Circle of Life Hospice

“Based on clinical record review and staff interview, it was determined the Agency failed to complete a Spiritual Needs Assessment in 2 (#8 and #19) of 27 (#1- 27) clinical records reviewed and failed to complete a Psychosocial assessment in 2 (#2 and #8) of 27 (#1-27) within 5 days after the election of Hospice services as part of the Initial Comprehensive Assessment. This failed practice by the Chaplain and Social Worker had the potential to affect all admissions to the Agency in that, there could be a delay in identification of patient and family spiritual and psychosocial needs and could place patient and/or family at risk of inadequate coping mechanisms with end-of-life issues, lack of resources and ineffective family support. Findings follow: Review of clinical record #2 with a start of care (SOC) of 01/11/24 revealed a patient with a diagnosis of End Stage Heart Failure. A document titled “;General Details” with an encounter type of “SW- OP Psychosocial Ass” and dated 01/19/24 revealed the psychosocial assessment was completed 8 days after SOC (3 days past 5-day requirement). Review of clinical record # 8 with a start of care date of 12/02/23 revealed a patient with a diagnosis of Malignant poorly differentiated neuroendocrine tumors. A document titled, “General Details” with an encounter type of “Chaplain-routine visit” dated 12/15/23 revealed a Chaplain spiritual assessment on 12/15/23 which was 13 days after the SOC (8 days late). A document titled, “General Details” with an encounter type of “SW-OP Psychosocial Assessment” and dated 12/08/23 revealed the psychosocial assessment was completed 6 days after the SOC (1 day late). Review of clinical record #19 with a SOC of 01/12/24 revealed a patient with a diagnosis of Kidney Cancer. A document titled “;General Details” with an encounter type of “Chaplain-Admission” and dated 01/18/24 revealed the spiritual assessment was completed 6 days after SOC (1 day past 5-day requirement). An interview on 02/09/24 at 10:16 AM with Agency Personnel #1 confirmed the Spiritual Needs Assessment and/or Psychosocial Assessment was not completed within the required 5-day time frame as part of the Comprehensive Assessment.”

“Based on clinical record review and staff interview, it was determined the Agency failed to individualize standing or routine orders in 1 of 1 (#17) patient with a pressure ulcer, 1 (#13) of 3 (#2, #13, and #18) patients with use of oxygen and 2 of 2 (#6 and #16) patients with an indwelling foley catheter. This failed practice could result in potential harm for all patients on census in that the agency did not obtain individual and specific orders to address the patient’s specific needs. Findings follow: Review of clinical record #6 with a start of care of 12/28/23 revealed a patient with a diagnosis of Prostate Cancer. A document titled, “;Plan of Care Effective 2/9/24” showed orders to “ ...Change catheter ...” and an order to “ ...Flush catheter with normal saline ...”. There was no evidence of individualized orders for catheter to include the type or size of catheter to be inserted or the amount of irrigating solution to be used to flush the catheter. Review of Clinical Record #13, with a certification period of 12/01/23 - 02/28/24, revealed a patient with a primary diagnosis of Chronic Obstructive Pulmonary Disease. The Plan of Care had an order for Oxygen (O2) at 1-4 Liters per minute prn [as needed] or continuous to maintain comfort. The initial comprehensive assessment by the Registered Nurse (RN) revealed Patient #13 had O2 saturation level at 81% on room air (RA). According to the document, the RN increased it to 2 Liters to maintain the O2 saturation over 90%. The Plan of Care was not updated to reflect the O2 at 2 liters continuously. Review of Clinical Record # 16, with a certification period of 01/26/24 - 04/24/24, revealed a patient with a primary diagnosis of other symptoms and signs involving Cognitive Functions following other Cerebrovascular Disease. The Plan of Care did not include specifics on the size of the catheter, including the balloon size. On 02/08/24, the Agency administrative staff were asked to provide any further information regarding the Plan of Care regarding the foley catheter specifics. There was no further information provided by the Agency. Review of Clinical Record #17, with a certification period of 11/07/23 - 02/05/24, revealed a patient with a primary diagnosis of Malignant Neoplasm of the Cecum. A form titled, “IPU [Inpatient Unit] RN [Registered Nurse] Comprehensive Assessment” dated 01/31/24 documented, “... DIAGNOSIS SPECIFIC DECLINE/SYMPTOM ISSUES: ...Patient has slight redness to coccyx. Area was covered with sacral Opti foam dressing...” The Plan of Care did not include orders for the treatment of the wound. On 02/08/24, the Agency administrative staff were asked to provide any further information regarding the Plan of Care. An Interview on 02/09/24 at 10:16 AM with Agency Personnel #1 confirmed the orders for patient’s #6, #13, #16, and #17 were not individualized and specific for each patient.”

“Based on record review and interviews, it was determined the Agency failed to maintain an accurate and updated plan of care in the skilled nursing facility (SNF) for 1 of 1 (Patient # 15) client records reviewed and SNF’s visited. This failed practice had the potential to affect all Agency patients that reside in SNF’s. Findings follow: Review of Clinical Record # 15 revealed a patient with a start of care date of 09/01/23 and certification period of 12/30/23 - 02/27/24. Patient # 15 had a diagnosis of Malignant Neoplasm of the rectum and resides at a local skilled nursing facility. On 02/07/24 at 1:17 p.m., the Licensed Practical Nurse (LPN) caring for patient #15 was interviewed. She stated, “They [Agency] don’t have a binder anymore. Everything we need is really in the electronic chart.” When asked specifically about the hospice care plan she stated, “We don’t really have that, but we update the ‘closet care plans’ so everyone knows what to do for them.” The Agency Registered Nurse (RN) assigned stated that signed paperwork is now scanned into the computer system. No other information regarding a specific hospice care plan to coordinate care with the SNF was provided. On 02/08/24 at 3:30 p.m., the Agency administrative team was provided this information and did not provide any further information prior to the end of the survey.”

“Based on clinical record review and staff interview, it was determined the Agency failed to facilitate or coordinate with the patients identified local clergy to provide support of the patient and/or family spiritual needs in 4 (#8, #11, #17, and #20) of 27 (#1-27) clinical records reviewed. This lack of facilitation and coordination had the potential to affect the patients and families in obtaining relief from spiritual and/or emotional conflict to improve the quality of life for the patient and/or family. Findings follow: 1. Review of clinical record # 8, with a start of care date of 12/02/23, revealed a patient with a diagnosis of Malignant poorly differentiated neuroendocrine tumors. A document titled, “General Details” an encounter type Chaplain Routine visit and dated 12/15/23 documented, “...pt [patient] is catholic and this faith tradition is important to both of them [pt and family]. they attend weekly mass locally at [name] and they also attend their old church in IL... pt plans to get the anointing of the sick at church after mass. pt takes communion each [time] at mass...” There was no notation in the record of any collaboration with the local catholic church. On 2/7/24, the Agency administrative staff were asked to provide any additional information regarding a collaboration between the chaplain and the patient’s local catholic church and none was provided. 2. Review of clinical record #11 with a start of care (SOC) of 01/04/24 revealed a patient with a diagnosis of Malignant neoplasm of Colon. A document titled, “General Details” with an encounter type of “Chaplain-Admission” dated 01/09/24 revealed “;General Visit Note Information............. Pt identifies as a Christian and is affiliated with Southern Baptist Church and Cross Church in Springdale. Faith is important to Pt.....”. No evidence of Pastors name or contact information. There was no evidence of contact made by Hospice Chaplain to local clergy to facilitate visits or support the patient’s/family’s spiritual needs. 3. Review of clinical record #17, with a start of care date of 11/07/23, revealed a patient with a diagnosis of Malignant Neoplasm of cecum. The clinical record revealed the patient attends the Nazarene church. A document titled, “Plan of Care” revealed, “.... patient/family apparently prefer contact and spiritual support by phone, and they will request face to face visits as needed...Patient/family will have a sense of dignity and respect and will feel validated and supported. Effective date 11/28/23 Last Updated 2/5/24 Interventions Provide patient/family with therapeutic non-anxious presence, validation, active listening, and blessing/prayer by phone or during visits per patient request and family permission...” There was no documentation to demonstrate the coordination of care with the local church that the patient attends. 4. Review of clinical record #20 with a SOC of 01/07/24 revealed a patient with a diagnosis of Parkinsons Disease. A document titled, “General Details” with an encounter type of “Chaplain-Admission” dated 01/10/24 revealed “;General Visit Note Information............. Is affiliated with The Church at Rock Creek in Little Rock......hopes to visit Dt [Named daughter] church, Cross Church at some point.....”. No evidence of Pastors name or contact information. There was no evidence of contact made by Hospice Chaplain to local clergy to facilitate visits or support the patient’s/family’s spiritual needs. 5. An interview on 02/09/24 at 10:20 AM, with Agency Personnel #1 and #4 confirmed the Chaplain did not facilitate visits or coordinate care with the patient’s local clergy or faith community.”

“Based on clinical record review and staff interview, it was determined the Registered Nurse (RN) failed to provide the Hospice aide with specific and individualized written instructions for patient care in 3 (#3, #9, and #15 ) of 16 (#1, #3, #4, #5, #6, #7, #9, #10, #11, #12, #15, #16, #20, #25, #26, and #27) current patient’s records reviewed with Hospice Aide (HA) services. This failed practice had the potential to affect all patients currently on census receiving aide services in that, the care provided may not be safe, efficient, and effective and had the potential for negative patient outcomes up to and including patient falls. Findings follow: 1. Review of clinical record #3, with a certification period of 12/13/23 - 03/11/24, revealed a patient with a primary diagnosis of Alzheimer’s disease. The hospice aide care plan was not specific to tasks which would be completed by the aide. The Visit Tasks documented, “.... Assist with chair bath or Shower...Bedrest, Assist up to BSC [bedside commode] or bathroom if requested by patient...” An RN comprehensive visit note dated 12/13/23 documented, “... Nursing Summary....Does not answer most questions appropriately...” Review of clinical record #9 with a start of care of 01/11/24 revealed at a patient with a diagnosis of Parkinson’s Disease. A document titled “Plan of Care Effective 2/9/24” revealed instructions for Hospice Aide services which stated, “Assist with Bed Bath, Chair Bath or Shower”. These instructions did not provide the specific type of bath the patient was to receive nor the level of activity in which the patient could safely participate. 3. Review of clinical record # 15, with a certification period of 12/30/23 - 02/27/24, revealed a patient with a primary diagnosis of Malignant Neoplasm of rectum. A document titled, “Visit Task Lists” (hospice aide care plan) documented, “.... Assist with bed bath, chair bath or shower... Assist with urinal [patient # 15 is female]. Bedrest, Assist up to BSC or bathroom if requested by patient **SPECIFY** ... Empty Urinary Catheter or Ostomy if applicable **SPECIFY** Foley care if foley present.... Supply delivery: SPECIFY supplies and size Transfer using walker, wheelchair, Hoyer lift per protocol to transfer **SPECIFY** When patient ambulates, use standby assist, X1 assistance, or x2 assistance **SPECIFY** 4. An interview on 02/09/24 at 10:17 AM with Agency Personnel #1 confirmed the lack of specific and individualized written instructions documented regarding bathing services.”

“Based on clinical record review and staff interview, it was determined the Registered Nurse (RN) failed to supervise and assess the quality of care and services through on-site Supervisory Aide Visits (SAV) every 14 days in 1 (#3) of 16 (#1, #3, #4, #5, #6, #7, #9, #10, #11, #12, #15, #16, #20, #25, #26, and #27) current patient’s records reviewed with Hospice Aide (HA) services. This lack of supervision by the RN had the potential to place all patients receiving HA services at risk for adverse outcomes due to possible delays in the discovery of noncompliance with the Plan of Care by the HA or possible changes in the needs of the patient and family. Findings follow: Review of patient # 3 with a start of care date of 12/13/23 and certification period of 12/13/23 - 03/11/24 and diagnosis of Alzheimer’s revealed hospice agency aide care ordered one time weekly. A supervisory aide visit by the Registered Nurse (RN) was conducted on 12/28/23 and again on 01/22/24. This was 23 calendar days in between visits. On 02/08/24 the Agency administrative staff were asked to provide any further information regarding a missed supervisory aide visit as required every 14 days. There was no further information provided at the end of the survey.”