Every finding on record at White Oak Hospice LLC

It is required that the hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by a clinical record reviews and observations. 2 of 5 (40%) records reviewed revealed the hospice did not ensure services provided to patients followed the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). Record #1 was reviewed and identified the patient elected hospice care on 6/17/2022. The patient's primary diagnosis was documented as COPD. The plan of care dated 6/17/2022 documented the skilled nursing (SN) visit frequency, "SN visits are to occur 1 time a week." The clinical record was missing documented evidence of SN visits for the weeks of June 19, 2022, and June 26, 2022. There was no evidence of documented missed visits or communication with the physician. Record #3 was reviewed and identified the patient elected hospice care on 7/6/2021. The patient's primary diagnosis was documented as COPD. The plan of care documented the patient declined spiritual services. During the home visit conducted on 7/6/2022, the chaplain stated "he visits 1 time a month to provide spiritual services." A review of the clinical record revealed the plan of care did not include chaplain services. During an interview on 7/7/2022, the alternate administrator confirmed the plan of care was not being followed as ordered. 2 of 5 (40%) of clinical records reviewed revealed the hospice did not ensure services provided followed the individualized plan of care established by the hospice IDG. During an interview on 7/7/2022 the alternate administrator confirmed the plan of care was not being followed as ordered.

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 a review of clinical records and interview. 2 of 5 (40%) records reviewed revealed the hospice did not ensure the plan of care contained interventions based on problems identified in the initial and updated comprehensive assessments. Record #1 was reviewed and identified the patient elected hospice care on 6/17/2022. The patient's primary diagnosis was documented as COPD .The initial comprehensive assessment completed by the registered nurse (RN) on 6/17/2022 identified the patient as being incontinent, with a decline in his ability to perform self care and ADLs. The plan of care did not include planned interventions to address the patient's problems of incontinence and inability to perform self care as identified during the initial comprehensive assessment.. Record #3 was reviewed and identified the patient with a diagnosis of COPD elected hospice care on 7/6/2021. The comprehensive assessment completed by the registered nurse (RN) on 1/4/2022 documented that the patient had tested positive for COVID-19. In addition, the RN documented, "Informed that she does not want to go to the hospital... She is doing breathing treatments.... MD notified...Orders received for symptoms management." The plan of care did not include planned interventions to address the patient's problem of symptom management for COVID19 as identified during the comprehensive assessment.. During an interview on 7/7/2022 the alternate administrator confirmed the plan of care did not include all planned interventions. 1 of 5 (20%) clinical records reviewed revealed hospice did not ensure the plan of care contained interventions and goals based on problems identified in the initial and updated comprehensive assessments.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 5 (20%) records reviewed revealed the hospice did not provide an assessment of the patient's and family's spiritual needs. Record #4 was reviewed and identified the patient elected hospice care on 3/24/2022. The patient's primary diagnosis was documented as heart failure Review of the clinical record revealed no documented evidence that a spiritual assessment was completed and no evidence that the patient or family refused a spiritual assessment. During an interview on 7/7/202, the alternate administrator confirmed the spiritual assessment was not completed and stated it was "overlooked." 1 of 5 (20%) patient files reviewed revealed the comprehensive assessment did not include a spiritual assessment.

It is required that if the care of a patient is transferred to another Medicare/Medicaid-certified facility, the hospice must forward, to the receiving facility, a copy of the hospice discharge summary and the patient's clinical record, if requested. This standard was not met as evidenced by clinical record reviews, document review, and interview.. 1 of 1 (100%) records reviewed of patients transferred to another hospice revealed the hospice did not provide the receiving facility, a copy of the hospice discharge summary. Record #1 was reviewed and identified the patient elected hospice care on 12/17/2021. The clinical record included a physician order dated 12/22/2021 which documented, "patient/family caregiver have elected to receive care from another hospice agency." The clinical record did not include documented evidence that the receiving facility was sent a discharge summary. During an interview on 7/7/2022, the alternate administrator confirmed that a summary was not sent to the receiving hospice. In 1 of 1 (100%) clinical record with a patient moving out of the area, it was revealed the RN did not provide coordination of care or ensure the implementation of the interdisciplinary plan of care while the patient was hospitalized.