Notre Dame Hospice

“Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed by the hospice interdisciplinary group no later than 5 calendar days after the election of hospice care for 2 patients (#3 and #1), out of a total of sample of 19 patients.Findings include: 2. Patient #1 was admitted to the agency in February 2025 and had a diagnosis of cerebrovascular disease (group of conditions that impact the brain’s blood vessels and blood flow).Review of the medical record indicated the following:*2/6/25 initial assessment Skilled Nursing Visit (SNV) note*2/13/25 initial assessment Medical Social Worker (MSW) noteFurther review of the medical record indicated the Comprehensive Skilled Nursing Assessment was completed on 2/14/25. During an interview on 8/6/24 at 3:24 P.M., the surveyor reviewed the medical record with the Executive Director, the Quality Assurance Nurse, and the Director of Psychosocial Services who said the initial SNV note is the comprehensive assessment, however, there was no documentation in the 2/6/25 note of other IDG members’ involvement. They said the initial MSW visit note was not completed until 2/13/25 and did not contain a narrative as to other IDG members’ involvement. They further said the Comprehensive Skilled Nursing Assessment was not completed within the required timeframe. Review of the agency policy entitled, Comprehensive Assessment of the Patient, with the revision date of September 2024, included the following:*The comprehensive assessment of the patient is completed by at least 3 designated members of the Interdisciplinary Group (IDG) including the Registered Nurse (RN) and medical director in consultation with the patient’s attending physician or primary caregiver prior to the provision of services no later than three (3) calendar days after the patient elects the hospice benefit. The initial care plan shall be reviewed and ratified by the full interdisciplinary team at their next scheduled meeting.1. Patient #3 was admitted to the agency in January 2025 with a diagnosis of ischemic cardiomyopathy (narrowing of the coronary arteries which supply blood to the heart).Review of the clinical record indicated the Comprehensive Skilled Nursing Assessment was completed on 1/13/25. During an interview on 8/6/25 at 5:00 P.M., the Quality Assurance Nurse after reviewing the clinical record said, the Comprehensive Assessment was not completed within the five calendar days after the patient was admitted to the agency, as required.”

“Based on record review and staff interview, the agency failed to ensure a Bereavement Care Plan was active for identified family members after a patient’s death for 2 patients (#16 and #17), out of a total sample of 3 bereavement records reviewed.Findings include: 2. Patient #17 was admitted to the agency in February 2025 with a diagnosis of hypertensive heart disease with heart failure. The patient expired on 3/4/25 while receiving hospice services. Review of the clinical record indicated the Bereavement Care Plan was resolved on 3/4/25.During an interview on 8/6/25 at 4:00 P.M., the Director of Psychosocial Services said the previous Bereavement Coordinator (no longer employed by the agency) resolved the Bereavement Care Plan, and that it should have remained active. Review of the agency policy entitled, Bereavement Care Planning, revised August 2024, indicated the following:*A bereavement care plan is developed for identified family members and other involved individuals after the patient’s death.*The Bereavement Coordinator is notified of all deaths and initiates the bereavement discussion and care planning at the first Interdisciplinary Group (IDG) meeting following the patient’s death. At this time, the bereavement plan of care is developed and information from the initial bereavement assessment is considered.*The bereavement plan of care reflects the assessed needs of the bereaved and notes the kind of bereavement services to be offered and the frequency of delivery.*The Bereavement Coordinator ensures the bereavement plan of care is followed for 13 months following the patient’s death, appropriate to the level of need assessed.1. Patient #16 was admitted to the agency in October 2024 with a diagnosis of systolic Congestive Heart Failure (the heart muscle weakens and cannot pump enough blood to meet the body’s needs) and expired in February 2025 while on hospice services.Review of the clinical record indicated the Bereavement Care Plan was resolved on 2/05/2025.During an interview on 8/6/25 at 4:00 P.M., the Director of Psychosocial Services said the Bereavement Coordinator, prior to leaving employment at the agency, resolved the Bereavement Care Plan. She further said the agency should have corrected the care plan to keep it current, but it did not.”

“Based on record review and interview, the agency staff failed to develop and implement an individualized care plan to address any grief/loss issues of the patient’s family for 1 patient (#15) out of a total sample of 19 patient records reviewed. Findings include:Review of the Agency Policy, titled Bereavement Services, revised 9/2024 indicated the following but not limited to:*The hospice provides bereavement services to the family, caregivers and/or significant others of deceased hospice patients for thirteen months following the patient’s death. Bereavement counseling also extends to residents of skilled nursing facilities or other formal care settings when appropriate and identified in the bereavement plan of care.*The bereavement services provided area based on the assessed needs of the deceased’s survivors and are in accordance with a bereavement plan of care formulated after the patient’s death.Patient #15 was admitted to Hospice services in February 2025 and expired in March 2025.Review of the clinical record did not indicate a Bereavement care plan had been developed and implemented.During an interview on 8/6/25 at 4:45 P.M., the Director of Psychosocial Services said there was no documentation found in the clinical record to indicate a Bereavement care plan had been developed and implemented as required.”

“Based on record review and staff interview, the agency failed to ensure clinical documentation was complete, and appropriately authenticated and dated in accordance with currently accepted standards of practice for patients (#3, #13, #1, #5, #12, #7 and #8), out of a total sample of 19 patients.Findings include: 5. Patient #1 was admitted to the agency in February 2025 and had a diagnosis of cerebrovascular disease (group of conditions that affect the brain’s blood vessels and blood flow).Review of the physician ordered plan of care for certification period 5/7/25 though 8/4/25 indicated the following:SNV; twice weekly for 12 weeks and 7 PRN, start the week of 5/7/25 and ending on 8/2/25Health Aide (HA) visit; three times a week for 13 weeks and 13 PRN, start the week of 5/7/25 and ending on 8/4/25Review of the clinical record indicated the following:*6/13/25 SNV note was signed on 6/16/25*6/27/25 HA note was signed 6/30/25During an interview on 8/6/25 at 3:24 P.M., the ED and Director of Psychosocial Services said the visit notes should have been electronically signed within 48 hours but weren’t.6. Patient #5 was admitted to the agency in June 2025 and had a diagnosis of Alzheimer’s Disease.Review of the physician ordered plan of care for certification period 6/18/25 through 9/15/25 indicated the following:SNV; to assess and evaluate 6/18/25 through 6/20/25; SNV once weekly for 12 weeks and 6 PRN, start the week of 6/22/25 and ending on 9/13/25Review of the clinical record indicated the following:*6/26/25 SNV note was signed on 7/1/25*7/3/25 SNV note was signed on 7/9/25*7/18/25 SNV note was signed on 7/22/257. Patient #12 was admitted to the agency in January 2025 and had a diagnosis of amyotrophic lateral sclerosis (ALS-nervous system disease that weakens muscles and impacts physical function).Review of the physician ordered plan of care for certification period 4/28/25 through 7/26/25 indicated the following:SNV; once weekly for 13 weeks and 7 PRN, start the week of 4/28/25 and ending on 7/26/25Review of the clinical record indicated the following:*6/9/25 SNV note was signed 6/13/25*6/17/25 SNV note was signed 7/1/25*7/1/25 SNV note was signed 7/6/25*7/8/25 SNV note was signed 7/13/25*7/15/25 SNV note was signed 7/24/25During an interview on 8/6/25 at 3:59 P.M., the Director of Psychosocial Services said Patient #5 and #12’s visit notes should have been electronically signed within 48 hours but weren’t. 3. Patient #7 was admitted to the agency in June 2025 with a diagnosis of Diffuse Large B Cell Lymphoma (a type of blood cancer).Review of the physician ordered plan of care for certification period 6/5/25-9/2/25 indicated the following:Skilled Nursing Visit (SNV) twice weekly for 4 weeks and 6 as needed (PRN) start week of 6/8/25 and ending 7/15/25.Review of the clinical record indicated the following:*6/9/25 SNV note was signed on 6/12/25*6/11/25 SNV note was signed 6/16/25*7/9/25 SNV note was signed 7/13/254. Patient #8 was admitted to the agency in May 2025 with a diagnosis of Progressive Supranuclear Palsy. Review of the physician ordered plan of care for certification period 5/16/25-8/13/25 indicated the following:Skilled Nursing Visit (SNV) twice weekly for 12 weeks and 5 as needed (PRN) start week of 5/19/25 and ending 8/13/25.Review of the clinical record indicated the following:*6/13/25 SNV note was signed 6/16/25*7/11/25 SNV note was signed 7/14/25*7/23/25 SNV note was signed 7/26/25During an interview on 8/6/25 at 4:00 P.M., Executive Director (ED) said that all notes should be completed and signed within 48 hours. She said after review of these clinical records the nurse did not sign the notes within the 48 hours making the notes late. Review of the agency policy entitled, Clinical Record and Documentation, revised April 2025, indicated the following:*To ensure continuum of care across all disciplines, clinical documentation must be complete, timely, and accurately reflect the patient’s status and plan of care. The clinical record must contain correct clinical information that is available to the patient’s attending physician and hospice staff. Whether hard copy or in electronic form, the clinical record is completed promptly and is readily accessible, and systematically organized to facilitate retrieval and made readily available on request by an appropriate authority.*Without exception, all visit notes must be completed and locked within 48 hours.Findings include:1. Patient #3 was admitted to the agency in January 2025 with a diagnosis of ischemic cardiomyopathy (narrowing of the coronary arteries which supply blood to the heart).Review of the physician ordered plan of care for certification period 1/6/25 through 4/5/25 indicated the following:Skilled Nurse Visit (SNV) once weekly for 9 weeks and 6 as needed (PRN) start the week of 2/2/25 and ending on 4/5/25.Medical Social Worker Visit (MSWV) once monthly for one month, 3 times monthly for 2 months and 2 PRN start 1/22/25 and end 3/31/25.Review of the clinical record indicated the following:*2/19/25 SNV note was signed on 2/25/25. *2/28/25 MSWV note was signed on 3/3/25.Review of the physician ordered plan of care for certification period 3/15/25 through 5/13/25 indicated the following:SNV twice weekly and 6 PRN visits.Review of the clinical record indicated the following:*3/19/25 SNV note was signed on 3/24/25.Review of the physician ordered plan of care for certification period 4/6/25 through 7/4/25 indicated the following:SNV twice weekly and 7 PRN visits.Review of the clinical record indicated the following:*6/20/25 SNV note was signed on 6/26/25.2. Patient #13 was admitted to the agency in July 2023 with a diagnosis of Huntington’s Disease (an inherited condition in which nerve cells in the brain break over time resulting in progressive movement, thinking and psychiatric symptoms).Review of the physician ordered plan of care for certification period 5/14/25 through 7/12/25 indicated the following:SNV twice weekly and 7 PRN visits.Review of the clinical record indicated the following:*7/1/25 SNV note was signed on 7/6/25.*7/3/25 SNV note was signed on 7/8/25. *7/11/25 SNV note was signed on 7/14/25.During an interview on 8/6/25 at 5:00 P.M., the Quality Assurance Nurse after reviewing the clinical records for Patients #3 and #13 said the staff is expected to sign their notes within 48 hours. She said the MSWV and SNV notes were dated and signed more than 48 hours after the visits, making them late.”