Every finding on record at Trinity Hospitals - Hospice

Based on review of the hospice volunteer report and staff interview, the Hospice failed to ensure volunteers provided services which equaled five percent of the total patient care hours of all paid hospice employees and contract staff within a one-year period (January-December 2024). This resulted in the failure to use volunteers to the extent specified. --- Findings Include: Review of the hospice volunteer report occurred on 03/19/25. This document identified the Hospice provided 1610.8 total hospice patient hours and 60.6 total volunteer hours in the one-year period of January-December 2024. The division of these values calculated a total of 3.77 percent and did not equal the required five percent minimum. During an interview on the afternoon of 03/19/25, an administrative staff member (#2) confirmed the number of volunteer hours did not meet the required five percent minimum.

Based on record review, agency policy review, and staff interview, the Hospice failed to complete an initial bereavement assessment as part of the comprehensive assessment for 4 of 7 closed patient (Patient #1, #6, #10, and #11) records reviewed who remained on services for five days or more. Failure to complete an initial bereavement assessment limited the Hospices' ability to readily identify evident factors that may impact the patient's family and/or other individuals' ability to cope with the patient's death. Findings include: Review of the agency policy titled "Bereavement Services" occurred on 05/25/22. The policy, revised July 2021, stated, "Purpose: To ensure that appropriate and coordinated bereavement services are provided to family/caregivers. Policy: . . . The program will provide bereavement services to the family/caregivers of hospice patients, before and after the patient's death, in accordance with the plan of care. The purpose of these services will be to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions that may interfere with the eventual resolution and integration of their losses. The purpose will also be to prepare the individual to function independently of hospice and to identify a support system with the individual. . . . Procedure: 1. A bereavement risk assessment will be completed by the hospice social worker/RN [registered nurse] case manager at the time of admission to hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care. . . . 2. After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented and updated as needed. 3. Depending on the patient and family/caregiver needs identified in the bereavement assessment, bereavement counselors may need to contact and/or provide supportive counseling to the patient and family/caregiver prior to the patient's death. 4. The bereavement counselors may provide supportive counseling to the patient and family/caregiver prior to the death. . . ." Review of the agency policy titled "Bereavement Assessment" occurred on 05/25/22. The policy, revised July 2021, stated, "Purpose: To provide guidance for the assessment and reassessment of the bereavement needs of family/caregivers. . . . Procedure: 1. On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that will be given to the Bereavement Coordinator. 2. The Bereavement Coordinator will review the bereavement risk assessment to determine potential needs of the survivors. 3. Bereavement needs will be reassessed during each contact. . . . 7. All bereavement documentation will be submitted for filing in the patient's permanent clinical record." Review of Patient #1, #6, #10, and #11's closed medical records occurred on May 23-25, 2022 and identified admission to hospice services between February to April 2022. The records lacked evidence of initial bereavement assessments completed within five days of the election to hospice as part of the comprehensive assessment. During an interview on 05/25/22 at 1:57 p.m., a Chaplain (#3) stated the social worker used to complete the initial bereavement assessments, but since the social worker resigned last year, the chaplain or nurse are responsible for completing the assessment during the admission process. During an interview on 05/25/22 at 4:15 p.m., an administrative nurse (#4) confirmed Patient #1, #6, #10, and #11's records failed to include an initial bereavement assessment and admitted the Hospice needed to work on a better process to ensure completion of the initial bereavement assessments. Failure to complete an initial bereavement assessment didn't allow staff to determine the caregiver, family member, and/or any other significant person's bereavement risk, limiting the staff's ability to recognize and deal with anticipatory grief.

Based on record review, policy review, and staff interview, the Hospice failed to ensure a social worker attended the Interdisciplinary Group (IDG) meetings for 10 of 11 sampled patients (Patient #1, #2, #3, #4, #5, #6, #8, #9, #10, and #11) who received services for 15 days or more. Failure to include the social worker as part of the IDG limited the group's ability to contribute to the patients' comprehensive assessments and plans of care related to social service concerns. Findings include: Review of the agency policy titled "Interdisciplinary Group Meeting" occurred on 05/25/22. This policy, dated November 2020, stated, ". . . The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths, and changes in patient and family/caregiver circumstances, referrals . . . The hospice Medical Director and all hospice interdisciplinary group members [includes a social worker] will be present . . ." Review of Patient #1, #2, #3, #4, #5, #6, #8, #9, #10, and #11's medical records occurred on May 23-25, 2022, and identified the Hospice provided care for each patient for part or all of the timeframe from January 25 - May 25, 2022. Record review showed IDG meetings held every two weeks from February 9 - May 18, 2022. The attendance roster for all eight of the IDG meetings failed to include a social worker. The IDG meeting minutes lacked documentation of a reason for the absence of the social worker. During an interview on 05/25/22 at 8:44 a.m., the interim social worker (#2) stated she worked at another facility but started helping the Hospice fill the social worker role in January 2022 after their social worker resigned. She stated she did not attend or participate in the IDG meetings, only submitted notes for the meetings if any of the patients had changes. During an interview on the morning of 05/25/22, an administrative nurse (#1) confirmed the current interim social worker works at another facility and does not attend the IDG meetings in person or per phone.