Concordia Hospice of Bethlen

“Based on review of agency policy/procedure, clinical records (CR), and staff (EMP) interview, the agency failed to conduct and 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 and incorporated findings in the plan of care for two (2) of two (2) bereavement records reviewed (CR 1 & 2). Findings included: Review of agency policy/procedure on 9/13/24 at approximately 10:30am revealed: “SUBJECT: Bereavement...Pre-Death: 1. The initial bereavement assessment is completed at time of admission or MSW/Bereavement evaluation and is updated as needed during the course of care, at time of death, and during bereavement follow-up...Following the Death: ...2. Concordia Hospice of Bethlen staff may make a bereavement visit to the bereaved and assess for the need of additional support or interventions as determined by the plan of care., 3. The initial bereavement assessment will be updated as needed by the Bereavement coordinator, Social Worker, or designee...” Review of clinical records on 9/12/24 at approximately 11:25am revealed: CR1, dates reviewed from election of benefits on 3/15/24 through date of death 3/23/24. CR failed to include documentation of initial bereavement assessment or incorporation of bereavement needs into plan of care. CR2, dates reviewed from election of benefits 3/14/24 through date of death 3/18/24. CR failed to include documentation of initial bereavement assessment or incorporation of bereavement needs into plan of care. Findings confirmed at exit interview conducted with Quality Manager, Director of compliance and Education, and Informatics Specialist on 9/13/24 at approximately 3:00pm.”

“Based on review of agency policy/procedure, personnel files (PF), and staff (EMP) interview, the agency failed to develop a plan of care (POC) that included all services necessary for the palliation and management of the terminal illness and related conditions for seven (7) of eleven (11) CR reviewed (CR 5-11). Findings included: Review of CR on 9/13/24 between approximately 10:30am and 3:00pm revealed: CR5, election of benefits (EOB) 5/6/24, dates reviewed 5/6/24-9/13/24. Interdisciplinary Group (IDG) Plan of Care (POC) update included the following updates effective 7/26/24: “Changes to discipline frequency: ... MSW (Medical Social Worker) 1-4x Month x3 Months, CH (Chaplain) 1x Week x 13 weeks, ...Chaplain to evaluate patient/family/caregiver and develop a plan of care, ...Medical Social Worker to evaluate social, emotional, and financial factors related to the patient’s illness, need for additional care/resources, adjustments to care and develop a plan of care...” CR failed to include POC developed by MSW or CH. CR6, EOB 6/11/24, dates reviewed 6/11/24-9/13/24. IDG POC update included the following updates effective 8/25/24: “Changes to discipline frequency: ... MSW 1-4x Month x3 Months, CH 1-4x Month x 3 Months. Also, updates effective 8/14/24 and 8/27/24: “Chaplain to evaluate patient/family/caregiver and develop a plan of care, ...Medical Social Worker to evaluate social, emotional, and financial factors related to the patient’s illness, need for additional care/resources, adjustments to care and develop a plan of care...” CR failed to include POC developed by MSW or CH. CR7, EOB 9/6/24, dates reviewed 9/6/24-9/13/24. POC dated 9/4/24 included: “MSW effective 6/30/24: 2 week 1, CH effective 6/30/24: 1 week 1, ...Medical Social Worker to evaluate social, emotional, and financial factors related to the patient’s illness, need for additional care/resources, adjustments to care and develop a plan of care, ...Chaplain to evaluate patient/family/caregiver and develop a plan of care...” 7/26/24 order: MSW 1 x Month, 7/28/24 order: MSW 1 every 2 weeks x2. CR failed to include POC developed by MSW or CH. CR8, EOB 6/28/24, dates reviewed 6/28/24-9/13/24. POC dated 6/28/24 included: “MSW 1 time a month for 3 months, CH 1 time a month for 3 months, ...Medical Social Worker to evaluate social, emotional, and financial factors related to the patient’s illness, need for additional care/resources, adjustments to care and develop a plan of care, ...Chaplain to evaluate patient/family/caregiver and develop a plan of care...” CR failed to include POC developed by MSW or CH. CR9, EOB 6/27/24, dates reviewed 6/27/24-9/13/24. POC dated 6/27/24 included: “MSW effective 6/30/24: 1 week 1, CH effective 6/30/24: 1 week 1, ...Medical Social Worker to evaluate social, emotional, and financial factors related to the patient’s illness, need for additional care/resources, adjustments to care and develop a plan of care, ...Chaplain to evaluate patient/family/caregiver and develop a plan of care...” Order 7/1/24: “Medical Social Worker to evaluate social, emotional, and financial factors related to the patient’s illness, need for additional care/resources, adjustments to care and develop a plan of care...Goals: A Medical Social Worker Plan of Care will be established... MSW effective 1 week 13...” Order 7/2/24: “Chaplain to evaluate patient/family/caregiver and develop a plan of care. Goal: A chaplain Plan of Care will be established...” Visit schedule confirmed MSW visits conducted 7/1/24, 7/10/24, 7/17/24, 7/24/24, 7/31/24, and 9/4/24. Chaplin visits conducted 7/2/24, 8/7/24, 8/22/24, and 9/12/24. CR failed to include POC developed by MSW or CH. CR10, EOB 9/6/24, dates reviewed 9/6/24-9/13/24. POC dated 9/6/24 included: “MSW effective 9/8/24: 1 week 1, 1 every 4 week 8, CH effective 9/8/24: 1 week 1, 1 every 4 week 8, ...Medical Social Worker to evaluate social, emotional, and financial factors related to the patient’s illness, need for additional care/resources, adjustments to care and develop a plan of care, ...Chaplain to evaluate patient/family/caregiver and develop a plan of care...” Order 9/11/24: “Medical Social Worker to evaluate social, emotional, and financial factors related to the patient’s illness, need for additional care/resources, adjustments to care and develop a plan of care... Goal: A Medical Social Worker Plan of Care will be established... MSW effective 9/8/24 5 week 1, 1 every 4 week 8...” Visit schedule confirmed MSW and CH visits conducted 9/9/24. CR failed to include POC developed by MSW or CH. CR11, EOB 8/21/24, dates reviewed 8/21/24-9/13/24. POC dated 8/21/24 included: “MSW effective 8/25/24: 1 week 1, CH effective 1 week 1...Medical Social Worker to evaluate social, emotional, and financial factors related to the patient’s illness, need for additional care/resources, adjustments to care and develop a plan of care, ...Chaplain to evaluate patient/family/caregiver and develop a plan of care...” Order 8/23/24: “Chaplain to evaluate patient/family/caregiver and develop a plan of care. Goal: A chaplain Plan of Care will be established...” Order 8/28/24: “Medical Social Worker to evaluate social, emotional, and financial factors related to the patient’s illness, need for additional care/resources, adjustments to care and develop a plan of care... Goal: A Medical Social Worker Plan of Care will be established... MSW effective MSW 1 time a month for 3 months and PRN (as needed) for additional social and emotional support and end of life care planning...” Findings confirmed at exit interview conducted with Quality Manager, Director of compliance and Education, and Informatics Specialist on 9/13/24 at approximately 3:00pm.”

“Based on review of agency policy/procedure, clinical records (CR), and staff (EMP) interview, the agency failed to develop a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery for two (2) of two (2) bereavement records reviewed (CR 1 & 2). Findings included: Review of agency policy/procedure on 9/13/24 at approximately 10:30am revealed: “SUBJECT: Bereavement...Pre-Death: 1. The initial bereavement assessment is completed at time of admission or MSW/Bereavement evaluation and is updated as needed during the course of care, at time of death, and during bereavement follow-up...Following the Death: ...2. Concordia Hospice of Bethlen staff may make a bereavement visit to the bereaved and assess for the need of additional support or interventions as determined by the plan of care., 3. The initial bereavement assessment will be updated as needed by the Bereavement coordinator, Social Worker, or designee...” Review of clinical records on 9/12/24 at approximately 11:25am revealed: CR1, dates reviewed from election of benefits on 3/15/24 through date of death 3/23/24. CR failed to include a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. CR2, dates reviewed from election of benefits 3/14/24 through date of death 3/18/24. CR failed to include a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. Findings confirmed at exit interview conducted with Quality Manager, Director of compliance and Education, and Informatics Specialist on 9/13/24 at approximately 3:00pm.”

“Based on review of agency policy/procedure, personnel files (PF), and staff (EMP) interview, the agency failed to document and provide volunteer orientation and supervision in accordance with agency policy for two (2) of two (2) volunteer records reviewed (PF 8 & 9). Findings included: Review of agency policy/procedure on 9/13/24 at approximately 10:30am revealed: SUBJECT: Volunteer Program...2. Screening Qualifications...Two references required; three references preferred...4. Supervision, a. Volunteer are under supervision of the Volunteer Coordinator., b. The volunteer Coordinator’s supervisory responsibilities include: ... Monitoring of volunteer performance, providing coaching as needed, completing annual evaluations, and providing opportunities for feedback, Maintaining organized individual volunteer files that include documentation of background screening information, orientation and training documentation, and annual evaluations...” Review of PF on 9/10/24 at approximately 1:00pm revealed: PF8, date of hire 4/20/22 failed to include evidence of 2 references. File also failed to include evidence of annual evaluations for 2023 and 2024. PF9, date of hire 3/24/22 failed to include evidence of 2 references. File also failed to include evidence of annual evaluations for 2023 and 2024. Findings confirmed at exit interview conducted with Quality Manager, Director of compliance and Education, and Informatics Specialist on 9/13/24 at approximately 3:00pm.”