Mercy Hospice Mt Shasta

“Based on record review, interviews, and policy review, the facility failed to ensure all members of the Interdisciplinary Group (IDG), specifically Medical Social Services (MSW) were involved with the development of a comprehensive assessment no later than five calendar days after the election of hospice services for one of 11 current patients out of a total of 14 patients (Patient (P) 6) reviewed. This failure has the potential to interfere with the hospices’ ability to address terminal diagnoses, develop a care plan, reevaluate the current care plan for effectiveness, and the need for additional services. Findings: Review of the “Patient Information Report,” and provided by the facility, revealed P6 was admitted for hospice care on 01/09/26, with the primary diagnosis of malignant neoplasm of the liver.Review of P6’s “Plan of Care,” dated 01/09/26, signed by the Hospice Manager (HM), and provided by the facility, identified the following physician’s orders for home visit frequency “SN (Skilled Nurse) 1 wk (week) 1, MSW 1 m (month) [visits: SN once a week and MSW once a month].”Review P6’s clinical record on 01/21/26, which was 13 days after admission, revealed no documented evidence to indicate a MSW ever made a home visit to complete a psychosocial assessment.Review, of the “Client Coordination Note Report,” dated 01/13/26, written by the Hospice Manager (HM), and provided by the facility, indicated, “Call placed to reschedule MSW visit due to availability. No answer. Unable to leave voice message.” During an interview, on 01/20/26, at 11:40 AM, P6’s family member (family member (F)2) was asked if the hospice was providing the support and assistance necessary. F2 replied “Well, the nurse has been coming and that helps, but we haven’t seen the social worker. When we were admitted, they said that he/she would be here soon, but that is the last time I heard of it. As you can see, we have quite a hoarding situation here, the place is a mess, and it is making me crazy. I was hoping I could get some advice and help with this.”During an interview, on 01/21/26 at 09:45 AM, the MSW was asked when the initial psychosocial work assessment must be done for a patient requesting social work services. The MSW replied, “Within five days of admission.” The MSW stated, “I was scheduled to see that patient [P6] on 01/14/26, but I got sick and couldn’t make it.” When asked if the visit was completed after the cancellation, the MSW stated “Not yet.” When asked if the MSW had reached out to P6 by phone since the visit cancellation, the MSW stated “No.” When the MSW was asked if a phone call to P6 may have been helpful to explain the delay in home visit, the MSW replied “That’s not my really my role. I told the Hospice Manager and thought it was taken care of.”During an interview, on 01/21/26 at 1:35 PM, the HM was unable to explain the extended delay in the MSW assessment after the start of care for P6 but stated there should be documentation in the record to clarify why the required comprehensive assessments could not be completed within the five-day period.Review of the agency policy titled, “Comprehensive and Ongoing Assessment,” revised 12/26/23, revealed, “The Hospice Interdisciplinary Group (IDG), in consultation with the individual’s attending physician (if any), must complete the comprehensive assessment no later than five (5) calendar days after the election of hospice care. The comprehensive assessment will identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the patient’s well-being.””

“Based on observation, record review, and staff interviews, the hospice failed to designate a registered nurse (RN) to provide coordination of care and to ensure continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary plan of care for four of 14 patients (Patient (P)5, P6, P7, and P8) reviewed. Failure to identify an RN who is responsible for coordination of care has the potential to negatively affect continuous symptoms and needs management while interfering with the ability to reevaluate the effectiveness of the current plan of care. This failure had the potential for the agency’s 11 current patients and all future hospice patients to have unmet needs. Findings: 1.Review of the “Patient Information Sheet,” provided by the facility, revealed P5 was admitted on 12/26/25 with the primary diagnosis of end stage congestive heart failure. Review of P5’s “Patient Information Report,” dated 12/26/25, provided by the facility, submitted by the Hospice Manager (HM), identified the Chaplain (CH) as the Case Manager under the section titled “Clinical Info{sic},” which lists all interdisciplinary team members. 2.Review of the “Patient Information Sheet,” provided by the facility, revealed P6 was admitted for hospice care on 01/02/26 with the primary diagnosis of malignant neoplasm of the liver. Review of P6’s “Patient Information Report,” dated 01/09/26, provided by the facility, submitted by the HM, identified the CH as the Case Manager under the section titled “Clinical Info{sic},” which lists all interdisciplinary team members. 3.Review of the “Patient Information Sheet,” provided by the facility, revealed P7 was admitted for hospice care on 08/29/25 with the primary diagnosis of malignant neoplasm of the liver. Review of P7’s “Patient Information Report,” dated 11/25/25, provided by the facility, submitted by the HM, identified RN1 as the Case Manager under the section titled “Clinical Info{sic},” which lists all interdisciplinary team members. A joint home visit to see P7 was conducted on 01/20/26 at 9:30 AM with RN1 and this surveyor observed skilled nursing care. RN1 was asked if he/she was the Case Manager for P7, RN1 stated that there “really isn’t a Case Manager per se,” but that RN1 and RN2 “shared” all the patients, instead of one RN being assigned to this role. RN1 also stated that sometimes the HM would share Case Manager duties. When asked if this interfered with continuity of care, RN1 stated “it’s just the way it has to work because none of the RN’s work more than part time.” During an interview on 01/20/26 at 4:35 PM, the HM verified this information and stated RN1 was correct. “We all share in Case Manager duties; no one person is identified.” When asked why the CH was identified as Case Manager for P5 and P6, the HM said, “That’s an error, there really isn’t a Case Manager assigned in the clinical record.”4. Review of P8’s “Patient Information Report,” provided by the facility, revealed P8 was admitted to hospice services on 02/19/25 with a terminal diagnosis of pancreatic mass. The “Patient Information Report” noted that RN1 was the case manager for P8. Review of P8’s “Coordination Notes,” dated 02/19/25, documented by RN2, and provided by the facility, revealed upon admission, P8 was “primarily chairbound, using a walker . . . was able to walk to recliner in living room . . .” There was no documented evidence P8 was offered the services of a home health aide. Review of P8’s “Coordination Note,” dated 0 4/02/25, documented by RN2, and provided by the facility, revealed, “. . . RN received phone call . . . [P8] fell and [he/she] is not able to get [P8] up . . . Patient has a fractured pelvis . . .” Review of P8’s “Coordination Note,” dated 04/03/25, documented by RN2, and provided by the facility, revealed, “. . . primarily bedbound due to pelvic fracture . . .” Review of P8’s “Coordination Note,” dated 04/08/25, documented by RN1, and provided by the facility, revealed, “. . . “Pt was sitting up in bed in [his/her] room, [caregiver] and hired CG [caregiver] . . . present for visit . . .” Review of P8’s “Coordination Note,” dated 04/09/25, documented by the Medical Social Worker (MSW) and provided by the facility, revealed, “. . . [caregiver] also reports hiring a homecare person, which has been helpful . . .” Review of P8’s clinical record revealed no documented evidence RN1 or RN2 had offered any home health aide services to P8 on admission or after the patient experienced the pelvic fracture and subsequent decline in function. During an interview, on 01/21/26 at 1:05 PM, RN1 was asked if she functioned in the role of RN Case Manager. RN1 stated the case management role was shared between [himself/herself], RN2, and the HM and no one was the case manager. RN1 was asked if the caregiver and P8 had been offered the services of a home health aide at admission and after P8 had sustained the fall resulting in a pelvic fracture. RN1 stated he/she believed they were, but he/she was not the only nurse assigned to the case so he/she could not be sure another nurse had not offered. RN1 was asked if this would be a responsibility of the Case Manager. RN1 stated he/she thought so, but he/she was not the only nurse assigned to the case. During an interview, on 01/21/26 at 2:07 PM, the HM and Manager of Operations (MO) were asked if the facility identified RN Case Managers for each patient. The HM stated that role was shared for each patient between RN1, RN2, and himself/herself. Review of the facility’s policy titled, “Interdisciplinary Group Coordination of Care,” dated 12/29/22, revealed, “. . . The Hospice uses a comprehensive, coordinated healthcare process and an Interdisciplinary Group (IDG) to provide services and aid to patients, caregivers, and families . . . An RN will be designated to coordinate the implementation of the POC [Plan of Care] for each patient. . .””

“Based on personnel file review, staff interviews, and policy review, the hospice failed to implement accepted standards of practice to prevent the transmission of infections and communicable diseases with regard to hepatitis B prevention for one of one Volunteer reviewed (Volunteer (V)1) who had direct patient care contact. This deficient practice had the potential to affect all current and future volunteer staff, and patients who were currently receiving hospice services. Findings: Review of V1’s personnel file revealed the volunteer’s date of hire was 04/12/24. There was no evidence that the hepatitis vaccine had been offered, accepted, or declined by this volunteer upon hire or thereafter. During an interview on 01/21/26 at 11:30 AM, after the personnel file review was completed, the Volunteer Coordinator verified these findings and stated, “I am not sure exactly what we offer the volunteers at hire because that is handled through our Human Services and Infection Control Department.” During an interview on 01/21/26 at 12:35 PM, the Infection Preventionist (IP) also verified these findings and stated, “We have never offered the volunteers the hepatitis vaccine upon hire, even the ones who will be making home visits to the hospice patients, because we consider them low risk.” When asked if salaried and hourly hospice employees were offered the hepatitis vaccine upon hire, the IP responded “Yes, they all are. Our policy requires it.” When asked if volunteers who were responsible for making home visits to hospice patients could be at risk of exposure to blood or body fluids, the IP replied “Yes, I suppose they could be.” Review of the agency policy titled, “Bloodborne Pathogen Exposure Control Plan,” dated 07/22/25, revealed, “Hepatitis B Vaccination Program. In an effort to provide maximum protection from Hepatitis B infection…offers a vaccination program, at no employee cost, to all staff who have occupational exposure to bloodborne pathogens.” The agency policy titled, “Pre-Placement Health Screen Clearance,” dated 05/13/24 stated: “Vaccinations. Hepatitis B…Must be offered to all HCP (Health Care Personnel) who are at risk of occupational exposure to blood or body fluids within 10 days of their start date. All HCP, who are at risk, must have valid documentation (both vaccination record and laboratory titers).””

“Based on interview, and record review, the facility failed to ensure Medical Social Services were provided for one of 14 patients (Patient (P) 12) whose clinical records were reviewed. Failure to provide social services as needed had the potential to cause patients and/or caregivers to have unmet psychosocial needs. Findings: Review of P12’s undated “Patient Information Report,” provided by the facility, revealed P12 was admitted to hospice services on 07/22/25 with a terminal diagnosis of cerebral vascular disease. Review of P12’s “Order,” dated 07/25/25 and provided by the facility, revealed, “MSW [Medical Social Worker] to assess for grieving issues/complication and provide supportive counseling . . . Caregiver(s) will experience a sense of accomplishments at having supported the dying person . . . patient/caregiver will express an increased sense of closure and peacefulness at the end of life. Caregiver(s) will experience a sense of accomplishments at having supported the dying person . . . MSW effective 07/22/25 1M1, 2M3, 3PRN [visits - one time a month for one month, two times a month for three months, and three as needed visits] for patient/family support . . .” Review of P12’s “IDG (Interdisciplinary Group) Summary Report,” dated 08/05/25 and provided by the facility, revealed, “. . .Bereavement Risk: The [son/daughter] needs bereavement assessment as I suspect he is at moderate risk . . .the patient is pleasant but the [son/daughter] is often overwhelmed and tearful. . .Continue with biweekly visits and as needed. . .” Review of P12’s “IDG (Interdisciplinary Group) Summary Report,” dated 08/19/25 and provided by the facility, revealed, “. . . Due to scheduling error, MSW did not see patient for prior biweekly visit. Next scheduled visit is due this week . . .” Review of P12’s “Visit Note Report,” dated 08/20/25, completed by the Medical Social Worker (MSW), and provided by the facility, revealed, “. . .The spouse reports mixed feelings. [He/She] stated, “It’s as if I’m on a rollercoaster.” The [son/daughter] reports continued stress and stated, “I have had a lot of losses in my life and sometimes I feel invisible.”. . . MSW conducted bereavement risk assessment on son. MSW addressed caregivers emotional and mental anguish and provided information on bereavement support. . . Goals Not Met. . . Patient/family verbalizes understanding of stages of grief. . .Additional time required to meet intervention/goal. . .” Review of P12’s “IDG (Interdisciplinary Group) Summary Report, dated 09/02/25, and provided by the facility, revealed, “. . .The [son/daughter] scored high on bereavement risk assessment, and he has experienced multiple losses, but open to bereavement f/u [follow up] when the time comes . . . Scheduled for f/u first week of September . . .” It was recorded this information was provided by the MSW. Review of P12’s “Visit Note Report,” dated 09/03/25, signed by the MSW, and provided by the facility, revealed, “. . .The spouse verbalized a desire to have continued SW biweekly visits to keep him from “falling off the edge.” The spouse also disclosed avoidance of addressing needs at this time as it is too much but will need help when the time comes. Therefore, he/[she] stated no needs at this time . . .Continue with biweekly visits for emotional support and preparation for other needs. . .” Review of P12’s “Client Coordination Note Report,” dated 09/17/25, documented by the MSW, and provided by the facility, revealed, “. . .Document reason for missed visit to be communicated to the physician: caregiver declined this week’s visit . . .Caregiver reports the patient continues to improve and there are no identified needs at this time. Caregiver still open to f/u in two weeks. . .” Review of P12’s “Client Coordination Note Report,” dated 10/01/25, documented by the MSW, and provided by the facility, revealed, “. . .Document reason for missed visit to be communicated to the physician: caregiver declined visit . . .caregiver sick and no needs identified . . .” Review of P12’s “Client Coordination Note Report,” dated 10/14/25, documented by the MSW, and provided by the facility, revealed, “. . .The patient’s spouse. . .returned my call and declined this week’s visit. The spouse disclosed the patient is still doing well as expected and there are no new/changing needs. However, he/[she] would like to keep biweekly schedule for possible changes . . .” Review of P12’s “IDG Summary Report,” dated 10/28/25 and provided by the facility, revealed, “. . .Social Worker. . .Retain PRN for any new or changing needs. . .” There was no documented evidence of why the social worker visits were changed to as needed. Review of P12’s clinical record revealed no documentation to show why MSW visits were not conducted per physician orders. There was no documentation to show the caregivers of P12 had requested MSW visits to be stopped. There was no documentation to show the caregivers of P12 were informed MSW visits were stopped. There was no documentation indicating the potential bereavement issues of the [son/daughter] were addressed during social worker visits or in the plan of care, with interventions identified and implemented. During an interview on 01/21/26 at 9:40 AM, the MSW stated his/her role was to advocate for the patient and family. The MSW stated a high-risk bereavement assessment score meant that the person could experience complicated grief following the death of a loved one. The MSW stated there were no patients with caregivers or family who had scored as high risk related to bereavement at this time that he/she was aware of. The MSW was asked if the son of P12 was assessed to be at high risk for bereavement concerns. He/She stated they were unaware the [son/daughter] had been assessed to be at high risk. The MSW was asked when bereavement care planning should begin. He/She stated, “On admission.” The MSW was asked why P12’s social services visits had been decreased from biweekly to as needed. He/She stated that would have been at the request of the family. The MSW was asked where that information was documented. He/She stated, “I must have forgotten to write a note.” The MSW was asked if the reason for decreasing visits would have been provided to the IDG. He/She stated if so, the information would have been minimal. During an interview on 01/21/26 at 10:30 AM, the Manager of Operations (MO), who also was the facility’s Bereavement Coordinator, stated when a caregiver or family member was assessed to be at high risk for bereavement concerns, it was the expectation that social service visits would continue from admission throughout a patient’s journey unless declined by the caregiver or family member. The MO stated it was the expectation that visits be continued as ordered by the physician and any deviation from that should be addressed in the IDG and documented in the patient’s record. Review of the Social Worker job description, dated 09/02/15 and provided by the facility, revealed, “. . .Performs initial bereavement assessment: provide bereavement counseling & support to high-risk individuals . . . Assesses caregiver’s ability to provide care and identifies needed assistance . . .Contributes social service update on every patient. Assist with development & revision of IDT care plans . . .” Review of the facility’s policy titled, “Bereavement Services,” dated 01/17/23, revealed, “. . .Bereavement services will reflect the needs of the bereaved . . .The Bereavement Assessment is initiated upon admission . . .assess for risk factors and document the findings . . .This Assessment continues throughout the patient’s stay, to prepare for and address potential bereavement needs . . .””

“Based on interview, record review, and policy review, the facility failed to ensure necessary care and services were offered and/or provided to meet the needs of the patients and/or caregivers for five of 14 sampled patients (Patient (P) 8, P12, P7, P6, and P5) whose records were reviewed. Failure to provide necessary care and services placed the patients at risk of unmet needs. Findings: 1. Review of P8’s “Patient Information Report,” provided by the facility, revealed P8 was admitted to hospice services on 02/19/25 with a terminal diagnosis of pancreatic mass. The “Patient Information Report” noted that Registered Nurse (RN)1 was the case manager for P8. Review of P8’s “Coordination Notes,” dated 02/19/25, documented by RN2, and provided by the facility, revealed upon admission, P8 was “primarily chairbound, using a walker . . . was able to walk to recliner in living room . . .” There was no documented evidence P8 was offered the services of a home health aide. Review of P8’s “Coordination Note,” dated 0 4/02/25, documented by RN2, and provided by the facility, revealed, “. . . RN received phone call . . . [P8] fell and [he/she] is not able to get [P8] up . . . Patient has a fractured pelvis . . .” Review of P8’s “Coordination Note,” dated 04/03/25, documented by RN2, and provided by the facility, revealed, “. . . primarily bedbound due to pelvic fracture . . .” Review of P8’s “Coordination Note,” dated 04/08/25, documented by RN1, and provided by the facility, revealed, “. . .”Pt was sitting up in bed in [his/her] room, [caregiver] and hired CG [caregiver] . . . present for visit . . .” Review of P8’s “Coordination Note,” dated 04/09/25, documented by the Medical Social Worker (MSW) and provided by the facility, revealed, “. . . [caregiver] also reports hiring a homecare person, which has been helpful . . .” Review of P8’s clinical record revealed no documented evidence RN1 or RN2 had offered any home health aide services to P8 on admission or after the patient experienced the pelvic fracture and subsequent decline in function. 2. Review of P12’s undated “Patient Information Report,” provided by the facility, revealed P12 was admitted to hospice services on 07/22/25 with a terminal diagnosis of cerebral vascular disease. Review of P12’s “Coordination Note,” dated 01/06/26 and provided by the facility, revealed, “. . . Recertification Visit . . . [He/She] reports [he/she] bathes [P12] daily per incontinence . . .” Review of P12’s clinical record revealed no documented evidence P12’s caregiver was offered home health aide services to assist with daily bathing needs after the caregiver reported the patient required daily bathing due to incontinence. Review of P12’s “Episode Detail Report,” for the certification period of 01/18/26 through 03/18/26 and provided by the facility, revealed physician orders to continue skilled nurse visits once a week for nine weeks. There were no orders for home health aide services. During an interview on 01/21/26 at 1:05 PM, RN1 was asked how patients and caregivers were notified of the services offered by hospice, including home health aide services. RN1 stated when a patient was admitted, the nurse would let them know that they do not have a home health aide, but if that is needed, the nurse can provide those services on one of their visits during the week. RN1 stated then one aide and nurse visit would be scheduled together during the week. RN1 stated if the caregiver/family was financially able, they would encourage them to hire a private caregiver. During an interview on 01/21/26 at 2:07 PM, the Hospice Manager (HM) and Manager of Operations (MO) were asked why the facility did not offer home health aide services. The MO stated the facility’s aide retired approximately three years ago, and they had been unable to fulfill the position. The HM stated home health services were provided by the RNs once a week. The HM was asked why home health aide services had not been offered for P8 and P12. The HM and MO stated the services should have been offered and provided as requested. 3.Review of the “Patient Information Report,” provided by the facility, revealed P7 was admitted to hospice services on 08/29/25 with a terminal diagnosis of malignant neoplasm of breast. Review of P7’s “Plan of Care Update,” dated 11/27/25, signed by RN1 and the physician, and provided by the facility, identified physician orders for skilled nursing, hospice aide and “Hospice MSW to evaluate social, emotional, and financial factors related to the patient’s illness, need for additional care/resources.” Review of P7’s clinical record revealed no documented evidence to indicate that a MSW ever made a home visit for P7 to complete a psychosocial assessment. During an interview on 01/20/26 at 9:55 AM, RN1 was asked if the MSW had made a home visit to see P7 and his/her family, RN1 stated “I don’t actually know.” During an interview on 01/20/26 at 10:15 AM, F3 was asked if the hospice provided the support and assistance, they felt necessary. F3 replied “I feel better now that the nurse is coming every day. It makes a big difference, but I wish I could have more hospice aide support. I mean, the nurses try to cover the aide visit, but most times I tell them that it’s not needed. I mean, it’s not really their job, and they are so busy. I try to get along without it. I had to hire paid caregivers; we have them round the clock now, which is a relief. I think we’re getting the care we need now. One other thing though, I really needed some emotional help at one point and asked to see a social worker. I was at a low, just needed someone to talk to. The nurse said the social worker would be around, but that was the last I heard of that. So overall, I guess I could say that I wish the hospice was more robust, had more resources.”4.Review of P6’s “Patient Information Sheet,” and provided by the facility, revealed P6 was admitted for hospice services on 01/09/26 with a terminal diagnosis of malignant neoplasm of liver. Review of P6’s “Plan of Care,” dated 01/09/26, signed by the HM, and provided by the facility, identified the following “Physician’s,” orders for home visit frequency “SN 1 wk (week) 1, Hospice Aide effective 01/11/26, MSW 1 m (month) [visits: SN once a week and MSW once a month].” Review of the clinical record review conducted on 01/21/26, which was 13 days after admission, revealed no documented evidence to indicate that a MSW ever made a home visit to see P6 or contacted the family to complete a psychosocial assessment. A joint home visit was conducted for P6 on 01/20/26 at 11:00 AM with this surveyor and RN1 to observe skilled nursing care, in conjunction with a hospice aide visit which was also scheduled to be completed by RN1. After entering the home, RN1 asked the F2 if P6 needed a shower. F2 replied “He had one two days ago so maybe he can wait. I guess I can help him also.” RN1 replied “If he doesn’t need one now, I will cancel the hospice aide visit for today. Actually, I will just cancel all the hospice aide visits until we hear differently from you.” During an interview on 01/20/26 at 11:40 AM, P6’s family member F2 was asked if the hospice provided the support and assistance, they felt necessary. F2 replied “Well, the nurse has been coming and that helps, but we haven’t seen the social worker. When we were admitted, they said that he/she would be here soon, but that is the last I heard of it. As you can see, we have quite a hoarding situation here, the place is a mess and it’s making me crazy. I was hoping I could get some advice and help with this. Also, it would really help if I could get a hospice aide visit more than just once a week. I definitely didn’t want to cancel those visits. Twice a week at least would be good, but I know the nurses must fill in because they don’t have an aide, so I don’t want to ask. I know they’re busy.”During an interview on 01/21/26 at 09:45 AM, the MSW was asked why the social work assessment was not completed as ordered for P6. The MSW responded, “I was scheduled to see that patient on 01/14/26, but I got sick and couldn’t make it.” When asked if the visit was completed after the cancellation, the MSW stated “Not yet.” When asked if the MSW had reached out to P6 by phone since the visit cancellation, the MSW stated “No.” When the MSW was asked if a phone call to P6 may have been helpful to explain the delay in home visit, the MSW replied “That’s not my really my role. I told the Hospice Manager and thought it was taken care of.”5. Review of P5’s “Patient Information Report,” and provided by the facility, revealed P5 was admitted for hospice care on 12/26/25 with diagnoses of end stage congestive heart failure and dementia. A joint home visit was conducted for P5 on 01/20/26 at 2:10 PM with this surveyor and the MSW to observe care. P5 was residing with F1, who assumed all aspects of care for this patient. During the home visit, F1 frequently voiced concern and frustration with the overwhelming needs that caring for a patient with dementia brings. F1 stated “I just wish I had someone to talk to, who could listen, I feel all alone, I just need to vent.” However, the MSW concluded this home visit without scheduling a follow up visit or offering routine visits to this patient and family. The MSW instead offered “as needed” visits, instructing F1 to “call if necessary.” During an interview on 01/20/26 at 2:40 PM, P5’s F1 was asked if they felt adequate support from the hospice. “At first I did, when the nurse was coming twice a week. But now, they dropped that to just one visit a week from the nurse and I don’t feel that’s enough. I wish the social worker could come regularly, just to listen you know … it really helps a lot. Also, the hospice aide just comes once a week. I feel like twice a week would be so much better for us. It’s really hard for me to manage it, and well, who takes a shower just once a week anyway? When this surveyor asked F1 if they had discussed these needs with the hospice, F1 stated “No, I feel like they are short staffed … and I don’t want to be a burden.”During an interview on 01/21/26 at 1:35 PM, these concerns were communicated to the HM. The HM was unable to clarify why visit frequency was not more closely assessed and updated as required to meet the needs of both patient and family members.Review of the facility’s policy titled, “Interdisciplinary Group Coordination of Care,” dated 12/29/22, revealed, “. . . The Hospice uses a comprehensive, coordinated healthcare process and an Interdisciplinary Group (IDG) to provide services and aid to patients, caregivers, and families . . . An RN will be designated to coordinate the implementation of the POC [Plan of Care] for each patient . . .” Review of the facility’s policy titled, “Interdisciplinary Group Coordination of Care,” dated 12/29/22, revealed, “. . . The Hospice uses a comprehensive, coordinated healthcare process and an Interdisciplinary Group (IDG) to provide services and aid to patients, caregivers, and families . . . The type and scope of services provided by the IDG are based upon the initial and ongoing assessments of the patient . . . The exact combination of services and the Level of Care are unique to each patient, caregiver, and family . . . The IDG will initiate changes as the patient, caregiver and/or family needs evolve during the terminal illness . . .””