Devotion Hospice, LLC

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed, it was revealed that the agency did not ensure an initial bereavement assessment was completed. Clinical Record 1: The patient elected hospice care on 05/30/2024. There was no documented evidence that an initial bereavement assessment was completed. During a joint review of the record and interview on 06/17/2024, the Director of Clinical Services agreed there was no documented evidence of a bereavement assessment.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, interview and observation. In 3 of 7 (43%) clinical records reviewed, it was revealed that the agency did not ensure that the plan of care included interventions and goals based on problems identified in the assessments. Clinical Record 1: The patient elected hospice care on 05/30/2024. The Registered Nurse assessment completed on 05/30/2024 documented that the patient had an 18 Fr Coude catheter. The plan of care for the period 05/30/2024-06/19/2024 was reviewed and did not include interventions and goals for the catheter. Clinical Record 3: The patient elected hospice care on 04/29/2024. The Registered Nurse assessment completed on 04/29/2024 revealed pain in the right shoulder as an active problem. Fentanyl 12.5 mcg every 72 hours was ordered. The plan of care for the period 04/29/2024-06/19/2024.was reviewed and did not include goals for the shoulder pain. Clinical Record 4: The patient elected hospice care on 4/25/2024. The Chaplain documentation on 05/09/2024 stated, “Continue to offer spiritual care to the patient and family.” The Chaplain documentation on 06/05/2024 stated in part, “Spiritual care through prayer and positive interaction.” During the home visit (Home Visit 2), with the Chaplain on 06/18/2024, the Chaplain was observed singing, praying, and providing communion. The Chaplain was interviewed and stated she sees the patient 1-2 x monthly to provide companionship and communion. The plan of care for the period 04/25/2024-06/19/2024 was reviewed and did not include interventions and goals for spiritual services. During a joint review of the record and interview on 06/19/2024, the Director of Clinical Services agreed that the plans of care did not include interventions and goals based on the problems identified in the assessments.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) bereavement records reviewed, it was revealed that the agency did not ensure that bereavement services were provided according to the bereavement plan of care and agency policy. Document 1: Agency policy, Bereavement Services, No. 9-023, stated in part, “After a death has occurred, the bereavement assessment will be updated. Within two (2) weeks after the death of the patient, a sympathy card will be sent to the bereaved. After three (3) weeks, a bereavement letter will be sent to the bereaved giving support and outlining the hospice bereavement services. After three (3) to five (5) weeks after the patient’s death, a bereavement assessment will be completed by the bereavement counselor. A bereavement file will be maintained on each family/caregiver. Each file will contain the following: all bereavement assessments made, a bereavement plan of care, all bereavement clinical notes that have been written and/or letters sent to the bereaved.” Clinical Record 6: The patient elected hospice care on 04/03/2024 and died on 05/03/2024. There was no documented evidence of a post-death bereavement assessment or bereavement plan of care. There was no documented evidence a sympathy card or 3-week letter outlining bereavement services was sent. Clinical Record 7: The patient elected hospice care on 05/15/2024 and died on 05/21/2024. The bereavement plan of care revealed telephone calls for support. There was no documented evidence of a post-death bereavement assessment. There was no documented evidence a sympathy card or 3-week letter outlining bereavement services was sent. There was no documented evidence that bereavement services were provided according to agency policy. During a joint review of the record and interview on 06/19/2024, the Director of Clinical Services agreed there was no documented evidence that bereavement services were provided according to agency policy. Additionally, during an interview on 06/19/2024, the Director of Clinical Services stated, “She’s a good chaplain but she isn’t good with the charting and administrative tasks.” During a joint review of the policy and interview on 06/19/2024, the Chaplain stated, “That’s a good policy. I don’t have the sympathy card or 3-week letter made up yet. I will catch up and send the letters.” Additionally, during an interview on 06/19/2024, the Chaplain agreed there was no documented evidence bereavement services were provided according to agency policy.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by interview and personnel record review. In 1 of 13 (8%) personnel records reviewed, revealed the agency did not ensure a skills assessment or competency was completed. Personnel Record 6: Nurse Practitioner, hire date 04/01/2024. There was no documented evidence of a skills assessment or competency. During a joint review of the record and interview on 06/19/2024, the Director of Clinical Services stated, “I am not sure how we missed it. I don’t see that one was completed.” Additionally, during an interview on 06/19/2024, the Director of Clinical Services confirmed that the Nurse Practitioner had been completing the face-to-face assessments.”