Every finding on record at VNA & Hospice of Cooley Dickinson, Inc

Based on record review, policy review and interview, the agency failed to ensure an initial bereavement risk assessment was completed upon admission for 5 Patients (#5, #15, #17, #18 and #8), out of a total sample of 19 patients. Findings include: --- Review of the agency policy, entitled, Comprehensive Assessment of the Hospice Patient, revised 4/2024, indicated the following: *The Hospice Interdisciplinary Group (IDG), in consultation with the patient's attending physician (if any), must complete the comprehensive assessment no later than five calendar days after the election of Hospice care. *The initial bereavement risk assessment is part of the initial comprehensive assessment and is updated as needed throughout a hospice episode of care as well as after death. 1. Patient #5 was admitted to the agency in September 2023 with a diagnosis of right lung cancer. Review of the clinical record did not contain any evidence that an initial bereavement risk assessment was completed upon admission. 2. Patient #15 was admitted to the agency in January 2024 with a diagnosis of Exacerbation of Chronic Obstructive Pulmonary Disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Review of the clinical record did not contain any evidence that an initial bereavement risk assessment was completed upon admission. 3. Patient #17 was admitted to the agency in November 2023 with a diagnosis of cerebrovascular disease (group of conditions that impact the brain's blood vessels). Review of the clinical record did not contain any evidence that an initial bereavement risk assessment was completed upon admission. 4. Patient #18 was admitted to the agency in December 2023 with a diagnosis of right lung cancer. Review of the clinical record did not contain any evidence that an initial bereavement risk assessment was completed upon admission. 5. Patient #8 was admitted to the agency in June 2023 with a diagnosis of chronic diastolic Congestive Heart Failure (CHF)-(heart does not pump blood adequately). Review of the clinical record indicated an initial bereavement risk assessment was not completed until 9/9/24, despite the patient's admission date of June 2023. During an interview on 11/27/24 at 8:15 A.M., the Quality Director after reviewing the clinical record, said the initial bereavement risk assessment was not completed timely upon admission for Patient #8, as required. During an interview on 11/27/24 at 12:30 P.M., the Quality Director after reviewing the clinical records for Patients #5, #15, #17 and #18, said the initial bereavement risk assessments were not completed upon admission, as required.

Based on record review and interview, the agency failed to ensure care and services were provided in accordance with the plan of care (POC), for 2 patients (#10 and #12), out of a total sample of 19 patients. Findings include: --- Review of the agency policy, entitled, Establishment & Revision of Hospice Plan of Care, revised 11/2023, included the following: *A comprehensive, individualized hospice plan of care is established, after initial assessment, by the interdisciplinary team (IDT), in collaboration with the community attending physician and the patient/family. *The care plan will include: 1. Problems expressed by the patient or assessed by staff. 2. Realistic and achievable goals. 3. Care, instruction, counseling, or support to be given to meet patient goals. 4. The disciplines qualified and assigned to give the care. 5. Medications and treatments. 6. Visit frequency. 7. Bereavement screening. 1. For Patient #10, the agency failed to ensure 2 Home Health Aide Visits (HHAVs) were provided, as ordered. Patient #10 was admitted to the agency in September 2024 with a diagnosis of Chronic Kidney Disease, Stage 5 (signifies kidney failure and dialysis or kidney transplant is required). Review of the physician ordered Hospice POC for certification period 9/3/24 through 12/1/24, indicated the following: *HHAV 2 visits weekly for 13 weeks. Review of the clinical record indicated the following: -1 HHAV was provided for the week of 10/13/24 through 10/19/24. -1 HHAV was provided for the week of 10/20/24 through 10/26/24. During an interview on 11/27/24 at 8:30 A.M., the Quality Director said 2 HHAVs were not provided for the weeks of 10/20/24 through 10/26/24 and 10/24/243 through 10/26/24, as ordered. 2. For Patient #12, the agency failed to ensure a HHAV was provided, as ordered. Patient #12 was admitted to the agency in October 2023 with a diagnosis of sequelae of cerebral infarction (long-term effects of a stroke). Review of the physician ordered Hospice POC for certification period 8/12/24 through 10/10/24, indicated the following: *HHAV 3 visits weekly for 9 weeks. Review of the clinical record indicated the following: -1 HHAV was provided for the week of 9/22/24 through 9/28/24. -2 HHAVs were provided for the week of 10/6/24 through 10/12/24. Review of the physician ordered Hospice POC for certification period 10/11/24 through 12/9/24, indicated the following: *3 HHAVS every week for 8 weeks. Review of the clinical record indicated the following: -2 HHAVs were provided the week of 10/13/24 through 10/19/24. During an interview on 11/26/24 at 3:00P.M., the Quality Director after reviewing the clinical record said the missed HHAVs were cancelled and she could not provide a reason why the visits were cancelled. She further said the POC was not followed, as required.

Based on record review and interview, the agency failed to ensure there was communication shared with the physician when services were not provided, as ordered, for 2 Patients (#10 and #12), out of a total sample of 19 patients. Findings include: --- 1.Patient #10 was was admitted to the agency in September 2023 with a diagnosis of Chronic Kidney Disease, Stage 5 (signifies kidney failure and dialysis or kidney transplant is needed). Review of the physician ordered Hospice Plan of Care (POC) for certification period 9/3/24 through 12/1/24, indicated the following: *Home Health Aide Visit (HHAV) 2 visits weekly for 13 weeks. Review of the clinical record indicated the following: -1 HHAV was provided for the week of 10/13/24 through 10/19/24. -1 HHAV was provided for the week of 10/20/24 through 10/26/24. Review of the clinical record did not contain documentation that the physician had been notified of the missed visits and that the POC was not followed. During an interview on 11/27/24 at 8:36 A.M., the Quality Director said the staff is to notify the physician and document the notification of of services not implemented, as ordered. She further said she could not find any evidence in the clinical record that the physician had been notified of the missed HHAVs, as required. 2. Patient #12 was admitted to the agency in October 2023 with a diagnosis of sequelae of cerebral infarction (long term effects of a stroke). Review of the physician ordered Hospice POC for certification period 8/12/24 through 10/10/24, indicated the following: *HHAV 3 visits weekly for 9 weeks. Review of the clinical record indicated the following: -1 HHAV was cancelled for the week of 9/22/24 through 9/28/24. Review of the physician ordered Hospice POC for certification period 10/11/24 through 12/9/24, indicated the following: *3 HHAVS every week for 8 weeks. Review of the clinical record indicated the following: -1 HHAV was cancelled for the week of 10/13/24 through 10/19/24. Review of the clinical record did not contain documentation that the physician had been notified of the missed HHAVs and that the POC was not followed. During an interview on 1126/24 at 3:00 P.M., the Quality Director said she could not find any evidence in the clinical record that the physician had been notified of the missed HHAVs, as required.

Based on record review, policy review and interview, the agency failed to ensure that clinical documentation was complete, appropriately authenticated, and dated in accordance with current accepted standards of practice for 8 Patients (#5, #8, #11, #13, #14, #16, #17 and #19), out of a total sample of 19 patients. Findings include: --- Review of the agency policy, entitled, Hospice Documentation Policy, revised 5/25/23, indicated the following: *All documentation must be completed according to the following guideline: -Routine Visit-1 calendar day. 1. Patient #5 was admitted to the agency in September 2023 with a diagnosis of right lung cancer. Review of the physician ordered Hospice Plan of Care for certification period 11/16/24 through 1/14/25, indicated the following: -Skilled Nurse Visit (SNV) 2 visits weekly for 8 weeks. Review of the clinical record indicated the following SNV notes that were signed/dated after the visit: *11/5/24 visit note was signed on 11/7/24. *11/8/24 visit note was signed on 11/10/24. 2. Patient #8 was admitted to the agency in June 2024 with a diagnosis of chronic diastolic Congestive Heart Failure (CHF)-(heart does not pump blood adequately). Review of a physician order, dated 11/12/24. indicated 1 Volunteer Visit (VV) weekly for the following weeks: -10/13/24-10/19/24. -10/27-10/31/24. -11/3-11/9/24. -11/17/24-11/23/24. Review of the clinical record indicated the following VV notes that were signed/dated after the visit: *10/17/24 visit note was signed on 10/21/24. *10/31/24 visit note was signed on 11/5/24. *11/7/24 visit note was signed on 11/11/24. 3. Patient #11 was admitted to the agency in October 2024 with a diagnosis of Parkinson's Disease (progressive disorder that affects the nervous system and causes tremors). Review of the physician order, dated 11/21/24, indicated 1 VV weekly for 2 weeks between 11/10/24 through 11/23/24. Review of the clinical record indicated the following VV note that was signed/dated after the visit: *11/13/24 visit note was signed on 11/21/24. 4. Patient #13 was admitted to the agency in October 2024 with a diagnosis of Alzheimer's Disease. Review of the physician ordered Plan of Care for certification period 10/7/24 through 1/14/25, indicated the following: -SNV 2 visits every week for 12 weeks. Review of the clinical record indicated the following SNV note that was signed/dated after the visit: *11/1/24 visit note was signed on 11/4/24. Review of a physician order, dated 11/10/24, indicated the following VV: -VV 2 times weekly 11/10/24 through 11/16/24. Review of the clinical record indicated the following VV notes that were signed/dated after the visit: *11/11/24 visit note was signed on 11/20/24. *11/15/24 visit note was signed on 11/20/24. 5. Patient #14 was admitted to the agency in October 2024 with a diagnosis of Myelodysplastic Syndrome (a group of cancers in which immature blood cells in the bone marrow do not mature). Review of the physician ordered Hospice Plan of Care for certification period 10/11/24 through 1/8/25, indicated the following: -SNV 2 visits weekly for 12 weeks. Review of the clinical record indicated the following visit notes that were signed/ dated after the visit: *11/1/24 visit note was signed on 11/4/24. *11/8/24 visit note was signed on 11/11/24. 6. Patient #16 was admitted to the agency in August 2024 with a diagnosis of kidney cancer. Review of the physician order, dated 11/5/24, indicated the following VVs: -1 Visit 9/1/24-9/7/24. -2 Visits 9/8/24-9/14/24. -1 Visit 9/15/24-9/21/24. -1 Visit 10/1/24-10/5/24. -1 Visit 10/27/24-10/31/24. Review of the clinical record indicated the following Volunteer visit notes that were signed/dated after the visit: *9/5/24 visit note was signed on 9/10/24. *9/14/24 visit note was signed on 9/23/24. *9/19/24 visit note was signed on 9/23/24. *10/2/24 visit note was signed on 10/8/24. *10/31/24 visit note was signed on 11/5/24. 7. Patient #17 was admitted to the agency in November 2023 with a diagnosis of cerebrovascular disease (group of conditions that impact the brain's blood vessels). Review of the physician ordered Plan of Care for certification period 11/22/23 through 2/19/24, indicated the following: -SNV 1 visit weekly for 13 weeks. Review of the clinical record indicated the following SNV note that was signed/dated after the visit : *11/22/23 visit note was signed on 11/27/23. 8. Patient #19 was admitted to the agency in March 2024 with a diagnosis of atherosclerosis of native coronary artery (build up of plaque in the arteries that supply the heart). Review of the physician ordered Plan of Care for certification period 3/12/24 through 5/17/24, indicated the following: -HHAV 3 visits weekly for 9 weeks (4/7/24 through 6/8/24, was discontinued as of 5/6/24). -HHAV 5 visits weekly for 5 weeks (5/5/24 through 6/8/24, was discontinued as of 5/17/24). Review of the clinical record indicated the following HHAV notes that were signed/dated after the visit: *4/24/24 visit note was signed on 4/28/24. *4/26/24 visit note was signed on 4/29/24. *4/29/24 visit note was signed on 5/2/24. *5/1/24 and 5/3/24 visit notes were signed on 5/5/24. *5/6/24 visit note was signed on 5/8/24. *5/9/24 and 5/10/24 visit notes were signed on 5/12/24. *5/13/24 visit note was signed on 5/15/24. *5/14/24 and 5/15/24 visit notes were signed on 5/18/24. During an interview on 11/26/24 at 1:00 P.M., the Quality Director, after reviewing the records for Patients #5, #8, #11, #13, #14, #16, #17 and #19, said the staff are expected to sign and date their notes as completed within 24 hours of the visit. She said the above notes were all signed and dated more than 24 hours after the visits, making them late.

Based on record review and staff interview, the Hospice Agency failed to update the plan of care relative to frequency of visits by Hospice Aides for one Patient (#1), out of a total sample of 13 patients. Findings include: Patient #1 was admitted onto hospice services in 10/2021 with a diagnosis of cerebral atherosclerosis. Review of the Plan of Care indicated the Hospice Aide to visit two times per week. There were no visits documented after 11/05/21. There was no physician order in place to indicate a change in the frequency of the Hospice Aide visits. Review of the Hospice Agency Physician Orders Policy, dated 4/2018, included: More frequent review/revision of the physician orders may be needed on the following instances, but not limited to: a. Change in patient condition b. Lapse in service c. Response to care d. New diagnosis e. Outcome related to care f. Payer requirement During an interview on 12/22/21 at 1:50 P.M., the Director of Quality said the Physician had not been notified timely that the Patient refused Hospice Aide visits. She further said there was no Physician Order obtained to discontinue the Hospice Aide visits due to patient/family not accepting of visits until 12/08/21.