Pathways Healthcare

“Based on review of hospice policies/procedures and clinical records and based on interview with the administrator (Employee #10), the hospice failed to ensure an initial social work ((SW) assessment was completed within 5 days of the hospice benefit election for four (4) of eight (8) hospice patients for whom hospice services were provided for more than 5 days during the initial hospice certification period. (Patients #1, #2, #3, #13) Findings include: On October 31, 2024 at approximately 12:20 PM, review of the hospice policy titled “Assessment-Initial and Comprehensive” revealed the following under “Policy”: Erwine Home and Hospice, Inc. interdisciplinary group, in consultation with the individual’s attending physician (if any), will complete the comprehensive assessment no later than 5 calendar days after the election of hospice care. On October 31, 2024 at approximately 12:21 PM, review of the hospice policy titled “Coordination of Services-Medical Social Worker (MSW)” revealed the following under “Policy”: Responsibilities: 1. The social services assessment visit shall be completed within 5 days of admission or sooner if indicated. Patient #1 (Closed Record): On October 30, 2024 at approximately 11:49 AM, review clinical record revealed the hospice benefit election date was 04/16/2024 and that the patient was discharged on 06/12/2024 due to no longer being terminally ill. Review of the “Initial Hospice Plan of Care” for the initial certification period of 04/16/2024 through 06/14/2024 revealed SW services were to be provided one (1) to two (2) month for 60 days. Review of the comprehensive assessment documentation revealed the SW (Employee #6) completed the initial SW assessment on 04/25/2024 which was seven (7) days after the hospice benefit election date. There was no documentation in the clinical record which provided evidence an initial SW assessment was completed within five (5) days of the hospice benefit election date. Patient #2 (Closed Record): On October 30, 2024 at approximately 12:57 PM, review of the clinical record revealed the hospice benefit election date was 05/02/2024 and that the patient was discharged on 05/10/2024 due to being transferred to a different hospice. Review of the “Initial Hospice Plan of Care” for the initial certification period of 05/02/2024 through 07/30/2024 revealed SW services were to be provided one (1) to two (2) days for 90 days. There was no documentation in the clinical record which provided evidence an initial SW assessment was completed within five (5) days of the hospice benefit election date. Patient #3 (Closed Record): On October 30, 2024 at approximately 1:23 PM, review of the clinical record revealed the hospice benefit election date was 08/20/2024 and that the patient expired on 09/04/2024. Review of the “Initial Hospice Plan of Care” for the initial certification period of 08/20/2024 through 11/17/2024 revealed SW services were to be provided one (1) to two (2) days for 90 days. Review of communication note documentation revealed the SW’s (Employee #5) first telephone contact with the patient occurred on 08/27/2024 which was seven (7) days after the hospice benefit election date. The initial SW assessment was completed on 08/29/2024 which was nine (9) days after the hospice benefit election date. There was no documentation in the clinical record which provided evidence an initial SW assessment had been completed within five (5) days of the hospice benefit election date. Patient #13 (Closed Record): On October 31, 2024 at approximately 11:26 AM, review clinical record revealed the hospice benefit election date was 12/04/2023 and that the patient expired on 01/28/2024. Review of the “Initial Hospice Plan of Care” for the initial certification period of 12/04/2023 through 03/02/2024 revealed SW services were to be provided one (1) to two (2) a month for 90 days. Review of the comprehensive assessment documentation revealed the SW (Employee #6) completed the initial SW assessment on 12/15/2023 which was 11 days after the hospice benefit election date. There was no documentation in the clinical record which provided evidence an initial SW assessment had been completed within 5 days of the hospice benefit election date. During interview conducted on October 31, 2024 at approximately 3:30 PM, the administrator confirmed there was no documentation in the clinical record which provided evidence the initial SW assessment had been completed within five (5) days of the hospice benefit election for the above identified patients.”

“Based on review of hospice policy/procedure, personnel files and clinical records and based on interview with the social worker (SW-Employee #6) and the administrator (Employee #10), the hospice failed to ensure a SW participated in interdisciplinary team (IDT) meetings for thirteen (13) of fourteen (14) hospice patients. (Patients #1, #2, #3, #4, #5, #6, #7, #9, #10, #11, #12, #13 and #14) Findings include: On October 31, 2024 at approximately 12:21 PM, review of the hospice policy titled “Coordination of Services-Medical Social Worker (MSW)” revealed the following under “Policy”: 2. The duties of the social worker include the following...q. Participates in Interdisciplinary Team (IDT) meetings and assists in developing and reviewing the care plans, admissions and discharges... Between 10/29/2024 at approximately 10:33 AM and 10/31/2024 at approximately 9:25 AM, review of personnel files revealed the following: 1. Employe #5: The date of hire of the SW was 06/29/2024. 2. Employee #6: The date of hire of the SW was 06/21/2020. Patient #1 (Closed Record): On October 30, 2024 at approximately 11:49 AM, review clinical record revealed the hospice benefit election date was 04/16/2024 and that the patient was discharged on 06/12/2024 due to no longer being terminally ill. Review of the “Initial Hospice Plan of Care” for the initial certification period of 04/16/2024 through 06/14/2024 revealed SW services were to be provided one (1) to two (2) month for 60 days. Review of the comprehensive assessment documentation revealed the SW (Employee #6) completed the initial SW assessment on 04/25/2024. There was no documentation in the clinical record which provided evidence the SW participated in the IDT meetings conducted on 05/24/2024 and 06/07/2024. Patient #2 (Closed Record): On October 30, 2024 at approximately 12:57 PM, review of the clinical record revealed the hospice benefit election date was 05/02/2024 and that the patient was discharged on 05/10/2024 due to being transferred to a different hospice. Review of the “Initial Hospice Plan of Care” for the initial certification period of 05/02/2024 through 07/30/2024 revealed SW services were to be provided one (1) to two (2) days for 90 days. There was no documentation in the clinical record which provided evidence an initial SW assessment was completed. There was no documentation in the clinical record which provided evidence a SW participated in the IDT meeting conducted on 05/24/2024. Patient #3 (Closed Record): On October 30, 2024 at approximately 1:23 PM, review of the clinical record revealed the hospice benefit election date was 08/20/2024 and that the patient expired on 09/04/2024. Review of the “Initial Hospice Plan of Care” for the initial certification period of 08/20/2024 through 11/17/2024 revealed SW services were to be provided one (1) to two (2) days for 90 days. The initial SW assessment was completed by the SW (Employee #5) on 08/29/2024. There was no documentation in the clinical record which provided evidence the SW participated in the IDT meetings conducted on 08/30/2024 and 09/13/2024. Patient #4 (Closed Record): On October 30, 2024 at approximately 2:13 PM, review of the clinical record revealed the hospice benefit election date was 12/07/2023 and that the patient expired on 12/10/2023. Review of the “Initial Hospice Plan of Care” for the initial certification period of 12/07/2024 through 03/05/2024 revealed SW services were to be provided one (1) to two (2) days for 90 days. Review of bereavement call documentation revealed the SW (employee #6) contacted a family member of the patient by telephone on 12/11/2023. There was no documentation in the clinical record which provided evidence the SW participated in the IDT meeting conducted on 12/22/2023. Patient #5 (Closed Record): On October 30, 2024 at approximately 2:35 PM, review of the clinical record revealed the hospice benefit election date was 01/31/2024 and that the patient expired on 02/17/2024. Review of the “Initial Hospice Plan of Care” for the initial certification period of 01/31/2024 through 04/29/2024 revealed SW services were to be provided one (1) to two (2) days for 90 days. Clinical record documentation revealed the SW (Employee #6) completed the initial social work assessment on 02/05/2024. There was no documentation in the clinical record which provided evidence the SW participated in the IDT meetings conducted on 02/02/2024, 02/16/2024 and 03/01/2024. Patient #6 (Closed Record): On October 30, 2024 at approximately 3:10 PM, review of the clinical record revealed the hospice benefit election date was 01/11/2024 and that the patient expired on 05/02/2024. Review of the “Hospice Plan of Care” for the recertification period of 04/10/2024 through 07/08/2024 revealed SW services were to be provided one (1) to two (2) days for 90 days. There was no documentation in the clinical record which provided evidence a SW participated in the IDT meeting conducted on 04/12/2024. Patient #7 (Closed Record): On October 31, 2024 at approximately 9:52 AM, review of the clinical record revealed the hospice benefit election date was 02/12/2024 and that the patient expired on 03/01/2024. Review of the “Initial Hospice Plan of Care” for the initial certification period of 02/12/2024 through 05/11/2024 revealed SW services were to be provided one (1) to two (2) days for 90 days. Clinical record documentation revealed the SW (Employee #6) attempted to contact the patient by telephone on 02/16/2024, 02/20/2024 and 02/22/2024 and that the SW attempted to contact the bereaved party by telephone on 03/07/2024. There was no documentation in the clinical record which provided evidence the SW participated in the IDT meetings conducted on 02/16/2024, 03/01/2024 and 03/15/2024. Patient #9 (Closed Record): On October 31, 2024 at approximately 10:20 AM, review of the clinical record revealed the hospice benefit election date was 09/18/2023 and that the patient expired on 01/05/2024. Review of the “Hospice Plan of Care” for the recertification period of 12/27/2023 through 03/15/2024 revealed SW services were to be provided one (1) to two (2) days for 90 days. Clinical record documentation revealed the SW (Employee #6) attempted to contact the bereaved by telephone on 01/06/2024. There was no documentation in the clinical record which provided evidence a SW participated in the IDT meeting conducted on 01/05/2024. Patient #10 (Closed Record): On October 31, 2024 at approximately 10:56 AM, review of the clinical record revealed the hospice benefit election date was 09/022024 and that the patient expired on 09/07/2024. Review of the “Initial Hospice Plan of Care” for the initial certification period of 09/02/2024 through 10/31/2024 revealed SW services were to be provided one (1) to two (2) days for 60 days. Clinical record documentation revealed the SW completed bereavement call on 10/08/2024. There was no documentation in the clinical record which provided evidence the SW participated in the IDT meeting conducted on 09/13/2024. Patient #11 (Closed Record): On October 31, 2024 at approximately 11:09 AM, review of the clinical record revealed the hospice benefit election date was 12/27/2023 and that the patient expired on 03/27/2024. Review of the “Hospice Plan of Care” for the recertification period of 03/26/2024 through 06/23/2024 revealed SW services were to be provided one (1) to two (2) month for 90 days. Clinical record documentation revealed the SW (Employee #6) attempted to contact the bereaved by telephone on 03/29/2024. There was no documentation in the clinical record which provided evidence a SW participated in the IDT meeting conducted on 03/29/2024. Patient #12 (Closed Record): On October 31, 2024 at approximately 11:19 AM, review of the clinical record revealed the hospice benefit election date was 07/24/2024 and that the patient expired on 09/22/2024. Review of the “Hospice Plan of Care” for the recertification period of 09/22/2024 through 11/20/2024 revealed SW services were to be provided one (1) to two (2) day for 60 days. Clinical record documentation revealed the SW (Employee #6) completed a bereavement call on 10/04/2024. There was no documentation in the clinical record which provided evidence a SW participated in the IDT meeting conducted on 03/27/2024. Patient #13 (Closed Record): On October 31, 2024 at approximately 11:26 AM, review clinical record revealed the hospice benefit election date was 12/04/2023 and that the patient expired on 01/28/2024. Review of the “Initial Hospice Plan of Care” for the initial certification period of 12/04/2023 through 03/02/2024 revealed SW services were to be provided one (1) to two (2) a month for 90 days. Clinical record documentation revealed the SW (Employee #6) completed the initial SW assessment on 12/15/2023 and that the SW completed a bereavement call on 02/03/2024. There was no documentation in the clinical record which provided evidence a SW participated in the IDT meetings conducted on 12/29/2024, 01/05/2024 and 02/02/2024. Patient #14 (Closed Record): On October 31, 2024 at approximately 11:51 AM, review of the clinical record revealed the hospice benefit election date was 01/042024 and that the patient expired on 02/15/2024. Review of the “Initial Hospice Plan of Care” for the initial certification period of 01/04/2024 through 04/02/2024 revealed SW services were to be provided one (1) to two (2) month for 90 days. Clinical record documentation revealed the SW (Employee #6) attempted to contact the patient by telephone on 01/05/2024, 01/06/2024 and 01/08/2024 and that the SW completed a bereavement call on 02/16/2024. There was no documentation in the clinical record which provided evidence the SW participated in the IDT meeting conducted on 02/16/2024. During interview conducted on 10/31/2024 at approximately 10:12 AM, the SW (Employee #6) reported SW input for IDT meetings is provided verbally to a hospice LPN. The SW reported that the SW attends some IDT meetings via teleconference but not all IDT meetings. During interview conducted on October 31, 2024 at approximately 12:52 PM, the administrator reported the SW (Employee #6) is employed full-time elsewhere; therefore, the SW is not available to attend all IDT meetings. During interview conducted on October 31, 2024 at approximately 3:30 PM, the administrator confirmed there was no documentation in the clinical record which provided evidence that a SW participated in the above referenced IDT meetings for the above referenced patients.”

“Based on review of hospice policies/procedures and clinical records and based on interview with the hospice licensed practical nurse (LPN-Employee #12) and the administrator (Employee #10), the hospice failed to ensure the hospice care plan was updated to reflect the patient’s refusal of hospice clergy (spiritual counseling) services during the interdisciplinary team (IDT) meetings for three (3) of nine (9) patient for whom hospice services were provided for more than five (5) days during the initial certification period. (Patients #2, #7 and #14) Findings include: On October 31, 2024 at approximately 12:23 PM, review of the hospice policy titled “Plan of Care” revealed the following under “Procedure”: 3) Interdisciplinary Team (IDT) Meeting and Plan of Care Update...b. A revised plan of care must include information from the patient’s updated comprehensive assessment... On October 31, 2024 at approximately 12:24 PM, review of the hospice policy titled “Interdisciplinary (IDT) Team Conferences” revealed the following under “Procedure”: 6) Routine IDT conferences include...c. Developing, reviewing and modifying patient/family plans of care, as appropriate... During interview conducted on October 31, 2024 at approximately 12:52 PM, the hospice LPN (Employee #12) reported that all hospice patients have refused hospice clergy services. Patient #2 (Closed Record): On October 30, 2024 at approximately 12:57 PM, review of the clinical record revealed the hospice benefit election date was 05/02/2024 and that the patient was discharged on 05/10/2024 due to being transferred to a different hospice. Review of the “Initial Hospice Plan of Care” for the initial certification period of 05/02/2024 through 07/30/2024 revealed clergy services were to be provided one (1) to three (3) days for 90 days as needed (PRN). There was no documentation in the clinical record which provided evidence hospice clergy services were provided during the aforementioned certification period. Review of the start of care nursing assessment dated 05/02/2024 revealed a hospice registered nurse (RN) documented there were no spiritual concerns but there was no documentation which provided evidence the patient had refused hospice spiritual counseling services. Review of IDT meetings dated 05/02/2024 and 05/10/2024 revealed the clergy frequency was documented as PRN or no spiritual concerns. There was no documentation in the clinical record which provided evidence the hospice care plan was updated to reflect the patient’s refusal of clergy services during the IDT meetings conducted on 05/02/2024 and 05/10/2024. Patient #7 (Closed Record): On October 31, 2024 at approximately 9:52 AM, review of the clinical record revealed the hospice benefit election date was 02/12/2024 and that the patient expired on 03/01/2024. Review of the “Initial Hospice Plan of Care” for the initial certification period of 02/12/2024 through 05/11/2024 revealed clergy services were to be provided one (1) to three (3) days for 90 days PRN. There was no documentation in the clinical record which provided evidence hospice clergy services were provided during the aforementioned certification period. Review of the start of care nursing assessment dated 02/12/2024 revealed a hospice registered RN documented there were no spiritual concerns but there was no documentation which provided evidence the patient had refused hospice spiritual counseling services. Review of IDT meeting minutes dated 02/16/2024 revealed the clergy frequency was unchanged and that the clergy frequency was PRN as documented during the 03/01/2024 IDT meeting. There was no documentation in the clinical record which provided evidence the hospice care plan was updated to reflect the patient’s refusal of clergy services during the IDT meetings conducted on 02/16/2024 and 03/01/2024. Patient #14 (Closed Record): On October 31, 2024 at approximately 11:51 AM, review of the clinical record revealed the hospice benefit election date was 01/042024 and that the patient expired on 02/15/2024. Review of the “Initial Hospice Plan of Care” for the initial certification period of 01/04/2024 through 04/02/2024 revealed clergy services were to be provided one (1) to three (3) days for 90 days PRN. There was no documentation in the clinical record which provided evidence hospice clergy services were provided during the aforementioned certification period. Review of the start of care nursing assessment dated 01/04/2024 revealed a hospice RN documented there were no spiritual concerns but there was no documentation which provided evidence the patient had refused hospice spiritual counseling services. Review of IDT meetings dated 01/05/2024, 01/19/2024 and 02/02/2024 revealed the clergy frequency was documented as no concerns or PRN. There was no documentation in the clinical record which provided evidence the hospice care plan was updated to reflect the patient’s refusal of clergy services during the IDT meetings conducted on 01/05/2024, 01/19/2024 and 02/02/2024. During interview conducted on October 31, 2024 at approximately 3:30 PM, the administrator confirmed there was no documentation in the clinical record which provided evidence that the hospice care plan was updated to reflect the patient’s refusal of clergy services during the above referenced IDT meetings for the above identified patients.”

“Based on review of agency policy/procedure, initial tuberculosis (TB) screening guidance from the Centers for Disease Control (CDC) and personnel files and based on interview with the administrator (Employee #10), the hospice failed to ensure TB screening was conducted in accordance with CDC recommendations for three (3) of three (3) core hospice employees whose date of hire was after October 22, 2021. (Employees #3, #4 and #5) Findings include: On October 31, 2024 at approximately 12:18 PM, review of the hospice policy titled “Employee Health” revealed the following under “Policy”: Hospice will monitor employee health to reduce the spread of infection to fellow employees and patients. On October 31, 2024 at approximately 3:59 PM, review of CDC recommendations for initial TB screening for health care personnel revealed the following as documented on the CDC website: https://www.cdc.gov/tb-healthcare-settings/hcp/screening-testing/baseline-testing.html : The TB screening process for health care personnel includes: -A baseline individual TB risk assessment; -TB symptom evaluation; and -A TB test (TB blood test or a TB skin test (2-Step)). Between October 29, 2024 at approximately 10:33 AM and October 31, 2024 at approximately 9:20 AM, review of personnel file documentation revealed the following: Employee #3: The date of hire of the chaplain was 07/12/2024. Employee #4: The date of hire of the dietician was 06/29/2024. Employee #5: The date of hire of the social worker was 08/05/2024. There was no documentation in the personnel file which provided evidence Employees #3, #4 and #5 had completed the second step of the TST nor the baseline individual TB risk assessment. During interview conducted on October 31, 2024 at approximately 3:30 PM, the administrator confirmed TB screening was not conducted in accordance with the above referenced CDC recommendations for the above identified core hospice staff members.”

“Based on review of hospice policies/procedures and clinical records, pressure injury (bedsore) guidance from the Cleveland Clinic and based on interview with the administrator (Employee #10), the hospice failed to ensure pressure ulcer assessment was completed in accordance with hospice plan of care orders for two (2) of two (2) patients for whom a new pressure wound had developed during the certification period. (Patients #6 and #14) Findings include: On October 31, 2024 at approximately 12:25 PM, review of the hospice policy titled “Coordination of Services-Nursing Services” revealed the following under “Procedure”: 4) Duties of the Registered Nurse include: a. Provides skilled nursing in accordance with the orders of a physician and under a plan of care in a patient’s home. Has the responsibility for the observation, assessment...of...patient... 5) Duties of the Licensed Practical Nurse include...g. Assess patient/family response to care... On October 31, 2023 at approximately 3:55 PM, review of the Cleveland Clinic website revealed the following under the article titled “Bedsores (Pressure Injuries)” https://my.clevelandclinic.org/health/diseases/17823-bedsores-pressure-injuries : Stages of bedsores or pressure ulcers include....Stage 2: A shallow wound with a pink or red base develops. You may see skin loss, abrasions and blisters. Patient #6 (Closed Record): On October 30, 2024 at approximately 3:10 PM, review of the clinical record revealed the skilled nursing (SN) services were to perform the following as ordered on the “Hospice Plan of Care” for the recertification period of 04/10/2024 through 07/08/2024: When potential or actual impairment, check skin every visit include location, size, color, drainage (amount and color)... Review of the SN visit note dated 04/23/2024 revealed an abraded area had developed on the bilateral (both) buttocks and that calamine cream was applied to the area. There was no documentation in the clinical record which provided evidence the registered nurse (RN-Employee #8) assessed the size, color and drainage of the bilateral buttock abrasion on 04/23/2024. Patient #14 (Closed Record): On October 31, 2024 at approximately 11:51 AM, review of the clinical record revealed the SN services were to perform the following as ordered on the “Initial Hospice Plan of Care” for the initial certification period of 01/04//2024 through 04/02/2024: When potential or actual impairment, check skin every visit include location, size, color, drainage (amount and color)... Review of the SN visit note dated 01/22/2024 revealed a developing pressure ulcer was noted on the sacrum (base of spine). There was no documentation in the clinical record which provided evidence the licensed practical nurse (Employee #12) assessed the size, color and drainage of the developing pressure ulcer of the sacrum on 01/22/2024. During interview conducted on October 31, 2024 at approximately 3:30 PM, the administrator confirmed there was no documentation in the clinical record which provided evidence pressure ulcer assessment had been completed in accordance with the orders included on the hospice plan of care for the above identified patients.”