Gana Hospice, Inc.

“It is required that the written Patient Bill of Rights includes the right to be involved in the development of his or her plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient live discharged for extended prognosis, the agency did not ensure documentation that the patient was involved in the development of the plan of care. Clinical Record 11: The patient elected the hospice benefit on 11/09/2023 for the diagnosis of malignant neoplasm of the prostate. The patient was discharged for extended prognosis on 08/10/2024. The Notification of Medicare Non-Coverage (NOMNC) was signed by the patient/family on 08/10/2024, the patient’s day of discharge. The clinical record did not include documentation that the patient participated in the discharge process and did not include documentation that the patient was provided with the NOMNC 48 hours prior to discharge. During an interview and joint record review on 08/27/2024, the Administrator/Director of Patient Care Services agreed the NOMNC form should have been given to the patient/family in “advance of the discharge so they could have time to plan if needed.””

“It is required that performance improvement activities track adverse patient events; analyze the causes; and implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by document review and interview. The hospice did not ensure performance improvement activities included documentation that showed the analysis of the cause, preventative actions taken, feedback mechanisms, and learning provided. Review of the 1st quarter 2024 performance improvement activities included documentation that the two Registered Nurse leaders met and discussed infections, pain management, and high hospitalizations. The agency documented 24 infections and for the improvement program, they were providing “ongoing education of staff.” The 2nd quarter 2024 performance improvement activities include documentation that the two Registered Nurse leaders met and discussed infections, pain management, and high hospitalizations. The agency documented 9 infections and for the improvement program, they were providing “ongoing education of staff.” The quality program and performance improvement activities did not include documentation that showed the analysis of the cause, preventative actions taken, feedback mechanisms, and learning provided. During an interview and joint review of the quality program on 08/27/2024, the Administrator/Director of Patient Care Services (DPCS) explained the current quality program consisted of the Administrator/DPCS and another Registered Nurse meeting and discussing the infections, pain management, and hospitalizations. The Administrator/DPCS advised they were the only staff that attended the quality meetings at this time. Although they complied the number of infections, there was not an analysis of the causes, preventative action taken or feedback and learning throughout the hospice. A review of the quality program on 08/27/2024 revealed the performance improvement activities for Quarter 1 and Quarter 2 of 2024 consisted of the following information: 1st Quarter of 2024 the 2 registered nurse leaders met and discussed infections, pain management, and high hospitalizations. They had 24 infections. For their improvement program, they were providing “ongoing education of staff”. 2nd Quarter of 2024 the 2 registered nurse leaders met and discussed infections, pain management, and high hospitalizations. They had 9 infections. For their improvement program, they were providing “ongoing education of staff.””

“It is required that the bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed with bereavement services accepted, the agency did not ensure a bereavement plan of care was developed that included the types of bereavement services to be offered. Clinical Record 13: The patient elected the hospice benefit on 09/15/2023 for the diagnosis of malignant neoplasm of prostate. The patient died on 12/05/2023. Clinical record review revealed no documented evidence that a bereavement plan of care was developed. During an interview and joint record review on 08/27/2024, the Administrator/Director of Patient Care Services confirmed the record did not contain the post death bereavement assessment and the bereavement plan of care had not been entered.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum, the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 8 (12%) clinical records reviewed with hospice aide services provided, the hospice did not ensure the hospice aide documented clinical notes as required by agency policy. Agency policy titled Timely Submission of Notes, dated April 2021, required in part, “All field staff must submit documentation of their visit notes within 48 hours.” Clinical Record 3: Clinical record review revealed the plan of care included an order for the hospice aide to provide visits twice a week. As of the date of record review on 08/27/2024, there was no documented evidence in the clinical record of the hospice aide visit notes for the week of 08/18/2024. During an interview and joint record review on 08/28/2024, the Administrator/Director of Patient Care Services stated the aide had completed visits the week of 08/18/2024 but had not documented them yet.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the clinical record contained complete physician orders. Clinical Record 6: The physician order dated 08/16/2024 stated, “Left buttock stage 4 pressure ulcer-cleanse with wound cleanser, pat dry, apply calcium alginate, cover with bordered foam dressing every 3 days and as needed for loss of integrity/soiling for 30 days.” The order did not include the discipline responsible for providing wound care to the patient. Clinical Record 14: The physician order dated 11/23/2023 stated, “Start CC (continuous care) effective today at 3 PM.” The order did not include a reason for starting the continuous care or clarification for the necessity of ordering continuous care. During an interview and joint record review on 08/28/2024, the Administrator/Director of Patient Care Services agreed the orders needed to be more concise and explain the need for continuous care.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which the patient revoked or was discharged for no longer being terminally ill, the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 11: The patient elected the hospice benefit on 11/09/2023 for the diagnosis of malignant neoplasm of the prostate. The patient was discharged for extended prognosis on 08/10/2024. Clinical record review revealed no documented evidence that the discharge summary was forwarded to the patient’s attending physician. During an interview and joint record review on 08/27/2024, the Administrator/Director of Patient Care Services stated the discharge summary had not been faxed or sent to the attending physician as “they [the hospice] did not realize this was required but they would do so in the future.””

“It is required that a social worker who holds a bachelor’s degree is supervised by a CMS-qualified MSW [Master of Social Work] who has a degree from a school of social work accredited by the Council on Social Work Education and has one (1) year of experience in a health care setting. This standard was not met as evidenced by document review, personnel record review, and interview. The agency did not ensure the BSW [Bachelor of Social Work] was supervised by an MSW. Agency policy No. 1-002.3 Qualifications of Hospice Personnel, no date, required in part, “4. Social Worker A. Holds at least a bachelor’s degree from a school of social work accredited by the Council of Social Work Education and is supervised by an MSW (Master of Social Work).” Personnel Record 4: Social Worker date of hire 09/01/2022. Personnel record review revealed the Social Worker was a bachelor’s degree Licensed (BSW) Social Worker. During an interview on 08/27/2024, the Administrator/Director of Patient Care Services confirmed the BSW is the only social worker employed by the agency. The Administrator explained the agency had a master’s degree Licensed Social Worker employed but the MSW left sometime in 2022, and they have had difficulty hiring another MSW since that time. The Administrator confirmed there has not been supervision of the BSW by an MSW from 2022 through the date of this review on 08/27/2024. During an interview and joint record review on 08/27/2024, the Administrator/Director of Patient Care Services stated the BSW has been a “hard worker and that the MSW has been a hard position to fill although she knows she needs to hire an MSW.” Staff 4, a Bachelor’s Degree Licensed (BSW) Social Worker was hired 09/01/2022 and is currently the only employed social worker. Per an interview with the Administrator/Director of Patient Care Services on 08/27/2024, a Master’s Degree Licensed Social Worker (MSW) was “employed and left sometime in 2022 and they have had difficulty hiring another MSW since that time. It was agreed there has not been supervision of the BSW by an MSW from 2022 to current date. The BSW has been completing initial assessments, meeting visit frequencies, and documenting during on the patient’s plans of care during IDG (interdisciplinary group meetings). It should be noted that most notes are very generic and state something similar to “will continue to provide monthly and as needed psychosocial services for the family and patient.””