Every finding on record at Unicare Hospice, Inc

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 record review, document review, and interview. In 9 of 11 (82%) clinical records reviewed which included medical social services, the agency did not ensure that each patient's individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Agency policy 1-019 Psychosocial Assessment dated April 2020, stated in part, issues identified related to patient coping will be included in the comprehensive assessment and addressed in the plan of care. Agency policy 9-017 The Plan of Care dated April 2020, stated in part, each patient will be monitored for his/her response to care, or services provided against established patient goals and patient outcomes to evaluate progress toward goals. Care decisions and services to be provided will be made as a result of the care planning process and analysis of patient response to care against goals and outcomes. The written plan of care will contain measurable outcomes anticipated from implementing and coordinating the plan of care. Agency policy 1-036 Interdisciplinary Group Meeting dated April 2020, stated in part, "The interdisciplinary group will conduct assessments, develop and update the plan of care and review the effectiveness of care." Clinical Record 3: The patient elected the hospice benefit on 3/2/2023 with a terminal diagnosis of Alzheimer’s disease. The plan of care included a physician order for the Medical Social Worker (MSW) to provide visits monthly. The MSW documented visits on 3/7/2023, 5/1/2023, and 8/24/2023. Review of the plans of care from admission on 3/2/2023 through the date of record review on 9/19/2023 revealed the plans of care did not include patient/family goals and planned interventions based on the patient’s psychosocial assessment by the MSW. Clinical Record 4: The patient elected the hospice benefit on 3/22/2022 with a terminal diagnosis of multiple sclerosis. The plan of care included a physician order for the MSW to provide visits monthly. The MSW documented visits on 3/31/2023 and 9/15/2023. Review of the plans of care from admission on 3/22/2022 through the date of record review on 9/19/2023 revealed the plans of care did not include patient/family goals and planned interventions based on the patient’s psychosocial assessment by the MSW. Clinical Record 5: The patient elected the hospice benefit on 5/15/2023. The plan of care dated 5/15/2023 included a physician order for the MSW to provide visits monthly. The MSW documented visits on 5/19/2023 and 8/10/2023. A review of the plans of care from admission on 5/15/2023 through the date of record review on 9/19/2023 revealed the plans of care did not include patient/family goals and planned interventions based on the patient’s psychosocial assessment by the MSW. Clinical Record 8: The patient elected the hospice benefit on 7/12/2023 with a terminal diagnosis of Parkinson’s disease. The plan of care included a physician order for the MSW to provide visits monthly. The MSW documented the initial visit dated 7/13/2023. Review of the plan of care dated 7/12/2023 revealed the plan of care did not include patient/family goals and planned interventions based on the patient’s psychosocial assessment by the MSW. Clinical Record 9: The patient elected the hospice benefit on 3/6/2023 with a terminal diagnosis of atherosclerotic heart disease. An order was documented on 3/7/2023 for MSW visits to be provided monthly. A review of the patient's plans of care from admission on 3/6/2023 through the date of record review on 9/19/2023 revealed the plans of care did not include patient/family goals and planned interventions based on the patient’s psychosocial assessment by the MSW. Clinical Record 10: The patient elected the hospice benefit on 7/5/2023 with a terminal diagnosis of anemia. An order was documented on 7/5/2023 for MSW visits to be provided monthly. A review of the patient's plan of care dated 7/5/2023 revealed the plan of care did not include patient/family goals and planned interventions based on the patient’s psychosocial assessment by the MSW. Clinical Record 11: The patient elected the hospice benefit on 2/20/2023 with a terminal diagnosis of Alzheimer’s disease. An order was documented on 2/20/2023 for MSW visits to be provided monthly. A review of the patient's plans of care from admission on 2/20/2023 through the date of discharge on 5/15/2023 revealed the plans of care did not include patient/family goals and planned interventions based on the patient’s psychosocial assessment by the MSW. Clinical Record 12: The patient elected the hospice benefit on 2/10/2023 with a terminal diagnosis of Alzheimer’s disease. An order was documented on 2/10/2023 for MSW visits to be provided monthly. A review of the patient's plan of care dated 2/10/2023 revealed the plan of care did not include patient/family goals and planned interventions based on the patient’s psychosocial assessment by the MSW. Clinical Record 14: The patient elected the hospice benefit on 10/7/2022 with a terminal diagnosis of lung cancer. An order was documented on 10/7/2023 for MSW visits to be provided monthly. A review of the patient's plans of care from admission on 10/7/2022 through the date of discharge on 4/22/2023 revealed the plans of care did not include patient/family goals and planned interventions based on the patient’s psychosocial assessment by the MSW. During an interview on 9/19/2023, the Director of Patient Care Services (DPCS) and the Clinical Manager confirmed that the Social Worker did not include documentation of any identified problems or interventions in the patient's care plans. When the DPCS spoke to the Social Worker, the Social Worker said that she thought putting information into the visit notes was all that was required to be documented.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. This standard was not met as evidenced by record review and interview. In 7 of 14 (50%) clinical records reviewed, the agency did not ensure that the Interdisciplinary Group (IDG) documented review and revision of the patient's care plan at least every 15 calendar days. Clinical Record 3: The patient elected the hospice benefit on 3/2/2023 with a terminal diagnosis of Alzheimer’s disease. Clinical record review revealed the IDG documented review of the patient’s plan of care during the IDG meeting dated 6/2/2023. The next IDG review/meeting was dated 6/20/2023, 18 days after the 6/2/2023 meeting and 3 days outstanding. Clinical Record 4: The patient elected the hospice benefit on 3/22/2022 with a terminal diagnosis of multiple sclerosis. Clinical record review revealed the IDG documented review of the patient’s plan of care during the IDG meeting dated 6/2/2023. The next IDG review/meeting was dated 6/20/2023, 18 days after the 6/2/2023 meeting and 3 days outstanding. Clinical Record 5: The patient elected the hospice benefit on 5/15/2023. Clinical record review revealed the IDG documented review of the patient’s plan of care during the IDG meeting dated 6/2/2023. The next IDG review/meeting was dated 6/20/2023, 18 days after the 6/2/2023 meeting and 3 days outstanding. Clinical Record 6: The patient elected the hospice benefit on 12/22/2022 with a terminal diagnosis of heart failure. Clinical record review revealed the IDG documented review of the patient’s plan of care during the IDG meeting dated 6/2/2023. The next IDG review/meeting was dated 6/20/2023, 18 days after the 6/2/2023 meeting and 3 days outstanding. Clinical Record 7: The patient elected the hospice benefit on 11/30/2022 with a terminal diagnosis of chronic obstructive pulmonary disease. Clinical record review revealed the IDG documented review of the patient’s plan of care during the IDG meeting dated 6/2/2023. The next IDG review/meeting was dated 6/20/2023, 18 days after the 6/2/2023 meeting and 3 days outstanding. Clinical Record 9: The patient elected the hospice benefit on 3/6/2023 with a terminal diagnosis of atherosclerotic heart disease. Clinical record review revealed the IDG documented review of the patient’s plan of care during the IDG meeting dated 6/2/2023. The next IDG review/meeting was dated 6/20/2023, 18 days after the 6/2/2023 meeting and 3 days outstanding. Clinical Record 13: The patient elected the hospice benefit on 11/5/2021 with a terminal diagnosis of congestive heart failure. Clinical record review revealed the IDG documented review of the patient’s plan of care during the IDG meeting dated 6/2/2023. The next IDG review/meeting was dated 6/20/2023, 18 days after the 6/2/2023 meeting and 3 days outstanding. During an interview on 9/18/2023, the Director of Patient Care Services and the Clinical Manager confirmed there was an 18-day gap between the Interdisciplinary Group Meetings held in June on 6/2/2023 and 6/20/2023.

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by record review, document review, and interview. In 1 of 12 (8%) clinical record reviews in which a Licensed Vocational Nurse (LVN) provided care, the agency did not ensure nursing care supervision by a Registered Nurse (RN). Agency policy 1-031 "Responsibilities/Supervision of Clinical Services" dated April 2020, stated in part, "A monthly patient visit will be completed by the RN to supervise licensed practical/vocational nursing services." Clinical Record 4: The patient elected the hospice benefit on 3/22/2022, with a terminal diagnosis of multiple sclerosis. The LVN provided nursing visits on 7/25/2023, 7/28/2023, 8/1/2023, 8/8/2023, 8/11/2023, 8/15/2023, 8/22/2023, 8/25/2023, and 8/29/2023. The RN documented supervision of the LVN on 7/21/2023. The next RN supervisory visit was dated 9/1/2021, 42 days after the RN Supervisory visit dated 7/21/2023. The RN did not provide LVN supervisory visits monthly as stated in agency policy. During an interview on 9/19/2023, the Director of Patient Care Services and the Clinical Manager confirmed the Registered Nurse did not document supervision of the LVN monthly as per agency policy.

It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, and per the plan of care. This standard was not met as evidenced by record review and interview. In 4 of 11 (36%) clinical records reviewed which include medical social services, the agency did not ensure medical social services were provided per the plan of care. Clinical Record 3: The patient elected the hospice benefit on 3/2/2023 with a terminal diagnosis of Alzheimer’s disease. The plan of care included a physician order for the Medical Social Worker (MSW) to provide visits monthly. The MSW documented visits on 3/7/2023, 5/1/2023, and 8/24/2023. The clinical record contained no documented evidence of MSW visits for April, June, and July 2023 and no documentation of missed visits by the MSW. Clinical Record 4: The patient elected the hospice benefit on 3/22/2022 with a terminal diagnosis of multiple sclerosis. The plan of care included a physician order for the MSW to provide visits monthly. The MSW documented visits on 3/31/2023 and 9/15/2023. The clinical record contained no documented evidence of MSW visits for April, May, June, July, and August 2023 and no documentation of missed visits by the MSW. Clinical Record 5: The patient elected the hospice benefit on 5/15/2023. The plan of care dated 5/15/2023 included a physician order for the MSW to provide visits monthly. The MSW documented visits on 5/19/2023 and 8/10/2023. The clinical record contained no documentation of MSW visits for June or July 2023 and no documentation of missed visits by the MSW. Clinical Record 8: The patient elected the hospice benefit on 7/12/2023 with a terminal diagnosis of Parkinson’s disease. The plan of care included a physician order for the MSW to provide visits monthly. The MSW documented the initial visit dated 7/13/2023 but did not document a MSW visit for August 2023. The clinical record contained no documentation of a missed visit by the MSW for August. During an interview on 9/19/2023, the Director of Patient Care Services (DPCS) and the Clinical Manager confirmed that the Social Worker did not provide visits per the plan of care frequency ordered and did not include documentation of missed visits in the clinical record.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by record review and interview. In 2 of 9 (22%) clinical records reviewed in which Hospice Aide services were provided, the agency did not ensure the Registered Nurse (RN) performed supervision of the Hospice Aide every 14 days. Clinical Record 4: The patient elected the hospice benefit on 3/22/2022, with a terminal diagnosis of multiple sclerosis. The Hospice Aide provided care once a week per physician order dated 3/22/2022. The RN documented a supervisory visit dated 7/21/2023. The next RN supervisory visit was dated 9/1/2021, 42 days after the supervisory visit dated 7/21/2023. The RN did not provide Hospice Aide supervisory visits every 14 days as required by the standard. Clinical Record 10: The patient elected the hospice benefit on 7/5/2023, with a terminal diagnosis of anemia. The Hospice Aide provided care twice a week per order dated 7/5/2023. The first Hospice Aide visit to the patient was dated 7/7/2023. The RN documented a Hospice Aide supervisory visit on 7/19/2023 and the next Aide supervisory visit by the RN was dated 8/3/2023, which was 15 days between supervisory visits. The RN then documented a supervisory Visit was dated 8/18/2023, which was 15 days between supervisory visits. The RN documented the next Aide Supervisory visit on 8/30/2023, and the following aide supervisory visit was dated 9/14/2023, which was 15 days between supervisory visits. During an interview on 9/19/2023, the Director of Patient Care Services and the Clinical Manager confirmed Hospice Aide supervision was not documented every 14 days as required.

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 and the patient's record, if requested. This standard was not met as evidenced by record review and interview. In 1 of 2 (50%) clinical records reviewed that included a live discharge from hospice care, the agency did not ensure the discharge summary was sent to the attending physician. Clinical Record 11: The patient elected the hospice benefit on 2/20/2023 with a terminal diagnosis of Alzheimer’s disease. The patient revoked the hospice benefit on 5/15/2023. The clinical record contained no documented evidence that the discharge summary was sent to the patient’s attending physician. During an interview on 9/19/2023, the Director of Patient Care Services and the Clinical Manager confirmed there was no documentation in the clinical record that the discharge summary was forwarded to the patient's 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 the following: 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 record review and interview. In 1 of 2 (50%) clinical records reviewed that included a live discharge from hospice care, the agency did not ensure the discharge summary included 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. Clinical Record 11: The patient elected the hospice benefit on 2/20/2023, with a terminal diagnosis of Alzheimer’s disease. The patient revoked hospice services on 5/15/2023. In the discharge summary completed by the Registered Nurse (RN) dated 5/15/2023, the RN documented “Patient decided to revoke hospice services due to patient decided to seek further treatment not included in hospice services. SN [skilled nurse] reviewed revocation form and process and form signed by daughter/POA. Notified MD and order carried out, notified IDG [interdisciplinary group] team." This was the only information documented for the patient’s discharge summary. The discharge summary did not include 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. During an interview on 9/19/2023, the Director of Patient Care Services and the Clinical Manager confirmed the discharge summary did not contain the required components.

It is required that the designated IDG [interdisciplinary group] member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: physician certification and recertification of the terminal illness. This standard was not met as evidenced by record review and observation. In 1 of 1 (100%) home visit observations with a patient that resided in a SNF/NF [skilled nursing facility/ nursing facility], the agency did not ensure that the patient's most recent Certification of Terminal Illness (CTI) was provided to the facility. Home Visit 2: The patient elected the hospice benefit on 3/2/2023 with a terminal diagnosis of Alzheimer's disease. During the home visit observation review of the facility chart revealed a copy of the patient's CTI for the benefit period 8/29/23 to 10/27/23 was no in the SNF chart. During an interview on 9/19/2023, the Director of Patient Care Services and the Clinical Manager confirmed that the agency did not have documentation that the latest Certification of Terminal Illness was sent to the skilled nursing facility.