Every finding on record at St. Johns Hospice LLC

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure that the individualized written plan of care included goals and interventions for problems identified in the comprehensive assessment. Policy PC.30 Plan of Care Process review fate 10/20/2022 stated in part "The POC (Plan of Care) includes but is not limited to interventions to manage pain and symptoms and identified issues/problems." Clinical Record 1: The social worker comprehensive assessment was completed on 8/19/2023. The Medical Social Worker (MSW) documentation included a visit frequency of Licensed Medical Social Worker (LMSW) visits one time a month and as needed for psychosocial resources and stated in part "would benefit by applying for the resources LMSW suggested of food bank, food assistance/SNAP/Lone Star, Meals on Wheels, and any others the Senior Center has to offer." The clinical record lacked evidence that goals and interventions to address psychosocial problems identified in the comprehensive assessment were included in the plan of care effective 8/25/2023. Clinical Record 4: The social worker comprehensive assessment was completed on 6/27/2023. The Medical Social Worker (MSW) documentation included a visit frequency of Licensed Medical Social Worker (LMSW) visits once a month and as needed for psychosocial support and end-of-life resources. The clinical record lacked evidence that goals and interventions to address psychosocial problems identified in the comprehensive assessment were included in the plan of care effective 6/30/2023. Clinical Record 5: The social worker comprehensive assessment was completed on 6/27/2023. The Medical Social Worker (MSW) documentation included a visit frequency of Licensed Medical Social Worker (LMSW) visits once a month and as needed for psychosocial support and end-of-life resources. The clinical record lacked evidence that goals and interventions to address psychosocial problems identified in the comprehensive assessment were included in the plan of care effective 6/30/2023. Clinical Record 12: The social worker comprehensive assessment was completed on 5/29/2023. The Medical Social Worker (MSW) documentation included a visit frequency of Licensed Medical Social Worker (LMSW) visits two times a month and as needed for psychosocial support and stated in part "Pt stated he would like to be cremated." The clinical record lacked evidence that goals and interventions to address psychosocial problems identified in the comprehensive assessment were included in the plan of care effective 6/2/2023. Clinical Record 13: The social worker comprehensive assessment was completed on 4/21/2023. The Medical Social Worker (MSW) documentation included a visit frequency of Licensed Medical Social Worker (LMSW) visits two times a month and as needed for psychosocial support. The clinical record lacked evidence that goals and interventions to address psychosocial problems identified in the comprehensive assessment were included in the plan of care effective 5/5/2023. The administrator confirmed findings in a joint record review on 2/29/2024 that clinical records 1, 4, 5, 12, and 13 lacked evidence that the plan of care included goals and interventions for problems identified in the psychosocial comprehensive assessment.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 5 (100%) clinical records reviewed revealed that the agency did not ensure that a discharge summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient's current plan of care, the patient's latest physician orders, and any other documentation was provided upon discharge to assist in the post-discharge continuity of care when the patient was discharged or revocated the hospice benefit. Policy PE.20 Patient Discharge review date 10/1/2021 stated in part "The Hospice will forward copies of the following to the patient's attending physician upon discharge from the hospice's services: The hospice discharge summary which includes but is not limited to: A summary of the patient's care (pain management, symptoms, and treatments), the patient's current plan of care, including the current medication profile, the latest physician orders, and any other documentation requested or that may assist with the patient's post-discharge continuity of care" Policy PE.35 Patient Revocation review date 10/1/2021 stated in part "The Hospice will forward copies of the following to the patient's attending physician upon discharge from the hospice's services: The hospice discharge summary which includes but is not limited to: A summary of the patient's care (pain management, symptoms, and treatments), the patient's current plan of care, including the current medication profile, the latest physician orders, and any other documentation requested or that may assist with the patient's post-discharge continuity of care". Clinical Record 4: The patient was discharged on 10/20/2023 due to being no longer terminally ill. The clinical record lacked evidence that a discharge summary was completed and forwarded to the attending physician. Clinical Record 5: The patient was discharged on 10/10/2023 due to being no longer terminally ill. The clinical record lacked evidence that a discharge summary was completed and forwarded to the attending physician. Clinical Record 6: The patient was discharged on 10/5/2023 due to being no longer terminally ill. The clinical record lacked evidence that a discharge summary was completed and forwarded to the attending physician. Clinical Record 7: The patient was discharged on 11/27/2023 due to moving out of the service area. The clinical record lacked evidence that a discharge summary was completed and forwarded to the attending physician. Clinical Record 8: The patient was discharged on 10/20/2023 due to moving out of the service area. The clinical record lacked evidence that a discharge summary was completed and forwarded to the attending physician. Clinical Record 10: The patient revocated hospice services on 10/6/2023. The clinical record lacked evidence that a discharge summary was completed and forwarded to the attending physician. The administrator confirmed findings in an interview and joint record review on 2/29/2024 that clinical records 4, 5, 6, 7, 8, and 10 lacked evidence that a discharge summary was completed and forwarded to the attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) clinical records reviewed that were transferred to another facility revealed that the agency did not ensure that a discharge summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient's current plan of care, the patient's latest physician orders, and any other documentation was provided upon discharge to assist in the post-discharge continuity of care. Policy PE.15 Patient Transfer review date 10/7/2022 stated in part "If the care of a patient is transferred to another Medicare/Medicaid-certified facility, the Hospice will forward copies of the following to the receiving facility: The hospice discharge summary which includes but is not limited to: A summary of the patient's care (pain management, symptoms, and treatments), the patient's current plan of care, including the current medication profile, the latest physician orders, and any other documentation requested or that may assist with the patient's post-discharge continuity of care". Clinical Record 9: The patient was transferred to another hospice on 10/12/2023. The clinical record lacked evidence that a discharge summary was completed and forwarded to the receiving facility. The administrator confirmed findings in an interview and joint record review on 2/29/2024 that clinical record 9 lacked evidence that a discharge summary was completed and forwarded to the receiving facility.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records and hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 10 (10%) personnel records reviewed revealed that the agency did not obtain a criminal background check for all hospice employees and contracted staff. Policy HR.115 Background Checks reviewed 10/1/2021 stated in part "The Hospice will obtain a criminal history check for applicants, employees, and contract staff that have direct contact with patients and/or access to patient records in accordance with state requirements." Personnel Record 8: A review of the Medical Director’s, date of hire 02/09/2023, personnel record lacked evidence that a criminal background check was performed. The administrator confirmed findings in joint personnel record review and interview on 3/1/2024 that the personnel record for staff 8 did not contain evidence that a criminal background check was obtained.