Crisp Regional Hospice and Palliative Care

“Observed in Record Review. In 14 of 14 patient records reviewed, it was noted that there was no documentation of the need for volunteer services to offer support or respite to the patient, family, or other caregivers. For example, in records HOSHV#1 through #4 and HOSNHV#1 through #10 there was no documentation of the need for volunteer services on initial assessment or at reassessment. In records HO RRNHV#2 and #9 there was no documentation of the patient’s psychosocial status, such as family relationships, social history, the source and adequacy of environmental and other resources, coping mechanisms, and the patient’s and family’s reactions to illness. This was discussed with the Director and Clinical Coordinator present.”

“Observed in Record Review. In 14 of 14 patient records reviewed, it was noted that the interdisciplinary group did not include a social worker, marriage and family therapist or mental health counselor. For example in records HOSHV#1 to #4 and HOSNHV#1 to #10 there was no documentation of a social worker, marriage and family therapist or mental health counselor attending IDG as a result the comprehensive assessment collaboration was not complete. .Upon discussion with the Director, Quality nurse and Clinical Coordinator the full time social worker had left suddenly and unexpectedly 2 months ago and the team had been working with a PRN MSW who did not attend IDG or provide regular patient care. The prn MSW was available only for emergency situations. Leadership stated that there is a new MSW who will be starting next week.”

“Observed in Record Review. In 14 of 14 patient records reviewed, it was noted that the interdisciplinary group did not include a social worker, marriage and family therapist or mental health counselor. For example in records HOSHV#1 to #4 and HOSNHV#1 to #10 there was no documentation of a social worker, marriage and family therapist or mental health counselor attending IDG. Upon discussion with the Director, Quality nurse and Clinical Coordinator the full time social worker had left suddenly and unexpectedly 2 months ago and the team had been working with a PRN MSW who did not attend IDG or provide regular patient care. The prn MSW was available only for emergency situations. Leadership stated that there is a new MSW who will be starting next week.”

“Observed in Record Review. In 13 of 14 patient records reviewed, it was noted that the written plan of care was not based on the patient’s individualized goals and the time frames, settings and services required to meet the goals. For example, the goals Patient achieves feelings of spiritual comfort. and Survivor will be knowledge of bereavement services and when needed, will use available support to achieve a more positive grief outcome.. were not individualized it was stated verbatim in multiple records. In record HOSRRHV#1 and HOSRRNHV#5 the plan of cares included a goal for emergency evacuation however the interventions were for fall risk. In record HOSHV#3 the patient had a G-tube that he received bolus feedings and medications through, However there were no goals or interventions related to the G-tube since admission over 3 months prior and no goals or interventions were documented when the patient was placed in a SNF for respite care 4 days ago. In record HOSRRHV#4 there were 3 respiratory goals started on admission in 2022, for example Patient/cg demonstrate proper administration of oxygen. The goals had not been updated and based on nurse notes appeared to have been achieved. This was discussed with the Clinical Coordinator present.”

“Observed in Record Review. In 14 of 14 patient records reviewed, it was noted that the interdisciplinary group did not include a social worker, marriage and family therapist or mental health counselor. For example in records HOSHV#1 to #4 and HOSNHV#1 to #10 there was no documentation of a social worker, marriage and family therapist or mental health counselor attending IDG. Upon discussion with the Director, Quality nurse and Clinical Coordinator the full time social worker had left suddenly and unexpectedly 2 months ago and the team had been working with a PRN MSW who did not attend IDG or provide review and revision of the plan of care as the patient’s condition required, but no less frequently than every 15 days. The prn MSW was available only for emergency situations. Leadership stated that there is a new MSW who will be starting next week.”

“Observed in Record Review. During review of a bereavement care plan with the chaplain/bereavement coordinator, the hospice pharmacy surveyor noted that two sisters were having a disagreement over the key elements which were involved in grieving the loss of their mother. Although the chaplain was aware this was occurring, he did not identify any documented interventions in the documented bereavement plan of care to improve this problem. This was reviewed with the chaplain at thentime of the survey. Observed in Record Review. During review of a bereavement care plan with the chaplain/bereavement coordinator, the hospice pharmacy surveyor noted that this patient’s bereavement care plan included the required telephone calls and mailings; however this record did not include that the calls were being made at the specified intervals. The chaplain indicated a call was probably last made to the bereaved in Dec 2024 with no documentation found in the record that this occurred or whether there was a connection made or what timeframe for a callback was planned. This issue was reviewed with the chaplain at the time of the survey.”

“Observed in Document Review. The volunteers must provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. The hospice must maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked. The Hospice pharmacy surveyor observed in tracer activities and during a discussion with the volunteer coordinator and review of available records prepared in 2024, documentation of direct patient care and administrative hours to equal 1.31% of the total patient care hours of all paid employees in 2023. The amount of savings achieved for 2024 was documented to be at 1.96 %,. The validation of this information was reviewed with the volunteer coordinator and director at the time of the survey”