Brookestone Home Health & Hospice

“Based on record review, policy and procedure review, and staff interview, the hospice failed to ensure staff notified the clinical manager (CM) when services could not be implemented according to the physician-approved plan of care (POC) for 3 of 14 patient records reviewed (Patient 6, 9, and 14). The census was 6. A. Review of hospice policy and procedure titled, Care/Services Coordination, Policy Number 4-099.1, revised 11/2021, revealed the CM is responsible for the cooperative care planning to minimize the potential for missed visits. It also requires personnel to communicate missed visits to the CM, and to document this communication in the patients clinical record. B. Review of hospice policy and procedure titled, Missed Visits, Policy Number 4-101.1, revised 11/2021, revealed if an aide visit is missed, the aide is to contact the CM. The CM is to track missed visits to assess for patterns and ensure the plan of care is followed. C. Review of Patient 6s clinical record revealed: 1. The Plan of Care (POC) effective 8/5/24 through 11/2/24 and the Interdisciplinary Group (IDG) Comprehensive Assessment Details form (an updated POC) for the period of 11/26/24 through 12/10/24 both included orders for Hospice Aide (HA) services 2 times per week. 2. There was no documentation in the clinical record of a second HA visit completed the weeks of 10/6/24 through 10/12/24, 10/27/24 through 11/2/24, and 12/1/24 through 12/7/24. 3. There was no documentation in the clinical record that the HA notified the CM when HA services could not be completed according to the patients physician-approved POC. D. Review of Patient 9s clinical record revealed: 1. The POC effective 11/22/24 through 2/19/25 included orders for HA services 2 times per week. 2. There was no documentation in the clinical record of HA visits completed the weeks of 11/22/24 through 11/23/24,11/24/24 through 11/30/24, and 12/1/24 through 12/2/24. 3. There was no documentation in the clinical record that the HA notified the CM when HA services could not be completed according to the patients physician-approved POC. E. Review of Patient 14s clinical record revealed: 1. The POC effective 8/13/24 through 11/10/24 included orders for HA services 1 times per week. 2. There was no documentation in the clinical record of a HA visit conducted the weeks of 8/13/24 through 8/17/24, 8/18/24 through 8/24/24, and 8/25/24 through 8/29/24. 3. There was no documentation in the clinical record that the HA notified the CM when HA services could not be completed according to the patients physician-approved POC. F. During an interview on 12/19/24 at 3:00 PM, the Hospice Administrator confirmed the hospice failed to ensure staff notified the CM when services could not be implemented according to the physician-approved POC for Patient 6, 9, and 14.”

“Based on record review, policy and procedure review, and staff interview, the hospice failed to ensure 2 of 2 Hospice Aides (HA)-D and HA-P documented missed visits, and/or the communication of these missed visits, in the clinical record as required by hospice policy and procedures for 3 of 6 patients who received HA services (Patient 6, 9, and 14). The total sample size was 14. The census was 6. A. Review of the hospice policy and procedure titled, Missed Visits, Policy Number 4-101.1, revised 11/2021, revealed missed visits will be documented in the clinical record. Documentation will include the date and type of visit missed, the reason for the missed visit, the description of patients unmet needs, and the signature of the staff member reporting the information. B. Review of Patient 6s clinical record revealed: 1.The Plan of Care (POC) effective 8/5/24 through 11/2/24 and the Interdisciplinary Group (IDG) Comprehensive Assessment Details form (an updated POC) for the period of 11/26/24 through 12/10/24 both included orders for Hospice Aide (HA) services 2 times per week. The POC also included that HA-P was assigned to Patient 6. 2. There was no documentation in the clinical record that HA-P conducted a second visit to the patient the weeks of 10/6/24 through 10/12/24, 10/27/24 through 11/2/24, and 12/1/24 through 12/7/24. 3. There was no documentation in the clinical record by HA-P of the date and type of visit missed, the reason for the missed visit, the description of patients unmet needs, and their signature as the staff member reporting the information. C. Review of Patient 9s clinical record revealed: 1. The POC effective 11/22/24 through 2/19/25 included orders for HA services 2 times per week. The POC also included that HA-D was assigned to Patient 9. 2. There was no documentation in the clinical record that HA-D conducted any visits to the patient the weeks of 11/22/24 through 11/23/24, 11/24/24 through 11/30/24, and 12/1/24 through 12/2/24. 3. There was no documentation in the clinical record by HA-D of the date and type of visit missed, the reason for the missed visit, the description of patients unmet needs, and their signature as the staff member reporting the information. D. Review of Patient 14s clinical record revealed: 1. The POC effective 8/13/24 through 11/10/24 included orders for HA services 1 times per week. The POC also included that HA-P was assigned to Patient 14. 2. There was no documentation in the clinical record that HA-P conducted any visits the weeks of 8/13/24 through 8/17/24, 8/18/24 through 8/24/24, and 8/25/24 through 8/29/24. 3. There was no documentation in the clinical record by HA-P of the date and type of visit missed, the reason for the missed visit, the description of patients unmet needs, and their signature as the staff member reporting the information. E. During an interview on 12/19/24 at 3:00 PM, the Hospice Administrator confirmed that HA-D and HA-P failed to document in the patients clinical record according to hospice policy and procedures, the date and type of visit missed, the reason for the missed visit, the description of patients unmet needs, and their signature as the staff member reporting the information.”