Survey Report for 261623

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	261623	A. BUILDING __________ B. WING ______________	12/04/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
HOSPICE COMPASSUS-NORTH CENTRAL MISSOURI	303 NORTH KEENE STREET, SUITE 306, COLUMBIA, MO, 65201
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0500
L0500	33392 Based on review of the agency's admission folder, policy review, record review, home visit observation and interview, the hospice agency failed to ensure the following patient rights: - The right to receive effective pain management and symptoms control from the hospice for conditions related to the terminal illness (L512) - The right to receive information about the scope of services that the hospice will provide and specific limitations on those services. (L519) The cumulative effect of these deficient practices resulted in the agency's inability to ensure the rights of all patients are met.
L0512
L0512	33392 Based on policy review, record review, home visit observation and interview, the agency failed to ensure effective pain management and symptom control from the hospice for conditions related to the terminal illness in one (Patient/Record #1) of three records reviewed. The deficiency example was identified at an immediate jeopardy (IJ) level. The deficiency has the potential to affect all patients on service with the agency. Findings included: Review of the agency's policy titled "Pain Management," dated 07/31/2019, showed the purpose was to provide comprehensive assessment of pain and implement a treatment plan to relieve, control and prevent pain in the hospice patient. The procedure showed: - At every nursing visit, fully assess and document the patient's pain, pain interventions and outcomes. Document any changes to pain medication regime, if indicated; - At every nursing visit, screen for pain by asking, "Are you uncomfortable due to pain?" Also, review the patient's medication list to identify whether the patient has medication prescribed for pain. If the patient is uncomfortable for pain, he/she is considered to have screened positive for pain. If the patient has medication prescribed for pain, he/she is considered to have screened positive for pain; - If the patient has pain above his/her self-identified threshold (SIT), or expresses dissatisfaction with his/her pain management, the nurse will contact the physician, obtain orders and will implement the interventions. The nurse will ensure that the patient is at or below his/her (SIT) before leaving the patient; - The nurse will also follow-up with the patient within 24 hours to assess the effectiveness of the intervention(s) and will document the patient's ongoing pain assessment; - The patient is the authority regarding whether the pain control is adequate; - Always assess the patient's satisfaction with his/her pain management and daily comfort by asking the question, "Are you satisfied with your current pain control?"; and - The goal is for the patient to be satisfied with his/her daily comfort, not just the efforts of the interdisciplinary team (IDT). RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the hospice agency on 06/10/2020 with a terminal diagnosis of lung cancer. The patient lived at home with his/her spouse and grandson. Review of the initial plan of care, dated 06/10/2020 showed the following: - Admission date 06/10/2020 with diagnosis of lung cancer; - The plan of care (POC) identified pain as an initial problem; - Goals included the patient will remain comfortable and pain managed while maximizing quality of life and patient/family will feel physically and emotionally supported during the dying process; and - The skilled nurse will make visits two times a week starting 06/15/2020. Review of the updated plan of care comprehensive assessment and plan of care, dated 06/18/2020 showed the skilled nurse visits (SNV) were decreased to one time a week and prn (as needed). Review of the skilled nurse visit (SNV) dated 09/30/2020 showed the patient's SIT score a five and the patient's pain level is a five. The patient reports using morphine for breakthrough pain every four hours where he/she was previously only using one time a day. New order received to increase fentanyl patch to 125 micrograms (mcg) every 72 hours. Review of the SNV dated 10/07/2020 (first contact with patient after new order to increase fentanyl) showed the patient's SIT score a four and the patient's pain level a four. The patient continues to report increased chest pain and using Roxanol every four to six hours after increase in fentanyl patch. The skilled nurse will notify the physician and see about increasing fentanyl. Review of physicians order dated 10/08/2020 showed the fentanyl patch was increased to 175 mcg every 72 hours. Review of the SNV dated 10/14/2020 (first contact with patient after new order to again increase fentanyl patch) showed the patient's SIT score a six and the patient's pain level an eight. The patient reports extreme pain greater than SIT score, reports he/she has been waking up in pain, but not taking medication until after he/she drives son to school. The patient took Norco and morphine during the SNV. Offered a compassion call (a call later in the day) but the patient declined. (There was no follow-up calls or visits documented to assess the patient's pain.) On 10/17/20, there was four phone calls documented with the patient about medications not being covered by insurance and not having any Norco. An e-script was sent for the Norco and patient notified. No documentation of any discussion about how the patient's pain was doing. Review of the SNV dated 10/21/2020 (first follow up with patient regarding pain since 10/14) showed the patient doing better with pain management, SIT score three, patient pain level three. Review of the SNV dated 10/28/2020 showed the SIT score a five and the patient's pain level a three. Review of the SNV dated 11/04/2020 showed the SIT score a seven and the patient's pain level a seven. The patient reports his/her pain has intensified and is continuous. Takes Norco two tabs every four hours and morphine 20 mg every one to one and half hours. New order received to increase fentanyl patch to 225 mcg every 72 hours. Review of the SNV dated 11/12/2020 (eight days after pain level seven and medication changes) showed the SIT score a six and the patient's pain level a four. The patient says he/she is waking up every one to two hours at night, continues using morphine 20 mg every one to one and half hours, Norco two tabs every four hours and fentanyl at 225 mcg. Registered nurse case manager (RNCM) will contact physician to review pain management. Review of physician's order dated 11/13/2020 showed an order for fentanyl patch 300 mcg every 72 hours and Norco 10-325 mg one to two tablets every four hours for pain. On 11/13/2020 a comfort call (a call in the evening to check on patient) was made to patient. The patient reports continued back pain and utilizing morphine and Norco as ordered, reports pain medications are effective at easing some of the pain. On 11/14/2020 a compassion call was placed to the patient. The patient reports he/she is feeling much better today. Current pain SIT score six and pain level a four. Review of the SNV dated 11/18/2020 showed an RN hospice recertification assessment was completed. The patient's SIT score was six and the patient's pain level was six. The patient is having to write down medications now to remember when he/she took them. The acuity level was documented a level three - heightened level of support needed, more frequent contact from the team is required to provide reassurance, training, or symptom management. (No change in frequency of visits) On 11/19/2020 the chaplain called to make a home visit. The patient stated his/her pain level was too high to enjoy a visit. The patient declined a visit and the chaplain notified the nursing team. On 11/23/2020 the patient called the social worker (SW). The patient wanted a copy of the contract between the agency and the insurance company to see what had been billed to reach the $3000 maximum. SW offered to call the agency's foundation for funding for the patient. Review of the SNV dated 11/25/2020 (six days after the patient refused a chaplain visit due to pain) showed the patient called prior to the SNV to say he/she continues to have severe pain in the right side and not getting much relief with current pain regimen. The RNCM contacted the physician and then the director of pharmacy for recommendations. The director of pharmacy gave recommendations for a morphine patient controlled analgesia pump (PCA) or methadone. The RNCM received an order from the physician for methadone 10 mg orally every eight hours. The RNCM spoke with the patient's sister in law and he/she picked up medications and administered first dose prior to the RNCM arrival to the home. On the RNCM's arrival to the home the patient said his/her pain had been so bad, she just wished he/she could die. The patient's SIT score was seven and the patient's pain level a seven. Pill planner was set up by the patient's sister in law to simplify medication management for patient. (Need for pill planner was never addressed by agency staff prior to sister-in-law obtaining it). Education provided on use of methadone and that it will take up to five days to reach steady state. Plan was to discontinue fentanyl patch in three days. The patient was reluctant to remove fentanyl patches until he/she has taken more methadone. The patient now taking methadone 10 mg every eight hours, Ativan and Zofran every eight hours and morphine as needed. The patient agreeable to increasing SNV's, will schedule visit on 11/27/2020 to evaluate pain management. Review of the SNV dated 11/27/2020 (two days after the patient stated he/she wished he/she could just die) showed a SIT score of six and the patient's pain level a three. The patient reports pain is much better managed since starting methadone and taking Ativan three times a day. The patient is still wearing fentanyl patches which are due to be changed tomorrow. Education provided to patient and to the sister in law that methadone dosage was calculated to allow discontinuance of fentanyl. The patient is to remove patches tomorrow (11/28/2020) and not replace. There is concern about managing breakthrough pain without fentanyl. Education provided on use of morphine for breakthrough pain. During an interview on 12/02/2020 at 11:00 AM, the patient's sister in law (SIL) said: - On 11/28/2020 when it was time for the fentanyl patches to come off as ordered, the patient's pain was an eight. The patches were removed by the patient's daughter in law and the patient was reminded to take his/her morphine every hour and to take two ml's if needed; - On 11/29/2020 around 8:00 PM, SIL spoke with the patient and the patient said he/she was "hurting" and rated his/her pain at a six, and the patient sounded short of breath; - SIL called the RNCM and received an order to go ahead and put one fentanyl 100 mcg patch on the patient and the RNCM would contact the physician in the morning on 11/30/2020 and get back with him/her; - On 11/30/2020 at 12:55 PM, SIL spoke with the patient who said he/she thought his/her pain was back tracking and it was worse. SIL had not heard from the RNCM yet and so SIL called the RNCM and was told the physician had not responded yet. The RNCM said he/she would call the physician and call SIL back; and - On 11/30/2020 at 1:25 PM, the RNCM called and said the physician did not want to try and track the fentanyl patches with Methadone but felt like the Methadone should control the patient's pain and would increase it to 12.5 mg three times a day. A prescription would be called into the pharmacy for the patient. The RNCM said to keep the fentanyl 100 mcg patch on the patient. A visit was not offered by the RNCM. He/she would be by to see the patient on 12/01/2020 at 5:00 PM (the next day) but if the patient or family needed anything to call the agency. Review of the SNV dated 12/01/2020 showed a SIT score of five and the patient's pain was documented as moderate. The patient reports that pain is ongoing and when he/she awakens from sleeping, he/she feels like he/she is behind on managing pain. The patient says the pain is really bad, but does not appear to be in severe pain. RNCM will contact the patient's physician's office in the morning to request order for fentanyl patches to provide more continuous pain management and to use morphine less frequently. (Call not made during this visit even though patient states the pain is really bad.) Review of the physician order dated 12/02/2020 showed an order for fentanyl patch 200 mcg's every 72 hours Review of all SNV notes from admission to the time of this survey, showed the SN did not ask the patient one time the question "Are you satisfied with your current pain control? ' ' as outlined in the agency's Pain Management Policy. During a home visit with the patient on 12/02/2020 at 10:10 AM, he/she stated: - His/her main goal is pain control; - The SW doesn't follow up with him/her; - It is rare that anyone follows up with him/her after med changes, he/she would be surprised if he/she got a call in between visits; - The agency has never offered continuous care or general inpatient care (GIP) for pain control; - The agency is trying to control his/her pain, some nurses do a better job; and - He/she doesn't feel his/her pain is controlled. During interview on 12/03/2020 at 1:45 PM, the RNCM said: - If a patient has a pain crisis, they usually call the patient that evening or visit the next day; and - The chaplain notified him/her on 11/19/2020 about the patient's pain being too great to enjoy a visit. The RNCM did not see or call the patient that day or the next day due to her declining a call or visit to the chaplain. During interview on 12/03/2020 at 2:30 PM, the director of clinical services (DCS) said: - The expectation is the staff are doing a call to follow up after medication changes; - It is a good idea to call the patients the next day after a medication change; - He/she wasn't sure if the question "Are you satisfied with your current pain control?" is populated in the questions in the agency's electronic medical record. - He/she would have expected a phone call or visit by the nurse after the chaplain notified the nursing team on 11/19/2020; - After the patient's fentanyl patches were removed would have expected the nurse to follow up on pain; and - Continuous care or general inpatient is offered when the agency is unable to manage symptoms within a tolerable level with collaboration with physicians. During interview on 12/2/2020 at 1:30 PM, the director of area operations said: - If a patient has pain medications increased or changed he/she would expect a phone call or visit to the patient. Follow up the same day before the nurse leaves or that evening or the next day would be the latest to check in with the patient; - He/she was not aware if GIP had been offered to the patient; - He/she would have expected the staff to follow up on the 10/14/2020 visit; - On the 11/04/2020 SNV would have expected the nurse to offer a compassion call that evening; - The patient's pain was therapeutic when the RNCM left the patient on 11/04/2020 and 11/25/2020; - When asked if the patient stating he/she had so much pain he/she wished he/she could die should have been followed up on, the director of area operations said, "but her pain level wasn't about his/her SIT level."
L0519
L0519	33392 Based on review of the agency's admission folder, policy review, record review, home visit observation, and interview, the hospice agency failed to ensure the patient/family received the correct information about specific limitations to the scope of hospice services when the patient was not notified of financial obligations at the time of election to hospice in one (Record/Patient #1) of three records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's admission folder handout titled, "Compassus Patient's Bill of Rights," showed in part: - Patients and families have the right to be advised, before care is initiated, the extent to which payment for hospice services may be expected from third party payers or other financial sources, and the extent to which payment may be required from the patient; and - To be advised, orally and in writing, of any changes in liability as soon as possible, but not later than 30 calendar days from the date that the hospice agency becomes aware of a change. Review of the agency's policy titled, "Continuation of Care and Services," dated 12/4/17 showed the following: - The agency ensures care and services for each patient remain consistent without regard to a patient's ability to pay for that care; - The agency maintains a consistent approach to the delivery of care and services necessary to meet the needs of patients on a 24-hour basis seven days a week; and - The agency will not discontinue nor diminish care/services to a patient because of the patient's inability to pay for that care. Review of the agency's policy titled, "Unfunded Care," last revised 6/3/2020 showed the following: - The purpose: to provide guidance to program colleagues regarding decision-making for patients without a funding source for hospice care and services. The hospice promotes the tenets of comfort, safety, and quality of life as the foundation of care delivery to patients receiving end of life care, regardless of the patient's ability to pay for such care; - At the time of hospice admission, the patient's funding source is evaluated and verified. If no verified means of payment is identified, the following actions may be taken to support clinical care delivery; - To best support patient comfort, the hospice nurse and hospice physician will evaluate the patient's current symptoms and disease trajectory in order to plan a course of pharmacological and non-pharmacological interventions accessible to the patient and family. The hospice is committed to the management of physical symptoms associated with the end of life care. To that end, the hospice will generally cover the following classes of medications, analgesics, anxiolytics, anti-nausea, and laxatives/stool softeners; and - The provision of other medications to support comfort is based on case-by-case review of the patient's circumstances and the social worker will seek additional funding resources through pharmacy drug manufacturers, etc. if needed. RECORD/PATIENT #1: Review of the clinical record showed: - The patient was admitted for hospice services on 06/10/2020 with a diagnosis of lung cancer, the patient lived at home with his/her spouse and grandson; - The Billing Information for Insurance and Private Pay Patients form, signed by the patient on 06/10/2020, showed reimbursement from insurance providers will be negotiated between the hospice and the insurance provider. Your financial responsibility will be $350.00. In the event there is a change in your benefits or liability, you will be notified in writing by the agency within 30 days of the hospice becoming aware of the change; - The Commercial Insurance Verification form dated 06/10/2020 showed the patient was in network, deductible was $350.00, out of pocket amount was $2000.00, coverage percentage was 90/10, and the lifetime maximum was left blank; - The social worker (SW) note dated 09/17/2020, showed the SW met with patient and spouse to discuss insurance. The patient had met the lifetime maximum benefit of $3000.00 on 07/03/2020, the spouse will call the insurance company and then call the SW back. - The SW note dated 09/18/2020, showed the patient called and verified he/she had met the maximum hospice benefit of $3000.00. The patient will be paying out of pocket for medications if not covered through insurance; and The SW note dated 09/21/2020, showed the SW called the patient regarding insurance coverage, the patient and spouse declined to fill out Medicaid application, have applied in past and did not qualify. Patient needs to talk to pharmacy if medications can be covered by insurance or get out of pocket amount. Patient is now considered indigent by the agency. During an interview during a home visit, on 12/02/2020 at 10:10 AM, the patient stated: - He/she was not told about $3000.00 lifetime maximum benefit at the start of hospice; - The SW told him/her and spouse about it in mid-September; - The hospice didn't give him/her any kind of written notice, just told him/her verbally the lifetime maximum had been reached. During an interview, on 12/03/2020 at 3:10 PM, the director of area operations stated: - If a patient comes on service with a commercial insurance, we reach out to our benefits department for verification of what is covered. The agency was not told about the lifetime maximum of $3000.00; - The middle of September we were notified by accounts receivable that the patient had reached the maximum benefit on 07/03/2020; - The family refused to apply for Medicaid, said they wouldn't qualify; - The agency was going to work with the foundation for assistance; (as of the date of the survey, this had not been done) - There was a discrepancy in the amount of assistance needed; - Hospice charges a per diem rate of $125.00 per day; - The agency did not notify the patient in writing of changes in payment.
L0536
L0536	33392 Based on policy review, record review, home visit observation, and interview, Hospice Compassus - North Central Missouri failed to ensure: - the plan of care (POC) specified all hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment (L538); and - the interdisciplinary group ensures care and services provided are based on all assessments of the patient and family needs (L556). The cumulative effect of these deficient practices resulted in the agency's inability to ensure the agency was able to meet the care needs of the patients.
L0538
L0538	33392 Based on policy review, record review, job descriptions, home visit observation, and interview the agency failed to ensure the plan of care (POC) included all care and services identified in the comprehensive assessment as necessary to meet the patient's and family needs in one (Record/Patient #1) of three records reviewed. This deficient practice has the potential to affect all patients receiving hospice services. Findings included: Review of the agency's procedure titled "Individualized Plan of Care," dated 01/20/2020 showed the following: - The POC is the complete treatment plan that provides the pathway for the hospice interdisciplinary group (IDG) to follow in providing care that is based on the initial and comprehensive assessments of the patient by all of the members of the IDG team as well as input from the patient and/or caregiver as appropriate; - The registered nurse (RN) performing the initial assessment at the time of the patient's admission to hospice services identifies the immediate physical, functional, emotional, spiritual, safety, and psychosocial needs in order to provide a safe plan of care for the immediate support of the patient and family (if applicable); - The social worker (SW) has the primary responsibility for collecting the informational elements which provide guidance to the IDG team about the patient/caregiver social, emotional, and financial needs which are or may be impacted by the effects of the terminal illness. These elements include, but are not limited to initial bereavement risk assessment based on primary and secondary caregivers, family members, and other bereaved individuals, advance care planning, funeral/burial service needs, and financial status, and family dynamics, communication practices, stress and coping; and - The RN has the responsibility for documenting clinical and functional revisions while the SW and spiritual counselor are each responsible for their respective areas of expertise in the revision of the POC. Review of the agency's SW job description, showed the following: - The SW provides preventive, educational, and evaluative and treatment services to meet the psychosocial needs of patients and their families, to help them improve, restore, and maintain their maximum level of coping; - The SW utilizes community resources and the interdisciplinary team to aid in this process; - Participates as a member of IDG, including development and implementation of the POC; - Provides psychosocial support and counseling services to the patient and family, supports the involvement of external counseling resources commensurate with the patient/family needs and scope of practice; - Maintains updated, comprehensive care plans which reflect current problems, goals, and interventions for patients; and - Completes initial and ongoing psychosocial assessments for patient and identifies and addresses concerns/issues related to financial means, insurance, living arrangements, caregiver stressors, pre-bereavement and anticipatory grief, and community resource needs. RECORD/PATIENT #1: Review of the clinical record showed: - The patient was admitted for hospice services on 06/10/2020 with a diagnosis of lung cancer, the patient lived at home with his/her spouse and grandson. EXAMPLE #1 Review of the Initial Assessment and Initial Plan of Care dated 06/10/2020, showed the following: - Initial problems identified were pain, cardiovascular status, gastrointestinal status, hematological/immunological status, all health management, and safety; and - Goals of care is for the patient/family will feel physically and emotionally supported during the dying process. Review of the Initial Psychosocial Assessment dated 06/16/2020, showed the following: - The patient declined face to face visit on 06/15/2020 due to family meeting; - The patient is married and has five children, a 16 year old grandson lives with patient and spouse; - The patient's emotional status was checked as stable, hopeless, sad, and accepting; - Psychosocial issues identified were loss of independence, establishing rapport, anticipatory grief and sad; - The patient was given one to two months to live by his/her physician; and - The SW will see the patient one time a month and as needed (PRN). Review of the Initial IDG meeting dated 06/18/2020, showed the SW would visit one time a month and PRN. Review of the SW note dated 09/17/2020, showed the SW met with patient and spouse to discuss insurance. The patient had met the lifetime maximum benefit of $3000.00 on 07/03/2020, the spouse will call the insurance company and then call the SW back. Review of the SW note dated 09/18/2020, showed the patient called and verified he/she had met the maximum hospice benefit of $3000.00. The patient will be paying out of pocket for medications if not covered through insurance. Review of the SW note dated 09/21/2020, showed the SW called the patient regarding insurance coverage, the patient and spouse declined to fill out Medicaid application, have applied in past and did not qualify. Patient needs to talk to pharmacy if medications can be covered by insurance or get out of pocket amount. Patient is now considered indigent by the agency. On 10/19/2020 the patient called the SW upset about paying $180.00 out of pocket for medications. The patient's spouse was calling insurance and while on phone with SW the spouse said the pharmacy had made a mistake. The SW updated team that the patient remains indigent in regards to hospice care. On 10/20/20 the patient called the SW in regards to helping him/her meet financial needs. The patient asked the SW to compose a letter on his/her behalf documenting that he/she has a terminal illness. The patient needs this letter to send to bill collectors to stop contacting him/her for payment. The SW composed the letter requested and made multiple copies to give to the patient for different bill collectors. There was no SW visit made or offered to the patient in October. Review of the SW visit note dated 11/13/2020, showed the following: -The SW not able to visit in person, spoke with the patient and family member (SIL) on phone; - The SW discussed patient concerns over his/her insurance, at this time he/she does not have any hospice benefits through his/her spouse's insurance. The patient is going to check on out of pocket expense for monthly medications for the SW to submit to foundation for assistance; -The patient could apply for Medicaid but is adamant he/she will not qualify; and - The patient wants his/her needs to be met, does not want to worry about medical coverage. During interview on 12/02/2020 at 10:25 AM, the patient stated: - The SW wanted a Medicaid application filled out and his/her spouse said no they wouldn't qualify and the SW got mad about it; - The SW has never gotten back with him/her since October about the foundation paying medication copays; and - The SW does not follow up with him/her. During interview on 12/03/2020 at 8:35 AM, the SW stated: - He/she had worked at the agency since September 2020; - His/her job duties include, psychosocial assessment, help patients with insurance questions and community resources, and to make requests to the foundation for grants for financial issues; - The patient had given him/her an approximate amount of $180.00 for out of pocket medications in mid-October; - He/she made a follow up phone call to the pharmacy and the pharmacy said the out of pocket amount for medications was $80.00 a month; - The patient asked for a contract between the hospice and insurance; - Then he/she (SW) got sick and was off work; - He/she sent an email to the patient around thanksgiving regarding the contract and asking for dollar amount for out of pocket pharmacy expenses; - He/she has not done anything since; and (no request to the foundation had been made as of 12/03/2020) - He/she did not get mad when patient wouldn't fill out Medicaid application. During interview on 12/03/2020 at 3:00 PM, the SW stated: - He/she felt one time a month was adequate for a young person with a child at home; - He/she discussed frequency of visits with the patient but it was not documented; - The patient had not asked for any pre bereavement support for his/her grandson or voiced any concern; - Pre bereavement is something he/she would assess and follow; - He/she took over the patient in September and had not offered any home visits to meet with the patient and the grandson; - He/she has only seen the patient one time in person in September, the patient declined a visit in October; (no documentation of declination of visit) - On 11/13/2020 he/she was planning on making a visit but was sick so made telephone call, did not discuss the kids; - He/she did not attempt to schedule another visit since unable to attend 11/13/2020 visit in person; and - He/she has not talked with the patient about grandson or bereavement since he/she came on in September. During interview on 12/03/2020 at 3:30 PM, the director of area operations stated: - He/she did not see a scheduled SW visit in October and he/she would have expected there to be a visit; - In November he/she would have expected the SW to try to make a home visit other than 11/13/2020; and - The relationship between the patient and the SW is not therapeutic. The POC failed to include all care and services necessary as identified in the comprehensive assessment to meet the patient and family's psychosocial needs. The agency failed to update the POC as patient and family's needs changed. EXAMPLE #2 Review of the initial plan of care, dated 06/10/2020 showed the following: - Admission date 06/10/2020 with diagnosis of lung cancer; - The plan of care (POC) identified pain as an initial problem; - Goals included the patient will remain comfortable and pain managed while maximizing quality of life and patient/family will feel physically and emotionally supported during the dying process; and - The skilled nurse will make visits two times a week starting 06/15/2020. Review of the updated plan of care comprehensive assessment and plan of care, dated 06/18/2020 showed the skilled nurse visits (SNV) were decreased to one time a week and prn (as needed). Review of the skilled nurse visit (SNV) dated 09/30/2020 showed the patient's SIT score a five and the patient's pain level is a five. The patient reports using morphine for breakthrough pain every four hours where he/she was previously only using one time a day. New order received to increase fentanyl patch to 125 micrograms (mcg) every 72 hours. Review of the SNV dated 10/07/2020 (first contact with patient after new order to increase fentanyl) showed the patient's SIT score a four and the patient's pain level a four. The patient continues to report increased chest pain and using Roxanol every four to six hours after increase in fentanyl patch. The skilled nurse will notify the physician and see about increasing fentanyl. Review of physicians order dated 10/08/2020 showed the fentanyl patch was increased to 175 mcg every 72 hours. Review of the SNV dated 10/14/2020 (first contact with patient after new order to again increase fentanyl patch) showed the patient's SIT score a six and the patient's pain level an eight. The patient reports extreme pain greater than SIT score, reports he/she has been waking up in pain, but not taking medication until after he/she drives son to school. The patient took Norco and morphine during the SNV. Offered a compassion call (a call later in the day) but the patient declined. (There was no follow-up calls or visits documented to assess the patient's pain.) On 10/17/20, there was four phone calls documented with the patient about medications not being covered by insurance and not having any Norco. An e-script was sent for the Norco and patient notified. No documentation of any discussion about how the patient's pain was doing. Review of the SNV dated 10/21/2020 (first follow up with patient regarding pain since 10/14) showed the patient doing better with pain management, SIT score three, patient pain level three. Review of the SNV dated 10/28/2020 showed the SIT score a five and the patient's pain level a three. Review of the SNV dated 11/04/2020 showed the SIT score a seven and the patient's pain level a seven. The patient reports his/her pain has intensified and is continuous. Takes Norco two tabs every four hours and morphine 20 mg every one to one and half hours. New order received to increase fentanyl patch to 225 mcg every 72 hours. Review of the SNV dated 11/12/2020 (eight days after pain level seven and medication changes) showed the SIT score a six and the patient's pain level a four. The patient says he/she is waking up every one to two hours at night, continues using morphine 20 mg every one to one and half hours, Norco two tabs every four hours and fentanyl at 225 mcg. Registered nurse case manager (RNCM) will contact physician to review pain management. Review of physician's order dated 11/13/2020 showed an order for fentanyl patch 300 mcg every 72 hours and Norco 10-325 mg one to two tablets every four hours for pain. On 11/13/2020 a comfort call (a call in the evening to check on patient) was made to patient. The patient reports continued back pain and utilizing morphine and Norco as ordered, reports pain medications are effective at easing some of the pain. On 11/14/2020 a compassion call was placed to the patient. The patient reports he/she is feeling much better today. Current pain SIT score six and pain level a four. Review of the SNV dated 11/18/2020 showed an RN hospice recertification assessment was completed. The patient's SIT score was six and the patient's pain level was six. The patient is having to write down medications now to remember when he/she took them. The acuity level was documented a level three - heightened level of support needed, more frequent contact from the team is required to provide reassurance, training, or symptom management. (No change in frequency of visits) On 11/19/2020 the chaplain called to make a home visit. The patient stated his/her pain level was too high to enjoy a visit. The patient declined a visit and the chaplain notified the nursing team. Review of the SNV dated 11/25/2020 (six days after the patient refused a chaplain visit due to pain) showed the patient called prior to the SNV to say he/she continues to have severe pain in the right side and not getting much relief with current pain regimen. The RNCM contacted the physician and then the director of pharmacy for recommendations. The director of pharmacy gave recommendations for a morphine patient controlled analgesia pump (PCA) or methadone. The RNCM received an order from the physician for methadone 10 mg orally every eight hours. The RNCM spoke with the patient's sister in law and he/she picked up medications and administered first dose prior to the RNCM arrival to the home. On the RNCM's arrival to the home the patient said his/her pain had been so bad, she just wished he/she could die. The patient's SIT score was seven and the patient's pain level a seven. Pill planner was set up by the patient's sister in law to simplify medication management for patient. (Need for pill planner was never addressed by agency staff prior to sister-in-law obtaining it). Education provided on use of methadone and that it will take up to five days to reach steady state. Plan was to discontinue fentanyl patch in three days. The patient was reluctant to remove fentanyl patches until he/she has taken more methadone. The patient now taking methadone 10 mg every eight hours, Ativan and Zofran every eight hours and morphine as needed. The patient agreeable to increasing SNV's, will schedule visit on 11/27/2020 to evaluate pain management. Review of the SNV dated 11/27/2020 (two days after the patient stated he/she wished he/she could just die) showed a SIT score of six and the patient's pain level a three. The patient reports pain is much better managed since starting methadone and taking Ativan three times a day. The patient is still wearing fentanyl patches which are due to be changed tomorrow. Education provided to patient and to the sister in law that methadone dosage was calculated to allow discontinuance of fentanyl. The patient is to remove patches tomorrow (11/28/2020) and not replace. There is concern about managing breakthrough pain without fentanyl. Education provided on use of morphine for breakthrough pain. During an interview on 12/02/2020 at 11:00 AM, the patient's sister in law (SIL) said: - On 11/28/2020 when it was time for the fentanyl patches to come off as ordered, the patient's pain was an eight. The patches were removed by the patient's daughter in law and the patient was reminded to take his/her morphine every hour and to take two ml's if needed; - On 11/29/2020 around 8:00 PM, SIL spoke with the patient and the patient said he/she was "hurting" and rated his/her pain at a six, and the patient sounded short of breath; - SIL called the RNCM and received an order to go ahead and put one fentanyl 100 mcg patch on the patient and the RNCM would contact the physician in the morning on 11/30/2020 and get back with him/her; - On 11/30/2020 at 12:55 PM, SIL spoke with the patient who said he/she thought his/her pain was back tracking and it was worse. SIL had not heard from the RNCM yet and so SIL called the RNCM and was told the physician had not responded yet. The RNCM said he/she would call the physician and call SIL back; and - On 11/30/2020 at 1:25 PM, the RNCM called and said the physician did not want to try and track the fentanyl patches with Methadone but felt like the Methadone should control the patient's pain and would increase it to 12.5 mg three times a day. A prescription would be called into the pharmacy for the patient. The RNCM said to keep the fentanyl 100 mcg patch on the patient. A visit was not offered by the RNCM. He/she would be by to see the patient on 12/01/2020 at 5:00 PM (the next day) but if the patient or family needed anything to call the agency. Review of the SNV dated 12/01/2020 showed a SIT score of five and the patient's pain was documented as moderate. The patient reports that pain is ongoing and when he/she awakens from sleeping, he/she feels like he/she is behind on managing pain. The patient says the pain is really bad, but does not appear to be in severe pain. RNCM will contact the patient's physician's office in the morning to request order for fentanyl patches to provide more continuous pain management and to use morphine less frequently. (Call not made during this visit even though patient states the pain is really bad.) Review of the physician order dated 12/02/2020 showed an order for fentanyl patch 200 mcg's every 72 hours Review of all SNV notes from admission to the time of this survey, showed the SN did not ask the patient one time the question "Are you satisfied with your current pain control? ' ' as outlined in the agency's Pain Management Policy. During a home visit with the patient on 12/02/2020 at 10:10 AM, he/she stated: - His/her main goal is pain control; - It is rare that anyone follows up with him/her after med changes, he/she would be surprised if he/she got a call in between visits; - The agency has never offered continuous care or general inpatient care (GIP) for pain control; - The agency is trying to control his/her pain, some nurses do a better job; and - He/she doesn't feel his/her pain is controlled. The POC failed to include all care and services necessary as identified in the comprehensive assessment to meet the patient's pain needs. The patient's pain remained uncontrolled and the agency failed to update the plan of care to include increasing visits, or offering continuous or general inpatient care.
L0556
L0556	33392 Based on record review, policy review, home visit observation, job descriptions, and interview, the agency's interdisciplinary group (IDG) failed to ensure services provided are based on assessment of the patient and family's needs in one (Record/Patient #1) of three records reviewed. This deficient practice had the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled "Written Interdisciplinary Plan of Care," dated 09/27/19, showed: - The agency utilizes an interdisciplinary approach to the development, implementation, and evaluation of the individualized plan of care (POC) for each patient; -The IDG is a group of hospice professionals designated to provide care plan development and support to the patient. The IDG consists of a hospice physician, nurse, social worker, and spiritual care provider (the CORE team who must attend the full IDG meeting) at minimum but can also include other counselors; -The IDG will ensure the provision of care and services according the POC and that the POC reflects updated patient and family/caregiver needs as determined in updated comprehensive assessments; - The POC is established by the patient's attending physician (if they have one), the hospice physician and the IDG in collaboration with the patient/family/representative prior to the start of care; - Care is provided to the patient in accordance with the plan; - The content of the plan includes at minimum, as assessment of the patient and family's needs and goals, identification of the services to be provided including management of symptoms, and detail scope and frequency of services necessary to meet the assessed needs, including level of care; - Staff assignments based on the POC will be managed by the director of clinical services or designee according to the identified needs of the patient/family as documented in the comprehensive plan of care; and - The hospice IDG, in collaboration with the hospice physician and the patient's attending physician (if the patient has one), reviews and updates the POC at least every 15 days or more often as needed as dictated by the patient's condition and this review is documented. Review of the agency's policy titled "Pain Management," dated 07/31/2019, showed the purpose was to provide comprehensive assessment of pain and implement a treatment plan to relieve, control and prevent pain in the hospice patient. The procedure showed: - At every nursing visit, fully assess and document the patient's pain, pain interventions and outcomes. Document any changes to pain medication regime, if indicated; - At every nursing visit, screen for pain by asking, "Are you uncomfortable due to pain?" Also, review the patient's medication list to identify whether the patient has medication prescribed for pain. If the patient is uncomfortable for pain, he/she is considered to have screened positive for pain. If the patient has medication prescribed for pain, he/she is considered to have screened positive for pain; - If the patient has pain above his/her self-identified threshold (SIT), or expresses dissatisfaction with his/her pain management, the nurse will contact the physician, obtain orders and will implement the interventions. The nurse will ensure that the patient is at or below his/her (SIT) before leaving the patient; - The nurse will also follow-up with the patient within 24 hours to assess the effectiveness of the intervention(s) and will document the patient's ongoing pain assessment; - The patient is the authority regarding whether the pain control is adequate; - Always assess the patient's satisfaction with his/her pain management and daily comfort by asking the question, "Are you satisfied with your current pain control?"; and - The goal is for the patient to be satisfied with his/her daily comfort, not just the efforts of the interdisciplinary team (IDT). Review of the agency's procedure titled "Individualized Plan of Care," dated 01/20/2020 showed the following: - The POC is the complete treatment plan that provides the pathway for the hospice interdisciplinary group (IDG) to follow in providing care that is based on the initial and comprehensive assessments of the patient by all of the members of the IDG team as well as input from the patient and/or caregiver as appropriate; - The registered nurse (RN) performing the initial assessment at the time of the patient's admission to hospice services identifies the immediate physical, functional, emotional, spiritual, safety, and psychosocial needs in order to provide a safe plan of care for the immediate support of the patient and family (if applicable); - The social worker (SW) has the primary responsibility for collecting the informational elements which provide guidance to the IDG team about the patient/caregiver social, emotional, and financial needs which are or may be impacted by the effects of the terminal illness. These elements include, but are not limited to initial bereavement risk assessment based on primary and secondary caregivers, family members, and other bereaved individuals, advance care planning, funeral/burial service needs, and financial status, and family dynamics, communication practices, stress and coping; and - The RN has the responsibility for documenting clinical and functional revisions while the SW and spiritual counselor are each responsible for their respective areas of expertise in the revision of the POC. Review of the agency's SW job description, showed the following: - The SW provides preventive, educational, and evaluative and treatment services to meet the psychosocial needs of patients and their families, to help them improve, restore, and maintain their maximum level of coping; - The SW utilizes community resources and the interdisciplinary team to aid in this process; - Participates as a member of IDG, including development and implementation of the POC; - Provides psychosocial support and counseling services to the patient and family, supports the involvement of external counseling resources commensurate with the patient/family needs and scope of practice; - Maintains updated, comprehensive care plans which reflect current problems, goals, and interventions for patients; and - Completes initial and ongoing psychosocial assessments for patient and identifies and addresses concerns/issues related to financial means, insurance, living arrangements, caregiver stressors, pre-bereavement and anticipatory grief, and community resource needs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the hospice agency on 06/10/2020 with a terminal diagnosis of lung cancer. The patient lived at home with his/her spouse and grandson. EXAMPLE #1 Review of the initial plan of care, dated 06/10/2020 showed the following: - Admission date 06/10/2020 with diagnosis of lung cancer; - The plan of care (POC) identified pain as an initial problem; - Goals included the patient will remain comfortable and pain managed while maximizing quality of life and patient/family will feel physically and emotionally supported during the dying process; and - The skilled nurse will make visits two times a week starting 06/15/2020. Review of the updated plan of care comprehensive assessment and plan of care, dated 06/18/2020 showed the skilled nurse visits (SNV) were decreased to one time a week and prn (as needed). Review of the skilled nurse visit (SNV) dated 09/30/2020 showed the patient's SIT score a five and the patient's pain level is a five. The patient reports using morphine for breakthrough pain every four hours where he/she was previously only using one time a day. New order received to increase fentanyl patch to 125 micrograms (mcg) every 72 hours. Review of the SNV dated 10/07/2020 (first contact with patient after new order to increase fentanyl) showed the patient's SIT score a four and the patient's pain level a four. The patient continues to report increased chest pain and using Roxanol every four to six hours after increase in fentanyl patch. The skilled nurse will notify the physician and see about increasing fentanyl. Review of physicians order dated 10/08/2020 showed the fentanyl patch was increased to 175 mcg every 72 hours. Review of the SNV dated 10/14/2020 (first contact with patient after new order to again increase fentanyl patch) showed the patient's SIT score a six and the patient's pain level an eight. The patient reports extreme pain greater than SIT score, reports he/she has been waking up in pain, but not taking medication until after he/she drives son to school. The patient took Norco and morphine during the SNV. Offered a compassion call (a call later in the day) but the patient declined. (There was no follow-up calls or visits to assess the patient's pain.) On 10/17/20, there was four phone calls documented with the patient about medications not being covered by insurance and not having any Norco. An e-script was sent for the Norco and patient notified. No documentation of any discussion about how the patient's pain was doing. Review of the SNV dated 10/21/2020 (first follow up with patient regarding pain since 10/14) showed the patient doing better with pain management, SIT score three, patient pain level three. Review of the SNV dated 10/28/2020 showed the SIT score a five and the patient's pain level a three. Review of the SNV dated 11/04/2020 showed the SIT score a seven and the patient's pain level a seven. The patient reports his/her pain has intensified and is continuous. Takes Norco two tabs every four hours and morphine 20 mg every one to one and half hours. New order received to increase fentanyl patch to 225 mcg every 72 hours. Review of the SNV dated 11/12/2020 (eight days after pain level seven and medication changes) showed the SIT score a six and the patient's pain level a four. The patient says he/she is waking up every one to two hours at night, continues using morphine 20 mg every one to one and half hours, Norco two tabs every four hours and fentanyl at 225 mcg. Registered nurse case manager (RNCM) will contact physician to review pain management. Review of physician's order dated 11/13/2020 showed an order for fentanyl patch 300 mcg every 72 hours and Norco 10-325 mg one to two tablets every four hours for pain. On 11/13/2020 a comfort call (a call in the evening to check on patient) was made to patient. The patient reports continued back pain and utilizing morphine and Norco as ordered, reports pain medications are effective at easing some of the pain. On 11/14/2020 a compassion call was placed to the patient. The patient reports he/she is feeling much better today. Current pain SIT score six and pain level a four. Review of the SNV dated 11/18/2020 showed an RN hospice recertification assessment was completed. The patient's SIT score was six and the patient's pain level was six. The patient is having to write down medications now to remember when he/she took them. The acuity level was documented a level three - heightened level of support needed, more frequent contact from the team is required to provide reassurance, training, or symptom management. (No change in frequency of visits) On 11/19/2020 the chaplain called to make a home visit. The patient stated his/her pain level was too high to enjoy a visit. The patient declined a visit and the chaplain notified the nursing team. On 11/23/2020 the patient called the SW. The patient wanted a copy of the contract between the agency and the insurance company to see what had been billed to reach the $3000 maximum. SW offered to call the agency's foundation for funding for the patient. Review of the SNV dated 11/25/2020 (six days after the patient refused a chaplain visit due to pain) showed the patient called prior to the SNV to say he/she continues to have severe pain in the right side and not getting much relief with current pain regimen. The RNCM contacted the physician and then the director of pharmacy for recommendations. The director of pharmacy gave recommendations for a morphine patient controlled analgesia pump (PCA) or methadone. The RNCM received an order from the physician for methadone 10 mg orally every eight hours. The RNCM spoke with the patient's sister in law and he/she picked up medications and administered first dose prior to the RNCM arrival to the home. On the RNCM's arrival to the home the patient said his/her pain had been so bad, she just wished he/she could die. The patient's SIT score was seven and the patient's pain level a seven. Pill planner was set up by the patient's sister in law to simplify medication management for patient. (Need for pill planner was never addressed by agency staff prior to sister-in-law obtaining it). Education provided on use of methadone and that it will take up to five days to reach steady state. Plan was to discontinue fentanyl patch in three days. The patient was reluctant to remove fentanyl patches until he/she has taken more methadone. The patient now taking methadone 10 mg every eight hours, Ativan and Zofran every eight hours and morphine as needed. The patient agreeable to increasing SNV's, will schedule visit on 11/27/2020 to evaluate pain management. Review of the SNV dated 11/27/2020 (two days after the patient stated he/she wished he/she could just die) showed a SIT score of six and the patient's pain level a three. The patient reports pain is much better managed since starting methadone and taking Ativan three times a day. The patient is still wearing fentanyl patches which are due to be changed tomorrow. Education provided to patient and to the sister in law that methadone dosage was calculated to allow discontinuance of fentanyl. The patient is to remove patches tomorrow (11/28/2020) and not replace. There is concern about managing breakthrough pain without fentanyl. Education provided on use of morphine for breakthrough pain. During an interview on 12/02/2020 at 11:00 AM, the patient's sister in law (SIL) said: - On 11/28/2020 when it was time for the fentanyl patches to come off as ordered, the patient's pain was an eight. The patches were removed by the patient's daughter in law and the patient was reminded to take his/her morphine every hour and to take two ml's if needed; - On 11/29/2020 around 8:00 PM, SIL spoke with the patient and the patient said he/she was "hurting" and rated his/her pain at a six, and the patient sounded short of breath; - SIL called the RNCM and received an order to go ahead and put one fentanyl 100 mcg patch on the patient and the RNCM would contact the physician in the morning on 11/30/2020 and get back with him/her; - On 11/30/2020 at 12:55 PM, SIL spoke with the patient who said he/she thought his/her pain was back tracking and it was worse. SIL had not heard from the RNCM yet and so SIL called the RNCM and was told the physician had not responded yet. The RNCM said he/she would call the physician and call SIL back; and - On 11/30/2020 at 1:25 PM, the RNCM called and said the physician did not want to try and track the fentanyl patches with Methadone but felt like the Methadone should control the patient's pain and would increase it to 12.5 mg three times a day. A prescription would be called into the pharmacy for the patient. The RNCM said to keep the fentanyl 100 mcg patch on the patient. A visit was not offered by the RNCM. He/she would be by to see the patient on 12/01/2020 at 5:00 PM (the next day) but if the patient or family needed anything to call the agency. Review of the SNV dated 12/01/2020 showed a SIT score of five and the patient's pain was documented as moderate. The patient reports that pain is ongoing and when he/she awakens from sleeping, he/she feels like he/she is behind on managing pain. The patient says the pain is really bad, but does not appear to be in severe pain. RNCM will contact the patient's physician's office in the morning to request order for fentanyl patches to provide more continuous pain management and to use morphine less frequently. (Call not made during this visit even though patient states the pain is really bad.) Review of the physician order dated 12/02/2020 showed an order for fentanyl patch 200 mcg's every 72 hours Review of all SNV notes from admission to the time of this survey, showed the SN did not ask the patient one time the question "Are you satisfied with your current pain control? " as outlined in the agency's Pain Management Policy. During a home visit with the patient on 12/02/2020 at 10:10 AM, he/she stated: - His/her main goal is pain control; - It is rare that anyone follows up with him/her after med changes, he/she would be surprised if he/she got a call in between visits; - The agency has never offered continuous care or general inpatient care (GIP) for pain control; - The agency is trying to control his/her pain, some nurses do a better job; and - He/she doesn't feel his/her pain is controlled. EXAMPLE #2 Review of the Initial Psychosocial Assessment dated 06/16/2020, showed the following: - The patient declined face to face visit on 06/15/2020 due to family meeting; - The patient is married and has five children, a 16 year old grandson lives with patient and spouse; - The patient's emotional status was checked as stable, hopeless, sad, and accepting; - Psychosocial issues identified were loss of independence, establishing rapport, anticipatory grief and sad; - The patient was given one to two months to live by his/her physician; and - The SW will see the patient one time a month and as needed (PRN). Review of the Initial IDG meeting dated 06/18/2020, showed the SW would visit one time a month and PRN. Review of the SW note dated 09/17/2020, showed the SW met with patient and spouse to discuss insurance. The patient had met the lifetime maximum benefit of $3000.00 on 07/03/2020, the spouse will call the insurance company and then call the SW back. Review of the SW note dated 09/18/2020, showed the patient called and verified he/she had met the maximum hospice benefit of $3000.00. The patient will be paying out of pocket for medications if not covered through insurance. Review of the SW note dated 09/21/2020, showed the SW called the patient regarding insurance coverage, the patient and spouse declined to fill out Medicaid application, have applied in past and did not qualify. Patient needs to talk to pharmacy if medications can be covered by insurance or get out of pocket amount. Patient is now considered indigent by the agency. On 10/19/2020 the patient called the SW upset about paying $180.00 out of pocket for medications. The patient's spouse was calling insurance and while on phone with SW the spouse said the pharmacy had made a mistake. The SW updated team that the patient remains indigent in regards to hospice care. On 10/20/20 the patient called the SW in regards to helping him/her meet financial needs. The patient asked the SW to compose a letter on his/her behalf documenting that he/she has a terminal illness. The patient needs this letter to send to bill collectors to stop contacting him/her for payment. The SW composed the letter requested and made multiple copies to give to the patient for different bill collectors. There was no SW visit made or offered to the patient in October. Review of the SW visit note dated 11/13/2020, showed the following: -The SW not able to visit in person, spoke with the patient and family member (SIL) on phone; - The SW discussed patient concerns over his/her insurance, at this time he/she does not have any hospice benefits through his/her spouse's insurance. The patient is going to check on out of pocket expense for monthly medications for the SW to submit to foundation for assistance; -The patient could apply for Medicaid but is adamant he/she will not qualify; and - The patient wants his/her needs to be met, does not want to worry about medical coverage. During interview on 12/02/2020 at 10:25 AM, the patient stated: - The SW wanted a Medicaid application filled out and his/her spouse said no they wouldn't qualify and the SW got mad about it; - The SW has never gotten back with him/her since October about the foundation paying medication copays; and - The SW does not follow up with him/her. During interview on 12/03/2020 at 8:35 AM, the SW stated: - He/she had worked at the agency since September 2020; - His/her job duties include, psychosocial assessment, help patients with insurance questions and community resources, and to make requests to the foundation for grants for financial issues; - The patient had given him/her an approximate amount of $180.00 for out of pocket medications in mid-October; - He/she made a follow up phone call to the pharmacy and the pharmacy said the out of pocket amount for medications was $80.00 a month; - The patient asked for a contract between the hospice and insurance; - Then he/she (SW) got sick and was off work; - He/she sent an email to the patient around thanksgiving regarding the contract and asking for dollar amount for out of pocket pharmacy expenses; - He/she has not done anything since; and (no request to the foundation had been made as of 12/03/2020) - He/she did not get mad when patient wouldn't fill out Medicaid application. During interview on 12/03/2020 at 3:00 PM, the SW stated: - He/she felt one time a month was adequate for a young person with a child at home; - He/she discussed frequency of visits with the patient but it was not documented; - The patient had not asked for any pre bereavement support for his/her grandson or voiced any concern; - Pre bereavement is something he/she would assess and follow; - He/she took over the patient in September and had not offered any home visits to meet with the patient and the grandson; - He/she has only seen the patient one time in person in September, the patient declined a visit in October; (no documentation of declination of visit) - On 11/13/2020 he/she was planning on making a visit but was sick so made telephone call, did not discuss the kids; - He/she did not attempt to schedule another visit since unable to attend 11/13/2020 visit in person; and - He/she has not talked with the patient about grandson or bereavement since he/she came on in September. Review of the IDG meeting dated 10/15/2020, showed the pain medications were increased, SNV visits remained once a week. The SW to continue to meet with the patient once a month and continue to provide supportive counseling and community resource referrals. Review of the IDG meeting dated 10/29/2020, showed the patient continued to have increased pain through right side of his/her chest, increased fentanyl to manage pain. (SNV remain once a week) Patient utilizing PRN pain medication frequently but around his/her schedule do to fear of driving impaired. The SW provided the patient with a statement on company letterhead stating he/she had a terminal illness. The letter was needed for the patient to send to bill collectors per the patient request. The SW will continue to visit once a month for continued support. Review of the IDG meeting dated 11/05/2020, showed the patient reporting pain in right side, ribs, chest, and upper back in more intense and constant. The physician contacted and fentanyl was increased to 225 mcg every 72 hours. (SNV remain once a week) Education provided and discussed with the patient regarding use of narcotics and safety concerns as he/she is continuing to drive his/her son to/from school. He/she is trying to manage his/her PRN narcotics around driving. He/she is aware the fentanyl is continuous release. The SW will continue to meet with patient one time a month to continue plan of care. Review of the IDG meeting dated 11/19/2020, showed the patient experiencing increased pain in right side, chest and back. Fentanyl increased from 175 mcg to 225 mcg on 11/04/2020 then increased to 300 mcg on 11/13/2020. Norco increased from 7.5/325 mg to 10/325 mg every four hours PRN on 11/13/2020. (SNV remain one time a week) No longer driving his/her car. Educated the patient regarding safety concerns with the increased narcotic use and the patient voiced understanding. The SW had recent discussions with family about applying for Medicaid, family is not interested. The patient had requested a copy of the contract with his/her insurance and hospice. This must be requested by the family directly to the insurance. Pain medications prescribed have a ten dollar co-pay. The SW to continue to work with the family for support and community resources one time a month and as needed. Review of nursing and social service notes, and the IDG meeting notes from 10/15/20 - 11/19-20, failed to show the IDT ensured that the care and services provided to the patient, based on all assessments of the patient and family needs, adequately addressed the psychosocial and pain needs of the patient.