Up Health System Home Care & Hospice

“Based upon record review and interview, the Hospice agency failed to document any participation and testing for its community-based exercise which is required every two years, potentially affecting staff and all 41 patients currently receiving services, resulting in an increased potential for harm in the event of an emergency. Findings include: On 1/30/24, review of the agency’s EP (Emergency Preparedness) binder found no evidence of staff sign in sheets, staff participation, or documentation of an AAR (After Action Report) concerning the required community-based drill(s) within the last two years. During an interview with the agency’s Executive Administrator (Staff A) on 1/30/24 at 2:20 PM., the above findings were reviewed and acknowledged. Staff A upon request, stated the last community drill participation occurred pm 11/21/2019. In addition, the agency is in “Region 8 Healthcare Coalition” which conducts quarterly drills on an annual basis to help facilitate agency compliance. The agency failed to adhere to its policy referenced below. Facility Policy: “Emergency Preparedness/Operational Plan” Policy No. 7.001 (Revised 06/01/2021) stated, “The agency shall test their emergency operations plan annually. The agency must do one of the following: a. Participate in a full-scale exercise that is community based, whenever accessible, or an individual facility-based if not accessible.””

“Based on record review and interview, it was determined that the Hospice failed to ensure the Initial Bereavement Assessment included the identification of the potential bereaved individuals, and the social, spiritual and cultural factors that may impact their ability to cope with the patient’s death in 2 (Patient #’s P-1, P-18) of 19 records reviewed that required a bereavement assessment, from a total sample of 19 records. Findings include: P-1: The patient’s hospice start of care (SOC) was 3/31/2023, with a terminal diagnosis of heart failure, chronic kidney disease, and anemia. During record review on 1/30/24, it was noted the Bereavement Risk Assessment (BRA) performed by MSW (Master of Social Work) services on 4/5/23 included the patient’s spouse as the only individual needing bereavement assessment. However, during an interview on 1/30/24 at 5:52 PM., P-1 along with his wife, were asked the following question: “;Who would be significantly affected by your passing, at a level that (wife) would experience?” Without hesitation, P-1 stated quite a few but particularly his grand-daughter and his son. Additional review of the Social Works clinical note dated 4/5/23 documented the following: “;(P-1) has three children; all of whom are very supportive. He has three grand-children and is expecting his first great-great grandchild this spring.” Another clinical note by MSW services on 4/30/23 documented, “;Patient has many family members and extended family members that come to visit. The family members have rented an air B&B to stay at when they come up to see him.” These findings were reviewed with and acknowledged by the Executive Administrator (Staff A) during an interview on 2/1/24 at 1010 AM. Staff A was noted more individuals should have been included in the BRA, and that this did not meet agency expectations, or its policy referenced below. Agency Policy: “Bereavement Assessment” Policy No. 2.004 (Revised 03/01/2021) stated, “To ensure appropriate and coordinated bereavement services are provided to families and caregivers of hospice patients. The Bereavement Coordinator will review the Bereavement Risk Assessment to determine potential needs of the survivors.” P-18: This patient’s start of care (SOC) with this agency was 9/7/23 with the terminal diagnoses of liver failure and pulmonary fibrosis. During record review on 1/30/24, it was noted the bereavement risk assessment included the patient’s spouse as the only individual needing a bereavement assessment. During further record review, it was noted that the social work evaluation dated 9/11/23 identified the patient’s daughter as the DPOA (durable power of attorney). During an interview with the bereavement coordinator (Staff B) on 1/31/24 at 1220, Staff B was asked how he determines who should be included in the initial bereavement risk assessment. Staff B reported a list of criteria he uses to identify individuals, but reported the patient’s DPOA should be included as they are often very close to the patient. There was no documentation of the patient’s daughter being assessed for bereavement needs or why she was not evaluated. Findings were reviewed with and acknowledged by the Executive Administrator (Staff A) during an interview on 2/1/24 at 0910. Staff A reported he was aware of issues with the bereavement program, and it is something they are focusing on improving. P-1: The patient’s hospice start of care (SOC) was 3/31/2023, with a terminal diagnosis of heart failure, chronic kidney disease, and anemia. During record review on 1/30/24, it was noted the Bereavement Risk Assessment (BRA) performed by MSW (Master of Social Work) services on 4/5/23 included the patient’s spouse as the only individual needing bereavement assessment. However, during an interview on 1/30/24 at 5:52 PM., P-1 along with his wife, were asked the following question: “;Who would be significantly affected by your passing, at a level that (wife) would experience?” Without hesitation, P-1 stated quite a few but particularly his grand-daughter and his son. Additional review of the Social Works clinical note dated 4/5/23 documented the following: “;(P-1) has three children; all of whom are very supportive. He has three grand-children and is expecting his first great-great grandchild this spring.” Another clinical note by MSW services on 4/30/23 documented, “;Patient has many family members and extended family members that come to visit. The family members have rented an air B&B to stay at when they come up to see him.” These findings were reviewed with and acknowledged by the Executive Administrator (Staff A) during an interview on 2/1/24 at 1010 AM. Staff A was noted more individuals should have been included in the BRA, and that this did not meet agency expectations, or its policy referenced below. Agency Policy: “Bereavement Assessment” Policy No. 2.004 (Revised 03/01/2021) stated, “To ensure appropriate and coordinated bereavement services are provided to families and caregivers of hospice patients. The Bereavement Coordinator will review the Bereavement Risk Assessment to determine potential needs of the survivors.” P-18: This patient’s start of care (SOC) with this agency was 9/7/23 with the terminal diagnoses of liver failure and pulmonary fibrosis. During record review on 1/30/24, it was noted the bereavement risk assessment included the patient’s spouse as the only individual needing a bereavement assessment. During further record review, it was noted that the social work evaluation dated 9/11/23 identified the patient’s daughter as the DPOA (durable power of attorney). During an interview with the bereavement coordinator (Staff B) on 1/31/24 at 1220, Staff B was asked how he determines who should be included in the initial bereavement risk assessment. Staff B reported a list of criteria he uses to identify individuals, but reported the patient’s DPOA should be included as they are often very close to the patient. There was no documentation of the patient’s daughter being assessed for bereavement needs or why she was not evaluated. Findings were reviewed with and acknowledged by the Executive Administrator (Staff A) during an interview on 2/1/24 at 0910. Staff A reported he was aware of issues with the bereavement program, and it is something they are focusing on improving.”

“Based on record review and interview, the agency failed to ensure bereavement services were provided and carried out according to the bereavement plan of care in 2 (P-17 and P-19) of 3 bereavement records reviewed, resulting in the potential for ineffective grieving and unmet bereavement needs. Findings include: **Policy titled “Bereavement Counseling” (revised 2/1/22) stated, “A bereavement record will be maintained on each family member/caregiver receiving bereavement services and will include the initial and subsequent bereavement risk assessment, bereavement plan of care, documentation of visits, calls, referrals and mailings made as part of the bereavement plan of care.” P-17: This patient’s hospice start of care (SOC) with this agency was 4/12/23 with the terminal diagnoses of malignant neoplasm of the left kidney and bilateral lungs and heart failure. His date of death was 5/8/23. During record review on 1/31/24, it was noted a plan of care was developed that included: Send initial sympathy card/letter; review bereavement risk assessment in IDG (Interdisciplinary Group); make visit within 7 days following death; provide information/referral to community resources, mail changing seasons newsletters, sent cards; letters and brochures PRN; invited to an annual memorial event; make visit 30 days following death; make visit 90 days following death; and make visit 180 days following death. According to the Bereavement Activity Planning Report, an initial bereavement phone call was made to the patient’s daughter on 5/15/23, however, there were no other activities recorded. There was also no mention of why further activities were not carried out as planned. The bereavement coordinator (Staff B) was interviewed on 1/31/24 at 1220. During the interview, Staff B was queried regarding how plan of care activities are tracked to ensure they are being done. Staff B stated each contact or activity should be documented in the bereavement activity section after they are completed. He admitted the chaplains sometimes forget to do this and should do a better job. P-19: This patient’s hospice SOC with this agency was 5/13/23 with the terminal diagnosis of left-sided small cell lung cancer with metastasis to the mediastinum. Her date of death was 6/19/23. During record review on 1/31/24, it was noted that a plan of care was developed for her husband, daughter and 2 sons that included: Send initial sympathy card/letter; review bereavement risk assessment in IDG (Interdisciplinary Group); make visit within 7 days following death; provide information/referral to community resources, mail changing seasons newsletters, sent cards; letters and brochures PRN; invited to an annual memorial event; make visit 30 days following death; make visit 90 days following death; and make visit 180 days following death. However, there was no documentation of any of the items being carried out as planned after the date of death. Staff B was asked during an interview on 1/31/24 at 1220 if there was any other way to determine if the activities had been completed. Staff B reported if they aren’t documented in the bereavement activity section, there is no evidence it was done. He was unsure why there hadn’t been anything documented on this patient. Findings were reviewed with and acknowledged by the Executive Administrator (Staff A) during an interview on 2/1/24 at 0910. Staff A reported he is aware of the issues with the bereavement plans, and it is something the agency is working on.”

“Based on record review and interview, it was determined the Hospice agency failed to ensure the clinical records for 2 (P-1 and P-4) of 16 sampled patients, out of a total sample of 19 records reviewed, had accurately portrayed the clinical status of the patients, resulting in misleading and in-accurate medical records. Findings include: P-1: The patient’s hospice start of care (SOC) was 3/31/2023, with a terminal diagnosis of heart failure, chronic kidney disease, and anemia. During record review on 1/30/24, a clinical note by skilled nursing (SN) documented the following: “;The acuity of the patient or the trajectory of illness continue to support the terminal diagnosis and the need hospice services because patient has had a decrease in appetite, decrease in food consumption, decrease in weight to 122 lbs., decrease in functional status, increase in dizziness, increase in sleep, increase in dyspnea (shortness of breath) and pain, increase in weakness, increase in difficulty in swallowing, increase in constipation, decrease in MUAC (mid-upper-arm-circumference) to LMUAC 22 cm. and RMUAC 21 cm.” However, on 1/29/24 during a home visit with Social Work services, it was observed and discussed during an interview at 3:50 PM., how well P-1 had progressed over the last nine months. P-1 and his wife stated he is now independent with all ADLs (activities of daily living), walking for exercise on the downstairs treadmill, and looking forward to going out in the spring to do some gardening. At the end of the visit, it was observed P-1 easily walked over to thank Social Work for the visit and firmly shake the surveyors (writer) hand with no signs or symptoms noted in SNs clinical note on 1/17/24. Further record review was performed on 1/30/24 to ascertain if any clinical data in the medical record would support the 1/17/24 clinical entry. A SN clinical note on 1/22/24 documented, “;Patients appetite has been fair, patient reports he now weighs 123 pounds. Patient reports no issues with bowel, bowel sounds active x 4. Last BM yesterday.” P-1 weights were documented as follow: 4/24/23-104 lbs., 6/5/23-97 lbs., 9/11/23-111 lbs., with no other weights obtained. Both SN and P-1 use the same digital scale in the home for weights. P-1 provided the following recorded weights which are as follow: 5/13/23-99.4 lbs., 6/22/23-103.8 lbs., 7/16/23 109.4 lbs., and 8/12/23-113.5. When asked during an interview on 1/29/24 at 5:52 PM., why there havent been any further recordings since last August, P-1s wife stated that he (P-1) was doing so well, there hasnt been a need to record. P-1 then stated his weight from last week was 128.4 lbs. with some light clothes on. These findings were reviewed with and acknowledged by the Executive Administrator (Staff A) during an interview on 2/1/24 at 1005 AM. Staff A also confirmed there was no information in the medical record to substantiate the clinical status of P-1 portrayed in the clinical note by SN on 1/17/24. P-4: The patient’s hospice start of care (SOC) was 8/8/2018, with a terminal diagnosis of dementia-Alzheimers, hematuria (blood in urine), and hypertension. During record review on 1/31/24, it was noted P-4 has been recertified 33 times since admission. Further review of the six most recent physician face to face home visits revealed the following documentation: Visit Date: 2/28/23, “;Her current weight is up to 122 pounds on February 1.” Visit Date: 5/3/23, “;(P-4s) weight is noted at 117.2 pounds in April. This is down from 122 last face to face visit.” Visit Date: 6/27/23, “;Last weight at facility was 120.2 pounds, up from 117.2 pounds last face to face visit.” Visit Date: 8/31/23, “;Her (P-4) last weight was 117.6 pounds, down from 120.2 last face to face visit.” Visit Date: 10/23/23, “;She has had significant weight loss of 15 pounds or so over the last few months.” Visit Date: 12/11/23, No weight was assessed. These findings were reviewed with and acknowledged by the Executive Administrator (Staff A) during an interview on 2/1/24 at 1015 AM. Staff A also confirmed there was no information in the medical record to substantiate the 15-pound weight loss documented in the face-to-face examination by the physician (Staff C) on 10/23/23. Further clinical record review failed to find acknowledgement by the agency which detailed why P-4 was habitually recertified 33 times and counting while portraying a consistent decline in clinical status with an expected death with six months since 2018.”