Every finding on record at Oshyn Hospice & Palliative Care, LLC Dba Oshyn Hospice

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness including interventions to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. THIS IS A CONTINUING PRIOR REQUIRED ACTION. In 1 of 4 (25%) clinical records reviewed revealed the hospice did not ensure the written plan of care reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 3: The patient’s benefit election was dated 11/29/2023. The RN initial assessment was dated 11/30/2023. The RN initial assessment on 11/30/2023 identified the patient's pain level at 7 on a scale of 1-10. The initial plan of care dated 11/30/2023 lacked goals and intervention(s) for pain. The Clinical Services Director who reviewed records with this site visitor on 12/11/2023 confirmed this finding. THIS IS A CONTINUING PRIOR REQUIRED ACTION. In 1 of 4 (25%) clinical records reviewed revealed the hospice did not ensure the written plan of care reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. THIS IS A CONTINUING PRIOR REQUIRED ACTION. In 1 of 4 (25%) clinical records reviewed revealed the hospice did not ensure a physician order was obtained for care and services to be provided to hospice patients. Clinical Record 5: The patient’s benefit election was dated 11/30/23. The RN initial assessment documented that the patient was using oxygen at 2 liters per minute via nasal cannula. Oxygen was listed on medication profile. The record lacked evidence of a physician order for oxygen. The Clinical Services Director who reviewed records with this site visitor on 12/11/2023 confirmed this finding. THIS IS A CONTINUING PRIOR REQUIRED ACTION. In 1 of 4 (25%) clinical records reviewed revealed the hospice did not ensure a physician order was obtained for care and services to be provided to hospice patients.

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. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 5 (20%) clinical records reviewed revealed the agency did not ensure an initial bereavement assessment was completed as part of the comprehensive assessment. THIS IS A CONTINUED REQUIRED ACTION. Document 1: The policy #H:2-046, "Comprehensive Assessment (Revised: 4/2013)," stated in part, "Procedure: During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least the following information, as relevant: W. A bereavement assessment of the needs of the patient's family and other individuals focusing on: 1. The nature of the relationship to the patient; 2. Circumstances surrounding the illness/prognosis; 3. Behaviors prior to and after the illness/prognosis; 4. Survivor needs (social, spiritual and cultural) that may impact coping skills; and, 5. Potential for pathological grief reactions." Clinical Record 5: The patient elected the hospice benefit on 4/28/23. The record lacked evidence of a completed initial bereavement assessment as part of the comprehensive assessment. Upon interview on 11/2/23, the Director of Nursing and the Office Manager reviewed and agreed the agency did not ensure an initial bereavement assessment was completed as part of the comprehensive assessment.

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members provide the care and services offered by the organization. This CONDITION of Participation was not met as evidenced by document review and interview. The agency did not ensure the hospice interdisciplinary group (IDG) was composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement: Social Worker. The office manager reported that the agency's former MSW left unexpectedly 9/30/23. The agency admitted the two current active patients to service on 10/6/23 and 10/24/23 respectively. Both the Office Manager and the DON reported multiple recruitment efforts have been ongoing since beginning of October 2023. "We have contacted MSWs working at other agencies in the area; posted the open position and notified a social worker staffing agency." Upon questioning the DON regarding the 2 current patients that had refused social work, she stated, "I have covered the nursing psychosocial assessment, and intervened with psychosocial support within my scope of practice." The cumulative effect of this issue resulted in the inability of the hospice to ensure safe, quality patient care. This is a CMS CONDITION LEVEL DEFICIENCY at CFR 418.56 The agency did not ensure the hospice interdisciplinary group (IDG) included individuals who are qualified and competent to practice in the professional role: Social Worker.

is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 5 (20%) clinical records reviewed revealed the agency did not ensure the written plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Document 5: The policy #H:2-030, "The Plan of Care (Revised: 4/2013)," stated in part, "Policy: The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments . . . This plan will focus on identified problems, goals, and interventions." Clinical Record 1: The patient elected the hospice benefit on 10/6/23. The interdisciplinary group (IDG) Comprehensive Assessment Details dated 10/27/23 stated, "Caregiver report pt is developing a sore on her bottom and caregiver requests wound care. RN will assess wound on 10/27 and develop a POC." The IDG POC dated 10/27/23 lacked a goal and intervention(s) for wound care for the patient "bottom". Upon interview on 11/2/23, the Director of Nursing and the Office Manager reviewed and agreed the agency did not ensure the IDG POC included a goal and intervention(s) for wound care for the patient "bottom".

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 5 (20%) clinical records reviewed revealed the agency did not ensure a physician order was obtained for care and services to be provided to hospice patients. Document 3: The policy #H:2-032, "Verification of Physician Orders (Revised: 4/2013)," stated in part, "Policy: Orders will be obtained from a licensed physician (or other authorized independent practitioner) for care and services to be provided to hospice patients." Clinical Record 1: The patient elected the hospice benefit on 10/6/23. The Registered Nurse (RN) visit note dated 10/31/23 stated, "Observed increased redness on curvature of pt's spine. Placed a foam dressing over the redness to protect from opening... Provided 2 dressings since learning pt's shower day is this afternoon after applying new dressing." The record lacked evidence of a physician order for the wound care for the spine. Upon interview on 11/2/23, the Director of Nursing and the Office Manager reviewed and agreed the agency did not ensure a physician order was obtained for the wound care to be provided to the patient's spine.

It is required that the hospice Interdisciplinary Group, completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by a review of clinical records. 4 of 11 (36%) clinical records reviewed revealed the agency did not ensure all initial comprehensive assessments were completed within the first five days of election of hospice care. Clinical Record 1: The patient elected the Hospice Benefit on 7/28/22. The Chaplain and Social Worker made their initial comprehensive assessment visit on 8/30/22. Clinical Record 3: The patient elected the Hospice Benefit on 8/18/22. The Chaplain and Social Worker made their initial comprehensive assessment phone calls on 8/30/22. Clinical Record 5: The patient elected the Hospice Benefit on 11/28/22. No initial comprehensive bereavement or spiritual assessment was completed until 12/18/22 during a phone call with the daughter by the chaplain. Clinical Record 11: The patient elected the Hospice Benefit on 7/21/22. No initial comprehensive bereavement, psycho-social, or spiritual assessment was completed. The initial Social Worker assessment was completed on 7/31/22. The initial Chaplain assessment visit was completed on 8/31/22.

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 a review of clinical records. 4 of 11 (36%) clinical records reviewed revealed that an initial bereavement assessment was not completed as part of the initial comprehensive assessment. Clinical Record 1: The patient was admitted to Hospice services on 7/28/22. The initial bereavement assessment was not completed until 8/30/22 which was 32 days after the start of care (SOC) initial comprehensive assessment. Clinical Record 3: The patient was admitted to Hospice services on 8/18/22. The initial bereavement assessment was not completed until 8/30/22 which was 12 days after the SOC initial comprehensive assessment. Clinical Record 5: The patient was admitted to Hospice services on 11/28/22. The initial bereavement assessment was not completed until 12/18/22 which was 20 days after the SOC initial comprehensive assessment. Clinical Record 11: The patient was admitted to Hospice services on 7/21/22. The initial bereavement assessment was not completed until 8/31/22 which was 41 days after SOC initial comprehensive assessment.

It is required that the hospice designates an Interdisciplinary Group who, in consultation with the patient's attending physician, prepares a written plan of care (POC) for each patient. This standard was not met as evidenced by a review of clinical records. 2 of 11 (18%) records reviewed revealed that the agency did not ensure each patient had a written POC that specified the hospice care and services necessary to meet the specific needs of the patient and family. Clinical Record 4: The patient's attending physician ordered Volunteer Services on 3/4/22 with a visit frequency of 1 x per month. The Volunteer provided visits on 3/4/22, 4/22/22, 5/23/22, 6/27/22, and 7/2/22. The Volunteer Coordinator did not identify problems, goals and interventions and did not prepare a written POC. Clinical Record 5: In the skilled nursing (SN) visit note on 11/29/22, the RN documented in part, "There is a rash in the groin and patient is using Nystatin powder." The RN did not prepare a written POC with problems, goals, and interventions to address skin integrity and treatment of the rash. In the SN visit note on 12/6/22, the nurse documented in part, “The patient received Ativan for anxiety that was effective.” In the same SN visit note on 12/6/22, the nurse documented in part, “The patient has abdominal pain, and the morphine was effective in relieving the pain.” Three different pain medications were included on the medication profile and were available to the patient. The RN did not prepare a written POC with problems, goals and interventions to address the patient’s anxiety and pain.

It is required that if a patient is discharged from hospice, the hospice forwards to the patient’s attending physician, a copy of the hospice discharge summary. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 3 (33%) records reviewed revealed the agency did not ensure that a discharge summary was sent to the attending physician upon discharge of the patient from hospice services. Clinical Record 1: The patient was discharged from Hospice services on 11/30/22. There is a computer-generated discharge summary, however, the nurse documented that the attending physician was not notified of the discharge. In an interview with the Team Assistant during joint clinical record review, the Team Assistant confirmed that the discharge summary was not sent to the attending physician.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement; This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) clinical records reviewed revealed the hospice did not ensure the hospice election statement documented the date of the patient signature. Record #32336 was reviewed and identified the patient signed the hospice election statement. The hospice election statement did not contain the date of the patient signature. The Office Manager was interviewed on 12/7/2021 and verified no date was associated with the patient's signature. No additional information was provided by the agency that changed the finding.