Acaring Hospice, LLC

“Based on review of policy titled “;Individualized Plans of Care/Service Plans,” record reviews, and staff interviews, it was determined the hospice failed to include all services necessary for the management of the terminal illness including Social Worker (SW) and Chaplin care plans for three patients (P) (P1, P2, P3) of three sampled patients. Findings include: Review of the policy titled, “;Individualized Plans of Care/ Service Plans,” Policy Number A: 28, dated 12/2023, reveals the following: Procedure B. The interdisciplinary written plan of care is based on initial and updated patient-specific comprehensive assessments by members of the IDG and is developed with measurable goals and outcomes for planned interventions. C. The written interdisciplinary plan of care is developed and individualized for each patient and family, reflects patient/family goals based upon problems identified in the initial/ updated assessments, and includes all services necessary for palliation and management of the terminal illness and related conditions, including the following: 12. Other disciplines 19. Additionally, the plan of care will include the following among others: b. identification of the physical, psychological, social, economic and spiritual status of the patient/ family; 1. Record review reveals P1 was admitted to hospice on 3/19/2024. The record failed to reveal SW and Chaplain care plans identifying discipline-specific problems, interventions, or goals. 2. Record review reveals P2 was admitted to hospice on 4/29/2024.The record failed to reveal SW and Chaplain care plans identifying discipline-specific problems, interventions, or goals. 3. Record review reveals P3 was admitted to hospice on 3/28/2024. The record failed to reveal SW and Chaplain care plans identifying discipline-specific problems, interventions, or goals. On 8/20/2024 at 10:30 am, an interview with Social Worker (SW) BB revealed the SW plan of care for P1 was to assess patients mental status, educate the family in grief, and provide emotional support to the patient during once-a-month visits. SW BB stated the nurse was responsible for documentation of the care plan for all disciplines. On 8/20/2024 at 12:30 pm, an office interview with the Administrator confirmed the clinical record lacked SW and Chaplain discipline-specific care plans. The Administrator revealed the SW and Chaplains are expected to enter and update discipline-specific care plans in the clinical record.”

“Based on record review and staff interview, it was determined the hospice failed to ensure the plan of care detailed the scope and frequency needed to meet the needs of the patient by ordering Hospice Aide visits in a range of frequencies for two patients (P) (P1, P2) of three sampled patients. Findings include: 1. Record review reveals P1 was admitted to hospice on 3/19/2024. P1 resides at an Assisted Living Facility (ALF). Review of the Initial Plan of Care reveals Hospice Aide services are ordered for 1-2 times/ week, with a notation stating patient/ family request no Hospice Aide visits at this time. 2. Record review reveals P2 was admitted to hospice on 4/29/2024. P2 resides at an Assisted Living Facility (ALF). Review of the Initial Plan of Care dated 4/30/2024 reveals Hospice Aide services were ordered 1-2 times/ week. On 8/20/2024 at 12:30 pm, an office interview with the Administrator confirmed Hospice Aide frequencies were written as a range of 1-2 times per week.”

“Based on record review and staff interview, it was determined the hospice failed to ensure that care and services were provided following the plan of care for one patient (P) (P2) of three sampled patients. Findings include: Record review reveals P2 was admitted to hospice on 4/29/2024. Review of the Initial Plan of Care dated 4/30/2024 reveals Hospice Aide services were ordered 1-2 times/ week. The initial Hospice Aide visit was made on 5/8/2024, nine days after admission. Hospice Aide visits reveal the following: 4/29/2024- 5/4/2024- Hospice Aide visits failed to be documented 5/5/2024 – 5/11/2024- Two Hospice Aide visits were made 5/12/2024- 5/18/2024- Hospice Aide visit made on 5/17/2024 5/19/2024- 4/6/2024- Hospice Aide visits failed to be documented 5/26/2024- 4/6/2024- Two Hospice Aide visits made. On 8/20/2024 at 12:35 pm, an office interview with the Administrator confirmed frequencies were not met for Hospice Aide visits for P2 The Administrator revealed the electronic medical record (EMR) does not always accurately reflect actual Hospice Aide visits made.”

“Based on record review and staff interview, it was determined the hospice failed to ensure the hospice plan of care identified who is responsible for performing care and services identified in the plan of care for two patients (P) (P1, P2) of two sampled patients residing in an Assisted Living Facility (ALF). Findings include: 1. Record review revealed P1 resides at an Assisted Living Facility (ALF). Review of documents titled “;Care Plan” fails to specify who is responsible for performing the care and services identified in the care plan. 2. Record review P2 resides at an Assisted Living Facility (ALF). Review of documents titled “;Care Plan” fails to specify who is responsible for performing the care and services identified in the care plan. On 8/20/2024 at 12:30 pm, an office interview with the Administrator confirmed the plan of care does not specify responsibility for performing care plan interventions for two patients in facilities.”

“Based on facility document review, staff interview, and review of the policy titled “;Written Contracts/ Agreements for Provision of Care & Services,” it was determined the hospice failed to ensure that all contracted entities obtain criminal background checks on contracted employees having access to patients or patient records. Findings include: Review of the policy titled “;Written Contracts/ Agreements for Provision of Care & Services,” Policy Number A: 73, dated 12/2023, reveals the following: Policy Contractor of services must comply with the provisions of the regulations regarding a coordinated program of home and in-patient care. The policy fails to include a procedure for requiring background checks for any contracted entity having access to patients or patient records. Review of agency contracts failed to reveal a requirement for background checks for two contracts with nursing facilities for in-patient services. On 8/20/2024 at 12:30 pm, an office interview with the Administrator confirmed the contracts lack a provision for background checks.”