Lehigh Valley Hospice

“Based on a review of agency policy/procedure, clinical records review, and an interview with the agency Administrator, agency failed to ensure the hospice interdisciplinary group completed the comprehensive assessment no later than 5 calendar days after the election of hospice, for eleven (11) of twenty-nine (29) patient clinical records (CR) reviewed (CR#2, CR#3, CR#5 - CR#8, CR#12, CR#14, CR#16, CR#17, CR#29). Findings: Agency policy/procedure was reviewed on May 7, 2024 at approximately 1:00 p.m. ‘Admission-Home Hospice-Home Health Services’ ‘Procedure’ (14) states “A comprehensive assessment will be completed by other disciplines involved in the patients care within 5 days of the election of the hospice benefit.” A review of clinical records was completed on 05/07/24 at approximately 1:30 p.m. CR#2, start of care 04/12/24: No documentation provided of social work/spiritual counselor services being declined by patient during hospice admission. Documentation provided of social worker (employee #13) leaving voicemail for patient/patient family on 04/17/24. “..... MSW will attempt to contact at a later time.” Voicemail left for patient/patient family on 04/24/24. “MSW placed call to patients (family member.....Unable to reach (family member), left voicemail ........” Documentation provided of spiritual counselor (employee #14) leaving voicemail for patient/patient family on 04/24/24. “Phone call made to patients (family member) .... Spiritual counselor left a message and phone number to call me back when she is able.” Comprehensive assessment was not conducted within five (5) calendar days after the election of hospice, in accordance with patient/family needs and desires. CR#3, start of care 03/29/24: No documentation provided of spiritual counseling services being declined by patient during hospice admission. Documentation provided of spiritual counselor (employee #15) calling patient/patient family on 04/03/24, ‘Communication Details: Spiritual counselor phoned, no answer.” Documentation provided of spiritual counselor (employee #15) initial evaluation visit on 05/02/24. Comprehensive assessment was not conducted within five (5) calendar days after the election of hospice, in accordance with patient/family needs and desires. CR#5, start of care 03/08/24: No documentation provided of social work services being declined by patient during hospice admission. Documentation provided of social worker (employee #13) calling patient/patient family on 03/13/24, “MSW placed call to patient (family member) ...Unable to reach... Left voicemail .... MSW will attempt to contact at later time. “Documentation provided of the social worker initial evaluation visit being completed on 03/21/24. Comprehensive assessment was not conducted within five (5) calendar days after the election of hospice, in accordance with patient/family needs and desires. CR#6, start of care 04/03/24: No documentation provided of social work services being declined by patient during hospice admission. Documentation provided of social worker (employee #13) calling patient/patient family on 04/05/24, “Called, no voicemail...”Documentation provided of the social worker calling a second time on on 04/18/24. No documentation provided of the social worker initial evaluation visit being completed. Comprehensive assessment was not conducted within five (5) calendar days after the election of hospice, in accordance with patient/family needs and desires. CR#7, start of care 01/11/24: No documentation provided of social work services being declined by patient during hospice admission. Documentation provided of social worker (employee #13) calling patient/patient family on 01/16/24, “MSW placed call to patients (family member) ...Unable to reach ... Left voicemail... MSW will attempt to contact at a later time.” Documentation provided of the social worker initial evaluation visit being completed on 02/29/24. Comprehensive assessment was not conducted within five (5) calendar days after the election of hospice, in accordance with patient/family needs and desires. CR#8, start of care 09/11/23: No documentation provided of social work services being declined by patient during hospice admission. Documentation provided of social worker (employee #16) calling patient/patient family on 09/14/23, “SW called patient and (family member) ..... schedule a home visit for initial assessment... no Answer, voicemail left ...”Documentation provided of the social worker initial evaluation visit being completed on 09/20/23. Comprehensive assessment was not conducted within five (5) calendar days after the election of hospice, in accordance with patient/family needs and desires. CR#12, start of care 12/31/23: No documentation provided of spiritual counseling services being declined by patient during hospice admission. Documentation provided of spiritual counselor (employee #15) initial evaluation visit on 01/08/24. Comprehensive assessment was not conducted within five (5) calendar days after the election of hospice, in accordance with patient/family needs and desires. CR#14, start of care 03/11/24: No documentation provided of spiritual counseling services being declined by patient during hospice admission. Documentation provided of spiritual counselor (employee #4) initial evaluation visit on 03/19/24. Comprehensive assessment was not conducted within five (5) calendar days after the election of hospice, in accordance with patient/family needs and desires. CR#16, start of care 03/21/24: No documentation provided of spiritual counseling services being declined by patient during hospice admission. Documentation provided of spiritual counselor (employee #15) calling patient/patient family on 03/25/24, ‘Communication Notes: Spiritual counselor phoned, no answer.” No documentation provided of the spiritual counselor initial evaluation visit being completed. Comprehensive assessment was not conducted within five (5) calendar days after the election of hospice, in accordance with patient/family needs and desires. CR#17, start of care 03/27/24: No documentation provided of spiritual counseling services being declined by patient during hospice admission. Documentation provided of spiritual counselor (employee #15) calling the patient on 04/01/24. “..... No answer.” No documentation provided of the spiritual counselor initial evaluation visit being completed. Comprehensive assessment was not conducted within five (5) calendar days after the election of hospice, in accordance with patient/family needs and desires. CR#29, start of care 06/23/23: No documentation provided of social work services being declined by patient during hospice admission. Documentation provided of social worker (employee #17) calling patient/patient family on 06/28/23, “MSW called and left message for (friend) ...MSW offered a visit and will wait for return call to schedule.” No documentation provided of the social worker initial evaluation visit being completed. Comprehensive assessment was not conducted within five (5) calendar days after the election of hospice, in accordance with patient/family needs and desires. An interview conducted with the agency Administrator on May 7, 2024, at approximately 2:00 p.m. confirmed the above findings.”

“Based on a request of agency policy/procedure, skilled nursing facility contracts, a review of clinical records, and an interview with the agency Administrator, agency failed to provide to the facility one or all of the following: The most recent hospice plan of care specific to each patient, the patient hospice election form, and the physician certification and/or recertification of the terminal illness for three (3) of three (3) skilled nursing facilities (SNF) visited (SNF#1, SNF#2, SNF#3). Findings: Agency policy/procedure related to the hospice ensuring the most recent Hospice plan of care specific to each patient, the Hospice benefit election form, and the Physician certification and/or recertification of the terminal illness was requested on May 7, 2024 at approximately 1:00 p.m. No policy provided. SNF #1: Review was conducted on May 9, 2024 at approximately 10:00 am of the agency/facility written agreement. Documentation provided of ‘Protocol and Agreement for the Provision of Hospice Home Care Services to Residents of Pleasant Valley Manor and Respite Care to Hospice Patients’ signed by Lehigh Valley Hospice Pocono (hereinafter referred to as “Hospice”) on 02/15/24 and Pleasant Valley Manor (hereinafter referred to as “The Home”) on 02/15/24. Section VI: ‘Preparation and Maintenance of Patient Records’ (B) states “The Home will designate an area in each patient chart wherein all Hospice administrative documentation shall be maintained. ....Copies of the following documentation shall remain a permanent part of the patients chart: Hospice Face Sheet, Hospice Election Statement, Hospice Consent Form, Hospice Medication Sheet, Hospice Initial and Ongoing Assessments, Hospice Plan of Care, ....” Note: Most recent certification/recertification of terminal illness is not included in the above stated required documentation.During a home visit conducted at the facility on 05/03/24, the most recent hospice plan of care, the hospice election form, and the physician certification and/or recertification of terminal illness was in the patients (CR#21) hospice chart. The date of the printed forms was 05/02/24. The hospice agency Director of Clinical Services (Pocono location) was present. Per the Director of Clinical Services, the agency just recently placed these items in the chart after the start of the onsite survey and upon knowing these items were asked for review the prior day (05/02/24), at the SNF’s in the Allentown location. Prior to that, “These items were not in the patients chart.” SNF #2: Review was conducted on May 9, 2024 at approximately 10:00 am of the agency/facility written agreement. Documentation provided of ’’Protocol and Agreement for the Provision of Hospice Home Care Services to Residents of Fellowship Community and Respite Care to Hospice Patients’ signed by Lehigh Valley Hospice Pocono (hereinafter referred to as “Hospice”) on 12/05/23 and Fellowship Community (hereinafter referred to as “The Home”) on 11/28/23. Section VI: ‘Preparation and Maintenance of Patient Records’ (B) states “The Home will designate an area in each patient chart wherein all Hospice administrative documentation shall be maintained. ....Copies of the following documentation shall remain a permanent part of the patients chart: Hospice Face Sheet, Hospice Election Statement, Hospice Consent Form, Hospice Medication Sheet, Hospice Initial and Ongoing Assessments, Hospice Plan of Care, ....” Note: Most recent certification/recertification of terminal illness is not included in the above stated required documentation.During a home visit conducted at the facility on 05/02/24, the most recent hospice plan of care, the hospice election form, nor the physician certification and/or recertification of terminal illness were in the patients (Clinical records #3, #9, #30) hospice chart nor the patients (Clinical records #3, #9, #30) SNF chart. The hospice agency MSW (Allentown location) was present. SNF #3: Review was conducted on May 9, 2024 at approximately 10:00 am of the agency/facility written agreement. Documentation provided of ’’Protocol and Agreement for the Provision of Hospice Home Care Services to Residents of Phoebe Home, Inc. d/b/a Phoebe Allentown .....” signed by Lehigh Valley Hospice Pocono (hereinafter referred to as “Hospice”) on 09/15/23 and Phoebe Allentown ... (hereinafter referred to as “The Home”) on 09/05/23. Section VI: ‘Preparation and Maintenance of Patient Records’ (B) states “The Home will designate an area in each patient chart wherein all Hospice administrative documentation shall be maintained. ....Copies of the following documentation shall remain a permanent part of the patients chart: Hospice Face Sheet, Hospice Election Statement, Hospice Consent Form, Hospice Medication Sheet, Hospice Initial and Ongoing Assessments, Hospice Plan of Care, ....” Note: Most recent certification/recertification of terminal illness is not included in the above stated required documentation.During a home visit conducted at the facility on 05/02/24, the most recent hospice plan of care, the hospice election form, nor the physician certification and/or recertification of terminal illness was in the patients (Clinical record #4) hospice chart nor the patients (Clinical record #4) SNF chart. The hospice agency MSW (Allentown location) was present. An interview conducted with the agency Administrator on May 7, 2024, at approximately 2:00 p.m. confirmed the above findings.”

“Based on a review of agency policy/procedure, a review of hospice services contracts, and an interview with the agency Administrator, agency failed to assure hospice philosophy orientation for skilled nursing facility staff for three (3) of three (3) skilled nursing facility contracts (SNFC) reviewed (SNFC#1, SNFC#2, SNFC#3). Findings: Agency policy/procedure was reviewed on May 7, 2024 at approximately 1:00 p.m. ‘Hospice in the Long-Term care Facility-Home health Services’ ‘Procedure’ (4) states “Lehigh Valley Hospice staff provides facility staff with in-service education on the hospice concept; palliative/terminal care, etc. at minimum once per year. The hospice staff provides ongoing education and training to the staff of the nursing home about patient care according to the Hospice philosophy. Documentation of these in-services will be maintained by the agency.” Facility contracts were reviewed on May 6, 2024 at approximately 10:00 a.m. SNFC#1: Documentation provided of ‘Protocol and Agreement for the Provision of Hospice Home Care Services to Residents of Pleasant Valley Manor and Respite Care to Hospice Patients’ signed by Lehigh Valley Hospice Pocono (hereinafter referred to as “Hospice”) on 02/15/24 and Pleasant Valley Manor (hereinafter referred to as “The Home”) on 02/15/24. ‘Subsection H. Hospice Orientation and Training’ states “Hospice agrees to provide sufficient orientation and training to personnel of The Home to acquaint them with the Hospice concept, Hospice policy and procedure, and as necessary, with the Hospices symptom control protocols.”Documentation provided of a ‘Vendor/Contractor Orientation Checklist’ provided to the facility on 04/01/24 (signed by the Director of Nursing). ‘Hospice Mission Statement/Philosophy/Overview’ was included on the checklist. No documentation provided of the hospice agency assuring the orientation of the skilled nursing facility staff who furnish care to hospice patients to the hospice philosophy. Documentation provided of the following hospice patient residing/having resided at the facility (Clinical record #21). SNFC#2: Documentation provided of ’’Protocol and Agreement for the Provision of Hospice Home Care Services to Residents of Fellowship Community and Respite Care to Hospice Patients’ signed by Lehigh Valley Hospice Pocono (hereinafter referred to as “Hospice”) on 12/05/23 and Fellowship Community (hereinafter referred to as “The Home”) on 11/28/23. ‘Subsection H. Hospice Orientation and Training’ states “Hospice agrees to provide sufficient orientation and training to personnel of The Home to acquaint them with the Hospice concept, Hospice policy and procedure, and as necessary, with the Hospices symptom control protocols.”Documentation provided of ‘Fellowship LVHN Hospice Education’ ‘Topic’ “Pain/Symptom Management’ dated 02/08/24. ‘Presenter: LVHN Hospice.’ The education sign in sheet included eight (8) facility staff members in attendance. No documentation provided of the hospice agency assuring the orientation of the skilled nursing facility staff who furnish care to hospice patients to the hospice philosophy. Documentation provided of the following three (3) hospice patients residing/having resided at the facility (Clinical records #3, #9, #30). SNFC#3: Documentation provided of ’’Protocol and Agreement for the Provision of Hospice Home Care Services to Residents of Phoebe Home, Inc. d/b/a Phoebe Allentown ..... “ signed by Lehigh Valley Hospice Pocono (hereinafter referred to as “Hospice”) on 09/15/23 and Phoebe Allentown ... (hereinafter referred to as “The Home”) on 09/05/23. ‘Subsection H. Hospice Orientation and Training’ states “Hospice agrees to provide sufficient orientation and training to personnel of The Home to acquaint them with the Hospice concept, Hospice policy and procedure, and as necessary, with the Hospices symptom control protocols.”Documentation provided of ‘Meeting Sign in Sheet’ facilitated by the Hospice agency, ‘Ethics at End of Life’ dated 07/26/23, at “Phoebe LTC”.The meeting sign in sheet included six (6) facility staff members in attendance. No documentation provided of the hospice agency assuring the orientation of the skilled nursing facility staff who furnish care to hospice patients to the hospice philosophy. Documentation provided of the following hospice patient residing/having resided at the facility (Clinical records #4). An interview conducted with the agency Administrator on May 7, 2024, at approximately 2:00 p.m. confirmed the above findings.”