Survey Report for 281540

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	281540	A. BUILDING __________ B. WING ______________	01/07/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
ANGELS CARE HOSPICE	10838 OLD MILL ROAD, STE 1, OMAHA, NE, 68154
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)
E0001
E0001	14779 Deficiencies cited at E004, E006 and E0039. E004: Based on review of the hospice's emergency management plan and policy and staff interview, the hospice failed to establish and maintain a comprehensive emergency preparedness program in 2018. E006: Based on review of the hospice's emergency management plan and policy and staff interview, the hospice failed to maintain documentation the hospice conducted a facility and community-based risk assessment in 2018 to identify the hospice's risk in the event of a natural or man-made disaster. This had the potential to affect 2 of 2 the hospice's patients. E0039: Based on review of the hospice Emergency Management Plan and staff interview, the hospice failed to conduct a second exercise, either a full-scale, individual facility-based, or table top exercise in 2018. This had the potential to affect 2 of 2 of the hospice's patients .
E0004
E0004	14779 Based on review of the hospice's emergency management plan and policy and staff interview, the hospice failed to establish and maintain a comprehensive emergency preparedness program in 2018. Hospice census was 2. Findings are: A. There was no documentation the hospice conducted a risk assessment, to maintain the comprehensive emergency preparedness program, in 2018. B. Interview with the hospice Director of Nursing on 1/2/2020 from 3:15 PM to 3:45 PM confirmed the hospice had not conducted a risk assessment in 2018.
E0006
E0006	14779 Based on review of the hospice's emergency management plan and policy and staff interview, the hospice failed to maintain documentation the hospice conducted a facility and community-based risk assessment in 2018 to identify the hospice's risk in the event of a natural or man-made disaster. This had the potential to affect 2 of 2 the hospice's patients. Findings are: A. There was no documentation in the hospice's Emergency Management Plan to indicate the hospice conducted an all-hazards vulnerability assessment in 2018. B. The hospice Director of Nursing during interview on 1/2/2020 from 3:15 PM to 3:45 PM confirmed the hospice had not conducted a risk assessment in 2018. C. Failure to conduct and maintain documentation of an all-hazard vulnerability assessment provided the opportunity to miss potential hazards in the event of a natural or man-made disaster.
E0039
E0039	14779 Based on review of the hospice Emergency Management Plan and staff interview, the hospice failed to conduct a second exercise, either a full-scale, individual facility-based, or table op exercise in 2018. This had the potential to affect 2 of 2 of the hospice's patients. Findings are: A. Review of the hospice Emergency Management Plan revealed: 1. The hospice was to conduct a second exercise, either full scale, individual facility-based, or table-top exercise annually. 2. There was no documentation a second exercise, either full scale, individual facility-based, or table-top exercise was conducted in 2018. B. The hospice Director of Nursing during interview on 1/2/2020 from 3:15 Pm to 3:45 PM confirmed the hospice had not conducted a second exercise, either full scale, individual facility-based, or table-top exercise was conducted in 2018. C Failure to conduct a second exercise, either a full-scale, individual facility-based, or table-top exercise provided the opportunity for the hospice to fail to identify additional components of the emergency management plan which required revision.
L0500
L0500	14779 Deficiencies cited at L 502, and 519. L 502 Based on review of the hospice Patient Bill of Rights form, with a revision date of 5/12/04, provided to the patient and/or the patient's representative at the time of admission, and staff interview, the hospice failed to include and make patients aware of the patient's right to expect pain relief; the right to be made aware verified allegations of abuse or neglect must be reported and require the hospice to implement corrective action and to report the verified allegation to appropriate authorities within 5 days. Sample size was 8 and census was 2. L 519 Based on review of clinical records and staff interview the hospice failed to provide patients notification of the scope of services the hospice was to provide and any limitations to the provision of those services.
L0502
L0502	14779 Based on review of the hospice Patient Bill of Rights form, with a revision date of 5/12/04, provided to the patient and/or the patient's representative at the time of admission, and staff interview, the hospice failed to include and make patients aware of the patient's right to expect pain relief; the right to be made aware verified allegations of abuse or neglect must be reported and the hospice is required to implement corrective action and to report the verified allegation to appropriate authorities within 5 days. Sample size was 8 and census was 2. Findings are: A. Review of the hospice Patient Bill of Rights form, with a revision date of 5/12/04, revealed there was no reference to the following patient rights: 1. To expect pain relief and to expect measures to be instituted by the hospice to ensure comfort; and 2. To be made aware verified violations involving mistreatment, neglect, or abuse require corrective action be implemented by the hospice and the hospice must report the verified allegations to the State Survey and Certification Agency within 5 working days of becoming aware of the violation. B. Interview with the hospice Director of Nursing on 1/6/2020 at 11:59 AM confirmed the patient rights regarding pain relief and information regarding verified allegations of abuse and neglect were not included in the written Patient Bill of Rights, provided to patients and/or representatives prior to admission to the hospice. C. This practice provided the opportunity for hospice patients and/or their representative to be unaware of all rights of the hospice patient.
L0519
L0519	14779 Based on review of clinical records, review of policy and procedure and staff interview the hospice failed to provide information to 8 of 8 patients of the scope of services the hospice was to provide and any limitations to the provision of those services. Sample size was 8 and hospice census was 2. This practice provided the opportunity for patients/family members and/or caregivers to be unaware of the services available to patients Findings are: A. Review of the policy and procedure titled Listing of Services Provided, dated 5/2011, revealed services provided directly by hospice employees included the services of a registered nurse, medical social worker, spiritual care counselor, and physician services. The same policy revealed the contracted services of Speech Therapy, Occupational Therapy and Physical Therapy were available through the hospice. B. Review of the clinical records for Patient 1, 2, 3, 4, 5, 6, 7, and 8 revealed there was no documentation the patient, patient representative or caregiver was made aware of the disciplines available for the provision of cares to the patient. C. Interview with Licensed Practical Nurse-E on 1/2/2020 at 11:35 AM confirmed the hospice did not document the patient/ patient's representative or caregivers were made aware of the disciplines available to provide services to the hospice patient and/or their understanding of the plan of care.
L0520
L0520	14779 Deficiencies cited at L 531 and L533. L 531 Based on review of clinical records, review of policy and procedure and staff interview, the hospice failed to have an organized program for the provision of bereavement services, under the supervision of a qualified professional and to include the provision of bereavement services in the individual plans of care for 8 of 8 patients reviewed (Patient 1, 2, 3, 4, 5, 6, 7, and 8). Sample size was 8 and hospice census was 2. L533 Based on review of clinical records, review of policy and procedure and staff interview the hospice failed to update the comprehensive assessment for 1 of 8 sampled patients (Patient 2) following the patient's fall and subsequent hospitalization. Sample size was 8 and hospice census was 2.
L0531
L0531	14779 Based on review of clinical records, review of policy and procedure and staff interview, the hospice failed to have an organized program for the provision of bereavement services, under the supervision of a qualified professional and to include the provision of bereavement services in the individual plans of care for 8 of 8 patients reviewed (Patient 1, 2, 3, 4, 5, 6, 7, and 8). Sample size was 8 and hospice census was 2. Findings are: A. Review of the policy and procedure titled Bereavement Services, dated 5/2011 revealed the hospice was to provide an organized bereavement program supervised by a qualified bereavement coordinator; and the program was to provide bereavement services to patients/families/and caregivers of hospice patients, both before and after the patient's death to facilitate a normal grieving process and to identify the need for referrals of the family/caregivers to a bereavement counselor. Outline of the procedure identified the bereavement risks assessment was to be completed at the time of admission, by the hospice social worker, and a bereavement plan was to be developed to address bereavement/ grief issues and implementation of interventions as needed. B. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, and 8 revealed no documentation of a bereavement assessment. C. Interview with the hospice Administrator on 12/19/2019 at 3:45 PM confirmed the hospice did not have a staff member designated as the bereavement coordinator, had not completed bereavement assessments for patients 1, 2, 3, 4, 5, 6, 7, or 8 and had not addressed the bereavement needs of the patients/ family or caregivers for Patients 1, 2, 3, 4, 5, 6, 7, or 8 in the hospice plan of care. D. This failed practice provided the opportunity for patients/family members and caregivers to not receive the interventions needed to aid in the individual's ability to cope with the patient's death.
L0533
L0533	14779 Based on review of clinical records, review of policy and procedure and staff interview the hospice failed to update the comprehensive assessment for 1 of 8 sampled patients (Patient 2) following the patient's fall and subsequent hospitalization. Sample size was 8 and hospice census was 2. Findings are: A. Review of the policy and procedure titled Interdisciplinary Group (IDG) Plan of Care, dated 5/2011, revealed the plan of care was to be reviewed and revised as frequently as deemed necessary; updates to the plan of care will be based on changes in the patient/ family/caregiver status and any change in the patient's condition must result in a change in the plan of care. B. Review of Patient 2's Certification and Plan of Care form for the certification period of 8/17/19 through 10/15/19 revealed the patient had diagnoses of chronic obstructive pulmonary disease, Heart failure and a history of falling. Review of the patient's IDG dated 8/20/19 revealed the patient had not had falls or injuries, fall prevention was to be maintained during cares and the patient was assessed and was instructed to use a walker. C. Review of the patient's clinical record revealed the patient's physician was notified a skilled nurse visit was missed on 8/23/19 due to the patient being hospitalized. The clinical record contained a physician order dated 8/26/19, for the hospice to assess the patient on 8/26/19 following the hospital stay. D. Documentation by Registered Nurse (RN)-L dated 8/26/19 at 1:15 PM revealed the RN had visited the patient to assess the patient following a hospital stay due to the patient falling at home and sustaining a fracture of the right wrist. The RN documented the patient had a splint/brace, a right black/blue eye and right lower extremity bruising. According to the RN's documentation, the patient's daughter was present during the visit and the patient and the daughter were ..."educated on the importance of de-cluttering home so patient has safe environment. Patient/family states understanding and agrees to the plan". E. Review of the Hospice IDG Meeting/Care Plan Update form dated 9/3/19, revealed no documentation Patient 2 had been hospitalized and the patient had ..."no falls or injuries ... F. Interview with Licensed Practical Nurse-E on 12/31/19 at 1:05 PM confirmed the patient's hospitalization on 8/23/19 secondary to a fall, and right wrist fracture was not addressed at the IDG held on 9/3/19. G. This failure provided the opportunity for the IDG to be unaware of changes in Patient 2's needs and to be unaware of the need to implement changes in the patient's plan of care to address the patient's needs.
L0536
L0536	14779 Deficiencies cited at L 537, L 538, L 541, L 543, L 545, L 547, and L 551 L 537 Based on review of personnel files, clinical records, and staff interview the hospice failed to ensure the staff member serving as the social worker for the hospice and as a core member of the Interdisciplinary Group (IDG) met the criteria for a qualified social worker; and to ensure the social worker participated in the development, implementation and revisions of plans of care for patients 5 of 8 sampled patients (Patient 1, 2, 5, 6, and 8). L538 Based on review of clinical records, review of policy and procedure and staff interview the facility failed to include the scope and frequency of services needed to meet the needs of patients in the plan of care for 1 of 8 patients reviewed (Patient 1). L541 Based on review of personnel files, clinical records, and staff interview the hospice failed to ensure the staff member serving as the social worker for the hospice and as a core member of the Interdisciplinary Group (IDG) met the criteria for a qualified social worker. . L 543 Based on review of clinical records, policy and procedures and staff interview the hospice failed to provide services as ordered by the physician for 5 of 8 patients reviewed (Patient 1, 2, 3, 4, and 5) L 545 Based on review of clinical records, policy and procedures and staff interview the hospice failed to ensure all disciplines compromising the IDG, contributed to the comprehensive and ongoing assessment and care planning process for 5 of 8 patients reviewed (Patient 1, 2, 5, 6, and 8) . L547 Based on review of clinical records, review of policy and procedure and staff interview the hospice failed to include the scope and frequency of services needed to meet the needs of patients in the plan of care for 1 of 8 patients reviewed (Patient 1). L551 Based on review of clinical records, policy and procedure and staff interview the hospice failed to document the patient's or representative's level of understanding, involvement, or agreement with the plan of care in the clinical record for 8 of 8 patients reviewed (Patients 1, 2, 3, 4, 5, 6, 7, and 8).
L0537
L0537	14779 Based on review of personnel files, clinical records, and staff interview the hospice failed to ensure the staff member serving as the social worker for the hospice and as a core member of the Interdisciplinary Group (IDG) met the criteria for a qualified social worker; and to ensure the social worker participated in the development, implementation and revisions of plans of care for 5 of 8 sampled patients (Patient 1, 2, 5, 6, and 8). Sample size was 8 and hospice census was 2. Findings are: A. Review of the personnel file for the hospice's Social Worker (SW), SW-H revealed the following: 1. Date of hire: 8/8/19; and 2. License type: Provisional Master Social Worker (PMSW), issued 5/13/19. B. There was no documentation in SW-H's personnel file the required post-degree work in an approved social work setting, with supervision by a Certified Master's Social Worker (CMSW) had been completed by SW-H and SW-H continued to be a provisionally licensed as a Master's Social Worker. C. Review of hospice's job description for a medical Social Worker (SW), signed by SW-H on 8/8/2019, revealed the medical social worker responsibilities included the following: 1. Assessing the psychosocial status of patients/families/caregivers related to the patient's terminal illness and environment; 2. Completes social evaluations and plans interventions based on the findings; 3. Counsels the patient/family/caregivers as needed in relationship to stress and other coping difficulties; and 4. Participates in the development of the plan of care and attends case conferences weekly. D. Review of documentation of the Interdisciplinary Group (IDG) meetings for review and revision of Patient 1's plan of care, revealed SW-H did not participate in the IDG meetings on 9/3/19, 9/17/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19, 11/26/19, 12/10/19, and 12/24/19. E. Review of documentation of the IDG meetings, for review and revision of Patient 2's plan of care, revealed SW-H did not participate in the IDG meetings on 9/3/19, 9/17/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19, 11/26/19, 12/10/19, and 12/24/19. F. Review of documentation of the IDG meetings, for review and revision of Patient 5's plan of care, revealed SW-H did not participate in the IDG meetings on 9/3/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19 and 11/26/19. G. Review of documentation of the IDG meetings, for the review and revision of Patient 6's plan of care, revealed SW-H did not participate in the patient's IDG meetings on 10/3/19 or 10/15/19. H. Review of documentation of the IDG meetings, for the review and revision of Patient 8's plan of care, revealed SW-H did not participate in the patient's IDG meetings on 11/12/19 or 11/26/19. I. Review of SW-H's time sheet confirmed the SW had not provided services for the hospice since 10/5/19. J. Interview with the hospice Administrator on 12/18/19 at 4:00 PM confirmed SW- H was not under the supervision of a CMSW and had not participated in the review and revisions of the plan of care for Patients 1, 2, 5, 6, or 8 as identified. The Administrator during the same interview confirmed SW-H had not provided services for the hospice since 10/5/19. K. Interview with Licensed Practical Nurse (LPN)-E on 1/6/2020 at 4:30 PM confirmed a medical social worker did not partipicate in the IDG meetings for Patient 1 and 2 on 12/24/19. L. This practice provided the opportunity for the psychosocial needs of the patient, family and/or caregivers to not be met.
L0538
L0538	14779 Based on review of clinical records, review of policy and procedure and staff interview the hospice failed to include the scope and frequency of services needed, to meet the needs of patient in the plan of care for 1 of 8 patients reviewed (Patient 1). Samples size was 8 and hospice census was 2. Findings are: A. Review of the policy titled Interdisciplinary Group (IDG) Plan of Care, dated 5/2011, revealed the plan of care was to state in detail the scope and frequency of services needed to meet the patient, family and caregiver needs. The policy indicated the plan of care was to contain the frequency and duration of visits. B. Review of Patient 1's clinical record revealed Certification and Plans of Care for the certification periods of 4/22/19 through 6/20/19, 6/21/19 through 8/19/19, and 8/20/19 through 10/18/19. The Certifications and Plans of Care contained no physician orders for which disciplines were to conduct visits to the patient's home, the frequency of the visits and/or the duration of the visits to be conducted to meet the needs of the patient. C. Interview with the Administrator on 12/18/19 at 3:00 PM confirmed Patient 1's Certifications and Plans of Care for 4/22/19 through 6/20/19, 6/21/19 through 8/19/19, and 8/20/19 through 10/18/19 did not contain physician orders for which disciplines were to conduct visits to the patient's home, the frequency of the visits and/or the duration of the visits to be conducted to meet the needs of the patient.
L0541
L0541	14779 Based on review of personnel files, clinical records, and staff interview the hospice failed to ensure the staff member serving as the social worker for the hospice and as a core member of the Interdisciplinary Group (IDG) met the criteria for a qualified social worker. Sample size was 8 and hospice census was 2. Findings are: A. Review of the personnel file for the hospice's Social Worker (SW), SW-H revealed the following: 1. Date of hire: 8/8/19; and 2. License type: Provisional Master Social Worker (PMSW), issued 5/13/19. B. There was no documentation in SW-H's personnel file the required post-degree work in an approved social work setting, with supervision by a Certified Master's Social Worker (CMSW) had been completed by SW-H and SW-H continued to be a provisionally licensed as a Master's Social Worker. C. Review of SW-H's time sheet confirmed the SW had not provided services for the hospice since 10/5/19. D. Interview with the hospice Administrator on 12/18/19 at 4:00 PM confirmed SW- H had not been under the supervision of a CMSW from date of hire on 8/8/19 to the last day worked on 10/5/19 and the hospice had not had a qualified Master Social Worker on staff for the provision of care to hospice patients since 7/12/19 when CMSW-C resigned. .
L0543
L0543	14779 Based on review of clinical records, policy and procedures and staff interview the hospice failed to provide services as ordered by the physician for 5 of 8 patients reviewed (Patient 1, 2, 3, 4, and 5) Findings are: A. Review of the policy and procedure, titled Missed Visits, revised 11/2017, revealed the purpose of the policy was to ensure missed visits do not affect the quality of patient care. The policy also revealed the hospice staff was to document the reason for the missed visit, and notify the patient's physician of the missed visits. B. Review of Patient 1's clinical record revealed the following: 1. A physician's order dated 10/15/19 for the patient to be seen by the chaplain 2 times per month. Documentation in the clinical record revealed the patient was visited by the chaplain 1 time in 10/2019 on 10/17/19; 1 time in 11/2019 on 11/1/19 and 1 time in 12/2019 on 12/11/19. There was no documentation to indicate the reason the patient was not seen as ordered or of physician notification . 2. A physician's order dated 6/18/19 for the patient to be seen by a Home Health Aide (HHA) 2 times per week for bathing. Documentation in the clinical record revealed the patient did not receive the services of a HHA after 6/26/19. There was no documentation to indicate the reason the patient was not seen as ordered or of physician notification 3. A physician's order date 7/2/19 for the Social Worker (SW) to see the patient 2 times per month. Documentation in the clinical record revealed the patient was not seen by the seen by the SW in 8/2019, and was seen 1 time in 9/2019. There was no documentation to indicate the reason the patient was not seen as ordered or of physician notification. 4. A physician's order dated 10/15/19 for the SW to see the patient 2 times per month. Documentation in the clinical record revealed the SW visited the patient 1 time in 10/2019 and there was no documentation the SW visited the patient in 11/2019 or in 12/2019. There was no documentation to indicate the reason the patient was not seen as ordered or of physician notification. C. Review of Patient 2's clinical record revealed the following: 1. A physician's order dated 4/19/19 for skilled nursing (SN) services 2 times per week. Documentation in the clinical record revealed the patient was seen 1 time the week of 4/19/19. There was no documentation to indicate the reason the patient was not seen as ordered or of physician notification. 2. A physician's order dated 4/19/19 for HHA services 2 times per week. Documentation in the clinical record revealed the patient was seen 1 time the week of 4/19/19. There was no documentation to indicate the reason the patient was not seen as ordered or of physician notification. 3. A physician's order, dated 9/11/19 for SN services 2 times per week. Documentation in the clinical record revealed the patient was seen by a SN 1 time the week of 9/15/19 through 9/21/19. There was no documentation to indicate the reason the patient was not seen as ordered or of physician notification. 4. A physician's order, dated 8/15/19 for the chaplain to see the patient 2 times per month. Documentation in the clinical record revealed the patient was not seen by a chaplain in 8/2019 or 9/2019. There was no documentation to indicate the reason the patient was not seen as ordered or of physician notification. D. Review of Patient 3's clinical record revealed the following: 1. A physician's order dated 1/18/19 for skilled nurse visits 5 times per week. Documentation in the clinical record revealed the patient was seen 1 time the week of 1/18/19. There was no documentation to indicate the reason the patient was not seen as ordered or of physician notification. 2. A physician's order dated 1/18/19 for HHA services 3 times per week. Documenation in the clinical record revealed the patient did not receive the services of a HHA the week of 1/18/19. There was no documentation to indicate the reason the patient was not seen as ordered or of physician notification. E. Review of Patient 4's clinical record revealed the following: 1. A physician's order, dated 5/17/19 for the patient to receive the services of a SN 2 times per week. Documentation in the clinical record revealed the patient was seen 1 time the week of 5/17/19. There was no documentation to indicate the reason the patient was not seen as ordered or of physician notification. 2. A physician's order, dated 5/17/19 for the patient to receive the services of a HHA 5 times per week. Documentation in the clinical record revealed the patient was seen 1 time the week of 5/17/19. There was no documentation to indicate the reason the patient was not seen as ordered or of physician notification. F. Review of Patient 5's clinical record revealed the following: 1. A physician's order, dated 8/20/19 for the patient to receive the services of a SW 2 times per month. There was no documentation in the clinical record the patient was seen by the SW between 8/16/19 and 8/31/19, in 9/2019 and/or in 10/2019. There was no documentation to indicate the reason the patient was not seen as ordered or of physician notification. 2. A physician's order dated 8/20/19 for the patient to receive the services of a chaplain 2 times per month. There was no documentation in the clinical record the patient received the services of a chaplain in 8/2019 or 9/2019. There was no documentation to indicate the reason the patient was not seen as ordered or of physician notification. G. Interview with Licensed Practical Nurse (LPN) - E on 1/6/2020 between 4:00 and 4:30 PM confirmed services were not provided to the patients 1, 2, 3, 4 or 5 as ordered by the physician and there was no documentation to indicate the reason the patients were not seen as ordered or of physician notification. H. The failures provided the potential for the needs of the patients, family and/or caregivers to not be meet and/or to allow the physician to make potential changes to the orders for the provision of services for their patients.
L0545
L0545	14779 Based on review of, clinical records, policy and procedures and staff interview the hospice failed to ensure all disciplines compromising the IDG, contributed to the comprehensive and ongoing assessment and care planning process for 5 of 8 patients reviewed (Patient 1, 2, 5, 6, and 8) . Sample size was 8 and hospice census was 2. Findings are: A. Review of the policy and procedure titled, Listing of Services Provided, dated 5/2011, revealed the IDG was to include a medical social worker and spiritual care counselor. B. Review Patient 1's clinical record revealed the following: 1. There was no documentation a medical social worker was involved in the Interdisciplinary Group (IDG) meetings for review and revision of the patient's plan of care, on 9/3/19, 9/17/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19, 11/26/19, 12/10/19, and 12/24/19. 2. There was no documentation a spiritual care counselor was involved in the IDG meetings for the review and revision of the patient's plan of care on 1/22/19, 2/19/19, 3/5/19, 4/2/19, 4/16/19, 5/13/19, 5/28/19, 6/25/19, 7/9/19, 7/23/19, 8/6/19, 8/20/19, 9/3/19, 10/29/19, 11/12/19 or 11/26/19. C. Review of Patient 2's clinical record revealed the following: 1. There was no documentation a medical social worker was involved in the IDG meetings for the review and revision of the patient's plan of care on 9/3/19, 9/17/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19, 11/26/19, 12/10/19, and 12/24/19. 2. There was no documentation a spiritual care counselor was involved in the IDG meetings for the review and revision of the patient's plan of care on 5/13/19, 5/28/19, 6/25/19, 7/9/19, 7/23/19, 8/6/19, 8/20/19, 9/3/19, 10/29/19, 11/12/19 and 11/26/19. H. Review of Patient 5's clinical record revealed the following: 1. There was no documentation a medical social worker was involved in the IDG meetings for review and revision of the patient's plan of care on 9/3/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19 and 11/26/19. 2. There was no documentation a spiritual care counselor was involved in the IDG meetings on 8/20/19, 9/3/19, 10/29/19, 11/12/19, and 11/26/19. D. Review of Patient 6's clinical record revealed the following: There was no documentation a medical social worker participated in the patient's IDG meetings on 10/3/19 or 10/15/19. E. Review of Patient 8's clinical record revealed the following: 1. There was no documentation a medical social worker participated in the patient's IDG meetings on 11/12/19 or 11/26/19. 2. There was no documentation a spiritual care counselor was involved in the IDG meetings on 11/12/19 and 11/26/19. F. Interview with the Administrator on 12/18/19 at 4:00 PM confirmed the hospice social worker had not provided services to the patients or the hospice since 10/5/19 and the hospice did not have a qualified medical social worker on staff to provide services for the patients G. During interview on 1/6/2020 at approximately 1:00 PM, Licensed Practical Nurse (LPN) - E confirmed all IDG members were not present at the IDG meetings, held to review and revise the patient's plans of care. H. This practice provided the opportunity for the hospice patients/family and/or caregivers to not receive the services and care required to cope with the terminal illness.
L0547
L0547	14779 Based on review of clinical records, review of policy and procedure and staff interview the facility failed to include the scope and frequency of services needed to meet the needs of patients in the plan of care for 1 of 8 patients reviewed (Patient 1). Samples size was 8 and hospice census was 2. Findings are: A. Review of the policy titled Interdisciplinary Group (IDG) Plan of Care, dated 5/2011, revealed the plan of care was to state in detail the scope and frequency of services needed to meet the patient, family and caregiver needs. The policy indicated the plan of care was to contain the frequency and duration of visits. B. Review of Patient 1's clinical record revealed Certification and Plans of Care for the certification periods of 4/22/19 through 6/20/19, 6/21/19 through 8/19/19, and 8/20/19 through 10/18/19. The Certifications and Plans of Care contained no physician orders for which disciplines were to conduct visits to the patient's home, the frequency of the visits and/or the duration of the visits to be conducted to meet the needs of the patient. C. Interview with the Administrator on 12/18/19 at 3:00 PM confirmed Patient 1's Certifications and Plans of Care for 4/22/19 through 6/20/19, 6/21/19 through 8/19/19, and 8/20/19 through 10/18/19 did not contain physician orders for which disciplines were to conduct visits to the patient's home, the frequency of the visits and/or the duration of the visits to be conducted to meet the needs of the patient. D. This failure provided the opportunity for Patient 1 to not receive the cares required to meet the patient needs or the needs of the patient's family and/or caregiver.
L0551
L0551	14779 Based on review of clinical records, policy and procedure and staff interview the hospice failed to document the patient's or representative's level of understanding, involvement, or agreement with the plan of care in the clinical record for 8 of 8 patients reviewed (Patients 1, 2, 3, 4, 5, 6, 7, and 8). Sample size was 8 and hospice census was 2. Findings are: A. Review of the policy and procedure, titled The Initial Plan of Care, dated 5/2011 revealed the plan of care and all updates thereafter will be developed always with the input of the patient/family, the physician and the Interdisciplinary Group. The policy indicated the following areas were to be reviewed and approved by the patient/family: 1. Scope and frequency of service; 2. Medication Administration and side effects; 3. Problems identified; 4. Activity level and safety measures; and 5. Dietary suggestions. B. Review of the plans of care and the updates to the plans of care for Patients 1, 2, 3, 4, 5, 6, 7, and 8, revealed no documentation the patient and/or family understood the plan of care, was involved in or was in agreement with the plan of care or updates for the 8 patients. C. During interview on 1/2/2020 at 11:35 AM Licensed Practical Nurse- E confirmed the hospice did not document the level of understanding, involvement or agreement with the plan of care in the clinical record of patients.
L0559
L0559	14779 Deficiencies cited at L 560, and L 562 L 560 Based on review of documentation of Quality Assurance Performance Improvement (QAPI) meeting minutes, policy and procedure and staff interview the hospice failed to have a system in place to audit and monitor the quality and appropriateness of care and to monitor for compliance and initiate a performance improvement plans when standards are not met. The hospice failed to have an ongoing self-assessment program to identify and resolve problems and to improve patient care. Sample size was 8 and hospice census was 2. L 562 Based on review of policy and procedure, documentation of meeting minutes, and staff interview the hospice failed to follow and/or implement the policy and procedure for Quality Assurance and Performance Improvement (QAPI). The hospice failed identify quality indicators, to measure, analyze and track quality indicator data, to assess the hospice's processes and to identify areas of noncompliance with regulations.
L0560
L0560	14779 Based on review of documentation of Quality Assurance Performance Improvement (QAPI) meeting minutes, policy and procedure and staff interview the hospice failed to have a system in place to audit and monitor the quality and appropriateness of care and to monitor for compliance and initiate a performance improvement plans when standards are not met. The hospice failed to have an ongoing self-assessment program to identify and resolve problems and to improve patient care. Sample size was 8 and hospice census was 2. Findings are: A. Review of the policy and procedure titled, Improving Organizational Performance, dated 10/2014, revealed hospice management was responsible for identifying and setting specific outcomes for measurable improvement and acceptable limits for findings. The policy indicated the QAPI was to identify and participate in benchmarking activities utilizing the following: 1. Internal standards: a. Measuring current performance against past performance; and b. Measuring against internally established goals. 2. Processes and protocols. 3. Practice or services guidelines. 4. Industry research or best practices. The policy revealed trends identified through quality assessment and performance measurement and analysis were to be reported to the Governing Body on a quarterly basis. B. Review of documentation, provided by the hospice Administrator on 12/18/19 at 4:45 PM, revealed the Board of Advisory met on 2/5/19 with the Administrator, Director of Nursing,the Medical Director and Licensed Practical Nurse-E in attendance. Documentation of the meeting agenda revealed the following areas were reviewed: 1. Introduction to role and responsibilities of the advisory board; 2. Reviewed and adopted policies and procedures; 3. Reviewed and adopted QAPI (Quality Assurance and Performance Improvement) programs; and 4. The hospice was "working on hiring a new sales team" There was no documentation the hospice identified or participated in identifying quality indicators to assess the hospice's processes and activities utilizing the criteria outlined in the hospice policy and procedure: C. Interview with the hospice Administrator, via phone, on 1/2/2020 at 1:00PM, confirmed no meetings, other than the 2/5/19 meeting had been held by the hospice and there was no documentation the hospice identified quality indicators for the assessment of the hospice's processes and/or tracked and trended the hospice's performance. D. The failure to monitor, identify indicators and track and trend data related to the provision of cares to hospice patients through the QAPI program, provided missed opportunities to address problem areas which could affect all current and future hospice patients.
L0562
L0562	14779 Based on review of policy and procedure, documentation of meeting minutes, and staff interview the hospice failed to follow and/or implement the policy and procedure for Quality Assurance and Performance Improvement (QAPI). The hospice failed identify quality indicators, to measure, analyze and track quality indicator data, to assess the hospice's processes and to identify areas of noncompliance with regulations. Sample size was 8 and census was 2. Findings are: A. Review of the policy and procedure titled, Improving Organizational Performance, dated 10/2014, revealed hospice management was responsible for identifying and setting specific outcomes for measurable improvement and acceptable limits for findings. The policy indicated the QAPI was to identify and participate in benchmarking activities utilizing the following: 1. Internal standards: a. Measuring current performance against past performance; and b. Measuring against internally established goals. 2. Processes and protocols. 3. Practice or services guidelines. 4. Industry research or best practices. The policy revealed trends identified through quality assessment and performance measurement and analysis were to be reported to the Governing Body on a quarterly basis. B. Review of documentation, provided by the hospice Administrator on 12/18/19 at 4:45 PM, revealed the Board of Advisory met on 2/5/19 with the Administrator, Director of Nursing, the Medical Director and Licensed Practical Nurse-E in attendance. There was no documentation the hospice identified or participated in identifying quality indicators to assess the hospice's processes, to measure, analyze and track quality indicator data, or to assess the hospice's processes to identify areas of noncompliance with regulation. C. Interview with the hospice Administrator, via phone, on 1/2/2020 at 1:00PM, confirmed no were no other meetings held by the hospice for QAPI purposes other than the meeting held on 2/5/19. D. The failure to monitor, identify indicators and track and trend data related to the provision of cares to hospice patients through the QAPI program, provided missed opportunities to address problem areas which could affect all current and future hospice patients.
L0583
L0583	14779 Deficiencies cited at L 585. L 585 Based on review of personnel files, clinical records, and staff interview the hospice failed to ensure the licensed professionals actively participated in the coordination of all aspects of the patient's hospice care, including participation in ongoing interdisciplinary comprehensive assessments, developing and evaluation of the plan of care and contributing to patient and family counseling and education. 5 of 8 sampled patients (Patient 1, 2, 5, 6, and 8).
L0585
L0585	14779 Based on review of personnel files, clinical records, and staff interview the hospice failed to ensure the licensed professionals actively participated in the coordination of all aspects of the patient's hospice care, including participation in ongoing interdisciplinary comprehensive assessments, developing and evaluation of the plan of care and contributing to patient and family counseling and education. 5 of 8 sampled patients (Patient 1, 2, 5, 6, and 8). Sample size was 8 and hospice census was 2. Findings are: A. Review of the personnel file for the hospice's Social Worker (SW), SW-H revealed the following: 1. Date of hire: 8/8/19; and 2. License type: Provisional Master Social Worker (PMSW), issued 5/13/19. B. Review of hospice's job description for a medical Social Worker (SW), signed by SW-H on 8/8/2019, revealed the medical social worker responsibilities included the following: 1. Assessing the psychosocial status of patients/families/caregivers related to the patient's terminal illness and environment; 2. Completes social evaluations and plans interventions based on the findings; 3. Counsels the patient/family/caregivers as needed in relationship to stress and other coping difficulties; and 4. Participates in the development of the plan of care and attends case conferences weekly. D. Review of documentation of the Interdisciplinary Group (IDG) meetings for review and revision of Patient 1's plan of care, revealed SW-H did not participate in the IDG meetings on 9/3/19, 9/17/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19, 11/26/19, 12/10/19, and 12/24/19. E. Review of documentation of the IDG meetings, for review and revision of Patient 2's plan of care, revealed SW-H did not participate in the IDG meetings on 9/3/19, 9/17/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19, 11/26/19, 12/10/19, and 12/24/19. F. Review of Patient 5's clinical record revealed the following: 1. A physician's order dated 8/20/19 for the hospice Social Worker to see patient 2 time per month for counseling, home assessment, assessment of psychosocial factors related to illness/financial needs and to manage the patient's social service needs. Documentation in the patient's clinical record revealed the social worker completed a visit to the patient on 9/16/19. There was no documentation of a psychosocial assessment completed by SW-H. 2.Review of documentation of the IDG meetings, for review and revision of Patient 5's plan of care, revealed SW-H did not participate in the IDG meetings on 9/3/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19 and 11/26/19. G. Review of documentation of the IDG meetings, for the review and revision of Patient 6's plan of care, revealed SW-H did not participate in the patient's IDG meetings on 10/3/19 or 10/15/19. H. Review of documentation of the IDG meetings, for the review and revision of Patient 8's plan of care, revealed SW-H did not participate in the patient's IDG meetings on 11/12/19 or 11/26/19. I. Review of SW-H's time sheet confirmed the SW had not provided services for the hospice since 10/5/19. J. Interview with the hospice Administrator on 12/18/19 at 4:00 PM confirmed SW- H had not participated in the review and revisions of the plan of care for Patients 1, 2, 5, 6, or 8 as identified. The Administrator during the same interview confirmed SW-H had not provided services for the hospice since 10/5/19. K. This practice provided the opportunity for the psychosocial needs of the patient, family and/or caregivers to not be met.
L0587
L0587	14779 Deficiencies cited at L 588, L 596 L 588 Based on review of clinical records, policy and procedure and staff interview the hospice failed to routinely provide the core services of a medical Social Worker for 5 of 8 patients (Patient 1, 2, 5, 6, and 8) and/or a spiritual care coordinator for 6 of 8 patients (Patients 1, 2, 3, 5, 6 and 8). L 596 Based on review of clinical records, review of policy and procedure and staff interview, the hospice failed to have an organized program for the provision of bereavement services, under the supervision of a qualified professional and to include the provision of bereavement services in the individual plans of care for 8 of 8 patients reviewed (Patient 1, 2, 3, 4, 5, 6, 7, and 8).
L0588
L0588	14779 Based on review of clinical records, policy and procedure and staff interview the hospice failed to routinely provide the core services of a medical Social Worker (SW) for 5 of 8 patients (Patient 1, 2, 5, 6, and 8) and/or a spiritual care coordinator for 6 of 8 patients (Patients 1, 2, 3, 5, 6 and 8). Sample size was 8 and hospice census was 2. Findings are: A. Review of the policy and procedure titled Listing of Services Provided, dated 5/2011, revealed services provided directly by hospice employees included the services of a registered nurse, medical social worker, spiritual care counselor, and physician services. B. Review of documentation of the Interdisciplinary Group (IDG) meetings for review and revision of Patient 1's plan of care, revealed a SWdid not participate in the IDG meetings on 9/3/19, 9/17/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19, 11/26/19, 12/10/19, and 12/24/19. Review revealed the hospice chaplain did not participate in the IDG for Patient 1 on 1/22/19, 2/19/19, 3/5/19, 4/2/19, 4/16/19, 5/13/19, 5/28/19, 6/25/19, 7/9/19, 7/23/19, 8/6/19, 8/20/19, 9/3/19, 10/29/19, 11/12/19, or 11/26/19 C. Review of documentation of the IDG meetings, for review and revision of Patient 2's plan of care, revealed a SW did not participate in the IDG meetings on 9/3/19, 9/17/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19, 11/26/19, 12/10/19, and 12/24/19. Review revealed the hospice chaplain did not participate in the IDG for Patient 2 on 5/13/19, 5/28/19, 6/25/19, 7/9/19, 7/23/19, 8/6/19, 8/20/19, 9/3/19, 10/29/19, 11/12/19, or 11/26/19. D. Review of documentation of the IDG meetings, for review and revision of Patient 3's plan of care revealed the hospice chaplain did not participate in the meeting on 2/19/19, or 3/5/19. E. Review of documentation of the IDG meetings, for review and revision of Patient 5's plan of care, revealed a SW did not participate in the IDG meetings on 9/3/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19 and 11/26/19. Review of documentation of the IDG meetings, for review and revision of Patient 5's plan of care revealed the hospice chaplain did not participate in the meeting on 8/20/19, 9/3/19, 10/29/19, 11/12/19, or 11/26/19. F. Review of documentation of the IDG meetings, for the review and revision of Patient 6's plan of care, revealed a SW did not participate in the patient's IDG meetings on 10/3/19 or 10/15/19. G. Review of documentation of the IDG meetings, for the review and revision of Patient 8's plan of care, revealed a SW did not participate in the patient's IDG meetings on 11/12/19 or 11/26/19. Review of documentation of the IDG meetings for the review and revision of the Patient 8's plan of care revealed the hospice chaplain did not participate in the IDG meetings on 11/12/19 or 11/26/19. H. Review of SW-H's time sheet confirmed the SW had not provided services for the hospice since 10/5/19. I. Interview with the hospice Administrator on 12/18/19 at 4:00 PM confirmed a SW had not participated in the review and revisions of the plan of care for Patients 1, 2, 5, 6, or 8 as identified. The Administrator during the same interview confirmed SW-H had not provided services for the hospice since 10/5/19. J. Interview with Licensed Practical Nurse-E, on 1/2/2020 at 11:40 AM confirmed the hospice had not employed a chaplain between 7/18/19 and 8/29/19 and there was no documentation to indicate the chaplain had attended the identified IDG meetings. K. This practice provided the opportunity for hospice patients/ family and/or caregivers to not receive the services needed for psychosocial wellbeing.
L0596
L0596	14779 Based on review of clinical records, review of policy and procedure and staff interview, the hospice failed to have an organized program for the provision of bereavement services, under the supervision of a qualified professional and to include the provision of bereavement services in the individual plans of care for 8 of 8 patients reviewed (Patient 1, 2, 3, 4, 5, 6, 7, and 8). Sample size was 8 and hospice census was 2. Findings are: A. Review of the policy and procedure titled Bereavement Services, dated 5/2011 revealed the hospice was to provide an organized bereavement program supervised by a qualified bereavement coordinator; and the program was to provide bereavement services to patients/families/and caregivers of hospice patients, both before and after the patient's death to facilitate a normal grieving process and to identify the need for referrals of the family/caregivers to a bereavement counselor. Outline of the procedure identified the bereavement risks assessment was to be completed at the time of admission, by the hospice social worker, and a bereavement plan was to be developed to address bereavement/ grief issues and implementation of interventions as needed. B. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, and 8 revealed no documentation a bereavement assessment was done. C. Interview with the hospice Administrator on 12/19/2019 at 3:45 PM confirmed the hospice did not have a staff member designated as the bereavement coordinator, had not completed bereavement assessments for patients 1, 2, 3, 4, 5, 6, 7, or 8 and had not addressed the bereavement needs of the patients/ family or caregivers for Patients 1, 2, 3, 4, 5, 6, 7, or 8 in the hospice plan of care. D. This failed practice provided the opportunity for patients/family members and caregivers to not receive the interventions needed to aid in the individual's ability to cope with the patient's death.
L0607
L0607	14779 Deficiency cited at L 629. L 629 Based on review of clinical records, policy and procedure and staff interview the hospice failed to conduct a visit to the home of 2 of 8 patients (Patient 1 and 2) who received the services of a Home Health Aide (HHA), at least every 2 weeks, to assess the provision of cares, review the patient's plan of care and to ensure the HHA was meeting the patient's needs.
L0629
L0629	14779 Based on review of clinical records, policy and procedure and staff interview the hospice failed to conduct a visit to the home of 2 of 8 patients (Patient 1 and 2) who received the services of a Home Health Aide (HHA), at least every 2 weeks, to assess the provision of cares, review the patient's plan of care and to ensure the HHA was meeting the patient's needs. Sample size was 8 and agency census was 2. This practice allowed for failure to ensure the HHA followed the plan of care and to determine the patient's satisfaction with the cares provided by the HHA. Findings are: A. Review of the hospice policy and procedure titled, Responsibilities/Supervision of Clinical Services, revised 10/2014, revealed the skilled personnel were to conduct on-site visit to the patient's home every 14 days. The policy did not include the requirement a Registered Nurse (RN) conduct the visit for the supervision of the HHA. B. Review of Patient 1's clinical record revealed: 1. A physician's order dated 6/14/19 for HHA services 1 to 2 times per week for bathing assistance. 2. Documentation of HHA visits to the patient on 6/14/19, 6/21/19 and 6/26/19. 2. Documentation revealed a HHA Supervisory visit was conducted on 6/14/19. 3. There was no documentation of a Supervisory visit being conducted after 6/14/19 and there was no physician's order to discontinue the provision of HHA services to the patient. C. Review of Patient 2's clinical record revealed: 1. A Hospice Initial Plan of Care, dated 4/19/19, included a physician's order for HHA 2 times per week for the certification period of 4/19/19 through 6/17/19. 2. Documentation revealed a HHA supervisory visit was conducted on 5/24/19 and 6/17/19 (23 days) 1. A physician's order dated 6/17/19 for HHA services 2 times per week for bathing and personnel care. 2. Documentation revealed a HHA onsite supervisory visit was conducted on 6/17/19 and 7/25/19 (38 days); and 8/26/19 (32 days);
L0641
L0641	14779 Deficiency cited at L 644 and L 645 L644 Based on review of clinical records, review of policy and procedures and staff interview, the hospice failed to have a designated staff member responsible for the supervision of the volunteer program; failed to have volunteers to provide day-to day administrative or direct patient care; and failed to have an active and ongoing program for the recruitment of volunteers. L 645 Based on review of clinical records, review of policy and procedures and staff interview, the hospice failed to have an active and ongoing program for the recruitment of volunteers.
L0644
L0644	14779 Based on review of clinical records, review of policy and procedures and staff interview, the hospice failed to have volunteers,to provide day-to day administrative or direct patient care. Sample size was 8 and the hospice census was 2. Findings are: A. Review of the policy and procedure titled, Volunteer Services, dated 5/2011, revealed the hospice was to ensure qualified volunteers provided appropriate services to patients in accordance with the Interdisciplinary Plan of Care (POC) and in accordance to hospice program needs. B. Review of the plans of care and the Interdisciplinary Group meetings for Patients 1, 2, 3, 4, 5, 6, 7, and 8 care revealed the services of a volunteer were not provided to the patients. C. During interview with the hospice Administrator on 12/19/19 at 4:00 PM, the Administrator confirmed the hospice did not have volunteers. D. Failure to have volunteers to provide day-to-day administrative or direct patient care to patients receiving hospice services, provided the opportunity for the needs of the patients/ family members and caregivers to not be met.
L0645
L0645	14779 Based on review of policy and procedures and staff interview, the hospice failed to have an active and ongoing program for the recruitment of volunteers. Sample size was 8 and the hospice census was 2. Findings are: A. Review of the policy and procedure titled, Volunteer Services, dated 5/2011, revealed the hospice was to ensure qualified volunteers provided appropriate services in accordance with the Interdisciplinary Plan of Care (POC) and hospice program needs, under the supervision of a volunteer coordinator; and the volunteer coordinator was to develop, implement and evaluate the volunteer program on an ongoing basis, document active and ongoing effort to recruit and retain volunteers, and arrange for volunteer support to patient/ family/ caregivers in accordance to the POC. B. Review of the plans of care and the Interdisciplinary Group meetings for Patients 1, 2, 3, 4, 5, 6, 7, and 8 care revealed the services of a volunteer were not provided to the patients. C. During interview with the hospice Administrator on 12/19/19 at 4:00 PM, the Administrator confirmed the hospice did not have volunteers; did not have a staff member designated as being responsible for the ongoing and active recruitment of volunteers. D. Failure to have volunteers to provide day-to-day administrative or direct patient care to patients receiving the services of the hospice, provided the opportunity for the needs of the patients/ family members and caregivers to not be met.
L0648
L0648	14779 Deficiency cited at L651 and L 652 L651 Based on review of hospice personnel files, job description, and interview with hospice staff, the hospice Administrator and/or governing body failed to oversee and be responsible for the provision of patient services by employing qualified personnel in position of Masters level Social Worker in accordance with hospice policy and procedure and job descriptions; and the hospice failed to have a system in place to audit and monitor the quality and appropriateness of care and to monitor for compliance and initiate a performance improvement plans when standards of patient care was not met. The hospice failed to have an ongoing self-assessment program to identify and resolve problems and to improve patient care. L 652 Based on review of policy and procedures, clinical records and staff interview the hospice failed to provide cares and services of medical social services, spiritual counseling, bereavement counseling, and volunteer services to meet the needs of patients, family and/or caregivers to 8 of 8 patients reviewed.
L0651
L0651	14779 Based on review of personnel files, job descriptions, and interview with hospice staff, the hospice Administrator and/or governing body failed to oversee and be responsible for the provision of patient services. The hospice failed to employ qualified personnel for the provision of medical social services in accordance with hospice policy and procedure and job descriptions; the hospice failed to have a system in place to audit and monitor the quality and appropriateness of care, to monitor for compliance and to initiate a performance improvement plan when standards of patient care were not met and the hospice failed to have an ongoing self-assessment program to identify problems and to implement processes for the resolution of problems to improve patient care. These practices had the potential to affect all past and current patients receiving the services of the hospice who required the services of a medical social worker; failure to monitor, identify indicators and track and trend data related to the provision of cares to hospice patients through Quality Assurance Program Improvement program (QAPI) program, provided missed opportunities to identify problem areas which could affect the provision of cares to all current and future hospice patients.Sample size was 8 and hospice census was 2. Findings are: A. Review of the job description for a medical social worker, dated 5/2011, revealed the position qualifications included: 1. A graduate of a Master's program in social work accredited by the Council on Social Work Education; and 2 Minimum of 1 years' experience in health care, experience preferred. Understands agency philosophy and issues of death/dying. B. Review of the personnel file for the hospice's Social Worker (SW), SW-H revealed the following: 1. Date of hire: 8/8/19; and 2. License type: Provisional Master Social Worker (PMSW), issued 5/13/19. C. There was no documentation in SW-H's personnel file, the required post-degree work in an approved social work setting, with supervision by a Certified Masters Social Worker (CMSW) had been completed and SW-H continued to be provisionally licensed. D. During interview on 12/18/19 at 4:00 PM the Administrator confirmed [gender] was unaware SW-H had a provisional Master Social Worker license issued on 5/13/19 and required supervision by a Certified Masters Social Worker during the completion of post-degree work in an approved social work setting. E. Review of the policy and procedure titled, Improving Organizational Performance, dated 10/2014, revealed hospice management was responsible for identifying and setting specific outcomes for measurable improvement and acceptable limits. The policy indicated the hospice management was to identify and participate in benchmarking activities through the QAPI, utilizing the following: 1. Internal standards: a. Measuring current performance against past performance; and b. Measuring against internally established goals. 2. Processes and protocols. 3. Practice or services guidelines. 4. Industry research or best practices. The policy revealed trends identified through the QAPI analysis were to be reported to the Governing Body on a quarterly basis. F. Review of documentation, provided by the hospice Administrator on 12/18/19 at 4:45 PM, revealed the Board of Advisory met on 2/5/19 with the Administrator, Director of Nursing and the Medical Director and Licensed Practical Nurse-E in attendance. There was no documentation the hospice identified or participated in identifying quality indicators to assess the hospice's processes and activities utilizing the criteria outlined in the hospice policy and procedure: G. Interview with the hospice Administrator, via phone, on 1/2/2020 at 1:00PM, confirmed no other meetings were held by the hospice management to identify quality indicators for the assessment of the hospice's processes and/or tracked and trended the hospice's performance.
L0652
L0652	14779 Based on review of policy and procedures, clinical records and staff interview the hospice failed to provide cares and services of medical social services, spiritual counseling, bereavement counseling, and volunteer services to meet the needs of patients, family and/or caregivers to 8 of 8 patients reviewed. Samples size was 8 and hospice census was 2. Findings are: A. Review of the policy and procedure titled Listing of Services Provided, dated 5/2011, revealed services provided directly by hospice employees included the services of a registered nurse, medical social worker (SW), spiritual care counselor, and physician services. B. Review of documentation of the Interdisciplinary Group (IDG) meetings for review and revision of Patient 1's plan of care, revealed a SW did not participate in the IDG meetings on 9/3/19, 9/17/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19, 11/26/19, 12/10/19, and 12/24/19. Review revealed the hospice chaplain did not participate in the IDG for Patient 1 on 1/22/19, 2/19/19, 3/5/19, 4/2/19, 4/16/19, 5/13/19, 5/28/19, 6/25/19, 7/9/19, 7/23/19, 8/6/19, 8/20/19, 9/3/19, 10/29/19, 11/12/19, or 11/26/19 C. Review of documentation of the IDG meetings, for review and revision of Patient 2's plan of care, revealed a SW did not participate in the IDG meetings on 9/3/19, 9/17/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19, 11/26/19, 12/10/19, and 12/24/19. Review revealed the hospice chaplain did not participate in the IDG for Patient 2 on 5/13/19, 5/28/19, 6/25/19, 7/9/19, 7/23/19, 8/6/19, 8/20/19, 9/3/19, 10/29/19, 11/12/19, or 11/26/19. D. Review of documentation of the IDG meetings, for review and revision of Patient 3's plan of care revealed the hospice chaplain did not participate in the meeting on 2/19/19, or 3/5/19. E. Review of documentation of the IDG meetings, for review and revision of Patient 5's plan of care, revealed a SW did not participate in the IDG meetings on 9/3/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19 and 11/26/19. Review of documentation of the IDG meetings, for review and revision of Patient 5's plan of care revealed the hospice chaplain did not participate in the meeting on 8/20/19, 9/3/19, 10/29/19, 11/12/19, or 11/26/19. F. Review of documentation of the IDG meetings, for the review and revision of Patient 6's plan of care, revealed a SW did not participate in the patient's IDG meetings on 10/3/19 or 10/15/19. G. Review of documentation of the IDG meetings, for the review and revision of Patient 8's plan of care, revealed a SW did not participate in the patient's IDG meetings on 11/12/19 or 11/26/19. Review of documentation of the IDG meetings for the review and revision of the Patient 8's plan of care revealed the hospice chaplain did not participate in the IDG meetings on 11/12/19 or 11/26/19. H. Review of SW-H's time sheet confirmed the SW had not provided services for the hospice since 10/5/19. I. Interview with the hospice Administrator on 12/18/19 at 4:00 PM confirmed SW-H had not participated in the review and revisions of the plan of care for Patients 1, 2, 5, 6, and 8 as identified in the paragraphs above. The Administrator during the same interview confirmed SW-H had not provided services for the hospice since 10/5/19. J. Interview with Licensed Practical Nurse-E, on 1/2/2020 at 11:40 AM confirmed the hospice had not employed a chaplain between 7/18/19 and 8/29/19 and a chaplain had not attended all IDG meetings to review and revise the patient's plans of care. K. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, and 8 revealed no documentation of a bereavement assessment or bereavement plans of care. L. Interview with the hospice Administrator on 12/19/2019 at 3:45 PM confirmed the hospice did not have a staff member designated as the bereavement coordinator, had not completed bereavement assessments for patients 1, 2, 3, 4, 5, 6, 7, or 8 and had not addressed the bereavement needs of the patients/ family or caregivers for Patients 1, 2, 3, 4, 5, 6, 7, or 8 in the hospice plan of care. M. Review of the plans of care and the Interdisciplinary Group meetings for Patients 1, 2, 3, 4, 5, 6, 7, and 8 care revealed the services of a volunteer were not provided to the patients. N. During interview with the hospice Administrator on 12/19/19 at 4:00 PM, the Administrator confirmed the hospice did not have volunteers; did not have a staff member designated as being responsible for the supervision of the volunteer program; did not have a program for the ongoing and active recruitment of volunteers; and did not have a program for training volunteers. O. These failures provided the opportunity for hospice patients, patient's family and/or caregivers to not receive the services needed for psychosocial well being and for needs to not be met.
L0664
L0664	14779 Deficiency cited at L 669 L669 Based on review of clinical records, review of policies and procedures and staff interview, the medical director failed to ensure hospice staff consistently provided social work services, and/ or spiritual counseling for 6 of 8 patients reviewed (Patient 1, 2, 3, 5, 6, and 8) or bereavement counseling for 8 of 8 patients reviewed, to meet patient/ family or caregiver needs.
L0669
L0669	14779 Based on review of clinical records, review of policies and procedures and staff interview, the medical director failed to ensure the hospice staff consistently provided social work services, and/ or spiritual counseling for 6 of 8 patients reviewed (Patient 1, 2, 3, 5, 6, and 8) or bereavement counseling for 8 of 8 patients reviewed to meet patient and family need. Sample size was 8 and hospice census was 2. Findings are: A. Review of the policy and procedure titled Listing of Services Provided, dated 5/2011, revealed services provided directly by hospice employees included the services of a registered nurse, medical social worker, spiritual care counselor, and physician services. B. Review of the policy and procedure titled Bereavement Services, dated 5/2011 revealed the hospice was to provide an organized bereavement program supervised by a qualified bereavement coordinator; and the program was to provide bereavement services to patients/families/and caregivers of hospice patients, both before and after the patient's death to facilitate a normal grieving process and to identify the need for referrals of the family/caregivers to a bereavement counselor. C. Review of documentation of the Interdisciplinary Group (IDG) meetings for Patients 1, 2, 3, 4, 5, 6, 7 and 8 revealed the hospice Medical Director was in attendance at all IDG meetings held every 2 weeks between 11/20/18 and 12/24/19. D. Review of documentation of the Interdisciplinary Group (IDG) meetings for review and revision of Patient 1's plan of care, revealed a Social Worker (SW) did not participate in the IDG meetings on 9/3/19, 9/17/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19, 11/26/19, 12/10/19, and 12/24/19. Review revealed the hospice chaplain did not participate in the IDG for Patient 1 on 1/22/19, 2/19/19, 3/5/19, 4/2/19, 4/16/19, 5/13/19, 5/28/19, 6/25/19, 7/9/19, 7/23/19, 8/6/19, 8/20/19, 9/3/19, 10/29/19, 11/12/19, or 11/26/19 E. Review of documentation of the IDG meetings, for review and revision of Patient 2's plan of care, revealed a SW did not participate in the IDG meetings on 9/3/19, 9/17/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19, 11/26/19, 12/10/19, and 12/24/19. Review revealed the hospice chaplain did not participate in the IDG for Patient 2 on 5/13/19, 5/28/19, 6/25/19, 7/9/19, 7/23/19, 8/6/19, 8/20/19, 9/3/19, 10/29/19, 11/12/19, or 11/26/19. F. Review of documentation of the IDG meetings, for review and revision of Patient 3's plan of care revealed the hospice chaplain did not participate in the meeting on 2/19/19, or 3/5/19. G. Review of documentation of the IDG meetings, for review and revision of Patient 5's plan of care, revealed a SW did not participate in the IDG meetings on 9/3/19, 10/3/19, 10/15/19, 10/29/19, 11/12/19 and 11/26/19. Review of documentation of the IDG meetings, for review and revision of Patient 5's plan of care revealed the hospice chaplain did not participate in the meeting on 8/20/19, 9/3/19, 10/29/19, 11/12/19, or 11/26/19. H. Review of documentation of the IDG meetings, for the review and revision of Patient 6's plan of care, revealed a SW did not participate in the patient's IDG meetings on 10/3/19 or 10/15/19. I. Review of documentation of the IDG meetings, for the review and revision of Patient 8's plan of care, revealed a SW did not participate in the patient's IDG meetings on 11/12/19 or 11/26/19. Review of documentation of the IDG meetings for the review and revision of the Patient 8's plan of care revealed a hospice chaplain did not participate in the IDG meetings on 11/12/19 or 11/26/19. J. Review of SW-H's time sheet confirmed the SW had not provided services for the hospice since 10/5/19. K. Interview with the hospice Administrator on 12/18/19 at 4:00 PM confirmed SW-H had not participated in the review and revisions of the plan of care for Patients 1, 2, 5, 6, and 8 as identified in the paragraphs above. The Administrator during the same interview confirmed SW-H had not provided services for the hospice since 10/5/19. L. Interview with Licensed Practical Nurse-E, on 1/2/2020 at 11:40 AM confirmed the hospice had not employed a chaplain between 7/18/19 and 8/29/19 and there was no documentation to indicate the chaplain had attended the identified IDG meetings as identified in the paragraphs above. M. Review of the clinical records for Patients 1, 2, 3, 4, 5, 6, 7, and 8 revealed no documentation of a bereavement assessment. N. Interview with the hospice Administrator on 12/19/2019 at 3:45 PM confirmed the hospice did not have a staff member designated as the bereavement coordinator, had not completed bereavement assessments for patients 1, 2, 3, 4, 5, 6, 7, or 8 and had not addressed the bereavement needs of the patients/ family or caregivers for Patients 1, 2, 3, 4, 5, 6, 7, or 8 in the hospice plan of care. O. This failed practice provided the opportunity for the patient and the patient's family and/or caregivers to not receive interventions needed to aid in the individual's ability to cope with the patient's death. P. The hospice Administrator during interview via phone on 1/2/2020 at 1:00 PM confirmed the hospice had not conducted meetings to review the hospice's Quality Assurance and Improvement Plan (QAPI), other than the meeting held on 2/5/19, and there was no documentation the hospice had identified quality indicators, for assessment of the hospice's processes, and/ or tracked and trended the hospice's QAPI data. There was no documentation to indicate the Medical Director had addressed with the hospice Administration, the lack of a medical social worker's or spiritual counselor's attendance at IDG meetings for the review of the care and services and/or to address the lack of bereavement counseling for patients/family members or caregivers with the hospice Administration.
L0670
L0670	14779 Deficiencies cited at L 672, and L 678. L 672 Based on review of clinical records, review of hospice policy and procedure and staff interview, the hospice failed to update the assessment of the patient and /or the plan of care every 15 days for 1 of 8 patients reviewed (Patient 6) and failed to update the plan of care every 62 days for 1 of 8 patients (Patient 5). L678 Based on review of clinical records, review of policy and procedure and staff interview, the hospice failed to obtain physician orders for the provision of cares for 2 of 8 patients reviewed (Patient 8 and 2). Patient 8 did not have physician orders for care of a right wrist wound and Patient 2 did not have physician orders for care of a right wrist fracture or to hold medications.
L0672
L0672	14779 Based on review of clinical records, review of hospice policy and procedure and staff interview, the hospice failed to update the assessment of the patient and /or the plan of care every 15 days for 1 of 8 patients reviewed (Patient 6) and failed to update the plan of care every 62 days for 1 of 8 patients (Patient 5). Sample size was 8 and hospice census was 2. Findings are: A. Review of the policy titled Interdisciplinary Group (IDG) Plan of Care, dated 5/2011 revealed documented updates of the plan of care will be based on the interdisciplinary group assessments. The frequency of the updates of the plan of care were to be based on changes in the patient, family, or caregiver status, but at a minimum the plan of care was to be updated every other week. B. Interview with Licensed Practical Nurse (LPN)-E and the hospice Administrator on 12/16/19 at 4:30 PM confirmed the IDG plan of care meetings were to be held every 2 weeks to assess hospice patients and to update the patient's plan of care. C. Review of Patient 6's clinical record revealed there was no documentation an IDG meeting was held to discuss and revise the patient's plan of care between 8/8/19 and 9/17/19. D. Interview with LPN-E on 1/6/2020 at 3:15 PM confirmed the clinical record for Patient 6 did not contain documentation of a review of the patient's plan of care by the IDG between 8/8/19 and 9/17/19. E. Review of Patient 5's clinical record revealed the patient was admitted on 8/16/19. Documentation in the patient's clinical record revealed a Certification and Plan of Care for the certification period of 8/16/19 through 11/13/19. Documentation in the patient's clinical record revealed a physician's order dated 11/12/19 for the patient to be recertified for hospice care. There was no documentation in the patient's clinical record a Certification and Plan of Care for the recertification period beginning on 11/14/19 was completed. F. Interview with the hospice Administrator on 12/19/19 at 10:00 AM, confirmed the plan of care was not updated for Patient 5 for the certification period beginning 11/14/19 as ordered by the physician on 11/12/19.
L0678
L0678	14779 Based on review of clinical records, review of policy and procedure and staff interview, the hospice failed to obtain physician orders for the provision of cares for 2 of 8 patients reviewed (Patient 8 and 2). Patient 8 did not have physician orders for care of a right wrist wound and Patient 2 did not have physician orders for care of a right wrist fracture or to hold medications. Samples size was 8 and hospice census was 2. This failure provided the opportunity for the physician caring for patients receiving hospice care to be unaware of patient needs and a need to alter the patient's plan of care. Findings are: A. Review of the hospice policy titled Verification of Physician Orders, dated 5/2011, revealed physician orders were to be obtained when indicated by the patient's condition; physician orders were to be documented on a form provided by the hospice; and the signed order form was to be retained in the patient's clinical record. B. Review of Patient 8's Hospice Initial/ Comprehensive Nursing Assessment dated 11/7/2019 identified the patient had a 2 centimeter (cm) erythematous (abnormal redness) burn on the right wrist sustained 2 days prior to admission from contact with a coffee pot. Review of the patient's clinical record revealed no documentation the patient's physician was made aware of the burn on the patient's wrist or of physician orders for care of the burn area on the patient's right wrist. C. Interview with Licensed Practical Nurse (LPN)-E on 12/31/19 at 4:30 PM confirmed there was no documentation Patient 8's physician was made aware of the burn on the patient's right wrist and physician orders for care of the wound were not obtained. D. Review of Patient 2's Certification and Plan of Care form for the certification period of 8/17/19 through 10/15/19 revealed the patient had a history of falling. Review of the patient's IDG dated 8/20/19 revealed the patient had not had falls or injuries, fall prevention was to be maintained during cares and the patient was assessed and was instructed to use a walker. E A physician order dated 8/26/19, revealed Patient 2 had been hospitalized and a skilled nurse visit for assessment of the patient post hospitalization was required. F. Documentation by Registered Nurse (RN)-L, dated 8/26/19 at 1:15 PM revealed RN-L conducted a visit to assess the patient, after a fell at home, fracturing the right wrist and being hospitalized. The RN documented the patient had a splint/brace, and also had a right black/blue eye and right lower extremity bruising. G. There was no documentation Patient 2's physician was contacted regarding the outcome of the assessment or to obtain physician orders for the care of the patient's right wrist fracture. H. Documentation of a skilled nurse visit dated 12/27/19, from 10:40 AM to 1:20 PM revealed Patient 2's insulin had been discontinued and the patient's oral medications were to be held. There was no documentation in the patient's clinical record the patient's physician was contacted and/or of a physician's order to discontinue the patient's insulin and/or to hold the patient's oral medications. I. Interview with LPN-E on 12/31/19 at 1:05 PM confirmed there was no physician's order to discontinue Patient 2's insulin or to hold the patient's oral medications.
L0783
L0783	14779 Deficiency cited at L787 L787 Based on review of personnel files, job description, and staff interview, the hospice failed to employ qualified personnel in the position of Masters-level Social Worker (SW) in accordance with hospice policy and procedure and job descriptions for 1 of 2 SW staff records reviewed (SW-H)
L0787
L0787	14779 Based on review of personnel files, job description, and staff interview, the hospice failed to employ qualified personnel in the position of Masters-level Social Worker (SW) in accordance with hospice policy and procedure and job descriptions for 1 of 2 SW staff records reviewed (SW-H). Sample size was 8 and hospice census was 2. Findings are: A. Review of the job description for a medical social worker, dated 5/2011, revealed the position qualifications included: 1. A graduate of a Master's program in social work accredited by the Council on Social Work Education; and 2. Minimum of 1 year of experience in health care preferred. Understands agency philosophy and issues of death/dying. B. Review of the personnel file for the hospice's Social Worker (SW)-H revealed the following: 1. Date of hire: 8/8/19; and 2. License type: Provisional Master Social Worker (PMSW), issued 5/13/19. C. There was no documentation in SW-H's personnel file that the required post-degree work in an approved social work setting, with supervision by a Certified Masters Social Worker (CMSW), had been completed and SW-H continued to be provisionally licensed. D. Review of hospice's job description for a medical Social Worker (SW), signed by SW-H on 8/8/2019, revealed the medical social worker responsibilities included the following: 1. Assessing the psychosocial status of patients/families/caregivers related to the patient's terminal illness and environment; 2. Completes social evaluations and plans interventions based on the findings; 3. Counsels the patient/family/caregivers as needed in relationship to stress and other coping difficulties; and 4. Participates in the development of the plan of care and attends case conferences weekly. E. During interview on 12/18/19 at 4:00 PM the Administrator confirmed [gender] was unaware SW-H had a provisional Master Social Worker license issued 5/13/19 which required supervision by a Certified Masters Social Worker during the completion of post-degree work in an approved social work setting. K. These practices had the potential for all hospice patients to receive services from unqualified SW staff and from unlicensed staff with a criminal history or with adverse findings of abuse, neglect, and/or misappropriation of patient property on the registries.
L0797
L0797	14779 A deficiency cited at L 798. L798 An Immediate Jeopardy (IJ) was identified and the Hospice staff was notified. A deficient practice related to the IJ was cited at Title 175 Nebraska Administrative Code (NAC) 16-006.05C, Tag Z 10A. Based on review of personnel files and staff interview the hospice failed to be in compliance with Title 175 Nebraska Administrative Code (NAC) 16-006.05C, Tag Z10A regarding the completion of pre-employment criminal background checks and registry checks with the Nurse Aide Registry, the Adult Protective Services Registry (APS), the Central Register of Child Protection Cases (CPS), and Nebraska State Patrol Sex Offender Registry for 2 of 2 unlicensed direct care staff, Home Health Aide (HHA)-J and HHA-I.
L0798
L0798	14779 Based on review of personnel files and staff interview the hospice failed to be in compliance with Title 175 Nebraska Administrative Code (NAC) 16-006.05C, Tag Z10A regarding the completion of pre-employment criminal background checks and registry checks with the Nurse Aide Registry, the Adult Protective Services Registry (APS), the Central Register of Child Protection Cases (CPS), and Nebraska State Patrol Sex Offender Registry for 2 of 2 unlicensed direct care staff, Home Health Aide (HHA)-J and HHA-I. An Immediate Jeopardy (IJ) was identified and the Hospice staff was notified. A deficient practice related to the IJ was cited at Title 175 Nebraska Administrative Code (NAC) 16-006.05C, Tag Z 10A. Sample size was 8 and hospice census was 2. Findings are: A. Review of HHA -J's personnel file revealed: 1. Date of hire was 10/6/2016. 2. Documentation in HHA- J's personnel file revealed the following: a. Results of APS and CPS registry checks dated 10/11/2017; b. Results of Sex Offender registry check dated 1/6/2017; c. Results of the Nurse Aide registry check dated 1/6/2017; and d. Results of a Criminal background check dated 3/14/17. 3. There was no documentation of criminal background and registry checks being completed prior to hire by the hospice. B. Interview with the interim business office manager on 1/7/20 at 10:45 AM confirmed criminal background and/or registry checks were not completed prior to HHA-J being hired and before the HHA was assigned to provide care for hospice patients on 10/26/16. C. Review of HHA-I's personnel file revealed: 1. Date of hire was 8/28/19. 2. Documentation in HHA-I's personnel file revealed the following: a. Results of a Criminal background check dated 9/30/2019. b. Results of the Nurse Aide registry check dated 9/18/19. c. Results of the Sex Offender registry check dated 9/18/19. 3. There was no documentation of criminal background and registry checks being completed prior to hire by the hospice. D. Interview with the interim office manager on 1/7/20 at 10:15 AM confirmed the hospice had not conducted pre-employment criminal background check, Nurse Aide registry check, and Sex offender registry checks for HHA-I. E. During a phone interview on 1/7/20 at 10:30 AM, the hospice Administrator confirmed APS and CPS registry checks were not completed for HHA-I. F. These failures had the potential to expose all hospice patients to receive care from unlicensed staff with a criminal background history, a sexual offender history and adverse findings for abuse, neglect, and/or misappropriation of patient property with APS, CPS and the Nurse Aide Registry. G. The hospice's IJ Removal Plan was implemented by the hospice on 1/7/20. This plan included: a. The hospice verified there were no unlicensed direct care staff currently employed by the hospice. b. HHA-I's employment with the hospice terminated on 11/30/19. c. HHA-J's employment with the hospice terminated on 8/28/19. d. Effective 1/7/20, the hospice will not allow unlicensed staff to provide services to hospice patients until the results of the criminal background and registry checks are received and reviewed to confirm no adverse findings. e. Effective 1/7/20, the hospice will not hire new unlicensed staff until the new process for completing the criminal background and registry checks is in place.