Salmon Valley Hospice

“Based on agency policy, record reviews, IDG minutes and staff interview, it was determined the agency failed to ensure the IDG meetings included a physician, a social worker and a pastor for 14 of 14 patients (#1-14) whose records were reviewed. These cumulative failures had the potential to interfere with quality of patient care and not meet all patient’s needs. Findings include: Refer to L0541 as it relates to the agency’s failure to ensure a physician, a licensed MSW, and a chaplain participated in IDG meetings for all hospice patients. Refer to L0543 as it relates to the agency’s failure to furnish MSW and chaplain services to assess and meet the needs of all hospice patients. ,”

“Based on agency medical record review, personnel file review, Idaho statute review, Idaho Professional license website review, IDG meeting minute review, and staff interview, it was determined the governing body failed to ensure full legal authority and responsibility for the management of the hospice. The governing body failed to ensure the agencys only social worker was qualified through education, experience, and licensing to perform social work duties. Additionally, the governing body failed to ensure physicians were involved in the development of patient specific and overall care of patients receiving services at the hospice agency. This resulted is systemic failures in overall operation and management of the agency. Findings include: 1. Refer to L-0536 and its associated standard level deficiencies as it relates to the governing bodys failure to ensure physicians were involved in the development and implementation of patient specific plans of care. Additionally, as it relates to the failure of the governing bodys failure to ensure services were provided in accordance with written POCs. 2. Refer to L-0783 and its associated standard level deficiencies as it relates to the governing bodys failure to ensure social work services were provided by a qualified and licensed social worker. The cumulative effects of these negative systemic practices greatly impeded the agencys ability to provide safe and effective care.”

“Based on personnel record review, IDAPA Statue Review, Idaho Professional Licensing website, medical record review and staff interview, it was determined the agency failed to ensure personnel providing services were qualified through licensing, education, and experience. This negatively impacted patient care and provided services. Findings include: Refer to L594 as it relates to the failure of the agency to ensure the social works visits were conducted by a qualified social worker. Refer to L787 as it relates to the failure of the agency to ensure the employed social worker was qualified through education, experience or licensure.”

“Based on agency policy, medical record reviews, IDG minutes and staff interview, it was determined the agency failed to ensure the IDG meetings included a physician, a social worker and a pastor for 14 of 14 patients (#1-14) whose records were reviewed. These failures had the potential to interfere with quality of patient care and not meet all patients needs. Findings include: An agency policy titled, “INTERDISCIPLINARY GROUP MEETING” and stated, “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.” The Administrator was interviewed on 2/28/24, beginning at 9:15 AM, and she confirmed the Medical Director is not in attendance for all IDG meetings. The agency failed to ensure a physician, MSW, and a chaplain were involved in all IDG meetings. For 14 of 14 patients (#1-14) whose records were reviewed, their medical record did not include physician, social worker and chaplain notes from the IDG meetings or any suggested changes to POC rom a social worker or chaplain/counselor. IDG minutes from September 2023- February 2024 did not include a social worker or chaplain/counselor attendance. The administrator/social worker was interviewed on 2/28/24, beginning at 9:15am. The administrator/social worker confirmed that a licensed social worker was not present at IDG meetings for the last 6 months. The administrator also confirmed that there has been no participation of pastoral/other counselor at IDG meetings nor involved in patient care since 2022.”

“Based on hospice policy review, medical record review, and staff interview, it was determined the agency failed to ensure the services outlined in the POC were provided for 8 of 14 patients (Patients #3, 4, 5, 6, 7, 9, 12 and 13) whose records were reviewed. Additionally, the agency failed to ensure POCs were signed by a physician for 2 of 14 patients (Patients #3 and #7) whose records were reviewed. This failure resulted in POC’s not having physician involvement and the patients not receiving the care and services outlined in their POC’s. This resulted in unmet patient needs and potential harm to the patients. Findings include: 1. MSW visits were not completed a. Patient #3 was an 85 year old female admitted to the agency on 1/17/24, with a diagnosis of age-related cognitive decline. Services ordered were SN, aide and MSW. Her record, including the POC, for the certification period 1/17/24 to 4/15/24, was reviewed. POC orders dated, 1/17/24 by an RN stated, “Orders/Treatments: Medical Social Worker to Assess and Evaluate; Psychosocial needs.” The SW was interviewed on 2/27/24, beginning at 2:35 PM, and she confirmed Patient #3 had an order for MSW and Patient #3 did not receive MSW services. b. Patient #7 was a 66 year old female admitted to the agency on 2/22/24 with a terminal diagnosis of left breast cancer that metastasized to the brain. Services ordered were SN, aide and MSW. Her record, including the POC, for the certification period 2/22/24 to 5/21/24, was reviewed. POC orders dated, 2/22/24 by an RN stated, “Orders/Treatments: Medical Social Worker to Assess and Evaluate.” The SW was interviewed on 2/27/24, beginning at 2:35 PM, and she confirmed Patient #7 had an order for MSW and Patient #7 did not receive MSW services. c. Patient #9 was a 91 year old female admitted to the agency on 11/24/23 with a diagnosis of Cerebral infarction. Services ordered were SN and MSW. Her record, including the POC, for the certification period 1/15/24 to 3/14/24, was reviewed. POC orders dated, 1/15/24 by an RN stated, “Orders/Treatments: Medical Social Worker; 1m 3m 3 PRN: Psychosocial needs.” The SW was interviewed on 2/27/24, beginning at 2:35 PM, and she confirmed Patient #9 had an order for MSW and Patient #9 did not receive MSW services. The agency failed to provide services as outline in the POC for hospice patients which had the potential for unmet patient needs. 2. POC’s did not have a verbal order or physician signature a. Patient #3 was an 85 year old female admitted to the agency on 1/17/24, with a diagnosis of age-related cognitive decline. Services ordered were SN, aide and MSW. Her record, including the POC, for the certification period 1/17/24 to 4/15/24, was reviewed. Patient #3’s POC dated 1/17/24, stated, “I have reviewed the above Plan of Care and certify that the services are required and authorized by me for the above patient.” The physician signature and date entry were blank. The SW was interviewed on 2/28/24, beginning at 9:00 AM, and she confirmed Patient #3’s POC did not have a signature from a physician. b. Patient #7 was a 66 year old female admitted to the agency on 2/22/24 with a terminal diagnosis of left breast cancer that metastasized to the brain. Services ordered were SN, aide and MSW. Her record, including the POC, for the certification period 2/22/24 to 5/21/24, was reviewed. Patient #7’s POC orders dated 2/23/24, stated, “ “I have reviewed the above Plan of Care and certify that the services are required and authorized by me for the above patient.” The physician signature and date entry were blank. The SW was interviewed on 2/28/24, beginning at 9:00 AM, and she confirmed Patient #7’s POC did not have a signature from a physician. The Administrator was interviewed on 2/27/24, beginning at 3:25 PM, and she confirmed the expectation is the POC’s should be signed by a physician. The agency failed to have a physician signed POC and services rendered to patient’s as outlined in the POC. It is unclear how hospice staff were providing treaments/services without physician involvement. The hospice policy titled “The Plan of Care” dated October 2014, stated “The care provided to the patient must be in accordance with the plan of care.” D. Patient #4, a 62 year old male with start of care 1/5/24, with primary diagnosis of alcoholic cirrhosis. His record, including POC, for certification period 1/5/24 – 4/3/24 was reviewed. Services ordered were SN, Aide and SW. The medical record did not include an assessment, evaluation or visits by social worker. The administrator/social worker was interviewed 2/27/2023 at 2:15pm. Medical records for patients #4 was reviewed in the administrator/social worker’s presence. The administrator/social worker confirmed patients #4 did not receive social work visits although ordered. E. Patient #5, an 89 year old female with start of care 10/7/22 with primary diagnosis of Alzheimers disease. Her record for certification period 1/30-3/29/24., including POC, was reviewed. Services ordered were SN, Aide and SW. The medical record did not include an assessment, evaluation or visits by social worker. The administrator/social worker was interviewed 2/27/2023 at 2:15pm. Medical records for patients #5 was reviewed in the administrator/social worker’s presence. The administrator/social worker confirmed patients #4 did not receive social work visits although ordered. F. Patient #6, an 89 year old female with primary diagnosis of chronic kidney disease, stage 3, with start of care of 10/22/23 . Her record for certification period of 1/20/24 to 4/18/24, including POC, was reviewed. Services ordered were SN, Aide and SW. The medical record did not include an assessment, evaluation or visits by social worker. The administrator/social worker was interviewed 2/27/2023 at 2:15pm. Medical records for patients #6was reviewed in the administrator/social worker’s presence. The administrator/social worker confirmed patients #4 did not receive social work visits although ordered. G. Patient #12, an 82 year old male with start of care 7/26/24 with primary diagnosis of malignant neoplasm of overlapping sites of esophagus. His record for certification period 7/26/24 – 8/10/24, including POC, was reviewed. Services ordered were SN, Aide and SW. The medical record did not include an assessment, evaluation or visits by social worker. The administrator/social worker was interviewed 2/27/2023 at 2:15pm. Medical records for patients #12 was reviewed in the administrator/social worker’s presence. Services ordered were SN, Aide and SW. The medical record did not include an assessment, evaluation or visits by social worker. H. Patient #13, an 82 year old female with start of care 11/7/2023 with primary diagnosis of acute combined systolic and diastolic heart failure. Her record for certification period of 11/7 – 2/4/2024, including POC, was reviewed. Services ordered were SN, Aide and SW. The medical record did not include an assessment, evaluation or visits by social worker. The administrator/social worker was interviewed 2/27/2023 at 2:15pm. Medical records for patients #13 was reviewed in the administrator/social worker’s presence. The administrator/social worker confirmed patients #4 did not receive social work visits although ordered. The agency failed to ensure that the patients received services as ordered.”

“Based on personnel record review, medical record review, staff interview, Idaho licensing website, and IDAPA statutes 54-3214, it was determined the agency failed to medical social services must be provided by a qualified social worker, under the direction of a physician. This failure resulted in the patients not receiving the care and services outlined in their POCs and had the potential to result in unmet needs and harm to the patient. Findings include: Idaho Work Licensing Act 54-3214 states “;LICENSE REQUIRED — REPRESENTATION TO PUBLIC. (1) No person may engage in the practice of social work unless that person is licensed under this chapter or is a student under the supervision of a person who is licensed under this chapter.” Patient #11, a 94 year old female, with Chronic Obstructive Pulmonary Disease with acute exacerbation with a SOC of 3/13/2023 and a certification period of 6/11/2023 - 9/8/2023 record, including POC, was reviewed. Patient #11 received a social work visit from the current administrator/social worker at the hospice on 8/16/2023. Review of personnel records and staff interview revealed that the current social worker role was filled by an employee who does not yet have her Masters in Social nor her baccalaureate degree in social work with one year of social work experience in a healthcare setting while supervised by MSW. Idaho Department of Occupational licensing website was reviewed (https://legislature.idaho.gov/statutesrules/idstat/title54/t54ch32/sect54-3214/). The social worker did have a current Social Work license in the state of Idaho. The social worker employee does not have an Idaho Social Worker license. The administrator, who also functions as the social worker, was interviewed 2/28/24 at 9:15am. The administrator confirmed that she, the social worker, did not yet have a Masters In Social Work or social work license. Patient #11 received medical social services from an unqualified social worker.”

“Based on medical record review, Medicare Benefit Manual review, and staff interview, it was determined the agency failed to ensure all patients had a verbal order or physician signature for a CTI within 2 calendar days of start of care as required in 42 CFR 418.22, for 1 of 14 patients (Patient # 7) whose record was reviewed. This had the potential to result in patients admitted to the agency without physician verification of their terminal status. Findings include: The Medicare Benefit manual was reviewed and states, “;...section 418.22 (3) Exceptions. (i) If the hospice cannot obtain the written certification within 2 calendar days, after a period begins, it must obtain an oral certification within 2 calendar days and the written certification before it submits a claim for payment.” Patient #7 was a 66 year old female admitted to the agency on 2/22/24 with a terminal diagnosis of left breast cancer that metastasized to the brain. Services ordered were SN, Aide, and MSW. Her record, including the POC, for the certification period 2/22/24-5/21/24, was reviewed. Patient #7s medical record did not contain a verbal order or signed CTI from a physician within 2 calendar days from the start of care. The SW was interviewed on 2/27/24 beginning at 2:35 PM and Patient #7s medical record was reviewed in her presence. The SW confirmed that Patient #7s medical record did not include a verbal or signed CTI within 2 days of start of care. The agency failed to ensure all patients had a verbal order or physician signature for a CTI within 2 calendar days of start of care. .”

“Based on Medicare Benefit manual review, IDG minutes, medical record review, and staff interview it was determined that the hospice failed to meet the requirements of a planned and safe discharge. This created the potential to result in unmet patient need and breakdown in continuity of patient care. The Medicare Benefit manual section 42 CFR 418.26 was reviewed. It stated, “;The situations under which a hospice may discharge a patient are addressed in the regulation at 42 CFR 418.26 and include the following situations: ....The hospice determines that the patient is no longer terminally ill.....The hospice must do the following... Prior to discharging a patient for any reason stated above, the hospice IDG must obtain a written physicians discharge order from the hospice medical director. If a patient has an attending physician involved in his or her care, this physician should be consulted before discharge and his/her review and decision included in the discharge note. This guideline was not followed. An example included: Patient #11 was a 93 year old female admitted to the agency 3/13/2023, with adiagnosis of Chronic Obstructive Pulmonary Disease with acute exacerbation. Her record, including the POC and discharge summary, for certification period of 6/11/2023 - 9/8/2023, was reviewed. A medical record note, dated 8/29/2023, stated “Pt informed of recert next week.” The discharge summary, dated 9/5/2023, found in the medical record listed the discharge condition as “Pt with no evidence of decline in this cert period.” IDG meeting minutes, dated 8/24/2023, were reviewed. There was no discussion on plans to discharge Patient #11. However, IDG meeting, dated 9/7/2023 (post discharge), included in additional notes section “No longer qualifies. Will send back to PCP” with no additional documentation of non qualifying events. Patient #11 medical record did not include a signed order from a physician for discharge. Additionally there was no documentation patient #11’s discharge prior to discharge. The social worker was interviewed on 2/28/2023, beginning at 9:15 AM, confirmed that there was no discussion of discharge prior to discharge for Patient #11. The agency failed to ensure that the physician was aware and signed off on the discharge prior to discharge.”

“Based on IDAPA statute, Department of Professional Licensing (https://dopl.idaho.gov/swo/) review, personnel record review, and staff interview, it was determined the agency failed to ensure personnel providing social work services were qualified. This negatively impacted patient care and provided services. Findings include: Idaho Work Licensing Act 54-3214 states “;LICENSE REQUIRED — REPRESENTATION TO PUBLIC. (1) No person may engage in the practice of social work unless that person is licensed under this chapter or is a student under the supervision of a person who is licensed under this chapter.” Department of Professional Licensing website was accessed (2/27/24). The hospice social workers did not possess current social work license. Review of personnel records revealed that the current social worker did not have a Masters of Social Work, nor a Social Work license. The employee filling the role of social worker role also did not have her baccalaureate degree in social work with one year of social work experience in a healthcare setting while supervised by MSW. The employee did not have an Idaho Social Worker license The social worker, was interviewed 2/28/24 at 9:15 AM. The social worker confirmed that she, the social worker, did not have a Masters In Social Work or social work license. This agency failed to ensure the social worker was qualified.”