NYU Langone Hospital - Suffolk Hospice

“Observed in Document Review. During review of the Admission Packet Patient Handbook and the organization’s Patient Rights and Responsibilities policy it was noted the organization had not ensured patients were informed in writing of their rights and responsibilities before beginning care, treatment, or services. For example: review of the Admission Packet Patient Handbook and Patient Rights and Responsibilities policy revealed no documentation that the patient had a right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness; Choose his or her attending physician; and receive information about the services covered under the hospice benefit. This is reviewed, discussed, and validated with the Administrator.”

“Observed in Record Review. In 1 of 16 patient records reviewed, During RRHV# 2’s patient record review it was noted the organization had not ensured the patient’s plan of care was based on the patient’s goals and services required to meet those goals. For example: review of RRHV# 2’s patient record revealed RRHV# 2 had a diagnosis of Type 2 Diabetes Mellitus and taking an oral hypoglycemic medication. Review of RRHV# 2’s plan of care revealed no goals or interventions related to Type 2 Diabetes Mellitus. This was reviewed, discussed, and validated with the Administrator.”

“Observed in Patient Home. In 1 of 4 home visits conducted, During RRHV# 4’s home observation it was noted the organization had not ensured staff followed the organization’s Wound Care policy that included removing gloves and performing hand hygiene after removing a wound dressing and putting on new gloves to clean the wound. For example: during RRHV# 4’s home observation the registered nurse was observed cleaning the sacral pressure ulcer wound with normal saline and gauze and then with the same gloves applied calcium alginate in the wound bed with an ABD pad. This was observed, discussed, and validated with the Director of Education.”

“Observed in HR File Review. In 1 of 12 HR files reviewed, During HR# 6’s HR file review it was noted the organization had not initially assessed and documented the staff competence. For example: review HR# 6’s HR file revealed HR# 6 was hired approximately four months prior to the surveyor review of the HR file as a Medical Social Worker, Bereavement Coordinator, and Volunteer Coordinator. Review of HR# 6’s HR file revealed an initial competency documented for the Medical Social Worker and no documentation of an initial competence assessment for the Bereavement Coordinator and Volunteer Coordinator. This was reviewed, discussed, and validated with the Administrator. Observed in HR File Review. In 1 of 12 HR files reviewed, During HR# 6’s HR files review it was noted the organization had not defined the competencies it required of its staff who provide patient care, treatment, or services. For example: There was no evidence the organization defined the clinical competencies for the Bereavement Coordinator or Volunteer Coordinator. This was reviewed, discussed, and validated with the Administrator.”

“Observed in Patient Home. In 1 of 4 home visits conducted, On record review, the medication list was discovered to be inaccurate. In 1 of 4 home visits conducted with medication reconciliation during HV#1 home observations it was noted that the organization had not ensured the patient record contained instructions that reflected the patient care, treatment or services. For example, during HV#1 medication list in the patient record contained inaccurate instructions that included Tylenol 650 mgs supp PR q 8 hourly PRN for fever. However HV#1 this medication was not in the home and spouse was unaware of this and it had been prescribed 4 months ago This was reviewed, discussed and validated with the Director of Education who was also present at the visit
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“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023, and interviews with the hospice Administrator/ Director of Patient Services, the Governing body failed to ensure the development, implementation and maintenance of a hospice-wide data driven Quality Assessment program (L561). The Governing body failed to show measurable improvement in indicators relating to improved palliative outcomes (L561). The Governing body failed to ensure that quality indicators, including adverse events defined by the agency, were tracked and analyzed to assess processes of patient care, hospice services and operations (L562). The Governing body failed to ensure the Quality Assessment and Performance Improvement program collected sufficient quality indicator data that included evaluating all aspects of patient service and activities that may impact patient and family care and all facets of the hospice’s operation (L563). The Governing body failed to ensure the data collected was used to monitor the effectiveness and safety of services and patient care, was used to identify and prioritize opportunities for improvement (L564). The Governing body failed to approve the frequency and detail of the data collection ( L 565). The Governing body failed to ensure Quality Assessment and Performance Improvement activities focused on high risk and problem prone areas (L566). The Governing body failed to identify the incidence, prevalence and severity of problems in those areas (L567). The Governing body failed to ensure the program activities palliative outcomes are the result of the palliative care provided. ( L 568). The Governing body failed to develop performance improvement activities that were tracked and analyzed to ensure improvements continued (L569). The Governing body failed to develop performance improvement activities, and take actions at performance improvements, after implementing these action, measure its success to ensure that improvements are sustained ( L 570). The Governing body failed to develop , implement and evaluate performance improvement projects ( L571). The Governing body failed to ensure the performance improvement projects contained documentation based on the needs of the patient population and internal organizational needs (L572). The Governing body failed to ensure performance improvement projects contained documentation of measurable goals ( L 573). The Governing body failed to ensure the hospice -wide Quality Assessment and Performance Improvement efforts addresses priorities for improved quality of care and patient safety and that all improvement actions are evaluated for effectiveness (L574). The Governing body and failed to ensure Quality Assessment and Improvement activities were prioritized to address improved quality care and patient safety, that the appropriate interventions were put in place and those interventions evaluated for their effectiveness (L575). The cumulative effect of these systemic practices resulted in the hospice’s inability to ensure the provision of quality health care and self-identify areas in need of improvement which has the potential for negative outcomes for the entire patient population and organizational operations. The Governing body failed to maintain an effective Quality Assessment and Performance Improvement program that reflects the complexity of its services, focuses on indicators related to improve palliative care, and takes actions to demonstrate in hospice performance.”

“Based on review of the Hospice’s Quality Assessment and Performance Improvement (QAPI) Program, the Hospice’s Infection Control and Surveillance Plan, the Infection Control Plan for FY2024 (Fiscal Year 2024), and interviews with the hospice Administrator, the Governing Authority failed to ensure an effective infection control program that protects patients, families, visitors and hospice personnel by preventing and controlling infections and communicable diseases was documented and maintained (L577). The Governing Authority failed to ensure the maintenance of a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of communicable diseases that is an integral part of the hospice’s quality assessment and improvement program (L580) that included a method of identifying infectious and communicable disease problems and a plan for implementing the appropriate actions that are expected to result in improvement and disease prevention (L581). The Governing Authority failed to ensure infection control education was provided to patients, family members, and other caregivers (L582). The cumulative effect of these systemic practices resulted in the hospice’s inability to ensure the provision of quality health care and self-identify areas in need of improvement which has the potential to result in negative outcomes for the entire patient population and adversely affect organizational operations.”

“Based on record review and staff interview, the Hospice failed to ensure completion and documentation of 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. This was evident for one (1) of twenty-two clinical records reviewed. (Patient #6). Failure to ensure an initial bereavement assessment is completed has the potential for negative patient outcomes. The findings are: Patient #6 has a Start of Care date of 08/29/2023 with diagnoses of Secondary Malignant Neoplasm of unspecified site, other nonspecific finding of lung field, and Pleural Effusion in other conditions classified elsewhere as documented on the “;Hospice Certification and Plan of Care” dated 08/29/2023 to 11/26/2023. The “;Hospice Certification and Plan of Care” dated 08/29/2023 to 11/26/2023 documents an order for “;Skilled Nurse (SN) 5 times per week for 1week, 7 times per week for 11 weeks, 1 time per week for 1week, and 5 times as needed; Medical Social Worker (MSW) 1 time per week for 1week.” The “;Registered Nurse (RN) Hospice Unattended Death Note Report” dated 08/30/2023 documents “;patient expired 5:50AM pronounced by (hospital) Physician Assistant (PA). Bereavement to follow. Emotional support provided to family”. The “;Hospice Interdisciplinary Group (IDG) Assessment and Plan of Care Update Report” dated 08/30/2023 documents “;patient expired on 08/30, prior to initial SW (social worker) assessment. Plans until next Interdisciplinary Group: Social Worker will provide bereavement support to patients family”. The record lacks documented evidence of a comprehensive bereavement assessment focused on the needs of the bereaved. The survey findings and interview were conducted with the Administrator/Director of Patient Services on 01/25/2024 at 4:15PM. No explanation was given for these findings and no additional information received.”

“Based on clinical record review, home visit observation and staff interview, the Hospice failed to ensure an evaluation for Physical Therapy services was included in the comprehensive assessment of the Hospice patient. This was evident in one (1) of three (3) home visit observation that included a record review (Patient #12). Failure to ensure that an evaluation for Physical Therapy services is included in the comprehensive assessment has the potential for negative patient outcomes. The findings include: Patient # 12 has a start of care date of 01/19/2024 with diagnoses of Malignant Neoplasm of Parietal Lobe, Secondary Malignant Neoplasm of Brain and Personal History of Other Malignant Neoplasm of Kidney as documented on the “;Hospice Certification and Plan of Care” for the certification period 01/19/2024 to 04/17/2024. The “;Hospice Certification and Plan of Care” for the certification period 01/19/2024 to 04/17/2024 documents an order for “;Skilled Nurse 1wk 1, 3 wk. 1, 2 wk. 10, 1 wk. 1, 5 PRN (one visit a week for one week, three visits a week for one week, two visits s week for ten weeks, one visits a week for one week and five as needed visits). Orders of Discipline treatments: “;Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care”. The “;Registered Nurse Hospice Start of Care” visit note report dated 01/19/2024, documents: “chairbound, maximal 2x (two person) assistance needed with walker to transfer in and out of bed”. A Home visit was conducted with the Hospice Registered Nurse on 01/23/2024, during the visit, the Surveyor observed the Registered Nurse assessing the patient. During the visit a Physical Therapist from a Certified Home Health Agency came to visit the patient for therapy services. In the patient’s home, an admission booklet for a Certified Home Health Agency was noted. The consent for services from the Certified Home Health Agency is dated “01/08/2024 for Physical Therapy evaluation”. The Hospice comprehensive assessment lacks documented evidence of the need for Physical Therapy referral/services. The comprehensive assessment lacks documented evidence that the Hospice offered or provided Physical Therapy services to the Hospice patient. The comprehensive assessment lacks documented evidence that the Hospice requested a Physical Therapy evaluation. On 01/24/2024 at 12:25 pm with the Administrator/Director of Patient Services was interviewed and no explanation was provided.”

“Based on record review and interviews, the Hospice interdisciplinary group (IDG) failed to update comprehensive assessments to ensure that the hospice IDG has the most recent accurate information about the patient/family as frequently as the condition of the patient requires in order to make accurate care planning decisions. This was evident in five (5) of twenty-three (23) clinical records reviewed. (Patient #1, #15, #16, #18 and #23). Failure to ensure the Hospice interdisciplinary group (IDG) update comprehensive assessments as frequently as the condition of the patient requires, has the potential for negative patient outcomes. The findings Are: The agencys policy titled, Hospice Interdisciplinary Group (IDG) with a review date of 2/22/2023, documents, “;Each patient is reviewed no less than every 15 days and as needed. Review of admissions, recertifications, deaths, discharges and revocations are completed along with updates on all patients on the IDG agenda”. On 1/24/24, The updated Interdisciplinary Group meeting minutes were requested for the following expired patients: 1. Patient # 1 has a start of care date of 11/9/23 and expired on 11/19/23 at 11:40 AM with diagnosis of Liver Cell Carcinoma documented on the Hospice Certification and Plan of Care for Certification Period for 11/9/23 to 2/6/24. The “;Hospice IDG (Interdisciplinary Group) comprehensive Assessment and Plan of Care Update Report” with Interdisciplinary Group meeting date of 11/19/23 documents, “;RN note: patient expired 11/19/23 at 11:40 AM; Physician note: achieved a comfortable death; Vital Signs: 11/19/23 11:34:00 AM -Temperature 98.6, Axillary, Pulse 96 Radial, Respirations 18, Blood Pressure 74/48”. There is no documented evidence this updated IDG comprehensive assessment confirmed that the patient has ceased vital bodily functions irreversible including, but not limited to the following: absence of heart rate for no less than one minute, auscultation of lungs for cessation of breath sounds and no response to verbal tactile stimuli. 2. Patient #15 has a start of care date of 6/8/23 and expired on 7/4/23 with diagnoses of Alzheimers Disease, Essential (Primary) Hypertension, and Pain, unspecified documented on the Hospice Certification and Plan of Care for Certification Period of 6/8/23 to 9/5/23. The IDG (Interdisciplinary Group) meeting reports dated 6/15/23 and 6/29/23 lack documented the patient has ceased vital bodily functions irreversible including, but not limited to the following: absence of heart rate for no less than one minute, auscultation of lungs for cessation of breath sounds and no response to verbal tactile stimuli. 3. Patient #16 has a start of care date of 6/26/23 and expired on 7/5/23 with diagnoses of Acute Respiratory Failure, Unspecified with Hypoxia or Hypercapnia, Pneumonia, Unspecified Organism and Sepsis due to Streptococcus Pneumoniae documented on the Hospice Certification and Plan of Care for Certification Period for 6/26/23 to 9/23/23. The IDG (Interdisciplinary Group) meeting reports dated 6/29/23 and 7/5/23 lack documented evidence the patient has ceased vital bodily functions irreversible including, but not limited to the following: absence of heart rate for no less than one minute, auscultation of lungs for cessation of breath sounds and no response to verbal tactile stimuli. 4. Patient # 18 has a start of care date of 9/18/23 and expired on 10/17/23 at home with diagnosis of Alzheimers Disease, Unspecified documented on the Hospice Certification and Plan of Care for Certification Period for 9/18/23 to 12/16/23. The IDG (Interdisciplinary Group) meeting reports dated 9/21/23 and 10/5/23 lack documented evidence the patient has ceased vital bodily functions irreversible including, but not limited to the following: absence of heart rate for no less than one minute, auscultation of lungs for cessation of breath sounds and no response to verbal tactile stimuli. 5. Patient # 23 has a start of care date of 10/31/23 and expired on 11/1/23 with diagnoses of Acute Respiratory Failure, Unspecified with Hypoxia, Sepsis, Unspecified Organism, Heart Failure, Unspecified and Non-ST Elevation (NSTEMI) Myocardial Infarction documented on the Hospice Certification and Plan of Care for Certification Period for 10/31/23 to 12/29/23. The IDG (Interdisciplinary Group) meeting reports dated11/2/23 and 11/1/23 lack documented evidence the patient has ceased vital bodily functions irreversible including, but not limited to the following: absence of heart rate for no less than one minute, auscultation of lungs for cessation of breath sounds and no response to verbal tactile stimuli. There is no documented the IDG (Interdisciplinary Group) is updated as often as necessary for each patient. There is no documented the IDG (Interdisciplinary Group) meeting reports titled, “;Hospice IDG (Interdisciplinary Group) comprehensive Assessment and Plan of Care Update Report” are complete. On 1/25/2024, at 11:30AM, the Administrator/ Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on clinical record reviews and staff interviews, the Governing Authority failed to ensure the Interdisciplinary Group included a qualified individual to practice in the pastoral counselor role as a core care service. This was evident for eighteen (18) out of the twenty three (23) clinical records reviewed. (Patient #1, #3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #19, #21, #23) Failure to ensure the Interdisciplinary Group included a qualified individual to practice in the pastoral counselor role as potential for negative patient outcomes. The Findings are: On 1/22/24 during the entrance conference, review of services the Hospice provides directly and indirectly, the Administrator/Director of Patient Services stated “chaplain services is not on services. It is contracted through the community, the hospital and patient preference”. The Hospice’s policy entitled “Hospice Interdisciplinary Group”, “last review date: 2/22/2023”, documents “1. Hospice must designate an IDG (Interdisciplinary Group)composed of individuals who work together to meet the physical, medical, psychosocial, emotional and spiritual needs of the hospice patients and caregivers(s) facing terminal illness and bereavement. 2. Members of the IDG (Interdisciplinary Group) must be appropriately trained in the hospice philosophy and competent according to New York State Department of Health Regulations to perform in their assigned areas(s). The team is composed but not limited to: a. Medical Director who is an employee or under contract with the hospice b. A Registered Nurse c. A Social Worker d. A Pastoral Care or other counselor”. The Hospice’s policy entitled “Spiritual Care”, “last review date: 5/16/2023”, documents “A. Chaplain Visitation 1. Upon admission, nursing completes the patient assessment, which includes screening for religious or spiritual needs. Consults for spiritual care are entered into the EPIC (electronic medical record) system or a referral is made by calling Spiritual Care”. The Hospice’s policy entitled “Scope of Services-Hospice”, “last review date: 05/15/2023”, documents “Pastoral Care: Clergy designated by the patient or family will be incorporated into the patient’s plan of treatment. A Hospice Chaplain is available to provide spiritual support and counseling at the patient’s or family’s request. Spiritual care includes: 1. Initial and comprehensive holistic assessment of the patient’s spiritual needs related to the terminal illness. 2. Interdisciplinary group care planning and coordination of services. 3. Assisting in planning for funeral and/ or other services. 4. Religious, spiritual or other support for patients, families, caregivers and significant others. 1. Patient # 1 Start of Care: 11/9/23, Date of Death: 11/19/23; pastoral counselor not addressed in Interdisciplinary Group meeting 11/16/23 and 11/19/23. 2. Patient # 3 Start of Care: 11/15/23, Date of Death: 12/4/23; pastoral counselor declined in Interdisciplinary Group meeting 11/16/23, 11/30/23 and 12/4/23. 3. Patient # 5 Start of Care: 3/3/23, Death of Death: 3/13/23; pastoral counselor declined in Interdisciplinary Group meeting 3/9/23. 4. Patient # 6 Start of Care: 8/29/23, Death of Death: 8/30/23; pastoral counselor declined in Interdisciplinary Group meeting 8/30/23. 5. Patient # 7 Start of Care: 1/17/24, Date of Death: 1/24/24; pastoral counselor declined in Interdisciplinary Group meeting 1/18/24 and 1/24/24. 6. Patient # 8 Start Of Care: 12/8/23, Date of Death: 12/15/23; pastoral counselor not addressed in Interdisciplinary Group meeting 12/14/23. 7. Patient # 9 Start of Care: 4/6/23, Date of Death: 4/16/23; pastoral counselor declined in Interdisciplinary Group meeting 4/13/23 and 4/16/23. 8. Patient # 10 Start of Care: 9/5/23, Date of Death: 9/16/23; pastoral counselor declined in Interdisciplinary Group meeting 9/7/23 and 9/18/23. 9. Patient # 11 Start of Care: 7/17/23, Date of Death: 8/3/23; pastoral counselor not addressed in Interdisciplinary Group meeting 7/20/23 and 8/3/23. 10. Patient # 12 Start of Care: 1/19/24; pastoral counselor declined in Interdisciplinary Group meeting 1/25/24. 11. Patient # 13 Start of Care: 12/15/21; pastoral counselor not addressed in Interdisciplinary Group meeting 12/22/23 and 1/5/24. 12. Patient # 14 Start of Care:1/16/24; pastoral counselor declined in Interdisciplinary Group meeting 1/18/24. 13. Patient # 15 Start of Care: 6/8/23, Date of Death: 7/4/23; pastoral counselor not addressed in Interdisciplinary Group meeting 6/15/23 and 6/29/23. 14. Patient # 16 Start of Care: 6/26/23, Date of Death: 7/5/23; pastoral counselor not addressed in Interdisciplinary Group meeting 6/29/23 and 7/5/23. 15. Patient # 18 Start of Care: 9/18/23, Date of Death: 10/17/23; pastoral counselor not addressed in Interdisciplinary Group meeting 9/21/23 and 10/5/23. 16. Patient # 19 Start of Care: 10/27/23, Date of Death: 12/19/23; pastoral counselor declined in Interdisciplinary Group meeting 11/2/23, 11/16/23, 11/30/23 and 12/19/23. 17. Patient # 21 Start of Care: 5/15/23, Date of Death: 5/22/23; pastoral counselor declined in Interdisciplinary Group meeting 5/18/23 and 5/22/23. 18. Patient # 23 Start of Care: 10/31/23, Date of Death: 11/1/23; pastoral counselor not addressed in Interdisciplinary Group meeting 11/1/23 and 11/2/23. There is no documented evidence the Interdisciplinary Group included individuals who are qualified and competent to met the pastoral/spiritual needs of all patients. On 1/23/24 at 2:48 pm, surveyors observed the Hospice’s Interdisciplinary Group team meeting. The Interdisciplinary Group meeting lacked the presence and incorporation of a pastoral counselor to discuss and address the spiritual needs of the patients and their families. On 1/24/24 at 11:00am, the Administrator/Director of Patient Services was interviewed and did not provide and explanation for the findings.”

“Based on record reviews, and interviews with the hospice staff and the hospice Administrator/ Director of Patient Services, the hospice failed to develop an individualized plan of care for all patients to include all services necessary for the palliation and management of terminal illness including pastoral care services. This was evident for seven (7) of twenty-three clinical records reviewed. (Patients #2, #9, #12, #13, #17, #20, and #22). Failure to develop an individualized plan of care for all patients to all services necessary for the palliation and management of terminal illness including pastoral care services has the potential for negative patient outcomes. The findings are: 6. Patient #9 has a start of care date of 04/06/2023 with diagnoses of Alzheimer’s Disease with late onset, Primary Generalized Osteoarthritis, Displaced Artic Fracture Head of Unspecified Femur, and Essential Hypertension as documented on the “;Hospice Certification and Plan of Care” for certification period 04/06/2023 to 07/04/2023. The Hospice patient has a death date of 04/16/2023. The “;Hospice Certification and Plan of Care” for certification period 04/06/2023 to 07/04/2023 documents an order for “;Skilled Nurse 2 wk. 12, 1 wk. 1, 5 PRN (two visits a week for twelve weeks, one visit a week for one week, five as needed visits). Hospice Registered Nurse to evaluate patient and develop a Nursing Plan of Care”. The Hospice Plan of Care lacks an order for Pastoral Care/Spiritual Counseling to ensure the spiritual need of the Hospice patient before death. The survey findings were reviewed on 01/25/2024 at 04:07 PM with the Hospice staff. Interview conducted with the Administrator/Director of Patient Services on 01/26/2024 at 10:30 AM. No explanation was provided. 7. Patient # 12 has a start of care date of 01/19/2024 with diagnoses of Malignant Neoplasm of Parietal Lobe, Secondary Malignant Neoplasm of Brain and Personal History of Other Malignant Neoplasm of Kidney as documented on the “;Hospice Certification and Plan of Care” for certification period 01/19/2024 to 04/17/2024. The “;Hospice Certification and Plan of Care” for certification period 01/19/2024 to 04/17/2024 documents an order for “;Skilled Nurse 1wk 1, 3 wk. 1, 2 wk. 10, 1 wk. 1, 5 PRN (one visit a week for one week, three visits a week for one week, two visits s week for ten weeks, one visit a week for one week and five as needed visits). Orders of Discipline treatments: “;Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care, Hospice Nurse to assess medication response and instruct on schedule, actions, purpose, side effects, compliance and need to report side effects to Hospice staff”. Medications include “;Levetiracetam 50 milligram tablet 2 times daily by mouth: Reason – Seizures”. The “;Registered Nurse Hospice Start of Care” visit note report dated 01/19/2024, the Registered Nurse documents the patient has “;Right great toe unstaged Deep Tissue Injury, and Left great toe unstaged Deep Tissue Injury”. The “;Medical Record Coordination Notes Report” dated 01/21/2024 and the “;Registered Nurse Subsequent visit” dated 01/21/2024, the Registered Nurse documents the patient has “;Two Diabetic Ulcers on Left and Right Great Toe”. A Home visit was conducted with the Hospice Registered Nurse on 01/23/2024, during the visit, the Surveyor observed the Registered Nurse assessing the patients Right great toe unstaged Deep Tissue Injury, measurement of “;0.3 X 0.3 X 0” centimeters. Left great toe Deep Tissue Injury, measurement of “;0.8 X 0.8 X 0” centimeters. The Hospice Certification and Plan of Care lacks pertinent diagnoses of Seizure, Diabetes Mellitus and Deep Tissue Injury. The Plan of Care lacks an order for Pastoral Care/Spiritual Counseling. The Hospice failed to establish an individualized Plan of Care to meet the Hospice patient current palliative needs. The survey findings were reviewed on 01/24/2024 at 12:25 pm with the Hospice staff. Interview with the Administrator/Director of Patient Services on 01/25/2024 at 12:10 PM. No explanation was provided. 5. Patient #17 has a start of care date of 01/09/24 and expired on 01/22/24 with diagnoses of Acute Diastolic Congested Heart Failure, Acute Respiratory Failure with Hypoxia, Pneumonia, and Sepsis as documented on the Hospice Certification and Plan of Care for Certification Period of 01/09/24 to 04/07/24. The Hospice Certification and Plan of Care for Certification Period of 01/09/24 to 04/07/24 as documents, “;Skilled Nursing 3 times per week for 1 week, 2 times per week for 11 weeks, 8 times per week for 1 week, 5 times as needed; Medical Social Worker 1time per week for 1 week”. The Hospice Certification and Plan of Care for Certification Period of 01/09/24 to 04/07/24 documents and an expiration of 01/22/2024 lacks documented evidence of interventions/tasks for Hospice nurse to observation/assessment of signs/symptoms of declining status/imminent death. There is no documented evidence the hospice developed a complete Plan of Care. On 1/24/24 at 11:30 AM, the Administrator/ Director of Patient Services and Clinical Manager were interviewed and did not provide any further explanation. 4. Patient #13 has a start of care date of 12/15/21 with diagnoses of Chronic Obstructive Pulmonary Disease, unspecified, Dependence on Supplemental Oxygen, Malignant Neoplasm of Esophagus, unspecified, Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms, Candidiasis unspecified, and Essential (Primary) Hypertension documented on the IDG (Interdisciplinary group) Summary Report dated 1/19/2024. The Hospice Certification has an Order date of 11/20/2023, effective date of 12/5/2023 and an expiration of 2/2/2024 documents, “;SN (Skilled Nursing) 2 times per week for 7 weeks, 7 times per week for 1 week, 2 times per week for 1 week; aide: 4 times per week for 1 week, 5 times per week for 8 weeks”. The Hospice Certification has an Order date of 11/20/2023, effective date of 12/5/2023 and an expiration of 2/2/2024 lacks documented evidence of diagnoses, interventions/tasks necessary to meet the patient/family needs identified in the comprehensive assessment; Safety Measures, Activities Permitted, Nutritional Requirements, Advance Directives, Mental Statuses, Allergies, Durable Medical Equipment and Medical Supplies. During a home visit conducted on 1/23/24 at 11:30 AM with the Hospice Nurse, Clinical Nurse Manager and Regulatory Manager the Surveyor requested the Aide Plan of Care (APOC). The Aide Plan of Care (APOC) was not provided and/or observed in the home. The Hospice failed to establish an individualized Plan of Care to meet the Hospice patient current palliative needs. On 1/25 2024, at 11:30AM, the Administrator/ Director of Patient Services was interviewed and did not provide an explanation for the findings. 3. Patient #2 has a start of care date of 10/30/2023 and a discharge date of 11/3/2023 with diagnoses that include Cerebral Atherosclerosis, Vascular Dementia, Unspecify Severity without Behavior/ Psychosis/mood, anxiety as documented on the “ Hospice Certification and Plan of Care” for the Certification Period of 10/30/2023 to 1/27/2023. The “ Home Health Certification and Plan of Care” for the Certification Period of 10/302023 to 1/27/2023 documents: “ Frequency/duration of visits Skilled Nursing five times a week for one week, twice a week for eleven weeks, once a week for one week, five as needed. Medical Social Worker 11/2/2023 once a week for one week”. The “ Visit note report” dated 10/30/2023 documents:” was the patient asked about spiritual existential concerns, yes and discussion occurred. current religious/ spiritual preference or affiliation: Name of Patient Religion. Spiritual./ existential concerns of patient and caregiver: no spiritual/ existential concerns presented by patient and or caregivers” There is no documented evidence of pastoral care services in the plan of care. There is no documented evidence of an individualized plan of care that includes pastoral care services. On 1/26/2024, at 11:50AM, the Administrator was interviewed and stated the last worked day for the hospice chaplain was 12/30/2022. No further explanation was provided The document titled” Long Island Community Hospital Hospice scope of services documents:” A hospice chaplain is available to provide spiritual support services at the patient or the patient’s family request. Spiritual care includes initial and comprehensive holistic assessment of spiritual needs related to the terminal illness. Interdisciplinary group care planning and coordination of services. Religious spiritual or other support for patients families, caregivers and significant others. Assisting in funeral planning and other rites”. The agencys policy titled, Plan of Care-Hospice with a review date of 3/25/2023, documents, “;The Plan of Care shall include a listing of all mental status and psychosocial needs, functional limitations, environmental and equipment needs, activities permitted, nutritional and fluid requirements and restrictions, safety measures; the plan must include the scope of the services being delivered”. 1. Patient #20 has a start of care date of 02/23/2023 with diagnoses of Alzheimers Disease with late onset, Pneumonia, Anemia in Chronic Kidney Diseases, Acute Kidney Failure, and Chronic Kidney Disease as documented on the “;Hospice Certification and Plan of Care” dated 02/23/2023 to 05/23/2023. The “;Hospice Certification and Plan of Care” dated 02/23/2023 to 05/23/2023 documents an order for “;Skilled Nurse (SN) 2 times weekly for 12 weeks, 1 time per week for 1 week, 5 times as needed; Medical Social Worker (MSW) effective 02/26/2023: 1 time per week for 1 week.” The Hospice patient has a date of death of 03/15/2023. The Registered Nurse “;Visit Note Report” dated 02/23/2023 documents: “;Was the patient/caregiver asked about spiritual/existential concerns: Yes and discussion occurred. Current religious/spiritual preference or affiliation: Name of Patient Religion. Spiritual/existential concerns of patient and caregiver: Family requesting anointing”. There is no documented evidence of pastoral care services in the plan of care. There is no documented evidence of an individualized plan of care that includes pastoral care services. The findings were reviewed with the Administrator/Director of Patient Services on 01/25/2024 at 4:25PM. The Administrator/Director of Patient Services was interviewed on 1/26/2024 at 11:50AM and stated the last worked day for the hospice chaplain was 12/30/2022. No further explanation was provided. 2. Patient #22 has a start of care date of 10/20/2023 with diagnoses of Acute Respiratory Failure with Hypoxia or Hypercapnia and Anoxia Brain Damage as documented on the “;Hospice Certification and Plan of Care” dated 10/20/2023 to 01/17/2024. The “;Hospice Certification and Plan of Care” dated 10/20/2023 to 01/17/2024 documents an order for “;Skilled Nurse (SN): 2 times per week for 1 week, 7 times per week for 11 weeks, 1 time per week for 1 week, and 5 times as needed; Medical Social Worker (MSW) effective 10/23/2023: 1 time per week for 1 week.” The Hospice patient has a date of death of 10/28/2023. The Registered Nurse “;Visit Note Report” dated 10/20/2023 documents: “;Was the patient/caregiver asked about spiritual/existential concerns: Yes and discussion occurred. Current religious/ spiritual preference or affiliation: Name of Patient Religion. Spiritual/existential concerns of patient and caregiver: No spiritual/existential concerns presented by patient and/or caregiver(s)”. The Medical Social Work “;Visit Note Report” dated 10/23/2023 documents “;patient is Name of Patient Religion, anointing previously completed”. There is no documented evidence of pastoral care services in the plan of care. There is no documented evidence of an individualized plan of care that includes pastoral care services. The findings were reviewed with the Administrator/Director of Patient Services on 01/25/2024 at 4:25PM. The Administrator/Director of Patient Services was interviewed on 1/26/2024 at 11:50AM and stated the last worked day for the hospice chaplain was 12/30/2022. No further explanation was provided.”

“Based on record reviews and interview with the Administrator/ Director of Patient Services, the hospice failed to ensure that the Medical Social Worker provide the ongoing sharing of all patients’ information to the Interdisciplinary Group. This was evident for three (3) of twenty-three (23) clinical records reviewed. (Patients # 4, #,14, and #17). Failure to ensure that the Medical Social Worker provide the ongoing sharing of all patients’ information to the Interdisciplinary Group has the potential for negative patient outcomes. 1. Patient #4 has a start of care date of 1/20/2023 and an expiration date of 2/7/2023 with diagnoses that include Alzheimer’s Disease with Late onset, Essential Hypertension, Anxiety Disorder as documented on the “ Hospice Certification and Plan of Care” for the Certification Period of 1/20/2023 to 4/19/2023. The “ Hospice Certification and Plan of Care” for the Certification Period of 1/20/2023 to 4/19/2023 documents:” Skilled Nursing once a week for one week, twice a week for twelve weeks, five as needed. Medical Social Worker effective 1/22/2023 once a week for one week”. The Skilled Nursing “Visit Note Report” dated 1/20/2023 documents:” Was the patient/caregiver asked about spiritual/ existential concerns: yes, and discussion occurred. current religious preference or an affiliation. Indicate the place of worship. Does Hospice have permission to contact the pastor/priest: yes. Address and telephone”. The Medical Social Worker” Visit Note Report” dated 1/23/2023 documents:” patients religion, though non practicing in later years, Social Worker arranged anointing, which was completed today.”. A review of the “ Hospice Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report” dated 1/26/2023 lacks documented evidence of the patient was anointed. The “Hospice Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report” dated 1/26/2023 documents:’ This discipline services have been offered but have been declined at this time by the patient caregiver”. There is no documented the Medical Social Worker is sharing all information about the patients status with the Interdisciplinary Group. 2. Patient # 14 has a start of care date of 01/16/24 with diagnoses of Acute Respiratory Failure with Hypoxia/Hypercapnia, Cardiac Arrest and Muscular Dystrophy as documented on the Hospice Certification and Plan of Care for Certification Period of 01/16/24 to 04/14/2024. The Hospice Certification and Plan of Care for Certification Period of 01/16/24 to 04/14/24 documents, “;Skilled Nursing three times a week for one week, twice a week for eleven weeks, once a week for one week, five visits as needed: Medical Social Worker once a week for one week”. Orders of Discipline treatments: “Hospice Registered Nurse to evaluate patient and develop a nursing plan of care”. The Skilled Nursing “Visit Note Report” dated 1/16/2024 documents:” Was the patient/caregiver asked about spiritual/ existential concerns: “;Yes, and discussion occurred. Current religious preference or Affiliation. Indicate the place of worship: “;Church”. Does Hospice have permission to contact the pastor: “;Yes”. Address and telephone “;. The Medical Social Worker” Visit Note Report” dated 1/17/2024 documents:” patient’ religion, anointing previously arranged at family request”. The “Hospice Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report” dated 1/18/2024 documents:’ This discipline ‘s services have been offered but have been declined at this time by the patient caregiver”. A review of the “ Hospice Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report” dated 1/18/2024 lacks documented evidence of the patient receiving the sacrament of the sick. There is no documented evidence the Medical Social Worker is sharing all information about the patients status to the Interdisciplinary Group. 3. Patient # 17 has a start of care date of 01/09/24 and expired on 01/22/24 with diagnoses of Acute Diastolic Congested Heart Failure, Acute Respiratory Failure with Hypoxia, Pneumonia, and Sepsis documented on the Hospice Certification and Plan of Care for Certification Period of 01/09/24 to 04/07/24. The Hospice Certification and Plan of Care for Certification Period of 01/09/24 to 04/07/24 documents, “;(Skilled Nursing three times a week for one week, twice a week for eleven weeks, eight times a week for one week , five visits as needed: Medical Social Worker once a week for one week”. The Skilled Nursing “Visit Note Report” dated 1/09/2024 documents:” Was the patient/caregiver asked about spiritual/ existential concerns: “;Yes, and discussion occurred. Current religious preference or Affiliation. Indicate the place of worship: . Does Hospice have permission to contact the pastor: “;Yes”. Address and telephone number was provided.” The Medical Social Worker Visit Note Report dated 1/10/2024 documents:” Pending priest visit”. The “Hospice Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report” dated 1/11/2024 documents: “;This discipline ‘s services have been offered but have been declined at this time by the patient caregiver”. The Medical Social Worker” Visit Note Report” dated 1/15/2024 documents:” pastoral care referral done and a Pastor visit patient and anoint patient”. A review of the “ Hospice Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report” dated 1/11/2024 lacks documented evidence of discussion of pending priest visit with the Interdisciplinary Group. There is no documented evidence the Medical Social Worker is sharing all information about the patients status to the Interdisciplinary Group On 1/24/24 at 11:30 AM with the Administrator/ Director of Patient Services and Clinical Manager were interviewed and did not provide an explanation for the findings. On 1/25 2024, at 3:00PM, the Administrator/ Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on review of the Hospice’s Quality Assessment and Performance Improvement (QAPI) meeting minutes for 2023, and interview with the Hospice Administrator/Director of Patient Services, the Governing Authority failed to ensure Quality Assessment and Performance Improvement initiatives are in place to measure improvement related to Palliative outcomes and Hospice services. Failure to develop a comprehensive Quality Assessment and Performance Improvement Program that documents measurable improvement in indicators related to improved Palliative outcomes and Hospice services hinders the Hospice’s ability to determine what Quality Assessment and Performance Improvement interventions have been successful and identify areas in need of improvement, has the potential for negative patient outcomes. The findings are: The Hospice lacks documented evidence of a Quality Improvement and Performance Improvement Policy. A policy was requested by the surveyor on 1/22/24 at 10:55am and 1/23/24 at 10:00 am, none received. No explanation provided by the Administrator. On 1/25/24 at 3:17pm the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the above findings and no additional evidence was provided.”

“Based on review of the Hospice’s Quality Assessment and Performance Improvement (QAPI) meeting minutes for 2023, and interview with the Hospice Administrator/Director of Patient Services, the Governing Authority failed to ensure quality indicators, including adverse patient events are measured, analyzed and tracked. Failure to measure, analyze and track quality indicators, including adverse events, hinders the Hospice’s ability to identify areas of needed improvement and has the potential for negative patient outcomes, adversely affecting care services and operations. The findings are: The Quality Assessment and Performance Improvement (QAPI) meeting minutes (dated 1/19/23, 2/23/23, 3/9/23, 4/20/23, 5/11/23, 6/22/23, 7/27/23, 8/24/23, 9/28/23, 10/12/23, 11/22/23, 12/7/23) lack documented evidence the Hospice has developed and documented in writing of quality indicators in areas of operation that might affect patient care, such as wound therapy, spiritual care, multi-drug resistant organisms that is measured, analyzed, and tracked. The Quality Assurance and Performance Improvement (QAPI) meeting minutes (dated 1/19/23, 2/23/23, 3/9/23, 4/20/23, 5/11/23, 6/22/23, 7/27/23, 8/24/23, 9/28/23, 10/12/23, 11/22/23, 12/7/23) lack documented evidence the Hospice has developed and documented in a writing specific definition of an adverse events such as falls and infection rates. On 1/25/24 at 3:17pm the Administrator/Director of Patient Services was interviewed and did not provided and explanation for the above findings, no additional evidence was provided.”

“Based on review of the Hospice’s Quality Assessment and Performance Improvement (QAPI) meeting minutes and initiative for 2023, and interview with the Hospice Administrator/Director of Patient Services, the Governing Authority failed to ensure quality indicators for data collection have been developed relevant to all facets of a Hospice operation, including all patient services and interventions that may impact patient care. Failure to ensure the data collection of quality indicators are relevant to all facets of the Hospice operation has the potential for negative patient outcomes and adversely affecting organizational operations. The findings are: A review of the 2023 Quality Assessment and Performance Improvement (QAPI) meeting minutes (dated 1/19/23, 2/23/23, 3/9/23, 4/20/23, 5/11/23, 6/22/23, 7/27/23, 8/24/23, 9/28/23, 10/12/23, 11/22/23, 12/7/23) lack documented evidence the committee developed quality indicators for data collection. The meeting minutes lack documented evidence the committee collected data regarding physician, nursing, medical social work, pastoral spiritual counseling, clinical records, infection control, pharmaceutical, durable medical equipment, patient rights, administrative, contract, volunteers services to assist in identifying areas in need of improvement. On 1/25/24 at 3:17pm the Administrator/Director of Patient Services was interviewed and did not provide and explanation for the above findings, no additional evidence provided.”

“Based on review of the Hospice’s Quality Assessment and Performance Improvement (QAPI) meeting minutes and initiative for 2023, and interview with the Hospice Administrator/Director of Patient Services. The Administrator/Director of Patient Services failed to ensure that the data collected during Quality Performance Improvement initiatives was used to identify areas for improvement. Failure to use the data collected to monitor the effectiveness and safety of services and quality of care, or identify opportunities and priorities for improvement has the potential for negative patient outcomes. The findings are: A review of the 2023 Quality Assessment and Performance Improvement (QAPI) meeting minutes (dated 1/19/23, 2/23/23, 3/9/23, 4/20/23, 5/11/23, 6/22/23, 7/27/23, 8/24/23, 9/28/23, 10/12/23, 11/22/23, 12/7/23) lack documented evidence the committee collected data to identify a need for improvement in areas of need such as physician, nursing, medical social work, spiritual counseling, clinical records, infection control, pharmaceutical, durable medical equipment, patient rights, administrative services, contract, volunteer, and adverse events such as falls to monitor the effectiveness and safety of services, quality of care and identify opportunities for improvement. On 1/25/24 at 3:17pm the Administrator/ Director of Patient Services was interviewed and did not provide and explanation for the above findings, no additional evidence provided.”

“Based on review of the Hospice’s Quality Assessment and Performance Improvement (QAPI) meeting minutes and initiative for 2023, and interview with the Hospice Administrator/Director of Patient Services, the Governing Body failed to ensure approval of all details of the data collection. Failure to ensure the Hospice’s Quality Assessment and Performance Improvement data collection is approved by the Governing Body has the potential for negative patient outcomes. The findings are: On 1/25/24, the surveyor requested the 2023 Governing Body meeting minutes. The surveyor received a post-it note from the Administrator/Director of Patient Services, who stated this is the “Governing Authority” meeting date written on the post-it note “4/7/23”. A review of the 2023 Quality Assessment and Performance Improvement (QAPI) meeting minutes (dated 1/19/23, 2/23/23, 3/9/23, 4/20/23, 5/11/23, 6/22/23, 7/27/23, 8/24/23, 9/28/23, 10/12/23, 11/22/23, 12/7/23) lack documented evidence the Hospice’s Governing Body was aware/responsible for the approval or rejection of the actions/data collection of the Quality Assessment and Performance Improvement Program committee. The Hospice’s Fiscal Year for Quality Assessment and Performance Improvement is July 1st through June 30th as reported by the Administrator/Director of Patient Services. There is no documented evidence of the Governing Body meeting minutes for the 2022/2023 and the 2023/2024 Hospice Fiscal Year. There is no documented evidence of the Governing Body reviewing and documenting the approval of the Quality Assessment and Performance Improvement Program data collection. On 1/25/24 at 3:17pm the Administrator/Director of Patient Services was interviewed the above findings were reviewed. The Administrator/Director of Patient Services stated “there is no documentation of approval, there was verbal discussion with the Vice President of Quality for the pain program”.”

“Based on review of the agency’s Quality Assessment and Performance Improvement Program and activities for 2023, and interview with the hospice Administrator/ Director of Patient Services, the hospice failed to ensure performance improvement activities focused on high risk, high volume or problem prone areas. Failure to ensure performance improvement activities are focused on high risk, high volume or problem prone areas has the potential to result in negative patient outcomes. The findings are: The 2023 QAPI Meeting minutes(dated01/23,02/23,03/23,04/23,05/23,06/2307/2308/23,10/2311/23) lack documented evidence data is reviewed and analyzed regarding high risk problem prone patient care areas such as patients receiving wound therapy, patients receiving spiritual care patients with multi-drug resistant organisms or fall and infection rates to determine if these are areas in need of improvement. The current data collection is of insufficient scope to identify high risk, high volume or problem prone areas. There is no documented evidence of analysis of the data in the meetings minutes to identify any opportunities for improvement and implementation of preventive actions that include feedback and review the plan to ensure the outcome results of the care provided to patients receiving Hospice care. On 01/25/2024 at 3:17 PM and on 1/26/2024 at 10:50 AM, the hospice Administrator/ Director of Patient Services was interviewed. The Administrator stated, “;meetings are held monthly, no discussion about record reviews at the meetings” No additional evidence was provided.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement activities for 2023, with the hospice Administrator/Director of Patient Services, the hospice failed to ensure performance improvement activities considered the incidence, prevalence and severity of the problems in high risk, high volume and problem-prone areas. Failure to consider the incidence, prevalence and severity of problems in high risk, high volume and problem-prone areas inhibits the hospice’s ability to identify areas of needed improvement in a timely manner and has the potential for negative patient outcomes. The findings are: The 2023 Quality Assessment and Improvement committee meeting minutes dated ( 01/23,02/23,04/23,05/23,06/23,07/23,08/23,09/23,10/23,11/23,12/23) lack documented evidence of performance improvement activities such as bowel regimen, pain management, high patient turnovers and the reasons these aspects of care were included in the Quality Assessment and Improvement program. The Quality Assessment and Performance Improvement meeting minutes dated 1/23 document” Instruction of strategy for education to prevent fall for hospice patient”. The meeting minutes dated 10/23 and 11/23 document “ Review of comprehensive pain assessment with focus of the non verbal patient. Education reinforced regarding the roll up questions of pain assessment”. There is no documented evidence data was collected to determine these indicators were a prevalent problem prone area of high risk and high volume. On 1/26/2023, at 10: 55 AM, the Administrator / Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023 and interview with the hospice Administrator/ Director of Patient Services, the hospice failed to ensure performance improvement interventions were tracked to ensure measurable improvements based on the data collected. Failure to track implemented interventions inhibits the hospice’s ability to measure improvement has the potential to result in negative patient outcomes. The findings are: The document titled” Excellence Committee or Performance Improvement Department annual hospice evaluation for 2022 documents: list of 2023 Indicators: fall rates, bowel regime, pain management within 48 hours of admission, weekly wound measurement, Length of Stay, Hospitalizations. The Quality Assessment and Performance Improvement I meeting minutes dated (02/23/2023, 03/09/2023, 04/20/2023,05/11/2023, 06/22/2023,07/27/2023, 08/24/2023, 09/28/2023, 10/12/2023) lack documented evidence the Performance Improvement Project or the indicators were reviewed and discussed, or the interventions put in place were tracked and analyzed to determine if the interventions have shown measurable improvements. The hospice Administrator/ Director of Patient Services was interviewed on 01/26/2024 at 10:50 AM. No further explanation was provided.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023, and interview with the hospice Administrator/ Director of Patient Services, the hospice failed to ensure Performance Improvement Projects were of sufficient scope to address the needs of the patient population improve the care of the patients receiving hospice services. Failure to develop Performance Improvement Projects that address the needs of the patient receiving hospice care or services has the potential for negative patient outcomes. The findings are: The Quality Assessment and Performance Improvement meeting minutes dated01/23,02/23,03/23,04/23,05/23,06/2307/2308/23,10/23,11/23, 12/23 ) lack documented lack documentation that sufficient data, that included evaluating all aspects of patient service and activities that may impact patient and family care and all facets of the hospice’s operation, was collected and quality indicators established and utilized to determine what Performance improvement projects would be appropriate to improve quality of care and improve the non-clinical operations of the hospice. The meetings minutes dated 01/23,02/23,03/23,04/23,05/23,06/2307/2308/23,10/23,11/23, 12/23 ) lack documented evidence of discussion of falls occurrences, analysis of the causes of patient falls, and implementation of preventive actions and mechanisms that include feedback and learning throughout the hospice . The “ Patient Information Report” dated 1/282023 documents a fall 1/28/2023 at 8:01 AM, and a fall at 6:26PM. The “ Client Occurrence Report” dated 1/28/2023 at 11:12 AM and 7:41 PM documents f two fall occurrences. The Quality Assessment and Performance Improvement meetings minutes of 02/23 to 12/23 lack documented evidence of tracking the patient falls occurrences and documentation of preventive actions to prevent further occurrences and to ensure the palliative needs of the patients are met. On 1/26/2024 at 10:55 AM, the Hospice Administrator / Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023 and interview with the hospice Administrator/ Director of Patient Services the hospice failed to measure its success and track its performance improvement interventions based on the data collected to ensure that improvements are sustained. Failure to measure its success and track its performance improvement interventions to ensure that improvements are sustained based on the data collected has the potential for negative patient outcomes. The findings are: The 2023 Quality Assessment and Improvement committee documented one Performance Improvement Plan titled “Improving Hospice Pain Documentation Through Real Time Auditing And The Provision Of Regulatory Based Education.” The Performance improvement project goal was to “;increase the percentage of hospice patient stays during which the patient is screened for pain during the initial assessment, et to increase the percentage of hospice patient stays during which the patient is screened positive for pain and received a comprehensive of pain within one day of screening”. The Quality Assessment and Performance Improvement meeting minutes dated: 01/19/23,02/23/23,03/9/23,4/20/23,5/11/23,6/22/23,7/27/23,8/24/23,9/28/23,10/12/23, lack documented evidence the performance improvement project was discussed or any action was implemented to measure the success of the project and to ensure improvements are sustained. The Quality Assessment and Improvement meeting minutes dated 11/22/23 documents: “; Education reinforced regarding completion of the roll up questions of pain assessment. The Quality Assessment and Improvement meeting minutes dated 12/07/2023 documents: “;Review of comprehensive pain assessment with focus on assessing the non verbal patient”. The Quality Assessment and Improvement meeting minutes lack documented evidence of implementation of interventions and its performance to ensure the outcome of pain management is achieved as a goal of palliative care. On 1/25/2024 at 3:17 PM, the Administrator/ Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023, and interview with the hospice Administrator/ Director of Patient Services , the hospice failed to develop, implement and evaluate performance improvement projects that address the needs of the patient receiving hospice care. Failure to develop, implement and evaluate performance improvement projects that address the needs of the patient receiving hospice care has the potential to result in negative patient outcomes. The findings are: The 2023 Quality Assessment and Performance Improvement meeting minutes dated: 01/23,02/23,03/23,04/23,05/23,06/23,07/23,08/23,10/23,11/ 23, 12/23 lacks documented evidence of formal performance improvement projects were developed to address the patient needs for bowel regimen, falls, spiritual care, and high turnover rates. On 1/26/2024 at 10:55 AM, the Administrator/ Director of Patient Services was interviewed and stated” The chaplain last worked day was 12/30/2022”. No further explanation was provided”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023, and interview with the hospice Administrator/ Director of Patient Services, the hospice failed to ensure Performance Improvement Projects were of sufficient scope to address the needs of the patient and improve hospice care and services. Failure to develop Performance Improvement Projects that address the needs of the patient and improve hospice care and services has the potential to result in negative patient outcomes. The findings include: A review of the meeting minutes dated( 01/123, 02/23,03/23,04/23, 05/23, 06/23,07/23,08/23, 09/2310/23,11/23,12/23) lack documentation that sufficient data, that included evaluating all aspects of patient service and activities that may impact patient and family care and all facets of the hospice’s operation, was collected and quality indicators established and utilized to determine what Performance Improvement Projects would be appropriate to improve quality of care and improve the non-clinical operations of the hospice. The meetings minutes lack documented evidence of discussion of lack of pastoral care services, the high turnover rates, pain management, bowel regimen, the impact on patient care services, the reasons patients declined pastoral services, and implementation of preventive actions or opportunities for improvement to address the spiritual needs of the patients receiving Hospice care. There is a lack of documented evidence of a formal Performance Improvement Project that was developed to address the patient needs to ensure adequate spiritual/ pastoral care services. There is no documented evidence this aspect of the patient care and services was discussed at the Quality Assessment and Performance Improvement meetings of 2023. On 1/26/2024 at 10:55 AM, the Hospice Administrator/ Director of Patient Services was interviewed and stated” the last day worked for the chaplain was12/30/2022”. No further explanation was provided.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023, and interview with the hospice Administrator/ Director of Patient Services, the hospice failed to ensure Performance Improvement Projects contained documentation that measured the progress that had been achieved. Failure to document progress toward the goal of the Performance Improvement Project has the potential to inhibit the hospice’s ability to evaluate what interventions have been successful or the need to expand the scope of the Performance Improvement Project to ensure the goals have been achieved has the potential for negative patient outcomes. The findings are: The 2023 Quality Assessment and Improvement documented one Performance Improvement Plan titled” Improving Hospice pain documentation through real time auditing and the provision of regulatory based education.” The Performance Improvement project goal was to “;increase the percentage of hospice patient stays during which the patient is screened for pain during the initial assessment, et to increase the percentage of hospice patient stays during which the patient is screened positive for pain and received a comprehensive of pain within one day of screening”. The Quality Assessment and Performance Improvement meeting minutes dated: 01/19/23,02/23/23,03/9/23,4/20/23,5/11/23,6/22/23,7/27/23,8/24/23,9/28/23,10/12/23. lack documented evidence of measurable progress achieved on this performance improvement project, and evaluation of interventions implemented to achieve the goal. The Quality Assessment and Improvement meeting minutes dated 11/22/23 documents: “;Education reinforced regarding completion of the roll up questions of pain assessment”. The Quality Assessment and Improvement meeting minutes dated 12/07/2023 documents: “;Review of comprehensive pain assessment with focus on assessing the nonverbal patient”. The meeting minutes of 11/23 and 12/23 lack documentation of the measurable outcome-oriented progress made toward the goal managing patients pain, and implementation of interventions to achieve the goal. There is no documented evidence of a complete Performance Improvement project based on the hospice quality monitoring. On 1/25/2024 at 3:17 PM, the Administrator / Director of Patient Services was interviewed and did not provide an explanation for the findings. On 1/26/2024 at 10:55 AM, the Administrator/ Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023 and interview with the hospice Administrator/ Director of Patient Services, the Governing Body failed to ensure Quality Assessment and Performance program activities for patient safety are defined, implemented, maintained, and evaluated annually. Failure of the Governing Body to ensure Quality Assessment and Improvement activities for patient safety are defined, implemented maintained, and evaluated annually has the potential for negative patient outcomes. The findings are: On 1/24/2024, the surveyor requested the Governing Body meeting Minutes for 2023 The agency provided a document titled:” 2022 Hospice Annual Report and Program Evaluation”. On 01/25/2024 at 3:17 PM the hospice Administrator/ Director of Patient Services was interviewed and gave a post it note with a meeting date of 4/7/2023, and stated she received a verbal approval for the pain management Performance improvement project from the Governing Body. The Hospice’s Fiscal Year for Quality Assessment and Performance Improvement is July 1st through June 30th as reported by the Administrator/Director of Patient Services. There is no documented evidence a report of the Quality Assessment and Performance Improvement Program for the fiscal year 2022-2023 and the fiscal year 2023-2024 was submitted to the Governing Body for review and approval of the program. There is no documented evidence the Governing Body was aware that all the Quality Assessment and Performance Improvement activities were not being performed. There is no documented evidence the Hospice’s Quality Assessment and Performance Improvement for patient safety is being evaluated annually by the Governing Body. On 1/25/2024, at 3:17 PM, the Administrator/ Director of Patient Services was interviewed and did not provide an explanation.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement Program and activities for 2023 and interview with the hospice Administrator/ Director of Patient Services, the Governing Body failed to ensure Quality Assessment and Performance Improvement program activities address priorities for improved quality of care and patient safety. and that all improvement actions are evaluated for effectiveness. Failure of the Governing Body to ensure Quality Assessment and Performance Improvement activities are prioritized to improve quality of care and patient safety, and that all improvement actions are evaluated for effectiveness has the potential for negative patient outcomes. The findings are: The Hospice’s Fiscal Year for Quality Assessment and Performance Improvement is July 1st through June 30th as reported by the Administrator/Director of Patient Services. The 2023 Quality Assessment and Performance Improvement meeting minutes dated: 01/23,02/23,03/23,04/23,05/23,06/23, 07/23,08/23/09/23,10/23/11/23,12/23 lacks documented evidence they were reviewed and approved by the Governing Body for the fiscal year 2022-2023 and the fiscal year 2023-2024. There is no documented evidence the Governing Body was made aware of the performance improvement efforts being monitored by the hospice. There is no documented evidence the Governing Body’s approval or disapproval of the hospice performance improvement activities. There is no documented evidence of the Governing Body oversight of the hospice’s improvement priorities for improved quality care and patient safety. There is no documented evidence the Governing Body evaluated the improvements actions for their effectiveness. On 1/25/2024 at 3:17 PM and 1/26/2024 at 10:50 AM, the Administrator/ Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on review of the Hospice’s Infection Control and Surveillance Plan, the Infection Control Plan for FY2024 (Fiscal Year 2024 07/01/2023-06/30/2024), and interviews with the Administrator, the hospice fails to develop and implement policies and procedures regarding accepted standards of practice to prevent the transmission of infections and communicable diseases. Failure to ensure the development and implementation of policies and procedures regarding accepted standards of infection control has the potential to place patients, families, and other caregivers at risk for exposure to infectious and/or communicable diseases which may result in negative patient outcomes. The findings are: The hospice’s infection control policies and procedures titled “Infection Control and Surveillance Plan” with a review date of 03/25/2023, and undated “;Long Island Community Hospital Infection Control Plan FY2024 (Fiscal Year 2024 07/01/2023-06/30/2024)” lack documented evidence of following standards of practice related to infection prevention, including standard precautions, for patients in the different settings care is provided. The agency failed to develop and implement an infection control plan inclusive of how to prevent the spread of communicable diseases and infections. The findings were reviewed with the Administrator/Director of Patient Services on 01/26/2024 at 1:45PM; no additional information was provided.”

“Based on review of the Hospice’s Quality Assessment and Performance Improvement (QAPI) Program, the Hospice’s Infection Control and Surveillance Plan, the Infection Control Plan for FY2024 (Fiscal Year 2024 07/01/2023-06/30/2024) and staff interviews, the hospice failed to ensure the development of a comprehensive infection control program that included the surveillance and investigation of infectious and communicable diseases and ensure it is an integral part of the hospice’s Quality Assessment Performance Improvement program. Failure to ensure the development of a comprehensive infection control program that includes surveillance and investigation of infectious and communicable diseases and ensure it is an integral part of the hospice’s Quality Assessment and Performance Improvement program has the potential to place patients and staff at risk for exposure to infectious and/or communicable diseases which may result in negative patient outcomes. The findings are: There is no documented evidence patient and volunteer illnesses are documented and tracked or that staff and volunteer illnesses are correlated with patient infections to determine commonalities among the infections. The Hospices Quality Assessment Performance Improvement meeting minutes for 2023 dated 01/19/2023, 02/23/2023, 03/09/2023, 04/20/2023, 05/11/2023, 06/22/2023, 07/27/2023, 08/24/2023, 09/28/2023, 10/12/2023, 11/22/2023, and 12/07/2023 lack documented evidence data is reviewed, tracked and analyzed regarding patient, staff and volunteer infections to determine if performance improvement activities should be implemented to improve patient safety outcomes and reduce the incidence of infection. The Administrator/Director of Patient Services was interviewed on 01/26/2024 at 1:45PM and findings reviewed; no additional information was provided.”

“Based on review of the hospice’s Quality Assessment and Performance Improvement (QAPI) activities for 2023 and staff interview, the hospice failed to ensure the development of a comprehensive infection control program that includes the implementation of strategies to reduce the incidence of patient infections. Failure to ensure the development of a comprehensive infection control program that includes the implementation of strategies to reduce the incidence of patient infections has the potential to place patients and staff at risk for exposure to infectious and/or communicable diseases and result in negative patient outcomes. The findings are: The Hospices Quality Assessment Performance Improvement meeting minutes for 2023 dated 01/19/2023, 02/23/2023, 03/09/2023, 04/20/2023, 05/11/2023, 06/22/2023, 07/27/2023, 08/24/2023, 09/28/2023, 10/12/2023, 11/22/2023, and 12/07/2023 lack documented evidence that patient infections were tracked and presented to Quality Assessment Performance Improvement committee members for analysis to determine if the committee needed to develop strategies to reduce the incidence of patient infections. The Administrator/Director of Patient Services was interviewed on 01/26/2024 at 1:45PM and findings reviewed; no additional information was provided.”

“Based on review of the Hospice’s Quality Assessment and Performance Improvement (QAPI) Program, the Hospice’s Infection Control and Surveillance Plan, the Infection Control Plan for FY2024 (Fiscal Year 2024 07/01/2023-06/30/2024), Patient Admission Packet and staff interviews, the hospice failed to ensure infection control education to patients, family members, and other caregivers. Failure to ensure infection control education is provided to patients, family members, and other caregivers has the potential to place patients, families, and other caregivers at risk for exposure to infectious and/or communicable diseases which may result in negative patient outcomes. The findings are: The hospice’s infection control policies and procedures titled “Infection Control and Surveillance Plan” with a review date of 03/25/2023, and undated “;Long Island Community Hospital Infection Control Plan FY2024 (Fiscal Year 2024 07/01/2023-06/30/2024)”, and Patient Admission Packet fails to document procedures and protocols for providing infection control education to patients, family members, and other caregivers. The Administrator/Director of Patient Services was interviewed on 01/26/2024 at 1:45PM and findings reviewed; no additional information was provided.”

“Based on record review and interview with the Administrator/ Director of Patient Services, the Hospice failed to ensure that counseling and bereavement services were made available to the family and other individuals in the bereavement plan of care for up to one year following the death of the patient, and to ensure that bereavement services reflect the needs of the bereaved. This was evident for seven (7) of twenty-two (22) deceased clinical records reviewed. (Patient #1, #6, #15, #16, #18, #21, and #22). Failure to ensure counseling and bereavement services are made available and reflect the needs of the bereaved has the potential for negative outcomes. 1. Patient #6 has a start of care date of 08/29/2023 with diagnoses of Secondary Malignant Neoplasm of unspecified site, other nonspecific finding of lung field, and Pleural Effusion in other conditions classified elsewhere as documented on the “;Hospice Certification and Plan of Care” dated 08/29/2023 to 11/26/2023. The “;Hospice Certification and Plan of Care” dated 08/29/2023 to 11/26/2023 documents an order for “;Skilled Nurse (SN) 5 times per week for 1 week, 7 times per week for 11 weeks, 1 time per week for 1 week, and 5 times as needed), Medical Social Worker (MSW) 1 time per week for 1week.” The “;Registered Nurse (RN) Hospice Unattended Death Note Report” dated 08/30/2023 documents “;patient expired 5:50AM pronounced by (hospital) Physician Assistant (PA). Bereavement to follow. Emotional support provided to family”. The “;Hospice Interdisciplinary Group (IDG) Assessment and Plan of Care Update Report” dated 08/30/2023 documents “;patient expired on 08/30, prior to initial SW (social worker) assessment. Plans until next Interdisciplinary Group: Social Worker will provide bereavement support to patients family”. The record lacks documented evidence of a comprehensive bereavement assessment focused on the needs of the bereaved. The record lacks documented evidence of counseling and bereavement services provided to the family and other caregivers from the date of patient death on 08/30/2023 the date of survey 01/22/2024. On 01/25/2024 at 4:15PM the Administrator/Director of Patient Services was interviewed and did not provide and explanation for the findings. 2. Patient #1 has a start of care date of 11/9/23 and expired on 11/19/23 at 11:40 AM with diagnosis of Liver Cell Carcinoma documented on the Hospice Certification and Plan of Care for Certification Period for 11/9/23 to 2/6/24. The record lacks documented evidence of counseling and bereavement services were provided. 3. Patient #15 has a start of care date of 6/8/23 and expired on 7/4/23 with diagnoses of Alzheimers Disease, Essential (Primary) Hypertension, and Pain, unspecified documented on the Hospice Certification and Plan of Care for Certification Period of 6/8/23 to 9/5/23. The record lacks documented evidence of counseling and bereavement services were provided. 4. Patient #16 has a start of care date of 6/26/23 and expired on 7/5/23 with diagnoses of Acute Respiratory Failure, Unspecified with Hypoxia or Hypercapnia, Pneumonia, Unspecified Organism and Sepsis due to Streptococcus Pneumoniae documented on the Hospice Certification and Plan of Care for Certification Period for 6/26/23 to 9/23/23. The record lacks documented evidence of counseling and bereavement services were provided. 5. Patient # 18 has a start of care date of 9/18/23 and expired on 10/17/23 at home with diagnosis of Alzheimers Disease, Unspecified documented on the Hospice Certification and Plan of Care for Certification Period for 9/18/23 to 12/16/23. The record lacks documented evidence of counseling and bereavement services were provided. 6. Patient #21 has a start of care date of 11/9/23 and expired on 11/19/23 with diagnosis of Liver Cell Carcinoma documented on the Hospice Certification and Plan of Care for Certification Period for 11/9/23 to 2/6/24. The record lacks documented evidence of counseling and bereavement services were provided. 7. Patient # 22 has a start of care date of 10/31/23 and expired on 11/1/23 with diagnoses of Acute Respiratory Failure, Unspecified with Hypoxia, Sepsis, Unspecified Organism, Heart Failure, Unspecified and Non-ST Elevation (NSTEMI) Myocardial Infarction documented on the Hospice Certification and Plan of Care for Certification Period for 10/31/23 to 12/29/23. The record lacks documented evidence of counseling and bereavement services were provided. On 1/24/ 2024, at 11:30AM, the Administrator/ Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Based on clinical record review and staff interview with the Administrator/Director of Patient Services, the Hospice failed to provide Spiritual Counseling to the terminally ill patients. This was evident for fourteen (14) of nineteen (19) clinical records reviewed. (Patients #1, #7, #8, #9, #10, #11, #12, #14, #15, #16, #18, #19, #21 and #23). Failure to ensure the Spiritual Counseling of the Hospice patient, has the potential for negative patient outcomes. The findings include: 10. Patient #1 has a start of care date of 11/9/23 and expired on 11/19/23 at 11:40 AM with diagnosis of Liver Cell Carcinoma documented on the Hospice Certification and Plan of Care for Certification Period for 11/9/23 to 2/6/24. The Hospice Certification and Plan of Care for Certification Period for 11/9/23 to 2/6/23 documents, “;SN (Skilled Nursing) 2x weekly x11 weeks, 1x week x1 week, 3 visits as needed; MSW (Medical Social Worker) 1x week x13 weeks, 2 as needed visits”. The clinical record lacks documented evidence that the Hospice ordered and/or provided spiritual counseling to ensure the spiritual need of the Hospice patients met before death. 11. Patient #15 has a start of care date of 6/8/23 and expired on 7/4/23 with diagnoses of Alzheimers Disease, Essential (Primary) Hypertension, and Pain, unspecified documented on the Hospice Certification and Plan of Care for Certification Period of 6/8/23 to 9/5/23. The Hospice Certification and Plan of Care for Certification Period of 6/8/23 to 9/5/23 documents, “;SN (Skilled Nursing) 2x weekly x 1 week, 2x weekly x11 weeks, 1x week x1 week, 5 PRN visits (as needed); MSW (Medical Social Worker) 1x week x1 week”. 12. Patient #16 has a start of care date of 6/26/23 and expired on 7/5/23 with diagnoses of Acute Respiratory Failure, Unspecified with Hypoxia or Hypercapnia, Pneumonia, Unspecified Organism and Sepsis due to Streptococcus Pneumoniae documented on the Hospice Certification and Plan of Care for Certification Period for 6/26/23 to 9/23/23. The Hospice Certification and Plan of Care for Certification Period for 6/26/23 to 9/23/23 documents, “;SN (Skilled Nursing) 6x weekly x1 week, 7x weekly x11 weeks, 1x week x1 week, 5 visits as needed”. The clinical record lacks documented evidence that the Hospice ordered and/or provided spiritual counseling to ensure the spiritual need of the Hospice patients met before death. 13. Patient # 18 has a start of care date of 9/18/23 and expired on 10/17/23 at home with diagnosis of Alzheimers Disease, Unspecified documented on the Hospice Certification and Plan of Care for Certification Period for 9/18/23 to 12/16/23. The Hospice Certification and Plan of Care for Certification Period for 9/18/23 to 12/16/23 documents, “;SN (Skilled Nursing) 2x weekly x10 weeks, 1x week x1 week, 3 visits as needed”. The clinical record lacks documented evidence that the Hospice ordered and/or provided spiritual counseling to ensure the spiritual need of the Hospice patients met before death. 14. Patient # 23 has a start of care date of 10/31/23 and expired on 11/1/23 with diagnoses of Acute Respiratory Failure, Unspecified with Hypoxia, Sepsis, Unspecified Organism, Heart Failure, Unspecified and Non-ST Elevation (NSTEMI) Myocardial Infarction documented on the Hospice Certification and Plan of Care for Certification Period for 10/31/23 to 12/29/23. The Hospice Certification and Plan of Care for Certification Period for 10/31/23 to 12/29/23. documents, “;SN (Skilled Nursing) 5x weekly x1 week, 7x/week x7weeks, 1x week x1 week, 5 visits as needed; MSW (Medical Social Worker) effective 11/2/23 1x week x1 weeks, 2 as needed visits”. The clinical record lacks documented evidence that the Hospice ordered and/or provided spiritual counseling to ensure the spiritual need of the Hospice patients met before death. On 1/25/2024, at 11:30AM, the Administrator/ Director of Patient Services was interviewed and did not provide an explanation for the findings. 4. Patient #7 has a start of care date of 01/17/2024 with diagnoes of Respiratory Syncytial Virus, COVID-19, Alzheimer’s Disease late onset, and Cerebral Infarction as documented on the “Hospice Certification and Plan of Care” for certification period 01/17/2024 - 04/15/2024. The Hospice patient has a date of death of 01/24/2024. The “Hospice Certification and Plan of Care” for certification period 01/17/2024 - 04/15/2024 documents an order for “;Skilled Nurse 4 wk 1, 7 wk 11, 1 wk1, 5 PRN (four visits a week for one week, seven visits a week for eleven weeks, one visit a week for one week, five as needed visits). Orders of Discipline treatments: “;Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care”. The clinical record lacks documented evidence that the Hospice offered and/or provided spiritual counseling to ensure the spiritual need of the Hospice patient before death. The survey findings and interview were conducted on 01/24/2024 at 12:11 PM with the Hospice staff. Interview conducted with the Administrator/Director of Patient Services on 01/25/2024 at 10:20 AM. No explanation was provided. 5. Patient #9 has a start of care date of 04/06/2023 with diagnoses of Alzheimer’s Disease with late onset, Primary Generalized Osteoarthritis, Displaced Artic Fracture Head of Unspecified Femur, and Essential Hypertension as documented on the “;Hospice Certification and Plan of Care” for certification period 04/06/2023 to 07/04/2023. The Hospice patient has a date of death of 04/16/2023. The “;Hospice Certification and Plan of Care” for certification period 04/06/2023 to 07/04/2023 documents an order for “;Skilled Nurse 2 wk. 12, 1 wk. 1, 5 PRN (two visits a week for twelve weeks, one visit a week for one week, five as needed visits). Orders of Discipline treatments: “Hospice Registered Nurse to evaluate patient and develop a Nursing Plan of Care”. The clinical record lacks documented evidence that the Hospice offered and/or provided spiritual counseling to ensure the spiritual need of the Hospice patient before death. The survey findings were reviewed on 01/25/2024 at 04:07 PM with the Hospice staff. Interview conducted with the Administrator/Director of Patient Services on 01/26/2024 at 10:30 AM. No explanation was provided. 6. Patient #10 has a start of care date of 09/05/2023 with diagnoses of Acute Respiratory Failure with Hypoxia, Sepsis due to Streptococcus Pneumonia, and Gastrointestinal Hemorrhage as documented on the “;Hospice Certification and Plan of Care” for certification period 09/05/2023 to 12/03/2023. The Hospice patient has a date of death of 09/18/2023. The “;Hospice Certification and Plan of Care” for certification period 09/05/2023 to 12/03/2023 documents an order for Skilled Nurse 3 wk 1, 3 wk 11, 1 wk 1, 5 PRN (three visits a week for one week, three visits a week for eleven weeks, one visit a week for one week, and five as needed vists). Orders of Discipline treatments: “;Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care”. The clinical record lacks documented evidence that the Hospice offered and/or provided spiritual counseling to ensure the spiritual need of the Hospice patient before death. The survey findings were reviewed on 01/24/2024 at 12:00PM with the Hospice staff. Interview conducted with the Administrator/Director of Patient Services on 01/25/2024 at 10:00 AM. No explanation was provided. 7. Patient #12 has a start of care date of 01/19/2024 with diagnoses of Malignant Neoplasm of Parietal Lobe, Secondary Malignant Neoplasm of Brain and Personal History of Other Malignant Neoplasm of Kidney as documented on the “;Hospice Certification and Plan of Care” for certification period 01/19/2024 to 04/17/2024. The “;Hospice Certification and Plan of Care” for certification period 01/19/2024 to 04/17/2024 documents an order for “;Skilled Nurse 1wk 1, 3 wk. 1, 2 wk. 10, 1 wk. 1, 5 PRN (one visit a week for one week, three visits a week for one week, two visits s week for ten weeks, one visits a week for one week and five as needed visits). Orders of Discipline treatments: “;Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care”. The clinical record lacks documented evidence that the Hospice offered and/or provided spiritual counseling to ensure the spiritual need of the Hospice patient. The survey findings were reviewed on 01/24/2024 at 12:25 pm with the Hospice staff. Interview with the Administrator/Director of Patient Services on 01/25/2024 at 12:10 PM. No explanation was provided. 8.Patient #19 has a start of care 10/27/2023 with diagnoes of Unspecified Dementia as documented on the “;Hospice Certification and Plan of Care” for certification period 10/27/2023 - 01/24/2024. The Hospice patient has a date of death on 12/19/2023. The “;Hospice Certification and Plan of Care” for certification period 10/27/2023 – 01/24/2024 documents an order for “;Skilled Nurse 1 wk 1, 3 wk 1, 2 wk 10, 1 wk 1, 5 PRN (one visit a week for one week, three visits a week for one week, two visits a week for ten weeks, one visit a week for one week, five as needed visits). Orders of Discipline treatments: “Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care”. The clinical record lacks documented evidence that the Hospice offered and/or provided spiritual counseling to ensure the spiritual need of the Hospice patient prior to death. The survey findings and interview were reviewed on 01/25/2024 at 04:07 PM with the Hospice staff. No explanation was provided. 9. Patient #21 has a start of care date of 05/15/2023 with diagnoses of Alzheimer’s Disease with late onset, Pneumonia unspecified Organism, and Dysphagia unspecified as documented on the “;Hospice Certification and Plan of Care” for certification period 05/15/2023 - 08/12/2023. The Hospice patient has a date of death of 05/22/2023. The “;Hospice Certification and Plan of Care” for certification period 05/15/2023 - 08/12/2023 documents an order for “Skilled Nurse 1 wk 1, 3 wk 1, 2 wk 10, 1 wk 1, 5 PRN (one visit a week for one week, three visits a week for one week, two visits a week for ten weeks, one visit a week for one week, five as needed visits). : “;Hospice RN (Registered Nurse) to evaluate patient and develop a nursing plan of care . The clinical record lacks documented evidence that the Hospice offered and/or provided spiritual counseling to ensure the spiritual need of the Hospice patient before death. The survey findings were reviewed on 01/25/2024 at 04:05 pm with the Hospice staff. Interview of the Adminitrator/Director of Patient Services on 01/26/2024 at 10:34 AM. No explanantion was provided. 2. Patient #8 has a start of care date of 12/8/2023, and an expiration date of 12/15/2024. with diagnoses of Myocardial Infarction, Type 2, Alzheimer’s Disease as documented on the “;Hospice Certification and Plan of Care” for Certification Period 12/8/2023 to 3/6/2024. The “;Hospice Certification and Plan of Care” for certification period of 12/8/2023 to 3/6/2024 documents an order for “;Skilled Nurse 2 wk1. 7WK 11, 5 as needed (PRN) (two visits/ week for one week, seven visits a week for eleven weeks, one visit a week x one week, and five visits as needed). Hospice Registered Nurse to evaluate patient, develop a nursing plan of care, monitor patient’s pain level, and report ineffective pain control to the physician.” The clinical record lacked documented evidence that the Hospice provided Spiritual Counseling to ensure the spiritual need of the patient before death. 3. Patient #11 has a start of care date of 7/17/2023 and expired at home on 8/3/2023.ith diagnoses of Acute Respiratory Failure with Hypoxia/Hypercapnia, Unspecified Dementia, Chronic lymphocytic Leukemia of B-Cell as documented on the “Hospice Certification and Plan of Care” for certification period of 7/17/2023 to 10/14/2023. The “Hospice Certification and Plan of Care, certification period of 7/17/2023 to 10/14/2023” documented an order for Skilled Nursing 6WK1, 7WK11, 1WK1, 5 (PRN) as needed. MSW effective 7/17/2023 1WK1(six weeks-one visit; seven weeks- eleven visits; one week - one visit; and five visits as needed). The clinical record lacked documented evidence that the Hospice provided Spiritual Counselling to ensure the spiritual needs of the patient before death. On 01/26/2024, at 2: 15.PM the Administrator/ Director of Patient Services was interviewed and did not provide an explanation for the findings. 1. Patient #14 has a start of care date of 01/16/24 with diagnoses of Acute Respiratory Failure with Hypoxia/Hypercapnia, Cardiac Arrest and Muscular Dystrophy as documented on the Hospice Certification and Plan of Care for Certification Period of 01/16/24 to 04/14/2024. The Hospice Certification and Plan of Care for Certification Period of 01/16/24 to 04/14/24 documents, “;Skilled Nursing 3x weekly x 1 week, 2x weekly x11 weeks, 1x week x1 week, 5 visits as needed; Medical Social Worker 1x week x1 week”. Orders of Discipline treatments: “Hospice Registered Nurse to evaluate patient and develop a nursing plan of care”. The Medical Social Worker” Visit Note Report” dated 1/17/2024 documents:” patient’ religion, anointing previously arranged at family request” The clinical record lacks documented evidence that the Hospice offered and/or provided spiritual counseling to ensure the spiritual need of the Hospice patient. Findings reviewed on 1/25/24 at 01:30 PM with the Administrator/ Director of Patient Services and Clinical Manager. They did not provide any further explanation.”