Agape Hospice Care

“Based on record review and interviews, the agency failed to ensure the comprehensive assessment was completed no later than 5 days after the election of benefits for 5 (3, 5, 6, 7, 8) of 8 active patients reviewed. This failure placed the patients at risk of having an inadequate plan of care and receiving inappropriate or inadequate care. Findings: Record review of patient 3s medical record revealed informed consents signed 3/25/24. The social worker completed the psychosocial assessment 4/3/24. This was 10 days after admission. Record review of patient 5s medical record revealed informed consents signed 10/6/23. The psychosocial assessment portion of the comprehensive assessment was not located in the medical record. Record review of patient 6s medical record revealed informed consents signed 10/20/23. The psychosocial assessment portion of the comprehensive assessment was not located in the medical record. Record review of patient 7s medical record revealed informed consents signed 11/3/23. The psychosocial assessment portion of the comprehensive assessment was not located in the medical record. Record review of patient 8s medical record revealed informed consents with an election date of 6/21/24. The psychosocial assessment portion of the comprehensive assessment was not located in the medical record. On 7/3/24 at 12:15 p.m. the OM informed the surveyor that the current SW is contracted through an agency. On 7/8/24 at 12:20 p.m., the surveyor discussed with the ADON when the comprehensive assessment had to be completed and what was included in the comprehensive assessment. The ADON stated, “;We call her [SW D] but she doesnt make it in the 5 days. Shes [SW D] just too busy.” In an interview 7/9/24 at 2:30 p.m., the ADM stated, “;The comprehensive assessment should be done within the 5 days. I dont know why they arent.” The agency had a policy titled; “;Assessments” dated 1/31/15. The policy read in parts: “;...Policy: The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patients need for hospice care and services, the patients need for physical, psychosocial, emotional, and spiritual care. Procedure: ...Time frame for completion of the Comprehensive Assessment B. The hospice interdisciplinary group, in consultation with the individuals attending physician (if any), will complete the comprehensive assessment no later than 5 calendar days after the election of hospice care...” The agency had a policy titled; “;Plan of Care” dated 3/25/25. The policy read in parts: “;...Policy: The hospice interdisciplinary group (IDG) must prepare an individualized and patient specific written plan of care for each patient. ...Procedure: ...C. Based on the needs identified in the comprehensive assessments (performed no later than 5 days after the election of hospice), the IDG will, in collaboration with the patients attending physician, if any, Hospice Medical Director, patient or representative and primary caregiver further develop the written plan of care...””

“Based on record reviews and interviews, the agency failed to ensure the IDT included a social worker in 7 (1, 2, 3, 4, 5, 6, 7) of 8 active patient records reviewed. This failure placed the patients at risk of not having their psychosocial needs met. Findings: Record review of patient 1s medical record revealed informed consents signed 4/14/23 and a plan of care dated 4/17/23. IDT meeting notes dated 4/9/24, 4/23/24, 5/7/24, 5/21/24, and 6/4/24 were located but did not contain evidence of input from a social worker. Record review of patient 2s medical record revealed informed consents signed 4/27/24 and a plan of care dated 4/27/24. IDT meeting notes dated 5/7/24, 5/21/24, 6/4/24, and 6/17/24 were located but did not contain evidence of input from a social worker. Record review of patient 3s medical record revealed informed consents signed 3/25/24 and the initial plan of care dated 3/25/24. IDT meeting notes dated 4/9/24, 4/23/24, 5/7/24, 5/21/24, 6/4/24, 6/17/24, and 7/2/24 were located but did not contain evidence of input from a social worker. Record review of patient 4s medical record revealed informed consents with an election date of 4/7/24 and an initial plan of care dated 4/7/24. IDT meeting notes dated 4/23/24, 5/7/24, 5/21/24, 6/4/24, 6/17/24, and 7/2/24 were located but did not contain evidence of input from a social worker. Record review of patient 5s medical record revealed informed consents signed 10/6/23 and an initial plan of care dated 10/6/23. IDT meeting notes dated 4/9/24, 4/23/24, 5/7/24, and 5/21/24 were located but did not contain evidence of input from a social worker. Record review of patient 6s medical record revealed informed consents signed 10/20/23 and an initial plan of care dated 10/20/23. IDT meeting notes dated 4/9/24, 4/23/24, 5/7/24, 5/21/24, and 6/4/24 were located but did not contain evidence of input from a social worker. Record review of patient 7s medical record revealed informed consents signed 11/3/23 and an initial plan of care dated 11/3/23. IDT meeting notes dated 4/23/24, 5/7/24, 5/21/24, 6/4/24, and 6/18/24 were located but did not contain evidence of input from a social worker. On 7/3/24 at 12:15 p.m. the OM stated, “;SW E left the agency 4/16/24. SW D an agency social worker started 5/2/24. To my knowledge no social worker attends IDT meetings.” On 7/8/24 at 12:20 p.m., the surveyor asked who attended IDT and how is team involvement documented. The ADON responded, “;me the OM, the chaplain, the aide, and the medical director attends the meeting, but no one signs it [the meeting notes] but me and the doctor.” The surveyor asked if the social worker attended IDT and the ADON stated, “;the social worker does not attend even by phone.” In an interview 7/9/24 at 2:30 p.m., the ADM stated, “;the social worker attends the IDT.” The AA corrected him saying, “;no they dont.” The ADM then stated, “;theyre supposed to.” The agency had a policy titled; “;Core Service” dated 1/31/15. The policy read in parts: “;Policy: A hospice must routinely provide substantially all core services directly by hospice employees and in a manner consistent with acceptable standards of practice. Procedure: Core Services: A. Core services will be provided directly by hospice employees and include the following: ...3. Medical Social Services...” The agency had a policy titled; “;Interdisciplinary Group (IDG)” dated 3/25/15. The policy read in parts: “;Policy: The hospice must designate an interdisciplinary group (ID) or groups which, in consultation with the patients attending physician, if any, must work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Procedure: IDG Members: A. The IDG will include, but is not limited to, individuals who are qualified and competent to practice in the following professional roles: ...3. Medical Social Worker...F. The meeting will include: ...4. Discussion by IDG for the update or ongoing plan of care for each problem by each service provided. This may include: ...b. Social Services ...G. The discussion and updates will be documented on the plan of care...””

“Based on record review and interviews the agency failed to ensure the plan of care included a detailed statement of the scope and frequency of the services necessary to meet the specific patient and family needs in 7 (1, 2, 3, 4, 5, 6, 7) of 8 active patient records reviewed. This failure placed the patients at risk of receiving inadequate or inappropriate care. Findings: Record review of patient 1s medical record revealed informed consents signed 4/14/23 and a plan of care dated 4/14/23. The initial plan of care documented the visit frequencies as follows: nurse 1-2 times a week, social worker 1 time a month, aide 3 times a week, and the chaplain was checked but did not contain a frequency. IDT meetings were held 4/9/24, 4/23/24, 5/7/24, 5/21/24, and 6/4/24 but the notes did not contain a detailed statement what services were needed or the scope and frequency of services necessary to meet the client and family needs. Record review of patient 2s medical record revealed informed consents signed 4/27/24 and a plan of care dated 4/27/24. The initial plan of care documented the visit frequencies as follows: nurse 1time a week, aide 2 times a week, and the chaplain was to visit within the first 5 days of admission. IDT meetings were held 5/7/24, 5/21/24, 6/4/24, and 6/17/24 but the notes did not contain a detailed statement what services were needed or the scope and frequency of services necessary to meet the client and family needs. Record review of patient 3s medical record revealed informed consents signed 3/25/24 and the initial plan of care dated 3/25/24. The initial plan of care documented the visit frequencies as follows: nurse 1time a week, and the chaplain was to visit within the first 5 days of admission. IDT meetings were held 4/9/24, 4/23/24, 5/7/24, 5/21/24, 6/4/24, 6/17/24, and 7/2/24 but the notes did not contain a detailed statement what services were needed or the scope and frequency of services necessary to meet the client and family needs. Record review of patient 4s medical record revealed informed consents with an election date of 4/7/24 and an initial plan of care dated 4/7/24. The initial plan of care documented the visit frequencies as follows: nurse 1time a week, aide 5 times a week, and the social worker and chaplain were to visit within the first 5 days of admission. IDT meetings were held 4/23/24, 5/7/24, 5/21/24, 6/4/24, 6/17/24, and 7/2/24 but the notes did not contain a detailed statement what services were needed or the scope and frequency of services necessary to meet the client and family needs. Record review of patient 5s medical record revealed informed consents signed 10/6/23 and an initial plan of care dated 10/6/23. The initial plan of care documented the visit frequencies as follows: social worker 1 time a week. The nurse and chaplain were checked but no frequency was documented. IDT meetings were held 4/9/24, 4/23/24, 5/7/24, and 5/21/24 but the notes did not contain a detailed statement what services were needed or the scope and frequency of services necessary to meet the client and family needs. Record review of patient 6s medical record revealed informed consents signed 10/20/23 and an initial plan of care dated 10/20/23. The initial plan of care documented the visit frequencies as follows: nurse every day, aide 2 times a week, social worker 1 time a month, chaplain 1 time a month. IDT meetings were held 4/9/24, 4/23/24, 5/7/24, 5/21/24, and 6/4/24 but the notes did not contain a detailed statement what services were needed or the scope and frequency of services necessary to meet the client and family needs. Record review of patient 7s medical record revealed informed consents signed 11/3/23 and an initial plan of care dated 11/3/23. The initial plan of care documented the visit frequencies as follows: nurse 2 times a week, aide 2 times a week, social worker 1 time a month, chaplain 1 time a month. IDT meetings were held 4/23/24, 5/7/24, 5/21/24, 6/4/24, and 6/18/24 but the notes did not contain a detailed statement what services were needed or the scope and frequency of services necessary to meet the client and family needs. On 7/8/24 at 12:20 p.m., the surveyor discussed with the ADON what should be included on the plan of care. The ADON stated, “;I didnt realize the frequencies had to be on there or why they arent on this new EMR system.” In an interview 7/9/24 at 2:30 p.m., the ADM stated, “;the frequencies arent on the plan of care? Have you told all of them [OM, ADON, AA] about it so they know what to do?” The agency had a policy titled; “;Plan of Care” dated 3/25/25. The policy read in parts: “;...Policy: The hospice interdisciplinary group (IDG) must prepare an individualized and patient specific written plan of care for each patient. ...Procedure: ...B. The written plan of care will include the following: ...3. ...b. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.” The agency had a policy titled; “;Interdisciplinary Group (IDG)” dated 3/25/15. The policy read in parts: “;Policy: The hospice must designate an interdisciplinary group (IDG) or groups which, in consultation with the patients attending physician, if any, must work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Procedure: IDH Meetings: ...F. The meeting will include: ...4. Discussion by IDG for the update or ongoing plan of care for each problem by each service provided. This may include: ...l. Frequency of visits by all services involved. ...G. The discussion and updates will be documented on the plan of care...””

“Based on record review and interview, the agency failed to ensure the IDT revised and documented the patients individualized plan of care every 15 days in 7 (1, 2, 3, 4, 5, 6, 7) of 8 active patients reviewed. This failure placed the patients at risk for receiving inappropriate or inadequate care. Findings: Record review of patient 1s medical record revealed informed consents signed 4/14/23 and a plan of care dated 4/17/23. IDT meetings were held 4/9/24, 4/23/24, 5/7/24, 5/21/24, and 6/4/24 but there were no plans of care or plan of care updates after 4/17/23 located in the medical record. Record review of patient 2s medical record revealed informed consents signed 4/27/24 and a plan of care dated 4/27/24. IDT meetings were held 5/7/24, 5/21/24, 6/4/24, and 6/17/24 but there were no plans of care or plan of care updates after 4/17/24 located in the medical record. Record review of patient 3s medical record revealed informed consents signed 3/25/24 and the initial plan of care dated 3/25/24. IDT meetings were held 4/9/24, 4/23/24, 5/7/24, 5/21/24, 6/4/24, 6/17/24, and 7/2/24 but there were no plans of care or plan of care updates after 3/25/24 located in the medical record. Record review of patient 4s medical record revealed informed consents with an election date of 4/7/24 and an initial plan of care dated 4/7/24. IDT meetings were held 4/23/24, 5/7/24, 5/21/24, 6/4/24, 6/17/24, and 7/2/24 but there were no plans of care or plan of care updates after 4/7/24 located in the medical record. Record review of patient 5s medical record revealed informed consents signed 10/6/23 and an initial plan of care dated 10/6/23. IDT meetings were held 4/9/24, 4/23/24, 5/7/24, and 5/21/24 but there were no plans of care or plan of care updates after 10/6/23 located in the medical record. Record review of patient 6s medical record revealed informed consents signed 10/20/23 and an initial plan of care dated 10/20/23. IDT meetings were held 4/9/24, 4/23/24, 5/7/24, 5/21/24, and 6/4/24 but there were no plans of care or plan of care updates after 10/20/23 located in the medical record. Record review of patient 7s medical record revealed informed consents signed 11/3/23 and an initial plan of care dated 11/3/23. IDT meetings were held 4/23/24, 5/7/24, 5/21/24, 6/4/24, and 6/18/24 but there were no plans of care or plan of care updates after 11/3/23 located in the medical record. On 7/8/24 at 12:20 p.m., the surveyor discussed with the ADON how often the plan of care should be reviewed and/ or updated. The ADON stated, “;I didnt realize we were supposed to update it every two weeks.” In an interview 7/9/24 at 2:30 p.m., the ADM stated, “;I dont know about the plan of care updates. Have you told all of them [OM, ADON, AA] about it so they know what to do?” The agency had a policy titled; “;Interdisciplinary Group (IDG)” dated 3/25/15. The policy read in parts: “;Policy: The hospice must designate an interdisciplinary group (IDG) or groups which, in consultation with the patients attending physician, if any, must work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Procedure: IDH Meetings: E. The IDG Members will meet, at a minimum, every 15 days to review and update the written plan of care for each patient. ...F. The meeting will include: ...4. Discussion by IDG for the update or ongoing plan of care for each problem by each service provided. ...G. The discussion and updates will be documented on the plan of care...” The agency had a policy titled; “;Plan of Care” dated 3/25/25. The policy read in parts: “;...Policy: The hospice interdisciplinary group (IDG) must prepare an individualized and patient specific written plan of care for each patient. ...Procedure: ...D. Based on the updated comprehensive assessments, in collaboration with the individuals attending physician, if any, the IDG will review, revise, and document the individualized plan as frequently as the patients condition requires, but no less frequently than every 15 calendar days...””