on 05/20/2024. The initial plan of care from 05/20/2024 to 08/17/2024 was reviewed. The comprehensive assessment completed on 05/20/2024 did not include documentation that an individual emergency plan was developed, documented, or discussed with the patient/family/caregivers as part of the comprehensive assessment. Clinical Record 5: The patient elected the hospice benefit on 05/27/2024. The initial plan of care from 05/27/2024 to 08/24/2024 was reviewed. The comprehensive assessment completed on 05/27/2024 did not include documentation that an individual emergency plan was developed, documented, or discussed with the patient/family/caregivers as part of the comprehensive assessment. Clinical Record 6: The patient elected the hospice benefit on 07/19/2023. The initial plan of care from 07/19/2023 to 09/16/2023 was reviewed. The comprehensive assessment completed on 07/19/2023 did not include documentation that an individual emergency plan was developed, documented, or discussed with the patient/family/caregivers as part of the comprehensive assessment. Clinical Record 18: The patient elected the hospice benefit on 05/20/2024. The initial plan of care from 05/20/2024 to 08/17/2024 was reviewed. The comprehensive assessment completed on 05/20/2024 did not include documentation that an individual emergency plan was developed, documented, or discussed with the patient/family/caregivers as part of the comprehensive assessment. Personnel Record 1: During joint clinical record review and interview with the Director of Nursing (Personnel Record 1) on 09/12/2024, she confirmed that the emergency plan assessment had not been completed for clinical records one, three, five, six, and eighteen.

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, document review and interview. In 3 of 19 (16%) clinical records reviewed revealed the agency did not ensure that the interdisciplinary group completed the initial comprehensive assessment within five calendar days after the patient was admitted into hospice care. Document 1: The hospice's policy "Initial Assessment/Comprehensive Assessment" (Policy No. URS-0031), with the latest revision date of 05/2023, read, in part, "...Each patient will receive a comprehensive assessment... The Hospice IDG (interdisciplinary group) ... must complete the comprehensive assessment no later than 5 calendar days after patient's election of hospice care..." Clinical Record 1: The patient elected the hospice benefit on 05/17/2024. The Initial Social Work Assessment was not performed until 06/12/2024, twenty-six days after admission. There was no documented evidence as to why the initial visit was delayed past the initial five-day comprehensive requirement. Clinical Record 13: The patient elected the hospice benefit on 01/22/2024. The initial Social Work Assessment was not completed until 01/29/2024, seven days after admission and past the initial five-day comprehensive assessment requirement. A note was documented by the social worker on 01/25/2024 that a call was placed to the patient's spouse and son, and a voicemail was left, but there was no further documentation of an attempt to visit until 01/29/2024. Clinical Record 14: The patient elected the hospice benefit on 12/22/2023. The Initial Social Work Assessment was not completed until 01/03/2024, twelve days after admission, and the initial Spiritual Assessment was not performed until 01/05/2024, fourteen days after admission. There was no documented evidence as to why both initial psychosocial and spiritual assessments were delayed past the initial five-day comprehensive assessment requirement. During a joint clinical record review and interview with the Director of Nursing (Personnel Record 1) on 09/12/2024, she confirmed that the initial visits were late and could not locate any documentation that the family requested a delay in the initial visits.

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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 8 of 19 (42%) clinical records reviewed revealed the agency did not ensure that an initial bereavement risk assessment was documented as part of the comprehensive assessment. Document 1: The hospice's policy "Initial Assessment/Comprehensive Assessment" (Policy No. URS-0031) with the latest revision date of 05/2023 read in part that "...Each patient will receive a comprehensive assessment... The comprehensive assessment will take into consideration the following factors ... An initial bereavement risk 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. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care. The assessment should include but is not limited to: history of previous losses, family problems, financial concerns, communication issues, drug and alcohol abuse, health concerns, legal and financial concerns, mental health issues, presence or absence of support system, feelings of despair, anger, guilt, or abandonment. The Hospice IDG ... must complete the comprehensive assessment no later than 5 calendar days after patient's election of hospice care..." Clinical Record 3: The patient elected the hospice benefit on 05/20/2024. The plan of care from 05/20/2024 to 08/17/2024 was reviewed. Neither the Initial Nursing Assessment on 05/20/2024, the Initial Spiritual Assessment dated 05/21/2024, nor the Initial Social Work Assessment documented on 05/21/2024 identified any assessment of the bereavement risks. Clinical Record 5: The patient elected the hospice benefit on 05/27/2024. The plan of care from 05/27/2024 to 08/24/2024 was reviewed. Neither the Initial Nursing Assessment on 05/27/2024, the Initial Spiritual Assessment dated 05/29/2024, nor the Initial Social Work Assessment documented on 05/30/2024 identified any assessment of the bereavement risks. Clinical Record 6: The patient elected the hospice on 07/19/2023. The plan of care from 07/19/2023 to 09/16/2023 was reviewed. Neither the Initial Nursing Assessment on 07/19/2023, the Initial Spiritual Assessment dated 07/20/2023, nor the Initial Social Work Assessment documented on 07/21/2023 identified any assessment of the bereavement risks. Clinical Record 12: The patient elected the hospice benefit on 02/16/2023. The plan of care from 02/16/2023 to 04/16/2023 was reviewed. Neither the initial Nursing Assessment on 02/16/2023, the initial Spiritual Assessment on 02/17/2023, nor the initial Social Work Assessment on 02/20/2023 included an assessment or identification of any bereavement risks. Clinical Record 13: The patient elected the hospice benefit on 07/15/2024. The plan of care from 07/15/2024 to 09/12/2024 was reviewed. Neither the initial Nursing Assessment on 07/15/2024, the initial Social Work Assessment on 07/17/2024, nor the initial Spiritual Assessment on 07/23/2024 included an assessment or identification of any bereavement risks. Clinical Record 14: The patient elected the hospice benefit on 12/22/2023. The plan of care from 12/22/2023 to 03/20/2024 was reviewed. The Initial Bereavement Risk Assessment was documented in the initial Social Work Assessment on 01/03/2024, twelve days after admission and after the initial five-day comprehensive assessment requirement. Clinical Record 16: The patient elected the hospice on 07/19/2024. The plan of care from 07/19/2024 to 09/16/2024 was reviewed. Neither the initial Nursing Assessment on 07/19/2024, the initial Social Work Assessment on 07/24/2024, nor the initial Spiritual Assessment on 07/24/2024 included an assessment or identification of any bereavement risks. Clinical Record 18: The patient elected the hospice benefit on 05/20/2024. The plan of care from 05/20/2024 to 08/17/2024 was reviewed. Neither the initial Nursing Assessment on 05/20/2024, the initial Spiritual Assessment on 05/23/2024, nor the initial Social Work Assessment on 05/24/2024 included an assessment or identification of any bereavement risks. During a joint clinical record review and interview with the Director of Nursing (DON)(Personnel Record 1) on 09/11/2024, it was confirmed that in the present electronic medical record (EMR) system, the bereavement risk assessment is located on the social worker's initial assessment visit only. If social services are declined, the registered nurse is to complete the bereavement risk assessment on a paper form to be scanned into the clinical record. The agency is in the process of migrating to a different EMR.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services. This standard was not met as evidenced by document review, interview and personnel record review. In 2 of 8 (25%) applicable personnel records reviewed, in which the staff member provided direct care to patients, revealed that the agency did not ensure documentation of competency per the agency policy for all personnel providing care. Document 1: The agency policy with the latest revision date of 12/2021 and entitled "Competencies" (Policy No. HR-C007) included in the part that "... Patient care staff will be competency assessed at defined intervals... For each new employee during orientation... At least every calendar year for all patient care staff..." Personnel Record 5: The Registered Nurse (RN) hired on 05/03/2021 had an Initial Registered Nurse Competency form completed on 05/11/2021 and an Annual Registered Nurse Competencies form completed on 01/03/2023 and 01/22/2024 but was missing a documented competency for 2022. Personnel Record 11: The Social Worker hired on 08/19/2024 did not have an initial Social Worker (SW) Competency Form completed in their personnel file. During a joint personnel record review and interview with the Administrator/Human Resource Director (Personnel Record 2) on 09/12/2024, it was confirmed that the personnel files for the social worker (Personnel Record 11) and the registered nurse (Personnel Record 5) were each missing a documented competency form.