A Caring Touch Home Health Services & Hospice Care

“It is required that the hospice must conduct and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, document review and interviews which revealed the hospice: Failed to ensure that the psychosocial assessment was completed as part of the initial comprehensive assessment no later than five calendar days after the election of hospice care {HCPC.9. I/L523; and Failed to ensure that the comprehensive assessment included the identification of the psychosocial and emotional needs related to the patient’s terminal illness to promote the patient’s well-being, comfort, and dignity throughout the dying process {HCPC.12. I/L524}. 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 418.54: Initial and comprehensive assessment of the patient. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by 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, document review and interview. In 12 of 14 (86%) clinical records reviewed revealed that the agency did not ensure that a psychosocial assessment was completed as part of the initial comprehensive assessment no later than five calendar days after the election of hospice care. Policy PE. 3 Initial Patient Assessments/Patient Admission dated 06/15/2020 stated in part “The Initial Comprehensive Health Assessment, with input from appropriate IDT members and the attending physician, will be completed within 5 calendar days. Clinical Record 1: The election of hospice care was 05/04/2022. The clinical record included documentation for a missed medical social worker visit on 05/04/2022 which stated in part “unable to reach pt nor family for completion of initial assessment”. The clinical record lacked evidence that a psychosocial assessment was completed no later than 5 calendar days after the election of hospice care. Clinical Record 2: The election of hospice care was 11/22/2023. The clinical record included documentation for a missed medical social worker visit on 11/22/2023. The psychosocial assessment was completed on 12/10/2023. The clinical record lacked evidence that a psychosocial assessment was completed no later than 5 calendar days after the election of hospice care. Clinical Record 4: The election of hospice care was 01/30/2024. The clinical record included documentation for a missed medical social worker visit on 01/30/2024 which stated in part “Worker unable to visit on this date”. The clinical record lacked evidence that a psychosocial assessment was completed no later than 5 calendar days after the election of hospice care. Clinical Record 5: The election of hospice care was 03/29/2023. A psychosocial assessment was completed on 11/03/20223. The clinical record lacked evidence that a psychosocial assessment was completed no later than 5 calendar days after the election of hospice care. Clinical Record 6: The election of hospice care was 01/30/2024. The clinical record included documentation for a missed medical social worker visit on 01/30/2024 which stated in part “Worker unable to visit on this date”. The psychosocial assessment was completed on 02/17/2024. The clinical record lacked evidence that a psychosocial assessment was completed no later than 5 calendar days after the election of hospice care. Clinical Record 7: The election of hospice care was 03/29/2023. The clinical record lacked evidence that a psychosocial assessment was completed no later than 5 calendar days after the election of hospice care. Clinical Record 8: The election of hospice care was 09/30/2023. The clinical record included documentation for a missed medical social worker visit on 09/30/2023 which stated in part “patient was still in skilled nursing home”. The psychosocial assessment was completed on 11/11/2023. The clinical record lacked evidence that a psychosocial assessment was completed no later than 5 calendar days after the election of hospice care. Clinical Record 9: The election of hospice care was 08/07/2023. The clinical record lacked evidence that a psychosocial assessment was completed no later than 5 calendar days after the election of hospice care. Clinical Record 10: The election of hospice care was 11/24/2021. The clinical record lacked evidence that a psychosocial assessment was completed no later than 5 calendar days after the election of hospice care. Clinical Record 11: The election of hospice care was 12/28/2023. The clinical record included documentation for a missed medical social worker visit on 12/28/2023 which stated in part “No answer to phone call”. The psychosocial assessment was completed on 01/06/2024. The clinical record lacked evidence that a psychosocial assessment was completed no later than 5 calendar days after the election of hospice care. Clinical Record 12: The election of hospice care was 06/27/2023. The clinical record included documentation for a missed medical social worker visit on 06/27/2023 which stated in part “No answer to phone call”. The clinical record lacked evidence that a psychosocial assessment was completed no later than 5 calendar days after the election of hospice care. Clinical Record 13: The election of hospice care was 05/26/2022. The clinical record included documentation for a missed medical social worker visit on 5/26/2022 which stated in part “No response”. The clinical record lacked evidence that a psychosocial assessment was completed no later than 5 calendar days after the election of hospice care. During joint record review and interview on 03/13/2024, the Director of Clinical Services confirmed findings that clinical record 1, 2, 4, 5, 6, 7, 8, 9, 10, 11,12, and 13 did not include evidence that a psychosocial assessment was completed as part of the initial comprehensive assessment.”

“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, document review and interview. In 12 of 14 (86%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment included the identification of the psychosocial and emotional needs related to the patient’s terminal illness to promote the patient’s well-being, comfort, and dignity throughout the dying process. Policy PE.3 Initial Patient Assessments/Patient Admission dated 06/15/2020 stated in part “The Comprehensive Health Assessment will identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process.” Clinical Record 1: The election of hospice care was 05/04/2022. The clinical record included documentation for a missed medical social worker visit on 05/04/2022 which stated in part “unable to reach pt nor family for completion of initial assessment”. The clinical record lacked evidence that the psychosocial and emotional needs of the patient were assessed as part of the initial comprehensive assessments. Clinical Record 2: The election of hospice care was 11/22/2023. The clinical record included documentation for a missed medical social worker visit on 11/22/2023. The clinical record lacked evidence that the psychosocial and emotional needs of the patient were assessed as part of the initial comprehensive assessments. Clinical Record 4: The election of hospice care was 01/30/2024. The clinical record included documentation for a missed medical social worker visit on 01/30/2024 which stated in part “Worker unable to visit on this date”. The clinical record lacked evidence that the psychosocial and emotional needs of the patient were assessed as part of the initial comprehensive assessments. Clinical Record 5: The election of hospice care was 03/29/2023. A psychosocial assessment was completed on 11/03/2023. The clinical record lacked evidence that the psychosocial and emotional needs of the patient were assessed as part of the initial comprehensive assessments. Clinical Record 6: The election of hospice care was 01/30/2024. The clinical record included documentation for a missed medical social worker visit on 01/30/2024 which stated in part “Worker unable to visit on this date”. A psychosocial assessment was completed on 02/17/2024. The clinical record lacked evidence that the psychosocial and emotional needs of the patient were assessed as part of the initial comprehensive assessments. Clinical Record 7: The election of hospice care was 08/24/2023. The clinical record lacked evidence that the psychosocial and emotional needs of the patient were assessed as part of the initial comprehensive assessments. Clinical Record 8: The election of hospice care was 09/30/2023. The clinical record included documentation for a missed medical social worker visit on 09/30/2023 which stated in part “patient was still in skilled nursing home”. The clinical record lacked evidence that the psychosocial and emotional needs of the patient were assessed as part of the initial comprehensive assessments. Clinical Record 9: The election of hospice care was 08/07/2023. The clinical record lacked evidence that the psychosocial and emotional needs of the patient were assessed as part of the initial comprehensive assessments. Clinical Record 10: The election of hospice care was 11/24/2021. The clinical record lacked evidence that the psychosocial and emotional needs of the patient were assessed as part of the initial comprehensive assessments. Clinical Record 11: The election of hospice care was 12/28/2023. The clinical record included documentation for a missed medical social worker visit on 12/28/2023 which stated in part “No answer to phone call”. The clinical record lacked evidence that the psychosocial and emotional needs of the patient were assessed as part of the initial comprehensive assessments. Clinical Record 12: The election of hospice care was 06/27/2023. The clinical record included documentation for a missed medical social worker visit on 06/27/2023 which stated in part “No answer to phone call”. The clinical record lacked evidence that the psychosocial and emotional needs of the patient were assessed as part of the initial comprehensive assessments. Clinical Record 13: The election of hospice care was 05/26/2022. The clinical record included documentation for a missed medical social worker visit on 05/26/2022 which stated in part “No answer to phone call”. The clinical record lacked evidence that the psychosocial and emotional needs of the patient were assessed as part of the initial comprehensive assessments. During joint record review and interview on 03/13/2024, the Director of Clinical Services confirmed findings that clinical record 1, 2, 4, 5, 6, 7, 8, 9, 10, 11,12, and 13 did not include evidence that psychosocial and emotional needs were assessed by a social worker and included as part of the initial comprehensive nursing assessment.”

“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, document review and interview. In 7 of 14 (50%) clinical records reviewed revealed that the agency did not ensure that an individualized written plan of care reflecting patient and family goals and interventions was developed based on the problems identified in the initial and comprehensive assessments. Policy PC.6 Care Planning Process dated 06/15/2020 stated in part “The IDT must develop an individualized written plan of care for each client. The plan of care must reflect client and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments.” Clinical Record 3: The chaplain assessment completed on 02/06/2024 stated in part “Coping issues need to be addressed in future sessions.” The clinical record lacked evidence that goals and interventions to address coping issues were included in the plan of care effective 02/07/2024. Clinical Record 4: The chaplain assessment completed on 01/30/2024 identified the patient and family’s request for prayer/meditation and that continuing care was needed. The clinical record lacked evidence that goals and interventions to address prayer and meditation were included in the plan of care effective 02/07/2024. Clinical Record 6: The chaplain assessment completed on 02/04/2024 identified patient and family requests for life review, prayer/meditation, religious resource material, sacred reading, scripture, and spiritual support/counsel and that continuing care was needed. The clinical record lacked evidence that goals and interventions to address life review, prayer/meditation, religious resource material, sacred reading, scripture, and spiritual support/counsel were included in the plan of care effective 02/07/2024. Clinical Record 7: The chaplain assessment completed on 08/26/2023 included documentation that stated in part “The patient/family requested a bible and verbalized that she loves to read the bible.” The clinical record lacked evidence that goals and interventions to address requests were included in the plan of care effective 09/06/2023. Clinical Record 9: The chaplain assessment completed on 08/07/2023 identified the patient and family’s request for prayer/meditation and that continuing care was needed. The clinical record lacked evidence that goals and interventions to address prayer and meditation were included in the plan of care effective 08/23/2023. Clinical Record 11: The chaplain assessment completed on 12/28/2023 identified the patient and family’s request for prayer/meditation and that continuing care was needed. The clinical record lacked evidence that goals and interventions to address prayer and meditation were included in the plan of care effective 12/28/2023 or updated plan of care effective 01/10/2024. Clinical Record 14: The Medical Social Work (MSW) assessment completed on 04/11/2022 included documentation that stated in part “SW will refer as needed for funeral planning needs. MSW plan of care will follow 1-2 routine visits every month to assess for needs and to provide emotional support and prn visits to manage urgencies.” The clinical record lacked evidence that goals and interventions to address funeral planning and emotional support were included in the plan of care effective 04/20/2022. During a joint record review and interview on 03/13/2024, the Director of Clinical Services confirmed findings that clinical record 3, 4, 6, 7, 9, 11, and clinical record 14 did not include evidence that reflected client and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments”

“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 contains at a minimum physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 14 (21%) clinical records reviewed revealed that the agency did not ensure that physician orders were obtained to discontinue the Medical Social Worker frequency and for the visits not completed. Policy Medical Record Content dated 06/15/2020 stated in part “Each medical record will contain the following: Physician orders that include medications, dietary information, treatment, and activity orders.” Clinical Record 5: The plan of care order effective 06/16/2023 included orders for the Medical Social Worker (MSW) to visit one time per quarter. The clinical record lacked evidence that an MSW visit was completed in July, August, or September or that a physician order was obtained for the missed visit. Clinical Record 7: The plan of care order effective 08/24/2023 included orders for the Medical Social Worker (MSW) to visit one time per quarter. The clinical record lacked evidence that an MSW visit was completed in August, September, or October or that a physician order was obtained for the missed visit. Clinical Record 9: The plan of care order effective 08/07/2023 included orders for the Medical Social Worker (MSW) to visit one time per quarter. The clinical record lacked evidence that an MSW visit was completed in August, September, or October or that a physician order was obtained for the missed visit. During a joint record review and interview on 03/13/2024, the Director of Clinical Services confirmed findings that physician orders were not obtained for the missed MSW visits for clinical record 5 and clinical record 7.”