Acg Hospice-Gardendale

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, document review, and observation. Agency policy #2-004, “Medication Profile,” stated in part, “Patients receiving medication administered by the organization will have a current, accurate medication profile in the medical record. The medication profile will be updated for each change to reflect current medications and new /or discontinued medications ...Deviations from taking medications as ordered will be documented in the medical records, and the Physician (or other authorized independent practitioner ) will be notified.” In 4 of 8 (50%) clinical records reviewed and home visits observed, the hospice did not ensure that the patient’s drug profile was accurately updated to reflect changes identified during patient assessments. Clinical Record 1: The patient elected the hospice benefit on 03/14/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris and died on 09/20/2024. The Registered Nurse (RN) visit note dated 08/23/2024 at 11:24 AM documented, “He is agitated. Trying to get out of bed, pull things, pick up things on floor. Family is noncompliant with medication orders to manage agitation. Family states they are exhausted caring for him. Explained that they have not utilized the help that hospice is offering in managing his symptoms. After discussing the regimen, family allowed Ativan 2mg and Haldol 1mg to be given. After approximately 30 min pt resting comfortably. Family to continue Ativan 2mg q 4hr.” The physician’s order dated 08/21/2024 ordered “Ativan 1mg every 4 hours as needed for anxiety or agitation. In the evenings, give a single dose of 1.5-2 tabs.” There was no documented evidence that the hospice medication profile was updated to include Ativan 2mg to be given outside of the evening dose. There was no documented evidence that the hospice medication profile was updated to include Ativan 2mg every four hours. On 03/19/2025, the leadership team provided a paper annotation by a RN documenting that, “On 08/23/2024, I, (Name of Nurse), RNCM, obtained an order for Ativan 1mg every 1-2 hours PRN for SOB and/or anxiety. In error, an order was not entered into the electronic medical record (EMR). This order was obtained from Dr. (Name of Doctor) via Backline secure messaging app.” This was signed by the RN on 03/19/2025. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 02/09/2025 with a primary diagnosis of malignant neoplasm of an unspecified part of the right bronchus or lung. During the home visit with the RN [Personnel Record 1] on 03/19/2025, the hospice medication profile was compared to the patient’s medications provided by the family. A prescription bottle dated 02/15/2025 for methadone 5mg, two (2) tablets twice daily, was located in a lockbox. The patient’s girlfriend confirmed the patient had been receiving two (2) tablets twice daily of methadone for at least the last week and up to two weeks. The RN visit note dated 02/10/2025 documented that “the doctor ordered methadone 10mg BID (twice a day).” The RN visit note dated 02/11/2025 documented, “comfort meds in last 24 hours oxycodone 10mg q4h prn and methadone 10mg q12 hr.” The RN visit note dated 02/12/2025 documented, “patient did not like the methadone previously prescribed he states he only wants to use the oxycodone 10mg q4hr prn. Nurse educated on the methadone use once more to attempt to convince him to try a regimen that would reduce peaks and valleys of pain.” The RN visit note dated 02/15/2025 documented, “pharmacy called (on-call nurse) OCN this am reporting they did not have methadone in stock, found pharmacy and family is going to pick up.” The RN visit notes dated 02/15/2025 and 02/18/2025 documented, “pt agreed to try methadone.” A clinical record review revealed no evidence that the hospice medication profile included methadone from 02/09/2025 through 03/19/2025. Clinical Record 4/Home Visit 1: The patient elected the hospice benefit on 03/12/2025 with a primary diagnosis of moderate protein-calorie malnutrition. The hospice medication profile dated 03/12/2025 documented, “Oxycodone 5mg tablet, take one (1) tablet every 6 hours as needed for pain.” The RN visit note dated 03/12/2025 documented, “He is currently on oxycodone 5mg Q6H PRN. After rolling and moving patient today after assessment, RN administered 10mg of oxycodone.” A clinical record review revealed no evidence that the hospice medication profile included oxycodone 10mg. During the home visit with the RN [Personnel Record 2] on 03/19/2025, the hospice medication profile was compared to the patient’s current medications as provided by the patient’s spouse. The spouse confirmed that the patient received the following doses as they were recorded on a written board in the room: on 03/14/2025, the patient received 5mg oxycodone at 3:20 AM, 7:00 AM, 11:00 AM, and 2:40 PM; on 03/17/2025, the patient received 5mg oxycodone at 11:30 AM, oxycodone 5mg x 2 tablets (10mg) at 4:00 PM, and oxycodone 5mg at 10:00 PM; on 03/18/2025, the patient received morphine 0.25ml (5mg) at 11:45 AM, oxycodone 5mg at 4:50 PM, oxycodone 5mg at 8:45 PM, and oxycodone 5mg at 11:00 PM; and on 3/19/2025, the patient received oxycodone 5mg at 6:00 AM and 8:30 AM. During the home visit and interview, the spouse stated that the RN instructed her during the admission visit on 03/12/2025 to give oxycodone 5mg x 2 tablets if the patient had excruciating pain. The hospice medication profile did not include documentation of oxycodone 10mg. The hospice medication profile did not include documentation of the administration of oxycodone more frequently than every 4-6 hours. Following the home visit on 03/19/2025, the agency provided an unsigned order with an order date of 03/19/2025 ordering 1x dose of Oxycodone 10mg on 03/12/2025. Additionally, the agency provided an annotation note dated 03/19/2025 documenting that on the admission date of 03/12/2025, a verbal order was received for 1x dose of oxycodone 10mg due to severe pain. Received an order from MD, oxycodone 5mg Q6 PRN is to remain ordered. Clinical Record 7: The patient elected the hospice benefit on 09/27/2024 with a primary diagnosis of neurocognitive disorder with Lewy bodies and died on 10/02/2024. The RN visit note dated 10/02/2024 documented, “Morphine Sulfate 0.25ml at 11:45, 0.25ml at 12:30, 0.5ml at 13:00 and Lorazepam 0.5mg at 12:30 and 13:00.” The physician’s order dated 10/01/2024 ordered “Morphine 20mg/ml, 0.25ml every 2 hours as needed for pain/sob.” The physician’s order dated 09/27/2024 ordered “Lorazepam 0.5mg tab, one tablet every 8 hours as needed for anxiety.” The hospice medication profile documented morphine 0.5ml. The hospice medication profile did not include documentation of the administration of morphine more frequently than every 2 hours. There was no documented evidence that the hospice medication profile included Lorazepam more frequently than every 8 hours. During an interview on 03/18/2025, the Director of Operations agreed that the Ativan given and instructed on clinical record 1 was not on the hospice medication profile. The Director of Operations agreed that the oxycodone 10mg given for clinical record 4 was not on the hospice medication profile. During an interview on 03/19/2025, the Director of Operations agreed that the methadone for clinical record 2 was not on the hospice medication profile. During an interview on 03/20/2025, the Director of Operations agreed that the morphine and Ativan administered for clinical record 7 were not on the hospice medication profile.”

“It is required that the hospice ensures that each patient and the primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. This standard was not met as evidenced by clinical record review, document review, observation, and interview. Agency policy #2.004 “Medication Profile” stated in part, “During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver. as well as other clinicians, understand the medication regimen. This includes ...Using the medication profile to teach purpose of medication, dosages, routes, administration times...Deviations from taking medications as ordered will be documented in the medical records, and the Physician (or other authorized independent practitioner ) will be notified.” In 3 of 8 (38%) clinical records reviewed and home visits observed, the agency did not ensure that the patient and caregiver received education and training for medications documented in the plan of care. Clinical Record 1: The patient elected the hospice benefit on 03/14/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris and died on 09/02/2024. The Registered Nurse (RN) visit note dated 08/23/2024 at 11:24 AM documented, “He is agitated. Trying to get out of bed, pull things, pick up things on floor. Family is noncompliant with medication orders to manage agitation. Family states they are exhausted caring for him. Explained that they have not utilized the help that hospice is offering in managing his symptoms. After discussing the regimen, family allowed Ativan 2mg and Haldol 1mg to be given. After approximately 30 min pt resting comfortably. Family to continue Ativan 2mg q 4hr.” The physician’s order dated 08/21/2024 ordered “Ativan 1mg every 4 hours as needed for anxiety or agitation. In the evenings, give a single dose of 1.5-2 tabs.” The plans of care dated 03/14/2024 to 09/02/2024 did not include documentation of Ativan 2mg in the morning or Ativan 2mg every four hours scheduled. There was no evidence that the medication regimen instruction provided by the RN was included in the medication regimen documented in the plan of care and medication profile. On 03/19/2025, the leadership team provided a paper annotation by a RN documenting that, “On 8/23/24, I, (Name of Nurse), RNCM, obtained an order for Ativan 1mg every 1-2 hours PRN for SOB and/or anxiety. In error, an order was not entered into HCHB. This order was obtained from Dr. (Name of Doctor) via Backline secure messaging app.” This was signed by the RN on 03/19/2025. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 02/09/2025 with a primary diagnosis of malignant neoplasm of an unspecified part of the right bronchus or lung. During the home visit with the RN [Personnel Record 1] on 03/19/2025, the hospice medication profile was compared to the patient’s medications provided by the family. A prescription bottle dated 02/15/2025 for methadone 5mg, two (2) tablets twice daily, was located in a lockbox. The patient’s girlfriend confirmed the patient had been receiving two (2) tablets twice daily of methadone for at least the last week and up to two weeks. The RN visit note dated 02/10/2025 documented that “the doctor ordered methadone 10mg BID (twice a day).” The RN visit note dated 02/11/2025 documented, “comfort meds in last 24 hours oxycodone 10mg q4h prn and methadone 10mg q12 hr.” The RN visit note dated 02/12/2025 documented, “patient did not like the methadone previously prescribed he states he only wants to use the oxycodone 10mg q4hr prn. Nurse educated on the methadone use once more to attempt to convince him to try a regimen that would reduce peaks and valleys of pain.” The RN visit note dated 02/15/2025 documented, “pharmacy called (on-call nurse) OCN this am reporting they did not have methadone in stock, found pharmacy and family is going to pick up.” The RN visit notes dated 02/15/2025 and 02/18/2025 documented, “pt agreed to try methadone.” A clinical record review revealed no evidence that the hospice medication profile included methadone from 02/09/2025 through 03/19/2025. There was no evidence that the medication regimen instruction provided by the RN was included in the medication regimen documented in the plan of care and medication profile. Clinical Record 4/Home Visit 1: The patient elected the hospice benefit on 03/12/2025 with a primary diagnosis of moderate protein-calorie malnutrition. The physician’s order dated 03/12/2025 ordered oxycodone 5mg tablet, take one (1) tablet every 6 hours as needed for pain. The RN visit note dated 03/12/2025 documented, “He is currently on oxycodone 5mg Q6H PRN. After rolling and moving patient today after assessment, RN administered 10mg of oxycodone.” During the home visit with the RN [Personnel Record 1] on 03/19/2025, the spouse confirmed that the patient received the following doses as they were recorded on a written board in the room: on 03/14/2025, the patient received 5mg oxycodone at 3:20 AM, 7:00 AM, 11:00 AM, and 2:40 PM; on 03/17/2025, the patient received 5mg oxycodone at 11:30 AM, oxycodone 5mg x 2 tablets (10mg) at 4:00 PM, and oxycodone 5mg at 10:00 PM; on 03/18/2025, the patient received morphine 0.25ml (5mg) at 11:45 AM, oxycodone 5mg at 4:50 PM, oxycodone 5mg at 8:45 PM, and oxycodone 5mg at 11:00 PM; and on 3/19/2025, the patient received oxycodone 5mg at 6:00 AM and 8:30 AM. During the home visit and interview, the spouse stated that the RN instructed her during the admission visit on 03/12/2025 to give oxycodone 5mg x 2 tablets if the patient had excruciating pain. There was no evidence that the instruction provided by the RN to administer oxycodone 5mg x 2 tablets if the patient had excruciating pain was documented in the plan of care or physician’s order. Following the home visit on 03/19/2025, the agency provided an unsigned order with an order date of 03/19/2025 ordering 1x dose of Oxycodone 10mg on 03/12/2025. Additionally, the agency provided an annotation note dated 03/19/2025 documenting that on the admission date of 03/12/2025, a verbal order was received for 1x dose of oxycodone 10mg due to severe pain. Received an order from MD, oxycodone 5mg Q6 PRN is to remain ordered.”

“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: 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, interview, and observation. In 1 of 8 (12%) clinical records reviewed, the hospice agency did not ensure that the patient’s record contained correct clinical information, including clinical notes documenting the care and services provided. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 02/09/2025 with a primary diagnosis of malignant neoplasm of an unspecified part of the right bronchus or lung. During the home visit on 03/19/2025 with the Registered Nurse (RN) [Personnel Record 1], the patient’s sister (#2) was interviewed and stated, “I am glad you are here, I am very unhappy, He did not want (morphine sulfate) MS on admission, as part of his med regimen or plan of care, the nurse (name stated for the RN Personnel Record 1] came out Monday and gave 0.5ml of morphine and left a syringe of morphine with our stepdad. This is against his wishes.” The patient’s girlfriend (GF) was listed as the primary caregiver (PCG) in the patient’s clinical record. The PCG/GF was on speakerphone during the visit. During the interview, the PCG/GF stated, “I was not aware he was given morphine on Monday. My dad told me that the social worker (SW) was going to pick it up. I didn’t know the nurse gave it to him.” The RN [Personnel Record 1] visit note dated 03/17/2025 documented, “Pain unmanaged initially until oxycodone crushed. Morphine concentrate ordered and picked up by hospice (Social Worker) SW. Educated father and girlfriend on dying process and med usage. Pt comfortable approximately 45 min after oxycodone.” The RN visit note dated 03/17/2025 did not include documentation of the RN’s administration of morphine 10mg (0.5ml) during the visit or that the syringe was filled to 0.5ml of morphine and left in the home. A physician’s order dated 02/09/2024 ordered morphine sulfate (MS) oral (20 ml/1 ml) 0.25 to 1.00ml 5-20mg hourly for pain or shortness of breath (SOB). During the home visit on the same day, the RN [Personnel Record 1] [who conducted the visit on 3/17/2025] stated, “On Monday, 03/17/2025, he was unable to swallow, so I crushed Oxycodone and gave him, and yes, I gave him 0.5ml morphine and left a syringe with 0.5ml morphine with the stepdad when he showed up.” The Director of Operations was interviewed on 03/20/2025 and had no additional information.”

“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: physician orders. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy # 2-002, “Verification of Physician Orders,” stated in part, “Orders will be obtained from a licensed Physician for care and services to be provided to hospice patients. Orders will be documented by hospice in the electronic medical record within 24 hours of receipt of order, with the date and identify of the professional receiving the order.” In 4 of 8 (50%) clinical records reviewed, the hospice agency did not ensure that the patient’s clinical record included the physician’s medication orders to meet the patient’s needs. Clinical Record 1: The patient elected the hospice benefit on 03/14/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris and died on 09/02/2024. The Registered Nurse (RN) visit note dated 08/23/2024 at 11:24 AM documented, “He is agitated. Trying to get out of bed, pull things, pick up things on floor. Family is noncompliant with medication orders to manage agitation. Family states they are exhausted caring for him. Explained that they have not utilized the help that hospice is offering in managing his symptoms. After discussing the regimen, family allowed Ativan 2mg and Haldol 1mg to be given. After approximately 30 min pt resting comfortably. Family to continue Ativan 2mg q 4hr.” The physician’s order dated 08/21/2024 ordered “Ativan 1mg every 4 hours as needed for anxiety or agitation. In the evenings, give a single dose of 1.5-2 tabs.” The plan of care dated 03/14/2024 to 09/02/2024 did not include documentation of Ativan 2mg in the morning or Ativan 2mg every four hours scheduled. A clinical record review revealed no physician’s order for the Ativan 2mg in the morning or Ativan 2mg every four hours scheduled. On 03/19/2025, the leadership team provided a paper annotation by a RN documenting that, “On 8/23/24, I, (Name of Nurse), RNCM, obtained an order for Ativan 1mg every 1-2 hours PRN for SOB and/or anxiety. In error, an order was not entered into HCHB. This order was obtained from Dr. (Name of Doctor) via Backline secure messaging app.” This was signed by the RN on 03/19/2025. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 02/09/2025 with a primary diagnosis of malignant neoplasm of an unspecified part of the right bronchus or lung. The RN visit note dated 02/28/2025 documented, “wound care provided to right buttock and area between buttocks, cleaned with wound cleanser, allowed to air dry, applied a generous layer of zinc barrier cream and covered with 2 4x4 bordered foam dressings.” The RN visit notes dated 03/06/2025 and 03/08/2025 documented, “wound care provided during the visit.” The RN visit note dated 03/15/2025 documented, “wound is likely worsening but barely got a glance at it before pt almost fell.” The plan of care dated 02/09/2025 to 05/09/2025 did not include documentation of orders for wound care. A clinical record review revealed no additional evidence of a physician’s order for wound care as of 03/18/2025. Clinical Record 4/Home Visit 1: The patient elected the hospice benefit on 03/12/2025 with a primary diagnosis of moderate protein-calorie malnutrition. The RN visit note dated 03/12/2025 documented, “He is currently on oxycodone 5mg Q6H PRN. After rolling and moving patient today after assessment, RN administered 10mg of oxycodone.” The physician’s order dated 03/12/2025 ordered oxycodone 5mg tablet, take one (1) tablet every 6 hours as needed for pain. During the home visit with the RN [Personnel Record 2] on 03/19/2025, the hospice medication profile was compared to the patient’s current medications as provided by the patient’s spouse. The spouse confirmed that the patient received the following doses as they were recorded on a written board in the room: on 03/14/2025, the patient received 5mg oxycodone at 3:20 AM, 7:00 AM, 11:00 AM, and 2:40 PM; on 03/17/2025, the patient received 5mg oxycodone at 11:30 AM, oxycodone 5mg x 2 tablets (10mg) at 4:00 PM, and oxycodone 5mg at 10:00 PM; on 03/18/2025, the patient received morphine 0.25ml (5mg) at 11:45 AM, oxycodone 5mg at 4:50 PM, oxycodone 5mg at 8:45 PM, and oxycodone 5mg at 11:00 PM; and on 3/19/2025, the patient received oxycodone 5mg at 6:00 AM and 8:30 AM. During the home visit and interview, the spouse stated that the RN instructed her during the admission visit on 03/12/2025 to give oxycodone 5mg x 2 tablets if the patient had excruciating pain. The plan of care did not include documentation of oxycodone 10mg before 03/18/2025. A clinical record review revealed no physician’s order for oxycodone 10mg. Following the home visit on 03/19/2025, the agency provided an unsigned order with an order date of 03/19/2025 ordering 1x dose of Oxycodone 10mg on 03/12/2025. Additionally, the agency provided an annotation note dated 03/19/2025 documenting that on admission date of 03/12/2025, verbal order was received for 1x dose of oxycodone 10mg due to severe pain. Received order from MD, oxycodone 5mg Q6 PRN is to remain ordered. Clinical Record 7: The patient elected the hospice benefit on 09/27/2024 with a primary diagnosis of neurocognitive disorder with Lewy bodies and died on 10/02/2024. The RN visit note dated 10/02/2024 documented, “Morphine Sulfate 0.25ml at 11:45, 0.25ml at 12:30, 0.5ml at 13:00 and Lorazepam 0.5mg at 12:30 and 13:00.” The physician’s order dated 10/01/2024 ordered “Morphine 20mg/ml, 0.25ml every 2 hours as needed for pain/sob.” The physician’s order dated 09/27/2024 ordered “Lorazepam 0.5mg tab, one tablet every 8 hours as needed for anxiety.” The hospice medication profile documented morphine 0.5ml. The hospice medication profile did not include documentation of the administration of morphine more frequently than every 2 hours. The plan of care did not include documentation of morphine 0.5ml, morphine administration more frequently than every 2 hours, or the administration of Lorazepam more frequently than every 8 hours. The Director of Operations was interviewed on 03/18/2025 and agreed there was no documented evidence that the plan of care did not include orders for the drugs for clinical records 1, 2, and 4. The Director of Operations was interviewed on 03/20/2025 and agreed there was no documented evidence that the plan of care included orders for the drugs for clinical record 7.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by document review, observation, and interview. In 1 of 4 (25%) home visit observations, the hospice did not ensure the patient’s medication profile was updated to include the patient’s current medication regimen. Agency policy 2-004 Medication Profile, no revision date, stated in part, “Upon admission, the nurse will initiate a medication profile to document the current medication regimen, including drug name, dose, strength, route, frequency, date and time if the administration. A drug regimen review will be performed at the time of the initial and comprehensive assessment when updates to the comprehensive assessment are performed and with the addition of a new medication. Deviations from taking medications as ordered will be documented in the medical record, and the physician will be notified.” Home Visit 3: During the home visit observation with the Registered Nurse (staff 4), review of the patient’s medications found in the home revealed the patient was taking six milligrams of Melatonin at bedtime. Clinical record review revealed the medication profile dated 02/27/2024 included an order for Melatonin 5 milligrams one tablet at bedtime. The medication profile was not updated to include the increased dose of Melatonin being taken by the patient. During joint record review and interview on 02/27/2024, the Administrator (staff 1) who was present for the home visit observation confirmed the medication profile was not updated with the patient’s current dose of Melatonin.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care and ensure continuous assessment of each patient’s and family’s needs. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 19 (5%) clinical records reviewed, the hospice did not ensure the RN documented coordination of care. Agency policy 1-011 Monitoring the Patient’s Response/Reporting to Physician, no revision date, stated in part, “The patient’s physician and the Hospice Medical Director will to be contacted promptly when any of the following occur: (A) changes in the patient’s condition, (D) inability to achieve goals within a specified time frame, (E) change in the patient’s expected response to Hospice care, or medications. Conferences or attempts to communicate with a physician will be documented in the medical record.” Clinical Record 9: The patient elected the hospice benefit on 11/27/2023 with a terminal diagnosis of hypertensive heart disease. The Registered Nurse (RN) documented on the skilled nurse visit note dated 01/12/2024 “Patient has dyspnea with conversation and refuses oxygen. Patient blood pressure 180/90. Patient still not taking blood pressure meds at this time.” The RN documented “No” in the section of the note label “Indicate if you communicated with other disciplines involved in the case.” The record contained no documented evidence the RN updated the physician about the patient’s assessment findings. During a joint record review and interview on 02/28/2024, the Manager of Accreditation and Regulatory Compliance (staff 2) confirmed the record contained no evidence that the RN updated the physician about changes in the patient’s assessment.”

“It is required that written patient care instructions for a hospice aide are prepared by a Registered Nurse (RN) who is who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed with aide services provided, the hospice agency did not ensure the RN prepared patient specific written care instructions for the hospice aide. Clinical Record 11: The patient elected the hospice benefit on 12/20/2023. The plan of care dated 12/20/2023 through 02/18/2024 included an order for hospice aide services one time per week. The physician ordered a sixteen French Foley catheter to be placed on 12/23/2023. Clinical record review revealed the hospice aide care plan dated 12/20/2024 assigned the aide the tasks of “perineal care” and was not updated by the RN to include the Foley catheter and catheter care. A joint record review and interview with the Manager of Accreditation and Regulatory Compliance (staff 2) on 02/28/2024 confirmed the RN did not instruct the hospice aide concerning the care of the Foley catheter initiated on 12/23/2024.”

“It is required that hospice aides report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 13 (15%) clinical records reviewed with hospice aid services accepted, the agency did not ensure the hospice aide reported changes in the visit frequency to the Registered Nurse (RN) when hospice aide visits were not completed as ordered on the plan of care. Agency policy 9-017 The Interdisciplinary Plan of Care, no revision date, stated in part, “The interdisciplinary group responsibilities include but are not limited to supervision of hospice care and services. Care provided to the patient will be in accordance with the plan of care.” Clinical Record 6: The patient elected the hospice benefit election on 03/16/2023. The plan of care dated 01/10/2024 through 03/9/2024 included an order for hospice aide services two times per week. Clinical record review revealed the aide provided one aide visit for the week of 01/14/2024 to 01/20/2024, on 01/18/2024. The aide documented on the missed visit note dated 01/15/2024, “The visit was not completed” but there was no documented evidence that the RN was notified of the missed hospice aide visit. The Interdisciplinary Group (IDG) meeting notes following the missed visit on 01/25/2024 did not contain documentation that the RN was updated about the missed hospice aide visit or that the IDG discussed the reason for the missed hospice aide visit. Clinical Record 13: The patient elected the hospice benefit on 01/10/2024. The plan of care dated 01/10/2024 through 04/08/2024 included an order for hospice aide services two times per week. Clinical record review revealed the aide provided one aide visit for the week of 01/28/2024 to 02/03/2024, on 01/29/2024. The aide documented on the missed visit note dated 02/03/2024, “The visit was not completed” but there was no documented evidence that the RN was notified of the missed hospice aide visit. The IDG meeting notes following the missed visit on 02/06/2024 did not contain documentation that the RN was updated about the missed hospice aide visit or that the IDG discussed the reason for the missed hospice aide visit. During joint record review and interview on 02/28/2024, the Manager of Accreditation and Regulatory Compliance (staff 2) confirmed the records did not include documentation that the RN was updated about missed hospice aide visits. The hospice aide documentation did not state that the RN was notified of the missed hospice aide visits.”

“It is required that each patient’s record includes, at a minimum, Physician orders. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 19 (5%) clinical records reviewed, the hospice did not ensure the clinical record contained physician orders. Agency policy 6-040 Contents of the Clinical Record, no revision date, stated in part, documentation will include …Appropriate, current, and signed medical orders by Physician. Clinical Record 11: The patient elected the hospice benefit on 12/20/2023 with diagnoses of hypertensive heart disease and chronic kidney disease. The clinical record included a physician order dated 12/23/2023 instructing the Registered Nurse (RN) to place a sixteen (16) French (F) Foley catheter. The RN documented on the clinical note dated 12/29/2023, “Patient requested Foley be taken out due to discomfort. Foley catheter removed with tip intact. Two hundred (200) cc clear yellow urine with no sediment noted in the drainage bag.” The clinical record did not contain a physician’s order to remove the Foley catheter. A joint record review and interview with the Manager of Accreditation and Regulatory Compliance (staff 2) on 02/28/2024 confirmed the record did not contain a physician’s order for the removal of the Foley catheter.”