Northeastern Health System Sequoyah

“Based on record review and interview, the IDG members failed to complete the comprehensive assessment within 5 days of the SOC in order to identify the patient/familys physical, psychosocial, emotional and spiritual needs and contribute to the development of the plan of care, failed to conduct a review of all of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy and failed to complete an initial bereavement risk assessment of the patient’s and family needs for fourteen (#1 - #14) of fourteen (#1 - #14) records reviewed. This failed practice had the potential to place all current patients and any future patients at risk of poor patient care and outcomes. Based on record review and interview, the IDG members failed to complete the comprehensive assessment within 5 days of the SOC in order to identify the patient/familys physical, psychosocial, emotional and spiritual needs and contribute to the development of the plan of care to address those needs for fourteen (#1 - #14) of fourteen (#1 - #14) records reviewed. This failed practice had the potential to place all current patients and any future patients at risk of poor patient care and outcomes. (See L523) Based on record review and interview the Agency failed to conduct a review of all of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy as part of the comprehensive assessment for six (#1, #2, #3, #5, #6 and #11) of fourteen (#1 - #14) records reviewed. This failed practice had the potential to place all current patients and any future patients at risk of poor patient care and outcomes. (See L530) Based on record review and interview the IDG failed to complete an initial bereavement risk assessment of the patient’s and family needs and to incorporate the information into the plan of care and develop a bereavement plan of care for fourteen (#1 - #14) of fourteen (#1 - #14) records reviewed. This failed practice had the potential to place all current patients and any future patients at risk of poor patient care and outcomes. (See L531)”

“Based on record review and interview, the agency failed to ensure its QAPI program showed measurable improvement in indicators related to improved palliative outcomes and hospice services, failed to ensure the development and analysis of performance improvement projects and quality indicators, failed to ensure that an ongoing program for quality improvement and patient safety was defined, implemented, maintained, and evaluated annually and failed to ensure the hospice-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness for fourteen (#1 - 14) of fourteen (#1 - #14) patients currently on census. This failed practice had the potential to place all fourteen current patient and any future patient admitted to the hospice at risk for poor outcomes. Based on record review and interview, the agency failed to ensure its QAPI program showed measurable improvement in indicators related to improved palliative outcomes and hospice services for fourteen (#1 - 14) of fourteen (#1 - #14) patients currently on census. This failed practice had the potential to place all fourteen current patients and any future patients at risk of poor patient care and outcomes. (See L561)Based on record review and interview, the Governing Body failed to ensure the development and analysis of performance improvement projects and quality indicators for fourteen (#1 - 14) of fourteen (#1 - #14) patients currently on census. This failed practice had the potential to place all fourteen patients and any future patients at risk for poor outcomes due to the lack oversight and Governing Body involvement. (See L571) Based on record review and interview, the Governing Body failed to ensure that an ongoing program for quality improvement and patient safety was defined, implemented, maintained, and evaluated annually for fourteen (#1 - 14) of fourteen (#1 - #14) patients currently on census. This failed practice had the potential to place all fourteen current patients and any future patients at risk for poor outcomes due to the lack oversight and Governing Body involvement. (See L574).Based on record review and interview, the Governing Body failed to ensure the hospice-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness for fourteen (#1 - 14) of fourteen (#1 - #14) patients currently on census. This failed practice had the potential to place all fourteen current patient and any future patient admitted to the hospice at risk for poor outcomes. (See L575)”

“Based on record review and interview, the agency failed to provide Nursing services according to acceptable standards of practice for two (#10 -#11) of fourteen (#1 - #14) records reviewed and failed to provide counseling services that reflect the needs of the patient and family and in a manner consistent with acceptable standards of practice for fourteen (#1 -#14) of fourteen (#1 - #14) records reviewed. This failed practice had the potential to place all current patients, families and any future patients at risk for unmet needs and poor outcomes due to the lack of provision of core services by the agency. Based on record review and interview, the agency failed to provide Nursing services according to acceptable standards of practice for two (#10 -#11) of fourteen (#1 - #14) records reviewed. This failed practice had the potential to place current patients, families and any future patients at risk for unmet needs and poor outcomes due to the lack of provision of core services by the agency. (See L591) Based on record review and interview, the agency failed to provide counseling services that reflect the needs of the patient and family and in a manner consistent with acceptable standards of practice for fourteen (#1 -#14) of fourteen (#1 - #14) records reviewed. This failed practice had the potential to place all fourteen patients, families and any future patients at risk for unmet needs and poor outcomes due to the lack of provision of core services by the agency. (See L596)”

“Based on record review and interview, the hospice failed to ensure governing body oversite of a patient centered QAPI Program and ongoing operations of the patient care delivery systems for calendar years 2021, 2022 and 2023, the agency failed to provide evidence personnel records included agency orientation and hospice philosophy for five (#3, #4, #7, #8, and #9) of ten staff (#1 - #10) and failed to provide evidence of annual skills competency evaluations for eight (#2- #9) of ten (#1 - #10) staff. This failed practice had the potential to negatively impact the quality of care and services provided to all current patients and to any future patients. Based on record review and interview, the hospice failed to ensure governing body oversite of a patient centered QAPI Program and ongoing operations of the patient care delivery systems for calendar years 2021, 2022 and 2023 effecting all patients and staff. This failed practice had the potential to affect care and services provided to all current patients and any future patients admitted to hospice services (See L651)Based on record review and interview, the agency failed to provide evidence personnel records included agency orientation and hospice philosophy for five (#3, #4, #7, #8, and #9) of ten staff (#1 - #10). This failed practice had the potential to affect the knowledge of staff causing an inability to provide patient’s medical emotional and spiritual needs. (See L662)Based on record review and interview, the hospice failed to provide evidence of annual skills competency evaluations for eight (#2- #9) of ten (#1 - #10) staff. This failed practice had the potential to negatively impact the quality of care and services provided to all current patients and to any future patients. (See L663)”

“Based on record review and interview the Agency failed to maintain a clinical record for each hospice patient containing past and current findings and to ensure the correct clinical information remains available to the patients attending physician and hospice staff for fourteen (#1 - 14) of fourteen (#1 - #14) records reviewed. This failed practice had the potential to place all current patients and any future patients at risk for patient safety issues and poor outcomes due to delayed communications and care coordination among the IDG and hospice staff. Based on record review and interview the Agency failed to maintain a clinical record for each hospice patient containing past and current findings and to ensure the correct clinical information remains available to the patients attending physician and hospice staff for fourteen (#1 - 14) of fourteen (#1 - #14) records reviewed. This failed practice had the potential to place all current patients and any future patients at risk for patient safety issues and poor outcomes due to delayed communications and care coordination among the IDG and hospice staff. (See L672). Based on record review and interview, the Agency failed to document events related to the Discharge for Cause of Patient (See L683).”

“Based on record review and interview the Agency failed to ensure timely delivery of care and services necessary to prevent deterioration of a pressure ulcer for one (#11) of five (#4, #10 - #13) records reviewed with wounds identified. Patient #11 Review of clinical record #11 for certification period 01/03/24 - 01/20/24 revealed a primary diagnosis of Dementia with Sepsis due to Pneumonia with . Review of RN Initial Assessment conducted on 01/03/24 stated “Pt has wound to coccyx. Wound care started. Skin barrier cream in place and optifoam placed over wound”. Wound assessment by the RN indicated a Stage 2 pressure ulcer. In addition, DME equipment needs of a hospital bed and specialty mattress/overlay were identified. Review of the Plan of Care indicated SN visits 1 time per week and HHA 2 times per week with skin care evaluation at every visit. SN Visit note for 01/09/24 indicated the Pt#11 was in a recliner and wound care was provided. No wound measurements or instructions to the wife regarding wound care or prevention were documented. SN Visit note for 01/17/24 stated, “Stage 4 decubitus ulcer with necrotic tissue”. The SN documented Pt #11 was in a recliner, and SN discussed the need for repositioning and a mattress and hospital bed to prevent further deterioration of the wound. The wife agreed to the DME equipment in the home. Further record review revealed the Agency failed to ensure timely delivery of pressure alleviating devices of hospital bed and mattress to prevent further wound deterioration as identified during the Initial Assessment on 01/03/24. Pt #11 expired at home on 01/20/24. During an interview on 05/22/24 at 11:15 AM, the Supervising RN stated the bed and mattress were delivered to the home after the 01/17/24 visit but no documentation was evident in the clinical record.”

“Based on record review and interview, the IDG members failed to complete the comprehensive assessment within 5 days of the SOC in order to identify the patient/familys physical, psychosocial, emotional and spiritual needs and contribute to the development of the plan of care to address those needs for fourteen (#1 - #14) of fourteen (#1 - #14) records reviewed. Review of records #1 - #14 failed to provide evidence the MSW or Chaplain conducted discipline evaluations as part of the Comprehensive Assessment. An Initial SOC Assessment conducted by the RN with a psychosocial and spiritual screening was identified for each record, but no other documentation by the IDG MSW or Chaplain was identified. During an interview on 05/21/24 at 08:30 AM, the Supervising RN stated she conducts the assessment at SOC and the MSW and Chaplain visits are scheduled as needed and documented per paper notes. The Supervising RN confirmed there was no documentation the MSW and Chaplain assessments were conducted within 5 days of the SOC as part of the Comprehensive Assessment for Pts #1 - #14.”

“Based on record review and interview the Agency failed to conduct a review of all of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy as part of the comprehensive assessment for six (#1, #2, #3, #5, #6 and #11) of fourteen (#1 - #14) records reviewed. Patient #1 A record review of Patient #1 for re-certification period 05/06/24 to 07/04/24 failed to provide evidence the SN staff conducted a drug regimen review during the re-certification comprehensive assessment. Patient #2 A record review of Patient #2 for certification period 03/29/24 to 06/26/24 failed to provide evidence the SN staff conducted a drug regimen review during the initial certification comprehensive assessment. Patient #3 A record review of Patient #3 for re-certification period 03/28/24 to 05/26/24 failed to provide evidence the SN staff conducted a drug regimen review during the re-certification comprehensive assessment. Patient #5 A record review of Patient #5 for certification period 04/01/24 to 06/29/24 failed to provide evidence the SN staff conducted a drug regimen review during the initial certification comprehensive assessment. Patient #6 A record review of Patient #6 for certification period 03/22/24 to 06/19/24 failed to provide evidence the SN staff conducted a drug regimen review during the initial certification comprehensive assessment. Patient #11 A record review of Patient #11 for certification period 01/03/24 to 01/20/24 failed to provide evidence the SN staff conducted a drug regimen review during the initial certification comprehensive assessment. During an interview on 05/22/24 at 11:15 AM, the Supervising RN stated there was no evidence in the clinical record the SN staff conducted a drug regimen review of all the medications the patients were currently taking as part of the comprehensive assessments for Patients #1, #2, #3 #5, #6 and #11.”

“Based on record review and interview the IDG failed to complete an initial bereavement risk assessment of the patient’s and family needs and to incorporate the information into the plan of care and develop a bereavement plan of care for fourteen (#1 - #14) of fourteen (#1 - #14) records reviewed. Review of Clinical Visit Notes and Bereavement Program documentation failed to provide evidence the IDG conducted an initial Bereavement Risk Assessment as part of the Comprehensive Assessment for fourteen (#1 - #14) records reviewed. During an interview on 05/22/24 at 11:15 AM, the Supervising RN stated the IDG failed to complete an initial bereavement risk assessment for Patients #1 - #14.”

“Based on record review and interview, the Agency failed to develop individualized written plan of care based on patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments for fourteen (#1-#14) of fourteen (#1 -#14) records reviewed. Review of records #1 - #14 failed to provide evidence the IDG developed individualized written POC based on discipline evaluations as part of the Comprehensive Assessment. Initial SOC Assessments conducted by the RN with a psychosocial and spiritual screening were identified for each record, but no other documentation by the IDG MSW or Chaplain were identified for the Initial POC or any IDG updates of the POC. During an interview on 05/21/24 at 08:30 AM, the Supervising RN stated she conducts the assessment at SOC and the MSW and Chaplain visits are scheduled as needed and documented per paper notes. The Supervising RN stated the MSW and Chaplain participate in IDG POC updates but confirmed there was no documentation of MSW and Chaplain assessments for the Initial POC or any IDG updates of the POC for Pts #1 - #14.”

“Based on record review and interview, the Agency failed to ensure governing body oversite of a patient centered QAPI Program and ongoing operations of the patient care delivery systems and to ensure its QAPI program showed measurable improvement in indicators related to improved palliative outcomes and hospice services for calendar years 2021, 2022 and 2023. This is a repeat deficiency from the previous re-certification survey. A review of agency QAPI documents and Board Meeting minutes for the years 2021, 2022, 2023 and 2024, indicated Hospice statistics [admissions, referrals, deaths] were tracked and reported, but the documents failed to provide evidence of hospice service indicators or palliative outcomes.During an interview on 05/22/24 at 10:30 AM, the Supervisory RN stated the statistics were provided for the Board Meeting each month and verified no additional measurable palliative care or hospice service indicators were tracked or measured.”

“Based on record review and interview, the Governing Body failed to ensure the development and analysis of performance improvement projects and quality indicators for fourteen (#1 - 14) of fourteen (#1 - #14) patients currently on census. This failed practice had the potential to place all fourteen patients and any future patients at risk for poor outcomes due to the lack oversight and Governing Body involvement. A review of the agency QAPI documents and Board Meeting minutes provided for the years 2022, 2023 and 2024 failed to provide evidence of hospice specific performance improvement projects.During an interview on 05/22/24 at 10:30 AM, the Supervisory RN stated there were no hospice performance improvement projects developed for the agency to analyze hospice services.”

“Based on record review and interview, the Governing Body failed to ensure that an ongoing program for quality improvement and patient safety was defined, implemented, maintained, and evaluated annually for fourteen (#1 - 14) of fourteen (#1 - #14) patients currently on census. This failed practice had the potential to place all fourteen current patients and any future patients at risk for poor outcomes due to the lack oversight and Governing Body involvement. This is a repeat deficiency from the previous survey. . A review of the agency QAPI documents and Board Meeting minutes for the years 2022, 2023 and 2024 failed to provide evidence of ongoing hospice program outcomes or annual evaluation.During an interview on 05/22/24 at 10:30 AM, the Supervisory RN stated she was not aware of an agency program evaluation and the Administrator was unable to provide evidence of an annual evaluation.”

“Based on record review and interview, the Governing Body failed to ensure the hospice-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness for fourteen (#1 - 14) of fourteen (#1 - #14) patients currently on census. This failed practice had the potential to place all fourteen current patient and any future patient admitted to the hospice at risk for poor outcomes. This is a repeat deficiency from the previous re-certification survey. A review of the agency QAPI documents and Board Meeting minutes for the years 2022, 2023 and 2024 failed to provide evidence of ongoing hospice-wide program with priorities identified for hospice outcomes, improvement action and effectiveness. During an interview on 05/22/24 at 10:30 AM, the Supervisory RN stated there was no agency hospice improvement and effectiveness action plan or monitoring.”

“Based on record review and interview, the Agency failed to provide Nursing services according to current standards of practice for two (#10, #11) of fourteen (#1 - #14) records reviewed. Patient #10 Review of clinical record #10 for certification period 03/08/23 - 06/05/23 revealed a primary diagnosis of Malignant Neoplasm of the Colon and documentation on 03/10/23 revealed Pt #10 had a fall at home and was admitted to the hospital with a fractured hip. An RN SOC assessment completed on 03/22/23 included routine hospice orders and orders for SN visits one time a week. The assessment did not identify any surgical wound or orders related to the recent hip fracture. In addition, review of the SN Visit Note for 03/30/23 did not identify any surgical wound or orders related to the recent hip fracture. Documentation by the RN for SN visit conducted on 04/06/23 indicated a surgical hip incision with 13 staples that appeared infected and a source of pain for the patient. The POC update by the IDG on 04/07/23 based on the RN assessment added Wound Infection and interventions to the POC. During an interview on 05/22/24 at 11:15 AM, the Supervising RN confirmed the RN SOC assessment of 03/22/23 and subsequent SN visit on 03/30/23 failed to identify and assess a surgical wound for Pt #10. Patient #11 Review of clinical record #11 for certification period 01/03/24 - 01/20/24 revealed a primary diagnosis of Dementia with Sepsis due to Pneumonia. Review of RN Initial Assessment conducted on 01/03/24 stated “Pt has wound to coccyx. Wound care started. Skin barrier cream in place and optifoam placed over wound”. Wound assessment by the RN indicated a Stage 2 pressure ulcer with SN visits one time per week and HHA two times per week with skin care evaluation at every visit. SN Visit note for 01/09/24 indicated wound care was provided but no wound measurements or instructions to the wife regarding wound care or prevention were documented. SN Visit note for 01/17/24 stated, “Stage 4 decubitus ulcer with necrotic tissue”. The SN documented wound care was provided and wound measurements and assessment indicated deterioration of wound from Stage 2 to Stage 4 with SN visits to continue at 1 time per week. During an interview on 05/22/24 at 11:15 AM, the Supervising RN stated the SN staff failed to timely assess and measure wounds for Pt #10 and #11 according to current Nursing standards of practice.”

“Based on record review and interview, the agency failed to conduct a bereavement risk assessment for fourteen (#1 -#14) of fourteen (#1 - #14) records reviewed and failed provide bereavement counseling services for the bereaved members of three (#10, #11 and #12) of three (#10, #11 and #12) death records reviewed. This is a repeat deficiency from the previous re-certification survey. Patients #1 -#14: Review of clinician visit notes and Bereavement electronic program documentation failed to provided evidence of a Bereavement Risk Assessment for each of the fourteen patient records reviewed. Patients #10 - #12: Review of clinician visit notes and Bereavement electronic program documentation failed to provided evidence of a Bereavement Plan of Care or documentation of bereavement activities for three death records reviewed. During an interview on 05/21/24 at 08:30 AM, the Supervising RN stated the Chaplain is responsible for oversight for the Bereavement Program, Bereavement Risk Assessment and Bereavement plan of care. The Supervising RN was unfamiliar with the Bereavement program and confirmed there was no documentation of Bereavement program activities in the clinical records for Patients #1 - #14.”

“Based on record review and interview the RN failed to complete a written aide plan of care with patient specific instructions for three (#3, #4 and #6) of thirteen (#1-#7, #9 - #14) records reviewed with orders for Hospice Aide services. Patient #3 Review of clinical record #3 for re-certification period 03/28/24 - 05/26/04 revealed a primary diagnosis of Alzheimer’s disease and orders for Hospice Aide services 2 times a week. Review of Aide Plan of Care documents indicated no current Aide Plan of Care was developed by the RN for the current re-certification period. Patient #4 Review of clinical record #4 for re-certification period 04/25/24 - 06/23/24 revealed a primary diagnosis of Dementia and orders for Hospice Aide services two times a week. Review of Aide Plan of Care documents indicated no current Aide Plan of Care was developed by the RN for the current certification period. Patient #6 Review of clinical record #6 for certification period 03/22/24 - 06/19/24 revealed a primary diagnosis of Left Ventricular Failure and orders for Hospice Aide services two times a week. Review of Aide Plan of Care documents indicated no current Aide Plan of Care was developed by the RN for the current certification period. During an interview on 05/22/24 at 11:15 AM, the Supervising RN stated the RN failed to complete an Aide Plan of Care as required for Patients #3,#4 and #6.”

“Based on record review and interviews the RN failed to conduct on site supervision of the Hospice Aide every 14 days as required for seven (#3 - #7, #9 and #12) of thirteen (#1-#7, #9 - #14) records reviewed with orders for Hospice Aide services. Patient #3 Review of clinical record #3 for re-certification period 03/28/24 - 05/26/04 revealed a primary diagnosis of Alzheimer’s disease and orders for Hospice Aide services 2 times a week. Review of RN Visit Notes indicated no on-site Supervisory Visit by the RN was conducted as of this survey 05/22/24 (41 days late) Patient #4 Review of clinical record #4 for re-certification period 04/25/24 - 06/23/24 revealed a primary diagnosis of Dementia and orders for Hospice Aide services two times a week. Review of RN Visit Notes indicated a SAV was conducted on 4/10/24 and no on-site Supervisory Visit had been conducted as of this survey 05/22/24 (28 days late). Patient #5 Review of clinical record #5 for certification period 04/01/24 - 06/29/24 revealed a primary diagnosis of Congestive Heart Failure and orders for Hospice Aide services two times a week. Review of RN Visit Notes failed to provide evidence an on-site Supervisory Visit by the RN was conducted during the first seven weeks of the certification period. (37 days late). Patient #6 Review of clinical record #6 for certification period 03/22/24 - 06/19/24 revealed a primary diagnosis of Left Ventricular Failure and orders for Hospice Aide services two times a week. Review of RN Visit Notes failed to provide evidence an on-site Supervisory Visit by the RN was conducted during the first nine weeks of the certification period. (47 days late). Patient #7 Review of clinical record #7 for certification period 04/22/24 - 07/20/24 revealed a primary diagnosis of Dementia and orders for Hospice Aide services two times a week. Review of RN Visit Notes failed to provide evidence an on-site Supervisory Visit by the RN was conducted during the first four weeks of the certification period. (16 days late). Patient #9 Review of clinical record #9 for certification period 04/25/24 - 07/23/24 revealed a primary diagnosis of Atrial Fibrillation and orders for Hospice Aide services two times a week. Review of RN Visit Notes failed to provide evidence an on-site Supervisory Visit by the RN was conducted during the first five weeks of the certification period.(13 days late). Patient #12 Review of clinical record #12 for certification period 11/15/23 - 02/12/24 revealed a primary diagnosis of Atrial Fibrillation and orders for Hospice Aide services two times a week. Review of RN Visit Notes failed to provide evidence an on-site Supervisory Visit by the RN was conducted during the last eight weeks of the certification period. (56 days late) During an interview on 05/22/24 at 11:15 AM, the Supervising RN stated the RN failed to document Supervisory Hospice Aide visits as required for Patients #3 - #7, #9 and #12.”

“Based on record review and interview, the hospice failed to ensure governing body oversite of a patient centered QAPI Program and ongoing operations of the patient care delivery systems for calendar years 2021, 2022 and 2023. A review of agency QAPI documents and Board Meeting minutes for the years 2021, 2022, 2023 and 2024, indicated the hospice failed to ensure governing body oversite of a patient centered QAPI Program and ongoing operations of the patient care delivery systems.During an interview on 05/22/24 at 10:30 AM, the Supervisory RN stated the statistics provided for the Board Meeting each month were the only program activities she was aware of and verified no additional measurable palliative care or hospice service indicators were tracked or measured.”

“Based on record review and interview, the agency failed to provide evidence personnel records included agency orientation and hospice philosophy for five (#3, #4, #7, #8, and #9) of ten staff (#1 - #10). Based on record review and interview, the agency failed to provide evidence personnel records included agency orientation and hospice philosophy for five (#3, #4, #7, #8, and #9) of ten staff (#1 - #10). During an interview on 05/22/24 at 11:00 AM, the Supervising RN stated she requested orientation documents from the Agency’s HR Department (Human Resources) but the documents were not located or provided for validation of orientation completion.”

“Based on record review and interview, the hospice failed to provide evidence of annual skills competency evaluations for eight (#2- #9) of ten (#1 - #10) staff. Based on record review and interview, the hospice failed to provide evidence of annual skills competency evaluations for eight (#2- #9) of ten (#1 - #10) staff. During an interview on 05/22/24 at 11:00 AM, the Supervising RN stated she had observed and validated competency of her newly hired staff but could not provide documentation of skills competency for any of the hospice staff. The Supervising RN continue to explain that documentation of personnel requirements was requested from the Agency’s HR Department (Human Resources) but were not located or provided for validation of competency.”

“Based on record review and interview the Agency failed to maintain a clinical record for each hospice patient containing past and current findings and to ensure the correct clinical information remains available to the patients attending physician and hospice staff for fourteen (#1 - 14) of fourteen (#1 - #14) records reviewed. Review of Clinical Visit Notes and IDG Plan of Care Updates failed to provide evidence of discipline assessments, clinical visit notes and plan of care updates by MSS and Chaplain for all fourteen (#1 - #14) current patients. During home observation visits on 05/21/24, Patients #1, #2 and #3 confirmed MSS and Chaplain visits were conducted and addressed the needs identified by each patient. During an interview on 05/21/24 at 08:30 AM, the Supervising RN stated the MSW and Chaplain do not document in the EMR. The MSW documents her visits in a notebook and the Chaplain documents visits on paper assessment record as no electronic device is provided for use in the home. The Supervising RN continued to explain the staff must return to the agency to document and she and the staff had not been trained on all aspects of the Agency’s EMR. During an interview on 05/22/24 at 11:00 AM, the Case Manager stated that IDG meetings occur every two weeks and the MSW and Chaplain verbally present their updates during the meeting. The Case Manager is responsible for updating IDG documentation for each individual POC reviewed during the meeting and stated she is behind in updating IDG information. During an interview on 05/22/24 at 11:15 AM, the Supervising RN confirmed the discipline assessments, clinical visit notes and plan of care updates were not available in the EMR for all fourteen (#1 -#14) records reviewed.”

“Based on record review and interview, the Agency failed to document events related to the Discharge for Cause of Patient #13 on 01/26/24. Patient #13 Review of clinical record #13 for re-certification period 10/26/23 - 01/23/24 revealed a primary diagnosis of Multiple Sclerosis. Review of RN Visit Notes indicated a discharge date of 01/26/24 for cause and non-compliance. No other documentation was identified related to the discharge for cause event. During an interview on 05/22/24 at 11:15 AM, the Supervising RN explained Pt#13 had been non-compliant with the hospice POC and abused use of narcotic pain medications. SN staff identified during medication reconciliation multiple refills for narcotic pain meds and the patient continued to request more frequent pain medications. Palliative care center had discharged the patient for narcotic abuse and the Hospice Medical Director was not willing to refill narcotics as requested by the patient. The Supervising RN stated she explained hospice requirements to the patient and husband and facilitated a discharge to another local hospice selected by the patient. The Supervising RN confirmed no documentation of the event or communications with the patient, husband or medical director were evident in the clinical record.”