A Healing Touch Hospice

“It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition was not met as evidenced by review of clinical records and interviews which revealed the hospice failed to ensure that the agency designate an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness [HCPC.1./L536]; failed to ensure that the Registered Nurse (RN) provided coordination of patient care, continuous assessment of the patient and family’s needs, and implementation of the interdisciplinary plan of care [HCPC.19.I/L540]; failed to ensure that the patient’s individualized written plan of care include all services necessary for the palliation and management of the terminal illness and related conditions, including the following interventions and goals for identified problems [HCPC.21. I/L545]; failed to ensure that the patient’s individualized written Plan of Care included the scope and frequency services [HCPC.21. I/L547]; failed to ensure that the patient’s individualized written Plan of Care included goals or measurable outcomes [HCPC.21. I/L548]; and failed to ensure that the clinical record included physician orders [HSIM.3. I/L678]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: Hospice Assessment, Care Planning, and Coordination.”

“It is required that the hospice designates a registered nurse (RN) member of the IDG to: Provide coordination of care; Ensure continuous assessment of each patient’s and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed revealed that the agency did not ensure that the registered nurse provided coordination of care to ensure continuous assessment of each patient’s and family’s needs. Clinical Record 2: The patient elected the hospice benefit on 9/21/2023. The Initial Plan of Care (POC) for 9/21/2023 - 12/19/2023 included no orders for Volunteer visits. The IDG Summary and comprehensive assessment updates dated 9/28/2023 and 10/12/2023 stated that Volunteer services were declined. The IDG Summary and comprehensive assessment updates dated 10/26/2023 included documentation that stated that the Volunteer did a home visit. The IDG Summary and comprehensive assessment update for 11/9/2023 indicated that the patient had accepted volunteer services and that the volunteer was assisting the patient with Bible reading and companionship. There was no documented evidence in the clinical record that the RN provided coordination of care to ensure continuous assessment of each patient’s and family’s needs. Clinical Record 4: The patient elected the hospice benefit on 10/4/2023. The Initial Plan of Care for 10/4/2023 - 1/1/2024 did not include any orders for Volunteer visits. The IDG Summary and comprehensive assessment updates for 10/12/2023, 10/26/2023, 11/9/2023, 11/22/2023, and 12/7/2023 all documented that Volunteer services were declined. A review of the clinical record revealed a volunteer visit note dated 11/27/2023. There was no documented evidence in the clinical record that the RN provided coordination of care to ensure continuous assessment of each patient’s and family’s needs. Clinical Record 8: The patient elected the hospice benefit on 11/30/2023. The Initial Plan of Care for 11/30/2023 - 2/27/2024 did not include any orders for Volunteer visits. The IDG Summary/Comprehensive Assessment update dated 12/1/2023 stated “volunteer: Update/Progress Toward Goals section, the volunteer coordinator noted, “Volunteer services accepted.” There was no documented evidence that the POC was updated during the IDG on 12/1/2023 and 12/15/2023 for volunteer services. There was no documented evidence in the clinical record that the RN provided coordination of care to ensure continuous assessment of each patient’s and family’s needs. Clinical Record 9: The patient elected the hospice benefit on 3/14/2023. The POC for 9/10/2023 - 11/8/2023 and 11/9/2023 - 1/7/2024 included no orders for volunteer visits. The IDG Summary/Comprehensive Assessment update dated 10/20/2023 and 11/2/2023, “volunteer: Update/Progress Toward Goals section, the volunteer coordinator noted Patient accepted volunteer services ...is assisting patient with Bible reading and companionship.”. The IDG Summary/Comprehensive Assessment Update for 11/17/2023, the Volunteer Coordinator documented, “Volunteer services were accepted. The Volunteer continues to provide companionship to patient by providing active listening and reassurance.” Included in the IDG Summary/Comprehensive Assessment Update for 12/1/2023 was, “Patient was seen ... for companionship and conversation...provided patient with comfort and effective listening. Patient was comfortable with volunteer presence...Patient will continue to benefit from Volunteer services at least once a month.” There was no documented evidence in the clinical record that the RN provided coordination of care to ensure continuous assessment of each patient’s and family’s needs. During interviews with the Alternate Director of Nursing and the LVN/Compliance Officer/Office Manager on 12/21/2023 confirmed that there were no volunteer services included in the patients’ Plan of Care. They further indicated that a new staff member began to assist with volunteers and that, together with reinstituting volunteer visits post-pandemic, may have resulted in a gap in the process for volunteer visits and documentation.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. In 3 of 4 (75%) clinical records reviewed in which volunteer services were accepted revealed that the agency did not ensure that the patient’s individualized written Plan of Care (POC) include all services necessary for the palliation and management of the terminal illness and related conditions, including the following interventions and goals for identified problems. Clinical Record 2: The patient elected the hospice benefit on 9/21/2023. The Initial Plan of Care (POC) for 9/21/2023 - 12/19/2023 included no orders for Volunteer visits. The IDG Summary and comprehensive assessment updates dated 9/28/2023 and 10/12/2023 stated that Volunteer services were declined. The IDG Summary and comprehensive assessment updates dated 10/26/2023 included documentation that stated that the Volunteer did a home visit. The IDG Summary and comprehensive assessment update for 11/9/2023 indicated that the patient had accepted volunteer services and that the volunteer was assisting the patient with Bible reading and companionship. There was no documented evidence that the POC was updated during the IDG on 10/26/2023 and 11/9/2023 for volunteer services interventions and goals. Clinical Record 8: The patient elected the hospice benefit on 11/30/2023. The Initial Plan of Care for 11/30/2023 - 2/27/2024 did not include any orders for Volunteer visits. The IDG Summary/Comprehensive Assessment update dated 12/1/2023 stated “volunteer: Update/Progress Toward Goals section, the Volunteer Coordinator noted, “Volunteer services accepted.” There was no documented evidence that the POC was updated during the IDG on 12/1/2023 and 12/15/2023. Clinical Record 9: The patient elected the hospice benefit on 3/14/2023. The POC for 9/10/2023 - 11/8/2023 and 11/9/2023 - 1/7/2024 included no orders for volunteer visits. The IDG Summary/Comprehensive Assessment update dated 10/20/2023 and 11/2/2023, “Volunteer: Update/Progress Toward Goals section, the volunteer coordinator noted patient accepted volunteer services ...is assisting patient with Bible reading and companionship.”. The IDG Summary/Comprehensive Assessment Update for 11/17/2023, the Volunteer Coordinator documented, “Volunteer services were accepted. The Volunteer continues to provide companionship to patient by providing active listening and reassurance.” Included in the IDG Summary/Comprehensive Assessment Update for 12/1/2023 was, “Patient was seen ... for companionship and conversation...provided patient with comfort and effective listening. Patient was comfortable with volunteer presence...Patient will continue to benefit from Volunteer services at least once a month.” There was no documented evidence that the POC was updated during the IDG on 10/20/2023, 11/3/2023, 11/17/2023, or 12/1/2023 for volunteer service. During interviews with the Alternate Director of Nursing and the LVN/Compliance Officer/Office Manager on 12/21/2023 confirmed that there were no volunteer interventions included in the patients’ Plans of Care. They further indicated that a new staff member began to assist with Volunteers and that, together with reinstituting Volunteer visits post-pandemic, may have resulted in a gap in the process for Volunteer visits and documentation.”

“It is required that each patient’s individualized written plan of care Includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 4 (100%) clinical records reviewed in which volunteer services were accepted revealed that the agency did not ensure that the patient’s individualized written Plan of Care included the scope and frequency of volunteer services. Agency policy “Medical Record Content” (IM.30) dated 11/30/2022 included in part, “Documentation of care provided will include ...Interdisciplinary Plans of Care, including problems, interventions, goals, and progress toward the goals...physician orders...documentation of ...frequency of visits...” Clinical Record 2: The patient elected the hospice benefit on 9/21/2023. The Initial Plan of Care (POC) for 9/21/2023 - 12/19/2023 included no orders for Volunteer visits. The IDG Summary and comprehensive assessment updates dated 10/26/2023 included documentation that stated that the volunteer did a home visit. The IDG Summary and comprehensive assessment update for 11/9/2023 indicated that the patient had accepted Volunteer services and that the volunteer was assisting the patient with Bible reading and companionship. There were volunteer visits notes dated 9/22/2023 and 10/23/2023. There was no documented evidence that the POC included the scope and frequency for volunteer services when identified during the IDG meetings and IDG Summary/Comprehensive Assessment updates. Clinical Record 4: The patient elected the hospice benefit on 10/4/2023. The Initial Plan of Care for 10/4/2023 - 1/1/2024 did not include any orders for volunteer visits. A review of the clinical record revealed a volunteer visit note dated 11/27/2023. There was no documented evidence in the POC that included the scope and frequency for volunteer services. Clinical Record 8: The patient elected the hospice benefit on 11/30/2023. The Initial Plan of Care for 11/30/2023 - 2/27/2024 did not include any orders for Volunteer visits. The IDG Summary/Comprehensive Assessment update dated 12/1/2023 in the Volunteer: Update/Progress Toward Goals section, the Volunteer Coordinator noted, “Volunteer services accepted.” The IDG Summary/Comprehensive Assessment Updates for 12/1/2023 and 12/15/2023. There was a Volunteer visit documented on 12/1/2023. There was no documented evidence that the POC included the scope and frequency for volunteer services when identified during the IDG meetings and IDG Summary/Comprehensive Assessment updates. Clinical Record 9: The patient elected the hospice benefit on 3/14/2023. In the Plans of Care for 9/10/2023 - 11/8/2023 and 11/9/2023 - 1/7/2024 included no orders for volunteer visits. The IDG Summary/Comprehensive Assessment Update dated 10/20/2023 in the volunteer: Update/Progress Toward Goals section, the volunteer coordinator noted, “Patient accepted volunteer services ...is assisting patient with Bible reading and companionship.” The IDG Summary/Comprehensive Assessment Update for 11/17/2023, the volunteer coordinator documented, “volunteer services were accepted. The volunteer continues to provide companionship to patient by providing active listening and reassurance.” There was a Volunteer visit documented on 11/27/2023. The IDG Summary/Comprehensive Assessment Update for 12/1/2023 stated, “Patient was seen ... for companionship and conversation...provided patient with comfort and effective listening. Patient was comfortable with volunteer’s presence...Patient will continue to benefit from Volunteer services at least once a month.” There was no documented evidence that the POC included the scope and frequency for volunteer services when identified during the IDG meetings and IDG Summary/Comprehensive Assessment updates. During interviews with the Alternate Director of Nursing and the LVN/Compliance Officer/Office Manager on 12/21/2023 confirmed that there were no Volunteer visit frequency orders included in the patients’ Plans of Care nor any physician orders documenting Volunteer visits. They further indicated that a new staff member began to assist with Volunteers and that, together with reinstituting Volunteer visits post-pandemic, may have resulted in a gap in the process for Volunteer visits and documentation.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 4 (100%) clinical records reviewed in which volunteer services were accepted revealed that the agency did not ensure that the patient’s individualized written Plan of Care included goals or measurable outcomes for volunteer services. Agency policy “Medical Record Content” (IM.30) dated 11/30/2022 included in part, “Documentation of care provided will include ...Interdisciplinary Plans of Care, including problems, interventions, goals, and progress toward the goals...physician orders...documentation of ...frequency of visits...” Clinical Record 2: The patient elected the hospice benefit on 9/21/2023. The Initial Plan of Care (POC) for 9/21/2023 - 12/19/2023 included no orders for Volunteer visits. The IDG Summary and comprehensive assessment updates dated 10/26/2023 included documentation that stated that the volunteer did a home visit. The IDG Summary and comprehensive assessment update for 11/9/2023 indicated that the patient had accepted Volunteer services and that the volunteer was assisting the patient with Bible reading and companionship. There were volunteer visits notes dated 9/22/2023 and 10/23/2023. There was no documented evidence that the POC included goals or measurable outcomes for volunteer services. Clinical Record 4: The patient elected the hospice benefit on 10/4/2023. The Initial Plan of Care for 10/4/2023 - 1/1/2024 did not include any orders for volunteer visits. A review of the clinical record revealed a volunteer visit note dated 11/27/2023. There was no documented evidence in the POC that included goals or measurable outcomes for volunteer services. Clinical Record 8: The patient elected the hospice benefit on 11/30/2023. The Initial Plan of Care for 11/30/2023 - 2/27/2024 did not include any orders for Volunteer visits. The IDG Summary/Comprehensive Assessment update dated 12/1/2023 in the Volunteer: Update/Progress Toward Goals section, the Volunteer Coordinator noted, “Volunteer services accepted.” The IDG Summary/Comprehensive Assessment Updates for 12/1/2023 and 12/15/2023. There was a Volunteer visit documented on 12/1/2023. There was no documented evidence that the POC included goals or measurable outcomes for volunteer services. Clinical Record 9: The patient elected the hospice benefit on 3/14/2023. In the Plans of Care for 9/10/2023 - 11/8/2023 and 11/9/2023 - 1/7/2024 included no orders for volunteer visits. The IDG Summary/Comprehensive Assessment Update dated 10/20/2023 in the volunteer: Update/Progress Toward Goals section, the volunteer coordinator noted, “Patient accepted volunteer services ...is assisting patient with Bible reading and companionship.” The IDG Summary/Comprehensive Assessment Update for 11/17/2023, the volunteer coordinator documented, “volunteer services were accepted. The volunteer continues to provide companionship to patient by providing active listening and reassurance.” There was a volunteer visit documented on 11/27/2023. The IDG summary/Comprehensive Assessment Update for 12/1/2023 stated, “Patient was seen ... for companionship and conversation...provided patient with comfort and effective listening. Patient was comfortable with volunteer’s presence...Patient will continue to benefit from Volunteer services at least once a month.” There was no documented evidence that the POC included goals or measurable outcomes for volunteer services. During interviews with the Alternate Director of Nursing and the LVN/Compliance Officer/Office Manager on 12/21/2023 confirmed that there were no goals for Volunteer visits included in the patients’ Plans of Care. They further indicated that a new staff member began to assist with Volunteers and that, together with reinstituting Volunteer visits post-pandemic, may have resulted in a gap in the process for Volunteer visits and documentation.”

“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. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed that the agency did not ensure that the clinical record included physician orders for visits. Clinical Record 2: The patient elected the hospice benefit on 9/21/2023. The Initial Plan of Care (POC) for 9/21/2023 - 12/19/2023 included no orders for volunteer visits. A review of the clinical record revealed volunteer visits notes dated 9/22/2023 and 10/23/2023. There was no documented evidence of a physician order for the two volunteer visits. Clinical Record 4: The patient elected the hospice benefit on 10/4/2023. The Initial Plan of Care for 10/4/2023 - 1/1/2024 did not include any orders for volunteer visits. A review of the clinical record revealed a volunteer visit note dated 11/27/2023. There was no documented evidence of a physician order for the volunteer visit. Clinical Record 8: The patient elected the hospice benefit on 11/30/2023. The Initial Plan of Care for 11/30/2023 - 2/27/2024 did not include any orders for Volunteer visits. A review of the clinical record revealed a volunteer visit note dated 12/1/2023. There was no documented evidence of a physician order for the volunteer visit.”