Every finding on record at Star Hospice LLC

Based on medical record review, interview, and policy review, the agency failed to ensure that the "Spiritual Counselor Comprehensive Assessment" was completed within five days of the election of the hospice benefit for 10 of 14 patients (Patient (P)1, P2, P3, P4, P5, P6, P8, P10, P11, and P14). Failure to complete a spiritual assessment had the potential to miss the identification of a patient or caregivers spiritual needs. --- Review of the "Patient Charts" section in the electronic medical record (EMR) for P1, P2, P3, P4, P5, P6, P8, P10, P11, and P14 revealed a "Spiritual Counselor Comprehensive Assessment" had not been completed by the agency's Spiritual Counselor for these patients who had been on hospice care for at least five days and had not refused spiritual counselor services. During an interview on 08/22/23 at 1:00 PM, the Administrator confirmed that a Spiritual Counselor assessment was not completed within five days of the election of hospice services for patients and/or caregivers who had not refused spiritual care or requested a delay. Review of the hospice agency policy titled, "Plan of Care Process," dated 10/20/22, revealed, "A comprehensive assessment will be completed by the IDG/IDT [interdisciplinary group/interdisciplinary team] no later than five calendar days after the election of hospice care in consultation with the attending Physician (if any) ... The IDG/IDT must include but is not limited to individuals who are qualified and competent to practice in the following professional roles. A. A Doctor of Medicine or Osteopathy ... B. A Registered Nurse. C A Social Worker. D. A pastoral or other counselor."

Based on record review, interview, and policy review, the agency failed to ensure an initial bereavement risk assessment was completed for 10 of 14 patients (Patient (P)1, P3, P4, P6, P7, P8, P10, P11, P13, P14). The failure to complete an initial bereavement risk assessment had the potential for the family or other individuals' bereavement needs to not be recognized or addressed in the plan of care. --- Review of the "Patient Charts" section in the electronic medical record (EMR) revealed that an initial "Bereavement Assessment" was not completed for P1, P3, P4, P6, P7, P8, P10, P11, P13, P14 who had received hospice services for at least five days. During an interview on 08/22/23 at 1:00 PM, the Administrator confirmed the Bereavement Assessment had not been completed on the patients identified. Review of the hospice agency polity titled, "Plan of Care Process," dated 10/20/22, revealed, "A comprehensive assessment will be completed by the IDG/IDT [interdisciplinary group/interdisciplinary team] no later than five calendar days after the election of hospice care ...The comprehensive assessment will take into consideration the following factors but is not limited to : ...An initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment will be incorporated into the POC [plan of care] and considered in the bereavement POC."

Based on record review, interview, and policy review, the agency failed to include supplies and equipment on the plan of care for eight of 14 patients (Patient (P)4, P5, P6, P7, P10, P11, P12, and P13). Failure to identify the supplies and equipment on the plan of care had the potential for the patient's safety and comfort needs to not be met. --- Review of the "Initial Plan of Care" (POC) located in the "Patient Charts" section of the electronic medical record (EMR) for P4, P5, P6, P7, P10, P11, P12, and P13 revealed the sections labelled "DME" (Durable medical equipment") and "Supplies" were left blank. During an interview on 08/23/23 at 8:30 AM, the Director of Nursing (DON) confirmed the sections of the POC labelled "DME" and "Supplies" were blank for the eight patients identified. Review of the hospice agency's policy titled, "Plan of Care Process," dated 10/20/22, revealed, "The POC includes, but is not limited to: ... Medical supplies, equipment, and appliances necessary to meet the needs of the patient."