Every finding on record at Worldwide Hospice Care

Observed in Record Review. In 1 of 1 patient records reviewed, for discharge due to extended prognosis it was noted that the Notice of Non Coverage was signed and dated the day of discharge. The IDG notes, communication notes, and RN and LVN notes prior to the discharge did not document any communication or discussion with the patient and caregiver about a possible discharge from hospice. This was confirmed with and discussed with the DPCS.

Observed in Record Review. In 9 of 10 patient records reviewed, it was noted that the hospice had not conducted and documented a patient-specific comprehensive assessment and reassessment. For example, in RRHV#3 no initial bereavement assessment had been documented. For example in RRHV#1 and RRHV#2 and RRNHV#1 through #7 the bereavement assessment was not completed by the social worker, as required by the organization's policy. This was discussed with the DPCS present.

Observed in Record Review. In 10 of 10 patient records reviewed, it was noted that the written plan of care was not individualized and based on the patient's goals and time frames, settings and services required. For example, in RRHV#1 7 of 9 goals were unchanged since admission over a year ago. The patient will have a bowel movement not more than 2 days for the next 2 weeks of hospice care. For example, RRHV#2 psychosocial goal Complement added resources and provide support as needed. For example, RRHV#3 MSW provided pt and family community resources and assisted with IHSS application for hours and Mau will remain free of injury within the review date. RRNHV#1 there was no goal and/or intervention documented for Spiritual Counselor who was seeing patient and charting patient visits 2 times a month and there was a psychosocial goal with interventions for MSW who did not have a visit frequency order and did not document visits. RRNHV#2 MSW and SC evaluations completed and visit frequencies were ordered, but no related goals or interventions were documented. RRNHV#5 SC evaluation completed, visit frequencies ordered and visits completed, but no POC goals or interventions documented. This was confirmed and discussed with the DPCS and staff nurse present.

Observed in Record Review. In 10 of 10 patient records reviewed, it was noted that PRN visits did not include the reason(s) for the use of the PRN visits.  For example in RRHV#1 through #3 and RRNHV#1 through #7 the nursing visit frequencies included 3 PRN visits with no reason for the use of the visit. In RRHV#1 and 2 the MSW included 3 PRN visits, but did not include the reason(s) for the use of the PRN visits.  This was confirmed and discussed with the DPCS present.

Observed in Record Review. In 4 of 10 patient records reviewed, it was noted that the organization had not obtained or renewed orders. For example, RRHV#1 and #2 the MSW was seeing the patients monthly however the IDG stated declined and there were no supplemental orders for these visits. RRNHV#2 record IDG included frequency visit orders for MSW and SC, but no POC goal or interventions. RRNHV#3 record IDG included frequency visit order for SC, but no POC goal or interventions. This was confirmed and discussed with the DPCS present.

Observed in Data Session. During the Data tracer it was noted that the organization had one performance improvement project that began in 2024 and ended March 2025 with no current performance improvement projects. This was confirmed and discussed with the DPCs, staff nurse and office manager present.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement services it was noted that the records were not based on a needs assessment. For example in RRBR#1 and #2 there was no bereavement plan of care documented, no goals or interventions identified. This was discussed with the bereavement coordinator, the DPCS and the office manager.

Observed in Record Review. In 1 of 1 patient records reviewed, for patients who were discharged it was noted that there was no discharge order. For example, in RRDC#2 the patient was discharged for extended prognosis and there was no discharge order documented. This was confirmed and discussed with the DPCS.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not follow its written policy addressing the privacy of health information. It was noted the organization's policy and procedure regarding privacy of health information included providing the patient/family a Notice of Privacy Practices. In HV#1, HV#2, and HV#3, it was noted the patient/family was informed in writing and verbally regarding the right to privacy/confidentiality, but a Notice of Privacy Practices was not provided according to organizational policy, and as indicated on the hopice consent form. This was reveiwed and confirmed with the Director of Patient Care Services.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not assess and reassess its patients. The hospice did not conduct and document a comprehensive assessment of the patient's/family's needs for physical, psychosocial, emotional, and spiritual care, including survivor risk factors before and after the death, availability of coping mechanisms, potential for pathological grief reactions, and cultural factors that may impact the patient's/family's ability to cope with the patient's death. In review of the record for HV#1, HV#2, HV#3, RR#1, RR#2, RR#3, RR#4, RR#5, RR#6, RR#7, and RR#8, an initial and/or post-death bereavement assessment was not completed and documented. This was reveiwed and confirmed with the Director of Patient Care Services.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization did not plan the patient's care by including all services needed for the palliation and management of the terminal illness and related conditions. In review of the record for HV#1 and HV#2, the scope of spiritual care and/or MSW services and interventions necessary to meet the patient's/family's needs was not included in the plan of care. This was reveiwed and confirmed with the Director of Patient Care Services.

Observed in Record Review. In 2 of 11 patient records reviewed, the hospice plan of care did not include all services needed for the palliative and management of the terminal illness and related conditions, including medications and treatments necessary to meet the patient's needs. In review of the record for HV#2, the patient's plan of care included Morphine Sulfate 15mg Tablet BID prn for pain, and Morphine Sulfate IR (Roxanol) 20mg/ml one (1) ml every 4 hours as needed for pain, with no clear indications for use of these two prn Morphine orders. In HV#3, the patient's plan of care included Duoneb Solution for Inhalation 0.5mg/3ml every 4 hours as needed for wheezing and shortness of breath and Morphine Sulfate IR (Roxanol) 5 mg Oral every 4 hours as needed for pain/shortness of breath. There was no clear indications for use of the two prn medications ordered for shortness of breath. This was reveiwed and confirmed with the Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not safely manage returned medications. In HV#1, HV#2, and HV#3, it was noted the organization did provide FDA Consumer Health Information on How to Dispose of Unused Medications, but it did not provide a copy of its written policies and procedures on the management and disposal of controlled medications to patients and families/caregivers when controlled medication were ordered. This was reviewed and confirmed with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not provide patient/caregiver education and training based on individual needs and abilities. In HV#1, there was no documentation that the patient/family was provided education and training related to an individualized disaster/emergency plan, including procedures to follow if care, treatment, or services were disrupted by a natural disaster or emergency. This was reveiwed and confirmed with the Director of Patient Care Services.