Every finding on record at Pdsf Hospice & Palliative Care Inc

Based on record review and interview the agency failed to maintain a system of communication and integration in accordance with its policies to ensure that patient care coordination was documented in the patient records for 4 (#2, #3, #5, #6) of 5 active patient records reviewed; the patient records did not contain documentation that coordination occurred with the physician, social worker, chaplain, and hospice aide at the interdisciplinary group meetings.    The failure placed the patients at risk that miscommunication could result in a negative outcome or poor symptom management. --- Review of the agency's policy titled "Coordination of Care," labeled PC.110, and last reviewed on 9/1/2024 read in part; "Purpose To ensure coordination of all care provided for patients receiving hospice services and/or services from other providers. Policy I. The Hospice will develop and maintain s system of communication and integration in accordance with the Hospice's own policies and procedures to...D Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement...Procedure VI. All communications and coordination of care is documented in the clinical record."   Review of the agency's policy titled "Interdisciplinary Group Roles and Responsibilities," labeled PC.40, and last reviewed on 9/1/2024 read in part; "Purpose To identify the roles and responsibility of the Interdisciplinary Group/Team (IDG/IDT). Policy I. The Hospice will designate an IDG/IDT, who, in consultation with the patient's attending physician, will work together to provide for the physical, medical, psychosocial, emotional, and spiritual needs of the terminally ill patient and/or family members as delineated in a patient specific Plan of Care (POC). II. The IDG/IDT must include...A. A Doctor of Medicine or Osteopathy (who is an employee or under contract with the hospice); B. A Registered Nurse; C. A Social Worker/Marriage Family Therapist or Mental Health Counselor; D. A pastoral or other counselor...Procedure...VII. The IDG/IDT meetings will be held during the course of patient care to monitor and evaluate the patient's interdisciplinary POC progress, at least every 15 days...XI. Formal communication regarding the patient's POC is documented at the IDG/IDT meeting ensuring care and services are provided in accordance with the POC. A. Informal and written communication demonstrating coordination of care among all staff members and other providing care is also documented in the medical record..."   The surveyor was given documents titled "IDT sign-in sheet" for the Interdisciplinary Group Meetings that occurred between 9/4/2024 through 11/27/2024. The sign in sheets indicated that a physician, registered nurse, social worker, chaplain, and home health aide were present at each of the interdisciplinary group meetings.   Patient #2: Record review of Patient #2's clinical record revealed an Initial Plan of Care dated 6/14/2024. The Plan of Care indicated that Patient #2 was admitted to the agency's service on 6/14/2024. The Plan of Care listed Hypertensive Heart Disease without Heart Failure (medical condition of the heart being affected by high blood pressure over a long period of time) as the terminal diagnosis.    Record review of Patient #2's record indicated that an interdisciplinary group meeting occurred on 9/4/2024, 9/11/2024, 9/25/2024, 10/9/2024, 10/23/20204, 11/6/2024, 11/13/2024, and 11/27/2024. The hospice failed to document in the patient record that coordination occurred with the physician, social worker, chaplain, and hospice aide at the interdisciplinary group meetings.    Patient #3: Record review of Patient #3's patient record contained an Interdisciplinary Group Meeting Comprehensive Assessment that was dated 11/27/2024. The Comprehensive Assessment indicated that Patient #3 was admitted to service on 11/5/2024. The Comprehensive Assessment indicated Chronic Diastolic Heart Failure (condition in which the heart's main pumping chamber, left ventricle, becomes stiff and unable to fill properly) as the terminal diagnosis.   Record review of Patient #3's record indicated that an interdisciplinary group meeting occurred on 11/6/2024, 11/13/2024, and 11/27/2024. The hospice failed to document in the patient record that coordination occurred with the physician, social worker, chaplain, and hospice aide at the interdisciplinary group meetings.        Patient #5: Record review of Patient #5's patient record revealed an Initial Plan of Care dated 6/22/2024. The Plan of Care indicated that Patient #5 was admitted to the agency's service on 6/22/2024. The Plan of Care listed Protein-Calorie Malnutrition (condition when the body doesn't get enough protein, calories, and other nutrients, ranging from starvation to semistarvation) as the terminal diagnosis.    Record review of Patient #5's patient record indicated that an interdisciplinary group meeting occurred on 9/11/2024, 9/25/2024, 10/9/2024, 10/23/2024, 11/6/2024, 11/13/2024, and 11/27/2024. The hospice failed to document in the patient record that coordination occurred with the physician, social worker, chaplain, and hospice aide at the interdisciplinary group meetings.    Patient #6: Record review of Patient #6's patient record revealed an Initial Plan of Care dated 11/18/2024. The Plan of Care indicated that Patient #6 was admitted to the agency's services on 11/18/2024. The Plan of Care listed Heart Failure Heart failure (condition developed when the heart doesn't pump enough blood for the body's needs) as the terminal diagnosis.    Record review of Patient #6's record indicated that an interdisciplinary group meeting occurred on 11/20/204 and 11/27/2024. The hospice failed to document in the Patient record that coordination occurred with the physician, social worker, chaplain, and hospice aide at the interdisciplinary group meetings.    During an interview on 12/5/2024 at 12:12 p.m. with the Alternate Administrator/Supervising Nurse/Registered Nurse C, the surveyor discussed that the patient records did not contain documentation of coordination with the physician, social worker, chaplain, and hospice aide at the interdisciplinary group meetings. The Alternate Administrator/Supervising Nurse/Registered Nurse C stated, "I am responsible. I thought the paper one (sign in sheet) was good enough." The surveyor asked were the sign in sheets included in the Patient records. The Alternate Administrator/Supervising Nurse stated, "No, they were not uploaded into the patient records."

It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. This standard was not met as evidenced by clinical record review, policy review and interview. In 2 of 5 (40%) clinical records reviewed it was revealed the hospice did not include all areas of a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services Record #59660: The patient elected hospice care on 11/4/2021. The clinical record stated that the patient requires seizure precautions. The medication profile included Keppra and Gabapentin. There was no diagnosis of Seizure Disorder in the clinical record and Seizure precautions were not included in the initial POC. Record #61460: The patient elected hospice care on 11/8/2021. There was no documented evidence a bowel assessment was completed that included bowel sounds on the initial comprehensive assessment. There was also no documented evidence of completion of a safety/fall risk assessment. The Director of Nursing confirmed this finding on 11/18/21 and stated, "that the initial comprehensive assessment did not contain all of the required elements".

It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s: Well-being; Comfort and Dignity throughout the dying process. This standard was not met as evidenced by clinical record review, policy review and interview. In 1 of 5 (20%) clinical records reviewed it was revealed that the comprehensive assessment did not identify the /spiritual needs of the patient. Record #61460: the patient elected hospice care on 11/8/21. Initial IDG on 11/8/21 indicated that Chaplain services declined; however, the POC on 11/8 and 11/15 indicated "Spiritual Need Interventions: Spiritual needs of the patient and caregiver; current clergy support a need for a spiritual counselor to provide spiritual support. There was no documented evidence that an initial assessment was completed to address spiritual needs. The Director of Nursing was interviewed on 11/17/21 and confirmed that there was “a need to clearly identify services and frequencies for all discipline.”

It is required that each patient’s individualized written plan of care 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 the following: Drugs and treatment necessary to meet the needs of the patient; the documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by clinical record review, observation and interview. In 1 of 5 (20%) clinical records reviewed it was revealed that all drugs/biologicals the patient was currently taking were not included were not included on the plan of care. Record #44081: The patient elected hospice care on 11/12/21. The plan of care did not include all medications that were being administered to the patient. During the home visit on 11/17/21, it was identified that there were 3 medications in the home that did not appear on the plan of care: Prednisone 5mg po q day; Alprazolam 1mg po every 4 hours PRN; and Levocitrizine 5mg po qhs. Lorazepam 1mg po q4 hours PRN was found on the drug profile but was not present in the patient home. The Director of Nursing was interviewed on 11/18/21 and confirmed that all current medications were not included in the plans of care.