Ivy Creek Hospice

“Based on observation, agency policies and procedures, and interview, it was determined the hospice agency failed to ensure coordination of services with the skilled nursing facility (SNF). This had the potential to affect all hospice patients residing in a SNF, and did affect Home Visit (HV) # 3. Findings include: Agency Policy: Care to Residents of a SNF/NF (nursing facility)... Policy Number: 7.9 Revised Date: April 2016 Policy: Hospice provides care to patients who are residents of a SNF/NF... Purpose: To define the roles of Hospice and the facility for patient care. Procedure: ...4. A written hospice Plan of Care (POC) will be established and maintained in consultation with the SNF...representatives. The hospice POC will identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions...in the hospice POC. 5. Hospice will designate a member of each IDG (interdisciplinary group) that is responsible for a patient who is a resident of a SNF/NF. The designated IDG member is responsible for: ...Documentation in both respective entities clinical records or other means to ensure continuity of communication and easy access to ongoing information... ...7. Hospice will provide to the SNF/NF...the following information: -The most recent hospice POC specific to each patient. ...- Hospice physician and attending physician (if any) orders specific to each patient. Agency Policy: Coordination of Patient Care Policy Number: 9.13 Revised Date: March 2016 Policy: Hospice staff members regularly communicate to ensure that their efforts are coordinated... Procedure: Hospice has developed and maintains a system of communication and integration to: ... - Ensure that care and services are provided in accordance with the POC... Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings... Provide for ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. 1. HV # 3 was admitted to hospice services on 2/16/24 with diagnoses including Cerebral Infarction, Unspecified and Urinary Tract Infection, Site Not Specified. A HV was conducted at the SNF where HV # 3 resided on 3/27/24 at 1:15 PM to observe care provided by Employee Identifier (EI ) # 4, Chaplain. A review of HV # 3’s hospice binder, located at the SNF nursing station, revealed there was no documentation of HV # 3’s POC, IDG meetings, or physician orders within the binder. This was confirmed by EI # 4 at 1:35 PM during the visit. The hospice agency failed to follow policy and provide documentation for the SNF clinical record including the POC and physician orders to ensure coordination of patient care. An interview with a licensed practical nurse at the SNF on 3/28/24 at 4:59 PM via phone confirmed that all hospice documentation brought to the SNF was placed within the patient’s hospice binder maintained at the nurses station.”

“Based on medical record (MR) review, agency policies and procedures, review of agency admission packet and interview, it was determined the hospice utilized photo copied physician signatures for DNR (Do Not Resuscitate) orders. This deficient practice affected 19 of 19 MR’s reviewed, including Home Visit (HV) # 1, HV # 2, HV # 3, HV # 4, MR # 5, MR # 6, MR # 7, MR # 8, MR # 9, MR # 10, MR # 11, MR # 12, MR # 13, MR # 14, MR # 15, MR # 16, MR # 17, MR # 18, MR # 19, and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: DNR/Allow Natural Death (AND) Policy Number: 12.10 Revised Date: April 2016 Policy: Hospice will obtain current orders regarding resuscitation from patient’s physician... Procedure: 1. All patients served by Hospice will be resuscitated except those patients who have signed physician orders for DNR. ...4. ...Should the patient desire a DNR...The appropriate professional staff member will then consult with the patient’s attending physician regarding a DNR/AND order. ...9. Hospice will utilize the State Alabama Portable Physician Do Not Attempt Resuscitation Order No CPR (cardiopulmonary resuscitation) / AND form found in the State of Alabama Administrative Code Chapter 420-5-19 / Appendices. Agency Policy: Physician Orders - Verbal Orders Policy Number: 11.11.1 Revised Date: April 2016 Procedure: 1. Orders for patient care are obtained from the physician, either verbally or in writing... ...3. Hospice will not accept stamped physician signatures on orders, treatments or other documents that are a part of the patient’s record. 1. A review of the hospice agency’s admission packet contents on 3/26/24 at 10:35 AM revealed it contained a copy of appendice page two of the Alabama Portable Physician Do Not Attempt Resuscitation Order form that had been pre-signed and photocopied with the agency’s Medical Director signature. Review of 19 MR’s revealed each record contained the physician pre-signed/photocopied DNR form. In an interview on 3/28/24 at 5:32 PM with Employee Identifier # 5, Branch Manager, he/she confirmed the physician signature on the DNR form was a photocopied signature.”

“Based on medical record (MR) review, Roche Diagnostics Package Insert for CoaguCheck Meter and interview, it was determined the hospice agency failed to obtain a Clinical Laboratory Improvement Amendments (CLIA) waiver to allow agency staff to perform CLIA waived laboratory (lab) tests. This deficient practice affected one of 19 MR’s reviewed, including MR # 10, and had the potential to affect all patients served by the agency requiring CLIA waived diagnostic lab tests. Findings include: Package Insert Roche CoaguCheck XS Meter: This insert is for healthcare professional use...This is a CLIA Waived test system. A Certificate of CLIA Waiver (or higher) is required to perform the test. Facilities performing testing must have a CLIA Certificate of Waiver... 1. MR # 10 was admitted to hospice services on 2/5/24 with diagnoses including Dilated Cardiomyopathy and Essential Primary Hypertension. Review of the 2/5/24 Hospice Plan of Care revealed a medication order for Warfarin (Coumadin) 4 milligrams daily, and an order for the Skilled Nurse (SN) to obtain a PT/INR (prothrombin time/international normalized ratio) lab test via bedside monitor weekly. Review of SN Visit Notes dated 2/12/24, 2/20/24, 2/26/24, 3/4/24, 3/11/24, and 3/18/24 revealed the SN obtained a PT/INR by fingerstick blood sample obtaining results utilizing a coagulation meter. Further review of SN visit dated 2/26/24 revealed the PT/INR result was not within normal limits, the SN notified the Nurse Practitioner of the PT/INR result and received a verbal order to adjust the coumadin dose. The hospice agency was performing the CLIA waived PT/INR lab and treating MR # 10 based on the lab result, without having a CLIA waiver. An interview was conducted on 3/28/24 at 6:01 PM with Employee Identifier # 5, Branch Manger, who confirmed the hospice agency did not have a CLIA waiver and the agency owned the Roche CoaguCheck XS Meter.”