Casa Hospice, LLC

“Based on record reviews and interviews, the hospice failed to include the initial bereavement assessment which needs to be incorporated into the comprehensive assessment for 1 of 13 patients (Patient #11) whom record was reviewed. This failure placed the hospice patients and all the potential admissions at risk of not addressing their social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Findings Include: Patient #11Record review of patient #11’s electronic CR showed a benefit period of 01/30/25 to 02/07/25 with a SOC date of 01/30/25. The CR revealed the social worker conducted the psychosocial assessment which was incorporated into the comprehensive assessment on 01/31/25, but there was no initial bereavement assessment done to be incorporated into the comprehensive assessment within 5 days. The patient elected hospice on 01/29/25, SOC was done on 01/30/25, and the patient expired on the 8th day (02/07/25) after admission into the hospice. The CR did not have the initial bereavement assessment within 5 days.During an interview with the Administrator on 03/31/25 at 8:00 pm., the surveyor asked the Administrator about who among the IDG team was responsible in conducting the initial bereavement assessment for the patients. The Administrator said the RN, or the social worker usually conducted the patients’ initial bereavement assessment. The surveyor informed the Administrator that patient #11 did not had initial bereavement assessment conducted on her and asked why didn’t the RN or the social worker conducted the initial bereavement assessment on the patient #11. The Administrator said either the RN or the social worker could had conducted the initial bereavement assessment but as it was now, they did not do it. During a telephone interview with the Social Worker/Bereavement coordinator on 03/31/25 at 8:40 p.m., the surveyor asked the social worker/bereavement coordinator why the initial bereavement assessment was not done. The social worker/bereavement coordinator said she did not do it because she thought the RN has done it. The social worker/bereavement coordinator said either her or the RN could had done the initial bereavement assessment and accepted the blame for not conducting the patient’s initial bereavement assessment. Record review of the undated agency Administrative Policy Manual titled “Bereavement” read in part; “...The Hospice will perform an initial bereavement assessment of the needs of the patient’s family and other care individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death as part of the Initial Comprehensive Assessment…””

“Based on record reviews and interviews, the agency failed to have an individualized written plan of care that must be followed to furnish hospice care and services for 2 of 13 patients (patient #7 & #11) whose records were reviewed; in that 1) Patient #7 CR did not have a written POC, and hospice services were provided.2) Patient #11 CR did not have a written POC, and hospice services were provided. This failure placed the hospice patients at risk of not receiving the services needed and has the potential for patient dissatisfaction regarding services. Findings include:Patient #7Record review of patient #7’s electronic CR showed a benefit period of 11/26/24 to 12/18/24. The CR revealed that the patient received SN services on 11/26/24, 12/03/24, 12/09/24, and 12/17/24. The CR showed that IDG meetings were held on 12/04/24 and 12/18/24. The patient expired on 12/18/24. The benefit period 11/26/24 to 12/18/24 reviewed did not have a written POC which the agency must follow to furnish hospice care. Patient #11Record review of patient #11’s electronic CR showed a benefit period of 01/30/25 to 02/07/25 with a SOC date of 01/30/25. The CR revealed an Aide Care Plan with the aide frequencies of 3 times per week. The CR showed that the patient received SN services on 02/04/25, 02/05/25, and 02/06/25, and Hospice Aide service on 02/04/25. The patient expired on 02/07/25. The benefit period 01/30/25 to 02/07/25 reviewed did not have a written POC which the agency must follow to furnish hospice care. During an interview with the Administrator on 03/31/25 at 8:00 p.m., the surveyor asked the Administrator who among the IDG members was responsible in developing a POC for the patients. The Administrator said all members of the IDG team contributed their input towards the development of the POC and the admission nurse (RN-3) was responsible for putting all the input together to formulate the patients’ POC. The surveyor further asked the Administrator what happened that the RN-3 did not do the POC for the patients. The Administrator said the agency requested the RN-3 to come and do the POCs but the RN-3 did not come. During a telephone interview with the admission nurse (RN-3) on 03/31/25 at 8:20 p.m., the surveyor asked the RN-3 how SN services were provided to the patients without a written POC. The RN-3 did not answer the question and started apologizing that it was his fault that the patients did not have a written POC in place. The surveyor redirected the RN-3 to answer the question on how SN services were provided to the patients without a written POC. The RN-3 did not answer the question. The surveyor further asked the RN-3 if he attended the IDG meetings on patients #7 and #11. The RN-3 said he attended the IDG meetings and continued to apologize for not doing the POCs.Record review of the undated agency policy titled “Plan of Care Process” read in part; “...All hospice care and services furnished to patients and their families will follow an individualized written POC established by the hospice interdisciplinary Group/Team (IDG/IDT) …””

“Based on record reviews and interviews, the agency did not have any evidence in the clinical record that the hospice offered and /or provided spiritual counseling in accordance with the patient/families’ desires for 9 of 13 patients (patients #2, #4, #6, #7, #8, #9, #10, #11, & #13).This failure placed the hospice patients and all the potential admissions and their families at risk of not having their spiritual needs met that would ease their grieving process. Findings Include: Patient #2Record review of patient #2’s electronic CR included an initial assessment and initial POC conducted on 01/08/25. The CR revealed the patient elected for hospice on 01/08/25 and there was no spiritual Assessment performed by the Chaplain. The CR did not show any evidence that the hospice offered or provided spiritual counseling to the patient/families. There was no documentation that the Chaplain performed spiritual assessment on patient #2 neither was there any documentation that the patient declined Chaplain’s services. Patient #4Record review of patient #4’s electronic CR included an initial assessment and initial POC conducted on 12/15/24. The CR revealed the patient elected for hospice on 12/13/24 and there was no spiritual Assessment performed by the Chaplain. The CR did not show any evidence that the hospice offered or provided spiritual counseling to the patient/families. There was no documentation that the Chaplain performed spiritual assessment on patient #4 neither was there any documentation that the patient declined Chaplain’s services. Client #6Record review of patient #6’s electronic CR included an initial assessment and initial POC conducted on 02/07/25. The CR revealed the patient elected for hospice on 02/07/25 and there was no spiritual Assessment performed by the Chaplain. The CR did not show any evidence that the hospice offered or provided spiritual counseling to the patient/families. There was no documentation that the Chaplain performed spiritual assessment on patient #6 neither was there any documentation that the patient declined Chaplain’s services. Client #7Record review of patient #7’s electronic CR included an initial assessment and initial POC conducted on 08/29/24. The CR revealed the patient elected for hospice on 08/29/24 and there was no spiritual Assessment performed by the Chaplain. The CR did not show any evidence that the hospice offered or provided spiritual counseling to the patient/families. There was no documentation that the Chaplain performed spiritual assessment on patient #7 neither was there any documentation that the patient declined Chaplain’s services. Client #8Record review of patient #8’s electronic CR included an initial assessment and initial POC conducted on 08/12/24. The CR revealed the patient elected for hospice on 08/12/24 and there was no spiritual Assessment performed by the Chaplain. The CR did not show any evidence that the hospice offered or provided spiritual counseling to the patient/families. There was no documentation that the Chaplain performed spiritual assessment on patient #8 neither was there any documentation that the patient declined Chaplain’s services. Client #9Record review of patient #9’s electronic CR included an initial assessment and initial POC conducted on 08/07/24. The CR revealed the patient elected for hospice on 08/07/24 and there was no spiritual Assessment performed by the Chaplain. The CR did not show any evidence that the hospice offered or provided spiritual counseling to the patient/families. There was no documentation that the Chaplain performed spiritual assessment on patient #9 neither was there any documentation that the patient declined Chaplain’s services. Client #10Record review of patient #10’s electronic CR included an initial assessment and initial POC conducted on 07/03/24. The CR revealed the patient elected for hospice on 07/03/24 and there was no spiritual Assessment performed by the Chaplain. The CR did not show any evidence that the hospice offered or provided spiritual counseling to the patient/families. There was no documentation that the Chaplain performed spiritual assessment on patient #10 neither was there any documentation that the patient declined Chaplain’s services. Client #11Record review of patient #11’s electronic CR included an initial assessment conducted on 01/30/25, there was no initial POC. The CR revealed the patient elected for hospice on 01/29/25 and there was no spiritual Assessment performed by the Chaplain. The CR did not show any evidence that the hospice offered or provided spiritual counseling to the patient/families. There was no documentation that the Chaplain performed spiritual assessment on patient #11 neither was there any documentation that the patient declined Chaplain’s services. Client #13Record review of patient #13’s electronic CR included an initial assessment and initial POC conducted on 10/18/24. The CR revealed the patient elected for hospice on 10/18/24 and there was no spiritual Assessment performed by the Chaplain. The CR did not show any evidence that the hospice offered or provided spiritual counseling to the patient/families. There was no documentation that the Chaplain performed spiritual assessment on patient #10 neither was there any documentation that the patient declined Chaplain’s services.During an interview with the Administrator on 03/31/25 at 7:40 p.m., the surveyor presented the above findings and asked why the agency failed to provide an assessment of the client and family’s spiritual needs on all nine patients. The administrator said most times, the clients declined the Chaplain’s services because of their beliefs, and some may prefer their own priest to visit them. The Administrator further said that the agency former chaplain was a contract staff who visited patients and refused to complete and submit her visit documentations. On 03/31/25 at 7:46 p.m., the surveyor attempted to contact the new chaplain that was hired two days ago but the new chaplain did not pick the call. The surveyor left a voice message with a call back number. On 03/31/25 at 8:15 p.m., the surveyor placed a phone call to the former chaplain for an interview. During an interview with the former chaplain, the surveyor asked the chaplain why spiritual assessment and counseling was not provided for nine patients (patients #2, #4, #6, #7, #8, #9, #10, #11, & #13). The former chaplain said she only visited three patients, and those three patients declined chaplain’s services and documented their declined of services in the patients CR. The surveyor further asked the former chaplain to give the names of the three patients she visited and who declined the services. The former chaplain said she could not remember their names.”