Grace Hospice

“Based on staff interview, medical record reviews and policy/procedure review the facility failed to ensure the initial comprehensive assessment addressed the emotional and spiritual needs of the patient/family that contributed to the development of the plan of care for four (4) of (11) medical records reviewed; Patient #5, #6, #7, and #11. Findings Include: During an interview with the Director of Nursing on 09/11/2024 at 3:45 p.m., it was confirmed that the facility failed to ensure the initial comprehensive Spiritual assessment was completed for Patients #5, #6, #7, and #11. Review of the medical records for Patients #5, #6, #7, and #11 reveals no documented evidence of the patients/familys emotional and spiritual needs were addressed that contributed to the development of the plan of care. Review of the facility policy and procedure titled, “;Patient Assessment”, effective date 09/01/2014, reveals, “;...Policy...Spiritual Counselor: Will be available for spiritual counseling services to the patient and the family/PCGs. Will assess with spiritual needs during each visit, as well as the response to the services being provided...The Chaplain will perform ongoing assessments of the patients/family/caregivers spiritual needs, and provide care based on these assessments. The chaplain will address all unresolved spiritual problems identified on previous visits...Spiritual Counselor: The Spiritual assessment will include but is not limited to the following: If the current Spiritual Support is adequate; Where the Spiritual Support is being provided from; What follow up is required, based on the assessment; When follow up visits are required/requested; If appropriate, what the patient/family/caregivers feelings are about dying...”. During Exit conference on 09/11/2024 at 4:00 p.m. with Administrator and Director of Nursing, survey findings were discussed, and no further documentation was submitted for review.”

“Based on staff interviews, medical record reviews and policy/procedure review the facility failed to ensure the comprehensive assessment was updated by the hospice interdisciplinary team (IDT) and failed to document changes, or progress toward desired outcomes, or reassessment of the patients response to care for nine (9) of 11 medical records reviewed; Patients #2, #3, #5, #6, #7, #8, #9, #10 and #11. Findings include: During an interview with the facility Administrator on 09/11/2024 at 1:10 p.m., it was confirmed the Hospice Medical Director (MD), Registered Nurse (RN), Social Worker (SW) and Chaplain failed to document an updated summary on Patient #5s Plan of Care (POC) for the IDG meetings dated 07/30/2024, 08/08/2024, 08/22/2024 and 09/05/2024. During an interview with the facility Administrator on 09/11/2024 at 1:25 p.m., it was confirmed the Hospice MD, RN, SW and Chaplain failed to document an updated summary on Patient #6s Plan of Care (POC) for the IDG meetings dated 08/08/2024, 08/22/2024 and 09/05/2024. During an interview with the facility Administrator on 09/11/2024 at 1:35 p.m., it was confirmed the Hospice MD, RN, SW and Chaplain failed to document an updated summary on Patient #7s Plan of Care (POC) for the IDG meetings dated 08/08/2024, 08/22/2024 and 09/05/2024. During an interview with the facility Administrator on 09/11/2024 at 1:50 p.m., it was confirmed the Hospice MD, RN, SW and Chaplain failed to document an updated summary on Patient #8s Plan of Care (POC) for the IDG meetings dated 08/08/2024, 08/22/2024 and 09/05/2024. During an interview with the facility Administrator on 09/11/2024 at 2:00 p.m., it was confirmed the Hospice MD, RN, SW and Chaplain failed to document an updated summary on Patient #9s Plan of Care (POC) for the IDG meetings dated 08/08/2024, 08/22/2024 and 09/05/2024. During an interview with the facility Administrator on 09/11/2024 at 2:15 p.m., it was confirmed the Hospice MD, RN, SW and Chaplain failed to document an updated summary on Patient #10s Plan of Care (POC) for the IDG meetings dated 07/30/2024, 08/08/2024, 08/22/2024 and 09/05/2024. During an interview with the facility Administrator on 09/11/2024 at 2:35 p.m., it was confirmed the Hospice MD, RN, SW and Chaplain failed to document an updated summary on Patient #11s Plan of Care (POC) for the IDG meetings dated 01/02/2024, 01/16/2024, 01/30/2024, 02/13/2024 and 02/27/2024. During an interview with Licensed Practical Nurse (LPN) #1 on 09/11/2024 at 3:50 p.m. it was confirmed the Hospice MD, RN, and SW failed to document an updated summary on Patient #2s Plan of Care (POC) for the IDG meeting dated 09/05/2024 and the LPN #1 further confirmed the Hospice MD, RN, and SW failed to document an updated summary on Patient #3s Plan of Care (POC) for the IDG meetings dated 07/16/2024, 07/30/2024, 08/08/2024, 08/22/2024 and 09/05/2024. Review of Patient #2s medical record confirmed the POC for the IDT meetings dated 09/05/2024 have no documented evidence of progress toward desired outcomes or the patients response to care by the MD, RN, or SW. Review of Patient #3s medical record confirmed the POC for the IDT meetings dated 07/16/2024, 07/30/2024, 08/08/2024, 08/22/2024 and 09/05/2024 have no documented evidence of progress toward desired outcomes or the patients response to care by the MD, RN, or SW. Review of Patient #5s medical record confirmed the POC for the IDG meetings dated 07/30/2024, 08/08/2024, 08/22/2024 and 09/05/2024 have no documented evidence of progress toward desired outcomes or the patients response to care by the MD, RN, SW or Chaplain. Review of Patient #6 and #7s medical records confirmed the POC for the IDG meetings dated 08/08/2024, 08/22/2024 and 09/05/2024 have no documented evidence of progress toward desired outcomes or the patients response to care by the MD, RN, SW or Chaplain. Review of Patient #8 and #9s medical records confirmed the POC for the IDG meetings dated 08/08/2024, 08/22/2024 and 09/05/2024 have no documented evidence of progress toward desired outcomes or the patients response to care by the MD, RN, or SW. Review of Patient #10s medical record confirmed the POC for the IDG meetings dated 07/30/2024, 08/08/2024, 08/22/2024 and 09/05/2024 have no documented evidence of progress toward desired outcomes or the patients response to care by the MD, RN, SW or Chaplain. Review of Patient #11s medical record confirmed the POC for the IDG meetings dated 01/02/2024, 01/16/2024, 01/30/2024, 02/13/2024 and 02/27/2024 have no documented evidence of progress toward desired outcomes or the patients response to care by the MD, RN, SW or Chaplain. Review of the facility policy and procedures titled, “;Interdisciplinary Team (IDT) Responsibilities and Role” Effective Date 09/01/2014, revealed “;...Policy: To maintain and manage a team of professionals, which at a minimum will consist of: Physician, RN, Social Worker, and Pastoral care...Procedure...The role of the IDT includes but is not limited to the following: Periodic review and update of the Plan of Care for each patient...IDT members will review all patients at least every two (2) weeks...”. Review of the facility policy and procedures titled, “;Interdisciplinary Group” Effective Date 09/01/2014, revealed “;...Procedure...The Interdisciplinary Group is responsible for the following...Periodic review and updating of the plan of care for each individual receiving hospice care...”. Review of the facility policy and procedures titled, “;Plan of Care” Effective Date: 09/01/2014, revealed “;...The care plan will be reviewed and updated at a minimum every two weeks...Care plans will be updated as needed, and at a minimum every 14 days...”. During the exit conference on 09/11/2024 at 4:00 p.m. with facility Administrator and Director of Nursing, survey findings were discussed, and no further documentation was submitted for review.”