Every finding on record at Tucumcari Hospice

Based on clinical record review and staff interview, it was determined the hospice failed to ensure all members of the interdisciplinary group (IDG) were involved with the development of a comprehensive assessment no later than five calendar days after the hospice election for 6 of 11 Patients (Patient (P2, P3, P4, P8, P9, P11) clinical records reviewed. Failure to complete this IDG consultation has the potential to interfere with the hospices ability to develop a care plan that addresses all areas of need related to the terminal illness and other conditions. This had the potential to affect each of the agency's 10 current patients and all future hospice patients. --- During an interview conducted on 10/18/22 at approximately 2:00 PM, the Hospice Manager was queried about the hospices process for development of a comprehensive assessment which involved input from all members of the IDG. The Hospice Manager stated ";The admitting nurse goes out to the home first, followed by the Medical Social Worker (MSW). Then during the next scheduled IDG meeting, we all meet with the physician and talk about the patient." When asked if this meeting took place within the first five calendar days after the election of hospice care, the Hospice Manager stated ";not always, no." Record review revealed P2 was admitted for hospice care on 09/02/22 by the hospice Registered Nurse (RN). Election of hospice benefit was signed by the patient on 09/02/22. The initial IDG meeting to discuss the comprehensive assessment of this newly admitted patient was not documented until 09/13/22, 11 days after admission. Additionally, on the start of care comprehensive assessment completed 09/02/22, the RN documented under Spiritual Care (SC) ";spiritual needs... refer to chaplain." At the time of the clinical record review on 10/17/22, there was no documented evidence in the record to indicate that a SC counselor ever made a home visit to this patient to complete a spiritual assessment. There was also no documentation to clarify why the SC had not conducted a home visit to complete a spiritual needs assessment for P2 no later than 5 calendar days after beginning of hospice care as required. The IDG failed to ensure that all members participated in the development of the comprehensive assessment within the required time. Record review revealed P3 was admitted for hospice care on 02/01/22 by the hospice RN. Election of hospice benefit was signed by the patient on 02/01/22. The initial IDG meeting to discuss the comprehensive assessment of this newly admitted patient was not documented until 02/15/22, 14 days after beginning of hospice care. The IDG failed to ensure that all members participated in the development of the comprehensive assessment. Record review revealed P4 admitted for hospice care on 10/05/22 by the hospice RN. Election of the hospice benefit was signed by the patient on 10/05/22. The initial IDG meeting to discuss the comprehensive assessment of the newly admitted patient was not documented until 02/11/22, six days after the beginning of hospice care. The IDG failed to ensure that all members participated in the development of the comprehensive assessment. Record review revealed P8 admitted for hospice care on 06/24/22 by the hospice RN. Election of the hospice benefit was signed by the patient on 06/24/22. The initial IDG meeting to discuss the comprehensive assessment of the newly admitted patient was not documented until 07/05/22, 12 days after the beginning of hospice care. The IDG failed to ensure that all members participated in the development of the comprehensive assessment. Record review revealed P9 was admitted for hospice care on 06/26/22 by the hospice RN. Election of hospice benefit was signed by the patient on 06/26/22. The initial IDG meeting to discuss the comprehensive assessment of this newly admitted patient was not documented until 07/05/22, nine days after beginning of hospice care. Additionally, on the IDG documentation of 07/05/22, it was noted that there was no documentation that the MSW had been in attendance to address psychosocial needs of the patient. There was no evidence the IDG had discussed, as a group, the information gathered from their individual assessments in an effort to develop a comprehensive assessment and plan of care. Record review revealed P11 was admitted for hospice care on 05/03/22 by the hospice RN. Election of hospice benefit was signed by the patient on 05/03/22. The initial IDG meeting to discuss the comprehensive assessment of this newly admitted patient was not documented until 05/10/22, seven days after beginning of hospice care. Additionally, The MSW did not complete and document an admission assessment until 05/12/22, two days after the IDG meeting was held. There was no evidence the IDG had discussed, as a group, the information gathered from their individual assessments in an effort to develop a comprehensive assessment and plan of care for this patient. The agency policy titled "Hospice Interdisciplinary Group Plan of Care," dated 06/29/22 indicated "The admitting RN will notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs.... The individualized plan of care will be reviewed by the rest of the interdisciplinary group within five (5) days of start of care." During an interview on 10/19/22 at approximately 12:00 PM, the Hospice Manager was unable to explain the delay in IDG communication after the beginning of hospice care but stated that there should be documentation in the record to clarify why the required comprehensive assessments could not be completed within the 5-day period.

Based on record review, interview, and review of agency policy, it was determined the hospice failed to ensure that the comprehensive assessment included data elements that were then used in individual patient care planning or used in the aggregate for the hospice's quality assessment and performance improvement program for 11 of 11 patients (Patient (P1-11) reviewed. Failure to include data elements has the potential to interfere with the hospices ability to measure outcomes and evaluate effectiveness. This had the potential to affect each of the agency's 10 current patients and all future hospice patients. --- Review of each of the clinical records for Patients 1-11 (P1-11) revealed the comprehensive assessments that were completed at admission failed to include objective assessments in any area other than pain. Objective assessments such as patient reported levels of dyspnea, nausea, vomiting, constipation, emotional distress, and/or spiritual needs at the time of admission which were then used in the hospice's quality assessment improvement program (QAPI) were not documented in the comprehensive assessments. There was no documented evidence in the comprehensive assessments that the hospice gathered data from each patient which would allow them to assess, measure and document patient reports on outcomes of treatments so as to determine the hospice's level of effectiveness. The agency policy titled ";Improving Organizational Performance, dated 01/13/2021, stated ";The scientific, problem-solving approach will include, minimally: implementing improvement on the basis of assessment and comparison data." During an interview on 10/19/22 at approximately 12:00 PM, the Hospice Manager, who was responsible for the hospices quality program, verified that the hospice did not include the measurement of any type of data elements other than pain, in the comprehensive assessment of patients for use in patient care planning or for use in the hospice's QAPI program. The Hospice Manager stated, ";we havent been able to find the right documentation tool to accomplish that."

Based on record review, observation during home visit, review of agency policy and staff interview, the hospice agency failed to ensure the plan of care reflected individualized patient interventions based on information obtained in the initial and comprehensive assessments for five of 11 patient (Patient (P1, P2, P3, P9, P11) records reviewed. Failure to develop an individualized plan of care presents a potential inability to effectively address and treat problems identified in the initial and updated assessments. This had the potential to affect the 10 patients who were currently receiving hospice services and all future hospice patients/patient family units. --- Review of the agency policy titled, "Hospice Interdisciplinary Group Plan of Care," dated 06/29/22 indicated "A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program." Record review revealed P1 was admitted to the hospice agency on 03/12/22 with the terminal diagnosis of metastatic breast cancer. During review of the plan of care dated 03/12/22, it was noted that patient was ordered to receive skilled nursing and hospice aide home visits. However, further review of this plan of care revealed multiple interventions for the medical social worker, the spiritual care counselor, and for volunteer services even though these services were not being delivered. The interventions included in the plan were generalized, generic and identical to plans of care reviewed for other patients. The plan of care was not individualized for this specific patient. Record review revealed P2 was admitted to the hospice agency on 09/02/22 with the terminal diagnosis of end stage renal disease. During review of the plan of care dated 09/02/22, it was noted that patient was ordered to receive skilled nursing visits only. However, further review of this plan of care revealed multiple interventions for the medical social worker, and for volunteer services even though these services were not being delivered. Additionally, interventions for management of home oxygen equipment were included. However, during a home visit conducted to this patient on 10/18/22, this surveyor noted there was no oxygen equipment in the home. The interventions included in the plan were generalized, generic, and identical to plans of care reviewed for other patients. The plan of care was not individualized for this specific patient. Record review revealed P3 was admitted to the hospice agency on 02/01/22 with the terminal diagnosis of prostate cancer. During review of the plan of care dated 02/01/22, it was noted that patient was ordered to receive skilled nursing visits and hospice aide home visits. However, further review of this plan of care revealed multiple interventions for the medical social worker and for the spiritual care counselor even though these services were not being delivered. During a home visit conducted to this patient on 10/18/22, when this surveyor asked the patient if visits from the social worker or spiritual care counselor were being conducted, the patient replied ";none." The interventions included in the plan were generalized, generic, and identical to plans of care reviewed for other patients. The plan of care was not individualized for this specific patient. Record review revealed P9 was admitted to the hospice agency on 06/26/22 with the terminal diagnosis of prostate cancer. During review of the plan of care dated 06/26/22, it was noted that patient was ordered to receive skilled nursing visits only. However, further review of this plan of care revealed multiple interventions for the medical social worker and for volunteer services even though these services were not being delivered. The interventions included in the plan were generalized, generic, and identical to plans of care reviewed for other patients. The plan of care was not individualized for this specific patient. Record review revealed P11 was admitted to the hospice agency on 05/03/22 with the terminal diagnosis of prostate cancer. During review of the plan of care dated 05/03/22, it was noted that patient was ordered to receive skilled nursing visits and hospice aide home visits. However, further review of this plan of care revealed multiple interventions for the medical social worker and for volunteer services even though these services were not being delivered. Additionally, this patient used oxygen and had a colostomy (an opening into the colon from the outside of the body). There were no interventions in the plan of care that addressed either the use of oxygen equipment or care of the colostomy. The interventions included in the plan were generalized, generic and identical to plans of care reviewed for other patients. The plan of care was not individualized for this specific patient. During an interview on 10/19/22 at approximately 1:00 PM, these findings were discussed with the Hospice Manager. The Hospice Manager confirmed the findings and stated, ";we know our plans of care outcomes are not individualized...the software program that we use is very limiting."

Based on record review, review of agency policy and staff interview, it was determined the hospice agency failed to ensure the scope and frequency of services in the plan of care (POC) addressed all interventions that were included in the plan of care for 8 of 11 patients (Patient (P)1, P2, P4, P6, P7, P8, P9, P11). This failure presents a potential for the hospice to be unable to ensure that each hospice patient receives services that were deemed necessary in the plan of care by the interdisciplinary group. This had the potential to affect the 10 patients who were currently receiving hospice services and all future hospice patients. --- The agency policy titled "Hospice Interdisciplinary Group Plan of Care," dated 06/29/22 indicated "The care provided to the patient must be in accordance with the plan of care. The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days." Record review revealed P1 was admitted to the hospice agency on 03/12/22 with the terminal diagnosis of metastatic breast cancer. During review of the plan of care dated 03/12/22, it was noted that one of the problems identified was titled ";Volunteer Services" with the goal of ";Volunteer services will support the needs of the patient/caregiver throughout the hospice episode." Interventions included ";emotional support, periodic respite care, and providing comfort interventions to assist with symptom management. However, no volunteer visits had been ordered or documented for this patient. There was no documentation in the clinical record to indicate that these interventions identified in the patients plan of care had ever been completed by a volunteer, or that the need for volunteer services had been re-assessed. Record review revealed P2 was admitted to the hospice agency on 09/02/22. During review of the plan of care dated 09/02/22, it was noted that one of the problems identified was titled ";Volunteer Services" with the goal of ";Volunteer services will support the needs of the patient/caregiver throughout the hospice episode." Interventions included ";emotional support, periodic respite care, and providing comfort interventions to assist with symptom management. However, no volunteer visits had been ordered or documented for this patient. There was no documentation in the clinical record to indicate that these interventions identified in the patients plan of care had ever been completed by a volunteer, or that the need for volunteer services had been re-assessed. Record review revealed P4 was admitted to the hospice agency on 10/05/22 with terminal diagnosis of end stage chronic obstructive pulmonary disease. During review of the plan of care dated 10/12/22, it was noted that one of the problems identified was titled ";Volunteer Services" with the goal of, ";Volunteer services will support the needs of the patient/caregiver throughout hospice episode." Interventions included emotional support, periodic respite care and providing comfort interventions to assist with symptom management. However, no volunteer visits had been ordered or documented for this patient. There was no documentation in the clinical record to indicate that these interventions identified in the patients plan of care had ever been completed by the volunteer, or that the need for volunteer services had been re-assessed. Record review revealed P6 was admitted to the hospice agency on 09/26/22 with terminal diagnosis of severe protein calorie malnutrition. During review of the plan of care dated 10/12/22, it was noted that one of the problems identified was titled ";Volunteer Services" with the goal of, ";Volunteer services will support the needs of the patient/caregiver throughout hospice episode." Interventions included emotional support, periodic respite care and providing comfort interventions to assist with symptom management. However, no volunteer visits had been ordered or documented for this patient. There was no documentation in the clinical record to indicate that these interventions identified in the patients plan of care had ever been completed by the volunteer, or that the need for volunteer services had been re-assessed. Record review revealed P7 was admitted to the hospice agency on 05/13/22 with terminal diagnosis of end stage liver disease. During review of the plan of care dated 10/12/22, it was noted that one of the problems identified was titled ";Volunteer Services" with the goal of, ";Volunteer services will support the needs of the patient/caregiver throughout hospice episode." Interventions included emotional support, periodic respite care and providing comfort interventions to assist with symptom management. However, no volunteer visits had been ordered or documented for this patient. There was no documentation in the clinical record to indicate that these interventions identified in the patients plan of care had ever been completed by the volunteer, or that the need for volunteer services had been re-assessed. Record review revealed P8 was admitted to the hospice agency on 06/24/22 with terminal diagnosis of malnutrition. During review of the plan of care dated 10/12/22, it was noted that one of the problems identified was titled ";Volunteer Services" with the goal of, ";Volunteer services will support the needs of the patient/caregiver throughout hospice episode." Interventions included emotional support, periodic respite care and providing comfort interventions to assist with symptom management. However, no volunteer visits had been ordered or documented for this patient. There was no documentation in the clinical record to indicate that these interventions identified in the patients plan of care had ever been completed by the volunteer, or that the need for volunteer services had been re-assessed. Record review revealed P9 was admitted to the hospice agency on 06/26/22. During review of the plan of care dated 06/26/22, it was noted that one of the problems identified was titled ";Volunteer Services" with the goal of ";Volunteer services will support the needs of the patient/caregiver throughout the hospice episode." Interventions included ";emotional support, periodic respite care, and providing comfort interventions to assist with symptom management. However, no volunteer visits had been ordered or documented for this patient. There was no documentation in the clinical record to indicate that these interventions identified in the patients plan of care had ever been completed by a volunteer, or that the need for volunteer services had been re-assessed. Record review revealed P11 was admitted to the hospice agency on 05/03/22. During review of the plan of care dated 05/03/22, it was noted that one of the problems identified was titled ";Volunteer Services" with the goal of ";Volunteer services will support the needs of the patient/caregiver throughout the hospice episode." Interventions included ";emotional support, periodic respite care, and providing comfort interventions to assist with symptom management. However, no volunteer visits had been ordered or documented for this patient. There was no documentation in the clinical record to indicate that these interventions identified in the patients plan of care had ever been completed by a volunteer, or that the need for volunteer services had been re-assessed. During an interview completed on 10/18/22 at 8:30 AM, the Volunteer Coordinator stated that the hospice did not have a volunteer program which utilized volunteers who provided direct patient care services. When queried further, the Volunteer Coordinator was unable to recall the last time that a volunteer had performed any direct patient care activities or home visits to hospice patients and stated, ";its been several years now... I wasnt aware that volunteer interventions were even on the plan of care." During an interview on 10/19/22 at approximately 1:00 PM, these findings were discussed with the Hospice Manager. The Hospice Manager confirmed these findings and stated ";I cant explain why there are orders for volunteer services on the plan of care.... we dont provide that."

Based on record review, review of agency policy and staff interview, it was determined the hospice agency failed to ensure the plan of care included measurable outcomes anticipated from implementing the plan of care for 11 of 11 patients (Patient (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11) records reviewed of a total 11 patient sample. Failure to identify measurable outcomes presents a potential inability to accurately evaluate the patients progress in meeting goals of care. This had the potential to affect the 10 patients who were currently receiving hospice services and all future hospice patients/patient family units. --- The agency policy titled "Hospice Interdisciplinary Group Plan of Care," dated 06/29/22 indicated "The written plan of care may contain, but will not be limited to: Measurable outcomes anticipated from implementing and coordinating the plan of care." Record review revealed P1 was admitted to the hospice agency on 03/12/22. During review of the plan of care dated 03/12/22, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 03/12/22 plan included ";will verbalize and demonstrate ability to manage the patients gastrointestinal symptoms throughout hospice episode," ";will demonstrate the ability to manage respiratory symptoms throughout hospice care," and ";will report pain/discomfort at verbalized acceptable level." Record review revealed P2 was admitted to the hospice agency on 09/02/22. During review of the plan of care dated 09/02/22, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 09/02/22 plan included ";will receive care using virtual visits as ordered by provider," ";will demonstrate the ability to manage respiratory symptoms throughout hospice care" and ";will report pain/discomfort at verbalized acceptable level." Record review revealed P3 was admitted to the hospice agency on 02/01/22. During review of the plan of care dated 02/01/22, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 02/01/22 plan included ";will have care coordination needs met while on service," and ";will verbalize and demonstrate ability to manage the patients gastrointestinal symptoms throughout hospice episode." Record review revealed P4 was admitted to the hospice agency on 10/05/22. During review of the plan of care dated 10/05/22, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 10/05/22 plan included ";will verbalize and demonstrate ability to manage the patients gastrointestinal symptoms throughout hospice episode," ";will demonstrate the ability to manage respiratory symptoms throughout hospice care," and ";will report pain/discomfort at verbalized acceptable level." Record review revealed P5 was admitted to the hospice agency on 10/15/22. During review of the plan of care dated 10/15/22, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 10/15/22 plan included ";will verbalize and demonstrate ability to manage the patients gastrointestinal symptoms throughout hospice episode," ";will demonstrate the ability to manage respiratory symptoms throughout hospice care," and ";will report pain/discomfort at verbalized acceptable level." Record review revealed P6 was admitted to the hospice agency on 09/26/22. During review of the plan of care dated 09/26/22, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 09/26/22 plan included ";will verbalize and demonstrate ability to manage the patients gastrointestinal symptoms throughout hospice episode," ";will demonstrate the ability to manage respiratory symptoms throughout hospice care," and ";will report pain/discomfort at verbalized acceptable level." Record review revealed P7 was admitted to the hospice agency on 05/13/22. During review of the plan of care dated 05/13/22, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 05/13/22 plan included ";will verbalize and demonstrate ability to manage the patients gastrointestinal symptoms throughout hospice episode," ";will demonstrate the ability to manage respiratory symptoms throughout hospice care," and ";will report pain/discomfort at verbalized acceptable level." Record review revealed P8 was admitted to the hospice agency on 06/24/22. During review of the plan of care dated 06/24/22, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 06/24/22 plan included ";will verbalize and demonstrate ability to manage the patients gastrointestinal symptoms throughout hospice episode," ";will demonstrate the ability to manage respiratory symptoms throughout hospice care," and ";will report pain/discomfort at verbalized acceptable level." Record review revealed P9 was admitted to the hospice agency on 06/26/22. During review of the plan of care dated 06/26/22, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 06/26/22 plan included ";will have care coordination needs met while on service" and ";will report pain/discomfort at verbalized acceptable level." Record review revealed P10 was admitted to the hospice agency on 10/14/22. During review of the plan of care dated 10/14/22, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 10/14/22 plan included ";will verbalize and demonstrate ability to manage the patients gastrointestinal symptoms throughout hospice episode," ";will demonstrate the ability to manage respiratory symptoms throughout hospice care," and ";will report pain/discomfort at verbalized acceptable level." Record review revealed P11 was admitted to the hospice agency on 05/03/22. During review of the plan of care dated 05/03/22, it was noted that the outcomes included in the plan were generalized, generic and not individualized for this specific patient. Examples of outcomes in the 05/03/22 plan included ";will understand social/emotional issues and follow-through," ";will have care coordination needs met while on service," and ";will report pain/discomfort at verbalized acceptable level." During an interview on 10/19/22 at approximately 1:00 PM, these findings were discussed with the Hospice Manager. The Hospice Manager confirmed the findings and stated, ";we know our plan of care outcomes are not measurable enough...it's very hard to do."

Based on review of quality improvement records, interview, and policy review, it was determined the hospice failed to develop, implement, and maintain an ongoing hospice data driven quality assessment and performance improvement (QAPI) program. Failure to develop an ongoing QAPI program has the potential to allow agency problems to remain unidentified and does not enable the hospice to reflect best practice patterns. This had the potential to affect the eleven patients who were currently receiving hospice services and all future hospice patients. --- On 10/19/22, at approximately 2:00 PM, documentation of the hospice's quality program was requested. The documentation provided did not include any information or data specifically related to the hospice program. The documentation failed to include indicators related to improved palliative outcomes or care delivery, failed to reflect any type of data collection, and failed to demonstrate action taken by the hospice to improve hospice performance. There was no documented evidence that the hospice had developed a QAPI program that included patient assessment data elements, review of clinical records, effectiveness of care delivery, adverse events, patient satisfaction surveys or hospice outcome measures. During an interview on 10/19/22, at approximately 2:30 PM, the Hospice Manager who was responsible for the QAPI program, confirmed these findings and stated, " right now, we discuss hospice and home health quality issues together... we dont really have a separate hospice quality program." During this interview, the Hospice Manager also verified that there currently was not a hospice quality committee responsible for conducting and documenting periodic meetings. The Hospice Manager stated ";basically, its just me at this point, there's no committee. The Hospice Manger also stated that there ";no meeting minutes had been documented that would reflect analysis of data for the purpose of implementing corrective action." The agency policy, titled "Improving Organizational Performance," dated 01/13/2021, stated "Purpose: To establish a performance improvement framework, which integrates activities to improve organization performance, improve patient safety, and reduce the risks for acquisition and transmission of infections and improve palliative care outcomes and services. All personnel will be active participants in the organizations quality assessment performance improvement (QAPI) activities." ";Procedure: Senior management will set expectations for performance improvement, set priorities and frequency of data collection and manage processes to improve organization performance."

Based on record review, interview and policy review, the hospice failed to ensure medical social work (MSW) services were provided as indicated in the plan of care (POC) for seven of 11 patients (Patient (P)1, P3, P4, P6, P7, P8, P11) in which social work interventions were included in the plan of care. This failure presents a potential for the hospice to be unable to ensure that the interdisciplinary group identify and address psychosocial issues that either impede or facilitate the patient's treatment. This had the potential to affect the 10 patients who were currently receiving hospice services and all future hospice patients. --- The agency policy titled "Social Services Assessment and Care," dated 07/13/20 indicated "The social worker will contribute to the comprehensive assessment and ongoing updated to the comprehensive assessment based on the needs of the patient... after the assessment is performed, ongoing contact will be maintained by phone and /or home visits by the social worker." 1. Record review revealed P1 was admitted to the hospice agency on 03/12/22 with the terminal diagnosis of metastatic breast cancer. During review of the plan of care dated 03/12/22, it was noted that the interventions included a patient problem/need titled ";Solution Focused Counseling" that listed multiple interventions for the medical social worker which included, ";Social Worker will provide solution focused counseling by explore and process patients thoughts [sic], feelings and perception...explore resources...discuss alternative coping mechanisms...address feelings of loss...provide psychosocial education... provide pre-bereavement counseling...provide emotional support... explore available sources of support... explore and address feelings of loss." Review of documentation of physician orders and visit notes revealed that after the initial assessment by the MSW dated 03/17/22, no further MSW visits were ordered or completed for this patient. There was no documentation in the clinical record to indicate that these interventions identified in the patients plan of care had been completed or had been re-assessed. 2. Record review revealed P3 was admitted to the hospice agency on 02/01/22 with the terminal diagnosis of prostate cancer. During review of the plan of care dated 02/01/22, it was noted that the interventions included a patient problem/need titled ";Medical Social Work: Care Coordination" that listed multiple interventions for the medical social worker which included, ";discuss resources for mortuary services...assist patient/caregiver with funeral planning as needed...educate patient/caregiver on respite care...assist with respite care arrangements." Review of physician orders and visit notes revealed that after the initial assessment by the MSW dated 02/08/22, no further MSW visits were ordered or completed for this patient. During a home visit conducted to this patient on 10/18/22, when this surveyor asked the patient if visits from the social worker were being conducted, the patient replied ";none." There was no documentation in the clinical record to indicate that these interventions identified in the patients plan of care had been completed or had been re-assessed. 3. Review of P4s medical record provided by the agency, revealed P4s assessment indicated a start of care (SOC) date 0f 10/05/22. Review of P4s plan of care dated 10/12/22 revealed, a problem as ";Solution Focused Counseling . . . Goal: Solution Focused Counseling Goal . . . Patient/caregiver will understand social/emotional issues and follow- through while on service. Intervention: Enhance coping . . . Frequency: Each visit: Social Worker will provide solution focused counseling by Explore and process patients thoughts, feelings and perceptions around issues related to current circumstances. Explore resources for coping with patient/family. Explore and discuss alternative coping strategies with patient/cg [care giver]/family, Explore available sources of support, Explore patient/cg/family understanding of disease, Explore aspects of personal history and Explore and address feelings of loss, anticipatory grief and expression of concerns and Provide psychological education regarding sign and symptoms of behaviors related to trauma, codependency, grief and loss and support needs, Provide a supportive positive feedback and encouragement, Reinforce the importance of self-care and encourage continued attention to self-care, Provide emotional support via active and reflective listening, Respond to patient/cg/family feelings, Normalize and validate patient/cg/family feeling/experience and Collaboration with interdisciplinary team members." Review of physician orders revealed a one-time visit during the week of 10/05/22 to 10/08/22. Further review revealed no future visits scheduled. 4. Review of P6s medical record provided by the agency, revealed P6s assessment indicated a SOC date of 09/26/22. Review of P6s plan of care dated 09/30/22 revealed, a problem as ";Solution Focused Counseling . . . Goal: Solution Focused Counseling Goal . . . Patient/caregiver will understand social/emotional issues and follow- through while on service. Intervention: Enhance coping . . . Frequency: Each visit: Social Worker will provide solution focused counseling by Explore and process patients thoughts, feelings and perceptions around issues related to current circumstances. Explore resources for coping with patient/family. Explore and discuss alternative coping strategies with patient/cg [care giver]/family, Explore available sources of support, Explore patient/cg/family understanding of disease, Explore aspects of personal history and Explore and address feelings of loss, anticipatory grief and expression of concerns and Provide psychological education regarding sign and symptoms of behaviors related to trauma, codependency, grief and loss and support needs, Provide a supportive positive feedback and encouragement, Reinforce the importance of self-care and encourage continued attention to self-care, Provide emotional support via active and reflective listening, Respond to patient/cg/family feelings, Normalize and validate patient/cg/family feeling/experience and Collaboration with interdisciplinary team members." Review of physician orders revealed a one-time visit during the week of 09/26/22 to 10/01/22. Further review revealed no future visits scheduled. 5. Review of P7s medical record provided by the agency, revealed P7s assessment indicated a SOC date 0f 05/13/22. Review of P7s plan of care dated 05/19/22 revealed, a problem as ";Solution Focused Counseling . . . Goal: Solution Focused Counseling Goal . . . Patient/caregiver will understand social/emotional issues and follow- through while on service. Intervention: Enhance coping . . . Frequency: Each visit: Social Worker will provide solution focused counseling by Explore and process patients thoughts, feelings and perceptions around issues related to current circumstances. Explore resources for coping with patient/family. Explore and discuss alternative coping strategies with patient/cg [care giver]/family, Explore available sources of support, Explore patient/cg/family understanding of disease, Explore aspects of personal history and Explore and address feelings of loss, anticipatory grief and expression of concerns and Provide psychological education regarding sign and symptoms of behaviors related to trauma, codependency, grief and loss and support needs, Provide a supportive positive feedback and encouragement, Reinforce the importance of self-care and encourage continued attention to self-care, Provide emotional support via active and reflective listening, Respond to patient/cg/family feelings, Normalize and validate patient/cg/family feeling/experience and Collaboration with interdisciplinary team members." Review of physician orders revealed a one- time visit during the week of 05/15/22 to 05/21/22. Further review revealed no future visits scheduled. 6. Review of P8s medical record provided by the agency, revealed P8s assessment indicated a SOC date 0f 06/24/22. Review of P8s plan of care dated 06/28/22 revealed, a problem as ";Solution Focused Counseling . . . Goal: Solution Focused Counseling Goal . . . Patient/caregiver will understand social/emotional issues and follow- through while on service. Intervention: Enhance coping . . . Frequency: Each visit: Social Worker will provide solution focused counseling by Explore and process patients thoughts, feelings and perceptions around issues related to current circumstances. Explore resources for coping with patient/family. Explore and discuss alternative coping strategies with patient/cg [care giver]/family, Explore available sources of support, Explore patient/cg/family understanding of disease, Explore aspects of personal history and Explore and address feelings of loss, anticipatory grief and expression of concerns and Provide psychological education regarding sign and symptoms of behaviors related to trauma, codependency, grief and loss and support needs, Provide a supportive positive feedback and encouragement, Reinforce the importance of self-care and encourage continued attention to self-care, Provide emotional support via active and reflective listening, Respond to patient/cg/family feelings, Normalize and validate patient/cg/family feeling/experience and Collaboration with interdisciplinary team members." Review of physician orders revealed a one- time visit during the week of 06/24/22 to 06/28/22. Further review revealed no future visits scheduled. 7. Record review revealed P11 was admitted to the hospice agency on 05/03/22 with the terminal diagnosis of prostate cancer. During review of the plan of care dated 05/03/22, , it was noted that the interventions included a patient problem/need titled ";Solution Focused Counseling" that listed multiple interventions for the medical social worker such as ";Social Worker will provide solution focused counseling by explore and process patients thoughts [sic], feelings and perception...explore resources...discuss alternative coping mechanisms...address feelings of loss...provide psychosocial education... provide pre-bereavement counseling...provide emotional support... explore available sources of support... explore and address feelings of loss." However, after the initial assessment by the MSW dated 05/12/22, no further MSW visits were ordered or completed for this patient. There was no documentation in the clinical record to indicate that these interventions identified in the patients plan of care had been completed or had been re-assessed. During an interview completed on 10/18/22 at 8:30 AM, the MSW stated that other than the assessment visit completed at the time of admission, additional MSW visits to the hospice patients are rarely scheduled. When asked if the MSW could provide an example of follow up visits that had been completed for any hospice patient, the MSW stated ";not that I can think of."

Based on interview and record review, the agency failed to ensure a dietician was consulted for two of two sampled patients reviewed (Patient (P)6 and P8). Both patients had diagnoses of malnutrition, however review of the plan of care and notes did not indicate a dietician was consulted for consult. This deficient practice had the potential to allow patients the consultation for minimizing the stress and problems a terminal illness may cause. --- Review of P6s medical record provided by the agency revealed a start of care (SOC) date of 09/26/22 and an admitting diagnosis of severe protein calorie malnutrition. Review of P6s plan of care dated 09/26/22 revealed no goals or interventions in place to assist with P6s malnutrition. There was no consult from a dietician with advice how to ensure P6s comfort in dealing with his terminal illness. During an interview on 10/18/22 at 2:49 PM, the Hospice Manager (Mgr) was asked if they had a dietician. The Mgr stated the dietician is available for consultation if the needed. The Mgr was asked if she would expect a dietician consult based on the diagnosis of the patient. The Mgr stated, ";Yes. I would expect a consult." Review of P8s medical record provided by the agency revealed a start of care (SOC) date of 06/24/22 and an admitting diagnosis of malnutrition. Review of P8s recertification plan of care dated 09/22/22 revealed no goals or interventions in place to assist with P8s malnutrition. There was no consult from a dietician with advice how to ensure P8s comfort in dealing with his terminal illness. During an interview on 10/19/22 at 11:00 AM, the Hospice Manager (Mgr) was asked if they had a dietician. The Mgr stated the dietician is available for consultation if the needed. The Mgr was asked if she would expect a dietician consult based on the diagnosis of the patient. The Mgr stated, ";Yes. I would expect a consult." During an interview on 10/19/22 at 2:21 PM, the Registered Nurse (RN)5 was asked about a consult with a dietician for the patients. RN5 stated the patients do eat and this is not something that came on suddenly. ";We do what the patient and family want." During exit on 10/19/22 at 4:00 PM, the Administrator was asked about a policy for consults. The Administrator stated there was not a policy.