Every finding on record at S. and M. S. LLC

Based on record review and interview the agency failed to provide hospice aide services as ordered in the plan of care for 2 of 14 patients (Pt #6 & #14) records were reviewed for patients that received HHA services.Failure to follow the Plan of Care (POC) caused these patients to not receive care as ordered by the physician. --- Findings Included: Review of the clinical record for Pt #6 revealed a start of care date of 07/01/2024 with a terminal diagnosis of Cerebrovascular Disease. This disease affects blood flow to the brain and places the individual at high risk for stroke. Review of the POC for the certification period 02/26/2025 – 04/26/2025 included order: Orders/Treatments: HHA Effective 02/26/2025 3WK1 (3 times per week for 1 week), 5Wk8 (5 times per week for 8 weeks). Review of visit notes revealed 4 HHA visits were conducted during the week of 03/16/2025-03/22/2025. Surveyor conducted an interview on 04/29/2025 at 2:10 PM with the A/SN and RVPCC. The clinical record for Pt #6 was reviewed. Surveyor requested documentation of HHA visits or missed visits for review for the week of 03/16/2025 – 03/22/2025. RVPCC stated, “The HHA visit scheduled on 03/20/2025 as not completed, and a missed visit note was not written.”   Review of the clinical record for Pt #14 revealed a start of care date of 12/05/2024 with a diagnosis of Senile Degeneration of the brain. This disease affects memory, communication, and mobility. Review of the POC for the certification period 12/05/2024 – 01/05/2025 included order: HHA 1WK1 (1 time per week for 1 week), 5WK12 (5 times per week for 12 weeks), 2WK1 (2 times per week for 1 week). Review of HHA visit notes revealed visits were not conducted 5 times per week during the weeks of 12/22/2024 - 02/28/2024 and 12/29/2024 - 01/04/2025. 04/30/2025 at 4:40 PM- During an interview with A/SN the clinical record for Pt #14 was reviewed. Surveyor requested to review documentation of visits or missed visit documentation for HHA visits during the weeks of 12/22/2024-12/28/2024 and 12/29/2024-01/04/2024. A/SN stated, “They were holiday weeks.” A/SN acknowledged HHA services were provided 4 times per week and not 5 times per week in accordance with the plan of care.Review of the agency’s policy and procedure manual revealed a policy titled, “Implementing Care and Treatment, PC.35 Reviewed: 090124”, which read “Purpose: To ensure patient care and treatment are provided as identified in the care planning process. Policy: The hospice designates a qualified registered nurse (RN), who is a member of the interdisciplinary Group/Team (IDG/IDT) who will provide coordination of care and to ensure the implementation of the Interdisciplinary Group/Team Plan of Care (POC) for each patient and family, including but not limited to the principles of the care to be provided”.

Based on record review and interviews the agency failed to ensure clinical records included documentation of missed HHA visits for 2 of 14 patients (Pt #6 and #14) records were reviewed for patients that received HHA services.Failure to ensure client records were completely and accurately documented, caused valuable client information to not be available to the IDT so that they could make informed decisions regarding care and services for these patients. --- Findings Included:Review of the clinical record for Pt #6 revealed a start of care date of 07/01/2024 with a terminal diagnosis of Cerebrovascular Disease. This disease affects blood flow to the brain and places the individual at high risk for stroke. Review of the POC (plan of care) for the certification period 02/26/2025 – 04/26/2025 included order: Orders/Treatments: HHA Effective 02/26/2025 3WK1 (3 times per week for 1 week), 5Wk8 (5 times per week for 8 weeks). Review of visit notes revealed HHA visits were not conducted 5 times during the week of 03/16/2025-03/22/2025. There was no documentation of a HHA missed visit during the week of 03/16/2025 – 03/22/2025. Surveyor conducted an interview on 04/29/2025 at 2:10 PM with the A/SN and RVP. The clinical record for Pt #6 was reviewed. Surveyor requested documentation of HHA visits or missed visits for review during the week of 03/16/2025 – 03/22/2025. RVP stated, “The HHA visit scheduled on 03/20/2025 was not completed, and a missed visit note was not written.” Review of the clinical record for Pt #14 revealed a start of care date of 12/05/2024 with a diagnosis of Senile Degeneration of the brain. This disease affects memory, communication, and mobility. Review of the POC for the certification period 12/05/2024 – 01/05/2025 included order: HHA 1WK1 (1 time per week for 1 week), 5WK12 (5 times per week for 12 weeks), 2WK1 (2 times per week for 1 week). Review of HHA visit notes revealed visits were not conducted 5 times per week during the weeks of 12/22/2024 - 02/28/2024 and 12/29/2024 - 01/04/2025 and missed visits were not documented. 04/30/2025 at 4:40 PM- During an interview with A/SN the clinical record for Pt #14 was reviewed. Surveyor requested to review documentation of visits or missed visit documentation for HHA visits during the weeks of 12/22/2024-12/28/2024 and 12/29/2024-01/04/2024. A/SN stated, “They were holiday weeks.” A/SN acknowledged HHA services were provided 4 times per week and not 5 times per week in accordance with the plan of care and HHA missed visits were not documented as required in the clinical record. Surveyor asked who is responsible for inputting missed visit notes. A/SN stated the employee who missed the visit should have documented it. Review of the agency’s policy and procedure manual revealed a policy titled, “Contents of Clinical Records, Review/Revision Date: August 2023,” which read in part “The clinical record must contain correct clinical information that is available to the patient’s attending physician and hospice staff. The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes.”