Community Hospice of Dale Medical Center

“Based on medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure all core members attended and participated in the Interdisciplinary Team (IDT). This deficient practice did affect seven of 14 MR’s reviewed, including, MR # 10, Home Visit (HV) # 1, MR # 7, MR # 1, MR # 2, MR # 4, MR # 3, and had the potential to affect all patients and caregivers served by this agency. Findings include: Agency Policy: Interdisciplinary Group Meeting Policy Number: 4-032.1 Policy Date: 11/2013 Purpose: To define the process for interdisciplinary group meetings and documenting patient status in the clinical record. Policy: The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care...no less frequently than every 15 days... The Medical Director and all hospice interdisciplinary group members will be present... Procedure: Members at the interdisciplinary group meeting will sign an attendance form ... 7. MR # 3 was admitted on 12/2/24 with a primary diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. Review of the IDT meeting notes dated 12/17/24, 12/31/24, 1/13/25, and 1/28/25 revealed no documentation the IDT core members participated or signed the document. An interview was conducted on 2/6/24 at 11:21 AM with EI # 1, who confirmed the agency failed to ensure all core members participated in the IDT meetings. 4. MR # 1 was admitted on 10/21/24 and recertified for hospice care from 12/20/24 to 2/17/25 with a primary diagnosis of Malignant Neoplasm of the Brain Stem. Review of the IDT meeting notes dated 1/13/25 revealed no documentation the IDT core members participated or signed the IDT document. On 1/28/25, documentation revealed the social worker was the only core member to participate or sign the IDT document. An interview conducted on 2/6/25 at 11:22 AM with EI # 1, who confirmed the agency failed to ensure all core members participated in the IDT meetings. 5. MR # 2 was admitted on 12/14/24 with a primary diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. Review of the IDT meeting note dated 1/28/25 revealed the social worker was the only member of the IDT who participated or signed the IDT document. An interview conducted on 2/6/25 at 11:27 AM with EI # 1, who confirmed the agency failed to ensure all core members participated in the IDT meetings. 6. MR # 4 was admitted on 11/9/24 with a primary diagnosis of End Stage Renal Disease. Review of the IDT meeting note dated 12/3/24 revealed no documentation the physician participated or signed the document. The IDT meeting notes dated 12/17/24, 12/31/24, 1/13/25, and 1/28/25 revealed no documentation the core members of the IDT participated or signed the document. An interview conducted on 2/6/25 at 11:34 AM with EI # 1, who confirmed the agency failed to ensure all core members participated in the IDT meetings. 1. MR # 10 was admitted on 12/13/23 and recertified for hospice care from 10/25/24 to 12/24/24 with a primary diagnosis of Alzheimer’s Disease, Unspecified. Review of the Hospice IDT meeting notes dated 11/5/24, 11/19/24, 12/3/24, 12/17/24, and 12/31/24 revealed no documentation a chaplain or spiritual leader participated or signed the IDT. An interview conducted on 2/6/25 at 12:20 PM with Employee Identifier (EI) # 1, Director, who confirmed the agency failed to ensure all core members participated in the IDT meetings. 2. HV # 1 was admitted on 12/31/24 with a primary diagnosis of Alzheimer’s Disease. Review of the Hospice IDT meeting note dated 1/28/25 revealed no documentation a chaplain or spiritual leader participated or signed the IDT. An interview conducted on 2/6/25 at 12:20 PM with Employee Identifier (EI) # 1, Director, who confirmed the agency failed to ensure all core members participated in the IDT meetings. 3. MR # 7 was admitted on 1/9/25 with a primary diagnosis of Heart Disease, Unspecified. Review of the Hospice IDT meeting note dated 1/28/25 revealed no documentation a chaplain or spiritual leader participated or signed the IDT. An interview conducted on 2/6/25 at 12:20 PM with Employee Identifier (EI) # 1, Director, who confirmed the agency failed to ensure all core members participated in the IDT meetings.”

“Based on medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure a range of visit frequency was included in the Plan of Care (POC) to meet each patient’s needs, and the staff followed the ordered frequency when included. This deficient practice affected six of 14 MR’s reviewed including MR # 10, MR # 7, Home Visit (HV) # 1, MR # 1, HV # 3, MR # 4, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: The Plan of Care Policy Number: 4-027.1-3 Policy Date: 11/2013 Purpose: To ensure that an individualized plan of care is completed... Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted... Procedure: ...4. The plan of care will identify the patient’s needs and services to meet those needs...It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals and outcome achievement... ...11. The written plan of care may contain, but will not be limited to, the following: ...M. Frequency/Amount/Duration of services... ...14. Care provided to the patient will be in accordance with the plan of care. 4. MR # 1 was admitted on 10/21/24 and recertified for hospice care from 12/20/24 to 2/17/25 with a primary diagnosis of Malignant Neoplasm of the Brain Stem. Review of the Hospice IDT meeting note dated 12/31/24 revealed physician’s orders for the next benefit period of 12/20/24 to 2/17/25 for the hospice aide (HA) frequency of three times per week for patient care established in the HA care plan. A review of the HA visit notes revealed the week of 12/23/24 the HA completed two of the three visits ordered and no missed visit was completed. An interview was conducted on 2/6/25 at 11:22 AM, with EI # 1, who confirmed the HA did not follow the ordered frequency or complete a missed visit note. 5. HV # 3 was admitted on 1/9/25 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. A review of the Hospice Plan of Care dated 1/9/25 revealed an order for SN two times a week, then one time a week. A review of the SN notes revealed the SN only completed one visit the week of 1/9/25. An interview was conducted on 2/6/25 at 11:33 AM with EI # 1, who confirmed the SN did not follow the ordered frequency or complete a missed visit note. 6. MR # 4 was admitted on 11/9/24 with a primary diagnosis of End Stage Renal Disease. A review of the Hospice Interdisciplinary Team meeting note dated 12/17/24 revealed orders for HA two times a week. A review of the HA visit notes revealed one visit completed on week of 12/23/24 and no missed visit note completed. An interview was conducted on 2/6/25 at 11:34 AM with EI # 1, who confirmed the HA did not follow the ordered frequency or complete a missed visit note. 1. MR # 10 was admitted 12/31/23 and recertified for hospice care from 12/25/24 to 2/22/25 with a primary diagnosis of Alzheimer’s Disease. Review of the Hospice Interdisciplinary Team (IDT) meeting note dated 12/17/24 revealed physician’s orders for the next benefit period of 12/25/24 to 2/22/25 for Skilled Nurse (SN) “as requested.” Review of the Hospice Interdisciplinary Team meeting note date 12/31/24 revealed orders for SN frequency “as requested.” There was no documentation a visit frequency was planned to meet the patient’s needs. An interview was conducted on 2/6/25 at 12:20 PM with Employee Identifier (EI) # 1, Director, who confirmed the agency failed to include a planned visit frequency to meet the patient and family/caregiver needs. 2. MR # 7 was admitted on 1/9/25 with a primary diagnosis of Heart Disease, Unspecified. Review of the Hospice POC dated 1/9/25 revealed no ordered frequency or goals for the Social Worker. Review of the Visit notes revealed the Social Worker Comprehensive Assessment was completed on 1/9/25. An interview was conducted on 2/6/25 at 11:35 AM with EI # 1 who confirmed the agency failed to ensure a visit frequency for the social worker was included in the POC. 3. HV # 1 was admitted on 12/31/24 with a primary diagnosis of Alzheimer’s Disease. Review of the Hospice POC dated 12/31/24 revealed no physician’s orders for chaplain visits. Review of the Nursing Admit Comprehensive Assessment dated 12/31/24 revealed no documentation chaplain services were offered or refused. There was no documentation a chaplain visit was completed. An interview was conducted on 2/6/25 at 12:00 PM with EI # 1 who confirmed there was no documentation a visit frequency for chaplain services was ordered on the POC and there was no documentation on the initial comprehensive assessment that chaplain services were offered or refused.”

“Based on review of medical records (MR), agency policies and procedures, and interviews with staff, it was determined the agency failed to ensure a frequency of visits was included on the Aide Care Plan. This deficient practice affected one of ten records reviewed with orders for Hospice Aide services including Home Visit (HV) # 1 and had the potential to affect all patients with orders for Hospice Aides. Findings include: Agency Policy: The Plan of Care Policy Number: 4-027.1 Policy Date: 11/2023 Purpose: To ensure that an individualized plan of care (POC) is completed... Policy: The (POC) will be based on the initial, comprehensive and ongoing comprehensive assessment... Procedure: ...11. The written (POC) may contain, but not limited to the following: ...M. Frequency/Amount/Duration of services... Agency Policy: Hospice Aide Services Policy Number: 4-003.1 Policy Date: 11/2013 Purpose: To specify the role of the hospice aide... Policy: Hospice aide services will include...activities in accordance with the plan of care and physician’s ... orders will be assigned and supervised by a hospice registered nurse (RN)... Procedure: ...3. Hospice aide assignments, plan of care, and interventions will be documented and included in the patient’s clinical record... 1. HV # 1 was admitted on 12/31/24 with a primary diagnosis of Alzheimer’s Disease. Review of the POC dated 12/31/24 revealed physician’s orders for interventions by discipline including Certified Nursing Assistant (CNA). HV # 1 requires the assistance of the Hospice Aide (HA). There was no documentation of a frequency for the HA in the POC. Review of the Aide Support Care Plan dated 12/31/24 revealed orders for interventions including personal care, vital signs, and housekeeping duties. There was no frequency of visits included in the Aide Support Care Plan. There was no documentation a HA visit was completed during week one from 12/31/24 to 1/5/25. An interview was conducted on 2/6/25 at 12:00 PM with Employee Identifier (EI) # 1, Director, who confirmed the agency failed to include a visit frequency on the Hospice POC and on the Aide Support Care Plan.”

“Based on medical Record (MR) review, policy and procedure, and Interviews with the staff it was determined the agency failed to ensure the Hospice Aide (HA) followed the plan of care (POC) and Agency policy. This affected four of 10 medical records reviewed with hospice aide services, to include MR # 4, MR # 1, MR # 3, Home Visit (HV) # 2, and had the potential to affect all patients receiving hospice aide services. Findings include: Agency Policy and Procedure: Hospice Aide Services Number: 4-003.1 Date: November 2013 Purpose: To specify the role of the hospice aide and/ or homemaker in hospice care. Policy: Hospice aide services will include personal care services provided by trained hospice aides... Procedure: ...4. Hospice aide duties may include: ...d. Reporting changes in the patient’s condition and needs... 5. Hospice aides will document care provided in accordance with the hospice aide assignment... 3. MR # 3 was admitted on 12/2/24 with a primary diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. A review of the hospice aide plan of care dated 12/2/24 revealed orders for the hospice aide to document the patient’s last bowel movement every visit and notify the nurse if greater than three days. A review of the HA visit notes dated 12/18/24, 12/23/24, 1/6/25, 1/13/25, 1/15/25, 1/20/25, 1/27/25, and 1/29/25 revealed the HA failed to document the patient’s last BM. An interview was conducted on 2/6/25 at 11:21 AM with EI # 1 who confirmed the HA failed to follow the plan of care. 4. HV # 2 was admitted on 8/29/24 and recertified for continued hospice care on 11/27/24 to 2/24/24 with a primary diagnosis of Parkinson’s Disease with Dyskinesia, without Mention of Fluctuations. A review of the HA POC dated 12/30/24 revealed orders for the HA to document the patient’s last BM every visit and notify the nurse if greater than three days. HA to check heart rate, respirations, temperature, and pain rating every visit, and notify the nurse for heart rate less than 50 or greater than 120, respirations less than ten and greater than 40, temperature greater than 101, and pain rating that is unrelieved or greater than seven. A review of the HA visit note dated 1/20/25 revealed the HA failed to document the heart rate, respirations, temperature, and pain rating. A review of the HA visit note dated 2/3/25 revealed the HA failed to document the patient’s last BM. An interview was conducted on 2/6/25 at 11:16 AM with EI # 1 who confirmed the HA failed to follow the plan of care. 1. MR # 4 was admitted on 11/9/24 with a primary diagnosis of End Stage Renal Disease. A review of the hospice aide POC dated 11/9/24 revealed orders for the HA to document the patient’s last bowel movement (BM) every visit, and notify the nurse if greater than three days. HA to check heart rate, respirations and temperature every visit, and notify the nurse for heart rate less than 50 or greater than 120, respirations less than 10 or greater than 40, and temperature greater than 101. A review of the HA visit notes dated 11/20/24, 11/27/24, 12/6/24,1/9/25,1/15/25, and 1/20/25 revealed the HA failed to document the patient’s last BM. A review of the HA visit note dated 1/24/25 revealed the HA failed to document the temperature, respirations, and heart rate for the patient. An interview was conducted on 2/6/25 at 11:34 AM with Employee Identifier (EI) # 1, Director, who confirmed the HA failed to follow the plan of care and agency policy. 2. MR # 1 was admitted on 10/21/24 and recertified for continued hospice care 12/20/24 to 2/17/25 with the primary diagnosis of Malignant Neoplasm of the Brain Stem. A review of the hospice aide POC dated 11/19/24 revealed orders for the HA to document the patient’s last BM every visit, and notify the nurse if greater than three days. A review of the HA visit notes dated 12/22/24, 12/23/24, 12/27/24, 1/1/25, and 1/10/25 revealed the HA failed to document the patient’s last BM. An interview was conducted on 2/6/25 at 11:22 AM with EI # 1, who confirmed the HA failed to follow the plan of care and agency policy.”

“Based on interviews with agency staff, and policies and procedures, it was determined the agency failed to use volunteers in the office performing administrative duties, or providing direct patient services. This had the potential to affect all patients served by the facility. Findings include: Agency Policy: Volunteer Services Policy number: 4-007.1 Dated: November 2013 Purpose: To ensure that qualified volunteer provide appropriate services in accordance with the plan of care and hospice program needs. Policy: Community Hospice of Dale Medical Center will provide volunteer services under the direction of Volunteer Coordinator and with the assistance of trained hospice volunteers... Volunteers may work in a variety of capacities, including: ... 4. Office Volunteers lend their services working in the hospice’s administrative offices. The activities may include assembling information packets, filing , photocopying and assisting with mailing... Review of the program data and interview with Employee Identifier (EI) # 3, Volunteer Coordinator, conducted 2/6/25 at 08:57 AM revealed no documentation of eligible hours provided by volunteers, including the type of services and time worked. An interview was conducted on 2/6/25 at 09:32 AM with EI # 1, Director, who confirmed no volunteer services were available.”