Every finding on record at Southern Pines Healthcare LLC

Based on record reviews and interviews the agency’s hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), failed to complete the comprehensive assessment for 3 (Patients 1,2, and 3) of 4 active patients’ records, no later than 5 calendar days after the election of hospice care. Failure to have all disciplines conduct initial assessments during the 5-day timeframe prevented the agency from developing a comprehensive plan of care that met all the patient’s needs, which had the potential for psychosocial, spiritual, and physical needs to be unmet by the interdisciplinary team. --- Record review of Patient 1 revealed a hospice plan of care for period 2/4/2025 to 5/4/2025 with a start of care date of 2/4/2025. The POC had MSW frequency as one visit in month 1. Records contained an initial medical social worker hospice evaluation dated 2/10/2025. Coordination notes in Patient 1’s records did not contain documentation or evidence that contact with the patient or family was made by the MSW within the 5-day timeframe. An interview was conducted with the former MSW on 4/16/2025 at 12:14pm. The surveyor asked about the agency’s policy on the timeframe for completion of the initial medical social worker hospice evaluation. The MSW stated “have to be out there within 5 days.” The surveyor shared the findings on Patient 1 and asked why the initial visit was completed after the 5-day time frame. The MSW said Patient 1’s family “didn’t want me coming out sooner, so I had to adjust my time around that.” The Surveyor asked if the communication was documented in the patient’s records. The MSW stated “I put down that I attempted to contact them. I wouldn't put it down every single time.” The surveyor asked why there was not a communication note in Patient 1’s records that a call was made. MSW stated, “I don't want to comment, but I'm not really sure why.”Record review of Patient 2 revealed a hospice plan of care for period 3/24/2025 to 6/21/2025 with a start of care date of 3/24/2025. The POC had MSW frequency as one visit in month 1. Records contained an initial medical social worker hospice evaluation dated 3/31/2025. Coordination notes in Patient 2’s records did not contain documentation or evidence that contact with the patient or family was made by the MSW within the 5-day timeframe. An interview was conducted with the former MSW on 4/16/2025 at 12:14pm. The surveyor asked about the agency’s policy on the timeframe for completion of the initial medical social worker hospice evaluation. The MSW stated “have to be out there within 5 days.” The surveyor shared the findings on Patient 2 and asked why the initial visit was completed after the 5-day time frame. The MSW said “I failed on the job” and did not document the call. Record review of Patient 3 revealed a hospice plan of care for period 2/20/2025 to 5/20/2025 with a start of care date of 2/20/2025. The POC had MSW frequency as one visit in month 1. Records contained an initial medical social worker hospice evaluation dated 2/26/2025. Coordination notes in Patient 3’s records did not contain documentation or evidence that contact with the patient or family was made by the MSW within the 5-day timeframe. An interview was conducted with the former MSW on 4/16/2025 at 12:14pm. The surveyor asked about the agency’s policy on the timeframe for completion of the initial medical social worker hospice evaluation. The MSW stated “have to be out there within 5 days.” The surveyor shared the findings on Patient 3 and asked why the initial visit was completed after the 5-day time frame. The MSW stated “I don't know what to say because I'm not sure why that didn't happen within a timely manner.”An interview was conducted with the Adm, DON and Alt DON on 4/16/2025 at 1:15pm. The surveyor shared the findings of Patients 1, 2 and 3. The surveyor asked about the agency’s policy on the timeframe for completion of the initial medical social worker hospice evaluation. The Adm stated “It needs to be within 5 days of the nursing start of care for the social worker and chaplain.” The surveyor asked why the agency’s policy was not followed. The Adm stated he was responsible for ensuring that the IDG team members completed patients’ assessments/evaluations within the 5-day time frame. The Adm said he contacted the IDG team through phone calls and text messages and notified the team of the scheduled initial patients' assessments/evaluations. The Adm stated when he followed up with the MSW with in the 5-day time frame, he was told by the MSW that the patients’ families wanted to reschedule the visits. The Adm stated the MSW told him that the phone calls were documented in the patient’s medical records. The Adm stated that once management noticed a pattern of rescheduled visits by the MSW they reviewed the patients’ records and “saw things that didn't happen.” The Adm stated the MSW “chose to leave because we knew there was an issue.” The Alt DON stated, review of patients’ records by management revealed missing documentation of phone calls by the MSW and rescheduled visits past the 5 days. The surveyor asked how the delay in the MSW’s patients’ initial evaluations could have affected patients’ outcomes. The Alt DON stated, the delay resulted in the MSW’s inability to contribute to the development of the patients’ comprehensive plan of cares, which had the potential for the patients’ psychosocial needs to be unmet.Review of agency’s policy “Comprehensive Assessment, Policy No. 2-030.1, revision November 2024,” reads in part “A comprehensive patient assessment will be performed by the hospice IDG no later than five (5) calendar days after the election of hospice care in consultation with the attending physician.”