Home Health Professional & Hospice

“Based on clinical record review and staff interview, it was determined the Agency failed to complete a Psychosocial Assessment as part of the initial comprehensive assessment within 5 days after the election of Hospice services in 1 (#3) of 5 (#1- #5) clinical records reviewed. This failed practice by the 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 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: A review of clinical record #1, with a start of care (SOC) date of 05/27/23, revealed a patient diagnosed with Malignant Neoplasm of the Endocrine Pancreas. No documented evidence that psychosocial or emotional needs were assessed within the required five-day timeframe of the initial comprehensive evaluation.A review of clinical record #3, with a SOC date of 04/22/23, revealed a patient diagnosed with Alzheimer’s Disease. Review of Documentation: The “MSW for MSW Phone Call Visit Summary” form, dated 05/07/23, indicated that a Licensed Social Worker contacted the patient to schedule a visit. However, there was no documented evidence that psychosocial or emotional needs were assessed within the required five-day timeframe of the initial comprehensive evaluation.During an interview conducted on 06/05/25 at 2:00 PM, Agency Personnel #1 confirmed that the psychosocial assessment was not completed within the required five-day timeframe as part of the initial comprehensive assessment.”

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to include all medications utilized by the patient on the medication list for one of five clinical records reviewed (Clinical Record #1). This failure had the potential to affect all patients admitted for care and may result in inadequate medication management, potential drug interactions, and prevent a thorough medication regimen review to ensure patient safety and effective symptom management. Findings follow: A review of clinical record #1, with a start of care date of 05/27/23, revealed a patient diagnosed with Malignant Neoplasm of the Endocrine Pancreas. On a form titled “SN for Hospice Admission Visit Summary” and dated 05/27/23 the Skilled Nurse documented the patient was currently utilizing oxygen. Review of a form titled “Medication List “ did not reflect oxygen as part of the patient’s active medications. There was no documentation in the chart to indicate that oxygen had been checked for actual or potential drug interactions. During an interview on 06/05/25 at 2:00 PM, Agency Personnel #1 confirmed that not all medications had been reviewed for actual or potential drug side effects or interactions. Specifically, oxygen was not listed on the medication profile and had not been assessed for drug interactions.”

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to ensure that all required members of the Interdisciplinary Group (IDG) actively participated in care planning and coordination of services in one (#2) of five (#1-#5) clinical records reviewed. Specifically, the chaplain and social worker did not actively participate or contribute in IDG meetings, resulting in incomplete psychosocial and spiritual assessments and gaps in patient-centered care. This failure had the potential to impact all patients admitted for care and compromised holistic support, as essential emotional and spiritual needs were not adequately addressed in the plan of care. Findings follow: A review of clinical record #2, with a start of care date of 11/19/22, revealed a patient diagnosed with Hemiplegia and Hemiparesis following Cerebral Infarction. Review of IDG meeting notes dated 11/13/2024, 11/27/2024, 12/11/2024, and 12/23/2024 lacked any documented participation or contribution from the social worker or chaplain.During an interview conducted on 06/05/25 at 2:00 PM, Agency Personnel #1 confirmed that not all members of the IDG actively participated in care planning and coordination efforts.”