Albemarle Home Care and Hospice

“Based on agency policy review, clinical record review, and staff interviews the Interdisciplinary Group [IDG] failed to project visit frequencies for the next 15 days for 15 of 19 charts reviewed [ #11, 12, 1, 4, 14, 2, 3, 5, 6, 7, 8, 9, 13, 17 and 18]. The findings included: The policy, Interdisciplinary Group HC.6.1 [07/2024], was provided by the agency administrator on 3/10/25 at 12:01 pm. The policy stated, “;The _______ [agency name] Hospice Interdisciplinary Group [IDG] meets at least every fifteen [15] days to discuss patient and family changes...The Interdisciplinary group responsibilities may include, but not limited to:...Reviewing and revising the plan of care...” 5. Patient # 14 had a Start of Care date of 10/26/24 with a terminal diagnosis of end stage renal [kidney] disease. Review of the Plan of Care for the certification period 1/24/25-4/23/25 included orders for SN [skilled nursing] 2 times a week for 12 weeks, 1 time a week for 1 week, HHA [hospice aide] 2 times a week for 12 weeks, 1 time a week for 1 weeks; MSW [medical social work] 1 time a month for 3 months; Chaplin 1 time a month for 3 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes dated 2/5/25, 2/18/25, and 3/5/25 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 6. Patient # 2 had a Start of Care date of 1/11/25 with a terminal diagnosis of cerebral vascular disease. Review of the Plan of Care for the certification period 1/11/25-4/10/25 revealed orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 12 weeks, 2 times a week for 1 week; MSW [medical social work] 1 time a month for 3 months; Chaplin 1 time a month for 3 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes for 1/15/25,1/29/25, 2/12/25, and 2/26/25 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 7. Patient # 3 had a Start of Care date of 1/25/25 with a terminal diagnosis of Alzheimers Disease. Review of the Plan of Care for the certification period 1/25/25-3/25/25 included orders for SN [skilled nursing] 1 time a week for 1 week 3 times a week for 1 week, 2 times a week for 7 weeks, 1 time a week for 1 week; HHA [hospice aide] 3 times a week for 8 weeks, 1 time a week for 1 week; Chaplin 1 time a month for 3 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes for 1/29/25, 2/5/25, 2/18/25, and 3/5/25 revealed no visit frequency projections for the next 15 days for the Chaplin. 8. Patient # 5 had a Start of Care date of 2/8/25 with a terminal diagnosis of Parkinsons Disease [a disorder of the central nervous system that affects movement]. Review of the Plan of Care for the certification period 2/8/25-5/8/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week, 2 times a week for 12 weeks; HHA [hospice aide] 2 times a week for 13 weeks; MSW [medical social work] 1 time a month for 4 months; Chaplin 1 time a month for 4 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes for 2/12/25 and 2/26/25 revealed no visit frequency projections for the next 15 days for the Chaplin. 9. Patient # 6 had a Start of Care date of 2/8/25 with a terminal diagnosis of COPD [chronic obstructive pulmonary disease-affects breathing]. Review of the Plan of Care for the certification period 2/8/25-4/8/25 included orders for SN [skilled nurse] 1 time a week for 1 week, 3 times a week for 1 week, 2 times a week for 12 weeks; MSW [medical social work] 1 time a month for 3 months; Chaplin 1 time a month for 3 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes for 2/12/25, 2/18/25, and 3/5/25 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 10. Patient # 7 had a Start of Care date of 2/2/25 with a terminal diagnosis of cerebral vascular disease. Review of the Plan of Care for the certification period 2/2/25-4/2/25 included orders for SN [skilled nursing] 3 times a week for 8 weeks, 1 time a week for 1 week; HHA [hospice aide] 2 times a week for 7 weeks, 1 time a week for 1 week; MSW [medical social work] 1 time a month for 2 months; Chaplin 1 time a month for 2 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes dated 2/5/25, 2/18/25 and 3/5/25 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 11. Patient # 8 had a Start of Care date of 2/4/25 with a terminal diagnosis of heart disease. Review of the Plan of Care for the certification period 2/4/25-4/4/25 included orders for SN [skilled nursing] 3 times a week for 9 weeks; HHA [hospice aide] 1 time a week for 1 week, 3 times a week for 8 weeks; MSW [medical social work] 1 time a month for 2 months; Chaplin 1 time a month for 2 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes dated 2/12/25, 2/18/25 and 3/5/25 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 12. Patient # 9 had a Start of Care date of 2/14/24 with a terminal diagnosis of severe protein-calorie malnutrition [a condition resulting from an inadequate intake of protein and or calories]. Review of the Plan of Care for the certification period 2/14/25-5/14/25 included orders for SN [skilled nursing] 2 times a week for 13 weeks, 1 time a week for 14 weeks; HHA [hospice aide] 2 times a week for 12 weeks, 1 time a week for 1 weeks; MSW [medical social work] 1 time a month for 4 months, Chaplin 1 time a month for 4 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes dated 2/18/25 and 2/26/25 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 13. Patient # 13 had a Start of Care date of 1/30/25 with a terminal diagnosis of cerebral vascular disease. Review of the Plan of Care for the certification period 1/30/25-4/29/25 included orders for SN [skilled nursing] 2 times a week for 13 weeks, 1 time a week for 1 week; HHA [hospice aide] 2 times a week for 12 weeks, 1 time a week for 1 week; MSW [medical social work] 1 time a month for 4 months; Chaplin 1 time a month for 4 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes dated 2/5/25, 2/12/25, and 2/26/25 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 14. Patient # 17 had a Start of Care date of 3/27/24 with a terminal diagnosis of acute myeloblastic leukemia [cancer affecting blood]. Review of the Plan of Care for the certification period 3/27/24-6/24/24 included orders for SN [skilled nursing] 2 times a week for 13 weeks; MSW [medical social work] 1 time a month for 4 months; Chaplin 1 time a month for 3 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes dated 4/3/24, 4/10/24, and 4/24/24 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 15. Patient # 18 had a Start of Care date of 9/16/24 with a terminal diagnosis of malignant neoplasm [cancer] of the prostate. Review of the Plan of Care for the certification period 9/16/24-12/14/24 included orders for SN [skilled nursing] 3 times a week for 1 week, 2 times a week for 12 weeks; HHA [hospice aide] 2 times a week for 13 weeks; MSW [medical social worker] 1 time a month for 3 months; Chaplin 1 time a month for 3 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes dated 9/25/24, 10/7/24, and 10/21/24 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. During an interview with the agency administrator on 3/12/25 at approximately 11:30 am, the administator confirmed the visit projections for the next 15 days were not included in the clinical record. 1. Patient #11 had a Start of Care (SOC) date of 4/6/2024 and a terminal diagnosis of Hemiplegia (paralysis or unable to move) and hemiparesis (weakness) following cerebral infarction (stroke) affecting right dominant side. The Plan of Care (POC) for the certification period of 1/25/2025-3/25/2025 included orders for Skilled nursing (SN) 2 times a week for 8 weeks, 1 time a week for 1 week; hospice aide 2 times a week for 8 weeks, 1 time a week for 1 week; Medical Social worker (MSW) 1 time a month for 2 months; Chaplain 1 time a month for 2 months; volunteer services 1 time a week for 8 weeks. Review of the clinical record revealed the Interdisciplinary Group (IDG) meetings were conducted on 2/5/2025, 2/18/2025, and 3/5/2025. Further review of the clinical record revealed no visit projections for the next 15 days by the MSW or the Chaplain during any of the 3 IDG meetings (1/29/25, 2/5/25, 2/18/25, 3/5/25). During an interview with the agency director on 3/12/2025 at approximately 12:15 pm, the director confirmed the POCs for the MSW and the Chaplain were not updated with visit projections for the next 15 days during the 2/5/25, 2/18/25, and 3/5/25 IDG meetings. 2. Patient #12 had a Start of Care (SOC) date of 2/19/2024 and a terminal diagnosis of Alzheimers disease. The Plan of Care (POC) for the certification period of 2/13/2025-4/13/2025 included orders for Skilled nursing (SN) 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks; hospice aide 1 time a week for 1 week, 2 times a week for 8 weeks; Medical Social worker (MSW) 1 time a month for 1 month; Chaplain 1 time a month for 2 months; and volunteer services 1 time a week for 8 weeks. Review of the clinical record revealed an Interdisciplinary Group (IDG) meeting was conducted on 2/26/2025. Further review of the clinical record revealed no visit projections for the next 15 days by the Chaplain or the MSW during the IDG meeting on 2/26/2025. During an interview with the agency director on 3/12/2025 at approximately 12:15 pm, the director confirmed the POCs for MSW and Chaplain were not updated with visit projections for the next 15 days during the 2/26/2025 IDG meeting. 3. Patient 1 had a Start of Care (SOC) date of 1/24/2025 and a terminal diagnosis of malignant neoplasm of right ovary (ovarian cancer). The Plan of Care (POC) for the certification period of 1/24/2025-3/24/2025 included orders for Skilled nursing (SN) 2 times a week for 1 week, 1 time a week for 8 weeks; Medical Social worker (MSW) 1 time a month for 3 months; Chaplain 1 time a month for 3 months. Review of the clinical record revealed the Interdisciplinary Group (IDG) meetings were conducted on 1/29/2025, 2/5/2025, 2/18/2025, and 3/5/2025. Further review of the clinical record revealed no visit projections for the next 15 days by the Chaplain or the MSW during any of the 4 IDG meetings (1/29/25, 2/5/25, 2/18/25, 3/5/25). During an interview with the agency director on 3/12/2025 at approximately 12:15 pm, the director confirmed the POCs for MSW and Chaplain were not updated with visit projections for the next 15 days during the 1/29/25, 2/5/25, 2/18/25, and 3/5/25 IDG meetings. 4. Patient 4 had a Start of Care (SOC) date of 1/24/2025 and a terminal diagnosis of hypertensive heart disease. The Plan of Care (POC) for the certification period of 1/24/2025-4/23/2025 included orders for Skilled nursing (SN) 1 time a week for 1 week, 2 times a month for 3 months and Medical Social worker (MSW) 1 time a month for 4 months. Review of the clinical record revealed the Interdisciplinary Group (IDG) meetings were conducted on 1/29/2025, 2/5/2025, 2/18/2025, and 3/5/2025. Further review of the clinical record revealed no visit projections for the next 15 days by the SN or the MSW during any of the 4 IDG meetings 1/29/25, 2/5/25, 2/18/25, 3/5/25. During an interview with the agency director on 3/12/2025 at approximately 12:15 pm, the director confirmed the POCs for the SN and the MSW were not updated with visit projections for the next 15 days during the 1/29/25, 2/5/25, 2/18/25, and 3/5/25 IDG meetings.”