Love and Light Hospice Care, Inc.

“Upon patient record review, 2 of 2 (Patients #1 and 2) did not contain evidence that a revised IDG Plan of Care included information from these patients’ updated comprehensive assessment(s), and note these patients’ progress towards outcomes/goals from their Plan of Care. Patient #1:The IDG Meeting dated 01/31/24, post the State survey, continued to have no SW signature/date. Patient #2: A Physician order was obtained on 12/12/23 noting that the patient had refused Volunteer services. Yet, the 12/20/23 IDG Plan of Care continued to include, “Volunteer per month, and (3) prn as needed,””

“Upon observation, there was not evidence that the Hospice had maintained all patients’ clinical record(s) in a confidential manner. CMS requires the protection of clinical record information. The clinical record, its contents and the information contained therein must be safeguarded against loss or unauthorized use. The Hospice must be in compliance with the Department’s rules regarding Personal Health Information (PHI), as set out at 45 CFR parts 160 and 164. The Hospice must ensure that unauthorized individuals cannot gain access to patient record. Upon Surveyor arrival, it was identified that the Hospice had only (1) active patient record, and (1) closed patient record available for Surveyor review. The current owner reports having purchased this Hospice Agency CCN in January 2022, and that there were no active patients on that date of purchase. Only (2) patients have been admitted since then. At the date of purchase, the previous owner had stated that he had only ever admitted the (5) minimum patients required for an initial Medicare Hospice survey process. The current owner reports that the previous owner had not provided her with those (5) closed clinical records at the time of purchase. The current owner reports that the previous owner is now deceased, and it is not known where these patient records are located.”

“Upon observation, it was noted that the Hospice was not in compliance with the CMS requirement for retention of clinical records as follows: Patient clinical records must be retained for 6 years after the death or discharge of the patient, unless State law stipulates a longer period of time. The current owner reports that this Hospice CCN became activated on August 19, 2020, after their initial Medicare survey, during which their initial (5) admitted patient records were reviewed. The current owner reports having purchased this Hospice Agency CCN in January 2022. These (5) patients had been discharged from services prior to that date. The current owner reports that the previous owner had not provided her with those (5) closed clinical records at the time of purchase. The current owner reports that the previous owner is now deceased, and it is not known where these patient records are located. Records were not retained for (6) years.”

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG, a meeting where the Registered Nurse (RN), Medical Social Worker (MSW), Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) completed the comprehensive assessment no later than five calendar days after hospice election for one of two sampled patients (Patient 1). This failure had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. A review of Patient 1s undated Electronic Medical Record (EMR) form titled “;Personal Information”, indicated a start of care date of 12/12/2023 and end of care date of 12/22/2023, with diagnosis including end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant). A review of Patient 1s Electronic Medical Record (EMR) record form titled “;POC (plan of care, an individualized care plan for the patient)/IDG Review” dated 12/12/2023, indicated section “;IDG Discussion – Psychosocial, Other/Physician” was left blank. The record also indicated section “;MSW Signature” was left blank. During an interview on 1/10/2024, at 12:30 p.m., with the Administrator/Director of Patient Care Services Designee (AD/DD), AD/DD stated IDG members included an RN, MSW, MD, and Chaplain. AD/DD stated all IDG members need to complete a comprehensive assessment within five days of a patients admission to generate a patients individualized plan of care. AD/DD stated the IDG team meets every two weeks to discuss patients status and to update their individualized plan of care. During a concurrent interview and record review on 1/10/2024, at 12:45 p.m., with AD/DD of Patient 1s EMR medical record form titled “;POC/IDG Review” dated 12/12/2023, AD/DD stated Patient 1s initial comprehensive assessment was not completed by the MSW on 12/12/2023. AD/DD stated all IDG members need to document their findings to be able to know the needs of the patient. A review of HA policy and procedure titled “;Interdisciplinary Group Meeting” revised 4/2020, indicated “;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, deaths, and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires.” A review of HA policy and procedure titled “;Comprehensive Assessment” revised 4/2020, indicated “;A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 (five) calendar days after the election of hospice care in consultation with attending physician.” A review of HA policy and procedure titled “;The Plan of Care” revised 10/2012, indicated “;The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care.” A review of HA policy and procedure titled “;Spiritual Care Counseling Services”, dated April 2020, indicated, “;Procedure...2. The Hospice Chaplain will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient and family...8. Spiritual care assessment and counseling will be documented in the patients clinical record as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care. 11. All referrals, assessments, clinical notes, intervention letters, and phone calls will be documented in the patients clinical record. A review of HA policy and procedure titled “;Psychosocial Services”, dated April 2020, indicated, “;Procedure. 1. The social worker will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient...3. Psychosocial assessments and interventions will be documented in the patients clinical record as part of the comprehensive assessment and interdisciplinary visit notes, as well as the plan of care.””

“Based on observation, interview and record review, the Hospice Agency (HA) staff failed to review all medications the patient was taking for one of two of sampled patients (Patient 2). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. A review of Patient 2s record titled, “;Personal Information”, indicated a start of care date into hospice care on 8/16/2023, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During an observation of the home visit on 1/10/2024, at 9:00 a.m., Registered Nurse 2 (RN 2) provided care to Patient 2. During the visit, RN 2 did not review the medications Patient 2 was taking. During an interview on 1/10/2024, at 9:30 a.m., RN 2 stated he did not review the medications Patient 2 was taking. RN 2 stated he was supposed to review the medications to see if the medications are working, and if Patient 2 is in need of a refill. During an interview on 1/10/2024, at 11:33 a.m., the Administrator designee/Director of Nurses designee (AD/DD) stated nurses were expected to review the medication list and compare it to the medications at home on every visit. This process was important because the condition of the patient changes day by day. Patients need to be aware of the medications patient is taking. A review of Patient 2s record titled, “;Plan Of Care”, printed on 1/10/2024, indicated, the nurse was to monitor and assess effectiveness of current and new medication/treatment. A review of the HAs policy and procedure titled, “;Medication Profile”, dated April 2020, indicated, “;Procedure...3. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen.””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG, a meeting where the Registered Nurse (RN), Medical Social Worker (MSW), Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the individualized quality of care and support to patients and families) met and updated the patient’s comprehensive assessment at least every 15 days for two of two sampled patients (Patient 1 and Patient 2). This deficient practice had the potential to result in patients’ identified needs and goals will not be reached due to IDG not addressing changes in the patient’s condition. During a record review of Patient 1s Electronic Medical Record (EMR) medical record form titled “;Personal Information” undated, indicated a start of care date of 12/12/2023 and end of care date of 12/22/2023, with diagnoses including end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant). During a record review of Patient 1s Electronic Medical Record (EMR) medical record form titled “;POC/IDG Review” dated 1/3/2024, indicated section “;IDG Discussion – Psychosocial, Other/Physician” were left blank. It also indicated section “;MSW Signature” was left blank. During a record review of Patient 1s Electronic Medical Record (EMR) medical record form titled “;POC/IDG Review” dated 12/20/2023, indicated section “;IDG Discussion – Psychosocial” was left blank. It also indicated sections “;MSW Signature” was left blank. During a concurrent interview and record review on 1/10/2024 at 12:56 p.m. with the Administrator/Director of Patient Care Services Designee (AD/DD) of Patient 1s EMR medical record form titled “;POC/IDG Review” dated 1/3/2024, AD/DD stated MSW did not document in the discussion section or signed the form. AD/DD stated the disciplines are to document their findings in their assigned discussion section. During a record review of Patient 2s Electronic Medical Record (EMR) medical record form titled “;Personal Information” undated, indicated a start of care date of 8/16/2023 with diagnoses including Hypertensive (high blood pressure) heart disease without heat failure. During a record review of Patient 2s Electronic Medical Record (EMR) medical record form titled “;POC/IDG Review” dated 1/3/2024, indicated section “;IDG Discussion – Psychosocial, Other/Physician” were left blank. It also indicated sections “;MSW Signature” and “;Chaplain Signature” were left blank. During a record review of Patient 2s Electronic Medical Record (EMR) medical record form titled “;POC/IDG Review” dated 12/20/2023, indicated section “;IDG Discussion – Spiritual, Psychosocial, Other/Physician” were left blank. It also indicated sections “;MSW Signature” and “;Chaplain Signature” were left blank. During a record review of Patient 2s Electronic Medical Record (EMR) medical record form titled “;POC/IDG Review” dated 12/6/2023, indicated section “;IDG Discussion – Psychosocial, Other/Physician” were left blank. It also indicated section “;MSW Signature” was left blank. During a concurrent interview and record review on 1/10/2024 at 1:10 p.m. with the AD/DD of Patient 2s EMR medical record form titled “;POC/IDG Review” dated 1/3/2024, 12/20/2023, and 12/6/2023, AD/DD stated Patient 2s last comprehensive assessment was on 1/3/2024. AD/DD stated discussion sections for MSW, and the physician were left blank. AD/DD stated MSW did not sign the forms. AD/DD stated Patient 2s comprehensive assessment must be updated and reviewed because his condition might have changed. During an interview on 1/10/2024 at 12:30 p.m. with the Administrator/Director of Patient Care Services Designee (AD/DD), AD/DD stated IDG members included an RN, MSW, MD, and Chaplain. AD/DD stated the IDG team meets every two weeks to discuss patients status and to update their individualized plan of care. During an interview on 1/10/2024 at 12:56 p.m. with the AD/DD, AD/DD stated patients comprehensive assessments need to be updated every two weeks by the IDG team. AD/DD stated each discipline is to document their findings on the discussion section and sign the form. AD/DD stated a disciplines signature indicated they agree with the patients plan of care. AD/DD stated patient condition changes daily and if their comprehensive assessments are not completed “;they wouldnt get the care that they are supposed to have”. During a record review of HA policy and procedure titled “;Interdisciplinary Group Meeting” revised 4/2020, indicated “;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, deaths, and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires.” During a record review of HA policy and procedure titled “;Ongoing Assessment” revised 4/2020, indicated “;Based on the assessments, the plan of care-including problems, needs, goals, and outcomes- will be reviewed and updated by the interdisciplinary group members responsible for the case.” During a record review of HA policy and procedure titled “;The Plan of Care” revised 10/2012, indicated “;The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician.” During a record review of HA policy and procedure titled “;Spiritual Care Counseling Services”, dated April 2020, indicated, “;Procedure...2.The Hospice Chaplain will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient and family...8.Spiritual care assessment and counseling will be documented in the patients clinical record as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care.11. All referrals, assessments, clinical notes, intervention letters and phone calls will be documented in the patients clinical record.12. The Hospice Chaplain will attend interdisciplinary group meetings...”. During a record review of HA policy and procedure titled “;Psychosocial Services”, dated April 2020, indicated, “;Procedure. 1. The social worker will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient...3. Psychosocial assessments and interventions will be documented in the patients clinical record as part of the comprehensive assessment and interdisciplinary visit notes, as well as the plan of care.” During a record review of Patient 1s Electronic Medical Record (EMR) medical record form titled “;Personal Information” undated, indicated a start of care date of 12/12/2023 and end of care date of 12/22/2023, with diagnoses including end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant). During a record review of Patient 1s Electronic Medical Record (EMR) medical record form titled “;POC/IDG Review” dated 1/3/2024, indicated section “;IDG Discussion – Psychosocial, Other/Physician” were left blank. It also indicated section “;MSW Signature” was left blank. During a record review of Patient 1s Electronic Medical Record (EMR) medical record form titled “;POC/IDG Review” dated 12/20/2023, indicated section “;IDG Discussion – Psychosocial” was left blank. It also indicated sections “;MSW Signature” was left blank. During a concurrent interview and record review on 1/10/2024 at 12:56 p.m. with the Administrator/Director of Patient Care Services Designee (AD/DD) of Patient 1s EMR medical record form titled “;POC/IDG Review” dated 1/3/2024, AD/DD stated MSW did not document in the discussion section or signed the form. AD/DD stated the disciplines are to document their findings in their assigned discussion section. During a record review of Patient 2s Electronic Medical Record (EMR) medical record form titled “;Personal Information” undated, indicated a start of care date of 8/16/2023 with diagnoses including Hypertensive (high blood pressure) heart disease without heat failure. During a record review of Patient 2s Electronic Medical Record (EMR) medical record form titled “;POC/IDG Review” dated 1/3/2024, indicated section “;IDG Discussion – Psychosocial, Other/Physician” were left blank. It also indicated sections “;MSW Signature” and “;Chaplain Signature” were left blank. During a record review of Patient 2s Electronic Medical Record (EMR) medical record form titled “;POC/IDG Review” dated 12/20/2023, indicated section “;IDG Discussion – Spiritual, Psychosocial, Other/Physician” were left blank. It also indicated sections “;MSW Signature” and “;Chaplain Signature” were left blank. During a record review of Patient 2s Electronic Medical Record (EMR) medical record form titled “;POC/IDG Review” dated 12/6/2023, indicated section “;IDG Discussion – Psychosocial, Other/Physician” were left blank. It also indicated section “;MSW Signature” was left blank. During a concurrent interview and record review on 1/10/2024 at 1:10 p.m. with the AD/DD of Patient 2s EMR medical record form titled “;POC/IDG Review” dated 1/3/2024, 12/20/2023, and 12/6/2023, AD/DD stated Patient 2s last comprehensive assessment was on 1/3/2024. AD/DD stated discussion sections for MSW, and the physician were left blank. AD/DD stated MSW did not sign the forms. AD/DD stated Patient 2s comprehensive assessment must be updated and reviewed because his condition might have changed. During an interview on 1/10/2024 at 12:30 p.m. with the Administrator/Director of Patient Care Services Designee (AD/DD), AD/DD stated IDG members included an RN, MSW, MD, and Chaplain. AD/DD stated the IDG team meets every two weeks to discuss patients status and to update their individualized plan of care. During an interview on 1/10/2024 at 12:56 p.m. with the AD/DD, AD/DD stated patients comprehensive assessments need to be updated every two weeks by the IDG team. AD/DD stated each discipline is to document their findings on the discussion section and sign the form. AD/DD stated a disciplines signature indicated they agree with the patients plan of care. AD/DD stated patient condition changes daily and if their comprehensive assessments are not completed “;they wouldnt get the care that they are supposed to have”. During a record review of HA policy and procedure titled “;Interdisciplinary Group Meeting” revised 4/2020, indicated “;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, deaths, and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires.” During a record review of HA policy and procedure titled “;Ongoing Assessment” revised 4/2020, indicated “;Based on the assessments, the plan of care-including problems, needs, goals, and outcomes- will be reviewed and updated by the interdisciplinary group members responsible for the case.” During a record review of HA policy and procedure titled “;The Plan of Care” revised 10/2012, indicated “;The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician.” During a record review of HA policy and procedure titled “;Spiritual Care Counseling Services”, dated April 2020, indicated, “;Procedure...2.The Hospice Chaplain will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient and family...8.Spiritual care assessment and counseling will be documented in the patients clinical record as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care.11. All referrals, assessments, clinical notes, intervention letters and phone calls will be documented in the patients clinical record.12. The Hospice Chaplain will attend interdisciplinary group meetings...”. During a record review of HA policy and procedure titled “;Psychosocial Services”, dated April 2020, indicated, “;Procedure. 1. The social worker will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient...3. Psychosocial assessments and interventions will be documented in the patients clinical record as part of the comprehensive assessment and interdisciplinary visit notes, as well as the plan of care.””

“Based on interview and record review, the hospice agency (HA) failed to ensure all care services furnished followed the individualized plans of care (POC, an individualized care planned for the patient) established by the interdisciplinary team (IDT) for one of two sampled patients (Patient 1). Volunteer (Vol) services did not conduct home visit as indicated in Patient 1s plan of care. This failure resulted in patients not receiving care/services from the home visits and placed the patients at risk for not provided care/services when they needed. A review of Patient 1s undated Electronic Medical Record (EMR) form titled “;Personal Information”, indicated a start of care date of 12/12/2023 and end of care date of 12/22/2023, with diagnoses including end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant). A review of Patient 1s Electronic Medical Record (EMR) form titled “;POC Summary” dated as of 1/9/2024, indicated “;Vol per month and 3 (three) PRN (as needed) ...” A review of Patient 1s Electronic Medical Record (EMR) form titled “;Vol Notes” indicated there were no notes documented. During an interview on 1/10/2024 at 1:20 p.m. with the Administrator/Director of Patient Care Services Designee (AD/DD), AD/DD stated patients are different and need individualized POC based on their needs. During a concurrent interview and record review on 1/10/2024 at 1:23 p.m. with the AD/DD of Patient 1s EMR, medical record form titled “;POC Summary” AD/DD stated Patient 1 was ordered volunteer assistance with a frequency of “;per month +3 PRN (as needed)”. AD/DD stated there was no documented volunteer visit notes or documentation that Patient 1 declined volunteer services. AD/DD stated staff have been asked to submit their visit notes within three days of the visit. AD/DD stated patients POC need to be followed if the appropriate outcomes want to be achieved. AD/DD stated patients do not get the care required when POCs are not followed. A review of HA policy and procedure titled “;The Plan of Care” revised 10/2012, indicated “;The plan of care will identify the patients’ needs and services to meet those needs, including the management of pain and discomfort and symptom relief.” A review of HA policy and procedure titled “;Volunteer Services” revised 4/2020, indicated “;Volunteers will document their activities/type of services and time worked on volunteer activity/clinical notes and submit this documentation for the patients clinical records.””

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure one of two sampled patients (Patient 2) was provided with the patients plan of care (POC) which provided information on the services/care being provided by the HA and a current medication list. This failure had the potential to result in placing the patients at risk for not receiving the services/care stated in their individualized POC. A review of Patient 2s record titled, “;Personal Information”, indicated a start of care date into hospice care on 8/16/2023, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During an observation of the home visit on 1/10/2024, at 9:00 a.m., Registered Nurse 2 (RN 2) provided care to Patient 2. Patient 2 provided documents that were provided by the hospice agency. There was no plan of care or medication list. During an interview on 1/10/2024, at 9:30 a.m., Registered Nurse 2 (RN 2) stated he would bring a copy of the plan of care and medication list next week when he visits Patient 2 again. RN 2 stated it was important for Patient 2 to have a copy of his plan of care and medication list so he can be aware of the medications and plan of care. During an interview on 1/10/2024, at 11:32 a.m., the Administrator/Director of Nurses designee (AD/DD) stated patients should have a copy of their plan of care, so they know what to expect of their care. The POC should have been provided after the start of care. A review of the HAs undated policy and procedure titled, “;Patient Bill of Rights/Responsibilities”, indicated, “;Policy: Each patient will be an active, informed participant in his/her plan of care.””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure one of two sampled patients (Patient 1) received psychological assessment as ordered on the plan of care. This failure had the potential to result in patient and caregiver/family not receiving assessment and support of their needs. A review of Patient 1s undated Electronic Medical Record (EMR) form titled “;Personal Information”, indicated a start of care date of 12/12/2023 and end of care date of 12/22/2023, with diagnosis including end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant). A review of Patient 1s Electronic Medical Record (EMR) form titled “;POC Summary” dated as of 1/9/2024, indicated “;MSW for psychosocial and bereavement support monthly”. A review of Patient 1s Electronic Medical Record (EMR) form titled “;Comprehensive Psychosocial Assessment” dated 12/13/2023, indicated form was left blank, but was signed by MSW1. During a concurrent interview and record review on 1/10/2024, at 1:15 p.m., with the Administrator/Director of Patient Care Services Designee (AD/DD) of Patient 1s EMR medical record form titled “;Comprehensive Psychosocial Assessment” dated 12/13/2023, AD/DD stated she did not know why Patient 1s psychosocial assessment was left blank. AD/DD stated it was important for the MSW to complete because Patient 1 could have had issues and planning she needed to discuss. AD/DD stated patients psychosocial assessments needed to be completed by the MSW within five days of a patients admission. A review of HA policy and procedure titled “;Psychosocial Services” revised 4/2020, indicated “;A social worker will be assigned to each patient and family/caregiver based on the patients and familys needs and acceptance of these services. The social worker will be a member of the interdisciplinary group and will participate in the development, implementation, and revision of the plan of care.” A review of HA policy and procedure titled “;Psychosocial Services”, dated April 2020, indicated, “;Procedure. 1. The social worker will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient...3. Psychosocial assessments and interventions will be documented in the patients clinical record as part of the comprehensive assessment and interdisciplinary visit notes, as well as the plan of care.””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure one of two sampled patients (Patient 2) received spiritual counseling services to meet their spiritual needs. This failure had the potential to result in not providing patients and their caregivers the spiritual assistance to provide comfort in the dying process. A review of Patient 2s undated Electronic Medical Record (EMR) form titled “;Personal Information”, indicated a start of care date of 8/16/2023 with diagnosis including hypertensive (high blood pressure) heart disease without heart failure. A review of Patient 2s Electronic Medical Record (EMR) form titled “;POC Summary” dated as of 1/9/2024, indicated “;MSW and Chaplain for evaluation for spiritual assessment.” A review of Patient 2s Electronic Medical Record (EMR) form titled “;Comprehensive Spiritual Assessment” dated 8/16/2023, indicated “;Pt (patient) is very spiritual. Although has not been active in church. Pt stated grew up very active in faith. SN explained that chaplain will be calling to provide spiritual support. Pt and sister verbalized understanding.” The record also indicated form was signed by Registered Nurse 1 (RN1). During a concurrent interview and record review on 1/10/2024 at 1:18 p.m. with the Administrator/Director of Patient Care Services Designee (AD/DD) of Patient 2s EMR medical record form titled “;Comprehensive Spiritual Assessment” dated 8/16/2023, AD/DD stated it was the responsibility of the Chaplain to complete Patient 2s spiritual assessment within five days of his admission. AD/DD stated when patient refuse Chaplain services, the Chaplain needs to get in touch with the patient and document their interactions. AD/DD stated Patient 2s initial spiritual assessment was completed by Registered Nurse 1 (RN1). AD/DD stated it was important for the Chaplain to conduct a spiritual assessment because these were hospice patients that could be dying. AD/DD stated, “;Most patients turn to God at the end, they would need a spiritual assessment.” A review of HA policy and procedure titled “;Spiritual Care Counseling Services” revised 4/2020, indicated “;Spiritual care assessments and counseling will be documented in the patient’s clinical record as part of the comprehensive assessment and in the interdisciplinary visit notes, as well as the plan of care. If the patient and family/caregiver refuse spiritual care services, the medical social worker will document refusal. The interdisciplinary group members will make continued inquires as appropriate.” A review of HA policy and procedure titled “;Spiritual Care Counseling Services”, dated April 2020, indicated, “;Procedure...2. The Hospice Chaplain will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient and family...8. Spiritual care assessment and counseling will be documented in the patients clinical record as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care. 11. All referrals, assessments, clinical notes, intervention letters, and phone calls will be documented in the patients clinical record.””

“Based on interview and record review, the hospice agency (HA) failed to ensure any entries within an electronic health record clearly identified the authorship of each record for one of two sampled patients (Patient 2). This failure has the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients clinical record that could affect the patients quality of care and well-being. A review of Patient 2s record titled, “;Personal Information”, indicated a start of care date into hospice care on 8/16/2023, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During an interview on 1/10/2024, at 12:57 p.m., the AD/DD stated each note written in the medical record had to have a signature to validate who was the author of the note. During a concurrent interview and record review on 1/10/2024, at 1:00 p.m., the Administrator/Director of Nurses designee (AD/DD) reviewed Patient 2s record titled, “;Spiritual Assessment”, dated 8/16/2023. The AD/DD stated there was no signature in the document. A review of the HAs policy and procedure titled, “;Contents of Clinical Record”, dated April 2020, indicated, “;Procedure: 1. The following information will be available in the clinical record as applicable to care and services provided...2. Documentation will include:...M. Signed and dated clinical notes...3. Each entry will be dated and signed, including title and credentials, by the person providing the care/service.””

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure two of two sampled patients (Patient 1 and Patient 2) clinical records were safeguarded. This failure had the potential to result in patients information being seen and possibly used by unknown persons, which could have cause patients information to be used illegally. A review of Patient 1s undated Electronic Medical Record (EMR) form titled “;Personal Information”, indicated a start of care date of 12/12/2023 and end of care date of 12/22/2023, with diagnosis including end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant). A review of Patient 2s undated Electronic Medical Record (EMR) form titled “;Personal Information”, indicated a start of care date of 8/16/2023 with diagnosis including hypertensive (high blood pressure) heart disease without heat failure. During a concurrent observation and interview on 1/10/2024 at 11:45 a.m., with the Administrator Designee/ Director of Patient Care Services Designee (AD/DD) of patients’ medical records, AD/DD stated Patient 1 and Patient 2 s medical records were locked in a storage area. AD/DD noted going from the third floor to the second floor of the building. AD/DD opened an unlocked/unmarked door. Secretary (ST) noted sitting on chair working on a computer. AD/DD requested ST to give her patients medical record. ST noted knocking on a locked door, a female opened the door. ST asked the female for the patients medical records. The female gave ST Patient 1 and Patient 2s medical records. There were two females in the room, which appeared to be an office staff. AD/DD stated both females did not work for the HA. AD/DD stated both females worked for her other agencies. During an interview on 1/10/2024 at 11:50 a.m. with the AD/DD, AD/DD stated she did not know how both patients medical records were stored in that office where the two females were. AD/DD stated both females did not work at HA. AD/DD stated both females worked at her other agency. AD/DD stated it was considered a HIPPA violation because both medical records have confidential information. A review of HA policy and procedure titled “;Safeguarding /Retrieval of Clinical Records” revised 10/2012, indicated “;All patient clinical record will be maintained in locked, waterproof file cabinets in a designated clinical records room: The clinical record room will be monitored during working hours. Only authorized personnel will have access.””