Every finding on record at Southern Utah Hospice and Home Care LLC

Based on interview and record review, it was determined the hospice agency did not ensure the interdisciplinary group, in consultation with the individual's attending physician, completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Specifically, spiritual counselor (SC) involvement in the comprehensive assessment could not be found for 9 of 14 sample patients who had a full medical record review completed. (Patient identifiers: 4, 6, 7, 8, 9, 10, 11, 13, and 14.) --- Findings Include: A review of the medical records for patients 4, 6, 7, 8, 9, 10, 11, 13, and 14 was completed from 10/21/2024 to 10/24/24. Nine of the fourteen medical records had no documented evidence that an initial spiritual care assessment occurred. In an interview with the Director of Nursing (DON) on 10/24/2024 at 1:04 PM, she stated that a spiritual assessment should occur within five days of admission. She further stated that if there are no visits titled Chaplain or Spiritual care coordinator (SCC) in the medical record then a spiritual assessment did not occur.

Based on interview and record review, it was determined the hospice interdisciplinary group (IDG) did not document they had reviewed the ability of the patient and/or family to safely administer drugs to the patient in his or her home for 14 out of 14 patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14). --- Findings include: A review of the medical records for patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 was completed from 10/21/2024 through 10/24/2024. Fourteen of fourteen medical records had no documented evidence that the IDG had reviewed the ability of the patient and/or family to safely administer drugs to the patient. On 10/24/2024 at approximately 1:15 PM, an interview was conducted with the Director of Nursing related to the IDG documentation on the ability of a patient/family to safely administer drugs to the patients. The Director of Nursing stated it was not documented in IDG notes in the patients medical records.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 5 (40%) records reviewed with hospice aide services revealed that aide services were not provided as ordered with respect to visit frequency. Record #22960: For the 2nd benefit period beginning 02/11/2022, an order written 2/13/2022, ordered aide visits 3xw, effective 2/13/2022. Two missed aide visits were noted for the weeks beginning 3/13/2022 and 4/03/2022. The record lacked evidence of documentation detailing why the visits were not completed as ordered. Record #54113: For the 1st benefit period beginning 02/03/2022, an order written 2/03/2022 ordered aide visits 2xw, effective 2/03/2022. Two missed aide visits were noted the weeks beginning 3/13/2022 and 3/20/2022. The record lacked documentation detailing why the visits were not completed as ordered. The Administrator and the Office Manager, during an interview on 4/12/2022, stated that the aides had reported the missed visits. The Administrator agreed the visits were not completed as ordered and the record lacked evidence of a communication note.