Every finding on record at Westminster Canterbury Richmond at Home

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment was updated at lease every 15 days CLINICAL RECORD 2: The patient elected the hospice benefit 01/07/2025 with a diagnosis of malignant neoplasm of upper right lobe bronchus or lung. The comprehensive assessment was completed on admission 01/07/2025 then again on 2/3/2025 (27 days), 2/20/2025 (17 days) and 3/21/2025 (29 days). CLINICAL RECORD 3: The patient elected the hospice benefit on 02/24/2025 with a diagnosis of Hypertensive Heart Disease. A comprehensive assessment was competed on 03/10/2025 and was due again on 03/25/2025. There was no documented evidence that the comprehensive assessment had been completed as of the end of the site visit on 03/26/2025. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/19/2024 with a diagnosis of chronic obstructive pulmonary disease. The comprehensive assessments done on admission 10/19/2024 then again on 11/07/2024 (19 days), 12/05/20245 (28 days) and 01/16/2025 (42 days). CLINICAL RECORD 6: The patient elected the hospice benefit on 02/17/2025 with a diagnosis of Sepsis. A comprehensive assessment was completed on admission 02/17/2025 and not again until 03/05/2025 (16 days). CLINICAL RECORD 8: The patient elected the hospice benefit on 11/05/2024 with a diagnosis of neoplasm of the right kidney. The comprehensive assessment was completed on 01/30/2025 and not again until 2/27/2025 (28 days). In an interview with the clinical director (Personnel Record 6), she agreed the RN case manager did not complete the comprehensive assessment updates in a timely manner.

It is required that each patient’s individualized written plan of care: Measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure that the plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 6: The patient elected the hospice benefit on 02/17/2025 with diagnosis of Sepsis Unspecified Organism. It was documented on the initial certification of terminal illness (CTI) dated 02/18/2025 that the patient has diabetes type 2. The medication profile dated 02/17/2025 included that the patient was taking Humalog and Lantus. The plan of care (POC) dated 02/17/2025 review revealed there were no measurable outcomes on the POC anticipated from implementing and coordinating the plan of care. In an interview with the clinical director, she agreed that the RN did not address measurable outcomes on the plan of care. CLINICAL RECORD 7: The patient elected the hospice benefit on 02/11/20025. It was documented on the POC dated 02/11/2025 that the patient has type 2 diabetes and currently taking Farxiga 5mg oral tablet once daily and Januvia 100mg oral tablet once a day (before a meal). A review of the POC revealed there were no measurable outcomes for managing or monitoring the diabetes anticipated from implementing and coordinating the plan of care. In an interview with the clinical director agreed that the RN did not address measurable outcomes on the plan of care.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical records review and interview. 2 of 11 (18%) clinical records reviewed revealed the hospice did not ensure the interdisciplinary group completed an initial comprehensive assessment within 5 calendar days of the election of hospice care. Record #84539: The patient's initial assessment and start of care were completed on 4/28/22. The chaplain's initial assessment was documented as completed on 5/5/22, 8 days outstanding. The staff confirmed the chaplain's visit was later than 5 days after the initial assessment. . Record #19543: The patient's initial assessment and start of care were completed on 4/13/22. The initial assessment completed by the registered nurse did not include a psychosocial assessment. The clinical record did not include evidence of a completed initial assessment by the social worker or the chaplain. There was no documented evidence of the patient's refusal of psychosocial services. During an interview and a joint review of the records on 6/6/2022 and 6/7/2022, the staff confirmed the findings.

It is required that the comprehensive assessment includes 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. This standard was not met as evidenced by clinical records review and interview. 6 of 11 (55%) clinical records reviewed revealed the hospice did not ensure information from an initial bereavement assessment was gathered and incorporated into the plan of care and considered in the bereavement plan of care. Record #61906: The initial assessment was completed on 11/16/2021 by the registered nurse. The social worker and spiritual coordinator completed initial assessments on 11/16/21 and 11/18/21, respectively. The clinical record included no documented evidence of an initial bereavement assessment and no documented evidence of the patient refusing a bereavement assessment. Record #84539: The initial assessment completed on 4/28/22 by the registered nurse did not include an initial bereavement assessment. The clinical record included documentation of the patient's refusal of the social worker and spiritual care coordinator. The clinical record included no documented evidence of an initial bereavement assessment and no documented evidence of the patient refusing a bereavement assessment. Record #32341: The initial assessment completed on 5/13/22 by the registered nurse did not include an initial bereavement assessment. The clinical record included documentation of the patient's refusal of the social worker and spiritual care coordinator. The clinical record included no documented evidence of an initial bereavement assessment and no documented evidence of the patient refusing a bereavement assessment. Record #19543: The initial assessment was completed on 4/13/21 by the registered nurse. The social worker and spiritual care coordinator completed an initial assessment. The clinical record included no documented evidence of an initial bereavement assessment and no documented evidence of the patient refusing a bereavement assessment. Record #20068: The initial assessment was completed on 3/2/22 by the registered nurse. The social worker and spiritual care coordinator completed an assessment. The clinical record included no documented evidence of an initial bereavement assessment and no documented evidence of the patient refusing a bereavement assessment. Record #28841: The initial assessment was completed on 5/6/22 by the registered nurse. The social worker and spiritual care coordinator completed an assessment. The clinical record included no documented evidence of an initial bereavement assessment and no documented evidence of the patient refusing a bereavement assessment. These findings were reviewed and confirmed by the agency's staff on 6/6/2022 and 6/7/2022 during interview and a joint review of the clinical records.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical records review and interview. 4 of 11 (36%) clinical records reviewed revealed the plans of care (POC) did not include problems and interventions identified in the comprehensive assessment. Record #84539: The initial assessment completed on 4/28/22 identified the patient was short of breath. The initial POC included no interventions to address the patient's shortness of breath and respiratory problems. Record #32341: The initial assessment completed on 5/13/22 identified the patient's use of oxygen at 2 liters prn. The initial POC included no interventions to address the patient's use of oxygen and respiratory problems. Record #20068: The initial assessment completed on 3/2/22 documented the patient's diagnosis of lung cancer and shortness of breath. The initial POC included no interventions to address the patient's diagnosis of lung cancer and shortness of breath. Record #43055: The initial assessment completed on 5/11/22 documented the patient was short of breath and using oxygen at 2 liters prn. The initial POC included no interventions to address the patient's use of oxygen and respiratory problems. These findings were reviewed and confirmed by the agency's staff on 6/6/2022 and 6/7/2022 during an interview and a joint review of the clinical records.