Greenleaf Hospice LLC

“Based on record review and interview, the agency failed to develop a bereavement plan of care that noted the kind of bereavement services and the frequency of service to be delivered for 2 (#12, #13) of 2 deceased patient records reviewed where the family or significant others received bereavement services. The failure placed the surviving family members or significant others at risk of inadequate support and that complicated grief would not be identified. Patient #12: Record review of Patient #12’s clinical record revealed an updated Plan of Care dated 6/1/2023. The Plan of Care listed Senile Degeneration of the Brain (loss of function in the cells of the brain) as the primary diagnosis. Patient #12’s clinical record contained documentation of a visit conducted by Social Worker D on 2/15/2023. Social Worker D identified that a nephew was involved in Patient #12’s care. Review of the agency’s discharge patient list given to the surveyor on 3/1/2024, indicated that Patient #12 died on 6/10/2023. Patient #12’s clinical record did not contain a Bereavement Plan of Care. The surveyor reviewed a binder that was titled “Bereavement Book.” The agency had their bereavement program documentation in the binder. A record review of the bereavement book revealed a document titled “General Patient Details” that identified Patient #12. The Bereavement book contained along with the patient details, a copy of 3 letters that contained a first name only of the recipient. The letters were dated 7/10/2023, 9/10/2023, and 12/10/2023. The agency was providing bereavement services to Patient #12’s Family Member. The Bereavement Book did not contain a Bereavement Plan of Care. Patient #13: Record review of Patient #13’s clinical record did not contain a Plan of Care. The agency provided a Certification of Terminal Illness that was dated 9/28/2023. The Certification of Terminal Illness indicated that Patient #13 was admitted to the agency’s services on 9/28/2023. The Certification listed the primary diagnosis as Senile Degeneration of the Brain as the primary diagnosis. Patient #13’s record contained documentation of a phone call that Social Worker D made to Patient #13’s Family Member on 9/28/2023 regarding bereavement services. Patient #13’s Family Member accepted bereavement services. Review of the agency’s discharge patient list given to the surveyor on 3/1/2024, indicated that Patient #13 died on 10/1/2023. Patient #13’s clinical record did not contain a Bereavement Plan of Care. The surveyor reviewed a binder that was titled “Bereavement Book.” The agency had their bereavement program documentation in the binder. A record review of the bereavement book revealed a document titled “General Patient Details” that identified Patient #13. The Bereavement book contained, along with the patient details, copies of 2 letters that contained a first name only of the recipient. The letters were dated 11/1/2023 and 1/1/2024. The agency was providing bereavement services to Patient #13’s Family Member. The Bereavement Book did not contain a Bereavement Plan of Care. On 3/4/2024 at 12:33 p.m. the surveyor requested the bereavement documentation. The Administrator stated, “The Chaplain [Chaplain C] has the book of bereavement.” The Administrator informed the surveyor that Chaplain C had a family member at the hospital having tests. The Administrator stated, “We have asked him to bring it.” On 3/4/2024 at 2:07 p.m., the surveyor asked if the bereavement could be in the computer. The Administrator informed the surveyor that Chaplain C preferred to do written documentation of the bereavement instead of putting it in the computer. During an interview on 3/6/2024 at 10:58 a.m. with the Administrator and Alternate Administrator, the surveyor discussed that the Bereavement Book did not have Bereavement Plans of Care. The Administrator looked in the computer and could not find Bereavement Plans of Care. The surveyor asked if Patient #12 and Patient #13 had Bereavement Plans of Care. The Administrator stated, “No.” During an interview on 3/7/2024 at 11:08 a.m. with Chaplain C, the surveyor discussed that the Bereavement Plans of Care for Patient #12 and Patient #13 were not in the Bereavement Book and were not in the clinical records. The surveyor asked if Chaplain C had developed Bereavement Plans of Care. Chaplain C stated, “I’m sure I did, I may have a paper Bereavement Plan of Care.” Chaplain C stated, “I’m not organized.” Chaplain C did not state how it could impact the agency. Bereavement Plans of Care were not developed. The agency had a policy titled “Bereavement” that was labeled TX.26 with a revision/reviewed date of 2/1/2023. The policy read in part; “Purpose To insure appropriate bereavement assessment and support for surviving hospice family members and significant others. Policy...Following the death, the Agency will develop and implement the bereavement plan of care based on the post death risk assessments...Procedure...5. The bereavement plan of care will be developed and implemented following the death according to individual risk assessment score. 6. The plan of care will include delineation of services and frequency to be provided...””

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided; Signed copies of the notice of patient rights and the hospice election statement; Responses to medications, symptom management, treatments, and services; Physician certification and recertification of terminal illness as required; and Physician orders. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by interview, document review, and clinical record review. The Governing Body failed to ensure that all records contained at a minimum initial and updated plans of care and updated comprehensive assessments and clinical notes [HSIM.3.I/L672] 25 % noncompliance; and failed to ensure that the Election of Hospice Benefit Statement included the effective date [HSIM.4.I/L679], 50% noncompliance. The cumulative effect of these deficiencies resulted in the hospice’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.104: Clinical Records. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice service from the agency.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical records reviewed revealed that the hospice interdisciplinary group did not ensure that the comprehensive assessment was completed within 5 calendar days of election of hospice care. Clinical Record 4: The patient elected the hospice benefit 10/23/2023 with a diagnosis of Malignant Neoplasm of Bladder. The initial RN comprehensive assessment was dated 10/23/2023. A chaplain evaluation was ordered on the plan of care dated 10/26/2023. There was no documented evidence in the RN or social work assessment that the patient’s spiritual needs was completed within 5 calendar days of the election of benefit date. During an interview and joint clinical record review, the Director of Nursing agreed that the comprehensive assessment did not include the spiritual assessment within 5days.”

“It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical records reviewed, the hospice did not ensure comprehensive assessments were performed initially identified the spiritual needs related to the patient’s terminal illness. Clinical Record 4: The patient elected the hospice benefit 10/23/2023 with a diagnosis of Malignant Neoplasm of Bladder. The initial RN comprehensive assessment was dated 10/23/2023. A chaplain evaluation was ordered on the plan of care dated 10/26/2023. There was no documented evidence that the RN assessment or the social work assessment included the patient’s spiritual needs. The clinical record did not contain a chaplain assessment visit. During a clinical record review the Director of Nursing agreed that no spiritual assessment was completed.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals; and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. 6 of 8 (75%) clinical records reviewed revealed that the hospice did not ensure that the plan of care (POC) included goals and interventions based on problems identified in the comprehensive assessment. Clinical Record 1: Patient elected the hospice benefit on 10/10/2023 with a diagnosis of Nontraumatic Subarachnoid hemorrhage. A nursing assessment dated 11/2/2023 identified the following problems: shortness of breath, use of oxygen, dyspnea on exertion, and dysphagia. The POC lacked these identified problems with associated interventions and goals. In addition, the interdisciplinary group (IDG) document dated 11/2/2023 was missing identification of these identified problems. Clinical Record 2: The patient elected the hospice benefit on 10/22/2022 with a diagnosis of Senile Degeneration of Brain. An RN comprehensive assessment dated 11/1/2023 identified problems of shortness of breath with activity, poor balance leading to fall risk, productive cough, and pain. The POC reviewed and updated by the IDG on 11/2/2023 lacked evidence that these identified problems with associated interventions and goals were included on the POC. In addition, problems identified on the POC of Deficit related to nutrition/hydration, deficit related to disruption of spiritual trust/anger, lacked evidence of associated interventions and goals. Clinical Record 3: The patient elected the hospice benefit on 8/9/2023 with a diagnosis of Senile Degeneration of Brain. The RN comprehensive assessment 11/4/2023 identified problems of dyspnea with activity. The POC reviewed and updated by the IDG on 11/2/2023 lacked evidence of this identified problem with associated interventions and goals. Clinical Record 4: The patient elected the hospice benefit on 10/23/2023 with a diagnosis of Senile Degeneration of the Brain. The nursing comprehensive assessment dated 10/23/2023 identified problems of dyspnea with walking, hopelessness and helplessness. The POC reviewed and updated by the IDG on 11/2/2023 lacked evidence of these identified problems with associated interventions and goals. Clinical Record 5: The patient elected the hospice benefit on 8/25/2023 with a diagnosis of Acute ischemic heart disease. The nursing comprehensive assessment dated 11/2/2023 identified problems of dyspnea, chronic pain and dyspnea. The POC reviewed and updated by the IDG on 11/2/2023 lacked evidence of these identified problems with associated interventions and goals. Clinical Record 6: The patient elected the hospice benefit on 5/17/2022 with a diagnosis of Senile Degeneration of Brain. The nursing comprehensive assessment dated 11/2/2023 identified problems of dyspnea on exertion and high risk of falls. The POC reviewed and updated by the IDG on 11/2/2023 lacked evidence of these identified problems with associated interventions and goals. Problems identified on the POC of physical comfort alteration due to pain, skin integrity, and deficit related to spiritual unworthiness anxiety lacked evidence of associated interventions and goals. The Director of Nursing stated in an interview on 11/1/3/2023 that she had performed an audit on the plans of care and did not think they were missing anything.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: Addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; Focuses on indicators related to improved palliative outcomes; Includes investigation and analysis of sentinel and adverse events; Includes defined data detail and frequency of collection, and approves such; Has evidence of action taken that results in improvement in hospice performance; Is evaluated annually. This standard was not met as evidenced by document review and interview which revealed that the hospice did not ensure that the QAPI program focused on quality improvement in care and patient safety. During a joint review on 11/14/2023, the Director of Nursing (DON) of the hospice QAPI program confirmed that she was appointed by the governing body to oversee the hospice QAPI program. However, the QAPI program documents provided by the DON did not include evidence that the program addressed related efforts or set priorities for improved quality of care and patient safety. There were no active performance improvement plans in place to track action taken to make improvements in patient care or the hospice’s performance. During the interview with the Director of Nursing she stated, “I have been so worried with all those audits and everything else that I haven’t had time for anything else especially anything in that notebook.” During a joint review of the hospice QAPI program and interview with the Director of Nursing on 11/14/2023 it was confirmed that she was appointed by the governing body to oversee the hospice QAPI program. During review of documents that the DON supplied associated with the QAPI program, there was no evidence that the program addresses efforts or had set priorities for improved quality of care and patient safety. There were no active performance improvement plans in place to track action taken to make improvements in patient care or the hospice’s performance. During the interview with the Director of Nursing she stated, “I have been so worried with all those audits and everything else that I haven’t had time for anything else especially anything in that notebook.””

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes, including the care and services provided. This standard was not met, as evidenced by clinical record review and interview. 2 of 8 (25%) clinical records reviewed revealed that the hospice FAILED to ensure the clinical record included the clinical notes, including the care and services provided. A review of an audit tool developed as a part of the abatement plan for tracking nursing documentation showed results that all nursing documentation is current. However, the clinical record review identified that nursing notes were missing back to September 2023. During an interview on 11/14/2023, when the DON became aware that these visits would result in a deficiency, she stated, “It’s my fault. I should have told her not to document those visits until after you were gone. You would have never known then.” Clinical Record 8: The patient elected the hospice benefit on 4/25/2023 with a diagnosis of Cerebrovascular Disease. During the review of the clinical record, it was found that the RN did not ensure that documentation of the RN assessments was entered in a timely manner. On 11/13/2023, the RN entered assessments notes from visits made on 9/5/2023, 9/12/2023, 9/22/2023, 9/29/2023, 10/3/2023, 10/13/2023, 10/17/2023, 10/24/2023, 10/31/2023, and 11/7/2023. Clinical Record 5: The patient elected the hospice benefit on 8/25/2023 with a diagnosis of Acute Ischemic Heart Disease. On review of the clinical record, it was found that the RN and hospice aide did not ensure that the documentation of RN assessments and hospice aide visits was entered in a timely manner. On 11/13/2023, the RN entered assessment notes from visits made on 11/2/2023, 11/6/2023, 11/7/2023, 11/8/2023, 11/9/2023, and 11/9/2023. On 11/12/2023 the hospice aide entered visit notes from 10/31/2023, 11/1/2023, 11/2/2023, 11/3/2023, 11/6/2023, 11/8/2023, 11/9/2023, and 11/10/2023. In an interview with the Director of Nursing on 11/14/2023, she stated that there had been issues with some staff members not documenting in a timely manner. When the DON was asked for the documentation policy, she stated, “It’s 48 hours”. She was unable to produce the policy. She said that no disciplinary action had been taken against the repeat offenders. She stated, “The medical director does not allow it.” She also stated, “If you put that in your report, I will lie and say you all just make up stories.””

“It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review and interview. 4 of 8 (50%) clinical records reviewed revealed that hospice FAILED to ensure that the Election of Hospice Benefit Statement was dated to indicate the effective date. Clinical Record 1: No effective date on election of benefits statement that was obtained on 10/10/2023. Clinical Record 2: No effective date on election of benefits statement that was obtained on 10/22/2022. Clinical Record 4: No effective date on election of benefits statement obtained on 10/23/2023. Clinical Record 7: No effective date on election of benefits statement obtained on 10/26/2023. In an interview and joint review of election of benefits statements with the Director of Nursing (DON) on 11/13/2023 she stated, “I have told the RN over and over to get put the date in that blank.” She did not offer any other explanation. The DON”