Hosparus Western Kentucky

“Based on record review, interview, and agency policy review, the hospice agency failed to ensure that an initial spiritual assessment was completed for two patients (Patient (P) 9 and P19) and failed to ensure an initial social worker (SW) assessment was completed for P10 within five days after election of hospice care, out of a sample of 19 patients. The findings include: Review of agency policy titled, “Interdisciplinary Group (IDG) Comprehensive Assessment and Reassessment,” dated 05/17/2022, indicated “...Procedure: 1. A comprehensive assessment of the patient is completed by members of the IDG within their scope of practice, in collaboration with the patients attending physician, no later than five calendar days after the patient elects the hospice benefit. The day of election is considered the first calendar day.’’ 1.Review of P9s agency provided “Face Sheet” indicated that P9 was admitted to hospice on 08/20/2024 with a diagnosis of malignant neoplasm of sigmoid colon (colon cancer). Review of P9s facility provided “Spiritual Care Focused Assessment,” dated 08/27/2024 (seven days after the election of hospice care) indicated “Visited for initial assessment of spiritual needs, resources.’’ During an interview with the Compliance Risk and Quality Field Retention and Risk Supervisor (CRQ) on 09/12/2024 at 4:00 PM, he/she confirmed the lateness of the initial assessment. 2.Review of P19s agency provided “Face Sheet” indicated that P19 was admitted to hospice on 08/23/2024 with a diagnosis of perforation of intestine. Review of P19s facility provided “Spiritual Care Focused Assessment,” dated 08/29/2024 (six days after the election of hospice care) indicated “Visited P19 for initial assessment of spiritual need, resources.” During an interview with the CRQ on 09/13/2024 at 11:06 AM, he/she confirmed that the assessment was completed late, indicating that it should have been completed by the fifth day. 3.Review of P10s agency provided “Face Sheet” indicated that P10 was admitted to hospice on 08/22/2024 with a diagnosis of malignant neoplasm of rectum (rectum cancer). Review of P10s facility provided “Social Worker Assessment,” dated 08/28/2024 (six days after the election of hospice care) indicated “SW completed initial assessment with the patient and patients wife.’’ During an interview with the CRQ on 09/12/2024 at 5:00 PM, he/she confirmed that the initial assessment was over the five days.”

“Based on record review, interview and agency policy review, the hospice agency failed to ensure that the Certified Nursing Assistant (CNA) notified the Registered Nurse (RN) when one patient (Patient (P) 4) had three days of refusals of visits out of a total of 10 active medical records reviewed. The findings include: Review of the agency policy titled, “CNA Services, Role, Plan of Care and Supervision,” dated 06/24/2022, indicated, “...CNA Role:...3. The CNA also reports observations/concerns/changes to the RN. These observations, as well as the notification of the RN, must be documented by the CNA in CellTrak.” Review of the agency provided “Face Sheet” indicated that P4 was admitted into hospice on 07/22/2024 with a diagnosis of malignant neoplasm of rectum (rectum cancer). Review of “Visit Exception,” dated 07/24/2024, indicated “Patient/ Family refused/declined visit. Patient said he/she was good and did not need me today.’’ There was no evidence that the RN was notified. Review of “Visit Exception,” dated 07/26/2024, indicated “Patient/ Family refused/declined visit. Talked to daughter she canceled for today, said was in a bad mood and being mean and hitting.’’ There was no evidence that the RN was notified. Review of “Visit Exception,” dated 07/30/2024, indicated “Patient/ Family refused/declined visit. Patient refused.’’ There was no evidence that the RN was notified. During an interview with the Compliance Risk and Quality Field Retention and Risk Supervisor (CRQ) on 09/11/2024 at 4:54 PM, confirmed that P4 and/or family did refuse CNA services on the above days and stated that the CNA did not notify the RN but should have.”

“Based on interview and record review, the agency failed to ensure that a discharge summary was completed for one patient (Patient (P)11) who was discharged out of service area from a sample of two live discharge records reviewed. The findings include: Review of the agency provided “Face Sheet” indicated that P11 was admitted to the hospice agency on 11/10/2023 with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the agency provided a “Modified Order,” dated 12/06/2023, that indicated “Order to discharge from hospice due to out of service area.’’ Review of P11s electronic medical record (EMR) revealed no evidence that a discharge summary was completed. Review of the agency provided “Discharge Summary and Checklist,” dated 12/06/2023, indicated “Routine Registered Nurse (RN) visit completed after patients daughter reported to RN that P11 will transfer to [name of healthcare] this day.’’ There was evidence of a discharge checklist; however, no evidence of a discharge summary. During an interview with the Compliance Risk and Quality Field Retention and Risk Supervisor (CRQ) on 09/13/2024 at 6:00 PM, he/she confirmed that P11 did not have a discharge summary, only a discharge checklist.”