Every finding on record at St Bernards Regional Med Ctr Hospice

Based on clinical record review and staff interview it was determined the Agency failed to include all required disciplines as part of the Interdisciplinary Team (IDT) in contributing to the patients comprehensive and ongoing assessments and care planning process in 5 (#1, #4, #6, #8 and #11) of 19 (#1-#19) clinical records reviewed. This failed practice had the potential to affect all patients currently on census in that there could be a delay in identification of the patient's response to care and/or the need for a change in the current treatment plan and services being provided. Findings follow: --- Review of clinical record #1 with a start of care (SOC) of 10/21/24 revealed a patient with a diagnosis of Malignant Neoplasm of Bilateral Ovaries. Review of a document titled ";IDT (Interdisciplinary Team) Report" and dated 01/22/2025 showed no evidence the Physician participated during the IDG meetings to plan and coordinate care. Review of clinical record #4 with a SOC of 08/23/24 revealed a patient with a diagnosis of Progressive Supranuclear Ophthalmoplegia. Review of a document titled ";IDT Report" and dated 03/05/2025 showed no evidence the Registered Nurse participated during the IDG meetings to plan and coordinate care. Review of clinical record #6 with a SOC of 03/04/25 revealed a patient with a diagnosis of Congestive Heart Failure. Review of a document titled ";IDT Report" and dated 03/05/2025 showed no evidence the Physician participated during the IDG meetings to plan and coordinate care. Review of clinical record #8 with a SOC of 01/29/25 revealed a patient with a diagnosis of Malignant Neoplasm of Pancreas. Review of a document titled ";IDT Report" and dated 02/05/2025 showed no evidence the Physician participated during the IDG meetings to plan and coordinate care. Review of clinical record #11 with a SOC of 08/23/24 revealed a patient with a diagnosis of Disease of Esophagus Unspecified. Review of a document titled ";IDT Report" and dated 03/05/2025 showed no evidence the Registered Nurse participated during the IDG meetings to plan and coordinate care. An interview on 03/12/25 at 3:30 PM with Agency Personnel #1 confirmed the IDT's failure to document the attendance of all IDT members as required.

Based on clinical record review and staff interview, it was determined the Interdisciplinary Team (IDT) failed to review, revise and document updates to the patient's Plan of Care (POC) at least every 15 days in 4 (#2, #5, #7, and #12) of 19 (#1-#19) clinical records reviewed. This failed practice had the potential to place all patients currently on census and their families at risk for adverse outcomes, ineffective care and services due to a delay in coordination of information to meet the patient's needs. Findings follow --- Review of clinical record #2 with a Start of Care (SOC) date of 10/01/24 revealed a patient with a diagnosis of Ovarian Cancer. There was no evidence of a review, revision or update to the POC by the IDT until 01/22/2025 (112 days after SOC 97 days late). Review of clinical record #5 with a SOC of 02/19/25 revealed a patient with a diagnosis of Chronic Kidney Disease Stage There was no evidence of a review, revision or update to the POC by the IDT as of this clinical review 03/12/2025 (21 days after SOC 6 days late). Review of clinical record #7 with a SOC of 02/17/25 revealed a patient with a diagnosis of Senile Degeneration of Brain There was no evidence of a review, revision or update to the POC by the IDT as of this clinical review 03/12/25 (23 days after SOC 8 days late). Review of clinical record #12 with a SOC date of 02/12/25 revealed a patient with a diagnosis of Lung Cancer. There was no evidence of a review, revision or update to the POC by the IDT as of this clinical review 03/12/25 (27 days after SOC 12 days late). An interview on 03/12/25 at 3:30 PM with Agency Personnel #1 confirmed the IDT's failure to document the review, revision and update to the patient's POC at least every 15 days as required.

Based on clinical record review and staff interview, it was determined the Agency failed to facilitate or coordinate with the patients identified local clergy to provide support of the patient and/or family spiritual needs in 4 (#8, #11, #13, and #17) of 19 (#1-19) clinical records reviewed. This lack of facilitation and coordination had the potential to affect the patients and families in obtaining relief from spiritual and/or emotional conflict to improve the quality of life for the patient and/or family. Findings follow: --- Review of clinical record #8 with a start of care (SOC) of 01/29/25 revealed a patient with a diagnosis of Malignant Neoplasm of Pancreas. A document titled ";Chaplain Admission Visit" and dated 01/30/2025 states ";she has a strong faith and a faith community at the Community Church going to Harrisburg." Review of a document titled ";IDT (Interdisciplinary Team) Report" and dated 02/05/25 states patient has a ";minister who comes by to see her." No evidence of Pastors name or contact information. There was no evidence of contact made by Hospice Chaplain to local clergy to facilitate visits or support the patient's/family's spiritual needs. Review of clinical record #11 with a SOC of 02/05/25 revealed a patient with a diagnosis of Disease of Esophagus Unspecified. A document titled ";Chaplain Admission Visit" and dated 02/06/2025 states ";She is a member of the First Baptist of Jonesboro." Review of a document titled ";IDT Report" and dated 03/05/25 states ";The patient has a faith and faith comunity [sic] from the First Baptist of Jonesboro." No evidence of Pastors name or contact information. There was no evidence of contact made by Hospice Chaplain to local clergy to facilitate visits or support the patient's/family's spiritual needs. Review of clinical record #13 with a SOC of 02/21/25 revealed a patient with a diagnosis of Brain Cancer. A document titled ";Chaplain Admission Visit" and dated 02/21/2025 states ";The wife expressed that they all attend the Maple Grove Baptist Church have a minister who will come by and visit on a regular basis." Review of a document titled ";IDT Report" and dated 03/05/25 states ";They have a minister but he does not come by as of this time." No evidence of Pastors name or contact information. There was no evidence of contact made by Hospice Chaplain to local clergy to facilitate visits or support the patient's/family's spiritual needs. Review of clinical record #17 with a SOC of 12/20/23 revealed a patient with a diagnosis of Unspecified Severe Protein-Calorie Malnutrition. A document titled ";Chaplain Admission Visit" and dated 12/22/2023 states ";they have a very good support system from their faith community the Bethel Station Baptist Church in Paragould. The pastor is a regualr [sic] visitor." No evidence of Pastors name or contact information. There was no evidence of contact made by Hospice Chaplain to local clergy to facilitate visits or support the patient's/family's spiritual needs. An interview on 03/12/25 at 3:30 PM, with Agency Personnel #1 confirmed the Chaplain did not facilitate visits or coordinate care with the patient's local clergy or faith community.

Based on clinical record review and staff interview it was determined the Agency failed to complete an individualized aide care plan in 3 (#13, #14, and #17) of 9 (#4, #5, #6, #8, #9, #13, #14, #16, and #17) clinical records reviewed with aide services ordered. This failed practice had the potential to place all patients who receive aide servicers at risk for adverse outcomes due to care being provided which might not meet the patient's needs and could result in injury such as falls. Findings follow: --- Review of clinical record #13 with a SOC of 02/21/25 revealed a patient with a diagnosis of Brain Cancer. The Hospice Plan of Care nor the Care Plan Summary provided by the Administrator documented shaving as part of the Aide Care Plan. Review of clinical record #14 with a SOC of 02/05/25 revealed a patient with a diagnosis of Malignant Neoplasm. The patient did not have aide services at home but was moved to inpatient respite care on 02/25/25. The Hospice Plan Care nor the Care Plan Summary provided by the Administrator documented an Aide Care Plan for the respite services in the inpatient unit. Review of clinical record #17 with a SOC of 12/20/23 revealed a patient with a diagnosis of Unspecified Severe Protein-Calorie Malnutrition. The Hospice Plan of Care with a certification period of 10/15/24 -12/13/24 documented in the aide care plan to assist with elimination, including a foley catheter. A Hospice PRN (as needed) RN (Registered Nurse) visit dated 10/27/24 documented a foley catheter was initially placed indicating there was no catheter in place on 10/15/24 when the plan of care was developed. An interview on 03/12/25 at 3:30 PM with Agency Personnel #1 confirmed the Agency failed to complete an individualized aide care plan.

Based on clinical record review and staff interview, it was determined the agency failed to ensure that discharge summaries were completed and sent to the physician as required for 5 of 5 (#15-19) clinical records reviewed of patients who were discharged. This failed practice prevented the patients physician from being informed of the patient's condition at time of discharge and had the potential to hinder coordination of care and services to all patients and/or family members who were discharged or revoked the election of hospice care. Findings follow: --- Clinical records #15 and #16 revoked the election of Hospice services and #17 - #19 expired under the care of Hospice services. There were no discharge summaries in the client records during the clinical record review. A Policy and Procedure provided by the Administrator titled, ";Clinical Record" documented, ";Clinical Record is the compilation of the patients total Hospice Plan of care and related documentation of the care delivery process, containing pertinent past and current findings...The Record includes...A discharge summary..." On 03/12/25 the Agency Administrator was asked to provide discharge summaries for #15 - #19. She stated the Agency has not and does not currently complete a discharge summary for those patients that discharge from the agency. An interview on 03/12/25 at 3:30 PM with Agency Personnel #1 confirmed the failure of the Agency to complete discharge summaries as required.

Based on staff interview and Clinical Record review, it was determined the Agency failed to incorporate documented evidence of the patient's progression toward the desired goals in the Plan of Care (POC) updates in 13 (#1-#13) of 13 (#1-#13) Clinical Records reviewed of current patients. This failure made it difficult for the Interdisciplinary Group to determine if the patient and family were progressing toward desired outcomes specified in the patient's plan of care. Findings follow: A. On 05/10/22 at 1:15 PM, Agency Personnel #1 reported that the Agency had IDT [Interdisciplinary Team] meetings every other week for all patients on current census and documented POC revisions and updates on an Agency form titled, "IDT Report". B. There was no documented evidence in all of the Clinical Records reviewed, (#1 - #13), of the patient's progression toward goals, inclusion of new interventions based on comprehensive assessments or discontinuance of goals achieved by patients or families. C. Review of Clinical Record #3 revealed the following: 1. A patient with a terminal diagnosis of "Unspecified protein-calorie malnutrition and a start of care date of 04/09/22. 2. The Registered Nurse (RN) documented on an Agency form titled, "Visit Note" and dated 04/21/22, "[Named Patient] has crusted wound to back of her head, she feel [fell] over weekend causing this laceration, taken to the er [Emergency Department] and wound closed with staples, [Named Patient] has since removed these staples." 3. The Agency conducted an IDT on 04/22/22 (one day after the RN noted a change in the patient's condition). There were no new interventions/goals or revision to the patient's POC relating to the patient's fall and subsequent wound to her head. D. Review of Clinical Record #4 revealed the following: 1. A patient with a terminal diagnosis of "Unspecified systolic (congestive) heart failure and a certification period of 04/03/22 through 07/01/2. 2. The Agency conducted IDT's on 04/08/22 and 04/22/22. The Agency Social Worker documented, "Patient is being followed by LSW [Licensed Social Worker]." The Agency Chaplain documented, "I have not seen pt [patient] this IDG [Interdiscplinary Group] period..." There were no new interventions/goals or revision to the patient's POC relating to the patient's fall and subsequent wound to her head. E. On 05/11/22 at 12:30 PM, Agency Personnel #3 reported she obtained information regarding the patient's current plan of care through reading the social worker's visit notes in the patient's clinical records and not from the patient's POC or IDT notes. F. On 05/13/22 at 09:45 AM, Agency Personnel #1 confirmed the Agency had not documented the patient's progress toward specific goals, inclusion of new interventions based on comprehensive assessments or discontinuance of interventions achieved by patients or families. .

Based on Administrative Documentation review and staff interview, it was determined the Agency's Governing Body did not approve the Agency's Quality Assurance Program and performance improvement projects for the year of 2021. Findings follow: 1. Review of the Agency's Quality Assurance Program documentation for the year of 2021 revealed no evidence the Governing Body had approved the program improvement projects. 2. On 05/12/22 at 2:45 PM, Agency Personnel #2 confirmed the Agency Governing Body did not approve the Quality Assurance program improvement projects for the year 2021.